H. Nolan1, E. Aydin1, J. Frischer1, J. L. Peiro1, B. Rymeski1, F. Lim1 1Cincinnati Children’s Hospital Medical Center,Cincinnati, OH, USA
Introduction: The defect in severe congenital diaphragmatic hernia (CDH) often requires a prosthetic patch (patch) or muscle flap (flap) repair. The patch is easy to use but is synthetic, while the flap’s autologous tissue dissection has potential for increased bleeding. Hemorrhage can be further exaggerated when maintained on therapeutic anticoagulation for extracorporeal membrane oxygenation (ECMO), especially if clinical status demands on-ECMO repair. The purpose of this study was to assess bleeding complications for on-ECMO patch compared to flap repair of CDH.
Methods: We retrospectively reviewed on-ECMO CDH repairs from 2010-2016 at a single academic children’s hospital (IRB2017-2322). Exclusions included incomplete records or concomitant procedures that could result in additional blood loss. Patients were grouped by repair type and bleeding complications were captured with intra-operative blood loss, 48-hour re-operation rates for bleeding, and 48-hour post-operative blood product use.
Results: Twenty-nine patients met criteria for analysis. Thirteen (44.8%) had patch repair and 16 (55.2%) had flap repair. Eight (62.5%) of the patch and 13 (81.2%) of the flap group were left-sided defects (p=0.223). All had Type C or D defects with comparable distribution (Type C: patch 56%, flap 54%, p=0.596). There was no difference in mean gestational age at delivery (patch 37.5±0.9 weeks, flap 37.2±1.3 weeks, p=0.390) or mean age at time of repair (patch 7.46±6.6 days, flap 6.00±4.3 days, p=0.476). Both had similar total ECMO duration (patch 361.4±167.1 hours, flap 277.1±149.4 hours, p=0.170) and time from repair to decannulation (patch 7.77±6.0 days, flap 7.00±6.0 days, p=0.734). Only one patient in each group was decannulated within 48 hours of repair for bleeding. Seven patch patients (53.8%) and 9 flap patients (56.2%) survived to discharge (p=0.596).
Estimated intra-operative blood loss was equivalent (patch 35.3±53.9 mL, flap 24.2±18.4 mL, p=0.443). One patient (7.6%) in the patch group and two patients (12.5%) in the flap group required re-operation for bleeding (p=0.580). Transfusion requirements in the re-operative group were no different for the patch compared to the flap repair (282.0 mL/kg vs 208.5±21.9 mL/kg, p=0.054). Transfusion requirements for those who did not require a reoperation were also similar (patch 120.7±111.7 mL/kg, flap 118.4±89.9 mL/kg, p=0.561).
Conclusions: Our study demonstrates the feasibility of CDH repair while on ECMO for both flap and patch techniques. Bleeding risks were no different between the two groups with regard to estimated blood loss, reoperation rates, and post-operative transfusions.
