Surgical approaches for neonatal congenital diaphragmatic hernia: a systematic review and meta-analysis.
OBJECTIVE
The optimal surgical approach for neonatal congenital diaphragmatic hernia (CDH) remains unclear. We conducted a systematic review and meta-analysis of the effectiveness of endoscopic surgery (ES) for neonatal CDH.


METHODS
A systematic literature search was conducted using MEDLINE and the Cochrane Library. Studies that compared surgical approaches for neonatal CDH were selected. Mortality and recurrence of herniation were analyzed as primary endpoints. Each study was evaluated following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.


RESULTS
Eight observational studies comparing ES and open surgery (OS) met the criteria. As compared with the OS group, the ES group showed both a significantly lower mortality rate [risk ratio (RR) 0.18, 95 % confidence interval (CI) 0.09-0.38, p < 0.0001] and a significantly higher recurrence rate (RR 3.10, 95 % CI 1.95-4.88, p < 0.00001). However, serious selection bias was seen in seven of the eight studies-because the indication of ES had been determined intentionally, the ES groups may have included less severe cases.


CONCLUSIONS
Although the evidence was insufficient, ES was clearly associated with more recurrence than was OS. Therefore, ES should not be the routine treatment for every neonate. It is crucially important to select suitable cases for ES.
Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba, 260-8677, Japan. kta@cc.rim.or.jp.
Keita
K
Terui
Department of Pediatric Surgery, Kyushu University, Fukuoka, Japan.
Kouji
K
Nagata
Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan.
Miharu
M
Ito
Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan.
Masaya
M
Yamoto
Osaka University Library, Osaka, Japan.
Masayuki
M
Shiraishi
Department of Pediatric Surgery, Kyushu University, Fukuoka, Japan.
Tomoaki
T
Taguchi
Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan.
Masahiro
M
Hayakawa
Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
Hiroomi
H
Okuyama
Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba, 260-8677, Japan.
Hideo
H
Yoshida
Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.
Kouji
K
Masumoto
Department of General Surgery, National Center for Child Health and Development, Tokyo, Japan.
Yutaka
Y
Kanamori
Division of Neonatology, Department of Maternal and Perinatal Medicine, National Center for Child Health and Development, Tokyo, Japan.
Keiji
K
Goishi
Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan.
Naoto
N
Urushihara
Department of Gynecology and Obstetrics, Tohoku University Graduate School of Medicine, Sendai, Japan.
Motoyoshi
M
Kawataki
Department of Pediatric Cardiology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan.
Noboru
N
Inamura
Department of Pediatric Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
Osamu
O
Kimura
Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Chiba, Japan.
Tadaharu
T
Okazaki
Section of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan.
Katsuaki
K
Toyoshima
Department of Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan.
Noriaki
N
Usui
D065630:Hernias, Diaphragmatic, Congenital / Q000601:surgery*; D006801:Humans; D007231:Infant, Newborn; D064887:Observational Studies as Topic; D020775:Thoracic Surgery, Video-Assisted; D013906:Thoracoscopy
Congenital diaphragmatic hernia; Conversion to open surgery, reoperation, meta-analysis; Minimally invasive surgical procedures; Video-assisted thoracic surgery