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. 1992 Nov;216(5):569–573. doi: 10.1097/00000658-199211000-00008

Congenital diaphragmatic hernia. Stabilization and repair on ECMO.

K P Lally 1, M S Paranka 1, J Roden 1, K E Georgeson 1, J M Wilson 1, C W Lillehei 1, C W Breaux Jr 1, M Poon 1, R H Clark 1, J B Atkinson 1
PMCID: PMC1242675  PMID: 1444648

Abstract

Availability of extracorporeal membrane oxygenation (ECMO) support and the potential advantages of delayed repair of congenital diaphragmatic hernia (CDH) have led several centers to delay CDH repair, using ECMO support if necessary. This study reviews the combined experience of five ECMO centers with infants who underwent stabilization with ECMO and repair of CDH while still on ECMO. All infants were symptomatic at birth, with a mean arterial oxygen pressure (PaO2) of 34 mmHg on institution of bypass despite maximal ventilatory support. A total of 42 infants were repaired on ECMO, with 18 (43%) surviving. Seven infants had total absence of the diaphragm, and 28 required a prosthetic patch to close the defect. Only five infants ever achieved a best postductal PaO2 over 100 mmHg before institution of ECMO. Prematurity was a significant risk factor, with no infants younger than 37 weeks of age surviving. Significant hemorrhage on bypass was also a hallmark of a poor outcome, with 10 of the 24 nonsurvivors requiring five thoracotomies and six laparotomies to control bleeding, whereas only one survivor required a thoracotomy to control bleeding. In follow-up, nine of the 18 survivors (50%) have developed recurrent herniation and seven (43%) have significant gastroesophageal reflux. Importantly, five of the 18 survivors were in the extremely high-risk group who never achieved a PaO2 over 100 mmHg or an arterial carbon dioxide pressure (PaCO2) less than 40 mmHg before the institution of ECMO. In conclusion, preoperative stabilization with ECMO and repair on bypass may allow some high-risk infants to survive. Surviving infants will require long-term follow-up because many will require secondary operations.

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Selected References

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  1. Bailey P. V., Connors R. H., Tracy T. F., Jr, Stephens C., Pennington D. G., Weber T. R. A critical analysis of extracorporeal membrane oxygenation for congenital diaphragmatic hernia. Surgery. 1989 Oct;106(4):611–616. doi: 10.1097/00132586-199008000-00058. [DOI] [PubMed] [Google Scholar]
  2. Breaux C. W., Jr, Rouse T. M., Cain W. S., Georgeson K. E. Congenital diaphragmatic hernia in an era of delayed repair after medical and/or extracorporeal membrane oxygenation stabilization: a prognostic and management classification. J Pediatr Surg. 1992 Sep;27(9):1192–1196. doi: 10.1016/0022-3468(92)90785-6. [DOI] [PubMed] [Google Scholar]
  3. Breaux C. W., Jr, Rouse T. M., Cain W. S., Georgeson K. E. 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 Mar;26(3):333–338. doi: 10.1016/0022-3468(91)90512-r. [DOI] [PubMed] [Google Scholar]
  4. Connors R. H., Tracy T., Jr, Bailey P. V., Kountzman B., Weber T. R. Congenital diaphragmatic hernia repair on ECMO. J Pediatr Surg. 1990 Oct;25(10):1043–1047. doi: 10.1016/0022-3468(90)90215-u. [DOI] [PubMed] [Google Scholar]
  5. Crombleholme T. M., Adzick N. S., Hardy K., Longaker M. T., Bradley S. M., Duncan B. W., Verrier E. D., Harrison M. R. Pulmonary lobar transplantation in neonatal swine: a model for treatment of congenital diaphragmatic hernia. J Pediatr Surg. 1990 Jan;25(1):11–18. doi: 10.1016/s0022-3468(05)80156-3. [DOI] [PubMed] [Google Scholar]
  6. Harrison M. R., Adzick N. S., Longaker M. T., Goldberg J. D., Rosen M. A., Filly R. A., Evans M. I., Golbus M. S. Successful repair in utero of a fetal diaphragmatic hernia after removal of herniated viscera from the left thorax. N Engl J Med. 1990 May 31;322(22):1582–1584. doi: 10.1056/NEJM199005313222207. [DOI] [PubMed] [Google Scholar]
  7. Hazebroek F. W., Tibboel D., Bos A. P., Pattenier A. W., Madern G. C., Bergmeijer J. H., Molenaar J. C. Congenital diaphragmatic hernia: impact of preoperative stabilization. A prospective pilot study in 13 patients. J Pediatr Surg. 1988 Dec;23(12):1139–1146. doi: 10.1016/s0022-3468(88)80330-0. [DOI] [PubMed] [Google Scholar]
  8. Heiss K., Manning P., Oldham K. T., Coran A. G., Polley T. Z., Jr, Wesley J. R., Bartlett R. H. Reversal of mortality for congenital diaphragmatic hernia with ECMO. Ann Surg. 1989 Feb;209(2):225–230. doi: 10.1097/00000658-198902000-00014. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Howell C. G., Hatley R. M., Boedy R. F., Rogers D. M., Kanto W. P., Parrish R. A. Recent experience with diaphragmatic hernia and ECMO. Ann Surg. 1990 Jun;211(6):793–798. [PMC free article] [PubMed] [Google Scholar]
  10. Langham M. R., Jr, Krummel T. M., Greenfield L. J., Drucker D. E., Tracy T. F., Jr, Mueller D. G., Napolitano A., Kirkpatrick B. V., Salzburg A. M. Extracorporeal membrane oxygenation following repair of congenital diaphragmatic hernias. Ann Thorac Surg. 1987 Sep;44(3):247–252. doi: 10.1016/s0003-4975(10)62064-4. [DOI] [PubMed] [Google Scholar]
  11. Mishalany H. G., Nakada K., Woolley M. M. Congenital diaphragmatic hernias: eleven years' experience. Arch Surg. 1979 Oct;114(10):1118–1123. doi: 10.1001/archsurg.1979.01370340024003. [DOI] [PubMed] [Google Scholar]
  12. Nakayama D. K., Motoyama E. K., Tagge E. M. Effect of preoperative stabilization on respiratory system compliance and outcome in newborn infants with congenital diaphragmatic hernia. J Pediatr. 1991 May;118(5):793–799. doi: 10.1016/s0022-3476(05)80048-4. [DOI] [PubMed] [Google Scholar]
  13. Newman K. D., Anderson K. D., Van Meurs K., Parson S., Loe W., Short B. Extracorporeal membrane oxygenation and congenital diaphragmatic hernia: should any infant be excluded? J Pediatr Surg. 1990 Oct;25(10):1048–1053. doi: 10.1016/0022-3468(90)90216-v. [DOI] [PubMed] [Google Scholar]
  14. Nguyen L., Guttman F. M., De Chadarévian J. P., Beardmore H. E., Karn G. M., Owen H. F., Murphy D. R. The mortality of congenital diaphragmatic hernia. Is total pulmonary mass inadequate, no matter what? Ann Surg. 1983 Dec;198(6):766–770. doi: 10.1097/00000658-198312000-00016. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. O'Rourke P. P., Lillehei C. W., Crone R. K., Vacanti J. P. The effect of extracorporeal membrane oxygenation on the survival of neonates with high-risk congenital diaphragmatic hernia: 45 cases from a single institution. J Pediatr Surg. 1991 Feb;26(2):147–152. doi: 10.1016/0022-3468(91)90896-2. [DOI] [PubMed] [Google Scholar]
  16. Sakai H., Tamura M., Hosokawa Y., Bryan A. C., Barker G. A., Bohn D. J. Effect of surgical repair on respiratory mechanics in congenital diaphragmatic hernia. J Pediatr. 1987 Sep;111(3):432–438. doi: 10.1016/s0022-3476(87)80475-4. [DOI] [PubMed] [Google Scholar]
  17. Stolar C. J., Levy J. P., Dillon P. W., Reyes C., Belamarich P., Berdon W. E. Anatomic and functional abnormalities of the esophagus in infants surviving congenital diaphragmatic hernia. Am J Surg. 1990 Feb;159(2):204–207. doi: 10.1016/s0002-9610(05)80261-2. [DOI] [PubMed] [Google Scholar]
  18. Stolar C., Dillon P., Reyes C. Selective use of extracorporeal membrane oxygenation in the management of congenital diaphragmatic hernia. J Pediatr Surg. 1988 Mar;23(3):207–211. doi: 10.1016/s0022-3468(88)80723-1. [DOI] [PubMed] [Google Scholar]
  19. Taylor G. A., Short B. L. Esophageal dilatation and reflux in neonates on extracorporeal membrane oxygenation after diaphragmatic hernia repair. AJR Am J Roentgenol. 1988 Nov;151(5):1055–1055. doi: 10.2214/ajr.151.5.1055. [DOI] [PubMed] [Google Scholar]
  20. Truog R. D., Schena J. A., Hershenson M. B., Koka B. V., Lillehei C. W. Repair of congenital diaphragmatic hernia during extracorporeal membrane oxygenation. Anesthesiology. 1990 Apr;72(4):750–753. doi: 10.1097/00000542-199004000-00028. [DOI] [PubMed] [Google Scholar]
  21. Weber T. R., Connors R. H., Pennington D. G., Westfall S., Keenan W., Kotagal S., Lewis J. E. Neonatal diaphragmatic hernia. An improving outlook with extracorporeal membrane oxygenation. Arch Surg. 1987 May;122(5):615–618. doi: 10.1001/archsurg.1987.01400170121018. [DOI] [PubMed] [Google Scholar]

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