On–Extracorporeal Membrane Oxygenation Congenital Diaphragmatic Hernia Repair: Decreased Bleeding Complications and Improved Survival with Muscle Flap Repair Technique

Abstract

INTRODUCTION: Prosthetic patches (patch) and muscle flaps (flap) are different techniques used for repair of congenital diaphragmatic hernia (CDH) with a large defect unamenable to primary closure. We hypothesized that the flap technique for CDH repair while on extracorporeal membrane oxygenation (on-ECMO) would have decreased bleeding complications compared with patch due to the hemostatic advantage of native tissue, and therefore also be associated with improved survival. METHODS: A single-center retrospective study of patients who underwent on-ECMO CDH repair between 2008 and 2021 was performed. Statistical significance was determined by Mann Whitney U, Fisher’s exact, chi-square, and Student’s unpaired t tests as appropriate (p < 0.05 significant). RESULTS: Forty-eight patients met criteria: 17 patch (35.4%) and 31 flap (64.6%). Characteristics between these 2 groups are summarized in Table 1. Reoperation for surgical bleeding was significantly decreased with flap repair compared with patch (35.5% vs 64.7%, respectively; p = 0.05). 48-hour postoperative blood product transfusion was also significantly decreased with flap repair (176.3 mL/kg vs 328.7 mL/kg patch; p = 0.027). Additionally, survival to hospital discharge was significantly increased in the flap repair group compared with the patch group (64.3% vs 27.8%, respectively; p = 0.033). Table 1. - Characteristics of Prosthetic Patch and Muscle Flap Repair for Congenital Diaphragmatic Hernia on Extracorporeal Membrane Oxygenation Variable Prosthetic patch repair (n = 17) Muscle flap repair (n = 31) p Value Left-sided defect 9 (52.9%) 26 (83.9%) 0.039* Gestational age at delivery (wk) 38 (37 - 39) 38 (37 - 38) 0.21† Birth weight (g) 2,842 ± 473.9 2,812 ± 430.4 0.82‡ Percent predicted lung volume 13.94 ± 5.1 14.99 ± 4.4 0.64‡ Observed-to-expected lung-to-head ratio 37.4 (31.1–42.0) 30 (21–42.5) 0.40† Days on ECMO 15 (8.5–28.5) 18 (12–25) 0.57† Values expressed as count (percentage of group), means ± standard deviation, or median (interquartile range). Statistical analysis by*Fisher’s exact test,†Mann Whitney U test, or‡Student’s unpaired t-test CONCLUSION: We conclude that the muscle flap technique for on-ECMO CDH repair is associated with decreased bleeding complications compared with prosthetic patch repair, which may in part be responsible for the improved survival seen in the flap repair group. Despite comparable CDH severity, these results support the flap repair technique as the safer method for on-ECMO CDH repair.