title: Liver position in fetal congenital diaphragmatic hernia retains a prognostic value in the era of lung-protective strategy.
abstract: OBJECTIVE
  The aims of this study were to analyze the outcomes of fetuses with congenital diaphragmatic hernia (CDH) treated by a lung-protective strategy using high-frequency oscillatory ventilation (HFOV) in a single center with a perinatology service and extracorporeal membrane oxygenation (ECMO) capability and to define the natural history of CDH in the era of lung-protective ventilation.
  
  
  METHODS
  A retrospective chart review of 30 neonates with CDH seen between April 2002 and October 2004 was conducted. All fetuses with a prenatal diagnosis were evaluated by fetal magnetic resonance imaging to define the liver position, and those with a significant volume of the liver in the chest were regarded as liver-up. Patients were managed by a lung-protective strategy using pressure-limited (maximum mean airway pressure [MAP], 18 cm H(2)O) HFOV. The patients were initially placed on HFOV with a fraction of inspired oxygen (Fio(2)) of 1.0 and a MAP of 12 cm H(2)O. Hypercapnea and preductal saturation as low as 85% were accepted. Inhaled nitric oxide and ECMO were introduced when the baby could not be oxygenated with a MAP of 18 cm H(2)O.
  
  
  RESULTS
  Twenty-six neonates (22 inborns with prenatal diagnosis and 4 outborns) were treated with this protocol. Four cases were not treated or died in utero because of severe associated anomalies. Thirteen of the 14 liver-down cases survived without ECMO and were discharged home (93% survival). On the contrary, 4 of 12 liver-up cases survived (33% survival). ECMO was required for initial stabilization in 5 cases with 1 survivor.
  
  
  CONCLUSIONS
  Liver-down CDH babies have a good chance for survival without ECMO by a planned delivery and the lung-protective strategy using HFOV. Liver herniation demonstrated by prenatal magnetic resonance imaging retains a poor prognostic value even with this approach.
authors.affiliation: Division of General Surgery, National Center for Child Health and Development, Tokyo 157-8535, Japan. kitano-y@ncchd.go.jp
authors.forename: Yoshihiro
authors.initials: Y
authors.lastname: Kitano
authors.forename: Satoshi
authors.initials: S
authors.lastname: Nakagawa
authors.forename: Tatsuo
authors.initials: T
authors.lastname: Kuroda
authors.forename: Toshiro
authors.initials: T
authors.lastname: Honna
authors.forename: Yushi
authors.initials: Y
authors.lastname: Itoh
authors.forename: Tomoo
authors.initials: T
authors.lastname: Nakamura
authors.forename: Nobuyuki
authors.initials: N
authors.lastname: Morikawa
authors.forename: Naoki
authors.initials: N
authors.lastname: Shimizu
authors.forename: Kyoko
authors.initials: K
authors.lastname: Kashima
authors.forename: Satoshi
authors.initials: S
authors.lastname: Hayashi
authors.forename: Haruhiko
authors.initials: H
authors.lastname: Sago
mesh_terms: D035641:Chest Wall Oscillation; D015199:Extracorporeal Membrane Oxygenation; D005333:Fetus; D006548:Hernia, Diaphragmatic / Q000175:diagnosis / Q000628:therapy*; D065630:Hernias, Diaphragmatic, Congenital; D006801:Humans; D008099:Liver / Q000033:anatomy & histology / Q000473:pathology*; D008279:Magnetic Resonance Imaging; D011296:Prenatal Diagnosis; D011379:Prognosis; D012189:Retrospective Studies; D016019:Survival Analysis