Delayed repair of congenital diaphragmatic hernia

Early reports of improved survival in newborns with congenital diaphragmatic hernias (CDH) utilizing extracorporeal membrane oxygenation (ECMO) and/or a delayed repair (DR) approach have been tempered by recent failures to document such an improvement. We have used ECMO to salvage emergently repaired patients with CDH since January 1984. From January 1990 to January 1991, we treated 16 CDH patients with mechanical ventilation and other supportive techniques until persistent pulmonary hypertension of the newborn resolved. We compared this DR group to 19 patients emergently repaired from February 1987 to December 1989. Of the 19 emergently repaired patients, 16 had a best post ductal (BPD) PO2 > 50 mm Hg. Eight patients survived (42 per cent of all and 50 per cent of those with a BPD PO2 > 50). Thirteen required ECMO and six of these survived. Five of six ECMO survivors had significant ECMO complications, and ECMO was "inappropriately" performed on three of six nonsurvivors. Of the 16 DR patients, nine achieved a BPD PO2 > 50 mm Hg and seven survived (44 per cent of all and 78 per cent of those with a BPD PO2 > 50). Seven required ECMO and four of these survived. All survivors in both groups had a BPD PO2 > 90 mm Hg. Delayed repair did not improve survival statistics for CDH with early respiratory distress at our hospital but it has allowed stratification of potential survivors, fewer inappropriate ECMO cannulations, and many fewer ECMO complications.