Hello, everyone. Welcome back to another episode of the Stay Current podcast. I'm Cecilia Gienna. I'm Egody, and we are research fellows at Cincinnati Children's Hospital, and along with Stay Current, we are sharing knowledge to improve child health around the globe. So, today we have another episode of the Case-based Journal Review podcast with Dr. Jose Campos. I'm Jose Campos. I work at Roberto del Rio Hospital in Santiago de Chile. I'm part of the Chilean Society for Pediatric Surgery, and I represent a group of 25 volunteers who are bringing you the best pediatric surgical literature called Journal Hive. So as a quick reminder, we're going to talk about the pathology and review the litera. Literature along with the experts on one topic. Today's topic is CDH. And for that, we also brought another expert, Dr. Fernando Bullettin. He's a neonatal and fetal surgeon in Chile. He did his training both in Cincinnati and in Barcelona. Yeah, it's a pleasure to talk with you and, and having me in this conversation. The articles are listed and linked in the description below. Follow along and read with us. We have a 24 week scan in the pregnancy that had a left CDH with a liver herniation, and all the predictors says it's a severe CDH. What do you do next? Refer the patient to fetal or to deliver in an ECMO center? Todd, do you want to start? I deliver in an ECHO center if it's severe. I don't do feto, so I would refer to a place that knows better than me. You do have ECMO in Cincinnati, don't you? EGCO and Fido. What about you, Fernando? What would you do? We don't have fetal treatment for this patient right now. I'm the same as Fernando. We, we don't have Firo anywhere in Chile. What did the data show? This is the first article for today. It's called. Video for moderate and severe congenital diaphragmatic hernia, a systematic review and meta-analysis, as the title says, of course, it's a systematic review and meta-analysis that was done in Germany, and they wanted to elucidate the efficacy of Vito for increasing survival in patients with moderate or severe CDH. So they looked at all the randomized controlled trials they find 4 that were useful that got 341 patients in total, and what they found is that the general survival was higher in the fetal group, specifically significant in patients who had severe CDH. So these are places that have fetal and ECMO. And so when they took the pathway of feto, they did better than if they didn't, which in turn probably would have required ECMO, but I'm assuming a lot of these feto patients also required ECMO. Some of them still needed ECMO, but some of them got to avoid ECMO due to the feO intervention. Well, I am not agree with that since you review the number of the center with a great number of babies with CDH that are doing ECMO, the survival of this patient is almost 50 or more%. So I don't know if when you read the total trial, not all the centers in Europe use ECMO. So what you're saying is that it depends on how good your results with ECMO are. If you have moderate or bad results with ECMO, then your, your fetal patients are going to look super good compared to them. Now, I do have a question, Fernando, though, about how this is all going to work. So, I can't think of many centers that do fetal but are not experts in neonatal and ECMO. Like that is so high level to be doing feto that it would be crazy that you would be doing feto but not have all the other elements. So is the algorithm going to be that a mom has a baby that is a severe CDH, they would travel to a fetal center because where they live, they may not get access in time to. Like, is that the algorithm? Well, that happened in Europe. They're just MFM. They're doing fetal, but then they're born in another center. Oh, so that's why they do it. That's Interesting. But if you do fedo, you're not taking out the chances of doing ECMO after. So you can do both. To summarize this, if you have a baby that has a severe CDH, you should consider sending to a center that does feto to evaluate if that would increase the prognosis of the baby's chance of survival at your center. OK, so let's say Fidel wasn't available. We're in Chile and now the baby is born and requires ECMO. Would you operate early on ECMO or after the ECMO? I'm going to answer first because I did my training with Fernando and while I was in training, we used to operate after ECMO. So they, they would go on ECMO if the baby survived. It was like a trial for life. They would take out the ECGMO and then we would do the repair. Nobody was comfortable. Doing this after the ECMO run. So we start doing this protocol of doing very early. So we put the baby, for example, 6 or 8 hours. They are connected on ECMO, and then the surgery is doing 8 or 10 hours later. My feeling is not doing better. How do you deal with the anticoagulation of the ECMO run and with your surgery? How do you do that? Well, the neuratologists are in charge of that and We decrease the Epirin and use Amicar previous, during, and after the surgery. I was always what you said, Jose. I always waited till after we decanangulated, and then it was a trial on life, and if they survived, they, they did or whatever, but we never repaired on because I did one as a fellow and it was a bloody mess. The one you brought is called surgical repair. Of CDH after ECMO cannulation early repair improves survival. The paper from 2021 from Boston Children's Hospital and they looked at basically what is the best surgical timing if you are using an ECMO and they created two arms in the study. It was a retrospective cohort study. In first arm, they compared the on versus after. After ECMO repair and the second arm they compared to early versus late repair on ECMO and in the first arm they found that patients in the on ECMO group demonstrated a lower mortality rate and lower hazard ratio and lower incidence of non-repair, and in the second arm, early repair of CDH on ECMO was associated with lower mortality rate, hazard ratio, and lower incidence of non-repair. So they're saying that on is better than after and early is better than late. I think there's been a bunch of these, and, and the one that you commented taught as well, but I think sometimes after a big study, many centers change their practice, and there's been, I think, at least 4 of these reports that confirm this data, and my feeling is that this is a practice change. Awesome. OK. So, we have to repair this patient. And what is your preferred technique? Do you use baths or do you use an open approach? If I can do it in the operating room, I do it thoracoscopic unless it unless the baby's sick and I do it in the neonatal intensive care unit. Then I do it open. What do you do, Fernando, nowadays? Most commonly is open approach. The baths are just for those babies that really don't need oxygen in the neonatal intensive care. And if we need, for example, a patch, we switch to open. Yeah, I was going to say I would like to be very selective, and I really like Todd's answer because actually if the child is able to go to a theater, it's like a summer. Of all that assessment like Fernando, if I have to put a patch, I will convert. We, not always, but sometimes in Argentina, we put patch through thoracoscopic technique. Same. So, let's talk about the paper that we brought today. It's called Minimally invasive versus Open Repair of Baselle Hernia, a metal analysis. Well, as the name says, this is a meta-analysis that was done in Canada in 2014 that looked back for. For all the studies between MIS and open surgery for CDH, and what they found is that the MIS approach has higher rates of recurrence, especially in patch, and a longer time for the surgery, and the open, the open repair got more post-op ventilator time and higher mortality rates. Yeah, the other thing about this is the, the what you say in the, in the paper is the time that you're required to do the. The bad procedure if you're doing in a baby that require drugs or special ventilation, increasing the, the, the CO2, decreasing the pH, I think it's, it's not good for the patient as well. I think it has to do that, like you can improve your technique by training, but this might be one of the cases that is just not as good a surgery as open, and that's kind of painful for me to say because I love minimal invasive surgery, but I don't know. I'm not sure. where, where the pendulum is swinging right now. Here's the deal. It's not about laparoscopy versus open. The question is, why would there be any difference in the recurrence rate? So, what would be the difference in the repair when you do it through a scope that these people are finding recurrences? What could be the difference? Well, one could be that maybe there's not enough scar, and so they don't oppose and scar together. One could be that people don't unfurl the diaphragm enough when they're going through the chest. Another could be That people are taking a bite at the exact same level when they're thoracoscopic every single time. So you're getting a bundle of muscle and it could pull away. Some could say that maybe we're not putting enough stitches in. Whatever it is, instead of saying whether it's with a camera or with an open incision, it would be better to understand what is happening in the operation that we believe is causing it. OK, so let's say you do it open and this time you're asking, do you prefer muscle flap or a mesh? Will depend on what kind of defect we have. Usually, I use mesh, but if I have good uh lift of uh diaphragm posteriorly, I use the flap. I applaud that, Fernando, because most people know how to do one or the other, and so, You're not really getting a good comparison because like I know how to do mesh, and I, I think it's great that you do both because you have sort of a protocolized way of deciding. So what I do nowadays is that I decide intraoperatively. So instead of doing a subcostal incision following the line of the ribs, I just do a much lower transverse one. With that, I have the possibility of developing a flap if I see that the defect is. Small or medium enough to fit my flap, but if not with my transverse instead of a subcostal incision, I've just made my mesh repair a bit more difficult, but not as difficult as is impossible. Yeah, let's look at the paper. It is called flap repair and congenital diaphragmatic hernia, leads to lower rates of recurrence. It's a paper from 2019 from the University of Colorado. Their main question to look at if Muscle flap repair as good as mesh repair in CDH cases. They had retrospective cohort of 52 patients from 2008 to 2018, and according to their study, patients who undergo flap repair have a lower risk of recurrence compared to those with patch repair, and this might be due to the ability of the flap to grow over time with the child. So even though they have a lower risk of recurrence, this paper doesn't tell us if any, any of them is way better than the other one. I don't think other articles or I don't think in my very small experience slaps are better, but I do think they could be as good as A patch if they are well indicated. And also there are some centers that they don't have the match. So if you don't have the possibility to, to, to get the match, you can use the flap and should be the same, at least the same rate of uh ra nation. OK, so when you use a mask, a biological or a synthetic one? I would never use a biologic by itself. It's not meant to be a bridge. That's not how it was designed. I do use biologic to reinforce the patch. You can put it on top, but I would not use it instead of a synthetic patch. I don't have experience with biological. So, the 5th article for today is synthetic versus biological. Ecological patterns for CE8 the comparisons of occurrence rates and adverse events, systematic review and meta-analysis. So as it says, it's a systematic review and meta-analysis done in the UK and their aim was to compare the recurrence rate and complication of these two patches. And what they found is that the biological one they got 986 patients. 226 received biological patches and 760 synthetic. The biological ones got a recurrence rate of 30.3%, whereas the synthetic patches got 16.7%. Also talking about additions, the biologicals got between 7 and 35 and the synthetic between 4 and 29. The only thing that's synthetic was worse was the chest wall deformities that it produced, that 80% of them got practice. The chest deformity rate of 80% seems super high. What do you think, Fernando? What's your experience? Have you had that amount of chest deformity in the long term? No. One of the problems is the skeletal deformity that is coming with the disease. So I don't know if it's the pen of the patch, but it does make sense. In Ay D that the synthetic patch will pull on the ribs and cause chest deformity, but Ty D defects are very rare. What they consider a chest deformity. Oh, that's a good point as well, yeah. And one of the drawbacks of this study was that there were different synthetic meshes, different biological meshes, different techniques to fixate on them. So there was quite a lot of heterogeneicity that was not accounted for. And the last one is, would you do a routine fund application at the time of CDH repair? I'm doing the fund obligation in those patients that are type D defect and are on ECMO. I haven't done any prophylactic fund application, and, and once I heard this from Fernando, I was very eager to find out his results because he's actually Always changing, always improving, always seeking for better results, and I don't know. So the paper called Anti-reflux Surgery in Children with CDH, prospective cohort Study on a controversial Practice, it's published at JPS in 2022. It's a study from France, and in this study, there were 762 CDH neonates included, 81 underwent. On application either preventative or the curative and according to the results, preventive fund application during a patchway does not necessarily decrease to require a curative fund application and is also associated with adverse GI outcomes for these kids. I got the result different what what the studies say in those babies that I have done the fund duplication. I haven't done another surgery for that. So, it's been a definitive repair both from the CDH and the fund obligation. What makes you decide to do a fund application at the, at the time of the repair, because according to the study, it doesn't change the chances of having to need another fund application. It's just the side of the thick that I know later on I will need to do a funduplication. A in a baby that just had a very difficult surgery. I was very surprised to see that they even have higher rates of failure to thrive, like 81% versus 51%. That is a lot, and it makes me wonder if these were selected patients. I think what this article is saying is don't do a routine fondle, but I think your approach is a bit different. Your approach is in very, very, very severe patients. Just do the funder because it's a nightmare to come back and have it done, and I think that would be a very, very good information to have for everyone. Awesome. What a great session. So to summarize a little bit, first we talk about fetal for CDH and we learned that it's good and improves outcome in severe CDH patients. But that depends on how good your ECMO center is, so it's not for everyone. The second thing we talked about is when to do the repair if a patient is in ECMO, and we all agree that as soon as we can, we should perform the repair because it's better. Outcomes for our patients to do an early repair in ACM. Third, minimal invasive surgery should be selected for the healthiest patients, not the ones that are requiring a lot of ventilator or vasoactive support. Talking about muscle flaps, our papers show us that muscle flaps are as good as patches, depending on how big the defect is. So in most cases we have to choose according to the patient. Then we talked about synthetic. Versus biological mesh definitely use synthetic. Last but not least, we talk about FD applications, patients with CDH at the moment of the repair, and based on the literature, it doesn't give our patients less gastroesophageal reflux in the future and the need of a new surgery. So we are not sure that's really beneficial, but Fernando is going to show us in a few years whether it's good for selected type D on ECMO patients. That was all for today. Don't forget to subscribe to our YouTube channel, follow us on social media, and download the Stay Current app for hundreds of pieces of content in pediatric surgery. I'm Em Goddy. Um, I'm Cecilia Aukena, and we are research fellows at Cincinnati Children's Hospital, and along with Stay Current, we are sharing knowledge to improve child health around the globe.
Comments