Aggressive Surgical Management of Congenital Diaphragmatic Hernia: Worth the Effort?
- 1 May 2018
- journal article
- research article
- Published by Ovid Technologies (Wolters Kluwer Health) in Annals of Surgery
- Vol. 267 (5), 977-982
- https://doi.org/10.1097/sla.0000000000002144
Abstract
The objectives of this study were (i) to evaluate infants with congenital diaphragmatic hernia (CDH) that do not undergo repair, (ii) to identify nonrepair rate by institution, and (iii) to compare institutional outcomes based on nonrepair rate. Approximately 20% of infants with CDH go unrepaired and the threshold to offer surgical repair is variable. Data were abstracted from a multicenter, prospectively collected database. Standard clinical variables, including repair (or nonrepair), and outcome were analyzed. Institutions were grouped based on volume and rate of nonrepair. Preoperative mortality predictors were identified using logistic regression, expected mortality for each center was calculated, and observed /expected (O/E) ratios were computed for center groups and compared by Kruskal-Wallis ANOVA. A total of 3965 infants with CDH were identified and 691 infants (17.5%) were not repaired. Nonrepaired patients had lower Apgar scores (P < 0.05) and increased incidence of anomalies (P < 0.0001). Low-volume centers (“Lo”, n=44 total, < 10 CDH pts/yr) and high-volume centers (“Hi”, n = 21) had median nonrepair rates of 19.8% (range 0%–66.7%) and 16.7% (5.1%–38.5%), respectively. High-volume centers were further dichotomized by rate of nonrepair (HiLo = 5.1–16.7% and HiHi = 17.6–38.5%), leaving 3 groups: HiLo, HiHi, and Lo. Predictors of mortality were lower birth weight, lower Apgar scores, prenatal diagnosis, and presence of congenital anomalies. O/E ratios for mortality in the HiLo, HiHi, and Lo groups were 0.81, 0.94, and 1.21, respectively (P < 0.0001). For every 100 CDH patients, HiLo centers have 2.73 (2.4–3.1, 95% confidence interval) survivors beyond expectation. There are significant differences between repaired and nonrepaired CDH infants and significant center variation in rate of nonrepair exists. Aggressive surgical management, leading to a low rate of nonrepair, is associated with improved risk-adjusted mortality.Keywords
This publication has 22 references indexed in Scilit:
- Protocolized management of infants with congenital diaphragmatic hernia: effect on survivalJournal of Pediatric Surgery, 2011
- Standardized Postnatal Management of Infants with Congenital Diaphragmatic Hernia in Europe: The CDH EURO Consortium ConsensusNeonatology, 2010
- Impact of Hospital Volume on In-Hospital Mortality of Infants Undergoing Repair of Congenital Diaphragmatic HerniaAnnals of Surgery, 2010
- Survival disparities in newborns with congenital diaphragmatic hernia: a national perspectiveJournal of Pediatric Surgery, 2010
- Protocolized approach to the management of congenital diaphragmatic hernia: benefits of reducing variability in careJournal of Pediatric Surgery, 2010
- Mortality in infants with congenital diaphragmatic hernia: a study of the United States National DatabaseJournal of Perinatology, 2010
- The Congenital Diaphragmatic Hernia Study Group: a voluntary international registrySeminars in Pediatric Surgery, 2008
- Defect Size Determines Survival in Infants With Congenital Diaphragmatic HerniaPublished by American Academy of Pediatrics (AAP) ,2007
- Treatment Evolution in High-Risk Congenital Diaphragmatic HerniaTransactions of the ... Meeting of the American Surgical Association, 2006
- Outcomes of Congenital Diaphragmatic Hernia: A Population-Based Study in Western AustraliaPublished by American Academy of Pediatrics (AAP) ,2005