Improved pulmonary function after surgical reduction of congenital diaphragmatic hernia in lambs

Neonatal endosurgical congenital diaphragmatic hernia repair: a systematic review and meta-analysis

OBJECTIVE

To compare outcomes of open and endosurgical neonatal congenital diaphragmatic hernia (CDH) repairs.

BACKGROUND

Historically a surgical emergency, neonatal CDH repair is now deferred pending stabilization of characteristically labile cardiopulmonary physiology. Usually accomplished via laparotomy, surgical repair may acutely worsen lung function; conversely, by reducing the visceral hernia, surgery might improve it. Theoretically, endosurgical repair could minimize deleterious effects of surgery while garnering benefits from decompressing the CDH lung. As endosurgical repair gains popularity, it is important to investigate whether or not minimally-invasive neonatal CDH repair has benefits.

METHODS

We searched Medline, Embase, and Cochrane Trials databases for studies comparing open with endosurgical CDH repair. Non-neonatal series and reports without comparison groups were excluded. References from papers and conference proceedings were also hand searched. Meta-analysis used a fixed effects model and was reported in accordance with PRISMA.

RESULTS

We included 3 studies (1 unpublished; none randomized); all compared thoracoscopic and open CDH repair and together described 143 patients. All studies had limitations, including use of historical controls. Demographics, CDH sidedness, APGAR and associated anomaly prevalence were similar between groups. For endosurgical repair, recurrence was higher (RR: 3.2 [1.1, 9.3], P = 0.03) and operative time longer (WMD 50 minutes [32, 69], P < 0.00001). Survival and patch usage were not different between open and endosurgical groups.

CONCLUSIONS

Neonatal thoracoscopic CDH repair has greater recurrence rates and operative times but similar survival and patch usage compared with open surgery. A prospective registry for all such cases would guide development of trials (Stage 2b; IDEAL recommendations).

Liquid ventilation

Liquid breathing has been proposed as a means of improving gas exchange in infants with acute respiratory failure since the 1970s. In addition, there are potential clinical applications of perfluorochemical (PFC) liquids that span many specialties in medicine. The ability to lower surface tension directed the initial clinical focus on neonatal therapy in the treatment of premature lung disease. The first clinical trial of PFC ventilation was performed in neonates in 1989. Additional trials using LiquiVent (Alliance Pharmaceutical San Diego, CA), a medical grade PFC liquid, were initiated in 1993 in infants, children, and adults. These studies have concluded that liquid ventilation appeared to be safe, improve lung function, and recruit lung volume in patients from these populations. The results of such trials are encouraging, but randomized trials have yet to be completed. We await these pivotal trials, which will probably be completed in adult patients first, before this promising technique can be clinically available.