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Epidemiology and Regional Variation in Additional Surgical Interventions for Children With Congenital Diaphragmatic
Nicole Cimbak1,2, Jennifer M Perez2,3, Alireza Akhondi-Asl2,3
1Department of Pediatric Surgery, Boston Children's Hospital, Boston, MA.
Insights
Nearly half of pediatric Congenital Diaphragmatic Hernia (CDH) patients require additional surgeries post-repair, including gastrostomy tubes and tracheostomies. Regional variations and patient factors influence these outcomes, impacting care and costs.
Area of Science:
- Pediatric Surgery
- Neonatal Care
- Surgical Outcomes Research
Background:
- Congenital Diaphragmatic Hernia (CDH) survival rates are increasing, leading to a rise in associated morbidities.
- Surgical interventions like tracheostomy and gastrostomy tube insertion are becoming more common in CDH survivors.
- Understanding practice variations in managing these co-morbidities is crucial for optimizing care.
Purpose of the Study:
- To investigate practice variations in the surgical management of co-morbidities among pediatric patients with Congenital Diaphragmatic Hernia (CDH).
- To identify factors associated with increased surgical morbidity following initial CDH repair.
- To compare the frequency of operations and hospital resource utilization by geographic region.
Main Methods:
- Analysis of the United States Pediatric Health Information System database (2012-2022) for neonates undergoing CDH repair.
- Inclusion of only patients with intensive care unit admission during their index hospitalization to standardize severity.
- Multivariable regression to identify predictive factors for additional surgical morbidity and secondary analysis of regional variations.
Main Results:
- 48% of 4003 CDH patients required at least one additional surgery post-repair, most commonly gastrostomy tube (28%), fundoplication (13%), and tracheostomy (5%).
- Prematurity, cardiac co-morbidity, and chromosomal anomalies were associated with increased surgical morbidity.
- Northeast, Midwest, and South regions showed higher rates of additional surgical morbidity, with longer hospital stays and higher costs for affected patients.
Conclusions:
- Significant surgical morbidity occurs in pediatric Congenital Diaphragmatic Hernia patients after initial repair.
- Informing families about potential post-operative surgical needs is essential for setting realistic expectations.
- Multi-institutional studies are needed to establish guidelines for optimal surgical management in CDH.
Objective:
To determine practice variation in the surgical management of comorbidities in pediatric patients with congenital diaphragmatic hernia (CDH).
Background:
A higher percentage of patients with CDH are surviving to discharge, accompanied by an increase in morbidity requiring surgical interventions, such as tracheostomy and gastrostomy tube insertion. The frequency, trends, and regional variations in operative management of these comorbidities in this population are unclear.
Methods:
Neonates who underwent CDH repair between 2012 and 2022 in the United States Pediatric Health Information System database were identified. Multivariable regression identified predictive factors for additional surgical morbidity after CDH repair, defined by an additional surgical intervention during the index hospitalization or within 1 year after discharge. To narrow the spectrum of severity of the disease, only patients with an intensive care unit admission on index hospitalization were included. Secondary analysis compared the frequency of operations and hospital resource utilization by region.
Results:
A total of 4003 patients underwent CDH repair and were discharged from their index hospitalization. Of the total, 1939 (48%) underwent at least one additional surgical procedure after the index CDH repair. Most performed surgeries were gastrostomy tube (28%), fundoplication (13%), and tracheostomy (5%). Covariates associated with additional surgical morbidity included: prematurity [odds ratio (OR): 1.38; 95% CI: 1.20-1.59], cardiac comorbidity (OR: 1.31; 95% CI: 1.14-1.49), and chromosomal anomalies (OR: 1.76, 95% CI: 1.30-2.40). Northeast (OR: 2.43; 95% CI: 1.42-3.52), Midwest (OR: 2.11; 95% CI: 1.45-3.07), and South (OR: 1.45, 95% CI: 1.02-2.12) regions were associated with additional surgical morbidity. Patients who required additional surgical procedures had longer initial inpatient length of stays (71 vs 31 days) and higher associated costs ($357,000 vs $161,000).
Conclusions:
Surgical morbidity exists in patients with CDH after initial CDH repair. Counseling families on these outcomes is important in establishing expectations for management. Establishing guidelines for optimal surgical management will require continued reporting from multi-institutional studies.
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