title: Timing of repair of congenital diaphragmatic hernia in patients supported by extracorporeal membrane oxygenation (ECMO).
abstract: OBJECTIVE
  The optimal timing of repair for congenital diaphragmatic hernia (CDH) in patients requiring extracorporeal membrane oxygenation (ECMO) is controversial. Repair during ECMO may improve respiratory function by restoring normal anatomy. However, there is increased risk of complications including surgical bleeding. The purpose of this study was to examine the impact of timing of CDH repair on outcomes in a large cohort of patients treated at a single institution.
  
  
  METHODS
  We retrospectively reviewed charts of all CDH patients in our Pulmonary Hypoplasia Program from 2004 to 2013. Categorical variables were analyzed by Fisher's exact test and continuous variables by Mann-Whitney t-test (p<0.05).
  
  
  RESULTS
  A total of 77 CDH patients required ECMO support during the study dates. Of these, 16 patients did not survive to repair, 3 patients were repaired prior to cannulation, 41 patients were repaired during ECMO, and 17 patients were repaired after decannulation. Survival was 67%, 43.9%, and 100% for those repaired prior to, during, or post ECMO, respectively, with statistical significance associated with repair after decannulation (P<0.0001). Operative bleeding requiring transfusion occurred in 12 patients repaired on ECMO, while no significant bleeding occurred in patients repaired after decannulation (P=0.003).
  
  
  CONCLUSIONS
  Outcomes were improved in CDH patients undergoing surgical repair following ECMO with significantly increased survival, lower rates of surgical bleeding, and decreased total duration of ECMO therapy compared to patients repaired on ECMO. In patients who can be successfully weaned from ECMO, our study supports a role for delayed repair off ECMO with reduced operative morbidity and increased survival.
authors: The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia PA, 19104.
authors: Emily A
authors: EA
authors: Partridge
authors: The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia PA, 19104.
authors: William H
authors: WH
authors: Peranteau
authors: The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia PA, 19104.
authors: Natalie E
authors: NE
authors: Rintoul
authors: The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia PA, 19104.
authors: Lisa M
authors: LM
authors: Herkert
authors: The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia PA, 19104.
authors: Alan W
authors: AW
authors: Flake
authors: The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia PA, 19104.
authors: N Scott
authors: NS
authors: Adzick
authors: The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia PA, 19104. Electronic address: hedrick@email.chop.edu.
authors: Holly L
authors: HL
authors: Hedrick
mesh_terms: D016063:Blood Loss, Surgical / Q000401:mortality*; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects*; D005260:Female; D065630:Hernias, Diaphragmatic, Congenital / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D061646:Operative Time; D010414:Pennsylvania / Q000453:epidemiology; D019106:Postoperative Hemorrhage / Q000453:epidemiology* / Q000209:etiology; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends
keywords: Bleeding complications; Congenital diaphragmatic hernia; Extracorporeal membrane oxygenation; Repair