Opportunity for a minimally invasive approach to Bochdalek congenital diaphragmatic hernia with protocolized perinatal management: A single center experience

Abstract

Summary: Introduction: Different studies have suggested that thoracoscopic treatment of congenital diaphragmatic hernia (CDH) is a safe and reproducible method. However, the patients selected for the procedure had the stomach and/or liver properly positioned within the abdomen and also with adequate cardiopulmonary stability. In our study, we used different clinical and anatomical selection criteria for thethoracoscopic approach in these neonates. Objective: Our study aims to present the clinical status and outcomes of the minimally invasive approach (MIA) in neonates with left Bochdalek CDH and their protocolized perinatal management at our center from 2015 to 2018. Materials and methods: An observational retrospective study was conducted at a tertiary pediatric hospital. Patients with a prenatal diagnosis and follow-up of isolated left CDH were counseled and treated by the same team of specialists following a predefined protocol. All fetuses underwent expectant management with in-utero transfer to the neonatal intensive care unit for scheduled delivery. Prenatal, perinatal, as well asclinical pre- and post-surgical variables were analyzed. The primary outcomes assessed were survival and the requirement for oxygen support at 90 days of life. The relevant secondary outcomes considered included days on mechanical ventilation (MV) and days of hospital stay. The data are expressed as median (range) or percentage (%). Results: 61 patients with left CDH were delivered in the operating room within the neonatal intensive care unit, nine died before reaching the surgical stage. Overall, 15/52 patients were operated using MIA. The 90-day mortality rate was 1/15 (6.7 %) due to multiorgan failure unrelated to the type of surgical approach. The duration on MV was 13 (7–22) days; patients were discharged at a mean of 37 (17–103) days of life, and no oxygen dependence was observed at 90 days. Conclusion: The thoracoscopic approach accounted for 28.8 % of the total surgeries performed and proved to be safe with a high survival rate of 93.3 % and no oxygen dependence. The presence of a type C defect and/or liver in the chest in this group of patients should be taken into account to alert the surgeon that higher conversion and recurrence rates can be expected.

Keywords

• Minimally invasive approach
• Thoracoscopy
• Congenital diaphragmatic hernia