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Congenital Diaphragmatic Hernia and Diaphragmatic Eventration 297
Table 45.1: Evidence-based research.
Title Extracorporeal membrane oxygenation in infants with
congenital diaphragmatic hernia: a systematic review of the
evidence
Authors Morini F, Goldman A, Pierro A
Institution Great Ormond Street Hospital for Children NHS Trust,
London, UK
Reference Eur J Pediatr Surg
Problem The aim of this study was to evaluate the evidence supporting
the use of extracorporeal membrane oxygenation (ECMO) in
infants with congenital diaphragmatic hernia (CDH).
Intervention A meta-analysis of randomised controlled trials (RCTs)
comparing ECMO and conventional mechanical ventilation
(CMV)
Comparison/ Meta-analysis
control
(quality of
evidence)
Outcome/ The early mortality was significantly lower with ECMO
effect compared to CMV (RR 0.73 [95 % CI 0.55-0.99]; p < 0.04);
however, late mortality was similar in the two groups (RR 0.83
[0.66-1.05]; p = 0.12).
Historical Nonrandomised studies suggest a reduction in mortality with
significance/ ECMO. However, differences in the indications for ECMO and
comments improvements in other treatment modalities may contribute to
this reduction. The meta-analysis of RCTs indicates a reduction
in early mortality with ECMO but no long-term benefit.

Key Summary Points
1. Congenital diaphragmatic hernia is associated with a relatively 5. Surgery for congenital diaphragmatic hernia is simple in most
high mortality related to the associated pulmonary and cases, but can be technically demanding in those with a large
cardiovascular abnormalities present, and carries some long- defect, requiring knowledge of methods available for secondary
term morbidity in most cases. However, self-selected patients closure. Surgery for recurrence can also be demanding, calling
who present late have little long-term morbidity. for advanced flap procedures.
2. Ventilatory and support mechanisms for patients with 6. Other surgical procedures for gastro-oesophageal reflux and
congenital diaphragmatic hernia have evolved significantly, but feeding difficulties or other complications may be required.
with minimal impact on survival in the severe cases.
7. Unlike congenital diaphragmatic hernia, eventration of the
3. At present, advanced support for congenital diaphragmatic diaphragm is not usually associated with severe morbidity and
hernia using ECMO is costly and does not seem to reduce the mortality in most cases. Surgical correction of symptomatic
long-term mortality; it may contribute to more morbidity. cases is most often rewarded with prompt recovery with little
long-term outcome.
4. The most important factors influencing outcome and long-term
morbidity seem to be associated chromosomal and cardiac
anomalies, the severity of the pulmonary hypertension, and the
size of the defect.

References

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