Timing of surgery for congenital diaphragmatic hernia: Is emergency operation necessary?

Jacob C. Langer, Robert M. Filler*, Desmond J. Bohn, Barry Shandling, Sigmund H. Ein, David E. Wesson, Riccardo A. Superina

*Corresponding author for this work

Research output: Contribution to journalArticle

109 Citations (Scopus)

Abstract

Congenital diaphragmatic hernia (CDH) is considered by most researchers to be a surgical emergency. However, early repair does not necessarily improve respiratory function or reverse fetal circulation, and many patients deteriorate postoperatively. As a result, in 1985, we began to employ a protocol in which surgery was delayed until the PCO2 was maintained below 40 and the child was hemody-namically stable; children in whom these criteria could not be achieved died without surgical repair. Sixty-one consecutive infants with CDH were managed over 4 years; 31 from 1983 to 1984 (group 1) and 30 from 1985 to 1986 (group 2). The groups were similar with respect to sex, side of the defect, birth weight, gestational age, incidence of pneumothorax, and blood gases. High frequency oscillation was used with increasing frequency during the study period, for patients with refractory hypercarbia (13% in group 1, 30% in group 2). All patients were initially paralyzed and ventilated. Mean time from admission to surgery was 4.1 hours in group 1 and 24.4 hours in group 2 (P<.05). In group 1, 87% of patients had surgical repair (77% within eight hours of admission, 10% after eight hours), and in group 2 only 70% of patients had surgery (10% within eight hours, 60% after eight hours). All patients who were not operated on died. Overall mortality was 58% in group 1 and 50% in group 2; this difference was not statistically significant. These data indicate that our current approach has not increased overall mortality. We believe that early repair in the face of labile respiratory and hemodynamic function may be harmful, and that delayed operation may allow patients with a borderline prognosis to survive. For these reasons we conclude that emergency surgery is not necessary, and that repair should be done only when the patient has been satisfactorily stabilized.

Original languageEnglish (US)
Pages (from-to)731-734
Number of pages4
JournalJournal of Pediatric Surgery
Volume23
Issue number8
DOIs
StatePublished - Jan 1 1988

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Emergencies
Mortality
Hypercapnia
Congenital Diaphragmatic Hernias
Pneumothorax
Birth Weight
Gestational Age
Gases
Hemodynamics
Research Personnel
Incidence

Keywords

  • Congenital diaphragmatic hernia
  • high frequency oscillation

ASJC Scopus subject areas

  • Surgery
  • Pediatrics, Perinatology, and Child Health

Cite this

Langer, Jacob C. ; Filler, Robert M. ; Bohn, Desmond J. ; Shandling, Barry ; Ein, Sigmund H. ; Wesson, David E. ; Superina, Riccardo A. / Timing of surgery for congenital diaphragmatic hernia : Is emergency operation necessary?. In: Journal of Pediatric Surgery. 1988 ; Vol. 23, No. 8. pp. 731-734.
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title = "Timing of surgery for congenital diaphragmatic hernia: Is emergency operation necessary?",
abstract = "Congenital diaphragmatic hernia (CDH) is considered by most researchers to be a surgical emergency. However, early repair does not necessarily improve respiratory function or reverse fetal circulation, and many patients deteriorate postoperatively. As a result, in 1985, we began to employ a protocol in which surgery was delayed until the PCO2 was maintained below 40 and the child was hemody-namically stable; children in whom these criteria could not be achieved died without surgical repair. Sixty-one consecutive infants with CDH were managed over 4 years; 31 from 1983 to 1984 (group 1) and 30 from 1985 to 1986 (group 2). The groups were similar with respect to sex, side of the defect, birth weight, gestational age, incidence of pneumothorax, and blood gases. High frequency oscillation was used with increasing frequency during the study period, for patients with refractory hypercarbia (13{\%} in group 1, 30{\%} in group 2). All patients were initially paralyzed and ventilated. Mean time from admission to surgery was 4.1 hours in group 1 and 24.4 hours in group 2 (P<.05). In group 1, 87{\%} of patients had surgical repair (77{\%} within eight hours of admission, 10{\%} after eight hours), and in group 2 only 70{\%} of patients had surgery (10{\%} within eight hours, 60{\%} after eight hours). All patients who were not operated on died. Overall mortality was 58{\%} in group 1 and 50{\%} in group 2; this difference was not statistically significant. These data indicate that our current approach has not increased overall mortality. We believe that early repair in the face of labile respiratory and hemodynamic function may be harmful, and that delayed operation may allow patients with a borderline prognosis to survive. For these reasons we conclude that emergency surgery is not necessary, and that repair should be done only when the patient has been satisfactorily stabilized.",
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Timing of surgery for congenital diaphragmatic hernia : Is emergency operation necessary? / Langer, Jacob C.; Filler, Robert M.; Bohn, Desmond J.; Shandling, Barry; Ein, Sigmund H.; Wesson, David E.; Superina, Riccardo A.

In: Journal of Pediatric Surgery, Vol. 23, No. 8, 01.01.1988, p. 731-734.

Research output: Contribution to journalArticle

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T1 - Timing of surgery for congenital diaphragmatic hernia

T2 - Is emergency operation necessary?

AU - Langer, Jacob C.

AU - Filler, Robert M.

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AU - Shandling, Barry

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AU - Superina, Riccardo A.

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