Congenital diaphragmatic hernia: an evaluation of risk factors for failure of thoracoscopic primary repair in neonates

Reasons for conversions in thoracoscopic repairs of neonatal congenital diaphragmatic hernias: a systematic review

PURPOSE

This systematic review focused on reasons for conversions in neonates undergoing thoracoscopic congenital diaphragmatic hernia (CDH) repair.

METHODS

Systematic search of Medline/Pubmed and Embase was performed for English, Spanish and Portuguese reports, according to PRISMA guidelines.

RESULTS

Of the 153 articles identified (2003-2023), 28 met the inclusion criteria and offered 698 neonates for analysis. Mean birth weight and gestational age were 3109 g and 38.3 weeks, respectively, and neonates were operated at a mean age of 6.12 days. There were 278 males (61.50%; 278/452) and 174 females (38.50%; 174/452). The reasons for the 137 conversions (19.63%) were: (a) defect size (n = 22), (b) need for patch (n = 21); (c) difficulty in reducing organs (n = 14), (d) ventilation issues (n = 10), (e) bleeding, organ injury, cardiovascular instability (n = 3 each), (f) bowel ischemia and defect position (n = 2 each), hepatopulmonary fusion (n = 1), and (g) reason was not specified for n = 56 neonates (40.8%). The repair was primary in 322 neonates (63.1%; 322/510) and patch was used in 188 neonates (36.86%; 188/510). There were 80 recurrences (12.16%; 80/658) and 14 deaths (2.48%; 14/565). Mean LOS and follow-up were 20.17 days and 19.28 months, respectively.

CONCLUSIONS

Neonatal thoracoscopic repair for CDH is associated with conversion in 20% of cases. Based on available data, defect size and patch repairs have been identified as the predominant reasons, followed by technical difficulties to reduce the herniated organs and ventilation related issues. However, data specifically relating to conversion is poorly documented in a high number of reports (40%). Accurate data reporting in future will be important to better estimate and quantify reasons for conversions in neonatal thoracoscopy for CDH.

Diagnosis and management of congenital diaphragmatic hernia: a 2023 update from the Canadian Congenital Diaphragmatic Hernia Collaborative

OBJECTIVE

The Canadian Congenital Diaphragmatic Hernia (CDH) Collaborative sought to make its existing clinical practice guideline, published in 2018, into a 'living document'.

DESIGN AND MAIN OUTCOME MEASURES

Critical appraisal of CDH literature adhering to Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Evidence accumulated between 1 January 2017 and 30 August 2022 was analysed to inform changes to existing or the development of new CDH care recommendations. Strength of consensus was also determined using a modified Delphi process among national experts in the field.

RESULTS

Of the 3868 articles retrieved in our search that covered the 15 areas of CDH care, 459 underwent full-text review. Ultimately, 103 articles were used to inform 20 changes to existing recommendations, which included aspects related to prenatal diagnosis, echocardiographic evaluation, pulmonary hypertension management, surgical readiness criteria, the type of surgical repair and long-term health surveillance. Fifteen new CDH care recommendations were also created using this evidence, with most related to the management of pain and the provision of analgesia and neuromuscular blockade for patients with CDH.

CONCLUSIONS

The 2023 Canadian CDH Collaborative's clinical practice guideline update provides a management framework for infants and children with CDH based on the best available evidence and expert consensus.

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.

Tension-free thoracoscopic repair of congenital diaphragmatic hernia combined with a percutaneous extracorporeal closure technique: how to do it

PURPOSE

Thoracoscopic repair (TR) of congenital diaphragmatic hernia (CDH) is associated with a higher recurrence rate than the conventional open method. We evaluated the effectiveness of our strategy for quality improvement, named "tension-free TR of CDH".

METHODS

The subjects of this retrospective analysis were 11 consecutive patients with CDH who underwent TR at our hospital between 2017 and 2021. Tension-free TR of CDH included the proactive use of an oversized patch for dome-shaped reconstruction and gapless suturing. We developed a percutaneous extracorporeal closure technique for secure suturing using a commercially available needle.

RESULTS

Patch repair was performed in 8 (73%) patients and none required conversion to open surgery because of technical difficulties. Recurrence developed in one patient (9%), who underwent successful reoperation via TR. All patients had an uneventful postoperative course.

CONCLUSION

Tension-free TR combined with extracorporeal closure could reduce the difficulty of suturing and the risk of recurrence of CDH.

A new simplified technique in thoracoscopic repair of congenital diaphragmatic hernia

BACKGROUND

This study aims to describe a new method of repairing the diaphragm with a venipuncture indwelling needle under thoracoscopy to treat congenital diaphragmatic hernia (CDH).

METHODS

We retrospectively analysed the clinical data of 43 children with CDH who underwent CDH repair with new technology in our hospital. In this study, we used the venipuncture indwelling needle suture method to treat children with CDH.

RESULTS

In this study, 3 children were converted to open surgery, and the remaining 40 children achieved better clinical results. Follow-up of 43 children was performed for 1 month to 6 years. Except for two patients who relapsed after surgery, there was no recurrence after another operation. The remaining 41 children recovered well; there were no deaths or serious complications. Postoperative chest X-ray and gastrointestinal angiography showed that the abdominal organs were in a normal position.

CONCLUSIONS

The use of a venipuncture indwelling needle to suture the diaphragm under thoracoscopy is a simple new technique. This method can not only improve the efficiency of sutures but also better handle the opening of the "V"-shaped defect of the diaphragm. At the same time, it has the advantages of minimal trauma, fast recovery, and improved cosmetic appearance.

Thoracoscopic surgery for congenital diaphragmatic hernia in neonates: Should it be the first choice?

OBJECTIVE

Congenital diaphragmatic hernia (CDH) is an uncommon but potentially life-threatening surgical condition in neonates. Surgery can be performed by either open or thoracoscopic techniques. In this study, we compared the clinical efficacy, safety, and effectiveness of thoracoscopic and open CDH repair.

METHODS

A retrospective review of neonates with CDH who underwent operations at our hospital from 2013 to 2021 was performed. The various perioperative parameters were compared between neonates undergoing thoracoscopic and open surgery.

RESULTS

There were 50 neonates in this study (37 in the thoracoscopic group and 13 in the open group). Thoracoscopic surgery was associated with significantly shorter hospital stay (13.32 vs. 18.77 days, p < 0.001); shorter duration of postoperative mechanical ventilation (3.70 vs. 5.98 days, p < 0.001); early feeding (4.34 vs. 7.46 days, p < 0.001); and shorter time to reach optimal feeding (8.21 vs. 13.38 days, p < 0.001). There was one postoperative death in the open group and no death in the thoracoscopic group. The median follow-up time of the two groups was 23.8 months (20.5 months in open group and 25.0 months in thoracoscopic group). Thoracoscopic surgery was associated with lower recurrence rates, but the difference was not statistically significant (2.7% vs. 7.7%, p = 0.456).

CONCLUSION

Thoracoscopy CDH repair, a safe and effective surgical technique for neonates, has better cosmesis, faster postoperative recovery, and a lower recurrence rate than other procedures. It can be considered the first choice for CDH treatment for neonates among experienced surgeons.

Thoracoscopic Repair of Neonatal Congenital Diaphragmatic Hernia: Minimizing Open Repair in a Low-Income Country

Aim: To assess the severity of persistent pulmonary hypertension (PPH) in congenital diaphragmatic hernia (CDH) neonates solely using oxygenation index (OI). Study Design: A prospective study was carried out from April 2016 to March 2019, where all confirmed CDH neonates were evaluated for the possibility repair through thoracoscopic approach. The severity of PPH was assessed using OI. It is calculated using the equation: mean airway pressure (MAP) × FiO₂ × 100 ÷ PaO₂. Neonates having OI <5 were considered to have a mild degree of pulmonary hypertension; hence, thoracoscopic repair was offered for them. Results: Thirty-nine CDH cases met the selection criteria; therefore, they underwent thoracoscopic repair. Primary diaphragmatic repair was successfully accomplished thoracoscopically in all neonates without any perioperative complications. Conversion from thoracoscopy to open method occurred in five cases. The causes were due to difficulties encountered during repair and none was due to a pure anesthetic problem or general deterioration during thoracoscopy. Recurrence had occurred in two cases only. Conclusion: OI is a reliable subjective parameter that could be used as an adjuvant to the usually used cardiovascular and pulmonary parameters for thoracoscopic repair decision. With increasing surgical experience, a wider range of neonates may be considered for thoracoscopic CDH repair.

One-year outcomes of congenital diaphragmatic hernia repair: Factors associated with recurrence and complications

PURPOSE

Congenital diaphragmatic hernia (CDH) is a congenital anomaly associated with lifelong multisystem morbidity. This study sought to identify factors contributing to hospital readmission after CDH repair.

METHODS

The Nationwide Readmissions Database from 2010 to 2014 was used to identify patients with CDH who underwent surgical repair. Primary outcomes included all cause readmission at 30-days and 1 year and readmission for hernia recurrence. Patient and hospital factors were compared using chi-squared analysis.

RESULTS

Five hundred eleven patients were identified with neonatal CDH. All repairs were performed at teaching hospitals via laparotomy in 59% (n = 303), thoracotomy in 36% (n = 183), and minimally invasive (MIS) repair in 5% (n = 25). The readmission rate within 30-days was 32% (n = 163), and 97% (n = 495) within 1 year. The most common conditions surrounding readmission were for gastroesophageal reflux (20%), CDH recurrence (17%), and surgery for gastrostomy tube and/or fundoplication (16%). Recurrence was significantly higher after MIS repair (48%) compared to those with open repair via either approach (16%), p < 0.001.

CONCLUSIONS

This is the first study to evaluate nationwide readmissions in newborns with CDH. Readmission is commonly due to CDH recurrence and reflux-associated complications. The recurrence rate is higher than previously reported and is more common after MIS and repair via thoracotomy.

LEVEL OF EVIDENCE

Level III treatment study.

The incidence of different forms of ileus following surgery for abdominal birth defects in infants: a systematic review with a meta-analysis method

Objectives

Ileus following surgery can arise in different forms namely as paralytic ileus, adhesive small bowel obstruction or as anastomotic stenosis. The incidences of these different forms of ileus are not well known after abdominal birth defect surgery in infants. Therefore, this review aims to estimate the incidence in general between abdominal birth defects.

Content

Studies reporting on paralytic ileus, adhesive small bowel obstruction or anastomotic stenosis were considered eligible. PubMed and Embase were searched and risk of bias was assessed. Primary outcome was the incidence of complications. A meta-analysis was performed to pool the reported incidences in total and per birth defect separately.

Summary

This study represents a total of 11,617 patients described in 152 studies of which 86 (56%) had a follow-up of at least half a year. Pooled proportions were calculated as follows; paralytic ileus: 0.07 (95%-CI, 0.05–0.11; I 2=71%, p≤0.01) ranging from 0.14 (95% CI: 0.08–0.23) in gastroschisis to 0.05 (95%-CI: 0.02–0.13) in omphalocele. Adhesive small bowel obstruction: 0.06 (95%-CI: 0.05–0.07; I 2=74%, p≤0.01) ranging from 0.11 (95% CI: 0.06–0.19) in malrotation to 0.03 (95% CI: 0.02–0.06) in anorectal malformations. Anastomotic stenosis after a month 0.04 (95%-CI: 0.03–0.06; I 2=59%, p=0.30) ranging from 0.08 (95% CI: 0.04–0.14) in gastroschisis to 0.02 (95% CI: 0.01–0.04) in duodenal obstruction. Anastomotic stenosis within a month 0.03 (95%-CI 0.01–0.10; I 2=81%, p=0.02) was reviewed without separate analysis per birth defect.

Outlook

This review is the first to aggregate the known literature in order approximate the incidence of different forms of ileus for different abdominal birth defects. We showed these complications are common and the distribution varies between birth defects. Knowing which birth defects are most at risk can aid clinicians in taking prompt action, such as nasogastric tube placement, when an ileus is suspected. Future research should focus on the identification of risk factors and preventative measures. The incidences provided by this review can be used in those studies as a starting point for sample size calculations.

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.

Thoracoscopic Repair of Congenital Diaphragmatic Hernia in Preterm Neonate at 1 Kilogram

We report the first successful primary thoracoscopic repair of congenital diaphragmatic hernia (CDH) in a preterm infant born at 28 weeks of gestation weighing 1,043 g. Left-sided CDH was incidentally diagnosed on postnatal chest X-ray on day 1. The neonate subsequently underwent thoracoscopic repair with primary closure of the defect on day 8 weighing 1,150 g. Intraoperative arterial blood gas monitoring including end tidal carbon-dioxide remained within normal range throughout. Postoperative recovery was uneventful. One year neurodevelopmental outcome was normal for age with no CDH recurrence.

Congenital diaphragmatic hernia in neonates: Open versus thoracoscopic repair

BACKGROUND

There are no standard criteria to select patients for thoracoscopic repair of congenital diaphragmatic hernia (CDH). The objective of this study was to compare open laparotomy versus thoracoscopic repair of CDH in neonates.

PATIENTS AND METHODS

This retrospective study included 41 patients who had repair of CDH from 2011 to 2019. Patients were divided into two groups according to the surgical approach; open laparotomy (n = 30) and thoracoscopic repair (n = 11). Study endpoints were duration of post-operative mechanical ventilation, hospital stay and the return to full enteral feeding.

RESULTS

Patients who had thoracoscopic repair were significantly younger (3 [25^th- 75^th percentiles: 3-3] vs. 4 [3-5] days; P = 0.004). Other pre-operative variables were comparable between both groups. The duration of surgery was significantly longer in the thoracoscopic repair (174 [153-186] vs. 91 (84-99) min; P < 0.001). The use of pre-operative nitrous oxide inhalation was associated with prolonged ventilation (P = 0.004), while the thoracoscopic repair was associated with shorter mechanical ventilation (P = 0.006). Hospital stay is lower in the thoracoscopic approach but did not reach a significant value (P = 0.059). The use of pre-operative nitrous oxide was associated with a prolonged hospital stay (P = 0.002). Younger age (HR: 1.33, P = 0.014) and open approach (HR: 3.56, P = 0.004) were significantly associated with delayed feeding.

CONCLUSIONS

The thoracoscopic approach is safe and effective for repairing the CDH. It is associated with shorter mechanical ventilation and rapid return to enteral feeding. Proper patient selection is essential to achieve good outcomes.

Innovative, Stabilizing Self-Expandable Patch for Easier and Safer Thoracoscopic Repair of Congenital Diaphragmatic Hernia

Introduction: Thoracoscopic repair of congenital diaphragmatic hernia (CDH) has become a popular approach and several benefits have been published. Patch closure requires demanding thoracoscopic skills and therefore primary closure with tight sutures is often pursued, which increases the risk of recurrence. The purpose of this study was to create and assess the performance of a new technique for thoracoscopic repair of CDH, which facilitates the surgical procedure. Materials and Methods: An innovative system for thoracoscopic repair of CDH with a novel patch was developed. The patch is self-expandable and offers a traction suture for stabilization, isolating and protecting the viscera. Its performance was assessed and compared with a conventional patch in an inanimate model of the disease through a quantitative and qualitative multivariate analysis. Results: Nine cases of CDH were repaired with each patch. The duration of the procedure was shorter (P < .05) and the level of difficulty was reported to be lower (P < .001) when using the self-expandable patch (SeP). The number of good quality knots was higher and adverse events were less common with this new technique. Conclusions: The stabilizing SeP offers safe and ergonomic performance for thoracoscopic CDH repair, facilitating the surgical technique. The main advantage is that it keeps the viscera isolated into the abdomen while offering a flap on the thoracic side for suturing in a practical manner, minimizing the risk of visceral injury and saving surgical time.

Thoracoscopic repair of congenital diaphragmatic hernia: a new anatomical reconstructive concept for tension dispersal at primary closure

BACKGROUND

Several measures were implemented among authors striving to tail off recurrence rates of thoracoscopic congenital diaphragmatic hernia repair. In the presented study, we extended the use of rib-anchoring stitches to reorient the diaphragmatic muscle leaflets in the types B&C diaphragmatic hernias, to achieve tension dispersal at primary thoracoscopic repair.

PATIENTS AND METHODS

Included in this study were early and late-onset lateral congenital diaphragmatic hernia patients, who had been operated upon in the years 2012 through 2018. A preliminary stitch was taken between posterior muscle edge and rib cage to reorient the diaphragmatic defect into a reversed C-shaped line. The lateral portion was closed by additional rib-anchoring stitches, while the medial one necessitated muscle to muscle stitches. Primary outcome being validated was the recurrence rate within a year post repair.

RESULTS

In the 7-year inclusion period, 36 congenital diaphragmatic hernia cases were managed using the described approach. The repair was accomplished thoracoscopically in all but two cases, who were excluded from the study. Mean operative time was 76 min. No pledgets or synthetic patches were applied. Mean length of hospital stay was 7.6 days. Early postoperative course was uneventful in all but four cases; two ventilatory barotrauma and two mortalities. After a mean follow-up period of 29 months, five recurrences were reported (16%). Ipsilateral chest wall deformity was noticed in one case 3 years post repair.

CONCLUSION

In the presented study, authors adopted thoracoscopic reorientation of diaphragmatic muscle leaflets in lateral congenital diaphragmatic hernia cases to achieve tension dispersal at primary repair. Short and mid-term results supported the efficacy and reproducibility of the described approach. However, long-term comparative studies seemed a necessity to validate this outcome.

Biologic Mesh Underlay in Thoracoscopic Primary Repair of Congenital Diaphragmatic Hernia Confers Reduced Recurrence in Neonates: A Preliminary Report

Purpose: The purpose of this study was to determine if utilization of biologic mesh underlay during thoracoscopic congenital diaphragmatic hernia (CDH) primary repair (PR) results in reduced 5-year hernia recurrence rates. Methods: A retrospective review was completed for all primarily repaired CDH utilizing a thoracoscopic approach from January 1, 2003 to June 31, 2013. Patients were included in the study cohort if they had a thoracoscopic PR of their CDH without any mesh reinforcement or with biologic mesh underlay. Charts were then reviewed for no less than 5 years postoperatively for reports of clinical and/or radiographic hernia recurrence. The cumulative annual hernia recurrence as well as other demographic factors were analyzed. Results: Within the study period, 46 patients were identified that met study criteria. Three patients were lost to follow-up. Fifteen of the remaining patients (15/43: 34.9%) had a biologic underlay. Within the cohort, seven recurrences were noted within 5 years of the index procedure (7/43; 16.7%). Four recurrences occurred within the first postoperative year, and all occurred by the third postoperative year. One recurrence was in a patient with a biologic underlay at 4 months after repair. This was a clinically/radiographically silent 4 mm defect and noted at laparoscopy for another indication (1/15: 6.6%). The remainder occurred in primarily repaired patients without mesh reinforcement (6/28: 21.4%). Conclusions: Thoracoscopic PR of CDH can be successfully performed in select patients. The use of a biologic mesh underlay in this subset of patients appears to confer reduced hernia recurrence.

Outcomes for thoracoscopic versus open repair of small to moderate congenital diaphragmatic hernias

INTRODUCTION

Indications for thoracoscopic versus open approaches to repair congenital diaphragmatic hernia (CDH) are unclear as the variability in defect size, disease severity and patient characteristics pose a challenge. Few studies use a patient and disease-matched comparison of techniques. We aimed to compare the clinical outcomes of open versus thoracoscopic repairs of small to moderate sized hernia defects in a low risk population.

METHODS

All neonates receiving CDH repair of small (type A) and moderate (type B) size defects at an academic children's hospital between 2006 and 2016 were retrospectively reviewed and analyzed. Patients <36weeks gestation, birth weight <1500g, or requiring extracorporeal life support were excluded. Demographics, including CDH severity index, and hernia characteristics were recorded. The primary outcome parameter was recurrence. Secondary outcomes included length of hospital stay, length of mechanical ventilation, time to goal feeds, and mortality.

RESULTS

The 51 patients receiving thoracoscopic (35) and open (16) repairs were similar in patient and hernia characteristics, with median 2-year follow-up for both groups. Patients with thoracoscopic repair had shorter hospital stay (16 vs. 23days, p=0.03), days on ventilator (5 vs. 12, p=0.02), days to start of enteral feeds (5 vs. 10, p<0.001), and days to goal feeds (11 vs. 20, p=0.006). Higher recurrence rates in the thoracoscopic groups (17.1% vs. 6.3%) were not statistically significant (p=0.28). Median time to recurrence was 88days for the open repair and 183days (IQR 165-218) for the thoracoscopic group. There were no mortalities in either group.

CONCLUSIONS

In low risk patients born with small to moderate size defects, a thoracoscopic approach was associated with decreased hospital length of stay, mechanical ventilation days, and time to feeding; however, there was a trend towards higher recurrence rates.

LEVEL OF EVIDENCE

Level III.

Pediatric thoracoscopic repair of congenital diaphragmatic hernias

Congenital diaphragmatic hernia (CDH) is a rare congenital disease requiring neonatal surgical treatment. The traditional surgical management of CDH consists of diaphragmatic repair by laparotomy. Thoracoscopic repair techniques have been well described for CDH with late presentation. Nevertheless, its feasibility for CDH treatment in neonates emerged only the past few years because the use of thoracoscopy with carbon dioxide insufflation remains controversial in these patients more vulnerable to hypothermia and acidosis. However, we think that thoracoscopy can be safely used to repair CDH in selected patients and the major limiting factor is pulmonary hypoplasia. Some patients should be excluded based on their higher potential need for patch closure with its technical difficulty and increased operative time. The close collaboration between pediatric surgeon, anesthetist and neonatologist is essential. We discuss here the patient selection criteria, expose the pre- and post-operative management, the procedure steps; regarding to our experience we deliver some tips to achieve the safest surgical procedure for the pediatric patient.

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.

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.

Management of congenital diaphragmatic hernia: A systematic review from the APSA outcomes and evidence based practice committee

OBJECTIVE

Variable management practices complicate the identification of optimal strategies for infants with congenital diaphragmatic hernia (CDH). This review critically appraises the available evidence to provide recommendations.

METHODS

Six questions regarding CDH management were generated. English language articles published between 1980 and 2014 were compiled after searching Medline, Cochrane, Embase and Web of Science. Given the paucity of literature on the subject, all studies irrespective of their rank in the levels of evidence hierarchy were included.

RESULTS

Gentle ventilation with permissive hypercapnia provides the best outcomes. Initial high frequency ventilation may be considered but its overall efficacy is unproven. Routine inhaled nitric oxide (iNO) or other medical adjuncts for acute, severe pulmonary hypertension demonstrate no benefit. Evidence does not support routine administration of pre- or postnatal glucocorticoids. Mode of extracorporeal membrane oxygenation (ECMO) has little bearing on outcomes. While the overall timing of repair does not impact outcomes, early repair on ECMO has benefits. Open repair leads to significantly fewer recurrences. Polytetrafluoroethylene (PTFE) is the most durable patch repair material.

CONCLUSIONS

Limited high-level evidence prevents the development of robust management guidelines for CDH. Prospective, multi-institutional studies are needed to identify best practices and optimize outcomes.

Congenital diaphragmatic hernia, management in the newborn

Congenital diaphragmatic hernia (CDH) in the newborn poses challenges to the multi-disciplinary teams involved in its management. Mortality remains significantly high, despite growing understanding and treatment options. Early intubation of antenatally diagnosed cases is crucial in preventing deterioration and persistent pulmonary hypertension. Early recognition of cases not diagnosed on antenatal scan, with appreciation of differential diagnosis, requires an index of suspicion and imaging. Increasing options and modalities are available, with only modest, if any, survival advantage. Permissive hypercapnea and minimal ventilation have made the most significant impact on survival in modern era. High-frequency oscillatory ventilation (HFOV), inhaled nitric oxide (iNO), treatment of pulmonary hypertension, and ECMO are used in a somewhat stepwise manner for stabilisation. Delayed surgery has become established later in management plan. The impact of individual therapies (e.g. HFOV, iNO, ECMO) on outcome is difficult to ascertain. Little level 1 or 2 evidence exists. Randomised studies and reviews on the role of ECMO have not yet proven any long-term survival benefit. One pilot randomised study of thoracoscopic repair suggests increased acidosis; intraoperative blood gases and CO2 levels should be closely monitored. Monitoring tissue oxygenation should be considered. There is no evidence to suggest the best patch material.

Thoracoscopic versus open repair of CDH in cardiovascular stable neonates

Background

Thoracoscopic surgery is an increasingly popular surgical technique to repair congenital diaphragmatic hernia (CDH). However, acidosis during surgery and the higher recurrence rate are considerable risk factors. The aim of this retrospective study is to compare the outcome of open versus thoracoscopic repair of the diaphragm in neonates with CDH with the same degree of cardiovascular and pulmonary illness who meet the criteria for thoracoscopic repair.

Methods

Retrospective analysis of all patients of two large national reference centers for CDH born in the years 2008 through 2012, and meeting the criteria for surgical repair on cardiopulmonary and physiological criteria according to the CDH EURO consortium consensus and meeting the criteria for thoracoscopic repair according to the review by Vijfhuize et al. The surgical technical aspects were comparable in both centers.

Results

108 patients were included, of whom 75 underwent thoracoscopic repair and 34 underwent open repair. The gestational age and lung-to-head ratio were significantly lower and stay on the ICU significantly longer in the open-repair group. The operation time was longer (178 vs. 150 min, p = .012) and the recurrence rate higher (18.9 vs. 5.9 %, p = .036) in the thoracoscopic-repair group. The arterial pH, pO₂, pCO₂ and base excess before and after thoracoscopic repair were all significantly different.

Conclusion

After critical selection for thoracoscopic repair of left-sided CDH based on the patient’s preoperative condition, the outcomes of open repair were almost identical to those of thoracoscopic repair. A notable exception is the recurrence rate, which was significantly higher in the thoracoscopic-repair group. For the time being, thoracoscopic primary closure seems a safe and effective procedure, but efficacy of thoracoscopic patch repair has not been established.

Congenital diaphragmatic hernia

There is a paucity of level 1 and level 2 evidence for best practice in surgical management of CDH. Antenatal imaging and prognostication is developing. Observed to expected lung-to-head ratio on ultrasound allows better predictive value over simple lung-to-head ratio. Based on 2 randomised studies, the verdict is still out in terms the best group and indication for antenatal intervention and their outcome. Tracheal occlusion is best suited for prospective randomised studies of benefit and outcome. Only one pilot randomised controlled study of thoracoscopic repair exists, suggesting increased acidosis; blood gases and CO2 levels should be closely monitored. Only poorly controlled retrospective studies suggest higher recurrence rates. Randomised studies on the outcome of thoracoscopic repair are needed. Careful selection, anaesthetic vigilance, monitoring and follow-up of these cases are required. There is no evidence to suggest the best patch material to decrease recurrences. Evidence suggests no benefit from routine fundoplication based on the one randomised study. Multi-disciplinary follow-up is required. This can be visits to different specialities, but may be best served by a multi-disciplinary one-stop clinic.