M. A. Verla1,2, T. C. Lee1,2, C. C. Style1,2, P. E. Lau2, A. R. Mehollin-Ray1,3, C. J. Fernandes1,4, S. C. Fallon2, C. A. Ikedionwu2, S. G. Keswani1,2, O. O. Olutoye1,2 1Texas Children’s Hospital,Fetal Center,Houston, TX, USA 2Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA 3Texas Children’s Hospital,Department Of Radiology,Houston, TX, USA 4Texas Children’s Hospital,Department Of Pediatrics – Newborn Section,Houston, TX, USA
Introduction: Congenital diaphragmatic hernia (CDH) is a major anomaly with high mortality and significant long-term comorbidities. Survivors are at risk for developing gastrointestinal (GI) disorders, some requiring corrective abdominal surgical procedures. The purpose of this study was to examine the GI outcomes in CDH.
Methods: This is a retrospective review of all infants evaluated for CDH at a single institution tertiary fetal center from April 2004 to March 2017. Data analyzed included prenatal imaging data and postnatal GI outcomes. Imaging features included liver position, stomach position, lung to head ratio, total fetal lung volume (TFLV), observed to expected total fetal lung volume (O/E TFLV) and laterality of defect. GI outcomes were defined as gastro-esophageal reflux disease (GERD), gastroparesis, and abdominal surgeries including fundoplication, gastrostomy tube (G-tube) placement, or exploratory laparotomy for bowel obstruction. Data were analyzed using chi-square, ANOVA, Mann-Whitney U test and student’s t-test as appropriate; a p-value of <0.05 was considered significant. Results are listed as percentages or median (interquartile range) unless otherwise stated.
Results: A total of 250 infants were evaluated over a thirteen year period. Of these, 55.2% were male (n=138). Seventy seven percent (n=192) had left sided CDH, 64% had an intrathoracic stomach, and 70% had an intrathoracic liver morphology prenatally. Postnatally, 78 neonates (31%) required ECMO (Extracorporeal Membrane Oxygenation). The cohort survival was 74% with a median age at repair of 3 days of life [3 – 6 days]. Of the 184 CDH survivors, 99% received total parental nutrition (TPN) for a median of 18 [14 – 28] days. After repair, enteral feeds were initiated at a median of 7 [5 – 10] days and full enteral feeds attained at a median of 11 [7 – 190] days. Of the survivors, 57% (n=105) had GERD requiring medication and 12% (n=21) had gastroparesis. Of those with GERD, 68% (n=71) had an intrathoracic stomach morphology prenatally and 27% (n=28) failed medical management requiring a fundoplication. Overall, 48% (n=89) of survivors had some form of abdominal surgery separate from the CDH repair. Neonates with unfavorable prenatal indices were more likely to require ECMO. There is a significant correlation between ECMO use and having a G-tube, GERD, gastroparesis, fundoplication, or need for other abdominal surgical intervention (p <0.05, Table 1).
Conclusion: A significant number of infants with CDH will have some form of GI morbidity postnatally. Those with severe CDH requiring ECMO are at an increased risk for needing a G-tube or other GI surgery. The results of our study may aid in pre- and postnatal counseling.
