CDH - MIS vs. Open: Update Course 2015

Just looking at this, this study that we have, um, and basically when you look at the complications and you do a multivariate analysis, the only thing that really comes out of all this is that if you do an open repair, you have a higher risk of a small bowel obstruction. And in our case, the recurrence was not statistically significant, although if you look at the absolute numbers, you know, on primary repairs, it was a 3.9% in the open and 7.8% in the MIS repairs. So is it trending that way? I don't know, but the question is, does that, you know, make up for the the the numbers of of small bowel obstructions that you have in the open repairs, Dan, Mark, can I just ask you? One question, one comment, uh, the question is, what's your follow up in terms of recurrence, and then the, the comment, and I'd love to hear your perspective on this because it has to do with the open repair versus the minimally invasive repairs that many of our guys who do this more frequently than I do, and Jason's more of an expert than I am, have gone to doing muscle flaps because of the data from Utah and other places that suggest that the recurrence rate is dramatically lower if you do a muscle flap than if you put a patch in there, and I don't know that that's something. In fact, I don't think that's something you can do using a minimally invasive technique, or maybe you can, but, but that's the rationale for not doing the kinds of things you're talking about. And you're right, the muscle flap is, is, is intriguing, and I don't know of anyone that's doing that minimally invasively. I know that in, uh, you know, we have two hospitals in our system, and in my other hospital, one of the docs there, Ted Brand, did a lot of muscle flaps, and he claimed, claimed a 0, 0% recurrence rate. And we have in 10 years at Cincinnati we have zero recurrences in our muscle flap patients. We have patients who've gotten patches or other type of repairs that have recurred, but in our muscle flaps, which is primarily our primary. Technique for repair, it's pretty amazing. I came from an institution where we use Gore-Tex everywhere and it's well documented our moderate recurrence also you got to compare apples to apples, which is if you're talking about primary repairs, um, you're not, those aren't the patients who you're getting out doing a muscle flap or Goretex. Primary repairs, I think. Patients, you have better choices in terms of laparoscopic orthoroscopic versus open. I think if you're talking about putting in a biologic to close too big of a defect or a cortex, it's a very different population of patients. No, I agree it's a biased population for sure, yeah. And the big and the issue is, I think the one issue is with patch repair, and everybody has a high recurrence with patch repair except for the muscle flaps. And you know, again, we don't, we used to do, you know, I, we used to do these, I, I, I say we, it's me, would, would go and tackle these big, you know, near age, if it was agenesis, I wouldn't, but if it was near agenesis, if I had anything to sew to, I'd do it with a scope, and I just, it was just such a long run for such a short slide and the kids did just as poorly. You know, as if you did it open, so I was like, OK, you know what, it's probably better to get in and get out as, as, as most expeditiously as you can and instead of trying to make it a technical exercise. So, but in the primary repairs, what, what concerns me is I think that for, I think with a scope, the scope is a really good option for primary repairs. And I think that there are some things that you can do, whether it's putting more stitches in, making sure you get that corner laterally to prevent recurrences, because there are folks that are good surgeons that have data that the recurrence rate is higher. And then, but I do think you have to look at long term follow up and again we have to follow these patients longer and is to balance the complications of a laparotomy versus a A thoracoscopy or versus versus a recurrence, a little higher recurrence. So, um, and these are just some things that, that we looked at here. And the other piece out of our data is for we had a period of time where we're using just biologics and they have a high recurrence rate if you use those as a patch, but I think everyone's pretty much, uh, abandoned those. So, you know, the technical points to take away from all this is open if a large defect, don't use biologic mesh alone. Don't put too much tension on your repair and place enough sutures. Do you, can I ask a question? Do you have a predictive way of when you're going to have a large repair or not? Like we will do if they have good prognostic factors, livers down or LHR or whatever numbers you want to use for your prognosis. If it looks like a favorable CDH, we'll be more aggressive and maybe do a minimally invasive approach versus if this is a patient that's. Already struggling and you're teetering on ECMO we're not, we're not going to be so I put a scope in everybody and 25% of those patients that you might have excluded when we, when we looked at, or let's say 25% of patients that have been on ECMO, we were able to successfully repair with a scope. It was a small enough defect. So I do think that there's enough variability in that population. It's heterogeneous enough that, you know, again, if you, if you, if you cut everybody open, you're going to cut everybody open. So if you, and it takes, it literally, you know, we set it all up, put a scope in, you don't futz around. You can decide very quickly whether you're going to need to need to convert to an open or not. And, and I just, you know, you look, if it's too big, you go ahead and open. It's taken maybe 5, 10 minutes longer. And, and that's it, you know, I think he is converting to open quickly. Yes, and also a conversation with the anesthesiologist about hypercapnia and the recent papers that have come out regarding that, and you want to pay attention to to what's going on at the head of the table as well. So I want to get through these cases. Is there another, no, we just have to, uh, yeah, go rapid fire, rapid fire.