Case-Based Journal Review: Congenital Diaphragmatic Hernia 2023

Centers with high CDH volume performing ECMO achieve survival rates of approximately 50% or more in severe CDH patients.

In Europe, some maternal-fetal medicine centers perform FETO but then transfer patients to separate centers for delivery and neonatal care, creating a separation between fetal intervention and postnatal ECMO expertise.

FETO does not eliminate the need for ECMO; both interventions can be performed in the same patient.

One Chilean center's protocol involves ECMO cannulation at 6-8 hours of life followed by CDH repair 8-10 hours after cannulation.

For CDH repair on ECMO, anticoagulation management involves decreasing heparin and using Amicar before, during, and after surgery, with neonatologists managing the protocol.

At least four published reports confirm the data showing benefit of early repair on ECMO, representing a practice change in the field.

Prolonged operative time required for thoracoscopic CDH repair in babies requiring inotropic support or special ventilation (with increased CO2 and decreased pH) is detrimental to the patient.

Possible technical factors contributing to higher recurrence in thoracoscopic CDH repair include: insufficient scar formation from lack of tissue opposition, inadequate unfurling of the diaphragm, taking bites at the same tissue level creating a bundle that can pull away, or insufficient number of sutures.

A transverse abdominal incision (rather than subcostal) allows intraoperative decision-making between flap and mesh repair based on defect size, making mesh repair slightly more difficult but not impossible.

Biological patches are not designed to function as a bridge and should not be used alone for CDH repair; they can be used to reinforce a synthetic patch by placing on top.

The 80% chest wall deformity rate with synthetic patches may be inflated by inclusion of skeletal deformities inherent to CDH disease rather than caused by the patch itself.

Type D CDH defects (large defects) are very rare.

One surgeon performs fundoplication at initial CDH repair selectively in patients with type D defects who are on ECMO.

In one surgeon's experience with selective fundoplication in type D ECMO patients, none have required subsequent fundoplication surgery, representing definitive repair of both CDH and reflux.