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Soni S, Moldenhauer JS, Kallan MJ, Rintoul N, Adzick NS, Hedrick HL, Khalek N. Influence of Gestational Age and Mode of Delivery on Neonatal Outcomes in Prenatally Diagnosed Isolated Congenital Diaphragmatic Hernia. Fetal Diagn Ther 2021; 48:372-380. [PMID: 33951652 DOI: 10.1159/000515252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 02/15/2021] [Indexed: 11/19/2022]
Abstract
AIM The optimal gestational age (GA) at delivery and mode of delivery (MoD) for pregnancies with fetal congenital diaphragmatic hernia (CDH) is undetermined. The impact of early term (37-38 weeks 6 days) versus full term (39-40 weeks 6 days) and MoD on immediate neonatal outcomes in prenatally diagnosed isolated CDH cases was evaluated. MATERIAL AND METHODS A retrospective chart review of pregnancies evaluated and delivered with the prenatal diagnosis of CDH between July 1, 2008, and December 31, 2018. The primary outcome was survival to hospital discharge. Secondary outcomes included neonatal intensive care unit (NICU) length of stay (LOS), extracorporeal membrane oxygenation (ECMO) requirement and need for supplemental oxygen at day 30 of life. RESULTS A total of 296 patients were prenatally evaluated for CDH and delivered in a single center during the study period. After applying exclusion criteria, data were available on 113 women who delivered early term and 72 women who delivered full term. Survival to hospital discharge was comparable between the 2 groups - 83.2% in the early term versus 93.1% in the full term (p = 0.07; 95% CI of 0.13-1.04). No difference was observed in any other secondary outcomes. MoD was stratified into spontaneous vaginal, induced vaginal, unplanned cesarean and scheduled cesarean delivery with associated neonatal survival rates of 74.2, 90.6, 89.7 and 88.2%, respectively, p = 0.13. The 5-min Apgar score was higher in the elective cesarean group (7.94) followed by the induced vaginal delivery group (7.8) compared to 7.17 and 7.18 in the spontaneous vaginal and unplanned cesarean groups, respectively (p = 0.03). The GA and MoD did not influence survival to hospital discharge nor NICU LOS in multivariate analysis. CONCLUSIONS Though there were no significant differences in neonatal outcomes for early term compared to full term deliveries of CDH neonates, a trend toward improved survival rates and lower ECMO requirements in the full term group may suggest an underlying importance GA at delivery. Further studies are warranted to validate these findings.
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Affiliation(s)
- Shelly Soni
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julie S Moldenhauer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael J Kallan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Natalie Rintoul
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Holly L Hedrick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Long AM, Bunch KJ, Knight M, Kurinczuk JJ, Losty PD. One-year outcomes of infants born with congenital diaphragmatic hernia: a national population cohort study. Arch Dis Child Fetal Neonatal Ed 2019; 104:F643-F647. [PMID: 31154421 DOI: 10.1136/archdischild-2018-316396] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 02/28/2019] [Accepted: 03/02/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To report outcomes to 1 year, in infants born with congenital diaphragmatic hernia (CDH), explore factors associated with infant mortality and examine the relationship between surgical techniques and postoperative morbidity. DESIGN Prospective national population cohort study. SETTING Paediatric surgical centres in the UK and Ireland. METHOD Data were collected to 1 year for infants with CDH live-born between 1 April 2009 to 30 September 2010. Factors associated with infant mortality are explored using logistic regression. Postoperative morbidity following patch versus primary closure, minimally invasive versus open surgery and biological versus synthetic patch material is described. Data are presented as n (%) and median (IQR). RESULTS Overall known survival to 1 year was 75%, 95% CI 68% to 81% (138/184) and postoperative survival 93%, 95% CI 88% to 97% (138/148). Female sex, antenatal diagnosis, use of vasodilators or inotropes, being small for gestational age, patch repair and use of surfactant were all associated with infant death. Infants undergoing patch repair had a high incidence of postoperative chylothorax (11/54 vs 2/96 in infants undergoing primary closure) and a long length of hospital stay (41 days, IQR 24-68 vs 16 days, IQR 10-25 in primary closure group). Infants managed with synthetic patch material had a high incidence of chylothorax (11/34 vs 0/19 with biological patch). CONCLUSION The majority of infant deaths in babies born with CDH occur before surgical correction. Female sex, being born small for gestational age, surfactant use, patch repair and receipt of cardiovascular support were associated with a higher risk of death. The optimum surgical approach, timing of operation and choice of patch material to achieve lowest morbidity warrants further evaluation.
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Affiliation(s)
- Anna-May Long
- Department of Paediatric Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Kathryn J Bunch
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
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Long AM, Bunch KJ, Knight M, Kurinczuk JJ, Losty PD. Early population-based outcomes of infants born with congenital diaphragmatic hernia. Arch Dis Child Fetal Neonatal Ed 2018; 103:F517-F522. [PMID: 29305406 DOI: 10.1136/archdischild-2017-313933] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 12/07/2017] [Accepted: 12/08/2017] [Indexed: 11/04/2022]
Abstract
PURPOSE This study aims to describe short-term outcomes of live-born infants with congenital diaphragmatic hernia (CDH) and to identify prognostic factors associated with early mortality. DESIGN A prospective population cohort study was undertaken between April 2009 and September 2010, collecting data on live-born infants with CDH from all 28 paediatric surgical centres in the UK and Ireland using an established surgical surveillance system. Management and outcomes are described. Prognostic factors associated with death before surgery are explored. RESULTS Two hundred and nineteen live-born infants with CDH were reported within the data collection period. There were 1.5 times more boys than girls (n=133, 61%). Thirty-five infants (16%) died without an operation. This adverse outcome was associated with female sex (adjusted OR (aOR) 3.96, 95% CI 1.66 to 9.47), prenatal diagnosis (aOR 4.99, 95% CI 1.31 to 18.98), and the need for physiological support in the form of inotropes (aOR 9.96, 95% CI 1.19 to 83.25) or pulmonary vasodilators (aOR 4.09, 95% CI 1.53 to 10.93). Significant variation in practice existed among centres, and some therapies potentially detrimental to infant outcomes were used, including pulmonary surfactant in 45 antenatally diagnosed infants (34%). Utilisation of extracorporeal membrane oxygenation was very low compared with published international studies (n=9/219, 4%). Postoperative 30-day survival was 98% for 182 infants with CDH who were adequately physiologically stabilised and underwent surgery. CONCLUSION This is the first British Isles population-based study reporting outcome metrics for infants born with CDH. 16% of babies did not survive to undergo surgery. Factors associated with poor outcome included female sex and prenatal diagnosis. Early postoperative survival in those who underwent surgical repair was excellent.
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Affiliation(s)
- Anna-May Long
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK.,Academic Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK
| | - Kathryn J Bunch
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | | | - Paul D Losty
- Academic Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK.,Institute of Child Health, University of Liverpool, Liverpool, UK
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4
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Burgos CM, Frenckner B. Addressing the hidden mortality in CDH: A population-based study. J Pediatr Surg 2017; 52:522-525. [PMID: 27745705 DOI: 10.1016/j.jpedsurg.2016.09.061] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 09/02/2016] [Accepted: 09/04/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Improvements in the clinical management of CDH have led to overall improved reported result from single institutions. However, population-based studies have highlighted a hidden mortality. AIM To explore the incidence in Sweden and to address the hidden mortality for CDH during a 27-year period in a population-based setting. MATERIALS AND METHODS This is a population based cohort study that includes all patients diagnosed with CDH that were registered in the National Patient Register, the Medical Birth Register, the Register of Congenital Malformations and the Register for Causes of Death between 1987 and 2013. The mortality rates were calculated based on the number deaths divided by the number of live born cases. The hidden mortality was defined as the number of CDH cases that were not born (because of TOP or IUFD), cases of neonatal demise during birth or demise the same day of birth in patients who were in peripheral institutions and who never reached tertiary centers. RESULTS In total, 861 CDH patients were born in Sweden between 1987 and 2013, which corresponds to an incidence of 3.0 born CDH per 10,000 live births. When adding the cases of TOP and IUFD, the total incidence of CDH in Sweden was 3.5/10,000 live born. The mortality rate between 1987 and 2013 was 36%: 44% during the first time period 1987-1999 and 27% in the later period 2000-2013. The hidden mortality in the second period was 30%, resulting in a total mortality rate of 45%. CONCLUSION The incidence of CDH during a 27-year period remained unchanged in the population. However, we observed a decrease in the prevalence because of the increasing numbers of TOP. A significant hidden mortality exists, with overall mortality rate of 45% for CDH in this population. LEVEL OF EVIDENCE II (cohort).
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Affiliation(s)
| | - Björn Frenckner
- Department of Pediatric Surgery, Karolinska Institutet, Stockholm, Sweden
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5
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Self-assessed physical health among children with congenital diaphragmatic hernia. Pediatr Surg Int 2016; 32:493-503. [PMID: 26909750 DOI: 10.1007/s00383-016-3879-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2016] [Indexed: 01/23/2023]
Abstract
PURPOSE The aim of this long-term follow-up study was to investigate the current self assessed physical health in a CDH birth cohort at a single center. METHODS Between 1990 and 2009, 195 children born with CDH were treated at Astrid Lindgren Children's Hospital. The primary survival rate was 85 %, and in 2010, 78 % were still alive. Data from medical records were supplemented by a questionnaire consisting of questions about perceived physical function. Patients were divided into groups according to time for intubation and need for extracorporeal membrane oxygenation. RESULTS Children born with CDH reported themselves to be having greater problems with asthma, developmental delay, seizure disorder, poor vision, and scoliosis in comparison with normal Swedish children. They also described a sense of having less strength and becoming breathless more often than healthy friends. Symptoms of gastroesophageal reflux and abdominal pain were also reported. CONCLUSIONS The majority of the children perceived their physical health as being overall good, but there was an increase of reported symptoms correlating with the severity of the malformation.
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Acute Neonatal Respiratory Failure. PEDIATRIC AND NEONATAL MECHANICAL VENTILATION 2015. [PMCID: PMC7193706 DOI: 10.1007/978-3-642-01219-8_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Acute respiratory failure requiring assisted ventilation is one of the most common reasons for admission to the neonatal intensive care unit. Respiratory failure is the inability to maintain either normal delivery of oxygen to the tissues or normal removal of carbon dioxide from the tissues. It occurs when there is an imbalance between the respiratory workload and ventilatory strength and endurance. Definitions are somewhat arbitrary but suggested laboratory criteria for respiratory failure include two or more of the following: PaCO2 > 60 mmHg, PaO2 < 50 mmHg or O2 saturation <80 % with an FiO2 of 1.0 and pH < 7.25 (Wen et al. 2004).
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Abstract
Congenital diaphragmatic hernia (CDH) retains high mortality and morbidity due to lung hypoplasia, pulmonary hypertension and severe co-existent anomalies. This article offers a comprehensive state-of-the-art review for the paediatric surgeon whilst also describing key contributions from the basic sciences in the search to uncover the cause of the birth defect together with efforts to develop new and better therapies for CDH.
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Affiliation(s)
- Paul D Losty
- Department of Paediatric Surgery, Alder Hey Children׳s Hospital NHS Foundation Trust, University of Liverpool, Liverpool, UK.
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8
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Hayakawa M, Ito M, Hattori T, Kanamori Y, Okuyama H, Inamura N, Takahashi S, Nagata K, Taguchi T, Usui N. Effect of hospital volume on the mortality of congenital diaphragmatic hernia in Japan. Pediatr Int 2013; 55:190-6. [PMID: 23360371 DOI: 10.1111/ped.12059] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 11/25/2012] [Accepted: 01/07/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND During the last decade, new supportive modalities and new therapeutic strategies to treat congenital diaphragmatic hernia (CDH) have been introduced. In Japan, the large number of hospitals prevents centralizing infants with CDH in tertiary centers. The aim of this study was to evaluate the correlations between the number of CDH patients, survival rates, and the current strategies employed to treat CDH at the individual hospitals. METHODS Eighty-three hospitals with 674 CDH cases were analyzed using questionnaires. We classified the hospitals into three groups according to the number of CDH patients treated: Group 1 (G1; more than 21 patients), Group 2 (G2; 11-20 patients), and Group 3 (G3; fewer than 10 patients). RESULTS The median number of CDH patients in G1, G2, and G3 were 28, 14, and 4, respectively. The overall survival rate was 74.5%. When only the isolated CDH cases with a prenatal diagnosis were included, the overall survival rate was 79.3%. The survival rate of isolated CDH cases with a prenatal diagnosis was significantly higher in G1 than that in G2 or G3 (87.2% vs 75.2% vs 74.3%; P < 0.001). There were no differences in perinatal therapeutic strategies among the three groups. CONCLUSIONS We concluded that it might therefore be important to centralize infants with CDH, especially those with isolated CDH with a prenatal diagnosis, to tertiary centers in Japan in order to improve the survival rates.
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Affiliation(s)
- Masahiro Hayakawa
- Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan.
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9
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Böhm G, Binnebösel M, Krähling E, Schumpelick V, Steinau G, Stanzel S, Anurov M, Titkova S, Öttinger A, Speer M. Influence of the Elasticity Module of Synthetic and Natural Polymeric Tissue Substitutes on the Mobility of the Diaphragm and Healing Process in a Rabbit Model. J Biomater Appl 2011; 25:771-793. [DOI: 10.1177/0885328209360423] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Mesh implants are frequently used in congenital diaphragmatic hernia. This experimental study aimed to examine the influence of different materials on the diaphragmatic movement over time as well as their mechanical qualities after 4 months. Ultrapro®, Surgisis®, and Proceed ® were implanted onto a diaphragmatic defect in growing rabbits. Diaphragmatic mobility was determined at three time points. At 4 months, defect shrinkage and mechanical properties were measured. The break strength decreased for Ultrapro® and Surgisis®, but did not change relevantly for Proceed®. Ultrapro® (32.46 N/cm) and Proceed® (31.75 N/cm) showed a four-fold higher resistance to tearing than Surgisis® (8.31 N/cm). The elasticity of Ultrapro® showed no significant difference compared to Surgisis® ( p = 0.75). Proceed®, on the other hand, was more than twice as elastic as Ultrapro® or Surgisis ® ( p = 0.015). Ultrapro® had a higher spring rate (6.48 N/mm) compared to Surgisis® (3.82 N/mm) or Proceed ® (5.23 N/mm). Observing the standardized movement rates of the diaphragm for each mesh group over time the only statistical differences were seen for the Proceed® group. On account of its material qualities Ultrapro® was found to be the most suitable mesh material for demanding locations in our model.
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Affiliation(s)
- G. Böhm
- Department of Surgery, University Hospital Technical University of Aachen (RWTH), Germany,
| | - M. Binnebösel
- Department of Surgery, University Hospital Technical University of Aachen (RWTH), Germany
| | - E. Krähling
- Department of Surgery, University Hospital Technical University of Aachen (RWTH), Germany
| | - V. Schumpelick
- Department of Surgery, University Hospital Technical University of Aachen (RWTH), Germany
| | - G. Steinau
- Department of Surgery, University Hospital Technical University of Aachen (RWTH), Germany
| | - S. Stanzel
- Institute for Medical Statistics Technical University of Aachen (RWTH), Germany
| | - M. Anurov
- Joint Surgical Research Institute, University Moskow, Russia
| | - S. Titkova
- Joint Surgical Research Institute, University Moskow, Russia
| | - A. Öttinger
- Joint Surgical Research Institute, University Moskow, Russia
| | - M. Speer
- Department of Chemistry, Technical University of Aachen (RWTH), Germany
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Perinatal management of congenital diaphragmatic hernia: when and how should babies be delivered? Results from the Canadian Pediatric Surgery Network. J Pediatr Surg 2010; 45:2334-9. [PMID: 21129540 DOI: 10.1016/j.jpedsurg.2010.08.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Accepted: 08/12/2010] [Indexed: 12/29/2022]
Abstract
PURPOSE A prenatal diagnosis of congenital diaphragmatic hernia (CDH) enables therapeutic decision making during the intrapartum period. This study seeks to identify the gestational age and delivery mode associated with optimal outcomes. PATIENTS AND METHODS A national data set was used to study CDH babies born between 2005 and 2009. The primary outcome was survival to discharge. Primary and secondary outcomes were analyzed by categorical gestational age (preterm, <37 weeks; early term, 37-38 weeks; late term, >39 weeks) by intended and actual route of delivery and by birth plan conformity, regardless of route. RESULTS Of 214 live born babies (gestational age, 37.6 ± 4.0 weeks; birth weight, 3064 ± 696 g), 143 (66.8%) had a prenatal diagnosis and 174 (81.3%) survived to discharge. Among 143 prenatally diagnosed pregnancies, 122 (85.3%) underwent abdominal delivery (AD) and 21 (14.6%) underwent cesarean delivery (CS). Conformity between intended and actual delivery occurred in 119 (83.2%). Neither categorical gestational age nor delivery route influenced outcome. Although babies delivered by planned CS had a lower mortality than those delivered by planned AD (2/21 and 36/122, respectively; P = .04), this difference was not significant by multivariate analysis. Conformity to any birth plan was associated with a trend toward improved survival. CONCLUSION Our data do not support advocacy of any specific delivery plan or route nor optimal gestational age for prenatally diagnosed CDH.
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CONTEMPORARY NEONATAL INTENSIVE CARE MANAGEMENT IN CONGENITAL DIAPHRAGMATIC HERNIA: DOES THIS OBVIATE THE NEED FOR FETAL THERAPY? ACTA ACUST UNITED AC 2009. [DOI: 10.1017/s096553950999012x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The management of congenital diaphragmatic hernia (CDH) in the newborn infant has changed radically since the first successful outcomes were reported 60 years ago. Then it seemed a surgical problem with a surgical solution – do an operation, remove the intestines and solid viscera from the thoracic cavity, repair the defect and allow the lung to expand. CDH in that era was regarded as the quintessential neonatal surgical emergency. The expectation was that urgent surgery would result in improvement in lung function and oxygenation. That approach persisted up to the 1980s when it was realized that the problem was far more complex and involved both an abnormal pulmonary vascular bed as well as pulmonary hypoplasia. The use of systemically delivered pulmonary vasodilator therapy, principally tolazoline, became a focus of interest in the 1980s with small case reports and case series suggesting improved survival. In the 1990s, based on studies that showed worsening thoracic compliance and gas exchange following surgical repair, deferred surgery and pre-operative stabilization became the standard of care. At the same time extracorporeal membrane oxygenation (ECMO) was increasingly used either as part of pre-operative stabilization or as a rescue therapy after repair. Other centres chose to use high frequency oscillatory ventilation (HFOV). Despite all these innovations the survival in live born infants with CDH did not improve to more than 50% in large series published from high volume centres. However, in the past 10 years there has been an appreciable improvement in survival to the extent that many centres are now reporting survival rates of greater than 80%. Probably the biggest impact on this improvement has been the recognition of the role that ventilation induced lung injury plays in mortality and the need for ECMO rescue. This has ushered in an era of a lung protective or “gentle ventilation” strategy which has been widely adopted as a standard approach. While there have been these radical changes in postnatal management attempts have been made to improve outcome with prenatal interventions, starting with prenatal repair, which was abandoned because of preterm labour. More recently there has been increasing experience in the use of balloon occlusion of the trachea as a prenatal intervention strategy with patients being selected based on prenatal predictors of poor outcome. This approach can only be justified if those predictors can be validated and the outcomes (death or serious long term morbidity) can be shown to be better than those currently achievable, namely 80% survival in high volume CDH centres rather than the 50–60% survival frequently quoted in historical papers.
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Fredly S, Aksnes G, Viddal KO, Lindemann R, Fugelseth D. The outcome in newborns with congenital diaphragmatic hernia in a Norwegian region. Acta Paediatr 2009; 98:107-11. [PMID: 18795908 DOI: 10.1111/j.1651-2227.2008.01024.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM To evaluate the therapeutic strategies used in neonates with congenital diaphragmatic hernia (CDH) during the last 15 years in our department. METHOD A retrospective study of 27 neonates with CDH treated at the Neonatal Intensive Care Unit at Ullevaal University Hospital between 1992 and 2006. Since 1992 we have used delayed operative repair and high-frequency ventilation (HFV). Because surfactant replacement and inhaled nitric oxide (iNO) therapy have been used since 1997, we divided the patients into two groups; group 1 from 1992 to 1996 (9 patients) and group 2 from 1997 to 2006 (18 patients). RESULTS The overall survival was 70%. Group 1 had an exceptionally good outcome, 100% survival versus 56% in the last group. CONCLUSION Pulmonary hypoplasia and pulmonary hypertension are still the most challenging factors in treatment of neonates with CDH, despite novel therapeutic modalities, such as HFV, surfactant and iNO. Delayed surgery in CDH allows pre-operative stabilization. Extracorporeal membrane oxygenation must be considered in the most severe cases.
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Affiliation(s)
- S Fredly
- Department of Paediatrics, Ullevaal University Hospital, Oslo, Norway.
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Gudbjartsson T, Gunnarsdottir A, Topan CZ, Larssons LT, Rosmundsson T, Dagbjartsson A. Congenital diaphragmatic hernia: improved surgical results should influence abortion decision making. Scand J Surg 2008; 97:71-6. [PMID: 18450209 DOI: 10.1177/145749690809700110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS To compare surgical results for congenital diaphragmatic hernia (CDH) in two Scandinavian university hospitals and to evaluate the effects of abortions on the clinical profile of CDH in Iceland. METHODS A retrospective study including all CDH-cases in Iceland 1983-2002 and children referred to Lund University Hospital 1993-2002. Aborted fetuses with CDH from a nation-wide Icelandic abort-registry were also included. RESULTS In Iceland, 19 out of 23 children with CDH were diagnosed < 24 hours from delivery, one with associated anomalies. Eight fetuses were diagnosed prenatally and seven of them aborted, three having isolated CDH at autopsy. In Iceland, 15 of 18 children operated on survived surgery (83% operative survival). In Lund 28 children were treated with surgery, 23 of them diagnosed early after birth or prenatally. Four children did not survive surgery (86% operative survival) and 9 (31%) had associated anomalies. All the discharged children treated in Iceland and Lund are alive, 3-22 years postoperatively. CONCLUSION CDH is a serious anomaly where morbidity and mortality is directly related to other associated anomalies and pulmonary hypoplasia. However, majority of CDH patients do not have other associated anomalies. In spite of improved surgical results (operative mortality < 20%), a large proportion of pregnancies complicated with CDH are terminated. We conclude that the improved survival rate after corrective surgery must be emphasized when giving information to parents regarding abortion of fetuses with a prenatally diagnosed CDH.
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Affiliation(s)
- T Gudbjartsson
- Department of Cardiothoracic surgery, Landspitali University Hospital, Reykjavik, Iceland.
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Büsing KA, Kilian AK, Schaible T, Debus A, Weiss C, Neff KW. Reliability and Validity of MR Image Lung Volume Measurement in Fetuses with Congenital Diaphragmatic Hernia and in Vitro Lung Models. Radiology 2008; 246:553-61. [DOI: 10.1148/radiol.2462062166] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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15
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Prediction of Mortality and Need for Neonatal Extracorporeal Membrane Oxygenation in Fetuses with Congenital Diaphragmatic Hernia: Logistic Regression Analysis Based on MRI Fetal Lung Volume Measurements. AJR Am J Roentgenol 2007; 189:1307-11. [DOI: 10.2214/ajr.07.2434] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Evaluation of congenital diaphragmatic hernia in a tertiary health center of a developing country: management and survival. Hernia 2007; 12:189-92. [PMID: 18004498 DOI: 10.1007/s10029-007-0309-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2007] [Accepted: 10/26/2007] [Indexed: 02/08/2023]
Abstract
AIM The purpose was to evaluate the diagnosis and efficacy of management of congenital diaphragmatic hernia (CDH) in a tertiary health center of a developing country. METHODS Forty-six children aged from 1 day to 7 years were studied. Parameters studied were age, sex, clinical features, and management. RESULTS Fifty-six percent of patients presented in the neonatal period; however, none of them presented on the first day of life. The majority (91.3%) of patients had left-sided CDH. Respiratory distress was the most common clinical feature observed (91.3%). Chest X-ray confirmed the diagnosis in 82.6% of patients, and contrast study was needed in the remaining 17.4%. The survival rate was 87%. It was better in patients presenting late than those presenting in the early neonatal period. Stabilization in the preoperative period improved survival. Not using a chest tube had no adverse effect on survival. CONCLUSION The relatively increased survival rate of CDH in a tertiary health center of a developing country is attributed to delayed arrival to the center. Respiratory infections compound the survival. More studies are needed before it can be safely said that not using a chest tube has no adverse outcome. Late presentation has been associated with varied manifestations, hence proper clinical evaluation, a high index of suspicion and adequate management, which includes imaging and surgery after stabilization, gives excellent results.
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Frenckner BP, Lally PA, Hintz SR, Lally KP. Prenatal diagnosis of congenital diaphragmatic hernia: how should the babies be delivered? J Pediatr Surg 2007; 42:1533-8. [PMID: 17848244 DOI: 10.1016/j.jpedsurg.2007.04.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
UNLABELLED Congenital diaphragmatic hernia (CDH) in many patients is diagnosed in utero. In these patients, the delivery can be planned as an elective cesarean, induced vaginal, or spontaneous vaginal delivery. The optimal method has yet to be determined. The aim of this study was to compare the outcome of patients with CDH delivered by different methods. METHODS The Congenital Diaphragmatic Hernia Study Group was formed in 1995 to compile data on liveborn babies with CDH. Beginning in 2001, data concerning delivery were collected. By October 2005, delivery data were available on 1039 term and near-term infants without cardiac malformations. Five hundred forty-eight had a prenatal diagnosis and complete data on delivery (194 delivered by elective cesarean delivery, 121 by induced vaginal delivery, and 233 by spontaneous vaginal delivery). Patients delivered by a nonelective cesarean delivery were assigned to the delivery group for which they were originally planned. RESULTS The overall survival among the 548 patients was 69%. It was highest in patients delivered by cesarean delivery (71%) followed by those delivered through induced vaginal delivery (70%) and spontaneous vaginal delivery (67%). The difference was not statistically significant. Fifty-three percent of all patients survived without extracorporeal membrane oxygenation (ECMO). This was significantly higher after cesarean delivery (60%) than after induced vaginal delivery (49%) or spontaneous vaginal delivery (49%) (P < .05). At 30 days of age, 45% of the patients delivered by cesarean delivery had survived and were on room air. This was slightly lower after induced vaginal delivery (37%) or after spontaneous vaginal delivery (37%), although not statistically significant. CONCLUSION Cesarean delivery was associated with a slightly better outcome in terms of a significantly higher survival without the use of extracorporeal membrane oxygenation, although there was no significant difference in total survival. Because this study was not randomized, it is not possible to determine if the elective cesarean delivery was the cause for the better outcome or if centers favoring elective cesarean delivery by protocol are more skillful in the management of patients with CDH. Mode of delivery for term and near-term infants with CDH deserves further prospective study.
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Affiliation(s)
- Björn P Frenckner
- Department of Pediatric Surgery, Astrid Lindgren Children's Hospital, Q3:03, SE-171-76, Stockholm, Sweden.
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Rygl M, Pycha K, Stranak Z, Melichar J, Krofta L, Tomasek L, Snajdauf J. Congenital diaphragmatic hernia: onset of respiratory distress and size of the defect: analysis of the outcome in 104 neonates. Pediatr Surg Int 2007; 23:27-31. [PMID: 17021736 DOI: 10.1007/s00383-006-1788-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2006] [Indexed: 10/24/2022]
Abstract
The purpose of this study was to evaluate the outcome in neonates with congenital diaphragmatic hernia (CDH) either presenting within the first 24 h of life or diagnosed prenatally. The study was particularly focused on the time of onset of respiratory distress and on the use of the Gore-Tex (GT) patch for diaphragmatic reconstruction. Records of 104 neonates with CDH were retrospectively reviewed. The data were analyzed by ANOVA, Kruskal-Wallis test or chi (2) test as appropriate. The result showed that the overall survival rate was 73.1% (76/104). Survival of operated neonates was 91.6% (76/83). Postnatally diagnosed neonates with the onset of respiratory distress within the first minute of life survived in 67%, with the onset between 2 and 10 min survived in 89%, whilst neonates with the onset of respiratory distress after l0 min survived in 100% (P = 0.007). Birth weight, gestational age, time of onset of respiratory distress and Apgar score significantly differed between survivors and nonsurvivors. Primary closure of the diaphragmatic defect was performed in 62 patients while the GT patch was used in 21 patients. The survival of patients with a large defect treated with a GT patch was lower (76.2 vs. 96.8%, P = 0.003). There was only one case of recurrence in our series with the GT patch. Survival depends on the time of onset of respiratory distress and size of the defect, both of which correlate with the degree of pulmonary hypoplasia. The term high-risk CDH is appropriate only for children with respiratory distress within the first 10 min of life and those diagnosed prenatally. The GT patch is a suitable material for the diaphragmatic reconstruction; we suppose that the recurrence is caused by incorrect attachment of the patch to the thoracic wall.
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Affiliation(s)
- Michal Rygl
- Department of Pediatric Surgery, 2nd Faculty of Medicine and Teaching Hospital in Motol, Charles University in Prague, V úvalu 84, Prague 5, 15000 Czech Republic.
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Abstract
Congenital diaphragmatic hernia (CDH) retains high mortality due to lung hypoplasia and pulmonary hypertension. Efforts to improve survival and outcome have included fetal intervention, delivery at specialist centres, elective operation after stabilisation of labile physiology and minimising barotrauma. Permissive hypercapnea ('gentle ventilation') represents a significant advance in therapy gaining wider acceptance in centres worldwide. Human genetic studies are underway to identify candidate genes for the birth defect. Progress in the basic sciences may uncover critical aspects of developmental biology fundamental to CDH. Clinical trends in perinatal management of CDH are highlighted, which underpin the challenges of this lethal human anomaly.
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Affiliation(s)
- Andrea F Conforti
- Department of Paediatric Surgery, The Royal Liverpool Children's Hospital (Alder Hey) Division of Child Health, University of Liverpool, United Kingdom
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Smith NP, Jesudason EC, Featherstone NC, Corbett HJ, Losty PD. Recent advances in congenital diaphragmatic hernia. Arch Dis Child 2005; 90:426-8. [PMID: 15781941 PMCID: PMC1720369 DOI: 10.1136/adc.2003.045765] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a common birth defect which continues to challenge paediatric surgeons and intensivists. Affecting approximately 1:2500 births, a baby with CDH is born every 24-36 hours in the UK.
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Affiliation(s)
- N P Smith
- Department of Paediatric Surgery, Royal Liverpool Children's Hospital (Alder Hey) and University of Liverpool, UK
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Abstract
The mortality rate associated with congenital diaphragmatic hernia (CDH) varies widely between centers and remains relatively high despite widespread use of new therapeutic modalities. Many of these have been implemented without properly controlled studies. Over the past 10 to 15 years, only 9 randomized trials enrolling a total of approximately 250 infants with CDH have been published. The limited evidence available suggests that better outcomes are observed by delivering infants with CDH at experienced centers, by delaying surgical repair until hemodynamic and respiratory stability is achieved, and by the judicious utilization of nonaggressive mechanical ventilation and permissive hypercapnea. Other therapeutic modalities, such as high frequency oscillatory ventilation, inhaled nitric oxide, and ECMO, may provide additional advantages for selected infants. There is a dire need to establish networks of centers that manage enough infants with CDH, to conduct appropriately sized randomized trials that can answer some of the critical questions about the management and long-term outcome of these infants.
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Affiliation(s)
- Fernando R Moya
- Department of Pediatrics, Coastal Area Health Education Center, Wilmington, NC 28402-9025, USA.
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