Delayed surgical repair and ECMO improves survival in congenital diaphragmatic hernia

Surgical Management of Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernia (CDH) is a challenging surgical disease that requires complex preoperative, perioperative, and postoperative care. Survival depends on successful reduction and repair of the defect, and numerous complex decisions must be made regarding timing and preparation for surgery. This review describes the challenges and controversies inherent to surgical CDH care and provides recommendations for management based on the most recent evidence.

Operative repair in congenital diaphragmatic hernia: How long do we really need to wait?

OBJECTIVE

To analyze preoperative cardiopulmonary support and define preoperative stability relative to timing of surgical repair for CDH neonates not on ECMO.

STUDY DESIGN

We retrospectively analyzed repeated measures of oxygenation index (OI; Paw*FiO₂×100/PaO₂) among 158 neonates for temporal preoperative trends. We defined physiologic stability using OI and characterized ventilator days and discharge age relative to delay in repair beyond physiologic stability.

RESULTS

The OI in the first 24 h of life was temporally reliable and representative of the preoperative mean (ICC 0.70, 95% CI 0.61-0.77). A pre-operative OI of ≤ 9.4 (AUC 0.95) was predictive of survival. Surgical delay after an OI ≤ 9.4 resulted in increased ventilator days (1.4, 95% CI 1.1-1.9) and discharge age (1.5, 95% CI 1.2-2.0). When prospectively applied to a subsequent cohort, an OI ≤ 9.4 was again reflective of physiologic stability prior to repair.

CONCLUSION

OI values are temporally reliable and change minimally after 24 h age. Delay in surgical repair of CDH beyond initial stability increases ventilator days and discharge age without a survival benefit.

LEVEL OF EVIDENCE

Prognosis study, Level III.

Discipline-Specific Perspectives on Caring for Babies with Trisomy 13 or 18 in the Neonatal Intensive Care Unit

OBJECTIVE

Care offerings vary across medical settings and between families for babies with trisomy 13 or 18. The purpose of this qualitative descriptive study was to explore nurse, advanced practice practitioner, and neonatologist perspectives on care for babies with trisomy 13 or 18 in the intensive care unit.

STUDY DESIGN

Voice-recorded qualitative interviews occurred with 64 participants (41 bedside nurses, 14 advance practice practitioners, and 9 neonatologists) from two neonatal intensive care units (NICU) in the midwestern United States. Consolidated Criteria for Reporting Qualitative Research guidelines were followed. Content analyses occurred utilizing MAXQDA (VERBI Software, 2020).

RESULTS

Over half of NICU staff perceived care for babies with trisomy 13 or 18 as different from care for other babies with critical chronic illness. Qualitative themes included internal conflict, variable presentation and prognosis, grappling with uncertainty, family experiences, and provision of meaningful care. Neonatologists emphasized the variability of presentation and prognosis, while nurses emphasized provision of meaningful care. Phrases "hard/difficult" were spoken 31 times; primarily describing the comorbidities, complexities, and prognostic uncertainty.

CONCLUSION

Care for babies with these genetic diagnoses reveals need for a shared dialogue not only with families but also across staff disciplines. While perspectives differ, participants depicted striving to offer compassionate, family-centered care while also balancing biomedical uncertainty about interventions for children with trisomy 13 and 18.

KEY POINTS

· Care for babies with trisomy 13 or 18 has been recognized as shifting.. · Controversy exists across the diverse and changing range of care models.. · This study describes perspectives of bedside neonatal nurses, advanced practitioners, and neonatologists.. · Differences in perspectives warrant attentiveness to insights and dialogue across disciplines..

Clinical guidelines for the treatment of congenital diaphragmatic hernia

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

Interdisciplinary care of children with trisomy 13 and 18

Children with trisomy 13 and 18 (previously deemed "incompatible with life") are living longer, warranting a comprehensive overview of their unique comorbidities and complex care needs. This Review Article provides a summation of the recent literature, informed by the study team's Interdisciplinary Trisomy Translational Program consisting of representatives from: cardiology, cardiothoracic surgery, neonatology, otolaryngology, intensive care, neurology, social work, chaplaincy, nursing, and palliative care. Medical interventions are discussed in the context of decisional-paradigms and whole-family considerations. The communication format, educational endeavors, and lessons learned from the study team's interdisciplinary care processes are shared with recognition of the potential for replication and implementation in other care settings.

Update on Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the diaphragm, characterized by herniation of abdominal contents into the chest that results in varying degrees of pulmonary hypoplasia and pulmonary hypertension (PH). Significant advances in the prenatal diagnosis and identification of prognostic factors have resulted in the continued refinement of the approach to fetal therapies for CDH. Postnatally, protocolized approaches to lung-protective ventilation, nutrition, prevention of infection, and early aggressive management of PH have led to improved outcomes in infants with CDH. Advances in our understanding of the associated left ventricular (LV) hypoplasia and myocardial dysfunction in infants with severe CDH have allowed for the optimization of hemodynamics and management of PH. This article provides a comprehensive review of CDH for the anesthesiologist, focusing on the complex pathophysiology, advances in prenatal diagnosis, fetal interventions, and optimal postnatal management of CDH.

The role of ECMO in the management of congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is the most common indication for extra-corporeal membrane oxygenation (ECMO) for neonatal respiratory failure. CDH management is evolving with advanced prenatal diagnostic imaging modalities. The risk profiles of infants receiving ECMO for CDH are shifting towards higher risk. Many clinicians are developing and following clinical practice guidelines to standardize and optimize the care of CDH neonates. Despite these efforts, there are significant differences in the practice patterns among ECMO centers as to how and when they choose to initiate ECMO for CDH, when they believe repair is safe, as well as many other nuances that are based on center experience or style. The purpose of this report is to summarize our current understanding of the new and recent developments regarding management of infants with CDH managed with ECMO.

Congenital diaphragmatic hernia repair in patients on extracorporeal membrane oxygenation: How early can we repair?

BACKGROUND

The benefits to early repair (<72 h postcannulation) of infants with congenital diaphragmatic hernia (CDH) on extracorporeal membrane oxygenation (ECMO) are increasingly recognized. Yet it is not known if even earlier repair (<24 h) results in comparable or improved patient outcomes. The goal of this study was to compare "super-early" (<24 h) to early repair (24-72 h) of CDH patients on ECMO.

METHODS

A retrospective review of infants with CDH placed on ECMO (2004-2017; n = 72) was performed. Data collected on the patients repaired while on ECMO within 72 h of cannulation (n = 33) included pre- and postnatal disease severity stratification variables and postnatal outcomes. Comparison groups were those patients repaired within 24 h of cannulation (n = 14) and those repaired between 24 and 72 h postcannulation (n = 19).

RESULTS

Patients undergoing "super-early" (<24 h) repair had an average survival of 71.4% compared to the average survival of 59.7% in the early repair group. Pre- and postnatal variables predicting disease severity were not significantly different between the groups. Mean hospital stays, ventilator days, and cannulation days were statistically similar between the groups.

CONCLUSIONS

Repair of patients with CDH patients on ECMO at less than 24 h postcannulation achieves outcomes that are comparable to those of repair between 24 and 72 h. While the present data suggest that there is not a "too early" time point for CDH repair on ECMO, larger multicenter studies are needed to validate our findings and determine the overall benefits.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Early versus late surgical correction in congenital diaphragmatic hernia

INTRODUCTION

The timing of surgical repair in patients with congenital diaphragmatic hernia has been a controversial topic over the years, and there is still no agreement as to whether immediate repair or late surgery with preoperative stabilization is preferable.

METHODS

To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS

We identified four systematic reviews including 38 studies overall, of which two were randomized trials. We concluded it is not clear whether immediate surgical repair in congenital diaphragmatic hernia increases mortality or decreases hospitalization days compared to late repair because the certainty of evidence is very low.

Congenital diaphragmatic hernia: outcomes of neonates treated at Mayo Clinic with and without extracorporeal membrane oxygenation

BACKGROUND

Congenital diaphragmatic hernia (CDH) is a rare anomaly with high mortality and long-term comorbid conditions.

AIMS

Our aim was to describe the presenting characteristics, treatment, and outcomes of consecutive patients with CDH treated at our institution.

METHODS

We performed a retrospective cohort study and identified consecutive neonates treated for CDH from 2001 to 2015 at our institution. For all patients identified, we reviewed hospital and postdischarge data for neonatal, disease, and treatment characteristics. We determined hospital survival overall and also according to the presence of prenatal diagnosis, liver herniation into the chest (liver up), and the use of extracorporeal membrane oxygenation (ECMO) in addition to surgery. We evaluated postdischarge chronic conditions in patients with at least one year of follow-up.

RESULTS

Thirty-eight neonates were admitted for treatment during the study period. In three who were in extremis, life support was withdrawn. The other 35 underwent surgical repair, of whom eight received ECMO. The overall survival was 79% (30/38). Survival for those who had surgical correction of CDH but did not need ECMO was 89% (24/27); it was 75% (6/8) for those who received ECMO and had surgery. Hospital survival was lower for liver-up vs liver-down CDH (61% [11/18] vs 95% [19/20]; odds ratio, 0.08; 95% CI, 0.01-0.77; P = 0.01). Among survivors, the median duration of hospitalization was 31 (interquartile range, 20-73) days. Major chronic pulmonary and gastrointestinal disorders, failure to thrive, and neurodevelopmental delays were the most noted comorbid conditions after discharge, and all were more prevalent in those who required ECMO.

CONCLUSION

The overall survival of neonates with CDH was 79%. Intrathoracic liver herniation was associated with more frequent use of ECMO and greater mortality. A substantial number of survivors, especially those who required ECMO, experienced chronic conditions after discharge.

Should Extracorporeal Membrane Oxygenation Be Offered? An International Survey

OBJECTIVES

To assess the current attitudes of extracorporeal membrane oxygenation (ECMO) program directors regarding eligibility for ECMO among children with cardiopulmonary failure.

STUDY DESIGN

Electronic cross-sectional survey of ECMO program directors at ECMO centers worldwide within the Extracorporeal Life Support Organization directory (October 2015-December 2015).

RESULTS

Of 733 eligible respondents, 226 (31%) completed the survey, 65% of whom routinely cared for pediatric patients. There was wide variability in whether respondents would offer ECMO to any of the 5 scenario patients, ranging from 31% who would offer ECMO to a child with trisomy 18 to 76% who would offer ECMO to a child with prolonged cardiac arrest and indeterminate neurologic status. Even physicians practicing the same specialty sometimes held widely divergent opinions, with 50% of pediatric intensivists stating they would offer ECMO to a child with severe developmental delay and 50% stating they would not. Factors such as quality of life and neurologic status influenced decision making and were used to support decisions for and against offering ECMO.

CONCLUSIONS

ECMO program directors vary widely in whether they would offer ECMO to various children with cardiopulmonary failure. This heterogeneity in physician decision making underscores the need for more evidence that could eventually inform interinstitutional guidelines regarding patient selection for ECMO.

Appropriate timing of surgery for neonates with congenital diaphragmatic hernia: early or delayed repair?

PURPOSE

This study was aimed to evaluate the influence of timing of surgery on patient outcomes, and to clarify appropriate timing of surgery in neonates with congenital diaphragmatic hernia (CDH).

METHODS

A total of 477 neonates with isolated CDH were included. Patients were classified into two groups by timing of surgery: early repair (ER) (≤48 h) and delayed repair (DR) (>48 h). The primary outcome was 90-day survival, with treatment duration (ventilation, oxygen, and hospitalization) being a secondary outcome. To adjust for disease severity, patients were stratified into three severities by Apgar score 1 min ("mild" 8-10, "moderate" 4-7, and "severe" 0-3), and outcomes were compared between ER and DR within each severity.

RESULTS

Although 90-day survival was significantly different among the three severities ("mild" 97%, "moderate" 89%, and "severe" 76%, p = 0.002), there were no differences in 90-day survival between DR and ER within each severity. In "mild", there were no differences in treatment duration between ER and DR. In "moderate", treatment duration was shorter in ER than DR (ventilation 11 vs. 16 days, oxygen 15 vs. 20 days, and hospitalization 34 vs. 48 days). In "severe", treatment duration was shorter in ER than DR, while the best OI was higher in DR than ER.

CONCLUSIONS

Timing of CDH repair seems to have no influence on 90-day survival regardless of disease severity. Patients with moderate severity may benefit from the early repair by reducing treatment duration.

Recurrent diaphragmatic hernia: Modifiable and non-modifiable risk factors

RATIONALE

The risk of recurrence of Congenital Diaphragmatic Hernia (CDH) in an era of thoracoscopic surgery is unclear.

OBJECTIVES

(1) estimate the incidence and (2) evaluate the perioperative factors associated with the symptomatic recurrence of CDH.

METHODS

Medical records of CDH infants operated on in the neonatal period at a single-tertiary hospital between January 2000 and January 2013 were retrospectively reviewed.

RESULTS

Of 119 infants with CDH, 34 (28.6%) were excluded: 17 (14.3%) died without recurrence and 17 (14.3%) presented beyond neonatal period or were followed elsewhere. Of 85 survivors, 71 infants had an open repair and 14 had a thoracoscopic repair. Eleven of 85 survivors (13%) developed a recurrence on average 19.8 weeks (range 15-34) after the initial repair. Of 11 recurrences, 6 had an initial thoracoscopic repair and 5 had an open repair (6/14 [43%] vs. 5/71 [7%]; P = 0.002). Two children had multiple recurrences. Statistically significant associations were found between recurrence and the presence of persistent pulmonary hypertension (PPHTN) (P = 0.006), severe PPHTN (P = 0.002), inhaled nitric oxide, or sildenafil use for treatment of PPHTN (P = 0.002), need for perioperative high frequency oscillatory ventilation (HFOV) (P = 0.0006), length of hospital stay (LOS) (P = 0.02), duration of ventilation (P = 0.016), and need for home oxygen (P = 0.003). In multivariate regression analysis both the closure type and home oxygen requirement were statistically significant, independent factors predicting a recurrence (P = 0.04 and 0.02, respectively) but the type of surgery (thoracoscopic vs. open) only approached significance (P = 0.052). The recurrence rate for the seven surgeons who performed at least 5 repairs ranged from 7% to 40%.

CONCLUSIONS

A high survival rate of 85% with a 13% incidence of symptomatic CDH recurrence was demonstrated. Potentially, improved selection of cases for thoracoscopic repair and concentrating the thoracoscopic technique amongst a dedicated team of experienced thoracoscopic surgeons may reduce the rate of recurrence of CDH.

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.

Clinical and billing review of extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) is a temporary technique for providing life support for cardiac dysfunction, pulmonary dysfunction, or both. The two forms of ECMO, veno-arterial (VA) and veno-venous (VV), are used to support cardiopulmonary and pulmonary dysfunction, respectively. Historically, ECMO was predominantly used in the neonatal and pediatric populations, as early adult studies failed to improve outcomes. ECMO has become far more common in the adult population because of positive results in published case series and clinical trials during the 2009 influenza A(H1N1) pandemic in 2009 to 2010. Advances in technology that make the technique much easier to implement likely fueled the renewed interest. Although exact criteria for ECMO are not available, patients who are good candidates are generally considered to be relatively young and suffering from acute illness that is believed to be reversible or organ dysfunction that is otherwise treatable. With the increase in the use in the adult population, a number of different codes have been generated to better identify the method of support with distinctly different relative value units assigned to each code from a very simple prior coding scheme. To effectively be reimbursed for use of the technique, it is imperative that the clinician understands the new coding scheme and works with payers to determine what is incorporated into each specific code.

Acute Neonatal Respiratory Failure

Acute respiratory failure requiring assisted ventilation is one of the most common reasons for admission to the neonatal intensive care unit. Respiratory failure is the inability to maintain either normal delivery of oxygen to the tissues or normal removal of carbon dioxide from the tissues. It occurs when there is an imbalance between the respiratory workload and ventilatory strength and endurance. Definitions are somewhat arbitrary but suggested laboratory criteria for respiratory failure include two or more of the following: PaCO₂ > 60 mmHg, PaO₂ < 50 mmHg or O₂ saturation <80 % with an FiO₂ of 1.0 and pH < 7.25 (Wen et al. 2004).

Congenital diaphragmatic hernia: treatment and outcomes

Congenital diaphragmatic hernia (CDH) is a congenital defect in the diaphragm that allows herniation of abdominal contents into the fetal chest and leads to varying degrees of pulmonary hypoplasia and pulmonary hypertension. Advances in prenatal diagnosis and the institution of standardized delivery and postnatal care protocols have led to improved survival. Fetal endoscopic tracheal occlusion shows early promise for patients with the most severe CDH, but prospective randomized data is still required. CDH survivors have a variety of associated morbidities that require long-term follow-up and early intervention strategies for optimal care.

Single incisional approach for reconstruction of hypospadias and concomitant inguinal hernia

OBJECTIVE

To demonstrate the feasibility, cosmetic outcome and therapeutic values of our single incisional approach in patients with both hypospadias and inguinal hernia (IH) in comparison with standard multiple incisional techniques.

MATERIALS AND METHODS

Sixty hypospadias-IH repairs were performed from February 2005 to February 2012. These patients were divided into two groups according to their age and hypospadias location. They were then separated randomly into multiple incision (MIG) and single incision (SIG) groups. Early and late complications were taken into consideration. Postoperative pain, need for analgesics, operative time, hospital stay and cosmetic results were recorded for further evaluation.

RESULTS

Patients were followed up at 6-month intervals for up to 2 years postoperatively. Early and late complication rates were approximately the same in the two groups. 73.3% of patients in MIG and 96.6% in SIG attained an excellent cosmetic result according to two external surgeons. There was no case with poor cosmetic outcome in either group. More analgesic consumption was demanded in MIG patients.

CONCLUSION

This method of surgery is reproducible with better cosmetic outcome and a slightly shorter hospital stay. It could be a viable option in the management of children with hypospadias and concomitant IH. Negligible postoperative pain and short operative time are the other advantages.

Costs of congenital diaphragmatic hernia repair in the United States-extracorporeal membrane oxygenation foots the bill

BACKGROUND

Congenital diaphragmatic hernia (CDH) is the costliest noncardiac congenital defect. Extracorporeal membrane oxygenation (ECMO) is a treatment strategy offered to those babies with CDH who would not otherwise survive on conventional therapy. The primary objective of our study was to identify the leading source of expenditures in CDH care.

METHODS

All patients surviving CDH repair were identified in the Kids' Inpatient Database (KID) from 1997 to 2006, with costs converted to 2006 US dollars. Patients were categorized into groups based on severity of disease for comparison including CDH repair only, prolonged ventilator dependence, and ECMO use. Factors associated with greater expenditures in CDH management were analyzed using a regression model.

RESULTS

Eight hundred thirty-nine patients from 213 hospitals were studied. Extracorporeal membrane oxygenation use decreased from 18.2% in 1997 to 11.4% in 2006 (P = .002). Congenital diaphragmatic hernia survivors managed with ECMO cost more than 2.4 times as much as CDH survivors requiring only prolonged ventilation postrepair and 3.5 times as much as those with CDH repair only (both P < .001). Age, multiplicity of diagnoses, patient transfer, inhaled nitric oxide use, prolonged ventilation, and ECMO use were all associated with higher costs. Extracorporeal membrane oxygenation use was the single most important factor associated with higher costs, increasing expenditures 2.4-fold (95% confidence interval, 2.1-2.8). Though the CDH repair with ECMO group constituted 12.2% of patients, this group has the highest median costs ($156,499.90/patient) and constitutes 28.5% of national costs based on CDH survivors in the KID. Annual national cost for CDH survivors is $158 million based on the KID, and projected burden for all CDH patients exceeds $250 million/year.

CONCLUSIONS

Extracorporeal membrane oxygenation use is the largest contributing factor to the economic burden in CDH. With limited health care resources, judicious resource utilization in CDH care merits further study.

Perinatal management of congenital diaphragmatic hernia: when and how should babies be delivered? Results from the Canadian Pediatric Surgery Network

PURPOSE

A prenatal diagnosis of congenital diaphragmatic hernia (CDH) enables therapeutic decision making during the intrapartum period. This study seeks to identify the gestational age and delivery mode associated with optimal outcomes.

PATIENTS AND METHODS

A national data set was used to study CDH babies born between 2005 and 2009. The primary outcome was survival to discharge. Primary and secondary outcomes were analyzed by categorical gestational age (preterm, <37 weeks; early term, 37-38 weeks; late term, >39 weeks) by intended and actual route of delivery and by birth plan conformity, regardless of route.

RESULTS

Of 214 live born babies (gestational age, 37.6 ± 4.0 weeks; birth weight, 3064 ± 696 g), 143 (66.8%) had a prenatal diagnosis and 174 (81.3%) survived to discharge. Among 143 prenatally diagnosed pregnancies, 122 (85.3%) underwent abdominal delivery (AD) and 21 (14.6%) underwent cesarean delivery (CS). Conformity between intended and actual delivery occurred in 119 (83.2%). Neither categorical gestational age nor delivery route influenced outcome. Although babies delivered by planned CS had a lower mortality than those delivered by planned AD (2/21 and 36/122, respectively; P = .04), this difference was not significant by multivariate analysis. Conformity to any birth plan was associated with a trend toward improved survival.

CONCLUSION

Our data do not support advocacy of any specific delivery plan or route nor optimal gestational age for prenatally diagnosed CDH.

Congenital diaphragmatic hernia: long-term risk of gastroesophageal reflux disease

OBJECTIVES

Gastroesophageal reflux disease (GERD) is a well-recognized consequence of congenital diaphragmatic hernia (CDH). Results of studies examining predictive factors for early and late GERD are inconclusive. The aim of this study was to assess the incidence of early (<2 years) and late GERD (≥6 years) following CDH repair and to identify predictive variables.

PATIENTS AND METHODS

Of 183 patients born with high-risk CDH, 107 survived and 38 were excluded. Perinatal and postnatal data of 69 eligible patients were analysed to identify variables predictive for early GERD. For the follow-up study, 58 patients (84%) (ages 12.1 ± 3.4 years; range 6-17) completed a standardised questionnaire. Results were compared with those from a healthy control group (n = 83). Patients who had a score indicating increased risk of GERD underwent further diagnostic assessment. Predictive factors for early and late GERD were identified using multivariate regression analysis.

RESULTS

Early GERD was demonstrated in 27 patients (39%). Patch closure and intrathoracic position of the stomach were independent predictive variables for early GERD. At the time of follow-up, 9 of 58 patients (16%) had symptoms suggestive of GERD. In 7 patients (12%), late GERD was confirmed. For late GERD, however, no perinatal or postnatal risk factors were identified.

CONCLUSIONS

Early GERD is more common in CDH patients with patch closure or intrathoracic position of the stomach. Predictive factors for late GERD could not be identified and screening for early GERD does not protect for future GERD; therefore, long-term follow-up for GERD in CDH survivors is mandatory.

Early repair of congenital diaphragmatic hernia on extracorporeal membrane oxygenation

BACKGROUND

Timing of repair of congenital diaphragmatic hernia (CDH) in babies that require stabilization on extracorporeal membrane oxygenation (ECMO) remains controversial. Although many centers delay operation until physiologic stabilization has occurred or ECMO is no longer needed, we repair soon after ECMO has been initiated. The purpose of this study is to determine if our approach has achieved acceptable morbidity and mortality.

METHODS

Charts of live-born babies with CDH treated at our institution between 1993 and 2007 were retrospectively reviewed. Data were then compared with The Congenital Diaphragmatic Hernia Study Group and Extracorporeal Life Support Organization registries.

RESULTS

Forty-eight (39%) patients required ECMO Thirty-four of these 48 neonates were cannulated before operative repair. Venoarterial ECMO was used exclusively. The mean (SD) time of repair from cannulation was 55 (21) hours. Survival for this subset of patients was 71%. Three patients (8.8%) who underwent repair on ECMO experienced surgical site hemorrhage that required intervention.

CONCLUSION

Early repair of CDH in neonates on ECMO can be accomplished with acceptable rates of morbidity and mortality.

CONTEMPORARY NEONATAL INTENSIVE CARE MANAGEMENT IN CONGENITAL DIAPHRAGMATIC HERNIA: DOES THIS OBVIATE THE NEED FOR FETAL THERAPY?

The management of congenital diaphragmatic hernia (CDH) in the newborn infant has changed radically since the first successful outcomes were reported 60 years ago. Then it seemed a surgical problem with a surgical solution – do an operation, remove the intestines and solid viscera from the thoracic cavity, repair the defect and allow the lung to expand. CDH in that era was regarded as the quintessential neonatal surgical emergency. The expectation was that urgent surgery would result in improvement in lung function and oxygenation. That approach persisted up to the 1980s when it was realized that the problem was far more complex and involved both an abnormal pulmonary vascular bed as well as pulmonary hypoplasia. The use of systemically delivered pulmonary vasodilator therapy, principally tolazoline, became a focus of interest in the 1980s with small case reports and case series suggesting improved survival. In the 1990s, based on studies that showed worsening thoracic compliance and gas exchange following surgical repair, deferred surgery and pre-operative stabilization became the standard of care. At the same time extracorporeal membrane oxygenation (ECMO) was increasingly used either as part of pre-operative stabilization or as a rescue therapy after repair. Other centres chose to use high frequency oscillatory ventilation (HFOV). Despite all these innovations the survival in live born infants with CDH did not improve to more than 50% in large series published from high volume centres. However, in the past 10 years there has been an appreciable improvement in survival to the extent that many centres are now reporting survival rates of greater than 80%. Probably the biggest impact on this improvement has been the recognition of the role that ventilation induced lung injury plays in mortality and the need for ECMO rescue. This has ushered in an era of a lung protective or “gentle ventilation” strategy which has been widely adopted as a standard approach. While there have been these radical changes in postnatal management attempts have been made to improve outcome with prenatal interventions, starting with prenatal repair, which was abandoned because of preterm labour. More recently there has been increasing experience in the use of balloon occlusion of the trachea as a prenatal intervention strategy with patients being selected based on prenatal predictors of poor outcome. This approach can only be justified if those predictors can be validated and the outcomes (death or serious long term morbidity) can be shown to be better than those currently achievable, namely 80% survival in high volume CDH centres rather than the 50–60% survival frequently quoted in historical papers.

The long-term follow-up of patients with a congenital diaphragmatic hernia: a broad spectrum of morbidity

Congenital diaphragmatic hernia (CDH) is a life-threatening anomaly with a mortality rate of approximately 40-50%, depending on case selection. It has been suggested that new therapeutic modalities such as nitric oxide (NO), high frequency oxygenation (HFO) and extracorporal membrane oxygenation (ECMO) might decrease mortality associated with pulmonary hypertension and the sequelae of artificial ventilation. When these new therapies indeed prove to be beneficial, a larger number of children with severe forms of CDH might survive, resulting in an increase of CDH-associated complications and/or consequences. In follow-up studies of infants born with CDH, many complications including pulmonary damage, cardiovascular disease, gastro-intestinal disease, failure to thrive, neurocognitive defects and musculoskeletal abnormalities have been described. Long-term pulmonary morbidity in CDH consists of obstructive and restrictive lung function impairments due to altered lung structure and prolonged ventilatory support. CDH has also been associated with persistent pulmonary vascular abnormalities, resulting in pulmonary hypertension in the neonatal period. Long-term consequences of pulmonary hypertension are unknown. Gastro-esophageal reflux disease (GERD) is also an important contributor to overall morbidity, although the underlying mechanism has not been fully understood yet. In adult CDH survivors incidence of esophagitis is high and even Barrett's esophagus may ensue. Yet, in many CDH patients a clinical history compatible with GERD seems to be lacking, which may result in missing patients with pathologic reflux disease. Prolonged unrecognized GERD may eventually result in failure to thrive. This has been found in many young CDH patients, which may also be caused by insufficient intake due to oral aversion and increased caloric requirements due to pulmonary morbidity. Neurological outcome is determined by an increased risk of perinatal and neonatal hypoxemia in the first days of life of CDH patients. In patients treated with ECMO, the incidence of neurological deficits is even higher, probably reflecting more severe hypoxemia and the risk of ECMO associated complications. Many studies have addressed the substantial impact of the health problems described above, on the overall well-being of CDH patients, but most of them concentrate on the first years after repair and only a few studies focus on the health-related quality of life in CDH patients. Considering the scattered data indicating substantial morbidity in long-term survivors of CDH, follow-up studies that systematically assess long-term sequelae are mandatory. Based on such studies a more focused approach for routine follow-up programs may be established.

Postnatal management and long-term outcome for survivors with congenital diaphragmatic hernia

Significant advances in the postnatal management of patients with congenital diaphragmatic hernia (CDH) have resulted in a remarkable improvement in survival rates over the past two decades. The success of current postnatal management of CDH patients has rendered fetal intervention to be limited to the most severe cases, and the role for prenatal treatment of CDH patients remains unclear. The adoption of lung-preserving strategies including high-frequency oscillatory ventilation (HFOV) and extracorporeal membrane oxygenation (ECMO) have improved CDH outcomes especially in those patients with significant ventilatory or circulatory compromise. Survival rates of up to 90% are being reported in some high-volume centers. However, the increased survival in CDH patients has been accompanied by an increase in neurological, nutritional and musculoskeletal morbidity among the long-term survivors. This has resulted in the need to provide resources for the long-term follow-up and support of this patient population. In this article, the postnatal management strategies and primary and secondary outcomes of high-volume international pediatric surgical centers will be reviewed. Finally, the role of a multidisciplinary management team for the follow-up of long-term CDH survivors will be discussed.

NKCC-1 and ENaC are down-regulated in nitrofen-induced hypoplastic lungs with congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is accompanied by pulmonary hypoplasia and pulmonary hypertension. Fetal lung growth is dependent on the secretion of lung liquid, which normally is absorbed at partus. The ion channel NKCC-1 is involved in this secretory process, but has recently also been reported to be implicated in absorption. CDH patients show a disturbed transition from secretion to absorption. alpha- and beta-ENaC are essential for lung liquid absorption. Common for all transcellular ion transport is the need for Na/K-ATPase as a primary driving force. The aim of the study was first to map the normal pulmonary expression of the above proteins during late gestation and secondly to see if the expression was affected in a CDH rat model. Pregnant Sprague-Dawley rat dams were given nitrofen on gestational day 9.5 to induce CDH. The fetuses were removed on gestational days E18 and E21. In addition, newborn rats were harvested postpartum on day P2. The fetuses were put into one of two groups: hypoplastic lungs without CDH (N-CDH) and hypoplastic lungs with CDH (N+CDH). The pulmonary expression of NKCC-1, alpha-/beta-ENaC and Na/K-ATPase was then analyzed using Western blot. We found that the protein levels of NKCC-1 on gestational days E18 and E21 were significantly lower among fetuses with N+CDH as well as N-CDH compared to controls. The expression of beta-ENaC was also significantly down-regulated in both the groups on E18 and E21. The protein levels of alpha-ENaC and Na/K-ATPase were not found to be significantly decreased, but both showed a tendency towards down-regulation. The marked down-regulation of NKCC-1 in fetal hypoplastic lungs with CDH indicates a possibly decreased lung liquid production. This may be one of the mechanisms behind the disturbed pulmonary development in CDH. We also show that beta-ENaC is down-regulated. Down-regulation of beta-ENaC may result in abnormal lung liquid absorption, which could be one of the mechanisms behind the respiratory distress seen in CDH patients postpartum.

Extracorporeal membrane oxygenation: current clinical practice, coding, and reimbursement

Extracorporeal membrane oxygenation (ECMO) is a technique for providing life support for patients experiencing both pulmonary and cardiac failure by maintaining oxygenation and perfusion until native organ function is restored. ECMO is used routinely at many specialized hospitals for infants and less commonly for children with respiratory or cardiac failure from a variety of causes. Its usage is more controversial in adults, but select medical centers have reported favorable findings in patients with ARDS and other causes of severe pulmonary failure. ECMO is also rarely used as a rescue therapy in a small subset of adult patients with cardiac failure. This article will review the current uses and techniques of ECMO in the critical care setting as well as the evidence supporting its usage. In addition, current practice management related to coding and reimbursement for this intensive therapy will be discussed.

Mortality prediction in congenital diaphragmatic hernia

BACKGROUND

A validated risk stratification tool for congenital diaphragmatic hernia (CDH) is required for accurate outcomes analyses. Existing mortality-predictive models include those of the CDH Study Group (CDHSG) based on birth weight and 5-minute Apgar score, the Canadian Neonatal Network (CNN) based on gestational age and admission score in Score for Neonatal Acute Physiology version II, and the Wilford Hall/Santa Rosa clinical prediction formula (WHSR(PF)) derived from blood gas measurements. The purpose of this study was to evaluate the calibration and discrimination of these predictive models using the Canadian Pediatric Surgical Network dataset.

METHODS

Neonatal risk variables and birth hospital survivorship were collected prospectively in 11 perinatal centers, between May 2005 and October 2006. Actual vs predicted outcomes were analyzed for each equation to measure the calibration and discrimination of each model.

RESULTS

Twenty (21.2%) of 94 infants with CDH died during birth hospitalization. The CDHSG model demonstrated superior discrimination (area under the receiver operator characteristic curve = 0.85; CNN = 0.79; WHSR(PF) = 0.63). Model calibration reflected by the Hosmer-Lemeshow P value was poorest with the WHSR(PF) = 0.37 and comparable between CDHSG and CNN (0.48 and 0.46, respectively).

CONCLUSION

Predictive outcome models are essential for risk-adjusted outcome analysis of CDH. The ideal predictive equation should prove robust across CDH datasets.

Reduction in ventilator-induced lung injury improves outcome in congenital diaphragmatic hernia?

The purpose of this historical study was to compare the outcome for two treatment strategies, for neonates with congenital diaphragmatic hernia (CDH). The records of 65 infants born between 1991 and 2005 with CDH from a single tertiary care perinatal centre in the United Kingdom were retrospectively reviewed. Conventional mechanical ventilation (CMV) and systemic vasodilators were used from 1991 to 1995 (era 1). High frequency oscillatory ventilation (HFOV) and nitric oxide (NO) were used between 1996 and 2005 (era 2). Main outcome measures were survival and incidence of chronic lung disease. The results showed that the survival rate was 38% (8/21) in era 1 and 73% (32/44) in era 2, 95% CI for difference -59 to -10%. The incidence of chronic lung disease in survivors was 45% (5/11) in era 1 and 30% (9/30) in era 2, 95% CI for difference -18 to 49%. These data show significantly improved survival with elective use of HFOV and NO compared to CMV and systemic vasodilators. The survival results for CDH at St George's Hospital are comparable to those published from other institutions. The results may reflect a reduction in ventilator-induced lung injury with HFOV compared to CMV.

The split abdominal wall muscle flap repair for large congenital diaphragmatic hernias on extracorporeal membrane oxygenation

BACKGROUND

Numerous techniques exist for repairing large congenital diaphragmatic hernias (CDHs) including prosthetic patches, tissue-engineered grafts, and various muscle flaps. A split abdominal wall muscle flap is a simple, durable way to repair a large diaphragmatic hernia. This technique has not gained widespread use, and some have suggested that it would be inappropriate in the setting of extracorporeal membrane oxygenation (ECMO) because of bleeding risk. We present our series of diaphragmatic hernias with a focus on those repaired with the split abdominal wall technique while on ECMO.

METHODS

A retrospective, single-institution chart review was performed on all patients who underwent surgical repair for CDH over 6 years beginning in August 2000.

RESULTS

Seventy-five patients underwent repair. Sixteen were performed with patients on ECMO. Of these, 4 were closed primarily, 7 used a prosthetic patch, and 5 used a split abdominal wall muscle flap. Two patients in the prosthetic group developed a recurrent hernia, and 2 required reoperation for bleeding while on ECMO. No reoperations for bleeding were required in the abdominal muscle flap group.

CONCLUSIONS

The split abdominal wall muscle flap can be safely performed on anticoagulated patients. We believe it is a practical option for repairing large CDHs.

Surgical management of neonates with congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is one of the most challenging and complex pediatric abnormalities to manage, both medically and surgically. The care of these neonates has seen significant evolution, from previous aggressive ventilation and emergent operation to current permissive hypercapnea, physiologic stabilization, and elective surgical repair, all in less than two decades. These changes have led to many centers reporting survival rates near 80%, a dramatic improvement from the 50% survival reported in the 1970s. This review covers the current principles guiding the surgical management of CDH in the neonate, including preoperative stabilization, operative timing, extracorporeal membrane oxygenation, surgical approach, and management of recurrence. Although many clinical challenges remain, multi-institutional collaboration and ongoing research efforts will hopefully improve the clinical care of these patients.

A risk-adjusted study of outcome and resource utilization for congenital diaphragmatic hernia

PURPOSE

Perinatal care of infants with congenital diaphragmatic hernia (CDH) is nonstandardized and costly. We examined a risk-adjusted cohort of patients with CDH and hypothesized that (1) among CDH survivors, the cost of the birth admission would be proportional to illness severity, and (2) this cost would be significantly higher compared with a matched non-CDH cohort.

METHODS

A retrospective review of costs and outcomes for all patients with CDH admitted to British Columbia Children's Hospital between 1999 and 2003 was performed. Risk grouping of patients with CDH using a validated admission severity score (Score for Neonatal Acute Physiology-version II [SNAP-II]) was conducted, enabling comparison among infants surviving to discharge. Hospital costs were also compared with a contemporaneous, non-CDH cohort matched for birth weight and SNAP-II.

RESULTS

Thirty-two infants with CDH were included, of who 5 required extracorporeal membrane oxygenation. Twenty-three (72%) infants survived to discharge, with an average length of stay of 46 days. Average cost per survivor to discharge was 54,102 dollars (vs 13,722 dollars for the non-CDH cohort; P < .05). After SNAP-II stratification of survivors into low-, moderate-, and high-risk groups, a significant cost difference was noted between the moderate- and low-risk and high- and low-risk groups, respectively.

CONCLUSIONS

Infants born with CDH require costly care and can be expected to consume disproportionate resources. Admission SNAP-II score correlates with total cost to discharge. Risk stratification and cost comparison of larger CDH populations may allow identification of cost-efficient treatment strategies.

Noninvasive assessment of the right and left ventricular function in neonates with congenital diaphragmatic hernia with persistent pulmonary hypertension before and after surgical repair

OBJECTIVE

To measure right and left ventricular function in neonates with congenital diaphragmatic hernia (CDH) and persistent pulmonary hypertension of the newborn (PPHN) before and after surgical repair.

METHODS

Ten newborns with CDH and PPHN before and after surgical repair and 24 normal newborns underwent Doppler echocardiographic measurements of the systolic time intervals (STI) and the index of myocardial performance (IMP) or Tei Index to assess pulmonary hypertension and ventricular function, respectively.

RESULTS

In newborns with CDH and PPHN before surgical repair, STI pre-ejection time/ejection time ratio and pre-ejection time/acceleration time ratio (0.39 ± 0.19 and 1.22 ± 0.6) were significantly prolonged when compared to newborns with CDH and PPHN after surgical repair (0.21 ± 0.05 and 0.80 ± 0.2) and normal newborns (0.20 ± 0.04 and 0.59 ± 0.2), respectively (all p < 0.001). Left IMP and right IMP were also significantly prolonged in newborns with CDH and PPHN before surgery (0.38 ± 0.16 and 0.53 ± 0.25) when compared to newborns with CDH and PPHN after surgery (0.30 ± 0.07 and 0.28 ± 0.13) and normal newborns (0.26 ± 0.09 and 0.20 ± 0.10), respectively (p < 0.05, left IMP) and (p < 0.001, right IMP).

CONCLUSIONS

Significant pulmonary hypertension and abnormal left and right ventricular function were found in newborns with CDH and PPHN before surgical repair when compared to the newborns with CDH and PPHN after surgical repair and normal newborns. The STI and the IMP or Tei index can accurately estimate the consequences of pulmonary hypertension and left and right ventricular function in neonates with CDH and PPHN, which may affect management in these critically ill neonates.

Diaphragmatic hernia: diagnostic approaches with review of the literature

Because surgical repair is indicated for the treatment of diaphragmatic hernia (DH), preoperative imaging of the diaphragmatic defect, hernia content, and associated complications with other organ's pathologies is important. While various techniques can be used on imaging of DHs, selection of the most effective but the least invasive technique will present the most accurate findings about DH, and will facilitate the management of DH. We reviewed the diaphragmatic hernia types associated with our cases, and we discussed the preferred imaging modalities for different DHs with review of the literature. We evaluated the imaging findings of 21 DH cases. They were Morgagni's hernia (n=4), Bochdalek hernia (n=2), iatrogenic DH (n=4), traumatic DH (n=6), and hiatal hernia (n=5). Although its limited findings on DH and indirect findings about the diaphragmatic rupture, plain radiography is firstly preferred technique on DH. We found that ultrasound (US) is a useful tool on DH, on traumatic DH cases especially. Not only it shows diaphragmatic continuity and herniated organs, but also it reveals associated abdominal organ's pathologies. Computed tomography (CT) scan is most effective in many DH cases. It shows the herniated abdominal organs together with complications, such as intestinal strangulation, haemothorax, and rib fractures. We stressed that Multislice CT scan with coronal and sagittal reformatted images is the most effective and useful imaging technique on DH. With high sensitivity for soft tissue, MR imaging may be performed in the selected patients, on the late presenting DH cases or on the cases of the diagnosis still in doubt especially.

The role of extracorporeal membrane oxygenation in the management of infants with congenital diaphragmatic hernia

Many infants with CDH can be managed with conventional mechanical ventilation and pharmacotherapy. However, some infants will require levels of ventilator support that are not compatible with survival. In these circumstances, extracorporeal membrane oxygenation (ECMO) has been used with varying results. The indication, type, and timing of ECMO in relation to surgery continue to evolve in an attempt to improve the outcome. At the same time, there is growing body of literature showing adverse outcomes among infants with CDH treated with ECMO, raising questions about the usefulness of ECMO in CDH. This paper reviews some of the controversies associated with the use of ECMO in CDH.

The use of extracorporeal membrane oxygenation in infants with congenital diaphragmatic hernia

The use of extracorporeal membrane oxygenation (ECMO) has revolutionized the care of the critical infant born with a congenital diaphragmatic hernia (CDH). In some respects, this is surprising given our current lack of understanding regarding optimal preoperative ventilation strategy, identification of patients most likely to benefit from ECMO, and the correct timing of hernia repair for the infant treated with ECMO. Historically, repair of CDH was considered one of the few true pediatric surgical emergencies. Mortality, however, was high. In the 1970s, ECMO was first utilized as a rescue therapy following repair of CDH when conventional methods failed. In the 1980s, advancements in neonatal intensive care and an understanding of the pathophysiology of pulmonary hypertension associated with CDH led to a strategy involving preoperative stabilization and delayed surgical intervention. Historical reviews demonstrate an improvement of survival in infants treated with ECMO from 56% to 71%. This paper will outline the advances in the care of the CDH patient and the approach used for treatment with ECMO.

New approaches to managing congenital diaphragmatic hernia

A number of new techniques have been studied for managing newborns with congenital diaphragmatic hernia and respiratory insufficiency. Among these have been the techniques of delayed approach to the repair of the diaphragmatic hernia; permissive hypercapnia; nitric oxide and surfactant administration; intratracheal pulmonary ventilation; liquid ventilation; perfluorocarbon-induced lung growth; and lung transplantation. These interventions are at various stages of development and evaluation of effectiveness. All, however, are being explored in the hopes of improving outcome in patients with congenital diaphragmatic hernia who continue to have significant morbidity and mortality in the newborn period.

Congenital Diaphragmatic Hernia Repair on Extracorporeal Life Support: A Decade of Lessons Learned

Congenital diaphragmatic hernia (CDH) is a vexing anomaly that manifests with variable pulmonary compromise in neonates. More than one-third of neonates with CDH require extracorporeal membrane oxygenation (ECMO) for refractory pulmonary hypertension (PHN). To assess the outcome of neonates having CDH repair on ECMO, we reviewed our experience for babies treated between 1992 and 2003. Of 97 neonates with CDH, 40 required ECMO, and 30 were repaired on bypass. Eighteen were supported by veno-venous bypass (VV) and 12 by veno-arterial bypass (VA). While on ECMO, transfusion requirements increased twofold postoperatively (15 to 33 cc · kg-1 · day-1, P = 0.03) and then significantly decreased after decannulation (1.5 cc · kg-1 · day-1, P < 0.01). Non-intracranial hemorrhage occurred in 7 (23%) infants and intracranial hemorrhage in 3 (10%). Twelve (40%) infants died; one (3%) on ECMO secondary to refractory PHN. The mean length of stay for the 18 (60%) survivors was 48 days. Comparisons between survivors and nonsurvivors showed a significantly increased mortality for infants placed on VA bypass ( P < 0.01). However, no other variable was predictive of survival. We conclude that CDH repair on ECMO is technically feasible, shows similar survival to the Extracorporeal Life Support Organization (ELSO) registry, and is associated with few bleeding complications.

Severe complications during the management of a child with late presentation of a diaphragmatic hernia

We report on a 3-year-old boy with late presentation of congenital diaphragmatic hernia who developed cardiac arrest after induction of anaesthesia. The paper discusses the anaesthetic technique, in particular ventilation during and after induction, how these techniques contributed to the complication, and how they might have been avoided.

Outcome at 2 years of infants with congenital diaphragmatic hernia: a population-based study

BACKGROUND

Management of neonates with congenital diaphragmatic hernia (CDH) has undergone many changes associated with increased survival of high-risk CDH. However, little is known about the long-term outcome of CDH infants.

METHODS

Follow-up was performed in 85 newborn infants with CDH admitted in our neonatal intensive care unit between January 1991 and December 1998. Early (< 2 months) and late mortality (> or = 2 months), and respiratory, nutritional, musculoskeletal, and neurosensory outcome at 2 years were recorded.

RESULTS

Surgical repair was performed in 59 infants (69%) at a median postnatal age of 124 (range, 38 to 246) hours. Extracorporeal membrane oxygenation was used in 26 (30%) newborn infants. Survival at 2 years was 51 of 85 (60%) (early death, 28/85 [33%]; late death, 6/85 [7%]). Late deaths occurred because of persistent pulmonary hypertension or iatrogenic complications. Twelve of 51 (24%) newborn infants were oxygen dependant at the postnatal age of 28 days, and 1 of 51 (1.9%) was still oxygen dependant at 2 years. Growth failure was noted in 9 of 51 (18%), mainly related to severe gastroesophageal reflux and oral aversion. Scoliosis was diagnosed in 2 infants. Neurologic examination at 2 years was normal in 45 of 51 (88%). Cerebral palsy and developmental delay were observed in 2 and 4 infants, respectively. Four infants (8%) experienced associated problems. Respiratory, nutritional, and musculoskeletal morbidity was higher in infants treated by extracorporeal membrane oxygenation (p < 0.05).

CONCLUSIONS

CDH infants are at risk for adverse nutritional and respiratory outcome. Despite severe respiratory failure at birth, prolonged oxygen therapy above 2 years of age is uncommon. Conversely, failure to thrive related at least in part to gastroesophageal reflux and oral dysfunction remains the major problem at 2 years of age. However, both nutritional and respiratory problems tend to improve with age.

Survival in early- and late-term infants with congenital diaphragmatic hernia treated with extracorporeal membrane oxygenation

BACKGROUND

Congenital diaphragmatic hernia (CDH) is a malformation of the diaphragm that allows bowel to enter the thoracic cavity, resulting in pulmonary hypoplasia and pulmonary hypertension. Approximately 50% of CDH patients are treated with extracorporeal membrane oxygenation (ECMO). The optimal gestational age for delivery of term infants with CDH at high risk for requiring ECMO is not known. The goal of this study was to compare survival of infants with CDH receiving ECMO born early term (38 0/7-39 6/7 weeks' gestation) with those born late term (40 0/7-41 6/7 weeks' gestation). Changes in survival rates of term infants and the factors associated with these changes were assessed over the 25 years that ECMO has been available.

DESIGN

Retrospective cohort study of infants with CDH treated with ECMO.

DATA SOURCES

The Extracorporeal Life Support Organization registry of patients treated at active Extracorporeal Life Support Organization centers from April 1976 through June 2001.

ANALYSIS

Survival and clinical predictors of survival were compared between infants born early term (38 0/7-39 6/7 weeks' gestation) and infants born late term (40 0/7-41 6/7 weeks' gestation). Changes in survival rates over time and factors associated with survival were evaluated.

RESULTS

Among full-term infants with CDH treated with ECMO, late-term compared with early-term delivery was associated with improved survival (63% vs 53%). Among full-term survivors of ECMO, late-term infants spent less time on ECMO (181 vs 197 hours) and less time in the hospital (60 vs 67 days). In multivariate analysis, greater birth weight, higher 5-minute Apgar score, higher arterial pH and PCO(2) <50 torr before ECMO, and absence of a prenatal diagnosis of CDH were associated with survival. Since the late 1980s, survival of infants with CDH requiring ECMO decreased from 63% to 52%. The decreased survival rate was associated with increased rates of prenatal diagnosis, early-term delivery, lower birth weight, longer ECMO runs, and more frequent complications on ECMO.

CONCLUSIONS

Among term infants with CDH receiving ECMO, late-term delivery compared with early-term delivery is associated with improved survival, shorter ECMO duration, shorter hospital length of stay, and fewer complications on ECMO. These data suggest that, at least for the approximately 50% of CDH patients treated with ECMO, outcomes for infants with CDH may be improved by delay of elective delivery until 40 completed weeks of gestation.

Inhaled nitric oxide with early surgery improves the outcome of antenatally diagnosed congenital diaphragmatic hernia

BACKGROUND/PURPOSE

The outcome of antenatally diagnosed congenital diaphragmatic hernia (CDH) has remained poor despite aggressive therapeutic strategies. Since 1996, the authors have used a new approach including early surgery and inhaled nitric oxide (iNO). The aim of this study is to determine whether early surgery in combination with iNO improves the clinical outcome of antenatally diagnosed CDH.

METHODS

From 1988, 40 consecutive neonates with antenatally diagnosed CDH were admitted to the authors' hospital. Ten cases of fatal chromosomal anomalies or major cardiac anomalies were excluded from this study. From 1988 through 1995 (period 1: n = 13), delayed surgery was used in high-risk CDH. From 1996 through 2000 (period 2: n = 17), early surgery in combination with iNO was used. The severity of lung hypoplasia was evaluated using the fetal lung/thorax transverse area ratio (L/T). High-frequency oscillatory ventilation (HFOV) was used routinely during the study periods, and extracorporeal membrane oxygenation (ECMO) was used on basis of conventional entry criteria. The authors compared the clinical outcome, use of ECMO, and the L/T between the 2 periods retrospectively.

RESULTS

Patients in the 2 periods were comparable in terms of birth weight, gestational age, and the L/T. The mean age at surgery was 3.1 +/- 4.9 days in period 1, and 0.8 +/- 1.1 days in period 2. Fewer infants in period 2 compared with period 1 were treated with ECMO (period 1, 62% v period 2, 6%; P <.01). There was significant difference in the survival rate between the 2 periods (period 1, 38% v period 2, 94%; P <.01).

CONCLUSION

Our data suggest that early surgery and iNO improves the outcome and reduces the requirement of ECMO in the treatment of antenatally diagnosed CDH.

Artificial lungs: a new inspiration

An estimated 16 million Americans are afflicted with some degree of chronic obstructive pulmonary disease (COPD), accounting for 100,000 deaths per year. The only current treatment for chronic irreversible pulmonary failure is lung transplantation. Since the widespread success of single and double lung transplantation in the early 1990s, demand for donor lungs has steadily outgrown the supply. Unlike dialysis, which functions as a bridge to renal transplantation, or a ventricular assist device (VAD), which serves as a bridge to cardiac transplantation, no suitable bridge to lung transplantation exists. The current methods for supporting patients with lung disease, however, are not adequate or efficient enough to act as a bridge to transplantation. Although occasionally successful as a bridge to transplant, ECMO requires multiple transfusions and is complex, labor-intensive, time-limited, costly, non-ambulatory and prone to infection. Intravenacaval devices, such as the intravascular oxygenator (IVOX) and the intravenous membrane oxygenator (IMO), are surface area limited and currently provide inadequate gas exchange to function as a bridge-to-recovery or transplant. A successful artificial lung could realize a substantial clinical impact as a bridge to lung transplantation, a support device immediately post-lung transplant, and as rescue and/or supplement to mechanical ventilation during the treatment of severe respiratory failure.

Extracorporeal membrane oxygenation for severe respiratory failure

The use of extracorporeal technology to accomplish gas exchange with or without cardiac support is based on the premise that "lung rest" facilitates repair and avoids the baso- or volutrauma of mechanical ventilator management. Extracorporeal membrane oxygenation (ECMO), a modified form of cardiopulmonary bypass, has been shown to decrease mortality of neonatal, pediatric and adult respiratory failure and is capable of total gas exchange. In neonates, over 20,638 patients have been treated with an overall survival of 77% in a population thought to have 78% mortality.

Neurodevelopmental outcome after congenital diaphragmatic hernia: Extracorporeal membrane oxygenation before and after surgery

BACKGROUND/PURPOSE

Extracorporeal membrane oxygenation (ECMO) as a treatment of last resort for neonates with persistent pulmonary hypertension of the newborn (PPHN) caused by congenital diaphragmatic hernia (CDH) may be used for preoperative stabilization or postoperative rescue. The aim of this study was to examine the acute and long-term morbidity associated with pre- and postoperative ECMO.

METHODS

Neonates born with CDH and needing ECMO were classified into 2 groups. Group 1 consisted of neonates placed on ECMO after CDH surgery. Patients in group 2 underwent preoperative ECMO stabilization. Medical records after birth were evaluated. Growth, neuromotor and cognitive development, hearing, and behavior were evaluated. Student t test and chi(2) were used to determine statistical significance between groups.

RESULTS

Subjects in group 2 had significantly more days on ECMO and loop diuretics. Alkalosis was induced for a longer duration in group 2. At follow-up 3 to 9 years later, no differences were found between the 2 groups in growth parameters, neuromotor outcome, or behavior. However, in group 1, 2 of 9 children had significant hearing impairment necessitating amplification compared with 6 of 6 subjects in group 2.

CONCLUSIONS

Neonates with CDH first stabilized on ECMO (group 2) had a higher incidence of hearing loss compared with those needing ECMO postrepair (group 1). The etiology of this finding is not clear. This may be secondary to the prolonged period of hyperventilation or general intensive care that is part of the protocol for neonates who are electively stabilized on ECMO preoperatively. J Pediatr Surg 36:539-544.

Fetal tissue engineering: diaphragmatic replacement

BACKGROUND/PURPOSE

Prosthetic repair of congenital diaphragmatic hernia has been associated with high complication rates. This study was aimed at applying fetal tissue engineering to diaphragmatic replacement.

METHODS

Fetal lambs underwent harvest of skeletal muscle specimens. Once expanded in vitro, fetal myoblasts were suspended in a collagen hydrogel submitted to controlled radial tension. The construct was then placed in a bioreactor. After birth, all animals underwent creation of 2 diaphragmatic defects. One defect was repaired with the autologous-engineered construct placed in between 2 acellular supporting membranes and the other with an identical construct but without any cells. Each animal was its own control (graft, n = 10). Animals were killed at different time-points postimplantation for histologic examination. Statistical analysis was by analysis of variance (ANOVA).

RESULTS

Fetal myoblasts expanded up to twice as fast as neonatal cells. Hydrogel-based radial tension enhanced construct architecture by eliciting cell organization within the scaffold. No eventration was present in 4 of 5 engineered constructs but in 0 of 5 acellular grafts (P<.05). At harvest, engineered constructs were thick and histologically resembled normal skeletal muscle, whereas acellular grafts were thin, floppy, and showed low cell density with increased fibrosis.

CONCLUSIONS

Unlike acellular grafts, engineered cellular diaphragmatic constructs are anatomically and histologically similar to normal muscle. Fetal tissue engineering may be a viable alternative for diaphragmatic replacement.