Intraoperative Transpyloric Tube Insertion for Congenital Diaphragmatic Hernia: Analysis of Japanese Study Group Data

Abstract

Congenital diaphragmatic hernia (CDH) is a severe congenital disease. Some CDH infants suffer from gastro-esophageal reflux disease (GERD), even after surgical correction of gastric position. A transpyloric tube (TPT) is inserted into CDH patients under direct observation intraoperatively in some hospitals in Japan to establish early enteral feeding. This strategy avoids gastric expansion to maintain a better respiratory condition. However, it is unclear whether the strategy has a secure effect for patient prognosis. This study aimed to evaluate the effectiveness of intraoperative TPT insertion on enteral feeding and postoperative weight gain. The Japanese CDH Study Group database was used to identify infants with CDH born between 2011 and 2016, who were then divided into two groups: the TPT group and gastric tube (GT) group. In the TPT group, infants underwent intraoperative TPT insertion; postoperative insertion/extraction of TPT was irrelevant to the analysis. Weight growth velocity (WGV) was calculated using the exponential model. Subgroup analysis was performed using Kitano's gastric position classification. We analyzed 204 infants, of which 99 and 105 were in the TPT and GT groups, respectively. Enteral nutrition (EN) in the TPT and GT groups was 52±39 and 44±41kcal/kg/day (p=0.17) at age 14 days (EN14), respectively, and 83±40 and 78±45kcal/kg/day (p=0.46) at age 21 days (EN21), respectively. WGV30 (WGV from day 0 to day 30) in the TPT and GT groups was 2.3±3.0 and 2.8±3.8g/kg/day (p=0.30), respectively, and WGV60 (WGV from day 0 to day 60) was 5.1±2.3 and 6.0±2.5g/kg/day (p=0.03), respectively. In infants with Kitano's Grade 2+3, EN14 in the TPT and GT groups was 38±35 and 29±35kcal/kg/day (p=0.24), respectively, EN21 was 73±40 and 58±45kcal/kg/day (p=0.13), respectively, WGV30 was 2.3±3.2 and 2.0±4.3g/kg/day (p=0.76), respectively, and WGV60 was 4.6±2.3 and 5.2±2.3g/kg/day (p=0.30), respectively. Intraoperative TPT insertion did not improve nutritional intake and WGV30. WGV60 in TPT was less than that in GT. In Grade 2+3 subgroup analysis, TPT also had no advantage. We could not recommend routine TPT insertion at surgery. III.