Is delayed surgery really better for congenital diaphragmatic hernia?: A prospective randomized clinical trial

Hunt, M.N de la; Madden, Nick; Scott, J. E.; Matthews, J. N. S.; Beck, John; Sadler, Chris; Barrett, A. M.; Boddy, Su-Anna; Bray, R. J.; Cusick, Eleri; Gardner, Leanne Margaret; Hargrave, S.A.; Hinton, William; Rangercroft, L; Spicer, R. D.; Stafford, Michael A.; Thomas, David G.; Vallis, C.J.; Wagget, J.

doi:10.1016/s0022-3468(96)90176-1

Cited by 57 publications

(28 citation statements)

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“…The only two prospective randomised trials and one systematic review of early or delayed closure have failed to show a statistically significant difference in mortality and secondary variables (such as length of hospital stay, need for ECMO and duration of respiratory support) [67][68][69].…”

Section: Timing Of Surgerymentioning

confidence: 99%

Congenital diaphragmatic hernia

Kotecha¹,

Barbato²,

Bush³

et al. 2011

Eur Respir J

141

122

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Infants with congenital diaphragmatic hernia (CDH) have significant mortality and long-term morbidity. Only 60-70% survive and usually those in high-volume centres. The current Task Force, therefore, has convened experts to evaluate the current literature and make recommendations on both the antenatal and post-natal management of CDH. The incidence of CDH varies from 1.7 to 5.7 per 10,000 live-born infants depending on the study population. Antenatal ultrasound scanning is routine and increasingly complemented by the use of magnetic resonance imaging. For isolated CDH, antenatal interventions should be considered, but the techniques need vigorous evaluation. After birth, management protocols are often used and have improved outcome in nonrandomised studies, but immediate intubation at birth and gentle ventilation are important. Pulmonary hypertension is common and its optimal management is crucial as its severity predicts the outcome. Usually, surgery is delayed to allow optimal medical stabilisation. The role of minimal invasive post-natal surgery remains to be further defined. There are differences in opinion about whether extracorporeal membrane oxygenation improves outcome. Survivors of CDH can have a high incidence of comorbidities; thus, multidisciplinary follow-up is recommended. Multicentre international trials are necessary to optimise the antenatal and post-natal management of CDH patients.

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Section: Timing Of Surgerymentioning

confidence: 99%

Congenital diaphragmatic hernia

Kotecha¹,

Barbato²,

Bush³

et al. 2011

Eur Respir J

141

122

View full text Add to dashboard Cite

show abstract

“…Details of management strategies are not provided, but the report suggests that survival is best achieved by caring for CDH infants at centers that have developed a standardized approach to care, with adequate numbers of CDH infants to develop expertise. 4 Literature review reveals a limited number of controlled clinical trials examining interventions that improve survival of infants with CDH; [5][6][7][8][9][10][11][12][13][14] however, several centers reporting relatively high rates of survival for CDH have described their management strategies in varying detail. [15][16][17][18][19][20][21][22][23][24][25] The objective of this report is to provide clinicians with a summary of specific details of clinical care strategies from these 'benchmark' centers.…”

Section: Introductionmentioning

confidence: 99%

Congenital diaphragmatic hernia: a systematic review and summary of best-evidence practice strategies

et al. 2007

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Objectives: Recent reports suggest that specific care strategies improve survival of infants with congenital diaphragmatic hernia (CDH). This review presents details of care from centers reporting high rates of survival among CDH infants.Study Design: We conducted a MEDLINE search (1995 to 2006) and searched all citations in the Cochrane Central Register of Controlled Trials. Studies were included if they contained reports of >20 infants with symptomatic CDH, and >75% survival of isolated CDH.Result: Thirteen reports from 11 centers met inclusion criteria. Overall survival, including infants with multiple anomalies, was 603/763 (79%; range: 69 to 93%). Survival for isolated CDH was 560/661 (85%; range: 78 to 96%). The frequency of extracorporeal membrane oxygenation (ECMO) use for isolated CDH varied widely among reporting centers 251/622 (40%; range: 11 to 61%), as did survival for infants with isolated CDH placed on ECMO: 149/206 (73%; range: 33 to 86%). There was no suggestion of benefit from use of antenatal glucocorticoids given after 34 weeks gestation or use of postnatal surfactant. Low mortality was frequently attributed to minimizing lung injury and adhering to center-specific criteria for ECMO.Conclusion: Use of strategies aimed at minimizing lung injury, tolerance of postductal acidosis and hypoxemia, and adhering to center-specific criteria for ECMO were strategies most consistently reported by successful centers. The literature lacks randomized clinical trials of these or other care strategies in this complex patient population; prospective studies of safety and long-term outcome are needed. Keywords: congenital diaphragmatic hernia; pulmonary hypertension; pulmonary hypoplasia; inhaled nitric oxide; extracorporeal membrane oxygenation; systematic review Introduction Congenital diaphragmatic hernia (CDH) is a rare malformation observed in approximately 1 in 3000 live births, with estimates of postnatal survival ranging from 50 to 70% despite advances in neonatal care. 1 The combination of pathophysiologic derangements associated with CDH, including lung hypoplasia, lung dysmaturity and pulmonary hypertension (PPHN), requires a multidisciplinary approach to care. 2,3 The complex nature of clinical management and the relatively infrequent presentation of infants with this rare malformation to single centers has lead to difficulty identifying consistent strategies for CDH management. A recent report from the Canadian Neonatal Research Network indicates better than predicted survival in Network centers, with significant improvement in the higher mortality odds strata, and 90% survival in the three centers that cared for at least 12 infants over a 22-month period. Details of management strategies are not provided, but the report suggests that survival is best achieved by caring for CDH infants at centers that have developed a standardized approach to care, with adequate numbers of CDH infants to develop expertise. 4 Literature review reveals a limited number of controlled clinical trials examining inter...

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“…[52][53][54] In addition, no studies have shown explicit "readiness for surgery" criteria that optimize outcome. [55][56][57][58][59] Although we recommend that certain physiologic criteria (including infrasystemic pulmonary artery pressures) be met before surgery, we have cautioned that failure to meet these criteria should not prevent surgery, which offers the only hope for survival.…”

Section: C-eo)mentioning

confidence: 99%