title: A risk-stratified analysis of delayed congenital diaphragmatic hernia repair: does timing of operation matter?
abstract: BACKGROUND
  Congenital diaphragmatic hernia (CDH) remains a significant cause of death in newborns and, despite improved outcomes with multimodality therapies, optimal timing of repair remains undefined. We sought to evaluate the influence of surgical timing on patient outcomes and hypothesized that delayed repair does not improve survival in CDH.
  
  
  METHODS
  Prospectively collected data from 1,385 CDH Registry infants without preoperative extracorporeal membrane oxygen therapy (ECMO) were evaluated. Patients were stratified by timing of repair: Day of life (DOL) 0-3 (group 1), 4-7 (group 2), or >8 (group 3), and the effect of surgical timing on mortality was determined by logistic regression and risk-adjusted for severity of illness.
  
  
  RESULTS
  The unadjusted odds ratio (OR) for mortality increased significantly with delayed repair (group 2, 1.73 [95% CI, 1.00-2.98; group 3, 3.42 [95% CI, 1.97-5.96]). However, when adjusted for severity of illness, delay in repair did not predict increased mortality (group 2, 1.2 [95% CI, 0.7-2.2]; group 3, 1.4 [95% CI, 0.8-2.6]), nor did it portend an increased need for postoperative ECMO (group 2, 1.1 [95% CI, 0.5-2.4]; group 3, 0.5 [95% CI, 0.2-1.4]).
  
  
  CONCLUSIONS
  After adjustment for known risk factors, the timing of CDH repair in low-risk infants does not seem to influence mortality. However, specific clinical parameters guiding timing of elective CDH repair remain unknown.
authors: Department of Surgery, The Methodist Hospital and Research Institute, Houston, TX; The Department of Pediatric Surgery, The University of Texas School of Medicine at Houston, TX; The Children's Memorial Hermann Hospital, Houston, TX.
authors: Laura E
authors: LE
authors: Hollinger
authors: The Department of Pediatric Surgery, The University of Texas School of Medicine at Houston, TX; The Children's Memorial Hermann Hospital, Houston, TX.
authors: Pamela A
authors: PA
authors: Lally
authors: The Department of Pediatric Surgery, The University of Texas School of Medicine at Houston, TX; The Children's Memorial Hermann Hospital, Houston, TX. Electronic address: KuoJenTsao@uth.tmc.edu.
authors: KuoJen
authors: K
authors: Tsao
authors: The Department of Surgery, The University of Texas School of Medicine at Houston, TX.
authors: Curtis J
authors: CJ
authors: Wray
authors: The Department of Pediatric Surgery, The University of Texas School of Medicine at Houston, TX; The Children's Memorial Hermann Hospital, Houston, TX.
authors: Kevin P
authors: KP
authors: Lally
mesh_terms: D015199:Extracorporeal Membrane Oxygenation; D006548:Hernia, Diaphragmatic / Q000473:pathology / Q000601:surgery / Q000628:therapy; D065630:Hernias, Diaphragmatic, Congenital; D059685:Herniorrhaphy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D006801:Humans; D007226:Infant Mortality; D007231:Infant, Newborn; D011446:Prospective Studies; D012042:Registries; D012307:Risk Factors; D012720:Severity of Illness Index; D013781:Texas / Q000453:epidemiology; D013997:Time Factors; D016896:Treatment Outcome