Potential survival benefit with repair of congenital diaphragmatic hernia (CDH) after extracorporeal membrane oxygenation (ECMO) in select patients: Study by ELSO CDH Interest Group

Patrick T Delaplain; Matthew T Harting; Tim Jancelewicz; Lishi Zhang; Peter T Yu; Matteo Di Nardo; Yanjun Chen; James E Stein; Henri R Ford; Danh V Nguyen; Yigit Guner

doi:10.1016/j.jpedsurg.2019.02.052

Potential survival benefit with repair of congenital diaphragmatic hernia (CDH) after extracorporeal membrane oxygenation (ECMO) in select patients: Study by ELSO CDH Interest Group

J Pediatr Surg. 2019 Jun;54(6):1132-1137. doi: 10.1016/j.jpedsurg.2019.02.052. Epub 2019 Mar 1.

Authors

Patrick T Delaplain¹, Matthew T Harting², Tim Jancelewicz³, Lishi Zhang⁴, Peter T Yu⁵, Matteo Di Nardo⁶, Yanjun Chen⁴, James E Stein⁷, Henri R Ford⁸, Danh V Nguyen⁹, Yigit Guner¹⁰

Affiliations

¹ Children's Hospital Los Angeles, Department of Pediatric Surgery, Los Angeles, CA; University of California Irvine Medical Center, Department of Surgery, Orange, CA.
² Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX.
³ Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Division of Pediatric Surgery, Memphis, TN.
⁴ University of California Irvine Biostatistics, Institute for Clinical and Translational Science, Irvine, CA.
⁵ University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital of Orange County, Division of Pediatric Surgery, Orange, CA.
⁶ Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy.
⁷ Children's Hospital Los Angeles, Department of Pediatric Surgery, Los Angeles, CA.
⁸ Children's Hospital Los Angeles, Department of Pediatric Surgery, Los Angeles, CA; University of Miami, Miller School of Medicine, Miami, FL.
⁹ University of California, Irvine School of Medicine, Department of Medicine, Orange, CA.
¹⁰ University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital of Orange County, Division of Pediatric Surgery, Orange, CA. Electronic address: yguner@uci.edu.

PMID: 30898399
DOI: 10.1016/j.jpedsurg.2019.02.052

Abstract

Purpose: Studying the timing of repair in CDH is prone to confounding factors, including variability in disease severity and management. We hypothesized that delaying repair until post-ECMO would confer a survival benefit.

Methods: Neonates who underwent CDH repair were identified within the ELSO Registry. Patients were then divided into on-ECMO versus post-ECMO repair. Patients were 1:1 matched for severity based on pre-ECMO covariates using the propensity score (PS) for the timing of repair. Outcomes examined included mortality and severe neurologic injury (SNI).

Results: After matching, 2,224 infants were included. On-ECMO repair was associated with greater than 3-fold higher odds of mortality (OR 3.41, 95% CI: 2.84-4.09, p<0.01). The odds of SNI was also higher for on-ECMO repair (OR 1.49, 95% CI: 1.13-1.96, p<0.01). A sensitivity analysis was performed by including the length of ECMO as an additional matching variable. On-ECMO repair was still associated with higher odds of mortality (OR 2.38, 95% CI: 1.96-2.89, p<0.01). Results for SNI were similar but were no longer statistically significant (OR 1.33, 95% CI: 0.99-1.79, p=0.06).

Conclusions: Of the infants who can be liberated from ECMO and undergo CDH repair, there is a potential survival benefit for delaying CDH repair until after decannulation.

Type of study: Treatment Study LEVEL OF EVIDENCE: III.

Keywords: Congenital diaphragmatic hernia (CDH); Extracorporeal membrane oxygenation (ECMO).

MeSH terms

Extracorporeal Membrane Oxygenation / mortality*
Hernias, Diaphragmatic, Congenital* / mortality
Hernias, Diaphragmatic, Congenital* / surgery
Herniorrhaphy* / methods
Herniorrhaphy* / mortality
Humans
Infant, Newborn
Propensity Score
Registries