Thoracoscopic CDH Repair--A Survey on Opinion and Experience Among IPEG Members.
BACKGROUND
Thoracoscopic repair of congenital diaphragmatic hernia (CDH) has become a popular approach. As there is an ongoing discussion on whether the benefits of the thoracoscopic repair outweigh the potential side effects, we aimed to investigate the opinion and experience of the members of the International Pediatric Endosurgery Group (IPEG) on this topic.


METHODS
An online survey was conducted between October and December 2013 on behalf of the IPEG Research Committee. All 536 IPEG members were contacted by e-mail and asked to complete an anonymous questionnaire that included 28 items on the management of CDH.


RESULTS
One hundred sixty-one pediatric surgeons completed the questionnaire. Contraindications to thoracoscopic repair included the following: patient on extracorporeal membrane oxygenation (ECMO) (78%); preoperative need for ECMO (42%); right-sided hernia (15%); liver in chest (32%); weight <2.5 kg (35%); and persistent right-to-left shunting (41%). Fifty-two percent of participants said that during thoracoscopic CDH repair they would tolerate any pH. In contrast, 48% indicated that they would only tolerate pH/partial pressure of CO2 (pCO2) levels down/up to 7.2/80 mm Hg (range: pH, 6.9-7.3; pCO2, 55-100 mm Hg). If a patch was needed, 39% of participants said they would continue thoracoscopically, 31% would convert, and 31% stated that the decision would depend on the size of the defect. Fifty-seven percent of participants reported recurrences after thoracoscopic repair, which occurred within 6 months in 43% of the cases, after 6 months in 37%, and both before and after in 20% of the cases. Overall, 50% of surgeons stated that CDH can be repaired equally by thoracoscopy and open approaches, and 50% disagreed with this statement.


CONCLUSIONS
Thoracoscopic CDH repair is currently being performed by 89% of all participating IPEG members. ECMO, either active or previously, and persistent right-to-left shunting are the main deterrents to thoracoscopic repair. The fact that only 50% of surgeons stated that CDH can be repaired equally by thoracoscopy and open surgery suggests that future studies should focus on identifying the appropriate patient population.
1 Center of Pediatric Surgery, Hannover Medical School , Hannover, Germany .|2 Department of Pediatric Surgery, University of Leipzig , Leipzig, Germany .
Martin
M
Lacher
3 Department of Surgery, Children's Mercy Hospital , Kansas City, Missouri.
Shawn D
SD
St Peter
4 Division of General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania.
Pablo
P
Laje
5 Department of Surgery, State University of New York at Buffalo , Buffalo, New York.
Carroll M
CM
Harmon
1 Center of Pediatric Surgery, Hannover Medical School , Hannover, Germany .
Benno
B
Ure
1 Center of Pediatric Surgery, Hannover Medical School , Hannover, Germany .
Joachim F
JF
Kuebler
D002983:Clinical Competence; D065630:Hernias, Diaphragmatic, Congenital / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D012008:Recurrence; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D013906:Thoracoscopy / Q000379:methods*; D016896:Treatment Outcome