J Pediatr Surg
. 2024 Dec 21;60(3):162110.
doi: 10.1016/j.jpedsurg.2024.162110. Online ahead of print. https://pubmed.ncbi.nlm.nih.gov/39740277/
Outcomes of an Individualized Hybrid Model for Repair of Infants With Congenital Diaphragmatic Hernia Requiring Extracorporeal Life Support
Nikhil R Shah 1, Dimitra M Lotakis 1, Keerthi Burgi 2, Joseph T Church 1, Meghan A Arnold 1, Ronald B Hirschl 1, Samir K Gadepalli 1, George B Mychaliska 1, Erin E Perrone 3
Affiliations Expand
- PMID: 39740277
- DOI: 10.1016/j.jpedsurg.2024.162110
Abstract
Introduction: Timing of repair for infants with congenital diaphragmatic hernia (CDH) requiring extracorporeal life support (ECLS) remains controversial. Approaches include early repair on ECLS, late repair on ECLS, or repair after ECLS decannulation; all have potential risks and benefits. To mitigate risk and maximize benefit, our group developed an individualized hybrid model in 2016 in which approach is based on prenatal risk stratification. Here we report the outcomes of this model.
Methods: This is a single-institution retrospective review (2002-2023) of infants diagnosed with CDH requiring ECLS, grouping patients according to temporal protocols: Delayed Repair (DR; 2002-2009), Early Repair (ER; 2010-2016), and Hybrid Model (HM; 2017-2023). Demographics, disease characteristics, and outcomes were analyzed. Chi-squared/Fisher’s exact/Kruskal-Wallis tests were used, with significance of p < 0.05.
Results: 103 infants were included- 35 (34 %) with DR, 32 (31 %) with ER, and 36 (35 %) using HM. Patient demographics and markers of prenatal severity were similar among groups. Median ECLS duration was significantly less in patients treated with HM (10 days; IQR: 5,17) compared to DR (12 days, IQR: 6,17) and ER (17 days, IQR: 11,22) [p = 0.019]. Survival to discharge was highest using the HM (78 %) compared to DR (69 %) and ER (34 %) groups [p < 0.001]. Subgroup analysis of the HM cohort demonstrated prenatal predictors differed significantly based on timing selected for repair.
Conclusion: We demonstrate a physiologic spectrum across infants with CDH requiring ECLS, suggesting utility of a hybrid model. This individualized approach may be beneficial in discerning patients of moderate severity who could be decannulated prior to repair to mitigate bleeding complications.
Level of evidence: III.
Keywords: Congenital diaphragmatic hernia; Extracorporeal life support; Individualized care; Pulmonary hypertension; Repair timing.
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