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Outcomes of an Individualized Hybrid Model for Repair of Infants With Congenital Diaphragmatic Hernia Requiring
Nikhil R Shah1, Dimitra M Lotakis1, Keerthi Burgi2
1Section of Pediatric Surgery, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA.
Insights
An individualized hybrid model for congenital diaphragmatic hernia (CDH) repair in infants on extracorporeal life support (ECLS) improved survival rates. This approach optimizes timing of surgical intervention, reducing extracorporeal life support duration and enhancing patient outcomes.
Area of Science:
- Pediatric Surgery
- Neonatal Intensive Care
- Critical Care Medicine
Background:
- Timing of surgical repair for congenital diaphragmatic hernia (CDH) in infants requiring extracorporeal life support (ECLS) is a critical, yet controversial, clinical decision.
- Existing approaches, including early repair on ECLS, late repair on ECLS, or repair post-decannulation, each carry distinct risks and potential benefits.
- An individualized hybrid model, incorporating prenatal risk stratification, was developed to optimize repair timing and mitigate risks.
Purpose of the Study:
- To evaluate the outcomes of an individualized hybrid model for surgical repair in infants with CDH requiring ECLS.
- To compare the efficacy of the hybrid model against traditional early and delayed repair protocols.
- To identify the impact of the hybrid model on ECLS duration and survival rates.
Main Methods:
- A single-institution retrospective review was conducted from 2002 to 2023, analyzing infants with CDH requiring ECLS.
- Patients were categorized into three groups based on repair timing: Delayed Repair (DR), Early Repair (ER), and the Hybrid Model (HM).
- Demographic and disease characteristics were analyzed, with statistical significance determined by Chi-squared, Fisher's exact, and Kruskal-Wallis tests (p < 0.05).
Main Results:
- A total of 103 infants were included: 35 (DR), 32 (ER), and 36 (HM).
- The Hybrid Model (HM) group demonstrated a significantly shorter median ECLS duration (10 days) compared to DR (12 days) and ER (17 days) (p = 0.019).
- Survival to discharge was highest in the HM group (78%) versus DR (69%) and ER (34%) (p < 0.001).
Conclusions:
- The study demonstrates the physiological variability in infants with CDH requiring ECLS, supporting the utility of an individualized hybrid approach.
- This hybrid model may be particularly beneficial for patients of moderate severity, allowing for decannulation before repair to reduce bleeding complications.
- The findings suggest that personalized, risk-stratified timing of surgical repair can significantly improve outcomes for infants with CDH on ECLS.
Introduction:
Timing of repair for infants with congenital diaphragmatic hernia (CDH) requiring extracorporeal life support (ECLS) remains controversial. Approaches include early repair on ECLS, late repair on ECLS, or repair after ECLS decannulation; all have potential risks and benefits. To mitigate risk and maximize benefit, our group developed an individualized hybrid model in 2016 in which approach is based on prenatal risk stratification. Here we report the outcomes of this model.
Methods:
This is a single-institution retrospective review (2002-2023) of infants diagnosed with CDH requiring ECLS, grouping patients according to temporal protocols: Delayed Repair (DR; 2002-2009), Early Repair (ER; 2010-2016), and Hybrid Model (HM; 2017-2023). Demographics, disease characteristics, and outcomes were analyzed. Chi-squared/Fisher's exact/Kruskal-Wallis tests were used, with significance of p < 0.05.
Results:
103 infants were included- 35 (34 %) with DR, 32 (31 %) with ER, and 36 (35 %) using HM. Patient demographics and markers of prenatal severity were similar among groups. Median ECLS duration was significantly less in patients treated with HM (10 days; IQR: 5,17) compared to DR (12 days, IQR: 6,17) and ER (17 days, IQR: 11,22) [p = 0.019]. Survival to discharge was highest using the HM (78 %) compared to DR (69 %) and ER (34 %) groups [p < 0.001]. Subgroup analysis of the HM cohort demonstrated prenatal predictors differed significantly based on timing selected for repair.
Conclusion:
We demonstrate a physiologic spectrum across infants with CDH requiring ECLS, suggesting utility of a hybrid model. This individualized approach may be beneficial in discerning patients of moderate severity who could be decannulated prior to repair to mitigate bleeding complications.
Level Of Evidence:
III.
