title: Hypercapnia and acidosis during open and thoracoscopic repair of congenital diaphragmatic hernia and esophageal atresia: results of a pilot randomized controlled trial.
abstract: OBJECTIVE
  We aimed to evaluate the effect of thoracoscopy in neonates on intraoperative arterial blood gases, compared with open surgery.
  
  
  BACKGROUND
  Congenital diaphragmatic hernia (CDH) and esophageal atresia with tracheoesophageal fistula (EA/TEF) can be repaired thoracoscopically, but this may cause hypercapnia and acidosis, which are potentially harmful.
  
  
  METHODS
  This was a pilot randomized controlled trial. The target number of 20 neonates (weight > 1.6 kg) were randomized to either open (5 CDH, 5 EA/TEF) or thoracoscopic (5 CDH, 5 EA/TEF) repair. Arterial blood gases were measured every 30 minutes intraoperatively, and compared by multilevel modeling, presented as mean and difference (95% confidence interval) from these predictions.
  
  
  RESULTS
  Overall, the intraoperative PaCO2 was 61 mm Hg in open and 83 mm Hg [difference 22 mm Hg (2 to 42); P = 0.036] in thoracoscopy and the pH was 7.24 in open and 7.13 [difference -0.11 (-0.20 to -0.01); P = 0.025] in thoracoscopy. The duration of hypercapnia and acidosis was longer in thoracoscopy compared with that in open. For patients with CDH, thoracoscopy was associated with a significant increase in intraoperative hypercapnia [open 68 mm Hg; thoracoscopy 96 mm Hg; difference 28 mm Hg (8 to 48); P = 0.008] and severe acidosis [open 7.21; thoracoscopy 7.08; difference -0.13 (-0.24 to -0.02); P = 0.018]. No significant difference in PaCO2, pH, or PaO2 was observed in patients undergoing thoracoscopic repair of EA/TEF.
  
  
  CONCLUSIONS
  This pilot randomized controlled trial shows that thoracoscopic repair of CDH is associated with prolonged and severe intraoperative hypercapnia and acidosis, compared with open surgery. These findings do not support the use of thoracoscopy with CO2 insufflation and conventional ventilation for the repair of CDH, calling into question the safety of this practice. The effect of thoracoscopy on blood gases during repair of EA/TEF in neonates requires further evaluation. (ClinicalTrials.gov Identifier: NCT01467245).
authors.affiliation: *UCL Institute of Child Health and Great Ormond Street Hospital for Children, London, United Kingdom †Great Ormond Street Hospital for Children, London, United Kingdom ‡UCL Institute of Child Health, London, United Kingdom.
authors.forename: Mark
authors.initials: M
authors.lastname: Bishay
authors.forename: Luca
authors.initials: L
authors.lastname: Giacomello
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Retrosi
authors.forename: Mandela
authors.initials: M
authors.lastname: Thyoka
authors.forename: Massimo
authors.initials: M
authors.lastname: Garriboli
authors.forename: Joe
authors.initials: J
authors.lastname: Brierley
authors.forename: Louise
authors.initials: L
authors.lastname: Harding
authors.forename: Stephen
authors.initials: S
authors.lastname: Scuplak
authors.forename: Kate M
authors.initials: KM
authors.lastname: Cross
authors.forename: Joe I
authors.initials: JI
authors.lastname: Curry
authors.forename: Edward M
authors.initials: EM
authors.lastname: Kiely
authors.forename: Paolo
authors.initials: P
authors.lastname: De Coppi
authors.forename: Simon
authors.initials: S
authors.lastname: Eaton
authors.forename: Agostino
authors.initials: A
authors.lastname: Pierro
mesh_terms: D000138:Acidosis / Q000209:etiology*; D004933:Esophageal Atresia / Q000601:surgery*; D005260:Female; D006548:Hernia, Diaphragmatic / Q000601:surgery; D065630:Hernias, Diaphragmatic, Congenital; D006801:Humans; D006935:Hypercapnia / Q000209:etiology*; D007231:Infant, Newborn; D007431:Intraoperative Complications / Q000209:etiology*; D008297:Male; D010865:Pilot Projects; D011446:Prospective Studies; D013514:Surgical Procedures, Operative / Q000379:methods; D013906:Thoracoscopy / Q000009:adverse effects*