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Intraoperative Transpyloric Tube Insertion for Congenital Diaphragmatic Hernia: Analysis of Japanese Study Group Data
Hidehiko Maruyama1, Shoichiro Amari1, Yutaka Kanamori2
1Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan.
Insights
Intraoperative transpyloric tube (TPT) insertion in infants with congenital diaphragmatic hernia (CDH) did not improve early nutritional intake or weight gain. Weight growth velocity at 60 days was lower in the TPT group, suggesting no benefit from this approach.
Area of Science:
- Pediatric Surgery
- Neonatology
- Gastroenterology
Background:
- Congenital diaphragmatic hernia (CDH) is a severe condition often complicated by gastro-esophageal reflux disease (GERD).
- Transpyloric tubes (TPTs) are used intraoperatively in some centers to facilitate early enteral feeding in CDH infants, potentially improving respiratory status.
- The clinical benefit of intraoperative TPT insertion on patient prognosis remains uncertain.
Purpose of the Study:
- To evaluate the effectiveness of intraoperative transpyloric tube (TPT) insertion compared to standard gastric tubes (GTs) in CDH infants.
- To assess the impact on early enteral nutrition and postoperative weight gain velocity.
Main Methods:
- Retrospective analysis of 204 infants with CDH from the Japanese CDH Study Group database (2011-2016).
- Infants were divided into an intraoperative TPT group and a gastric tube (GT) group.
- Weight growth velocity (WGV) was calculated using an exponential model; subgroup analysis was performed based on Kitano's gastric position classification.
Main Results:
- No significant difference in enteral nutrition at 14 (EN14) or 21 days (EN21) between TPT and GT groups.
- Weight growth velocity at 30 days (WGV30) was similar; however, WGV at 60 days (WGV60) was significantly lower in the TPT group (p=0.03).
- Subgroup analysis for severe CDH (Kitano's Grade 2+3) showed no advantage for TPT in nutritional intake or weight gain.
Conclusions:
- Intraoperative TPT insertion in CDH infants does not enhance nutritional intake or short-term weight gain.
- Longer-term weight gain (WGV60) was negatively impacted by TPT use.
- Routine intraoperative TPT insertion is not recommended for CDH patients.
Background:
Congenital diaphragmatic hernia (CDH) is a severe congenital disease. Some CDH infants suffer from gastro-esophageal reflux disease (GERD), even after surgical correction of gastric position. A transpyloric tube (TPT) is inserted into CDH patients under direct observation intraoperatively in some hospitals in Japan to establish early enteral feeding. This strategy avoids gastric expansion to maintain a better respiratory condition. However, it is unclear whether the strategy has a secure effect for patient prognosis. This study aimed to evaluate the effectiveness of intraoperative TPT insertion on enteral feeding and postoperative weight gain.
Methods:
The Japanese CDH Study Group database was used to identify infants with CDH born between 2011 and 2016, who were then divided into two groups: the TPT group and gastric tube (GT) group. In the TPT group, infants underwent intraoperative TPT insertion; postoperative insertion/extraction of TPT was irrelevant to the analysis. Weight growth velocity (WGV) was calculated using the exponential model. Subgroup analysis was performed using Kitano's gastric position classification.
Results:
We analyzed 204 infants, of which 99 and 105 were in the TPT and GT groups, respectively. Enteral nutrition (EN) in the TPT and GT groups was 52 ± 39 and 44 ± 41 kcal/kg/day (p = 0.17) at age 14 days (EN14), respectively, and 83 ± 40 and 78 ± 45 kcal/kg/day (p = 0.46) at age 21 days (EN21), respectively. WGV30 (WGV from day 0 to day 30) in the TPT and GT groups was 2.3 ± 3.0 and 2.8 ± 3.8 g/kg/day (p = 0.30), respectively, and WGV60 (WGV from day 0 to day 60) was 5.1 ± 2.3 and 6.0 ± 2.5 g/kg/day (p = 0.03), respectively. In infants with Kitano's Grade 2 + 3, EN14 in the TPT and GT groups was 38 ± 35 and 29 ± 35 kcal/kg/day (p = 0.24), respectively, EN21 was 73 ± 40 and 58 ± 45 kcal/kg/day (p = 0.13), respectively, WGV30 was 2.3 ± 3.2 and 2.0 ± 4.3 g/kg/day (p = 0.76), respectively, and WGV60 was 4.6 ± 2.3 and 5.2 ± 2.3 g/kg/day (p = 0.30), respectively.
Conclusion:
Intraoperative TPT insertion did not improve nutritional intake and WGV30. WGV60 in TPT was less than that in GT. In Grade 2 + 3 subgroup analysis, TPT also had no advantage. We could not recommend routine TPT insertion at surgery.
Level Of Evidence:
III.
