Current surgical management of congenital diaphragmatic hernia: A report from the congenital diaphragmatic hernia study group

doi:10.1016/S0022-3468(98)90522-X

Journal of Pediatric Surgery

Volume 33, Issue 7, July 1998, Pages 1004-1009

https://doi.org/10.1016/S0022-3468(98)90522-X Get rights and content

Abstract

Background: Repair of congenital diaphragmatic hernia (CDH) has changed from an emergent procedure to a delayed procedure in the last decade. Many other aspects of management have also evolved since the first successful repair. However, most reports are from single institutions. The lack of a large multicenter database has hampered progress in the management of congenital diaphragmatic hernia (CDH) and makes determination of the current standard difficult.

Methods: The CDH study group was formed in 1995 to collect data from multiple institutions in North America, Europe, and Australia. Participating centers completed a registry form on all live-born infants with CDH during 1995 and 1996. Demographic information, data about surgical management, and outcome were collected for all patients.

Results: Sixty-two centers participated, with 461 patients entered. Overall survival was 280 of 442 patients (63%) where survival was recorded. The defect was left-sided in 78%, right-sided in 21%, and bilateral in 1%. A subcostal approach was used in 91% of patients, with pleural drainage used in 76%. A patch of some kind was used in just over half (51%) of the patients, with polytetrafluoroethylene being the most commonly used material (81%) in those patients with a patch. The mean surgical time was 102 minutes, with an average blood loss of 14 mL (range, 0 to 500 mL). The overwhelming majority of patients underwent repair between 6:00 am and 6:00 pm (289 of 329, 88%). Ninteen percent of patients has surgical repair on extracorporeal membrane oxygenation (ECMO) at a mean time of 170 hours into the ECMO course (range, 10 to 593 hours). The mean age at surgery in patients not treated with ECMO was 73 hours (range, 1 to 445 hours).

Conclusions: The multicenter nature of this report makes it a snapshot of current management. The data would indicate that prosthetic patching of the defect has become common, that after-hours repair is infrequent, and that delayed surgical repair has become the preferred approach in many centers. Furthermore, the mean survival rate of 63% indicates that despite decades of individual effort, the CDH problem is far from solved. This highlights the need for a centralized database and cooperative multicenter studies in the future.

References (21)

JC Langer et al.
Timing of surgery for congenital diaphragmatic hernia: Is emergency operation necessary?
J Pediatr Surg
(1988)
H Sakai et al.
The effect of surgical repair on respiratory mechanics in congenital diaphragmatic hernia
J Pediatr
(1987)
FWJ Hazebroek et al.
Congenital diaphragmatic hernia: The impact of preoperative stabilization. A prospective study in 13 patients
J Pediatr Surg
(1988)
JT Wung et al.
Congenital diaphragmatic hernia: Survival treated with very delayed surgery, spontaneous respiration, and no chest tube
J Pediatr Surg
(1995)
M Nio et al.
A prospective randomized trial of delayed versus immediate repair of congenital diaphragmatic hernia
J Pediatr Surg
(1994)
CA Ryan et al.
Radiological decompression of bowel gas and return of mediastinal shift in congenital diaphragmatic hernia: a signal for surgical repair?
J Pediatr Surg
(1995)
CWJ Breaux et al.
Improvement in survival of patients with congenital diaphragmatic hernia utilizing a strategy of delayed repair after medical and/or extracorporeal membrane oxygenation stabilization
J Pediatr Surg
(1991)
JM Wilson et al.
Evolution of the technique of congenital diaphragmatic hernia repair on ECMO
J Pediatr Surg
(1994)
JJ Schnitzer et al.
Experience with abdominal wall closure for patients with congenital diaphragmatic hernia repaired on ECMO
J Pediatr Surg
(1995)
NMA Bax et al.
The advantages of reconstruction of the dome of the diaphragm in congenital posterolateral diaphragmatic defects
J Pediatr Surg
(1984)

There are more references available in the full text version of this article.

Cited by (281)

Muscle Flap Technique Safe for On-ECMO Congenital Diaphragmatic Hernia Repair
2024, Journal of Pediatric Surgery
Prosthetic patches (patch) and muscle flaps (flap) are techniques used for repair of congenital diaphragmatic hernia (CDH) with a large defect unamenable to primary closure. We hypothesized that the flap technique for CDH repair while on extra-corporeal membrane oxygenation (on-ECMO) would have decreased bleeding complications compared to patch due to the hemostatic advantage of native tissue.
A single-center retrospective comparative study of patients who underwent on-ECMO CDH repair between 2008 and 2022 was performed.
Fifty-two patients met inclusion criteria: 18 patch (34.6%) and 34 flap (65.4%). There was no difference in CDH severity between groups. On univariate analysis, reoperation for surgical bleeding was lower following flap repair compared to patch (23.5% vs 55.6%, respectively; p = 0.045), 48-h postoperative blood product transfusion was lower after flap repair (132 mL/kg vs 273.5 mL/kg patch; p = 0.006), and two-year survival was increased in the flap repair group compared to patch (53.1% vs 17.7%, respectively; p = 0.036). On multivariate analysis adjusting for CDH side, day on ECMO repaired, and day of life CDH repaired, flap repair was significantly associated with lower five-day postoperative packed red blood cell transfusion amount, improved survival to hospital discharge, and improved two-year survival.
Our experience suggests that the muscle flap technique for on-ECMO CDH repair is associated with reduced bleeding complications compared to prosthetic patch repair, which may in part be responsible for the improved survival seen in the flap repair group. These results support the flap repair technique as a favored method for on-ECMO CDH repair.
Level III.
Biological versus synthetic patch for the repair of congenital diaphragmatic hernia: 8-year experience at a tertiary center
2021, Journal of Pediatric Surgery
The aim of this study is to compare outcome between small intestinal submucosal (SIS) and polytetrafluoroethylene (PTFE) patches in patients with congenital diaphragmatic hernia (CDH) with large muscular defects.
We performed a retrospective review of prospectively collected data of patients who underwent CDH repair from January 2011 to June 2019, with a minimum follow-up of 1 year. Data were collected regarding length of stay (LOS), mortality and recurrence. Kaplan-Meier analyses was used.
In the study period, 195 patients with CDH were admitted, 176 underwent surgical repair and 19 died before surgery. Sixty-two (35%) required a patch. Over the last 5 years, our institution transitioned from the use of all SIS to all PTFE. SIS was used in 18 cases and PTFE in 25. Overall survival rate was 89% (174/195). There was no significant difference regarding LOS and mortality. Nine patients (50%) of SIS and 1 (4%) of PTFE repairs recurred (P < 0.01; log-rank test P < 0.01), with a time course of recurrence of 18 (SD = 13) and 8 months, respectively. Median follow-up was 60 months (SD: 23) for the SIS group and 26 (SD: 10) for the PTFE group.
A significant lower recurrence was found using PTFE patches instead of SIS for the repair of large CDH.
Level 3. Retrospective comparative study.
Patch repair of congenital diaphragmatic hernia is not at risk of poor outcomes
2020, Journal of Pediatric Surgery
Citation Excerpt :
The risk of recurrence has been associated with the nature of defect and associated co-morbidities. The CDH study group proposed a classification to highlight defect types and associated these with different outcomes [17]. The hypothesis was that larger defects would be correlated with more severe forms of lung hypoplasia.
Recurrence of congenital diaphragmatic hernia (CDH) was retrospectively evaluated after correction with or without a patch in an institution where tension-free repair is advocated.
Demographics and outcomes of patients with a postero-lateral CDH repaired (2000–2016) were analyzed (univariate tests and binary logistic regression adjusting for time since start of study, gender, defect side, liver herniation, patch, surgical approach, absence of postero-lateral rim and length of follow-up).
Of 203 patients, 107 received a patch (P), and 96 were not patched (NP). Groups were not different for gestational age birthweight, gender, defect side and minimally invasive approach rate. Preoperative ECMO incidence (P:29.9% vs. NP:2.1%, p < 0.01), liver herniation (P:57.0% vs. NP:22.9%, p < 0.01) and absence of a postero-lateral rim (P:61.7% vs. NP:8.3%, p < 0.01) were higher in the P group. The mortality rate was 10.8% (P:15.0% vs. NP:6.2%, p = 0.07). Recurrence was not different (P:9.3% vs. NP:4.2%, p = 0.15). Multivariate analysis showed that recurrence was higher after thoracoscopy compared to open (OR = 12.2 [2.2–68], p < 0.01); neither the use of patch (OR = 2.3, [0.5–10.4], p = 0.28) nor any other factors were associated with recurrence.
In this single centre series where tension-free repair was advocated, patch repair of CDH was not associated with higher recurrence, though access route was.
Cohort Study.
Level III.
Development of a multi-institutional registry for children with operative congenital lung malformations
2020, Journal of Pediatric Surgery
The purpose of this study was to develop a multi-institutional registry to characterize the demographics, management, and outcomes of a contemporary cohort of children undergoing congenital lung malformation (CLM) resection.
After central reliance IRB approval, a web-based, secure database was created to capture retrospective cohort data on pathologically-confirmed CLMs performed between 2009 and 2015 within a multi-institutional research collaborative.
Eleven children's hospitals contributed 506 patients. Among 344 prenatally diagnosed lesions, the congenital pulmonary airway malformation volume ratio was measured in 49.1%, and fetal MRI was performed in 34.3%. One hundred thirty-four (26.7%) children had respiratory symptoms at birth. Fifty-eight (11.6%) underwent neonatal resection, 322 (64.1%) had surgery at 1–12 months, and 122 (24.3%) had operations after 12 months. The median age at resection was 6.7 months (interquartile range, 3.6–11.4). Among 230 elective lobectomies performed in asymptomatic patients, thoracoscopy was successfully utilized in 102 (44.3%), but there was substantial variation across centers. The most common lesions were congenital pulmonary airway malformation (n = 234, 47.3%) and intralobar bronchopulmonary sequestration (n = 106, 21.4%).
This multicenter cohort study on operative CLMs highlights marked disease heterogeneity and substantial practice variation in preoperative evaluation and operative management. Future registry studies are planned to help establish evidence-based guidelines to optimize the care of these patients.
Level II.
Flap repair in congenital diaphragmatic hernia leads to lower rates of recurrence
2019, Journal of Pediatric Surgery
Congenital diaphragmatic hernia (CDH) repair is technically challenging with different approaches for repair. The aim of this study was to compare outcomes between patch and flap repair.
CDH repairs performed at a quaternary care children's hospital between 2008 and 2018 were reviewed. Seventy CDH repairs were analyzed after primary repairs were excluded (n = 52). Analysis included proportions or median with interquartile range and chi-square or Wilcoxon rank-sum test.
Comparing patch and flap repairs, demographic characteristics and hernia parameters were similar. Examining outcomes, length of stay, 30-day mortality, and 1-year mortality were all similar between groups, but total/symptomatic recurrence was higher in the patch group (10%/7% vs. 3%/0%), and the median time to recurrence was 3 months. A sub-analysis comparing those who recurred to those who did not demonstrated no significant difference between the two groups.
Patients who undergo flap repair have a lower risk of recurrence compared to those who undergo patch repair, and this may be due to the ability of the flap to grow over time with the child.
Treatment Study.
III
Role of Biomaterials in Surgery
2019, Encyclopedia of Tissue Engineering and Regenerative Medicine: Volumes 1-3
A biomaterial is any matter, surface, or construct that interacts with biological systems. Such substances can range from an inert implant to biologically integrated grafts often categorized in generations. First generation biomaterials are naturally available, for example hair, catgut, or wood. Technological advances produced second generation biomaterials, which include polymers and laboratory constructed agents, which may be beneficially bioactive like silicone, metal alloys, or synthetic polymers such as polyglycolic acid (PGA). Third generation biomaterials are currently in development and include those that can potentially interact with biologic tissues in a regenerative capacity. A set of lofty ideals directs success: biomaterials in surgery should resist immune rejection, offer appropriate biomechanical properties, and interact with the host in a beneficial way.

View all citing articles on Scopus

^☆

The manuscript was prepared by the above-noted investigators for the CDH Study Group; they assume responsibility for the overall contents.

Presented at the 1997 Annual Meeting of the Section on Surgery of the American Academy of Pediatrics, New Orleans, Louisiana, October 31–November 2, 1997.

Supported in part by a grant from American Medical Management, Inc and the MacGregor Medical Association of Houston, Texas, and by the Extraordinary Life Support Organization, Ann Arbor, Michigan.

View full text

Current surgical management of congenital diaphragmatic hernia: A report from the congenital diaphragmatic hernia study group☆

Abstract

J Pediatr Surg

J Pediatr

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg