Delayed repair and preoperative ECMO does not improve survival in high-risk congenital diaphragmatic hernia

Abstract

It has been suggested that delayed repair with preoperative stabilization might improve survival in high-risk (symptomatic within 6 hours of birth) congenital diaphragmatic hernia (CDH). This study compares the results of immediate operation versus delayed repair using extracorporeal membrane oxygenation (ECMO) when necessary. Since we first used ECMO in 1984, 101 high-risk CDH infants have been treated. Prior to 1987, we used immediate repair and postoperative ECMO if necessary. Between 1987 and 1990 we combined delayed operation (24 to 36 hours) with preoperative ECMO as necessary. No infant in this series was excluded from ECMO therapy unless absolute contraindications existed (prematurity, intracranial hemorrhage, or other major anomalies). Fifty-five patients received immediate operation and 46 had delayed repair. The two groups were comparable populations based on gestational age, birth weight, age at onset of symptoms, Apgar scores, best postductal PO₂ (BPDPO₂), and frequency of antenatal diagnosis. There was no statistically significant difference in overall survival between the two groups. Differences in survival among subpopulations (BPDPO₂ >100 or <100, antenatal diagnosis, inborn v outborn) also are not significant. The requirement for ECMO was similar in both groups. Survivors in the delayed repair group were ventilated longer and on ECMO longer, but had fewer late deaths (>21 days) and fewer pulmonary sequelae (O₂ dependency at discharge) than infants in the immediate repair group (P < .05). We conclude: (1) operative delay with preoperative ECMO did not improve overall survival but led to fewer late deaths and fewer pulmonary sequelae than immediate repair with post-operative ECMO; (2) BPDPO₂ continued to be an accurate predictor of outcome in these patients; and (3) nonresponders to aggressive conventional therapy (BPDPO₂₂ < 100), which represented 43% of our population, continued to be unsalvageable despite the addition of delayed operative management and preoperative ECMO.