Gastroesophageal reflux after repair of congenital diaphragmatic hernia

Congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a lethal human birth defect. Hypoplastic lung development is the leading contributor to its 30-50% mortality rate. Efforts to improve survival have focused on fetal surgery, advances in intensive care and elective delivery at specialist centres following in utero diagnosis. The impact of abnormal lung development on affected infants has stimulated research into the developmental biology of CDH. Traditionally lung hypoplasia has been viewed as a secondary consequence of in utero compression of the fetal lung. Experimental evidence is emerging for a primary defect in lung development in CDH. Culture systems are providing research tools for the study of lung hypoplasia and the investigation of the role of growth factors and signalling pathways. Similarities between the lungs of premature newborns and infants with CDH may indicate a role for antenatal corticosteroids. Further advances in postnatal therapy including permissive hypercapnia and liquid ventilation hold promise. Improvements in our basic scientific understanding of lung development may hold the key to future developments in CDH care.

Congenital diaphragmatic hernia

Congenital diaphragmatic hernia occurs in approximately 1 in every 2500 live births and is associated with a reported mortality of almost 35% in live-born patients and a higher mortality when in utero deaths are counted. Ventilator-induced lung injury, pulmonary hypoplasia, and other associated anomalies account for the high death rate. Numerous adjunctive measures have been used to treat these patients. Inhaled vasodilators (nitric oxide), intravenous vasodilators, and fetal therapy have no proven benefit. While animal models of congenital diaphragmatic hernia are surfactant deficient, controversy remains over the use of surfactant in infants. There has been no clinical trial showing any clear benefit with the use of exogenous surfactant in these patients. Similarly, prenatal corticosteroids show some improvements in animal models, but again, there is a complete absence of supportive data to show benefit in humans. Mechanical ventilator strategies that limit ventilator-induced lung injury by avoiding hyperventilation and lung over inflation are the strategies currently in use that have been associated with improved survival. Long-term follow-up of these patients is quite important since gastroesophageal reflux, developmental delay, chronic lung disease, and chest wall deformity are all seen with increased frequency in these children.

Nutritional morbidity in survivors of congenital diaphragmatic hernia

PURPOSE

The purpose of this report is to detail the nutritional sequelae seen in survivors of congenital diaphragmatic hernia (CDH) followed in a multidisciplinary clinic.

METHODS

Data on 121 surviving CDH patients seen between 1990 and 2000 were collected. Regression analysis was used to determine the impact of factors such as Apgar score, birth weight, extracorporeal membrane oxygenation (ECMO), and patch repair on outcomes associated with nutritional morbidity.

RESULTS

There were 100 left and 21 right CDH defects. Mean birth weight and 5-minute Apgar score were 3.1 kg (+/-0.8) and 6.8(+/-2), respectively. Extracorporeal membrane oxygenation was required in 43 (36%) patients and patch repair in 39 (32%). A gastrostomy was required in 39 (32%) patients and a fundoplication in 23 (19%) patients. The side of the defect did not affect the frequency of these procedures. Fifty-six percent of patients were below the 25th percentile for weight during most of their first year. Regression analysis found that duration of ventilation (P <.001) and the presence of a patch repair (P =.03) were independent variables predictive of failure to thrive thereby requiring a gastrostomy tube. Patch repair also was predictive of need for subsequent fundoplication caused by gastroesophageal reflux (P <.001). Twenty-nine patients (24%) had severe oral aversion. Risk factors were prolonged ventilation (P =.001) and oxygen requirement at discharge (P =.015). Two thirds of these patients subsequently improved.

CONCLUSIONS

Nutritional problems continue to be a source of morbidity for survivors of CDH, particularly in the first year of life. Not surprisingly, patients who had prolonged intubation and prosthetic material at the gastroesophageal junction fared worse. Despite aggressive nutritional management, 56% of the population remained below the twenty-fifth percentile for weight. These data show the need for careful nutritional assessment in all CDH patients, especially those at high risk for malnutrition.

Current and emerging treatment for congenital diaphragmatic hernia

Management of congenital diaphragmatic hernia has changed dramatically over the past couple of decades. Until the early 1980s, it was felt that the abdominal contents should be returned to the abdomen as soon as possible to allow the lungs to expand. It is now known that it is not the defect that causes respiratory distress, but the infant's hypoplastic lungs and accompanying pulmonary hypertension. Advances in treatment and technology have contributed to changes in management. Ultrasonography now allows for early prenatal detection. Prenatal treatment modalities include in utero tracheal ligation and maternal antenatal steroids. Postnatal modalities have expanded to include permissive hypercapnia, high-frequency ventilation, inhaled nitric oxide, pharmacologic support, exogenous surfactant, and extracorporeal membrane oxygenation. Liquid ventilation and lobar lung transplantation have also been tried. In spite of these advances, the overall survival rate remains about 63 percent.

[Prolonged length of stays in pediatric intensive care. Retrospective study of 100 stays]

New issues have arisen in pediatric intensive care units, especially concerning long-stay patients. The aims of the present study were to describe the etiologic factors of these long-stay patients and to recognize the comorbidities.

MATERIAL AND METHODS

Ninety-five patients who had a total of 100 hospitalizations of more than 30 days were admitted to the pediatric intensive care unit at Robert-Debre Hospital during a 3-year period (1993-1995); this accounted for 9.1% of total admissions. We retrospectively reviewed these 100 long-stay hospitalizations.

RESULTS

Most of these patients were newborns (65%). Patients with severe congenital anomalies (44 patients) and very premature infants (26 patients) constituted the majority of long-stay patients. The mean duration of mechanical ventilation for the 95 patients was 110 days (ranges 17-789 days). Two factors of comorbidity were found: gastroesophageal reflux (41% of cases) and nosocomial infections (89% of cases).

CONCLUSION

In order to prevent long stays, pediatric intensive care units must be directed toward these factors.

Antireflux surgery in children under 3 months of age

PURPOSE

The aim of this study was to analyze the indications and results of fundoplication in 110 infants under 3 months of age.

METHODS

A retrospective review was conducted on the charts of all infants operated on for gastroesophageal reflux disease (GERD) at the UCLA Medical Center from January 1980 to December 1997. There were 59 boys and 51 girls. Recurrent emesis was the indication for operation in 62 of 110 infants, and respiratory symptoms in 85 of 110, with 54 of 110 having both. Neurological impairment was present in 32%. Prematurity was present in 21%; 35% had associated anomalies. Overall, 81 of 110 infants (73.6%) had one or more associated major malformations or disorders. Reflux was confirmed by upper gastrointestinal series findings in 63 of 78, esophageal pH monitoring in 60 of 62, and endoscopy in five of seven.

RESULTS

Mean age at operation was 1.8+/-0.1 months and mean weight was 3,686+/-90.2 g. A Nissen fundoplication was performed on 104 children, and six underwent a Thal procedure. Thirty-one had a gastric emptying procedure for delayed gastric emptying. Complications occurred in 7 infants. Emesis was controlled in 57 of 62 patients, aspiration in 38 of 48, and apneic spells in 54 of 57. Follow-up greater than 6 months was available for 73 patients. There were nine late deaths, all related to severe associated malformations. Seven patients required a redo fundoplication for recurrent reflux.

CONCLUSIONS

Nissen fundoplication can be performed safely in symptomatic infants under 3 months of age with low mortality and morbidity rates and with resolution of the presenting symptoms in 79% of infants.

Care of the surgical intensive care nursery graduate. The primary care pediatrician's perspective

Care of the intensive care nursery graduate may be quite challenging. It is important that primary care pediatricians become familiar with the complications unique to surgical patients so that they may properly prepare and educate parents and provide appropriate long-term follow-up for these often complex patients. Maintenance of a close relationship with the pediatric surgeon with an open line of communication regarding the approach to various surgical problems facilitates the effective integration of the intensive care nursery graduate into the primary care pediatrician's practice and provides the foundation for a successful clinical outcome.

Neurological outcome is diminished in survivors of congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation

In a series of 61 infants who had congenital diaphragmatic hernia (CDH) treated at our center from 1978 through 1996, 37 of 59 (61%) survived the perioperative period with two infants lost to follow-up. Nine (47%) of 19 infants survived before the introduction of extracorporeal membrane oxygenation (ECMO) into our region in 1986. Since 1986, 28 (70%) of 40 infants survived. Eighteen infants required ECMO, and 12 (75%) survived. A chart review was performed to determine whether infants surviving CDH are suffering from delays in neurological development, and, if so, whether this is attributable to ECMO. Of 12 ECMO survivors, 8 (67%) exhibited functional or anatomic evidence for neurological delay. Of 21 non-ECMO survivors, where adequate follow-up was available to make an assessment of neurological development, five (24%) exhibited evidence for delay. This difference was significant (P < .05, Fisher's Exact test). Of these five infants, three were premature, and one had DiGeorge syndrome. More ECMO survivors required diaphragmatic (67%) and abdominal (67%) patches at the time of diaphragmatic repair than non-ECMO survivors (4% and 12%, respectively; P < .05, Fisher's Exact test). In addition, more ECMO survivors required gastrostomy tube placement for feeding (50%) than non-ECMO survivors (16%; P < .05, Fisher's Exact test). A greater need for Nissen fundoplication in ECMO survivors (42%) than in non-ECMO survivors (12%) approached significance (P = .05, Fisher's Exact test). There were trends toward higher 1 and 5 minute APGAR scores and initial and best preoperative P(O2) in the non-ECMO survivors. A comparison between ECMO survivors who exhibited evidence of neurological delay with those who did not showed no differences in duration of ECMO, incidence of intracranial complications during ECMO, need for gastrostomy tube feeding or Nissen fundoplication, or incidence of carotid artery repair between the two groups. Infants surviving CDH who require ECMO have a greater incidence of neurological delay than those who do not. This is likely because of severity of the presenting illness as reflected by a greater need for diaphragmatic and abdominal patches during diaphragmatic repair, the need for Nissen fundoplication and gastrostomy tube feeding, and a trend toward poor APGAR scores and best preoperative P(O2) levels in these patients. However, there may be characteristics of ECMO, as yet unidentified, that may contribute to this outcome.