Surgical intervention for congenital diaphragmatic hernia: open versus thoracoscopic surgery

Open Versus Thoracoscopic Repair of Congenital Diaphragmatic Hernia: A 19-Year Review in a Tertiary Referral Centre in Hong Kong

BACKGROUND

Congenital diaphragmatic hernia (CDH) is a developmental defect that causes herniation of abdominal organs into the thoracic cavity with significant morbidity. Thoracoscopic repair of CDH is an increasingly prevalent yet controversial surgical technique, with limited long-term outcome data in the Asian region. The aim of this study was to compare open laparotomy versus thoracoscopic repair of CDH in paediatric patients in a major tertiary referral centre in Asia.

METHODS

We performed a retrospective analysis of neonatal patients who had open laparotomy or thoracoscopic repair for CDH in our institution between July 2002 and November 2021. Demographic data, perioperative parameters, recurrence rates and surgical complications were analysed.

RESULTS

64 patients were identified, with 54 left sided CDH cases. 33 patients had a prenatal diagnosis and 35 patients received minimally invasive surgical repair. There was no significant difference between open and minimally invasive repair in recurrence rate (13 % vs 17 %, P = 0.713), time to recurrence (184 ± 449 days vs 81 ± 383 days, P = 0.502), or median length of ICU stay (11 ± 14 days vs 13 ± 15 days, P = 0.343), respectively. Gastrointestinal complications occurred in 7 % of neonates in the open group and none in the thoracoscopic group. Median follow-up time was 9.5 years.

CONCLUSIONS

This study is a large congenital diaphragmatic hernia series in Asia, with long term follow-up demonstrating no significant difference in recurrence rate, time to recurrence or median length of ICU stay between open and minimally invasive repair, suggesting thoracoscopic approach is a non-inferior surgical option with avoidance of gastrointestinal complications compared to open repair.

LEVEL OF EVIDENCE: 3

TYPE OF STUDY

Retrospective Cohort Study.

A Systematic Review Comparing the Surgical Outcomes of Open Versus Minimally Invasive Surgery for Congenital Diaphragmatic Hernia Repair

Introduction: Surgical intervention is the definitive management for congenital diaphragmatic hernia (CDH) repair from 1902. Since this time, two mainstay approaches have been used, open and minimally invasive surgical (MIS) repair. An invasive laparotomy is used in around 91% of cases. So, this systematic review of the published literature will compare the surgical outcomes of open (CDH) repair vs MIS for CDH repair and will determine which approach is superior. Material and Methods: Our literature search across MEDLINE and EMBASE included articles from 2004 to 2022, incorporating pediatric CDH repairs, human subjects only, and English language articles. Primary outcomes analyzed were rate of recurrence, length of surgery, length of hospital stay, use of diaphragmatic patch, mortality, postoperative chylothorax, and extracorporeal membrane oxygenation (ECMO) use postoperatively. Results: After application of exclusion criteria, 32 articles were reviewed. Comparison of MIS repair versus open repair had a rate of recurrence at 8.6% versus 1.6% (P < .00001). Length of hospital stay was 19.6 days versus 33.6 days (P = .0012), mortality rate at 4.6% versus 16.6% (P < .0001), patch repair required in 19.6% versus 55.4% (P = < .00001), and postoperative ECMO use of 3.7% versus 12.3% (P < .00001), respectively. Conclusion: MIS repair is associated with decreased length of hospital stay, reduced mortality rate, and postoperative ECMO usage. Hernia recurrence is still high among MIS repair groups compared to the open repair groups. Large, multicentered randomized control trials are recommended for further analysis to decipher the true superior surgical intervention.

Anesthesia for thoracic surgery in infants and children

The management of infants and children presenting for thoracic surgery poses a variety of challenges for anesthesiologists. A thorough understanding of the implications of developmental changes in cardiopulmonary anatomy and physiology, associated comorbid conditions, and the proposed surgical intervention is essential in order to provide safe and effective clinical care. This narrative review discusses the perioperative anesthetic management of pediatric patients undergoing noncardiac thoracic surgery, beginning with the preoperative assessment. The considerations for the implementation and management of one-lung ventilation (OLV) will be reviewed, and as will the anesthetic implications of different surgical procedures including bronchoscopy, mediastinoscopy, thoracotomy, and thoracoscopy. We will also discuss pediatric-specific disease processes presenting in neonates, infants, and children, with an emphasis on those with unique impact on anesthetic management.

Thoracoscopic repair of congenital diaphragmatic hernia in neonates: findings of a multicenter study in Japan

PURPOSE

We compared the efficacy of thoracoscopic repair (TR) with that of open repair (OR) for neonatal congenital diaphragmatic hernia (CDH).

METHODS

The subjects of this multicenter retrospective cohort study were 524 infants with left-sided isolated CDH, diagnosed prenatally, and treated at one of 15 participating hospitals in Japan between 2006 and 2018. The outcomes of infants who underwent TR and those who underwent OR were compared, applying propensity score matching.

RESULTS

During the study period, 57 infants underwent TR and 467 underwent OR. Ten of the infants who underwent TR required conversion to OR for technical difficulties and these patients were excluded from the analysis. The survival rate at 180 days was similar in both groups (TR 98%; OR 93%). Recurrence developed after TR in 3 patients and after OR in 15 patients (TR 7%, OR 3%, p = 0.40). The propensity score was calculated using the following factors related to relevance of the surgical procedure: prematurity (p = 0.1), liver up (p < 0.01), stomach position (p < 0.01), and RL shunt (p = 0.045). After propensity score matching, the multivariate analysis adjusted for severity classification and age at surgical treatment revealed a significantly shorter hospital stay (odds ratio 0.50) and a lower incidence of chronic lung disease (odds ratio 0.39) in the TR group than in the OR group.

CONCLUSIONS

TR can be performed safely for selected CDH neonates with potentially better outcomes than OR.

Clinical guidelines for the treatment of congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a birth defect of the diaphragm in which abdominal organs herniate through the defect into the thoracic cavity. The main pathophysiology is respiratory distress and persistent pulmonary hypertension because of pulmonary hypoplasia caused by compression of the elevated organs. Recent progress in prenatal diagnosis and postnatal care has led to an increase in the survival rate of patients with CDH. However, some survivors experience mid- and long-term disabilities and complications requiring treatment and follow-up. In recent years, the establishment of clinical practice guidelines has been promoted in various medical fields to offer optimal medical care, with the goal of improvement of the disease' outcomes, thereby reducing medical costs, etc. Thus, to provide adequate medical care through standardization of treatment and elimination of disparities in clinical management, and to improve the survival rate and mid- and long-term prognosis of patients with CDH, we present here the clinical practice guidelines for postnatal management of CDH. These are based on the principles of evidence-based medicine using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. The recommendations are based on evidence and were determined after considering the balance among benefits and harm, patient and society preferences, and medical resources available for postnatal CDH treatment.

Video-Assisted Thoracoscopic or Conventional Thoracic Surgery in Infants and Children: Current Evidence

INTRODUCTION

 The pros and cons of video-assisted thoracoscopic versus conventional thoracic surgery in infants and children are still under debate. We assessed reported advantages and disadvantages of video-assisted thoracoscopy in pediatric surgical procedures, as well as the evidence level of the available data.

MATERIALS AND METHODS

 A systematic literature search was performed to identify manuscripts comparing video-assisted thoracoscopic and the respective conventional thoracic approach in classic operative indications of pediatric surgery. Outcome parameters were analyzed and graded for level of evidence (according to the Oxford Centre of Evidence-Based Medicine).

RESULTS

 A total of 48 comparative studies reporting on 12,709 patients, 11 meta-analyses, and one pilot randomized controlled trial including 20 patients were identified. More than 15 different types of advantages for video-assisted thoracoscopic surgery were described, mostly with a level of evidence 3b or 3a. Most frequently video-assisted thoracoscopic surgery was associated with shorter hospital stay, shorter postoperative ventilation, and shorter time to chest drain removal. Mortality rate and severe complications did not differ between thoracoscopic and conventional thoracic pediatric surgery, except for congenital diaphragmatic hernia repair with a lower mortality and higher recurrence rate after thoracoscopic repair. The most frequently reported disadvantage for video-assisted thoracoscopic surgery was longer operative time.

CONCLUSION

 The available data point toward improved recovery in pediatric video-assisted thoracoscopic surgery despite longer operative times. Further randomized controlled trials are needed to justify the widespread use of video assisted thoracoscopy in pediatric surgery.

Postnatal Ultrasound to Determine the Surgical Strategy for Congenital Diaphragmatic Hernia

OBJECTIVES

To compare defect sizes in congenital diaphragmatic hernia (CDH) measured by postnatal ultrasound (US) between neonates who underwent thoracoscopic surgery and neonates who underwent open surgery and between neonates who underwent primary repair and those who underwent patch repair; additionally, to compare the accuracy of US diagnosis with that of surgical diagnosis for the location of the diaphragmatic hernia and the hernial contents.

METHODS

We included 8 neonates who underwent preoperative US evaluations of CDH. We compared anterior-to-posterior diaphragm defect sizes between thoracoscopic and open surgery approaches and between primary and patch repair by using the Mann-Whitney U test. The diaphragm was divided into 3 segments: anterior, lateral, and posterior. We evaluated the location of the diaphragmatic hernia and the hernial contents.

RESULTS

Four neonates who underwent open surgery had larger diaphragmatic hernias than those who underwent thoracoscopic surgery (mean ± SD, 30.5 ± 5.6 versus 16.3 ± 3.3 mm; P = .030). They were also larger in neonates who underwent patch repair than in those who underwent primary repair (33.0 ± 3.0 versus 17.6 ± 4.2 mm; P = .037). Detection of anterior and lateral diaphragm segments was consistent between US and surgical findings. Three of 4 neonates who underwent open surgery and all 3 neonates who underwent patch repair did not show the lateral segment. The hernial contents were also consistent between US and surgical findings.

CONCLUSIONS

Postnatal US examinations of neonates with CDH could provide surgeons with useful information to determine the surgical approach and repair method. However, since our study cohort was small, further studies are needed with a larger number of neonates with CDH.

Usefulness of Ultrasound in Evaluating the Diaphragm in Neonates and Infants With Congenital Diaphragmatic Hernias

This report describes the evaluations of 2 patients with congenital diaphragmatic hernias using ultrasound (US). Identifying the size of the diaphragmatic defect is important when determining the type of surgical repair required. In case 1, the US evaluation of a Bochdalek hernia showed the rim of the anterolateral diaphragm; therefore, thoracoscopic primary repair was performed. In case 2, (Morgagni-Larrey hernia), US revealed the left side of a retrosternal diaphragmatic hernia sac; therefore, thoracoscopic repair from the left thorax was performed. Ultrasound was useful for detecting the location and defect size of the diaphragmatic hernia and determining optimal surgical management.

Risk Factors for Surgical Site Infection in Neonates: A Systematic Review of the Literature and Meta-Analysis

Purpose: Surgical site infections (SSI) contribute to postoperative morbidity and mortality in children. Our aim was to evaluate the prevalence and identify risk factors for SSI in neonates. Methods: Using a defined strategy, three investigators searched articles on neonatal SSI published since 2000. Studies on neonates and/or patients admitted to neonatal intensive care unit following cervical/thoracic/abdominal surgery were included. Risk factors were identified from comparative studies. Meta-analysis was conducted according to PRISMA guidelines using RevMan 5.3. Data are (mean ± SD) prevalence. Results: Systematic review-of 885 abstracts screened, 48 studies (27,760 neonates) were included. The incidence of SSI was 5.6% (1,564 patients). SSI was more frequent in males (61.8%), premature babies (77.4%), and following gastrointestinal surgery (95.4%). Meta-analysis-10 comparative studies (16,442 neonates; 946 SSI 5.7%) showed that predictive factors for SSI development were gestational age, birth weight, age at surgery, length of surgical procedure, number of procedure per patient, length of preoperative hospital stay, and preoperative sepsis. Conversely, preoperative antibiotic use was not significantly associated with development of SSI. Conclusions: Younger neonates and those undergoing abdominal procedures are at higher risk for SSI. Given the lack of evidence-based literature, prospective studies may help determine the risk factors for SSI in neonates.

Thoracoscopic Versus Open Congenital Diaphragmatic Hernia Repair: Single Tertiary Center Review

BACKGROUND

Congenital diaphragmatic hernia (CDH) can be repaired open or through thoracoscopy. Thoracoscopic CDH repair could improve cosmesis and avoid the complications of laparotomy, but may have higher recurrence rates. The purpose of this study was to examine the outcomes of thoracoscopic versus open CDH repair, with regard to recurrence, perioperative parameters, and postoperative complications.

METHODS

We performed a retrospective review of open versus thoracoscopic CDH repairs over an 8.5-year period. The primary outcome was hernia recurrence. Secondary outcomes included intraoperative partial pressure of carbon dioxide (pCO₂) levels, length of stay, and postoperative complications. All statistical analyses were performed using standard statistical methods.

RESULTS

A total of 54 infants underwent CDH repair during the study period, of whom 25 underwent successful thoracoscopic repair. Two patients who had undergone open repair developed recurrent diaphragmatic hernias (recurrence rate 3.7%). Operative time and intraoperative pCO₂ levels did not differ between groups. Length of stay was shorter in the thoracoscopic cohort. Four patients in the open cohort developed ventral hernias and five developed bowel obstructions during follow-up. No long-term complications were identified in the thoracoscopic cohort. The median follow-up was 27 months.

CONCLUSIONS

In our experience, thoracoscopic CDH repair was performed safely and with similar outcomes compared to open repair. In addition to improved cosmesis, thoracoscopic repair may avoid some of the long-term complications of laparotomy. In our series, none of the thoracoscopic CDH repairs recurred. We conclude that thoracoscopic CDH repair is a safe and appropriate technique for select neonates.

Intraoperative ventilation during thoracoscopic repair of neonatal congenital diaphragmatic hernia

PURPOSE

To evaluate the optimal ventilation mode during thoracoscopic repair (TR) of neonatal congenital diaphragmatic hernia (CDH), we compared high-frequency oscillatory ventilation (HFOV) with conventional mechanical ventilation (CMV).

METHODS

Twenty-three neonatal CDH cases who underwent TR without intraoperative inhalation of nitric oxide at our institution between 2007 and 2016 were reviewed. Patients were initially ventilated with HFOV, which was converted to CMV if the HFOV settings were decreased to FiO₂ <0.4, stroke volume <4 mL/kg and mean airway pressure <12 cmH₂O. Arterial blood gases in the perioperative period were compared between HFOV and CMV.

RESULTS

Seventeen patients were ventilated with HFOV (group I), and six patients were ventilated with CMV (group II). Preoperative PaCO₂ was significantly higher and pH was significantly lower in group I compared with group II. In both groups I and II, intraoperative PaCO₂ increased significantly and pH decreased significantly compared with preoperation. Although intraoperative PaCO₂ and pH were not different between the groups, group II showed greater worsening of intraoperative PaCO₂ and pH as compared to their respective preoperative values.

CONCLUSIONS

HFOV seems to prevent deterioration of hypercapnia and acidosis to a greater extent than CMV during TR in neonatal cases of CDH, although patients can also be ventilated with CMV.

Congenital diaphragmatic hernia in neonates: factors related to failure of thoracoscopic repair

PURPOSE

To evaluate factors related to conversion to open repair (OR) during thoracoscopic repair (TR) in congenital diaphragmatic hernia (CDH).

METHODS

CDH subjects who were diagnosed prenatally or within 6 h of birth and underwent TR at our institution from 2007 to 2015 were reviewed. Two groups were defined: Group A, subjects who tolerated TR; and Group B, subjects who required conversion to OR.

RESULTS

Twenty-nine subjects (Group A, 20; Group B, 9) underwent TR. Patients' demographics were not significantly different between the two groups. In Group A, pre-operative arterial blood gas analysis showed mean PaCO2 37.4 mmHg, mean pH 7.45, and mean PaO2 201.6 mmHg, which were not significantly different from those of Group B (PaCO2 40.6 mmHg, pH 7.43, and PaO2 251.1 mmHg). Two Group B cases required conversion due to cardiopulmonary instability. The remaining seven cases were converted for technical reasons (large defect in two, anterior location of the defect in two, bleeding from short gastric vessels or spleen in two, and insufficient operative view in one).

CONCLUSIONS

TR can be performed safely in selected cases of CDH. CDH with a large defect and/or an unusual location of the defect remains a challenge for pediatric surgeons.

Safety of surgery for neonatal congenital diaphragmatic hernia as reflected by arterial blood gas monitoring: thoracoscopic versus open repair

PURPOSE

We monitored arterial blood gases during thoracoscopic (TR) and open repair (OR) of congenital diaphragmatic hernia (CDH) to assess the safety of intraoperative hypercapnia and acidosis.

METHODS

We reviewed 30 neonatal CDH cases (OR = 10, TR = 20) diagnosed prenatally or within 6 h of birth at out institution from 2002 to 2014 not requiring inhaled nitric oxide (NO) intraoperatively. OR, routine until 2006 was replaced by TR in 2007. All subjects were managed identically.

RESULTS

Five TR cases requiring conversion to OR were excluded. Prenatal diagnosis, gestational age at birth, gender, birth weight, and side of CDH were similar. Preoperative PaCO2 and pH were not significantly different. However, while intraoperative increase in mean PaCO2 (38.8-62.8 mmHg; p < 0.01) and decrease in mean pH (7.44-7.25; p < 0.01) were significant in TR, intraoperative PaCO2 was <70 mmHg in 12/15 cases and intraoperative pH was >7.20 in 11/15 cases. Both PaCO2 and pH reverted to normal on completion of surgery; pre- and postoperative results were comparable. There were no postoperative complications.

CONCLUSIONS

It would appear that neonatal cases of CDH not requiring NO can tolerate TR, despite transient reversible deterioration in acid/base balance, indicating that TR is safe for the treatment of selected cases of CDH.

Surgical approaches for neonatal congenital diaphragmatic hernia: a systematic review and meta-analysis

PURPOSE

The optimal surgical approach for neonatal congenital diaphragmatic hernia (CDH) remains unclear. We conducted a systematic review and meta-analysis of the effectiveness of endoscopic surgery (ES) for neonatal CDH.

METHODS

A systematic literature search was conducted using MEDLINE and the Cochrane Library. Studies that compared surgical approaches for neonatal CDH were selected. Mortality and recurrence of herniation were analyzed as primary endpoints. Each study was evaluated following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

Eight observational studies comparing ES and open surgery (OS) met the criteria. As compared with the OS group, the ES group showed both a significantly lower mortality rate [risk ratio (RR) 0.18, 95 % confidence interval (CI) 0.09-0.38, p < 0.0001] and a significantly higher recurrence rate (RR 3.10, 95 % CI 1.95-4.88, p < 0.00001). However, serious selection bias was seen in seven of the eight studies-because the indication of ES had been determined intentionally, the ES groups may have included less severe cases.

CONCLUSION

Although the evidence was insufficient, ES was clearly associated with more recurrence than was OS. Therefore, ES should not be the routine treatment for every neonate. It is crucially important to select suitable cases for ES.

Minimally invasive surgery for diaphragmatic diseases in neonates and infants

Owing to recent advances in minimally invasive surgery (MIS), laparoscopic and thoracoscopic surgery have been gradually introduced for use in neonates and infants. This review focuses on two popular MIS procedures for diaphragmatic diseases in neonates and infants: congenital diaphragmatic hernia (CHD) repair and plication for diaphragmatic eventration. While several advantages of MIS are proposed for CDH repair in neonates, there are also some concerns, namely intraoperative hypercapnia and acidosis and a higher recurrence rate than open techniques. Thus, neonates with severe CDH, along with an unstable circulatory and respiratory status, may be unsuitable for MIS repair, and the use of selection criteria is, therefore, important in these patients. It is generally believed that a learning curve is associated with the higher recurrence rate. Contrary to CDH repair, no major disadvantages associated with the use of MIS for diaphragmatic eventration have been reported in the literature, other than technical difficulty. Thus, if technically feasible, all pediatric patients with diaphragmatic eventration requiring surgical treatment are potential candidates for MIS. Due to a shortage of studies on this procedure, the potential advantages of MIS compared to open techniques for diaphragmatic eventration, such as early recovery and more rapid extubation, need to be confirmed by further studies.

The great debate: open or thoracoscopic repair for oesophageal atresia or diaphragmatic hernia

Controversy exists over the best method and technique of repair of oesophageal atresia and diaphragmatic hernia. Open surgical repairs have a long established history of over 60 years of experience. Set against this has been a series of successful thoracoscopic repairs of both congenital anomalies reported over the past decade. This review was based upon a four-handed debate on the merits and weaknesses of the two contrasting surgical philosophies and reviews existing literature, techniques, complications, and importantly outcome and results.

Thoracoscopic repair of congenital diaphragmatic hernia: two centres' experience with 60 patients

INTRODUCTION

Congenital diaphragmatic hernia is a potentially life-threatening neonatal condition which required surgical intervention. With the advances in endosurgical instruments and techniques, thoracoscopic approach is gaining popularity as a standard procedure in the treatment of this condition. In this study, we reviewed our two centres' experience with thoracoscopic repair of congenital diaphragmatic hernia in recent years.

METHODS

All patients who underwent thoracoscopic repair of congenital diaphragmatic hernia between 2010 and 2013 at the two tertiary referral centres were identified. Medical records were retrospectively reviewed. Data including patients' demographics, peri-operative outcomes, length of hospitalisation and post-operative complications were extracted and analysed.

RESULTS

60 patients were identified over the study period, with 46 males and 14 females. 48 patients received operation within the first 7 days of life. There were seven patients with delayed presentation and were operated after 1 month old. The average body weight was 3.03 kg. Left-sided hernia was more prevalent (n = 50). The mean operative time was 88.5 min (range 31-194 min). No conversion to open thoracotomy or laparotomy was required in any of the patients. All patients except one were intubated and paralysed in neonatal intensive care units for at least 3 days after operation. Average hospital stay was 14.6 days. There was no mortality in this series. There were five recurrences, one being the patient without post-operative paralysis, and the others with deficient posterior muscle rim. No musculoskeletal deformity was noted on follow-up examination.

CONCLUSION

Thoracoscopic repair of congenital diaphragmatic hernia can be performed safely in specialised centres. The post-operative recovery and cosmesis are excellent. Diaphragmatic hernia with large defect remains a challenge for surgeons.