1
|
Jank M, Boettcher M, Keijzer R. Surgical management of the diaphragmatic defect in congenital diaphragmatic hernia: a contemporary review. WORLD JOURNAL OF PEDIATRIC SURGERY 2024; 7:e000747. [PMID: 39183804 PMCID: PMC11340723 DOI: 10.1136/wjps-2023-000747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 07/15/2024] [Indexed: 08/27/2024] Open
Abstract
Worldwide, 150 children are born each day with congenital diaphragmatic hernia (CDH), a diaphragmatic defect with concomitant abnormal lung development. Patients with CDH with large defects are particularly challenging to treat, have the highest mortality, and are at significant risk of long-term complications. Advances in prenatal and neonatal treatments have improved survival in high-risk patients with CDH, but surgical treatment of large defects lacks standardization. Open repair by an abdominal approach has long been considered the traditional procedure, but the type of defect repair (patch or muscle flap) and patch material (non-absorbable, synthetic or absorbable, biological) remain subjects of debate. Increased experience and improved techniques in minimally invasive surgery (MIS) have expanded selection criteria for thoracoscopic defect repair in cardiopulmonary stable patients with small defects. However, the application of MIS to repair large defects remains controversial due to increased recurrence rates and unknown long-term effects of perioperative hypercapnia and acidosis resulting from capnothorax and reduced ventilation. Current recommendations on the surgical management rely on cohort studies of varying patient numbers and data on the long-term outcomes are sparse. Here, we discuss surgical approaches for diaphragmatic defect repair highlighting advancements, and knowledge gaps in surgical techniques (open surgery and MIS), patch materials and muscle flaps for large defects, as well as procedural adjuncts and management of CDH variants.
Collapse
Affiliation(s)
- Marietta Jank
- Division of Pediatric Surgery, Departments of Surgery and Pediatrics & Child Health, Max Rady College of Medicine, Rady Faculty of Heath Sciences, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pediatric Surgery, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Michael Boettcher
- Department of Pediatric Surgery, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Richard Keijzer
- Division of Pediatric Surgery, Departments of Surgery and Pediatrics & Child Health, Max Rady College of Medicine, Rady Faculty of Heath Sciences, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| |
Collapse
|
2
|
Holden KI, Ebanks AH, Lally KP, Harting MT. The CDH Study Group: Past, Present, and Future. Eur J Pediatr Surg 2024; 34:162-171. [PMID: 38242150 DOI: 10.1055/s-0043-1778021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
The Congenital Diaphragmatic Hernia Study Group (CDHSG) is an international consortium of medical centers actively collecting and voluntarily contributing data pertaining to live born congenital diaphragmatic hernia (CDH) patients born and/or managed at their institutions. These data are aggregated to construct a comprehensive registry that participating centers can access to address specific clinical inquiries and track patient outcomes. Since its establishment in 1995, 147 centers have taken part in this initiative, including 53 centers from 17 countries outside the United States, with 95 current active centers across the globe. The registry has amassed data on over 14,000 children, resulting in the creation of over 75 manuscripts based on registry data to date. International, multicenter consortia enable health care professionals managing uncommon, complex, and diverse diseases to formulate evidence-based hypotheses and draw meaningful and generalizable conclusions for clinical inquiries. This review will explore the formation and structure of the CDHSG and its registry, outlining their functions, center participation, and the evolution of data collection. Additionally, we will provide an overview of the evidence generated by the CDHSG, with a particular emphasis on contributions post-2014, and look ahead to the future directions the study group will take in addressing CDH.
Collapse
Affiliation(s)
- Kylie I Holden
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, Texas, United States
- Center for Surgical Trials and Evidence-based Practice (CSTEP), University of Texas McGovern Medical School, Houston, Texas, United States
| | - Ashley H Ebanks
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, Texas, United States
- Center for Surgical Trials and Evidence-based Practice (CSTEP), University of Texas McGovern Medical School, Houston, Texas, United States
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, Texas, United States
- Center for Surgical Trials and Evidence-based Practice (CSTEP), University of Texas McGovern Medical School, Houston, Texas, United States
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, Texas, United States
- Center for Surgical Trials and Evidence-based Practice (CSTEP), University of Texas McGovern Medical School, Houston, Texas, United States
| |
Collapse
|
3
|
Quigley CP, Folaranmi SE. A Systematic Review Comparing the Surgical Outcomes of Open Versus Minimally Invasive Surgery for Congenital Diaphragmatic Hernia Repair. J Laparoendosc Adv Surg Tech A 2023; 33:211-219. [PMID: 36445735 DOI: 10.1089/lap.2022.0348] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
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.
Collapse
Affiliation(s)
| | - Semiu E Folaranmi
- Cardiff University School of Medicine, Cardiff, United Kingdom.,Department of Paediatric Surgery, University Hospital of Wales, Cardiff, United Kingdom
| |
Collapse
|
4
|
Sullivan GA, Skertich NJ, Kwong J, Owen G, Pillai S, Madonna MB, Shah AN, Gulack BC. Minimally Invasive Approaches and Use of a Patch Are Not Associated with Increased Recurrence Rates After Congenital Diaphragmatic Hernia Repair. J Laparoendosc Adv Surg Tech A 2022; 32:1228-1233. [PMID: 36161877 DOI: 10.1089/lap.2022.0236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Minimally invasive surgery (MIS) is increasingly used for repair of congenital diaphragmatic hernia (CDH). Reported recurrence after MIS repair varies and is limited by short follow-up and low volume. Our objective was to compare recurrence after MIS versus open repair of CDH. Materials and Methods: Infants who underwent CDH repair between 2010 and 2020 were identified using the PearlDiver Mariner database, a national patient claims data set allowing longitudinal follow-up of patients across systems. Kaplan-Meier analysis and Cox proportional hazards regression models were used to evaluate the association of surgical approach (MIS versus open) and use of a patch with time to recurrence while adjusting for comorbidities (congenital heart disease and pulmonary hypertension) and length of stay (LOS). Results: In a cohort of 629 infants, 25.6% (n = 161) underwent MIS repair with a median follow-up of 4.8 years and recurrence rate of 38.6% (n = 243). Rates of recurrence after MIS repair were lower than open (5 years: 38.6% versus 44.3%; P = .03) and higher with use of patch (5 years: 60.1% versus 40.1%; P = .02). After adjustment for comorbidities and LOS as a proxy for patient complexity, there was no significant difference in recurrence based on approach (adjusted hazard ratio [aHR]: 0.79; confidence interval [95% CI]: 0.57-1.10; P = .16) or use of patch (aHR: 1.22; 95% CI: 0.83-1.79; P = .32). Conclusions: Recurrence rates after repair of CDH were not different based on surgical approach or use of patch after adjustment. Previous data were likely biased by patient complexity, and surgeons should consider these factors in determining approach.
Collapse
Affiliation(s)
- Gwyneth A Sullivan
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Nicholas J Skertich
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Jacky Kwong
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Grant Owen
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Srikumar Pillai
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Mary Beth Madonna
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Ami N Shah
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian C Gulack
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| |
Collapse
|
5
|
Li H, Zhao S, Wu C, Pan Z, Wang G, Fu J, Dai J. A new simplified technique in thoracoscopic repair of congenital diaphragmatic hernia. Pediatr Surg Int 2022; 38:861-865. [PMID: 35230487 DOI: 10.1007/s00383-022-05076-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 11/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- Hua Li
- Department of Thoracic Surgery, Second Affiliated Hospital of Army Medical University, Chongqing, People's Republic of China
| | - Shengliang Zhao
- Department of Thoracic Surgery, Second Affiliated Hospital of Army Medical University, Chongqing, People's Republic of China.,Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Chun Wu
- Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China.,Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, No. 20, Jinyu Avenue, Liangjiang New District, Chongqing, People's Republic of China
| | - Zhengxia Pan
- Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China.,Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, No. 20, Jinyu Avenue, Liangjiang New District, Chongqing, People's Republic of China
| | - Gang Wang
- Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China.,Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, No. 20, Jinyu Avenue, Liangjiang New District, Chongqing, People's Republic of China
| | - Jian Fu
- Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China.,Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, No. 20, Jinyu Avenue, Liangjiang New District, Chongqing, People's Republic of China
| | - Jiangtao Dai
- Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China. .,Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, No. 20, Jinyu Avenue, Liangjiang New District, Chongqing, People's Republic of China.
| |
Collapse
|
6
|
Macchini F, Raffaeli G, Amodeo I, Ichino M, Encinas JL, Martinez L, Wessel L, Cavallaro G. Recurrence of Congenital Diaphragmatic Hernia: Risk Factors, Management, and Future Perspectives. Front Pediatr 2022; 10:823180. [PMID: 35223699 PMCID: PMC8864119 DOI: 10.3389/fped.2022.823180] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 01/17/2022] [Indexed: 11/13/2022] Open
Abstract
Recurrence is one of the most common surgical complications in Congenital Diaphragmatic Hernia (CDH). It could remain clinically silent for a long time or present as an acute complication week, months, or even years after the primary surgery. Several risk factors have been identified so far. An extended diaphragmatic defect represents one of the leading independent risk factors, together with indirect signs of large defect such as the liver position related to the diaphragm and the use of the prosthetic patch and with the use of a minimally invasive surgical (MIS) approach. However, the exact contribution of each factor and the overall risk of recurrence during the life span still need to be fully understood. This mini-review aims to give an overview of the current knowledge regarding CDH recurrence, focusing on predisposing factors, clinical presentation, management and follow-up of high-risk patients, and future perspectives.
Collapse
Affiliation(s)
- Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Genny Raffaeli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Ilaria Amodeo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Martina Ichino
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - José Luis Encinas
- Department of Pediatric Surgery, La Paz Children's Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - Leopoldo Martinez
- Department of Pediatric Surgery, La Paz Children's Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - Lucas Wessel
- Department of Pediatric Surgery, Faculty of Medicine Mannheim at Heidelberg University, Mannheim University Medical Center, Mannheim, Germany
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
7
|
Liu R, Zheng Z, Tang C, Zhang K, Du Q, Gong Y, Zhu D, Xia X, Zhou W, Huang L, Liu Y, Jin Z. Thoracoscopic surgery for congenital diaphragmatic hernia in neonates: Should it be the first choice? Front Pediatr 2022; 10:1020062. [PMID: 36389344 PMCID: PMC9659751 DOI: 10.3389/fped.2022.1020062] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 10/07/2022] [Indexed: 11/23/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Rui Liu
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Zebing Zheng
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Chengyan Tang
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Kaizhi Zhang
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Qing Du
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Yuan Gong
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Daiwei Zhu
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Xingrong Xia
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Wankang Zhou
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Lu Huang
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Yuanmei Liu
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Zhu Jin
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| |
Collapse
|
8
|
Kotb M, Shehata S, Khairi A, Mohamed Shehata S, Ghoneim T, Rabie A. Thoracoscopic Repair of Neonatal Congenital Diaphragmatic Hernia: Minimizing Open Repair in a Low-Income Country. J Laparoendosc Adv Surg Tech A 2021; 31:1341-1345. [PMID: 34491842 DOI: 10.1089/lap.2021.0210] [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] [Indexed: 11/13/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Mostafa Kotb
- Department of Pediatric Surgery, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Sameh Shehata
- Department of Pediatric Surgery, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Ahmed Khairi
- Department of Pediatric Surgery, Alexandria Faculty of Medicine, Alexandria, Egypt
| | | | - Tamer Ghoneim
- Department of Anesthesia, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Aliaa Rabie
- Department of Anesthesia, Alexandria Faculty of Medicine, Alexandria, Egypt
| |
Collapse
|
9
|
Liu H, Le C, Chen J, Xu H, Yu H, Chen L, Liu H. Anesthetic management of thoracoscopic procedures in neonates: a retrospective analysis of 45 cases. Transl Pediatr 2021; 10:2035-2043. [PMID: 34584873 PMCID: PMC8429869 DOI: 10.21037/tp-21-265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 08/05/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Advances in medical techniques and equipment have enabled the thoracoscopic repair of certain congenital abnormalities in neonates including congenital esophageal atresia/tracheoesophageal fistula (EA/TEF) and congenital diaphragmatic hernia (CDH). A retrospective analysis was conducted to examine the anesthetic management of neonates (7 days or younger) undergoing thoracoscopic surgery in our hospital department, and to determine the efficacy of anesthetic management in neonates. METHODS Clinical data from 45 neonates who underwent thoracoscopic surgery in our hospital from December 2015 to March 2020 were retrospectively analyzed. A total of 25 patients underwent repair of CDH and 20 underwent repair of an EA/TEF. RESULTS All patients received general anesthesia with endotracheal intubation, standard ASA monitoring, and arterial blood gas (ABG) analysis. All patients survived the surgery. A total of 14 patients experienced decreases in SpO2, pH, PaO2, and increases in PETCO2 and PaCO2 30 minutes after CO2 insufflation. Our anesthetic management protocols are outline and analyzed. CONCLUSIONS Thorough preoperative preparation is critical for a desirable outcome in neonates undergoing a thoracoscopic repair of CDH or EA/TEF. In our cohort, intraoperative ventilation strategies included pressure control ventilation with peak airway pressure maintained at 15-25 cmH2O, a respiratory rate of 35-55 breaths/minute, a fraction of inspired oxygen (FiO2) of 60-80%, an inspiratory/expiratory ratio (I:E) of 1:1-1.5, and careful airway suctioning to clear secretions. Postoperatively, maintaining normovolemia and hemodynamic stability are critical for successful weaning of ventilatory support and extubation.
Collapse
Affiliation(s)
- Hua Liu
- Department of Anesthesiology, Hubei Women & Children's Hospital, Wuhan, China
| | - Chengjin Le
- Department of Anesthesiology, Hubei Women & Children's Hospital, Wuhan, China
| | - Jing Chen
- Department of Anesthesiology, Hubei Women & Children's Hospital, Wuhan, China
| | - Heng Xu
- Department of Anesthesiology, Hubei Women & Children's Hospital, Wuhan, China
| | - Hui Yu
- Department of Anesthesiology, Hubei Women & Children's Hospital, Wuhan, China
| | - Lin Chen
- Department of Anesthesiology, Hubei Women & Children's Hospital, Wuhan, China
| | - Henry Liu
- Department of Anesthesiology and Perioperative Medicine, Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
| |
Collapse
|
10
|
Bökkerink GM, Joosten M, Leijte E, Lindeboom MY, de Blaauw I, Botden SM. Validation of low-cost models for minimal invasive surgery training of congenital diaphragmatic hernia and esophageal atresia. J Pediatr Surg 2021; 56:465-470. [PMID: 32646664 DOI: 10.1016/j.jpedsurg.2020.05.045] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/16/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Minimal invasive surgery (MIS) is increasingly used for the correction of congenital diaphragmatic hernia (CDH) and esophageal atresia (EA). It is important to master these complex procedures, preferably preclinically, to avoid complications. The aim of this study was to validate recently developed models to train these MIS procedures preclinically. METHODS Two low cost, reproducible models (one for CDH and one for EA) were validated during several pediatric surgical conferences and training sessions (January 2017-December 2018), used in either the LaparoscopyBoxx or EoSim simulator. Participants used one or both models and completed a questionnaire regarding their opinion on realism (face validity) and didactic value (content validity), rated on a five-point-Likert scale. RESULTS Of all 60 participants enrolled, 44 evaluated the EA model. All items were evaluated as significantly better than neutral, with means ranging from 3.7 to 4.1 (p < 0.001). The CDH model was evaluated by 48 participants. All items scored significantly better than neutral (means 3.5-3.9, p < 0.001), with exception of the haptics of the simulated diaphragm (mean 3.3, p = 0.054). Both models were considered a potent training tool (means 3.9). CONCLUSION These readily available and low budget models are considered a valid and potent training tool by both experts and target group participants. TYPE OF STUDY Prospective study. LEVEL OF EVIDENCE Level II.
Collapse
Affiliation(s)
- Guus Mj Bökkerink
- Princess Máxima Center, Department of Pediatric Surgery, Utrecht, The Netherlands
| | - Maja Joosten
- Radboudumc-Amalia Children's Hospital, Department of Pediatric Surgery, Nijmegen, The Netherlands.
| | - Erik Leijte
- Radboudumc-Amalia Children's Hospital, Department of Pediatric Surgery, Nijmegen, The Netherlands
| | - Maud Ya Lindeboom
- University Medical Centre Utrecht-The Wilhelmina Children's Hospital, Department of Pediatric Surgery, The Netherlands
| | - Ivo de Blaauw
- Radboudumc-Amalia Children's Hospital, Department of Pediatric Surgery, Nijmegen, The Netherlands
| | - Sanne Mbi Botden
- Radboudumc-Amalia Children's Hospital, Department of Pediatric Surgery, Nijmegen, The Netherlands
| |
Collapse
|
11
|
Epidemiology and One-Year Follow-Up of Neonates with CDH-Data from Health Insurance Claims in Germany. CHILDREN-BASEL 2021; 8:children8020160. [PMID: 33672568 PMCID: PMC7924040 DOI: 10.3390/children8020160] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/17/2021] [Indexed: 01/13/2023]
Abstract
Congenital diaphragmatic hernia (CDH) is a major congenital malformation with high mortality. Outcome data on larger unselected patient groups in Germany are unavailable as there is no registry for CDH. Therefore, routine data from the largest German health insurance fund were analyzed for the years 2009–2013. Main outcome measures were incidence, survival and length of hospital stay. Follow-up was 12 months. 285 patients were included. The incidence of CDH was 2.73 per 10,000 live births. Overall mortality was 30.2%. A total of 72.1% of the fatalities occurred before surgery. Highest mortality (64%) was noted in patients who were admitted to specialized care later as the first day of life. Patients receiving surgical repair had a better prognosis (mortality: 10.8%). A total of 67 patients (23.5%) were treated with ECMO with a mortality of 41.8%. The median cumulative hospital stay among one-year survivors was 40 days and differed between ECMO- and non-ECMO-treated patients (91 vs. 32.5 days, p < 0.001). This is the largest German cohort study of CDH patients with a one-year follow-up. The ECMO subgroup showed a higher mortality. Another important finding is that delayed treatment in specialized care increases mortality. Prospective clinical registries are needed to elucidate the treatment outcomes in detail.
Collapse
|
12
|
Kiblawi R, Zoeller C, Zanini A, Ure BM, Dingemann J, Kuebler JF, Schukfeh N. Video-Assisted Thoracoscopic or Conventional Thoracic Surgery in Infants and Children: Current Evidence. Eur J Pediatr Surg 2021; 31:54-64. [PMID: 33027837 DOI: 10.1055/s-0040-1716878] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
Collapse
Affiliation(s)
- Rim Kiblawi
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Christoph Zoeller
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Andrea Zanini
- Department of Pediatric Surgery, University of Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Benno M Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Jens Dingemann
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Joachim F Kuebler
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Nagoud Schukfeh
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| |
Collapse
|
13
|
Choudhry M, Rusu S, Brooks P, Ogundipe E, Chuang SL. Thoracoscopic Repair of Congenital Diaphragmatic Hernia in Preterm Neonate at 1 Kilogram. European J Pediatr Surg Rep 2021; 9:e13-e16. [PMID: 33532173 PMCID: PMC7844161 DOI: 10.1055/s-0040-1721473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 02/09/2020] [Indexed: 11/22/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Muhammad Choudhry
- Department of Pediatric Surgery, Chelsea and Westminster Hospital National Health Service Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Simona Rusu
- Department of Pediatric Surgery, Chelsea and Westminster Hospital National Health Service Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Peter Brooks
- Department of Anaesthesia, Chelsea and Westminster Hospital National Health Service Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Enitan Ogundipe
- Department of Neonatology, Chelsea and Westminster Hospital National Health Service Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Shu-Ling Chuang
- Department of Neonatology, Chelsea and Westminster Hospital National Health Service Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| |
Collapse
|
14
|
Abstract
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 [25th- 75th 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.
Collapse
Affiliation(s)
| | - Abdullah Bawazir
- Medical Student, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Makkah, Saudi Arabia
| |
Collapse
|
15
|
Abello C, Varela MF, Oria M, Molinari T, Peiro JL. Innovative, Stabilizing Self-Expandable Patch for Easier and Safer Thoracoscopic Repair of Congenital Diaphragmatic Hernia. J Laparoendosc Adv Surg Tech A 2020; 30:1242-1247. [PMID: 32960151 DOI: 10.1089/lap.2020.0467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Cristobal Abello
- Department of Pediatric Surgery, Clínica CMI Pediátrica International, Barranquilla, Colombia
| | - Maria Florencia Varela
- Pediatric General and Thoracic Surgery Division, Center for Fetal and Placental Research, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
| | - Marc Oria
- Pediatric General and Thoracic Surgery Division, Center for Fetal and Placental Research, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA.,College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Tomas Molinari
- Department of Pediatric Surgery, Clínica CMI Pediátrica International, Barranquilla, Colombia
| | - Jose L Peiro
- Pediatric General and Thoracic Surgery Division, Center for Fetal and Placental Research, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA.,College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| |
Collapse
|
16
|
Thoracoscopic repair of congenital diaphragmatic hernia: a new anatomical reconstructive concept for tension dispersal at primary closure. Surg Endosc 2020; 35:3279-3284. [PMID: 32617656 DOI: 10.1007/s00464-020-07764-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
Abstract
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.
Collapse
|
17
|
Kotb M, Shehata M, Shehata S, Shehata S, Khairi A, Rabie A, Ghonaim T. Thoracoscopic Repair of Congenital Diaphragmatic Hernia: a Tale from Two Cities. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02154-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
18
|
Kawano T, Muensterer OJ. A new gentle reduction technique for patients with congenital diaphragmatic hernia-A case report. Int J Surg Case Rep 2019; 57:5-8. [PMID: 30875626 PMCID: PMC6417398 DOI: 10.1016/j.ijscr.2019.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 02/19/2019] [Accepted: 03/01/2019] [Indexed: 11/06/2022] Open
Abstract
The number of cases which can undergo thoracoscopic repair for congenital diaphragmatic hernia is limited. Reducing the herniated viscera in thoracoscopic repair of CDH can be dangerous due to their vulnerability of neonatal organs. This twisting technique allows for gentle reduction of diaphragmatic hernias with a hernia sac, without a risk of injury.
Reducing the herniated viscera such as the spleen, the liver, and the bowel in thoracoscopic repair of congenital diaphragmatic hernia can be challenging. The small instruments involved can easily create damage, particularly to the friable capsule of the solid organs involved. We herein demonstrate a new gentle method of reducing the diaphragmatic hernia using sequential twisting of the sac. The patient was a 3 day old girl with left sided Bochdalek diaphragmatic hernia. Chest X-ray showed intestinal herniation into the thoracic cavity, and we planned to perform elective Minimal-invasive surgery. Once in the chest, the fundus of the hernia sac is grasped with a blunt endosurgical grasper. The grasper is then turned, twisting the sac around the shaft of the instrument and thereby reducing the hernia content. Once maximal reduction with one hand is achieved, the twisted tissue is grasped with the contralateral instrument and the maneuver repeated until the entire hernia content is reduced. Subsequently, the sac is removed circumferentially using the monopolar electrocautery hook. The diaphragm is then closed with interupted figure-eight sutures of 2-0 silk. The operative time was 65 min, and there were no intraoperative complications. She was discharged home on postoperative day 5. Half a year later, she was asymptomatic without any signs of recurrence. In conclusion, the twisting technique allows for gentle, gradual reduction of diaphragmatic hernias with a sac without injury to the herniated viscera.
Collapse
Affiliation(s)
- Takafumi Kawano
- Department of Pediatric Surgery, University Medicine Mainz, Germany.
| | | |
Collapse
|
19
|
Schlager A, Arps K, Siddharthan R, Glenn I, Hill SJ, Wulkan ML, Keene SD, Clifton MS. Thoracoscopic Repair of Congenital Diaphragmatic Hernia After Extracorporeal Membrane Oxygenation: Feasibility and Outcomes. J Laparoendosc Adv Surg Tech A 2018; 28:774-779. [PMID: 29641364 DOI: 10.1089/lap.2016.0583] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Thoracoscopic repair of congenital diaphragmatic hernia (CDH) has been associated with faster recovery, earlier extubation, and decreased morbidity. Nevertheless, thoracoscopic repair is rarely attempted in the post-extracorporeal membrane oxygenation (ECMO) patient. Commonly cited reasons for not attempting thoracoscopy include concerns that the patients' respiratory status is too tenuous to tolerate insufflation pressures or that presumed defect size is so large that it precludes thoracoscopic repair. Our purpose is to review our experience with post-ECMO thoracoscopic CDH repair and evaluate the success of this approach. METHODS We performed retrospective analysis of attempted thoracoscopic CDH repairs after ECMO decannulation at our institution from 2001 to 2015. Primary outcome was rate of conversion. Secondary outcomes were intraoperative end-tidal CO2, time to extubation, and rate of recurrence. RESULTS We identified 21 post-ECMO patients in whom thoracoscopic CDH repair was attempted. Thoracoscopic repair was successfully completed in 28%. No patients had reported intolerance to insufflation at 3-7 mmHg. Average end-tidal CO2 at 15 operative minutes was 36.9 mmHg in the thoracoscopic group versus 50.7 mmHg in the open group and at 60 minutes was 34.25 mmHg versus 45.6 mmHg, respectively. One patient in the thoracoscopic group died and 1 experienced a large pneumothorax. In the converted group there was one clinically significant pneumothorax and three pleural effusions. Survivors after thoracoscopy were extubated an average of 5.6 ± 2.6 days after surgery versus 19.4 ± 10 days in the converted group (P < .05). Recurrence rates at last follow-up were equal between the two groups at 20%. CONCLUSIONS Thoracoscopic CDH repair is both safe and feasible after ECMO with no increase in operative morbidity or mortality. Insufflation pressures of 3-7 mmHg are well tolerated without undue increase in end-tidal CO2. When compared to conversion cases, thoracoscopic repair is associated with significantly decreased time to extubation with no difference in recurrence.
Collapse
Affiliation(s)
| | - Kelly Arps
- 2 Department of Surgery, Emory University/Children's Healthcare of Atlanta , Atlanta, Georgia
| | - Ragavan Siddharthan
- 3 Department of Surgery, Oregon Health and Sciences University , Portland, Oregon
| | - Ian Glenn
- 1 Akron Children's Hospital , Akron, Ohio
| | - Sarah J Hill
- 2 Department of Surgery, Emory University/Children's Healthcare of Atlanta , Atlanta, Georgia
| | - Mark L Wulkan
- 2 Department of Surgery, Emory University/Children's Healthcare of Atlanta , Atlanta, Georgia
| | - Sarah D Keene
- 2 Department of Surgery, Emory University/Children's Healthcare of Atlanta , Atlanta, Georgia
| | - Matthew S Clifton
- 2 Department of Surgery, Emory University/Children's Healthcare of Atlanta , Atlanta, Georgia
| |
Collapse
|
20
|
Outcomes for thoracoscopic versus open repair of small to moderate congenital diaphragmatic hernias. J Pediatr Surg 2018; 53:635-639. [PMID: 29055487 DOI: 10.1016/j.jpedsurg.2017.09.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/29/2017] [Accepted: 09/02/2017] [Indexed: 11/20/2022]
Abstract
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.
Collapse
|
21
|
Neunhoeffer F, Warmann SW, Hofbeck M, Müller A, Fideler F, Seitz G, Schuhmann MU, Kirschner HJ, Kumpf M, Fuchs J. Elevated intrathoracic CO 2 pressure during thoracoscopic surgery decreases regional cerebral oxygen saturation in neonates and infants-A pilot study. Paediatr Anaesth 2017; 27:752-759. [PMID: 28544108 DOI: 10.1111/pan.13161] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Intraoperative hypercapnia and acidosis are risk factors during thoracoscopy in neonates and infants. METHODS In a prospective pilot study, we evaluated the effects of thoracoscopy in neonates and infants on cerebral microcirculation, oxygen saturation, and oxygen consumption. Regional cerebral oxygen saturation and blood flow were measured noninvasively using a new device combining laser Doppler flowmetry and white light spectrometry. Additionally, cerebral fractional tissue oxygen extraction and approximated oxygen consumption were calculated. Fifteen neonates and infants undergoing thoracoscopy were studied using the above-mentioned method. The chest was insufflated with carbon dioxide with a pressure of 2-6 mm Hg. Single lung ventilation was not used. As control group served 15 neonates and infants undergoing abdominal surgery. RESULTS Data are presented as median and range. The 95% confidence intervals for differences of means (95% CI) are given for the mean difference from baseline values. We observed a correlation between intrathoracic pressure exceeding 4 mm Hg and transient decrease in regional cerebral oxygen saturation of 12.7% (95% CI: 9.7-17.2, P<.001). Peripheral oxygen saturation was normal at the same time. Intraoperative increase in arterial paCO2 (median maximum value: 48.8 mm Hg, range: [36.5-65.4]; 95% CI: -16.0 to -3.0, P=.002) and decrease in arterial pH (median minimum value: 7.3, range: [7.2-7.4]; 95% CI: 0.04-0.12, P=.008) were observed during thoracoscopy with both parameters recovering at the end of the procedure. Periods of regional cerebral oxygen saturation below 20% from baseline were significantly more frequent during thoracoscopy as compared to the control group (median maximum value: 1.3%min/h, range: [0.0-66.2] vs median maximum value: 0.0%min/h, range: [0.0-4.0]; 95% CI: -16.6 to -1.1, P=.028). CONCLUSION We suggest that thoracoscopic surgery in neonates and infants, although generally safe, may be associated with a decrease in regional cerebral oxygen saturation correlating with the applied intrathoracic pressure. According to our data an inflation pressure >4 mm Hg should be avoided during thoracoscopic surgery.
Collapse
Affiliation(s)
- Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital, Tuebingen, Germany
| | - Steven W Warmann
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Tuebingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital, Tuebingen, Germany
| | - Alisa Müller
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital, Tuebingen, Germany
| | - Frank Fideler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tuebingen, Germany
| | - Guido Seitz
- Department of Pediatric Surgery, University Hospital Giessen/Marburg, Marburg, Germany
| | - Martin U Schuhmann
- Department of Pediatric Neurosurgery, University Hospital, Tuebingen, Germany
| | - Hans-Joachim Kirschner
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Tuebingen, Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital, Tuebingen, Germany
| | - Jörg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Tuebingen, Germany
| |
Collapse
|
22
|
He QM, Zhong W, Zhang H, Li L, Wang Z, Tan Y, Lv J, Liu F, Yu J, Xia H. Standardized Indications to Assist in the Safe Thoracoscopic Repair of Congenital Diaphragmatic Hernia in Neonates. J Laparoendosc Adv Surg Tech A 2016; 26:399-403. [DOI: 10.1089/lap.2015.0327] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Qiu-ming He
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
- Southern Medical University, Guangzhou, Guangdong, China
| | - Wei Zhong
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Hong Zhang
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Le Li
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Zhe Wang
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yunpu Tan
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Junjian Lv
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Fen Liu
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jiakang Yu
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Huimin Xia
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
- Southern Medical University, Guangzhou, Guangdong, China
| |
Collapse
|
23
|
Puligandla PS, Grabowski J, Austin M, Hedrick H, Renaud E, Arnold M, Williams RF, Graziano K, Dasgupta R, McKee M, Lopez ME, Jancelewicz T, Goldin A, Downard CD, Islam S. Management of congenital diaphragmatic hernia: A systematic review from the APSA outcomes and evidence based practice committee. J Pediatr Surg 2015; 50:1958-70. [PMID: 26463502 DOI: 10.1016/j.jpedsurg.2015.09.010] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/06/2015] [Accepted: 09/09/2015] [Indexed: 10/23/2022]
Abstract
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.
Collapse
Affiliation(s)
| | | | - Mary Austin
- The University of Texas Medical School at Houston
| | | | | | | | - Regan F Williams
- University of Tennessee Health Science Center, Le Bonheur Children's Hospital
| | | | | | | | | | - Tim Jancelewicz
- University of Tennessee Health Science Center, Le Bonheur Children's Hospital
| | - Adam Goldin
- Seattle Children's Hospital, University of Washington
| | - Cynthia D Downard
- Kosair Children's Hospital, University of Louisville, Louisville, KY
| | | |
Collapse
|
24
|
Lacher M, St Peter SD, Laje P, Harmon CM, Ure B, Kuebler JF. Thoracoscopic CDH Repair—A Survey on Opinion and Experience Among IPEG Members. J Laparoendosc Adv Surg Tech A 2015; 25:954-7. [DOI: 10.1089/lap.2015.0243] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Martin Lacher
- Center of Pediatric Surgery, Hannover Medical School, Hannover, Germany
- Department of Pediatric Surgery, University of Leipzig, Leipzig, Germany
| | - Shawn D. St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Pablo Laje
- Division of General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Carroll M. Harmon
- Department of Surgery, State University of New York at Buffalo, Buffalo, New York
| | - Benno Ure
- Center of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | | |
Collapse
|
25
|
Abstract
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.
Collapse
Affiliation(s)
- Merrill McHoney
- Royal Hospital for Sick Children Edinburgh, Sciennes Road, Edinburgh, EH9 1LF, UK.
| |
Collapse
|
26
|
Thoracoscopic versus open repair of CDH in cardiovascular stable neonates. Surg Endosc 2015; 30:2818-24. [PMID: 26490767 PMCID: PMC4912591 DOI: 10.1007/s00464-015-4560-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 09/04/2015] [Indexed: 11/17/2022]
Abstract
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.
Collapse
|
27
|
Zhu Y, Wu Y, Pu Q, Ma L, Liao H, Liu L. Minimally invasive surgery for congenital diaphragmatic hernia: a meta-analysis. Hernia 2015; 20:297-302. [PMID: 26438082 PMCID: PMC4789196 DOI: 10.1007/s10029-015-1423-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Accepted: 09/12/2015] [Indexed: 02/05/2023]
Abstract
Objectives To compare the safety and efficacy of minimally invasive surgery (MIS) with traditional open surgical approach for congenital diaphragmatic hernia (CDH). Methods A literature search was performed using the PubMed database, Embase, and the Cochrane central register of controlled trials using a defined set of criteria. The outcomes, which include post-operative mortality, incidence of hernia recurrence, rates of patch use and complications, were analyzed. Results We investigated nine studies, which included 507 patients. All studies were non-randomized historical control trials. The MIS group had a significantly lower rate of post-operative death with a risk ratio of 0.26 [95 % confidence interval (CI) 0.10–0.68; p = 0.006] but a greater incidence of hernia recurrence with a risk ratio of 3.42 (95 % CI 1.98–5.88; p < 0.00001). Rates of prosthetic patch use were similar between the two groups. Fewer cases of surgical complications were found in the MIS group with a risk ratio of 0.66 (95 % CI 0.47–0.94; p = 0.02). Conclusions MIS for CDH repair is associated with lower post-operative mortality and morbidity compared with traditional open repair. Although rate of patch use appears to be comparable, the increased risk of CDH recurrence should not be ignored. The lack of well-controlled prospective trials still limits strong evaluations of the two surgical techniques.
Collapse
Affiliation(s)
- Y Zhu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, 610041, Chengdu, People's Republic of China
| | - Y Wu
- Department of Pediatric Surgery, West China Hospital, Sichuan University, 610041, Chengdu, People's Republic of China
| | - Q Pu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, 610041, Chengdu, People's Republic of China
| | - L Ma
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, 610041, Chengdu, People's Republic of China
| | - H Liao
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, 610041, Chengdu, People's Republic of China
| | - L Liu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, 610041, Chengdu, People's Republic of China.
| |
Collapse
|
28
|
Fujishiro J, Ishimaru T, Sugiyama M, Arai M, Suzuki K, Kawashima H, Iwanaka T. Minimally invasive surgery for diaphragmatic diseases in neonates and infants. Surg Today 2015; 46:757-63. [PMID: 27246508 DOI: 10.1007/s00595-015-1222-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 06/29/2015] [Indexed: 10/23/2022]
Abstract
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.
Collapse
Affiliation(s)
- Jun Fujishiro
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Tetsuya Ishimaru
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Masahiko Sugiyama
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Mari Arai
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Keisuke Suzuki
- Division of Surgery, Saitama Children's Medical Center, Magome 2100, Iwatsuki-ku, Saitama, Saitama, 339-8551, Japan
| | - Hiroshi Kawashima
- Division of Surgery, Saitama Children's Medical Center, Magome 2100, Iwatsuki-ku, Saitama, Saitama, 339-8551, Japan
| | - Tadashi Iwanaka
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan.,Saitama Children's Medical Center, Magome 2100, Iwatsuki-ku, Saitama, Saitama, 339-8551, Japan
| |
Collapse
|
29
|
Davenport M, Rothenberg SS, Crabbe DCG, Wulkan ML. The great debate: open or thoracoscopic repair for oesophageal atresia or diaphragmatic hernia. J Pediatr Surg 2015; 50:240-6. [PMID: 25638610 DOI: 10.1016/j.jpedsurg.2014.11.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 11/02/2014] [Indexed: 10/24/2022]
Abstract
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.
Collapse
Affiliation(s)
- Mark Davenport
- Department of Paediatric Surgery, Kings College Hospital, London, UK.
| | - Steven S Rothenberg
- 2055 High St Suite 370, Rocky Mountain Hospital For Children, Denver, CO, USA.
| | - David C G Crabbe
- Department of Paediatric Surgery, Leeds General Infirmary, Leeds, UK.
| | - Mark L Wulkan
- Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, GA, USA.
| |
Collapse
|
30
|
Harting MT, Lally KP. The Congenital Diaphragmatic Hernia Study Group registry update. Semin Fetal Neonatal Med 2014; 19:370-5. [PMID: 25306471 DOI: 10.1016/j.siny.2014.09.004] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The Congenital Diaphragmatic Hernia Study Group (CDHSG) is an international consortium of centers that prospectively collect and voluntarily contribute data about live-born CDH patients they manage. These data are compiled to form a registry from which any participating center may utilize the dataset to answer specific clinical questions and monitor outcomes. Since its inception in 1995, 112 centers have participated (including 66 centers from 13 countries currently active), data on more than eight thousand total children have been collected, and 35 manuscripts have been generated using registry data. This review covers the formation and structure of the CDH study group and registry, including function, center involvement, and the evolution of data collection. We also review reports generated by the CDHSG, with particular focus on the work after 2008. International multicenter consortiums, such as the CDHSG, allow physicians that manage uncommon, complex, heterogeneous diseases to develop evidence-based hypotheses and conclusions for clinical questions.
Collapse
Affiliation(s)
- Matthew T Harting
- Department of Pediatric Surgery, University of Texas Medical School at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA.
| | - Kevin P Lally
- Department of Pediatric Surgery, University of Texas Medical School at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| |
Collapse
|
31
|
Abstract
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.
Collapse
|
32
|
Lacher M, Kuebler JF, Dingemann J, Ure BM. Minimal invasive surgery in the newborn: current status and evidence. Semin Pediatr Surg 2014; 23:249-56. [PMID: 25459008 DOI: 10.1053/j.sempedsurg.2014.09.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The evolution of minimally invasive surgery (MIS) in the newborn has been delayed due to the limited working space and the unique physiology. With the development of smaller instruments and advanced surgical skills, many of the initial obstacles have been overcome. MIS is currently used in specialized centers around the world with excellent feasibility. Obvious advantages include better cosmesis, less trauma, and better postoperative musculoskeletal function, in particular after thoracic procedures. However, the aim of academic studies has shifted from proving feasibility to a critical evaluation of outcome. Prospective randomized trials and high-level evidence for the benefit of endoscopic surgery are still scarce. Questions to be answered in the upcoming years will therefore include both advantages and potential disadvantages of MIS, especially in neonates. This review summarizes recent developments of MIS in neonates and the evidence for its use.
Collapse
Affiliation(s)
- Martin Lacher
- Center of Pediatric Surgery, Hannover Medical School, Carl Neuberg St. 1, Hannover 30625, Germany.
| | - Joachim F Kuebler
- Center of Pediatric Surgery, Hannover Medical School, Carl Neuberg St. 1, Hannover 30625, Germany
| | - Jens Dingemann
- Center of Pediatric Surgery, Hannover Medical School, Carl Neuberg St. 1, Hannover 30625, Germany
| | - Benno M Ure
- Center of Pediatric Surgery, Hannover Medical School, Carl Neuberg St. 1, Hannover 30625, Germany
| |
Collapse
|
33
|
Chan E, Wayne C, Nasr A. Minimally invasive versus open repair of Bochdalek hernia: a meta-analysis. J Pediatr Surg 2014; 49:694-9. [PMID: 24851750 DOI: 10.1016/j.jpedsurg.2014.02.049] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 02/13/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Diaphragmatic hernia can be repaired by open or minimally invasive surgery (MIS), although it is unclear which technique has better outcomes. Our objective was to compare the outcomes of these procedures in a systematic review and meta-analysis. METHODS We sought all publications describing both techniques through MEDLINE, Embase, and CENTRAL. Our primary outcome of interest was recurrence. We conducted statistical analyses using Review Manager 5.2. RESULTS We did not identify any randomized controlled trials. Our pooled estimate of results from 10 studies showed that total recurrence was higher after MIS (OR: 2.81 [1.73, 4.56], p<0.001). Subgroup analyses indicated higher recurrence after MIS for patch repairs (OR: 4.29 [2.13, 8.67], p<0.001), but not for primary repairs. Operative time was longer for MIS (MD: 55.25 [40.21, 70.28], p<0.001), while postoperative ventilator time and postoperative mortality were higher after open surgery (MD: 1.33 [0.05, 2.62], p= 0.04; OR: 7.54 [3.36, 16.90], p<0.001, respectively). CONCLUSIONS Recurrence rate is higher after MIS than open repair when a patch is used. Operative time is also longer with MIS. Poorer outcomes after open surgery may be a result of selection bias rather than surgical technique. Surgeons should carefully consider the potential morbidity associated with MIS when deciding on a repair method.
Collapse
Affiliation(s)
- Emily Chan
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Carolyn Wayne
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Ahmed Nasr
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada.
| |
Collapse
|
34
|
Barsness KA, Rooney DM, Davis LM. The Development and Evaluation of a Novel Thoracoscopic Diaphragmatic Hernia Repair Simulator. J Laparoendosc Adv Surg Tech A 2013; 23:714-8. [DOI: 10.1089/lap.2013.0196] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Katherine A. Barsness
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Deborah M. Rooney
- Department of Medical Education, University of Michigan Medical School, Ann Arbor, Michigan
| | - Lauren M. Davis
- Center for Simulation Technology and Immersive Learning, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
35
|
Cha C, Hong YJ, Chang EY, Chang HK, Oh JT, Han SJ. Minimally invasive surgery in infants with congenital diaphragmatic hernia: outcome and selection criteria. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2013; 85:84-8. [PMID: 23908966 PMCID: PMC3729992 DOI: 10.4174/jkss.2013.85.2.84] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 05/10/2013] [Accepted: 05/16/2013] [Indexed: 11/30/2022]
Abstract
Purpose The aim of the study was to determine clinical indications for performing minimally invasive surgery (MIS) with acceptable results by reviewing our experience in congenital diaphragmatic hernia (CDH) repair and comparing outcomes of MIS with open surgery. Methods Medical records of patients who underwent CDH repair were reviewed retrospectively between January 2008 and December 2012, and outcomes were compared between MIS and open repair of CDH. Results From 2008 to 2012, 35 patients were operated on for CDH. Among these patients, 20 patients underwent open surgery, and 15 patients underwent MIS. Patients with delayed presentations (60.0% [9/15] in the MIS group vs. 20.0% [4/20] in the open surgery group; P = 0.015) and small diaphragmatic defect less than 3 cm (80.0% [12/15] in the MIS group vs. 0.0% [0/20] in the open surgery group; P < 0.001) were more frequently in the MIS group than the open surgery group. All 10 patients who also had other anomalies underwent open surgery (P = 0.002). Moreover, nine patients who needed a patch for repair underwent open surgery (P = 0.003). Patients in the MIS group showed earlier enteral feeding and shorter hospital stays. There was no recurrence in either group. Conclusion CDH repair with MIS can be suggested as the treatment of choice for patients with a small sized diaphragmatic defect, in neonates with stable hemodynamics and without additional anomalies, or in infants with delayed presen tation of CDH, resulting in excellent outcomes.
Collapse
Affiliation(s)
- Chihwan Cha
- Department of Pediatric Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | | | | | | | | |
Collapse
|