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Experience with abdominal wall closure for patients with congenital diaphragmatic hernia repaired on ECMO
J J Schnitzer1, C S Kikiros, B L Short
1Department of Pediatric Surgery, George Washington University School of Medicine, Children's National Medical Center, Washington, DC.
Insights
Infants with congenital diaphragmatic hernia (CDH) needing extracorporeal membrane oxygenation (ECMO) often require prosthetic patches for diaphragm repair and face abdominal closure issues. Survival rates were lower in infants repaired on ECMO compared to those repaired before or without ECMO.
Area of Science:
- Pediatric Surgery
- Neonatal Intensive Care
- Thoracic Surgery
Background:
- Congenital diaphragmatic hernia (CDH) presents significant surgical challenges, particularly in neonates requiring extracorporeal membrane oxygenation (ECMO).
- The absence of abdominal domain in CDH impacts diaphragmatic and abdominal wall reconstruction.
- Managing critically ill infants with CDH on ECMO necessitates specialized surgical approaches.
Purpose of the Study:
- To compare surgical outcomes and challenges in infants with CDH undergoing repair on ECMO versus those repaired before ECMO or without ECMO.
- To identify specific technical difficulties associated with CDH repair in ECMO-dependent neonates.
Main Methods:
- Retrospective review of medical records for infants with CDH.
- Comparison of three groups: CDH repair on ECMO (group 1), CDH repair before ECMO (group 2), and CDH repair without ECMO (group 3).
- Analysis of surgical interventions, including diaphragmatic reconstruction and abdominal wall closure, and survival rates.
Main Results:
- Overall survival was 74% (37/50 patients).
- Infants repaired on ECMO (group 1) showed a significantly higher requirement for polytetrafluoroethylene (PTFE) diaphragmatic patches (P < .001).
- A significant difference was observed in the inability to close the abdomen in group 1 compared to groups 2 and 3 (P < .001), indicating loss of abdominal domain.
Conclusions:
- Infants requiring ECMO before CDH repair are prone to larger diaphragmatic defects necessitating prosthetic repair.
- Loss of abdominal domain is more common in ECMO-dependent CDH infants, complicating abdominal wall closure.
- These factors exacerbate the physiological challenges of pulmonary hypoplasia and persistent pulmonary hypertension in CDH patients requiring ECMO.
Abstract:
Congenital diaphragmatic hernia (CDH) and its attendant lack of abdominal domain can create major technical challenges with respect to diaphragmatic and abdominal wall reconstruction, especially in seriously ill infants who require extracorporeal membrane oxygenation (ECMO). The authors reviewed the medical records of all infants with CDH repaired on ECMO at their institution (group 1, 15 patients), and compared them with infants having CDH repair before ECMO (group 2, 20 patients) and with those who had CDH repair but did not require ECMO (group 3, 15 patients). Thirty-seven of 50 patients survived (74%): 10 in group 1, 12 in group 2, and all 15 in group 3. There was a statistically significant difference (P < .001) with respect to the requirement of a polytetrafluoroethylene (PTFE) diaphragmatic patch for patients in group 1 versus those in both groups 2 and 3. There was also a significant difference in the number of patients in whom the abdomen could not be closed (P < .001 for group 1 v groups 2 and 3). Infants who require ECMO before CDH repair are more likely to have large diaphragmatic defects that require prosthetic reconstruction, and abdominal wall closure problems resulting from loss of abdominal domain, which further complicate the management of the physiological derangements from pulmonary hypoplasia and persistent pulmonary hypertension.