Annals of Emergency Surgery

Cite this article: Heiwegen K, de Blaauw I, Janssen S, van Rooij IALM, van Heijst A, et al. (2017) Short Term Surgical Outcomes in the Treatment of Congenital Diaphragmatic Hernia: An Overview of 15 Years Experience. Ann Emerg Surg 2(1): 1005.

CentralBringing Excellence in Open Access

*Corresponding authorKim Heiwegen, Department of Pediatric Surgery, Radboudumc – Amalia Children’s Hospital, route 618, PO box 9101, 6500 HB Nijmegen, the Netherlands, Phone: 31-24-361-97 61; Fax: 31-24-361-35-47; Email:

Submitted: 27 December 2016

Accepted: 24 January 2017

Published: 26 January 2017

Copyright© 2017 Heiwegen et al.

OPEN ACCESS

Keywords•Congenital diaphragmatic hernia•Treatment•Surgery•Outcomes

Research Article

Short Term Surgical Outcomes in the Treatment of Congenital Diaphragmatic Hernia: An Overview of 15 Years ExperienceKim Heiwegen1*, Ivo de Blaauw1, Stan Janssen1, Iris ALM van Rooij2, Arno van Heijst3, and Sanne MBI Botden1

1Department of Pediatric Surgery, Radboudumc-Amalia Children’s Hospital, The Netherlands2Department of Health Evidence, Radboud Institute for Health Sciences, The Netherlands3Department of Neonatology, Radboudumc-Amalia Children’s Hospital, The Netherlands

Abstract

Introduction: Congenital diaphragmatic hernia (CDH) is characterized by a defect of the diaphragm, pulmonary hypoplasia and pulmonary hypertension. Data on surgical outcome are scarce since pulmonary function seems to predominate the outcome. This study gives an overview of recent short term surgical outcomes of a large single center cohort.

Method: All CDH patients treated in a high volume centre, from 2000-2015, were retrospectively evaluated. Surgical outcome was described. Furthermore, demographics, patient and CDH characteristics and treatments were registered. Differences in these parameters between survivors and non-survivors were analyzed.

Results: In total 215 patients were included, with a 1-year mortality rate of 27%. Of the 197 repaired patients, 40% needed patch repair. In most patients the abdominal fascia could be closed after the repair (77%), however in 15% an abdominal patch was needed, because both the fascia and skin could not be closed. In total 31% of the patients had surgical complications, of which 14% hemorrhage postoperative, 17% chylothorax and recurrence occurred in 6% within one year/ recurrence showed no statistical difference between primary and patch repair (p=1.00). No patch infections were encountered. Surgical hemorrhage and chylothorax were encountered significantly more in non-survivors compared to survivors (30% versus 5%, p=< 0.001, 28% versus 14%, p=0.04, respectively). An abdominal patch was needed in 28% of non-survivors and 8% of survivors (p< 0.001).

Conclusion: This overview shows the incidence of surgical short term outcome in a high volume center. Survivors had a significant lower incidence of surgical complications and had a relatively low recurrence rate within one year (6%).

ABBREVIATIONSCDH: Congenital Diaphragmatic Hernia; CDHSG: CDH Study

Group; DOL: Days of Life; ECMO: Extra Corporeal Membranous Oxygenation; FETO: Fetal Endoscopic Tracheal Occlusion; NICU: Neonatal Intensive Care Unit; NO: Nitric Oxide; PTFE: Poly Tetra Fluoro Ethylene

INTRODUCTIONCongenital diaphragmatic hernia (CDH) is a possible lethal

birth defect, which occurs in approximately 1:2000-3000 live births [1,2]. The defect is caused by improper developed diaphragm and lungs during embryogenesis, allowing abdominal viscera to protrude into the thorax. CDH is furthermore characterized by pulmonary hypoplasia and, due to maldevelopment of the lung

vasculature, also by pulmonary hypertension [1,3,4]. Pulmonary problems remain the most challenging issue in the treatment of CDH patients and can lead to lethal persistent pulmonary hypertension in the neonatal period and chronic lung problems later in life [5]. Over the last decades, modern medical advances have led to modest improvements in perinatal care [1,6]. These advances not only include improvements in antenatal care, such as fetal endoscopic tracheal occlusion (FETO), but also better techniques to stabilize newborns with CDH after birth, using gentle ventilation techniques and extracorporeal membranous oxygenation (ECMO) [7-9]. Because of these advances in treatment, more neonates survive nowadays (70-80%), but possibly at the cost of more morbidity [1]. The clinical course of CDH still remains unpredictable in many cases despite intensive monitoring and extensive analysis of patient data [6].

Heiwegen et al. (2017)Email:

Ann Emerg Surg 2(1): 1005 (2017) 2/6

CentralBringing Excellence in Open Access

Surgery seems to be of less influence on the outcome and surgical outcome data have been less extensively analyzed. There are still ongoing discussions concerning several key aspects of the surgical repair. This includes exact timing of repair, when to use a patch and what type of patch is best in a large defect (e.g. synthetic or biodegradable) and its influence on morbidity and final outcome [6,10]. Moreover, surgical treatment strategies vary widely in the diverse CDH treating centers. Therefore, different studies and experiences are required to identify best treatment interventions and their outcomes. This study gives an overview of 15 years experience of short term surgical outcomes of neonates with a CDH treated in a Dutch high volume center.

MATERIALS AND METHODSAll patients diagnosed with a CDH and treated in the high

volume center of the Radboudumc – Amalia Children’s hospital, Nijmegen, the Netherlands, between January 1, 2000 and December 31, 2015 were included in this study. The electronic and scanned patient files were reviewed for multiple parameters. Demographics, perinatal parameters, patient characteristics and CDH characteristics, such as side and size of the defect, position of the liver, chromosomal anomalies, and other birth defects were collected. Pulmonary hypertension was diagnosed using cardiac ultrasound. Cardiac malformations were classified as major, when hemodynamic effects occurred or needed treatment, as stated by CDH Study Group (CDHSG) [11].

Primary outcomes of this study were surgical outcomes, including hemorrhage, chylothorax, patch infections and recurrence rate of CDH within one year. Secondary outcomes were survival up to the age of one, the need for extracorporeal membrane oxygenation (ECMO), duration of stay at the neonatal intensive care unit (NICU), total hospital stay in this high volume center and the number of surgeries performed in the first year of life. Prenatally diagnosed neonates with CDH were delivered at the Radboudumc and transported to the NICU immediately after birth. Out born patients or patients diagnosed postnatally were transported to the NICU of this center shortly after diagnosis. The neonates were managed according to the standard care for CDH patients at the time of presence [12]. ECMO was offered to patients with severe respiratory failure and pulmonary hypertension when standard therapy and ventilation techniques failed [13].

The repair of CDH was performed by two specialized pediatric surgeons. A tension-free closure with silk 3-0 was first choice of surgical closure. Poly tetra fluoro ethylene (Goretex) patch was used in all cases of patch repair, when the performing surgeon(s) were in the opinion that the defect could not be closed primarily without tension. In case of ECMO treatment, the repair was targeted after stabilization and weaning, but before decanulation. Defect size was noted according to the CDHSG scale, in which A is a small defect (< 25% of the hemi diaphragm), B is a defect including 25-50% of the hemi diaphragm, C a defect of 50-75% of the hemi diaphragm, and in D most of the hemi diaphragm is absent (> 75%) [11].

Values are expressed as means and standard deviations, median with range, or in percentages, when appropriate. Differences in patient and CDH characteristics, surgical treatment,

complications and outcome between survivors and non-survivors were tested using the independent student’s T-test or Mann-Whitney U test for continuous variables and with the chi-square or Fisher exact tests for categorical data, as appropriate. A p-value of <0.05 was considered statistically significant. All statistical analyses were performed using IBM SPSS Statistics 22.

RESULTS AND DISCUSSION

Results

The demographics and patient characteristics of the total population (n=215) are presented in (Table 1). Of the inborn patients, 92% was diagnosed prenatally, while only 7% of those born elsewhere was diagnosed prenatally. FETO was performed on eleven prenatal diagnosed patients, which is 5% of the total population. Sizes of the hernias, based on the classification of the CDH registry group, were most often classified as B or C, but missing for many. Some patients were also diagnosed with other anomalies as described in Table 1. The most common major cardiac malformations encountered were coarctation of the aorta (n=2), tetralogy of Fallot (n=2) and hypoplastic left heart syndrome (n=2). Other types of birth defects reported were dysmorphic features (18%), vertebra anomalies (11%) and omphalocele (7%). Chromosomal anomalies reported more than once were chromosomes 7, 11, 17 and X, which were all diagnosed in two of the thirteen patients.

Direct postnatal treatment interventions for stabilization of all patients are presented in (Table 2). Pulmonary hypertension was diagnosed in 97 patients using cardiac ultrasound. This was most often treated with oxygen therapy and inhaled nitric oxide (NO). Sixty-six patients needed ECMO to support the cardiopulmonary system and/or treat persistent pulmonary hypertension. However fourteen patients had contra-indications for ECMO treatment and did not survive due to the pulmonary hypertension. Of the 44 patients with pulmonary hypertension who were not treated with ECMO, 32% did not survive, compared to 59% of the 53 patients who were treated with ECMO (p=0.009). Four patients were canulated on ECMO, however were not surgically repaired because they did not survive, regardless of the ECMO treatment.

Of all patients, 197 survived until surgical repair. The median amount of days between diagnosis and surgical repair was 4 (range: 0-133). A reason for delayed Repair was late diagnosis. Approximately 60% percent of the surgically repaired patients could be repaired primarily and almost 40% needed patch repair. Twelve patients were repaired after 90 days of life, one of them by patch repair During surgery, the abdominal fascia was closed in most patients (n=141, 77%), however, this was only possible in half of the patch repaired patients. When also the skin could not be closed, an abdominal patch was used, which was necessary in 34% of the patch repaired patients, compared to 3% in primary repaired patients (p< 0.001). A chest drain was placed peri-operative in 58% (n=106) of the patients, which was done in 80% (n=47) of the patients canulated on ECMO compared to 47% (n=58) of the non ECMO patients (p< 0.001).

The clinical outcomes, including survival and surgical complications, are presented in (Table 3). The median age of death

Heiwegen et al. (2017)Email:

Ann Emerg Surg 2(1): 1005 (2017) 3/6

CentralBringing Excellence in Open Access

Table 1: Demographics, perinatal, and anomaly characteristics of the total patient group with congenital diaphragmatic hernia.

Total group (n=215)Gender - male, n (%) 133 (61.9)

Inborn1, n (%) 120 (58.0)Prenatal diagnosis of CDH2, n (%) 114 (56.2)Birth weight in grams3, mean (SD) 2970 (653)Gestational age in weeks4, median

(range)38.3 (27.7-42.7)

Apgar score, median (range)1 minute5

5 minutes66 (0-9)

8 (0-10)Side hernia7, n (%)

LeftRight

Bilateral

174 (80.9)35 (16.3)

5 (2.3)Liver up8 70 (35.4)

Size hernia9, n (%)ABCD

16 (15.2)46 (43.8)36 (34.3)

7 (6.7)Major cardiac malformations10, n (%) 9 (4.2)

Other birth defects11, n (%) 28 (13.1)Chromosomal anomalies12, n (%) 13 (6.1)

Missing values: 1 8, 2 12, 3 33, 4 37, 5 45, 6 44, 71, 819, 9110, 102, 112, 123CDH: Congenital Diaphragmatic Hernia

Table 2: Postnatal treatment characteristics of neonates with congenital diaphragmatic hernia.

Total group (N=215)Postnatal treatment

Primary intubated1*, n (%) 137 (73.3)Duration of ventilation (days), median

(5-95% range)10 (1.0-41.8)

Pulmonary hypertension2, n (%) 97 (52.4)Use of inhaled NO3 (a), n (%) 88 (42.3)

ECMOb, n (%) 66 (30.7)Duration of ECMO (days) 8 (1.0-20.0)

Surgical treatmentRepaired patients, n (%) 197 (91.6)Method of repair, n (%)

PrimaryPatch

119 (60.4)78 (39.6)

Approach of repair4, n (%)Subcostal

ThoracotomyThoracoscopicLaparoscopic

169 (88.9)5 (2.6)

12 (6.3)4 (2.1)

Closure of abdominal wall fascia5, n (%) 141 (76.6)Abdominal patch6, n (%) 28 (14.6)

Chest drain peri-operative7, n (%) 106 (57.6)DOLc at surgical repair, median

(5-95% range)5 (1.0-148.4)

Missing values: 18, 230, 37, 410, 47, 513, 65, 713*Of the 215 patients, 189 patients were intubated, which was unknown in 12 patients. 14 patients were not intubated at all mostly related to late diagnosis of CDH (79%).aNO: Nitric Oxide; bECMO: Extracorporeal Membranous Oxygenation; cDOL: Days of Life

Table 3: Main clinical outcomes of the total group congenital diaphragmatic hernia patients.

Total group (N=215)

Survival, n (%)30 days survival1 year survival

170 (79.1)157 (73.0)

Surgical complications of repaired patients (n=197), n (%)

Hemorrhage peri-operativeIntraventricular hemorrhage

Surgical hemorrhageChylothorax

60 (30.5)

7 (3.6)20(10.2)33 (16.8)

Recurrent hernia of repaired patients (n=197), n (%)Within 30 daysWithin 1 year

1 (0.5)12 (6.1)

Diaphragm/ patch infection within 1 year, n (%) 0 (0)Length of stay NICUa, median (range) 15 (0-323)

Length of stay hospital*, median (range)All patientsSurvivors

18 (0-329)20 (3-329)

Number of surgeries in first year, median (range) 2 (1-12)*Length of stay in this high volume center, including patients referred to regional hospitalaNICU: Neonatal Intensive Care Unit

was 15 days (range 0-184) and 78% of the 58 deceased before 30 days of age. Those that deceased after 30 days died mostly due to cardio respiratory failure and rebound pulmonary hypertension (5 versus 4 patients respectively). Those repaired after 90 days all survived (p=0.13). The mortality rate for patients who got surgically repaired was 20%. Hemorrhagic complications of repaired patients included intra ventricular (n=7) and surgical site hemorrhage (n=20). Of these latter patients, ten had spleen injuries and five of them needed splenectomy for this cause. None of those bleedings were fatal. Six patients were obligatory weaned from ECMO due to several bleeding complications and died shortly after decanulation.

Twelve of the 197 repaired patients (6%) had a recurrence of the diaphragm defect within one year, of which only one patient did not survive due to persistent pulmonary hypertension. There was no difference in recurrence rate between primary and patch repaired patients (both 6%, p=1.00). The mean time at which the patients were Reoperated on their recurrent hernias was 145 days of life (SD 90.3). None of the patients corrected after 90 days of life had a recurrence after one year follow up. Because the mean time to reoperation was longer than the mean time to death, the recurrence rate was also calculated excluding all deceased patients (7%, n=11/157).

Table 4 describes the differences in patient and CDH characteristics, treatment, and surgical complications between the survivors and non survivors. Apgar scores from patients who did not survive were significantly lower than those from patients who did survive (median 5 versus 7 at 1 minute and median 7 versus 8 at 5 minutes, respectively). Other significant differences in the patient and CDH characteristics that were found more in non-survivors were liver up, pulmonary hypertension and chromosomal anomalies. Also inhaled NO and ECMO were used significantly more often (p< 0.001) in this group. Of the primary

Heiwegen et al. (2017)Email:

Ann Emerg Surg 2(1): 1005 (2017) 4/6

CentralBringing Excellence in Open Access

Table 4: Congenital diaphragmatic hernia specific characteristics and outcome in survivors and non survivors.Survivors(n=157)

Non-survivors(n=58) P-value

Patient/ CDH specific characteristicsGender – male, n (%) 96 (61.1) 37 (63.8) 0.72

Inborn, n (%) 77 (51.7) 43 (74.1) 0.03

Prenatal diagnosis1 72 (49.7) 42 (72.4) 0.03

Birth weight in grams, mean (SD)2 3028 (666) 2526 (604) 0.06

Gestational age in weeks, median (range)3 38 (27.7-42.7) 38 (29.1-42.3) 0.07Apgar score, median (range)

1 minute4

5 minutes57 (1-9)

8 (1-10)5 (0-9)

7 (0-10)<0.001 <0.001

Side hernia6, n (%)Left

RightBilateral

128 (81.5)25 (15.9)

3 (1.9)

46 (79.3)10 (17.2)

2 (3.4)

0.83

Liver up7 47 (30.9) 23 (50) 0.02

Major cardiac malformations8, n (%) 1 (0.6) 8 (14) 0.001

Other birth defects9, n (%) 19 (12.2) 9 (15.8) 0.49

Chromosomal anomalies10, n (%) 6 (3.8) 7 (12.5) 0.04

Pulmonary hypertension11, n (%) 52 (38) 45 (93.8) <0.001

Treatment/ surgical complicationsUse of inhaled NO12 (a), n (%) 43 (28.5) 45 (78.9) <0.001

ECMOb, n (%) 28 (17.9) 38 (65.5) <0.001

Duration of ECMO, mean (SD) 7.8 (3.3) 9.4 (3.7) 0.11

Repaired patients, n (%) 157 (100) 40 (69) <0.001Method of repair, n (%)

PrimaryPatch

113 (72)44 (28)

6 (15)34 (85)

<0.001

DOL at surgical repair, median (range) 6 (2-25) 6 (1-16) 0.03

Closure of fascia13, n (%) 119 (82.1) 22 (56.4) 0.001

Abdominal patch14, n (%) 12 (7.8) 16 (41) <0.001

Surgical complications of repaired patients (n=197), n (%) 37 (23.6) 23 (57.5) <0.001Surgical hemorrhage, n (%)

Chylothorax, n (%)8 (5.1)22 (14)

12 (30)11 (27.5)

<0.0010.04

Missing values: 112, 233, 337, 445, 544, 61, 717, 82, 92, 103, 1130, 127, 1331, 145aNO: Nitric Oxide; bECMO: Extracorporeal Membranous Oxygenation

repaired patients, 95% survived the one year study period, compared to 56% of the patch repaired patients (p< 0.001). Survival was significantly lower in the group that needed ECMO (42%) compared to those that were not treated with ECMO (87%) (p< 0.001). When this latter group was corrected for the fourteen patients who had a contra-indication for ECMO, survival was 96%. Surgical morbidity such as inability to close the fascia, use of an abdominal patch, surgical site hemorrhage, and chylothorax were all encountered significantly more often in non-survivors. Surgical complications compared between survivors and non-survivors are also presented in (Figure 1). Moreover, those who did not survive required more surgeries than survivors (median 3 and 1, respectively), which included removal of abdominal patches, ECMO canulation and decanulation, though this was not statistically significant (p=0.10). A sub analysis for major cardiac malformations (n=9) showed that these patients had a very high frequency of mortality (89%) and pulmonary hypertension

(84%). Moreover, they were less often repaired (44.4%) versus those without cardiac malformations (versus 94.1%, p< 0001).

Discussion

In this retrospective cohort study we examined several factors that could be associated with surgical outcome in CDH patients. The overall 1-year mortality rate in this study was 27%. Diverse overall survival rates have been reported, ranging from 40% to 90%, [6,7,14]. However, as in ours and most other studies the so called hidden mortality of CDH, including antenatal losses and terminated pregnancies, are not taken into account [4,15,16]. The survival rates for the different defect sizes were also comparable to other studies, ranging from 99% in a defects and 39% in D defects in the study of Harting et al., (2014) to 100% respectively 46% in this study [14]. Mortality is highest for CDH patients in need of ECMO treatment, which was 58% in our study. Also inborn patients had a higher mortality (Table 4), which could be

Heiwegen et al. (2017)Email:

Ann Emerg Surg 2(1): 1005 (2017) 5/6

CentralBringing Excellence in Open Access

based on the fact that larger defects, with smaller lungs are more easily detected prenatally and therefore a planned birth in a high volume center. Unfortunately, the observed/expected lung-to-head ratio, an early predictor of high risk CDH patients, was not well documented in our cohort and therefore not included in the analysis.

The surgical complication rate was 31% of the repaired patients, of which 14% hemorrhage postoperative, 17% chylothorax and recurrence occurred in 6% within one year. No diaphragm patch infections were encountered within the year. Due to the retrospective nature of this study, some data was unfortunately incomplete. For the primary outcome parameters and survival however, no major differences were expected in the results. Moreover, if the data had missing results in these main outcome parameters they were excluded from the comparison on survival. The secondary outcomes with too many missing values were included in the comparison, but no conclusion could be made on these results (Table 4). Patients who did not survive had lower Apgar scores, had more major cardiac and chromosomal anomalies, more often needed ECMO treatment and had more patch repairs, which is also known from previous studies [2,17-19]. However, specific surgical outcomes have not been related to survival or disease severity previously. Our results show that non-survivors had more surgical complications, such as hemorrhage and chylothorax, which suggests a relation of these complications with the severity of the disease. It is often stated that the size of the defect is a surrogate for the severity and therefore that the need for a patch indicates a more severely affected patient. However, the rate of recurring diaphragmatic hernia within one year in this cohort was 6%, without a significant difference between primary and patch repaired patients. This might suggest that there is no relationship between surgical morbidity and the severity of the disease or defect size. Though a longer follow up might show a significant difference in favor of primary respectively patch, other studies showed that most recurrences occur in the first year life [20]. The low recurrence rate of the current study is probably based on the fact that they are treated in a high volume center and all CDH’s are repaired in a standardized manner. Preoperative

care and timing of surgery is also standardized and in all patients repaired with a patch, a polytetrafluorethylene (PTFE), Gore-Tex® patch was used. Although various recurrence rates of PTFE patches have been described, without a clear superiority in the patch material [19-25], in this cohort there is no bias in patch material, because the sole use of Gore-Tex® patches. Slight downside of Gore-Tex® patches is the restriction in stretching during growth of the patient and diaphragm [21-23]. Comparison of recurrence rates of CDH repair with patches is difficult because in most studies the inclusion of the patients is from 9-46 years ago; this explains the variability of the recurrence rates reported in most studies (ranging from 4.5-41%) [21,23,24]. Because the correlation between CDH characteristics and surgical outcomes is complex, a multivariate logistic regression will be performed on this cohort in the future. The independent odds ratios for the risk on surgical outcomes for high risk patients requiring ECMO and patch repair will be calculated by adjustment for each other.

CONCLUSIONThis study gives an overview of the short term surgical

morbidity and mortality of CDH patients over the past 15 years in a high volume center. The mortality rate was 27% and non survivors had a significant higher incidence of surgical complications. Whether this increased surgical morbidity is caused by the severity of the disease or that there is room for improvement in the surgical treatment to decrease mortality and morbidity remains to be seen. Using only PTFE patches could account for the relatively low recurring diaphragmatic hernia after one year.

REFERENCES1. Leeuwen L, Fitzgerald DA. Congenital diaphragmatic hernia. Journal of

paediatrics and child health. 2014; 50: 667-673.

2. Morini F, Lally PA, Lally KP, Bagolan P. The Congenital Diaphragmatic Hernia Study Group Registry. European journal of pediatric surgery. 2015; 25: 488-496.

3. Greer JJ. Current concepts on the pathogenesis and etiology of congenital diaphragmatic hernia. Respir Physiol Neurobiol. 2013; 189: 232-240.

0102030405060708090

100

Inci

denc

e (%

)Survivors

Non-survivors

Figure 1 Surgical complications after repair in CDH patients.This figure shows the comparison of surgical complications between survivors and non survivors. Surgical complications, surgical hemorrhage and chylothorax were statistically significant (p< 0.001, p< 0.001 and p=0.04 respectively).

Heiwegen et al. (2017)Email:

Ann Emerg Surg 2(1): 1005 (2017) 6/6

CentralBringing Excellence in Open Access

4. Wilkinson DJ, Losty PD. Management of congenital diaphragmatic hernia. Paediatrics and Child Health. 2013; 24: 23-26.

5. Danzer E, Hedrick HL. Controversies in the management of severe congenital diaphragmatic hernia. Semin in fetal neonatal med. 2014; 19: 376-384.

6. Losty PD. Congenital diaphragmatic hernia: where and what is the evidence? Semin pediatr surg. 2014; 23: 278-282.

7. Badillo A, Gingalewski C. Congenital diaphragmatic hernia: treatment and outcomes. Semin Perinatol. 2014; 38: 92-96.

8. Mugford M, Elbourne D, Field D. Extracorporeal membrane oxygenation for severe respiratory failure in newborn infants. Cochrane Database Syst Rev. 2008; 16: 3.

9. Keijzer R, Wilschut DE, Houmes RJ, van de Ven KP, van den Hout L, Sluijter I, et al. Congenital diaphragmatic hernia: to repair on or off extracorporeal membrane oxygenation? J Pediatr Surg. 2012; 47: 631-636.

10. Puligandla PS, Grabowski J, Austin M, Hedrick H, Renaud E, Arnold M, et al. Management of congenital diaphragmatic hernia: A systematic review from the APSA outcomes and evidence based practice committee. J Pediatr Surg. 2015; 50: 1958-1970.

11. Lally KP, Lasky RE, Lally PA, Bagolan P, Davis CF, Frenckner BP, et al. Standardized reporting for congenital diaphragmatic hernia--an international consensus. J Pediatr Surg. 2013; 48: 2408-2415.

12. Reiss I, Schaible T, van den Hout L, Capolupo I, Allegaert K, van Heijst A, et al. Standardized postnatal management of infants with congenital diaphragmatic hernia in Europe: the CDH EURO Consortium consensus. Neonatology. 2010; 98: 354-364.

13. Van den Hout L, Tibboel D, Vijfhuize S, te Beest H, Hop W, Reiss I. The VICI-trial: high frequency oscillation versus conventional mechanical ventilation in newborns with congenital diaphragmatic hernia: an international multicentre randomized controlled trial. BMC pediatr. 2011; 11: 98.

14. Harting MT, Lally KP. The Congenital Diaphragmatic Hernia Study Group registry update. Semin Fetal Neonatal Med. 2014; 19: 370-375.

15. Brownlee EM, Howatson AG, Davis CF, Sabharwal AJ. The hidden mortality of congenital diaphragmatic hernia: a 20-year review. J Pediatr Surg. 2009; 44: 317-320.

16. Harrison MR, Bjordal RI, Langmark F, Knutrud O. Congenital diaphragmatic hernia: the hidden mortality. J Pediatr Surg. 1978; 13: 227-230.

17. Lupo E, Castoldi F, Maestri L, Rustico M, Dani C, Lista G. Outcome of congenital diaphragmatic hernia: analysis of implicated factors. Minerva pediatr. 2013; 65: 279-285.

18. Van den Hout L, Reiss I, Felix JF, Hop WC, Lally PA, Lally KP, et al. Risk factors for chronic lung disease and mortality in newborns with congenital diaphragmatic hernia. Neonatology. 2010; 98: 370-380.

19. Yao CT, Wang JN, Lin CH, Yeh CN, Tai YT, Wu MH, et al. Prediction of outcome in infants with congenital diaphragmatic hernia or severe diaphragmatic eventration. Acta Paediatr Taiwan. 2004; 45: 131-135.

20. Grethel EJ, Cortes RA, Wagner AJ, Clifton MS, Lee H, Farmer DL, et al. Prosthetic patches for congenital diaphragmatic hernia repair: Surgisis vs Gore-Tex. J Pediatr Surg. 2006; 41: 29-33.

21. Tsai J, Sulkowski J, Adzick NS, Hedrick HL, Flake AW. Patch repair for congenital diaphragmatic hernia: is it really a problem? J Pediatr Surg. 2012; 47: 637-641.

22. Riehle KJ, Magnuson DK, Waldhausen JH. Low recurrence rate after Gore-Tex/Marlex composite patch repair for posterolateral congenital diaphragmatic hernia. J Pediatr Surg. 2007; 42: 1841-1844.

23. Moss RL, Chen CM, Harrison MR. Prosthetic patch durability in congenital diaphragmatic hernia: a long-term follow-up study. J Pediatr Surg. 2001; 36: 152-154.

24. Nasr A, Struijs MC, Ein SH, Langer JC, Chiu PP. Outcomes after muscle flap vs prosthetic patch repair for large congenital diaphragmatic hernias. J Pediatr Surg. 2010; 45: 151-154.

Heiwegen K, de Blaauw I, Janssen S, van Rooij IALM, van Heijst A, et al. (2017) Short Term Surgical Outcomes in the Treatment of Congenital Diaphragmatic Hernia: An Overview of 15 Years Experience. Ann Emerg Surg 2(1): 1005.

Cite this article