Recurrent diaphragmatic hernia: Modifiable and non-modifiable risk factors.
BACKGROUND
The risk of recurrence of Congenital Diaphragmatic Hernia (CDH) in an era of thoracoscopic surgery is unclear.


OBJECTIVE
(1) estimate the incidence and (2) evaluate the perioperative factors associated with the symptomatic recurrence of CDH.


METHODS
Medical records of CDH infants operated on in the neonatal period at a single-tertiary hospital between January 2000 and January 2013 were retrospectively reviewed.


RESULTS
Of 119 infants with CDH, 34 (28.6%) were excluded: 17 (14.3%) died without recurrence and 17 (14.3%) presented beyond neonatal period or were followed elsewhere. Of 85 survivors, 71 infants had an open repair and 14 had a thoracoscopic repair. Eleven of 85 survivors (13%) developed a recurrence on average 19.8 weeks (range 15-34) after the initial repair. Of 11 recurrences, 6 had an initial thoracoscopic repair and 5 had an open repair (6/14 [43%] vs. 5/71 [7%]; P = 0.002). Two children had multiple recurrences. Statistically significant associations were found between recurrence and the presence of persistent pulmonary hypertension (PPHTN) (P = 0.006), severe PPHTN (P = 0.002), inhaled nitric oxide, or sildenafil use for treatment of PPHTN (P = 0.002), need for perioperative high frequency oscillatory ventilation (HFOV) (P = 0.0006), length of hospital stay (LOS) (P = 0.02), duration of ventilation (P = 0.016), and need for home oxygen (P = 0.003). In multivariate regression analysis both the closure type and home oxygen requirement were statistically significant, independent factors predicting a recurrence (P = 0.04 and 0.02, respectively) but the type of surgery (thoracoscopic vs. open) only approached significance (P = 0.052). The recurrence rate for the seven surgeons who performed at least 5 repairs ranged from 7% to 40%.


CONCLUSIONS
A high survival rate of 85% with a 13% incidence of symptomatic CDH recurrence was demonstrated. Potentially, improved selection of cases for thoracoscopic repair and concentrating the thoracoscopic technique amongst a dedicated team of experienced thoracoscopic surgeons may reduce the rate of recurrence of CDH.
Department of Respiratory Medicine, Children's Hospital at Westmead, Sydney, Australia.
Montaha M
MM
Al-Iede
Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, New South Wales, Australia.|Department of Surgery, Children's Hospital at Westmead, Sydney, Australia.
Jonathan
J
Karpelowsky
Department of Respiratory Medicine, Children's Hospital at Westmead, Sydney, Australia.|Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, New South Wales, Australia.
Dominic A
DA
Fitzgerald
D001315:Australia / Q000453:epidemiology; D005260:Female; D065630:Hernias, Diaphragmatic, Congenital / Q000401:mortality / Q000601:surgery*; D006612:High-Frequency Ventilation; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate; D013906:Thoracoscopy / Q000379:methods / Q000401:mortality; D016896:Treatment Outcome
Congenital Diaphragmatic Hernia; modifiable risk factors; open repair; recurrence; thoracoscopic surgery