Congenital diaphragmatic hernia: experience without extracoporeal membrane oxygenation

While extracorporeal membrane oxygenation (ECMO) is used in the management of congenital diaphragmatic hernia (CDH), its value is questioned. The charts of all newborn infants who presented in respiratory distress due to CDH over the past 27 years were reviewed. Inborn versus outborn, year of repair, use of ultrasound (US), and the predictive value of various parameters was evaluated. Fisher's exact test and logistic regression tests were used to analyze data. There were 81 patients. 43 males and 38 females. Repair occurred after stabilization without ECMO; 65 patients survived (80%). Apgar scores at 1 min (P = 0.03) and 5 min (P = 0.005), best postductal PaO2 (BPDPaO2) (P = 0.02), and type of repair (P = 0.01) were predictive of outcome. There was no difference in survival between inborn and outborn patients or over the years of review (P = 0.29). Forty-six patients had documented prenatal US scans, with no obvious impact on outcome. Thus, survival of CDH patients without ECMO is comparable to the best results reported with ECMO, suggesting that the costs and associated morbidity of ECMO may not justify its use for such patients. Apgar scores, BPDPaO2, and type of repair are good predictors of outcome. Although relatively rare, the dramatic presentation of newborns with CDH (especially those not diagnosed prenatally) makes it one of the most challenging problems in the field of pediatric surgery. In the last few decades many aspects of CDH management have changed, and one of the most popular options is extracorporeal membrane oxygenation (ECMO). While ECMO is used in the management of CDH and considered by some to be the most important emerging therapy for such patients [1-4], its value is still in question. It is suggested that ECMO can improve survival by minimizing persistent pulmonary hypertension [5, 6]. However the impact of pulmonary hypoplasia coupled with significant complications associated with ECMO has led some observers to conclude that ECMO has no overall positive impact on survival [7, 8]. This study reviewed our experience with managem ent of CDH without ECMO over the past 27 years. Our goals were: (1) to define CDH survival at our center, (2) to examine whether CDH survival changed over the period of review, and (3) to determine significant predictors of survival in this group of patients.