Congenital posterolateral diaphragmatic hernia: new dimensions in management

A retrospective analysis of 93 consecutive children with congenital posterolateral diaphragmatic hernia (CDH) was performed to determine outcome, ability to predict the development of persistent fetal circulation (PFC) requiring pharmacologic or extracorporeal membrane oxygenation (ECMO), and whether drugs or ECMO have improved survival. No patient died who was more than 24 hours of age at operation. Of 66 (71%) infants who were younger than 24 hours, 38 (58%) died. Preoperative and postoperative alveolar-arterial oxygen differences (AaDo2) did not consistently predict survival or death. Pharmacologic management of PFC in 30 patients resulted in a temporary improvement in 13 (43%). Survival was attributable to drugs in only seven (23%). ECMO was used in eight patients, all of whom had failed to improve with pharmacologic therapy and had a 100% predicted mortality rate based on the Neonatal Pulmonary Insufficiency Index. All eight had temporary improvement, while five (62%) completely cleared the PFC and four (50%) survived. Significant complications occurred in six patients. Earlier and more reliable methods of predicting high-risk infants are needed. Pharmacologic manipulation of PFC associated with CDH did not significantly improve survival. ECMO may prove to be a useful means of supporting these infants until more effective ventilatory and pharmacologic methods become available.