Intervention Review

Late versus early surgical correction for congenital diaphragmatic hernia in newborn infants

  1. Virginia A Moyer1,*,
  2. Fernando R Moya2,
  3. Dick Tibboel3,
  4. Paul D Losty4,
  5. Masahiro Nagaya5,
  6. Kevin P Lally6

Editorial Group: Cochrane Neonatal Group

Published Online: 12 MAY 2010

Assessed as up-to-date: 2 FEB 2010

DOI: 10.1002/14651858.CD001695

Database Title

Additional Information

How to Cite

Moyer VA, Moya FR, Tibboel D, Losty PD, Nagaya M, Lally KP. Late versus early surgical correction for congenital diaphragmatic hernia in newborn infants. Cochrane Database of Systematic Reviews 2000, Issue 4. Art. No.: CD001695. DOI: 10.1002/14651858.CD001695.

Author Information

  1. 1

    Baylor College of Medicine and Texas Children's Hospital, Academic General Pediatrics, Houston, Texas, USA

  2. 2

    New Hanover Regional Medical Center, PLLC Director of Neonatology, Wilmington, NC, USA

  3. 3

    Sophia Children's Hospital, Department of Pediatric Surgery - ICU, Rotterdam, Netherlands

  4. 4

    Royal Liverpool Children's Hospital, Institute of Child Health, Liverpool, UK

  5. 5

    Central Hospital, Department of Pediatric Surgery, Kasugai, Aichi, Japan

  6. 6

    University of Texas at Houston, Houston, Texas, USA

*Virginia A Moyer, Academic General Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA. moyer@bcm.edu.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 12 MAY 2010

SEARCH

ARTICLE TOOLS

View Full Article (HTML) Summary (59K)Standard (191K)Full (202K)
 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Congenital diaphragmatic hernia, although rare (1 per 2-4,000 births), is associated with high mortality and cost. Opinion regarding the timing of surgical repair has gradually shifted from emergent repair to a policy of stabilization using a variety of ventilatory strategies prior to operation. Whether delayed surgery is beneficial remains controversial.

Objectives

To summarize the available data regarding whether surgical repair in the first 24 hours after birth rather than later than 24 hours of age improves survival to hospital discharge in infants with congenital diaphragmatic hernia who are symptomatic at or immediately after birth.

Search methods

Search of MEDLINE (1966 to Sept 2003), EMBASE (1978 to Oct 2003) and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2003); citations search, and contact with experts in the field to locate other published and unpublished studies.

This search was updated in 2009.

Selection criteria

Studies were eligible for inclusion if they were randomized or quasi-randomized trials that addressed infants with CDH who were symptomatic at or shortly after birth, comparing early (< 24 hours) vs late (> 24 hours) surgical intervention, and evaluated mortality as the primary outcome.

Data collection and analysis

Data were collected regarding study methods and outcomes including mortality, need for ECMO and duration of ventilation, both from the study reports and from personal communication with investigators. Analysis was performed in accordance with the standards of the Cochrane Neonatal Review Group.

Main results

Two trials met the pre-specified inclusion criteria for this review. Both were small trials (total n<90) and neither showed any significant difference between groups in mortality. Meta-analysis was not performed because of significant clinical heterogeneity between the trials.

Authors' conclusions

There is no clear evidence which favors delayed (when stabilized) as compared with immediate (within 24 hours of birth) timing of surgical repair of congenital diaphragmatic hernia, but a substantial advantage to either one cannot be ruled out. A large, multicenter randomized trial would be needed to answer this question.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Late versus early surgical correction for congenital diaphragmatic hernia in newborn infants

No clear evidence about when to perform surgery to correct congenital diaphragmatic hernia. Congenital diaphragmatic hernia is a rare but often fatal condition. It occurs when a newborn baby's diaphragm has a defect in it that allows abdominal organs (such as the stomach or liver) to enter the chest and displace the lung and heart. Surgery can correct the defect, but damage to the lung may be so severe that the baby still cannot survive. It has been thought that correcting the defect was so urgent that emergency surgery should be performed within the first 24 hours following birth, but more recent thinking suggests that a period of stabilization before surgery could help the lung develop. Only two trials have been done, and these provide no clear evidence to support delayed surgery over emergency surgery.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

新生兒先天性橫膈疝氣晚期和早期手術時機的比較

雖然先天性橫膈疝氣罕見 (每兩千到四千人有一人) ，但有很高的致死率和醫療費用。目前手術的時機由立即的手術修復，逐漸轉成先用呼吸器穩定病情再進行手術，關於延遲手術的時機是否較好還是有爭議性。

目標

總結出生就有或立即出現症狀的先天性橫膈疝氣開刀時機的資料，判斷是否在24小時以內立即手術，比起延遲手術至24小時以後，能改善出院的存活率。

搜尋策略

搜尋MEDLINE (1966Sept 2003) 、EMBASE (1978  Oct 2003) 和Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2003) ，引用搜尋結果並聯絡專家看看是否有已發表或是未發表的研究。

選擇標準

納入之研究為相關於出生時或出生後不久出現症狀的新生兒先天性橫膈疝氣之隨機或準隨機試驗，比較早期手術 (24小時以內) 和晚期手術 (24小時以後) 結果，以死亡作為主要預後根據。

資料收集與分析

資料收集包含研究方法以及預後，包括死亡率、需要使用ECMO和呼吸器使用時間，資料來源為研究報告以及和研究者接觸。分析乃根據Cochrane Neonatal Review Group的標準。

主要結論

兩個研究符合此評論的範圍，兩者皆為小型研究 (總數小於90人) ，且皆顯示兩組死亡率無顯著差異。因為這兩研究臨床上的差異性，並未進行統合分析。

作者結論

沒有證據顯示對於先天性橫膈疝氣，延遲手術 (直到病人狀況穩定時) 比立即手術 (出生24小時以內) 好，但不能排除兩者中真的有其一較好。目前還是需要大規模、多家醫學中心的隨機研究來回答這個問題。

翻譯人

本摘要由馬偕醫院蕭玥玲翻譯。

此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。

總結

沒有明確證據顯示何時為矯正先天性橫膈疝氣的最佳時機。先天性橫膈疝氣罕見但常可致命。腹腔內的器官 (像是胃或肝) 因為新生兒的橫膈有缺陷而進入胸腔導致心肺的移位；手術可以矯正這個缺陷，但是嬰兒仍可能因為肺部的傷害過於嚴重而死亡。以往都覺得這是一個該於出生24小時內施行的手術，但是最近的看法逐漸偏向在手術前先穩定病情讓肺部發育；目前僅有兩個研究，都無法提供明確證據來支持延遲手術比立即手術佳。

View Full Article (HTML) Summary (59K)Standard (191K)Full (202K)