Surgery For Congenital Diaphragmatic Hernia Research Articles

Fertility, pregnancy and gynecological outcomes after fetoscopic surgery for congenital diaphragmatic hernia.

What is the impact of fetoscopic surgery for isolated Congenital Diaphragmatic Hernia (CDH) on future reproductive and gynecological outcomes? We did not observe an increase of obstetric or gynecological problems after fetoscopic surgery nor was there an increased risk for subsequent infertility. The reproductive and gynecological outcomes of patients undergoing open maternal-fetal surgery are known. The most relevant counseling items are the elevated risk for uterine dehiscence and rupture (up to 14%). Bi-centric study over a 10-year period including 371 women carrying a fetus with isolated CDH either managed expectantly (n = 167) or operated in utero (n = 204). Consenting patients filled out a survey with 23 questions (2 open and 21 multiple choice). Questionnaires were custom designed to obtain information on subsequent reproductive or gynecological problems as well as psychological impact. The response rate was 40% (147/371). More women in the FETO group attempted a subsequent pregnancy: 70% (62/89) when compared with 47% (27/58) in controls (P = 0.009). This coincided with a longer follow-up in the FETO group (76 versus 59 months; P < 0.001) and a lower survival rate in the index pregnancy (53 versus 72%; P = 0.028). There was no difference in the number of nulliparous or parous women, neither in the conception rate. In total, there were 129 subsequent pregnancies. Nobody reported secondary fertility problems. Four women in the FETO group and one in the control reported a congenital anomaly in a subsequent pregnancy. Twenty-one pregnancies were reported with at least one complication (FETO: 23% (14/60), controls 27% (7/26)). During delivery or in the post-partum period 11 patients reported at least 1 complication (FETO 17% (10/59), controls 4% (1/24)). New onset gynecological problems occurred in 14 participants (10%). None of these events were more likely in one or the other group. Psychological and emotional impacts were frequent in both the FETO (41%) and the control groups (46%) (P = 0.691). The response rate was 40% (147/371), less than desired. The use of unvalidated self-reported outcomes may skew exact determination of the nature and severity of medical complications. The number of observations for uncommon events was low. The mean follow-up period to detect gynecological complications may be too short. This is the first evidence that fetoscopic surgery for CDH does not compromise future reproductive potential or obstetrical outcome when compared with expectant management. A pregnancy complicated by a serious congenital birth defect, such as CDH, frequently has a measurable psychological impact. The authors have no conflicts to declare. J.D. receives a fundamental clinical research grant of the Fonds Wetenschappelijk Onderzoek - Vlaanderen (FWO; 18.01207). A.C.E. is supported by the Erasmus+Program of the European Union (Framework agreement number 2013-0040; contract 1011990). This was presented at the 61st meeting of the Society of Gynaecologic Investigation, in Florence, March 2014 (F-111).

Research progress of minimally invasive surgery for congenital diaphragmatic hernia

Congenital diaphragmatic hernia(CDH) is characterized by a spectrum developmental defects in the diaphragm caused by embryogenesis disorders, and lead to incomplete fusion of elements which results in rise of the diaphragm.With the promotion of antenatal diagnosis, postoperation rehabilitation and neonatal intensive care unite, the mortality of CDH has been remarkably decreased.Nevertheless, the condition is uncommon enough that it has proven to be difficult to conduct prospective studies, leading to the lack of evidence of evidence-based medicine to explore the pathological mechanism and therapies.With the rise of endoscopic technique, the laparoscopy and thoracoscopy are also gradually carried out for the surgical management of CDH.Now, the minimally invasive surgery for CDH was reviewed. Key words: Congenital diaphragmatic hernia; Minimally invasive surgery; Laparoscopy; Thoracoscopy; Patch

Case series on anesthesia for video-assisted thoracoscopic surgery for congenital diaphragmatic hernia in children

Video-assisted thoracoscopic surgery (VATS) in the pediatric population is a challenging task for any anesthesiologist, moreover considering the high incidence of associated congenital anomalies which are individual predictors of poor prognosis. A thorough preoperative evaluation, knowledge of the physiology of one lung ventilation - pertaining to various methods of lung isolation, individualized meticulous planning, and continuous vigilance to detect any untoward event at the earliest with good communication between the anesthesiology and surgical teams contributes to a safe and successful surgery. We present a case series of anesthetic management of congenital diaphragmatic hernia with VATS.

The evaluation of diastolic function using the diastolic wall strain (DWS) before and after radical surgery for congenital diaphragmatic hernia.

The measurement of diastolic wall strain (DWS), a new method of evaluating cardiac diastolic function, was employed to evaluate ventricular diastolic function in patients with congenital diaphragmatic hernia (CDH). Eighteen neonates with a CDH who were born and treated in our hospital between September 2009 and January 2013 were studied. The left ventricular posterior wall thickness during the systolic phase (PWs) and diastolic (PWd) phase was measured using M-mode imaging, and the DWS was calculated as (PWs-PWd)/PWs. The Tei index, the isovolumic relaxation time (IRT), and the fraction shortening (FS) were measured as indices of cardiac function in 14, 15, and 18 cases, respectively. Cardiac function was measured before and after surgery. Statistical analyses were performed using the paired t test. The pre- and postoperative DWS, Tei index, IRT and FS values were 0.19 ± 0.06 and 0.26 ± 0.11 (P < 0.01), 0.40 ± 0.12 and 0.31 ± 0.11 (P < 0.05), 48 ± 14 and 39 ± 5.0 ms (P < 0.05), 30 ± 7.7 and 34 ± 7.4 % (P < 0.05), respectively. The diastolic and systolic functions were not only measured by the Tei index, IRT and FS values, but also by the DWS value, which improved after surgery. The measurement of DWS is an easy and useful method for evaluating the diastolic function of CDH patients.

Repair of congenital diaphragmatic hernia under high-frequency oscillatory ventilation in high-risk patients: an opportunity for earlier repair while minimizing lung injury.

BACKGROUNDRepair of congenital diaphragmatic hernia (CDH) is ideally delayed until ventilatory parameters are stabilized and patients are switched to conventional ventilation. However, in selected high-risk patients, repair can be performed earlier while they are still on high-frequency oscillatory ventilation (HFOV).DESIGN AND SETTINGSA retrospective review of all CDH cases treated in our tertiary referral center between 1997 and 2013.METHODSIn 1997, we started repairing selected high-risk CDH cases under HFOV with or without inhaled nitric oxide (iNO). All repairs were performed once the infants’ blood gas levels were acceptable. The infants were gradually weaned to conventional ventilation followed by extubation as their ventilatory parameters improved. Their records were reviewed to determine the group-wide outcomes.RESULTSBetween 1997 and 2013, 55 infants with CDH were treated in our institute; of these 12 high-risk cases were repaired under HFOV/iNO combinations and 1 was repaired without iNO. All patients had significant pulmonary hypertension and 8 had herniated livers. The mean age at repair was 9.1 (6.3) days. Two mortalities occurred at the first and tenth postoperative days. Among the remaining 11 survivors, the median ventilation and hospitalization days were 29.5 (11–84) and 45.5 (25–107), respectively, and the median duration under HFOV and conventional ventilation days were 15 (9–40) and 12 (3–47), respectively.CONCLUSIONCDH repair can be performed earlier under HFOV and iNO. The possible advantages are earlier restoration of normal anatomy and earlier start of enteral feeding while minimizing the risk of lung injury.

Right-sided congenital diaphragmatic hernia: the challenge remains.

Fetal surgery is without a doubt one of the greatest achievements in fetal medicine over the last three decades, addressing a number of lethal or otherwise debilitating congenital conditions and pregnancy complications. Fetal endotracheal occlusion (FETO) for the treatment of pulmonary hypoplasia secondary to congenital diaphragmatic hernia (CDH), although always ‘high on the fetal surgery agenda’, has seen many waves of ‘hope and despair’ (Deprest JA et al., Fetal surgery for congenital diaphragmatic hernia is back from never gone, Fetal Diagn Ther 2011;29:6–17). Indeed, despite sound physiological theories and animal experiments suggesting its potential benefits, randomised controlled trials comparing FETO to expectant management have not consistently shown the expected success (Harrison MR et al., A randomized trial of fetal endoscopic tracheal occlusion for severe fetal congenital diaphragmatic hernia, N Engl J Med 2003;349:1916– 24). Notwithstanding the low incidence of CDH, a continued challenge surrounding FETO has been the difficulty in accurately determining fetal prognostic factors which may prompt intervention. These concerns appear to be greater in right-sided CDH (RCDH), given that its incidence is 70–80% lower than leftsided defects, and that liver herniation, a major prognostic factor in contralateral cases, is almost universally present (Hedrick HL et al., Right congenital diaphragmatic hernia: prenatal assessment and outcome, J Pediatr Surg 2004;39:319– 23). In their study, DeKoninck et al. correctly point out that most CDH studies address isolated left-sided defects, and that perhaps RCDH may be a different pathology altogether, worthy of its own evaluation. To describe the specific characteristics and outcomes of RCDH, they conducted a retrospective review of cases with isolated RCDH and liver herniation subjected to FETO at two centres over 10 years, and find that fetuses with a lung-to-head ratio ≤45% have a tendency towards increased survival at 42% relative to 17% among expectantly managed cases (P = 0.09), without a significant increase in preterm birth. Akin to left-sided defects, they re-iterate that initial lung size predicts survival following FETO in right-sided defects. These results, although not statistically significant, point to the value that FETO may have in severe RCDH. Or do they? The issue with retrospectively analysing rare pathologies using observational data that is collected outside the realm of a controlled trial, in addition to not offering a power calculation, is that facing non-statistically significant results such as those provided in this study, one cannot attribute the differences, or lack thereof, between subjects and controls either to a lack of statistical power or to the absence of a true relationship between intervention and outcome. The nuanced interpretation in conclusions such as ‘Though the current data do not show benefit, in poor prognosis cases FETO may seem to be justifiable’ needs to be therefore regarded with the utmost caution. Indeed, the same way in which a trend towards positive outcomes, such as increased survival, may prompt intervention, the risk of rendering a non-statistically significant negative outcome such as preterm birth significant, increases. All in all, it would seem from these results that at best, FETO

Risk factors associated with death of newborn with congenital diaphragmatic hernia

Objective To investigate the risk factors of congenital diaphragmatic hernia (CDH) deaths. Methods A retrospective study was conducted on 37 CDH patients during 10 years. Clinical characteristics and risk factors were compared and non-conditional logistic regression analysis was performed to determine independent predictors for mortality. Results Twenty nine patients, from a total of 37, underwent surgery for CDH. The total mortality rate in patients with CDH was 32.4% (12/37) and the overall operative mortality was 13.8% (4/29). There was a significant difference between CDH patients who survived (n=25) and those who died (n=12) in birth weight [(3.12±0.41) kg vs (2.66±0.65) kg], the age on admission [(135.14±209.71) h vs (6.67±7.79) h], hospital length of stay [(16.52±6.23) d vs (1.25±1.38) d], oxygenation index [(239.55±115.95) mmHg vs (96.10±59.18) mmHg, 1 mmHg=0.133 kPa], early antenatal diagnosis (3 cases vs 6 cases), right congenital diaphragmatic hernia (1 cases vs 4 cases), cardiac malformations (2 cases vs 6 cases) and presence of persistent pulmonary hypertension of newborn (3 cases vs 7 cases) (P<0.05). Using logistic regression analysis, the following factors independently predicted mortality were antenatal diagnosis (OR=20.97, 95%CI 1.60~275.78), low oxygenation index (OR=18.12, 95%CI 0.80~123.12) and cardiac malformations (OR=22.0, 95%CI 1.46~332.32). Conclusion CDH patients have higher mortality. Risk factors for mortality in neonatal CDH are associated with early antenatal diagnosis, low oxygenation index and cardiac malformations. Key words: Congenital diaphragmatic hernia; Risk factors; Mortality; Infant, newborn

Collagen plug sealing of iatrogenic fetal membrane defects after fetoscopic surgery for congenital diaphragmatic hernia

To investigate the efficacy of collagen plugs at reducing the risk of preterm premature rupture of membranes (PPROM) after fetoscopic surgery for congenital diaphragmatic hernia (CDH). This was a single-center cohort study on all consecutive cases undergoing fetoscopic endoluminal tracheal occlusion (FETO) for severe or moderate CDH, between April 2002 and May 2011 (n = 141). Cases either received a collagen plug for sealing the fetal membrane defect after FETO or did not, depending on the operating surgeon. The principal outcome measure was the time from fetal surgery to PPROM, further referred to as 'latency'. A multivariable Cox regression model was used to investigate the association between collagen plug and latency while adjusting for risk factors for PPROM. Of the 141 cases, 54 (38%) received a collagen plug and 87 (62%) did not. Sixty cases experienced PPROM, 26 among cases with and 34 among cases without a plug (48 vs 39%). The hazard ratio of plug use was 1.29 (95% CI, 0.76-2.19), which does not exclude a potentially increased risk for PPROM when a collagen plug is used. For cases with a plug, 24% had PPROM before balloon removal and 24% had PPROM after elective balloon removal. For cases without a plug, these rates were 30 and 9%, respectively. Perinatal outcomes were similar in both groups. No evidence was found that collagen plugs reduce the risk of PPROM after FETO for CDH.

OP10.02: Sealing of iatrogenic fetal membrane defects after fetoscopic surgery for congenital diaphragmatic hernia by collagen plugs

<scp>OP10</scp>.02: Sealing of iatrogenic fetal membrane defects after fetoscopic surgery for congenital diaphragmatic hernia by collagen plugs

Hepatopulmonary fusion in a newborn. An uncommon intraoperatory finding during right congenital diaphragmatic hernia surgery: case description and review of literature

Hepatic pulmonary fusion is a rare malformation associated with right congenital diaphragmatic hernia (CDH), often only discovered during surgical repair of the defect. Fourteen previous cases have been reported in the literature. We describe a case of a full term male newborn with prenatal ultrasound diagnosis of right CDH who underwent a thoracoscopy converted to a thoracotomy, due to this rare aforementioned intraoperative incidental finding. We reviewed the previous reported literature, especially focusing on the chosen surgical approach, concluding that an early and appropriate preoperative imaging investigation may be crucial for the best management of these kinds of patients.

401: Prevention of iatrogenic PPROM by collagen plugs after fetoscopic surgery for congenital diaphragmatic hernia

401: Prevention of iatrogenic PPROM by collagen plugs after fetoscopic surgery for congenital diaphragmatic hernia

Use of octeriotide in the management of neonatal Chylothorax secondary to repair of congenital diaphragmatic hernia: A report of two cases and review of literature

Chylothorax, a known complication of surgery for Congenital Diaphragmatic hernia, can sometimes be resistant to treat. Octeriotide (Somatostatin analogue) can be useful in this situation. However, the dose and schedule of Octeriotide therapy in neonates is not well established. We report two cases of resistant chylothorax following surgery for congenital diaphragmatic hernia which were successfully managed by using an escalating infusion of octeriotide. The literature on the subject is also reviewed.

Chylothorax after Repair of Congenital Diaphragmatic Hernia in a Neonate: Usefulness of Conservative Management

Aim: Chylothorax is a recognized complication after surgery for congenital diaphragmatic hernia (CDH) in a neonate. Management strategies for chylothorax include cessation of enteral feedings, repeated aspiration, chest drainage, and total parenteral nutrition. It is important to determine which is the better plan for treatment of chylothorax after repair of CDH. The authors report successful management by use of the MCT diet for a neonate with chylothorax after repair of CDH. Case: A male infant weighing 3.0 kg was delivered by cesarean section at 38 weeks of gestation and intubated immediately after birth. Prenatal ultrasonography had disclosed left-sided posterolateral diaphragmatic hernia. After stabilization, surgery was performed via a left-sided transverse supra-abdominal incision. The unfixed colon, small bowel, stomach, and spleen were reduced from the chest with little difficulty. A hernia sac was not present and the left-sided posterolateral diaphragm showed a defect 3.5 cm × 2.0 cm in width. The child was fed via a nasogastric tube starting on postoperative day 4 and dyspnea disappeared. Plain chest X-ray on postoperative day 7 showed left pleural radioopacity. A specimen of the chest drainage examined on postoperative day 10 was typical of lymph, with a triglyceride level of 328 mg/dl. The chest drainage was dark yellowish, and a medium-chain triglyceride formula was used until postoperative day 30, by which time the effusion has disappeared. Discussion: Chylothorax after repair of CDH may be a transient disorder that will resolve after a period of diminished flow through the thoracic lymphatics.

When referring physicians and researchers disagree on equipoise: the TOTAL trial experience

In this article, we reflect on whether randomized controlled trials (RCTs) are adequate for the clinical evaluation of maternal-fetal surgery for congenital diaphragmatic hernia (CDH), focusing on the role of patients' preferences in the setting up of research protocols, on the requirement of equipoise and on the concept of therapeutic misconception (TM). We describe the conception and setting up of the tracheal occlusion (TO) to accelerate lung growth trial and analyze the ethical dilemmas faced by the research team during that time. Depending on the view adopted regarding the scope of equipoise, there are two ways of dealing with patient's preferences concerning fetoscopic endoluminal TO and expectant management during pregnancy for CDH. The solution adopted for fetoscopic endoluminal tracheal occlusion (FETO) is justified by the extended period of time it has been available to patients before the start of the RCT. Strong patient and referring physician preferences do not entail a right to have FETO, since it is a procedure of yet unproven efficacy and safety. In the future, to avoid the dilemmas posed by the TM and in name of the right of future generations of patients to have access to treatment of proven safety and efficacy, researchers must be able to plan RCT in due time.

2P2-H10 胎児外科手術用細径・多自由度マニピュレータの開発(手術支援ロボティクス・メカトロニクス)

The clinical target of this study is intratracheal balloon occlusion from minimally invasive fetal surgery for Congenital Diaphragmatic Hernia (CDH). The target for the surgery is prenatal temporary tracheal occlusion which enlarges the fetal lungs, and this procedure is promising for severe cases. A balloon is supposed to be inserted for tracheal occlusion using the manipulator. We propose a novel robotic manipulator for intrauterine fetal surgery for tracheal occlusion. In this study, the 3-unit robotic manipulator with ball joint-shaped arthroses and shaft diameter of 2.4 mm using a wire-driven mechanism has been developed to approach the fetal trachea without the damage of fetal tissue. The robotic manipulator is thin in structure and has 7 degrees of freedom to avoid damage to the fragile cells of the fetus.

Delayed surgery for congenital diaphragmatic hernia.

Between January 1987 and December 1990, 67 neonates were treated for congenital diaphragmatic hernia, symptomatic within 6 h of birth. The mortality rate was 33 per cent. Preoperative stabilization was achieved in 47 patients, all of whom survived initial treatment, although two died later. Stabilization could not be achieved in 20 neonates, all of whom died within 3 days of birth, 18 without undergoing operation and two after early repair. Intensive resuscitation with controlled, delayed operation for congenital diaphragmatic hernia gives long-term results similar to those of urgent operative repair. This approach avoids operation in the majority of those who subsequently die.

Outcomes of Congenital Diaphragmatic Hernia Repair

Sources: (1) Poley MJ, Elly AS, Tibboel D, et al. The cost-effectiveness of treatment for congenital diaphragmatic hernia. J Pediatr Surg. 2002;37:1245–1252. (2) Skari H, Bjornland K, Frenckner B, et al. Congenital diaphragmatic hernia in Scandinavia from 1995 to 1998: predictors of mortality. J Pediatr Surg. 2002;37:1269–1275.Two recent articles review the treatment and predictors of mortality for congenital diaphragmatic hernia (CDH). The Poley, et al article analyzed the “cost effectiveness” of neonatal surgery for congenital diaphragmatic hernia at the Sophia Children’s Hospital of Rotterdam, The Netherlands, for 168 patients who underwent CDH repair after 1969. (Of the original 285 patients who had the surgery, 24 could not be traced, 86 had died, and 7 were mentally disabled.) Patients born after 1996 were excluded to allow adequate follow-up periods. Outcome measures included hospital costs, loss of productivity, out-of-pocket expenses, and “quality adjusted years of life.” The total cost of treatment for these children averaged in excess of 42,000 Euro dollars (approximately 36,500 US dollars). Most costs were incurred with the initial hospitalization, and “productivity” losses for both parents and patients were minimal. CDH patients suffered from respiratory difficulties and abdominal pain, but quality of life did not differ between the population studied and the general population. These results suggest that CDH repair is cost-effective.A somewhat different perspective was reported in the Skari, et al article. The authors conducted a retrospective multicenter cohort review of mortality from CDH in 195 children treated for CDH in 12 of the 13 pediatric surgical centers in Scandinavia from 1995 through 1998. The overall hospital mortality from CDH was 30%. Of the 168 neonates presenting with symptoms in the first 24 hours of life, 35% (P=.001) died before discharge from the hospital and all these deaths occurred in children presenting with symptoms in the first 2 hours of life. Multi-variant analysis of these “early presenters” showed that predictors of increased risk of death included a prenatal diagnosis (Hazards Ratio [HR]=2.7 [95% CI, 1.4–5.4; P=.004]), right-sided congenital diaphragmatic hernia (HR=2.1 [95% CI, 1.03–4.2; P=.042]), and low 1-minute Apgar score (HR=.82 [95% CI, .73–.93; P=.001]).The authors found that prenatal diagnosis and right-sided congenital diaphragmatic hernia were significant independent predictors of total mortality. However, the increase in mortality for those children diagnosed prenatally may suggest a “hidden mortality” due to those fetuses (with diaphragmatic hernia) who expired in utero or following birth but before transfer to a pediatric surgical center.While these 2 articles may seem somewhat interesting in their own light, viewed in the current context of limited health care resources, the worrisome potential for care directives exists. Given that prenatal diagnosis and right-sided defects were demonstrated to be strong predictors for overall mortality, it is not difficult to hypothesize that groups with an economic interest in overall healthcare resource utilization might use this information for planning purposes. As such, transfer to a pediatric surgical center might be discouraged (or not “facilitated”) for those infants with a prenatal diagnosis of congenital diaphragmatic hernia until after birth, and early mortality adversely affected in “borderline” neonates as a result of withholding expensive treatment (ECMO). As advocates for the optimum health of every child, pediatric care providers at every level must resist external forces based on “cost-effectiveness” to dictate healthcare policy—especially in the vulnerable neonatal population.While previous reports of survival for CDH, which occurs in 1 out of every 5,800 live births, indicate about a 30–50% survival rate,1–2 the Skari, et al study examines mortality risk in more detail. In this study, mortality was restricted to neonates presenting with symptoms at <24 hours. These “early presenters” could additionally stratify3 into low, moderate and high-risk groups with a 17%, 53%, and 62% mortality rate, respectively. This study was limited by heterogeneity between centers, particularly in relation to differences in perinatal treatment strategies and the absence of a predetermined treatment protocol.

Neurodevelopmental outcome after congenital diaphragmatic hernia: Extracorporeal membrane oxygenation before and after surgery

Background/Purpose: Extracorporeal membrane oxygenation (ECMO) as a treatment of last resort for neonates with persistent pulmonary hypertension of the newborn (PPHN) caused by congenital diaphragmatic hernia (CDH) may be used for preoperative stabilization or postoperative rescue. The aim of this study was to examine the acute and long-term morbidity associated with pre- and postoperative ECMO. Methods: Neonates born with CDH and needing ECMO were classified into 2 groups. Group 1 consisted of neonates placed on ECMO after CDH surgery. Patients in group 2 underwent preoperative ECMO stabilization. Medical records after birth were evaluated. Growth, neuromotor and cognitive development, hearing, and behavior were evaluated. Student t test and χ2 were used to determine statistical significance between groups. Results: Subjects in group 2 had significantly more days on ECMO and loop diuretics. Alkalosis was induced for a longer duration in group 2. At follow-up 3 to 9 years later, no differences were found between the 2 groups in growth parameters, neuromotor outcome, or behavior. However, in group 1, 2 of 9 children had significant hearing impairment necessitating amplification compared with 6 of 6 subjects in group 2. Conclusions: Neonates with CDH first stabilized on ECMO (group 2) had a higher incidence of hearing loss compared with those needing ECMO postrepair (group 1). The etiology of this finding is not clear. This may be secondary to the prolonged period of hyperventilation or general intensive care that is part of the protocol for neonates who are electively stabilized on ECMO preoperatively. J Pediatr Surg 36:539-544. Copyright © 2001 by W.B. Saunders Company.

Requirements for fetal surgery: the diaphragmatic hernia model

Fetal surgery for congenital diaphragmatic hernia and other fetal conditions can only be considered if (1) the morbidity of antenatal intervention is acceptable, (2) the diagnosis of the condition can be made accurately, (3) the condition can be differentiated from other, non-surgical anomalies. In addition, (4) the natural evolution of the disease, if left untreated, should be predictable, and the condition should be lethal or severely debilitating, (5) there should not exist adequate postnatal treatment, and (6) the proposed in utero operation should be technically feasible. Open fetal surgery has proven too invasive to be justified for the treatment of diaphragmatic hernia, and progress in postnatal therapy (including ECMO) has dramatically improved the neonatal outcome in all but a severe subgroup of patients. Recently, advances in endoscopic fetal surgery (which appears to be less stressful for the fetus and the gravid uterus) and a new approach to accelerate fetal lung growth and maturation have renewed the feasibility of in utero intervention for diaphragmatic hernia.

CONGENITAL DIAPHRAGMATIC HERNIA: SURVIVAL TREATED WITH VERY DELAYED SURGERY, SPONTANEOUS RESPIRATION, AND NO CHEST TUBE

This report suggests that stabilization of the intrauterine to extrauterine transitional circulation, combined with a respiratory care strategy that avoids pulmonary overdistension, takes advantage of inherent biological cardiorespiratory mechanics, and very delayed surgery for congenital diaphragmatic hernia results in improved survival and decreases the need for extracorporeal membrane oxygenation (ECMO). This retrospective review of a 10-year experience in which the respiratory care strategy, ECMO availability, and technique of surgical repair remained essentially contant describes the evolution of this method of management of congenital diaphragmatic hernia.