title: Value of liver herniation in prediction of outcome in fetal congenital diaphragmatic hernia: a systematic review and meta-analysis.
abstract: OBJECTIVE
  Intrathoracic liver herniation (ILH) is being used to estimate prognosis and hence guide antenatal interventions in fetal congenital diaphragmatic hernia (CDH). However, the literature regarding its utility in this role is conflicting. This review systematically examines the currently available evidence of ILH use in fetal CDH.
  
  
  METHODS
  MEDLINE and EMBASE databases were searched for the terms ((congenital diaphragmatic hernia) OR CDH) AND liver. Inclusion criteria were human case series of fetuses diagnosed with CDH using either ultrasound or magnetic resonance imaging. Included studies were required to have reported the antenatal liver position and the outcome (survival or not). Case reports, reviews and eventration series were excluded. Studies reporting similar cases from the same center over an overlapping time period were considered duplicates; only the larger of the studies were therefore included. Absolute totals were extracted and sums calculated. Fisher's exact test (FET) was used to compare survival rates in different groups.
  
  
  RESULTS
  The original search retrieved 338 studies. Applying inclusion/exclusion criteria and removing duplicates left 21 case series in 20 studies. Retrieved studies differed in the definitions of liver herniation, survival and treatment modality. In total, there were 407 fetuses in the liver-up (herniated) and 303 in the liver-down (not herniated) groups. Survival rates were 45.4% and 73.9%, respectively. The difference was statistically significant (FET = 56.4, P < 0.005). Sensitivity analysis for cases that had only conventional postnatal treatment was still significant (FET = 52.8, P < 0.005).
  
  
  CONCLUSIONS
  Liver herniation is associated with poorer prognosis in fetal CDH. Grading liver herniation or using it as part of a panel of markers may enhance the value of liver herniation as a prognostic test in fetal CDH.
authors.affiliation: Division of Child Health, University of Liverpool, Alder Hey Children's Hospital NHS Trust, Liverpool, UK. mdhanya@liverpool.ac.uk
authors.forename: D
authors.initials: D
authors.lastname: Mullassery
authors.forename: M E
authors.initials: ME
authors.lastname: Ba'ath
authors.forename: E C
authors.initials: EC
authors.lastname: Jesudason
authors.forename: P D
authors.initials: PD
authors.lastname: Losty
mesh_terms: D005260:Female; D005865:Gestational Age; D006548:Hernia, Diaphragmatic / Q000175:diagnosis* / Q000401:mortality; D065630:Hernias, Diaphragmatic, Congenital; D006801:Humans; D008107:Liver Diseases / Q000151:congenital / Q000175:diagnosis* / Q000401:mortality; D011247:Pregnancy; D011296:Prenatal Diagnosis / Q000379:methods; D011379:Prognosis