Thoracoscopic versus open repair of CDH in cardiovascular stable neonates

Abstract

BackgroundThoracoscopic 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.MethodsRetrospective 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.Results108 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.ConclusionAfter 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.

Standardized Postnatal Management of Infants with Congenital Diaphragmatic Hernia in Europe: The CDH EURO Consortium Consensus - 2015 Update

“…A meta-analysis from Lansdale et al [59] showed that thoracoscopic repair had greater recurrence rates and operative times but similar survival and patch usage compared with open surgery. Recently, Costerus et al [60] concluded that thoracoscopic primary closure seems a safe and effective procedure, but efficacy of thoracoscopic patch repair has not been established. To allow for better comparison of patient groups between studies it is recommended to record the diaphragmatic defect size in all surgeries [37].…”

Minimal Invasive Surgery for Pediatric Thoracic Pathologies

“…After three recurrences out of seven thoracoscopic hernia repairs in the current study, the thoracoscopic approach was abandoned. Hospital stay time is also longer in the open group (11). For these reasons, the candidates for thoracoscopic surgery have to be chosen carefully.…”

Perioperative Complications of Congenital Diaphragmatic Hernia Repair

“…42,43 Even though keeping an adequate arterial oxygenation might be vital to prevent neurological damage, 42 it is still unknown whether hypercapnia and acidosis leading to prolonged postoperative low brain oxygenation 20 have consequences on the long-term neurological development. 43,44 A recent animal study from our group showed that neonatal CO 2 -pneumothorax has no significant outcome over neurodevelopment. 45 Meanwhile several strategies can be found to minimize hypercapnia and acidosis during surgery.…”