Surgical and local control outcomes after sequential short-course radiation therapy and chemotherapy for rectal cancer.

Background: Total neoadjuvant therapy (TNT) is an accepted approach for the management of locally advanced rectal cancer (LARC) and is associated with a decreased risk of development of metastatic disease compared to standard neoadjuvant therapy. However, questions remain regarding surgical outcomes and local control in patients who proceed to surgery, particularly when radiation is given first in the neoadjuvant sequence. We report on our institution's experience with patients who underwent short-course radiation therapy, consolidation chemotherapy, and surgery. Methods: We retrospectively reviewed surgical specimen outcomes, postoperative complications, and local/pelvic control in a large cohort of patients with LARC who underwent neoadjuvant therapy incorporating upfront short-course radiation therapy followed by consolidation chemotherapy. Results: In our cohort of 83 patients who proceeded to surgery, a complete/near-complete mesorectal specimen was achieved in 90 % of patients. This outcome was not associated with the time interval from completion of radiation to surgery. Postoperative complications were acceptably low. Local control at two years was 93.4 % for all patients- 97.6 % for those with low-risk disease and 90.4 % for high-risk disease. Conclusion: Upfront short-course radiation therapy and consolidation chemotherapy is an effective treatment course. Extended interval from completion of short-course radiation therapy did not impact surgical specimen quality.

Prevalence of cannabis use disorder and perioperative outcomes in adult colectomy patients: A propensity score-matched analysis.

BACKGROUND: The decriminalization of cannabis across the United States has led to an increased number of patients reporting cannabis use prior to surgery. However, it is unknown whether preoperative cannabis use disorder (CUD) increases the risk of postoperative complications among adult colectomy patients. METHODS: Adult patients undergoing an elective colectomy were retrospectively analyzed from the National Inpatient Sample database (2004-2018). To control for potential confounders, patients with CUD, defined using ICD-9/10 codes, were propensity score matched to patients without CUD in a 1:1 ratio. The association between preoperative CUD and composite morbidity, the primary outcome of interest, was assessed. Subgroup analyses were performed after stratification by age (≥50 years). RESULTS: Among 432,018 adult colectomy patients, 816 (0.19%) reported preoperative CUD. The prevalence of CUD increased nearly three-fold during the study period from 0.8/1000 patients in 2004 to 2.0/1000 patients in 2018 (P-trend<0.001). After propensity score matching, patients with CUD exhibited similar rates of composite morbidity (140 of 816; 17.2%) as those without CUD (151 of 816; 18.5%) (p = 0.477). Patients with CUD also had similar anastomotic leak rates (CUD: 5.64% vs. No CUD: 6.25%; p = 0.601), hospital lengths of stay (CUD: 5 days, IQR 4-7 vs. No CUD: 5 days, IQR 4-7) (p = 0.415), and hospital charges as those without CUD. Similar findings were seen among patients aged ≥50 years in the subgroup analysis. CONCLUSIONS: Though the prevalence of CUD has increased drastically over the past 15 years, preoperative CUD was not associated with an increased risk of composite morbidity among adult patients undergoing an elective colectomy.

Factors associated with not undergoing surgery for locally advanced rectal cancers: An NCDB propensity-matched analysis.

BACKGROUND: The traditional treatment paradigm for patients with locally advanced rectal cancers has been neoadjuvant chemoradiation followed by curative intent surgery and adjuvant chemotherapy. This study aimed to assess surgery trends for locally advanced rectal cancers, factors associated with forgoing surgery, and overall survival outcomes. METHODS: Adults with locally advanced rectal cancers were retrospectively analyzed using the National Cancer Database (2004-2019). Propensity score matching was performed. Factors associated with not undergoing surgery were identified using multivariable logistic regression. Kaplan-Meier and log-rank tests were used for 5-year overall survival analysis, stratified by stage and treatment type. RESULTS: A total of 72,653 patients were identified, with 64,396 (88.64%) patients undergoing neoadjuvant + surgery ± adjuvant therapy, 579 (0.80%) chemotherapy only, 916 (1.26%) radiation only, and 6,762 (9.31%) chemoradiation only. The proportion of patients who underwent surgery declined over the study period (95.61% in 2006 to 92.29% in 2019, P trend < .001), whereas the proportion of patients who refused surgery increased (1.45%-4.48%, P trend < .001). Factors associated with not undergoing surgery for locally advanced rectal cancers included older age, Black race (odds ratio 1.47, 95% CI 1.35-1.60, P < .001), higher Charlson-Deyo score (score ≥3: 1.79, 1.58-2.04, P < .001), stage II cancer (1.22, 1.17-1.28, P < .001), lower median household income, and non-private insurance. Neoadjuvant + surgery ± adjuvant therapy was associated with the best 5-year overall survival, regardless of stage, in unmatched and matched cohorts. CONCLUSION: Despite surgery remaining an integral component in the management of locally advanced rectal cancers, there is a concerning decline in guideline-concordant surgical care for rectal cancer in the United States, with evidence of persistent socioeconomic disparities. Providers should seek to understand patient perspectives/barriers and guide them toward surgery if appropriate candidates. Continued standardization, implementation, and evaluation of rectal cancer care through national accreditation programs are necessary to ensure that all patients receive optimal treatment.

Procedure-specific risks of robotic simultaneous resection of colorectal cancer and synchronous liver metastases.

An estimated 25% of patients with colorectal cancer (CRC) present with distant metastases at the time of diagnosis, the most common site being the liver. Although prior studies have reported that a simultaneous approach to resections in these patients can lead to increased rates of complications, emerging literature shows that minimally invasive surgical (MIS) approaches can mitigate this additional morbidity. This is the first study utilizing a large national database to investigate colorectal and hepatic procedure-specific risks in robotic simultaneous resections for CRC and colorectal liver metastases (CRLM). Utilizing the ACS-NSQIP targeted colectomy, proctectomy, and hepatectomy files, 1,721 patients were identified who underwent simultaneous resections of CRC and CRLM from 2016 to 2021. Of these patients, 345 (20%) underwent resections by an MIS approach, defined as either laparoscopic (n = 266, 78%) or robotic (n = 79, 23%). Patients who underwent robotic resections had lower rates of ileus compared to those who had open surgeries. The robotic group had similar rates of 30-day anastomotic leak, bile leak, hepatic failure, and post-operative invasive hepatic procedures compared to both the open and laparoscopic groups. The rate of conversion to open (8% vs. 22%, p = 0.004) and median LOS (5 vs. 6 days, p = 0.022) was significantly lower for robotic compared to laparoscopic group. This study, which is the largest national cohort of simultaneous CRC and CRLM resections, supports the safety and potential benefits of a robotic approach in these patients.

Procedure-Specific Risks of Robotic Simultaneous Resection of Colorectal Cancer and Synchronous Liver Metastases.

An estimated 25% of patients with colorectal cancer (CRC) present with distant metastases at the time of diagnosis, the most common site being the liver. Controversy exists regarding the safety of a simultaneous versus staged approach to resections in these patients, but reports have shown that minimally invasive surgery (MIS) approaches can mitigate morbidity. This is the first study utilizing a large national database to investigate colorectal and hepatic procedure-specific risks in robotic simultaneous resections for CRC and colorectal liver metastases (CRLM). Utilizing the ACS-NSQIP targeted colectomy, proctectomy, and hepatectomy files, 1,550 patients were identified who underwent simultaneous resections of CRC and CRLM from 2016-2020. Of these patients, 311 (20%) underwent resections by an MIS approach, defined as an either laparoscopic (n = 241, 78%) or robotic (n = 70, 23%). Patients who underwent robotic resections had lower rates of ileus compared to those who had an open surgery. The robotic group had similar rates of 30-day anastomotic leak, bile leak, hepatic failure, and post operative invasive hepatic procedures compared to both the open and laparoscopic groups. The rate of conversion to open was significantly lower for robotic compared to laparoscopic group (9% vs. 22%, p = 0.012). This report is the largest study to date of robotic simultaneous CRC and CRLM resections reported in the literature and supports the safety and potential benefits of this approach.

Colorectal Surgery Outcomes in the United States During the COVID-19 Pandemic.

INTRODUCTION: The purpose of this study was to assess colorectal surgery outcomes, discharge destination, and readmission in the United States during the COVID-19 pandemic. METHODS: Adult colorectal surgery patients in the American College of Surgeons National Surgical Quality Improvement Program database (2019-2020) and its colectomy and proctectomy procedure-targeted files were included. The prepandemic time period was defined from April 1, 2019 to December 31, 2019. The pandemic time period was defined from April 1, 2020 to December 31, 2020 in quarterly intervals (Q2 April-June; Q3 July-September; Q4 October-December). Factors associated with morbidity and in-hospital mortality were assessed using multivariable logistic regression. RESULTS: Among 62,393 patients, 34,810 patients (55.8%) underwent colorectal surgery prepandemic and 27,583 (44.2%) during the pandemic. Patients who had surgery during the pandemic had higher American Society of Anesthesiologists class and presented more frequently with dependent functional status. The proportion of emergent surgeries increased (12.7% prepandemic versus 15.2% pandemic, P < 0.001), with less laparoscopic cases (54.0% versus 51.0%, P < 0.001). Higher rates of morbidity with a greater proportion of discharges to home and lesser proportion of discharges to skilled care facilities were observed with no considerable differences in length of stay or worsening readmission rates. Multivariable analysis demonstrated increased odds of overall and serious morbidity and in-hospital mortality, during Q3 and/or Q4 of the 2020 pandemic. CONCLUSIONS: Differences in hospital presentation, inpatient care, and discharge disposition of colorectal surgery patients were observed during the COVID-19 pandemic. Pandemic responses should emphasize balancing resource allocation, educating patients and providers on timely medical workup and management, and optimizing discharge coordination pathways.

Preoperative Frailty Assessment, Operative Severity Score, and Early Postoperative Loss of Independence in Surgical Patients Age 65 Years or Older.

BACKGROUND: Preoperative discussions around postoperative discharge planning have been amplified by the COVID pandemic. We wished to determine whether our preoperative frailty screen would predict postoperative loss of independence (LOI). STUDY DESIGN: This single-institutional study included demographic, procedural, and outcomes data from patients 65 years or older who underwent frailty screening before a surgical procedure. Frailty was assessed using the Edmonton Frail Scale. The Operative Severity Score was used to categorize procedures. The Hierarchical Condition Category risk-adjustment score, as calculated by the Centers for Medicare and Medicaid Services, was included. LOI was defined as an increase in support outside of the home after discharge. Univariable, multivariable logistic regressions, and adjusted postestimation analyses for predictive probabilities of best fit were performed. RESULTS: Five hundred and thirty-five patients met inclusion criteria and LOI was seen in 38 patients (7%). Patients with LOI were older, had a lower BMI, a higher Edmonton Frail Scale score (7 vs 3.0; p < 0.001), and a higher Hierarchical Condition Category score than patients without LOI. Being frail and undergoing a procedure with an Operative Severity Score of 3 or higher was independently associated with an increased risk of LOI. In addition, social dependency, depression, and limited mobility were associated with an increased risk for LOI. On multivariable modeling, frailty status, undergoing an operation with an Operative Severity Score of 3 or higher, and having a Hierarchical Condition Category score ≥1 were the most predictive of LOI (odds ratio 12.72; 95% CI, 12.04 to 13.44; p < 0.001). In addition, self-reported depression, weight loss, and limited mobility were associated with a nearly 11-fold increased risk of postoperative LOI. CONCLUSIONS: This study was novel, as it identified clear, generalizable risk factors for LOI. In addition, our findings support the implementation of preoperative assessments to aid in care coordination and provide specific targets for intervention.

Loss of Independence in Older Patients after Operation for Colorectal Cancer.

BACKGROUND: Disease-free survival is the cornerstone for colorectal cancer outcomes. Maintenance of independence may represent the preferred cancer outcome in older patients. Frailty and cognitive impairment are associated with adverse clinical outcomes after operation in patients ≥65 years. The aim of this study was to determine the impact of frailty and cognitive impairment on loss of independence (LOI) among colorectal cancer patients. STUDY DESIGN: From 2016 to 2018, patients undergoing operation for colorectal cancer and having geriatric-specific American College of Surgeons NSQIP variables recorded were included. Frailty was assessed using the modified frailty index. Loss of independence was defined by the need for assistance with activities of daily living. Complications were assessed using the Clavien-Dindo (CD) scoring system. Multivariable analyses examining LOI, length of stay (LOS), and 30-day postoperative complication and readmission were performed. RESULTS: There were 1,676 patients included. Preoperatively, 118 (7%) patients reported cognitive impairment, 388 (23%) patients used a mobility aid, and 82 (5%) patients were partially or totally dependent. Loss of independence upon discharge was seen in 344 (20.5%) patients and was independently associated with an increase in LOS (incidence rate ratio [IRR] 1.44, 95% CI 1.30 to 1.59) and major complication (odds ratio [OR] 1.86, 95% CI 1.36 to 2.53). Risk factors predictive of LOI upon discharge were increasing age, cognitive impairment, use of mobility aid, and postoperative delirium. In patients ≥80 years old, 93 (18%) had LOI at 30 days. Risk factors predictive of LOI at 30 days included a preoperative mobility aid, postoperative delirium, and the need for a new mobility aid. CONCLUSIONS: One of 5 older patients undergoing operation for colorectal cancer experience LOI, and risk factors include a decline in cognition and mobility. Future studies should evaluate risks for long-term LOI and explore interventions to optimize this patient population.

Outcomes for Ulcerative Colitis With Delayed Emergency Colectomy Are Worse When Controlling for Preoperative Risk Factors.

BACKGROUND: Increasing evidence supports immediate colectomy in acute fulminant ulcerative colitis in comparison with ongoing medical management. Prior studies have been limited to inpatient-only administrative data sets or single-institution experiences. OBJECTIVE: The purpose of this study was to compare outcomes of early versus delayed emergency colectomy in patients admitted with ulcerative colitis flares while controlling for known preoperative risks and acuity. DESIGN: This is a cohort study of patients undergoing emergent total abdominal colectomies for ulcerative colitis compared by the timing of surgery. SETTING: Adult patients undergoing an emergent total abdominal colectomy for ulcerative colitis, 2005 to 2015, were identified in the American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS: Patients undergoing total abdominal colectomy with an operative indication of ulcerative colitis admitted on a nonelective basis were selected. MAIN OUTCOME MEASURE: The primary outcomes measured were 30-day National Surgical Quality Improvement Program-reported mortality and postoperative complications, and early operation within 2 days of admission. RESULTS: We identified 573 total abdominal colectomies after propensity score matching. Median time to surgery was 1 hospital day in the early group versus 6 hospital days in the delayed group (p < 0.001). Early operation was associated with a lower mortality rate (4.9% versus 20.3% in matched groups, p < 0.001) and lower complication rate (64.5% versus 72.0%, p = 0.052). Multivariable logistic regression with propensity weighting of mortality on preoperative risk factors demonstrated that early surgery is associated with an 82% decrease in the odds of death compared with delayed surgery (p < 0.001). Regression of morbidity on preoperative risk factors demonstrated that early surgery is associated with a 35% decrease in the odds of a complication with delayed surgery (p = 0.034). LIMITATIONS: Quality improvement data were used for clinical research questions. CONCLUSIONS: Patients undergoing immediate surgical intervention for acute ulcerative colitis have decreased postoperative complications and mortality rates. Rapid and early transitioning from medical to surgical management may benefit those expected to require surgery on the same admission. See Video Abstract at http://links.lww.com/DCR/A800.

Risk of readmission after laparoscopic vs. open colorectal surgery.

PURPOSE: Laparoscopic colorectal resection (LC) is associated with known recovery benefits and earlier discharge when compared to open colorectal resection (OC). Whether earlier discharge leads to a paradoxical increase in readmission has not been well characterized. The aim of this study is to compare the risk of readmission after the two procedures in a large, nationally representative sample. METHODS: Patients who underwent colorectal resection in 2011 were identified from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. LC and OC patients were compared for patient factors, complications, and readmission rates. A multivariable analysis controlling for significant factors was performed to evaluate factors associated with readmission. RESULTS: Of 30,428 patients who underwent colorectal resection, 40.2% underwent LC. Length of stay (LOS) after LC was shorter than after OC (5.7 vs. 9.7 days, p < 0.001). LC was associated with a significantly lower rate of surgical site infections (SSI), bleeding, reoperation, 30-day mortality, and complications. Risk of readmission was greater for patients undergoing proctectomy than colectomy (12.7 vs. 10.6 %, p < 0.001), but was lower after laparoscopic than open for both procedures after controlling for confounding factors. Obesity, DM, operating time ≥180 min, steroid use, and ASA class 3-5 were found to be associated with readmission. CONCLUSION: Despite its technical complexity, LC can be performed without concerns for increased complications or readmission. The shorter length of stay and the lower risk of readmissions underline the true benefits of the laparoscopic approach for colorectal resection.

Extracorporeal fetal support: a new animal model with preservation of the placenta.

BACKGROUND: Previous models of support for premature sheep fetuses have consisted of cesarean delivery followed by catheterization of umbilical or central vessels and support with extracorporeal membrane oxygenation (ECMO). The limitations of these models have been insufficient blood flow, significant fetal edema, and hemorrhage related to anticoagulation. METHODS: We performed a gravid hysterectomy on 13 ewes between 135 and 145days gestational age. The uterine vessels were cannulated bilaterally and circulatory support was provided via ECMO. Successful transition was defined as maintenance of fetal heart rate for 30minutes after establishing full extracorporeal support. Circuit flow was titrated to maintain mixed venous oxygen saturation (SvO2) of 70-75%. RESULTS: Seven experiments were successfully transitioned to ECMO, with an average survival time of 2hours 9minutes. The longest recorded time from cannulation to death was 6hours 14minutes. By delivering a circuit flow of up to 2120ml/min, all but one of the transitioned uteri were maintained within the desired SvO2 range. CONCLUSION: We report a novel animal model of fetal ECMO support that preserves the placenta, mitigates the effects of heparin, and allows for increased circuit flow compared to prior techniques. This approach may provide insight into a technique for future studies of fetal physiology.

Provider density and health system facility factors and their relationship to rates of pediatric perforated appendicitis in US counties.

OBJECTIVE: To examine whether density of providers or health care facility factors have a significant effect on the rates of perforated appendicitis in the pediatric population. DESIGN: A retrospective database analysis. Data were linked to the Area Resource File to determine if there was an association between perforated appendicitis and density of provider and facility factors. SETTING: The National Inpatient Sample database and the Kids' Inpatient Database from 1988 to 2005. PATIENTS: All patients included had an age at admission of younger than 18 years and were selected by International Classification of Diseases, Ninth Revision code as having perforated appendicitis (540.0 or 540.1) or acute appendicitis (540.9). Main Outcome Measure Odds ratio of perforated appendicitis to acute appendicitis by county-level density of provider and health care facility factors. RESULTS: The odds ratio of perforated appendicitis to acute appendicitis when stratified by quartiles of increasing density of providers and facility-level factors was statistically significant only for the highest-density quartile of pediatricians (odds ratio = 0.88; 95% confidence interval = 0.78-0.99). CONCLUSIONS: Increasing geographic density of pediatricians was associated with a decreasing trend in the odds ratio of perforated appendicitis, with a statistically significant protective effect observed in the highest-density quartile of pediatricians. The density of all other provider and health care facility factors analyzed did not demonstrate a significant association with the rates of perforated appendicitis.

Seasonal and day of the week variations of perforated appendicitis in US children.

PURPOSE: The present study aimed to determine whether children with perforated appendicitis were more likely to present during specific days of the week or seasons of the year. METHODS: After obtaining IRB exemption, a retrospective, population-based study of patients <18 with ICD9 codes of acute (540.9) or perforated (540.0, 540.1) appendicitis in the Kids' Inpatient Database (KID) was performed. Univariate and multivariate analyses were performed analyzing patient and hospital factors. RESULTS: A total of 31,457 children were identified with acute appendicitis, of whom 10,524 (33.5%) were perforated. Mondays [odds ratio (OR): 1.16; 95% Confidence Interval (CI): 1.05-1.28] were significant for increased likelihood as day of presentation with perforation in US children more than any other day of the week. In seasonal analysis, fall (OR: 1.12; 95% CI: 1.04-1.21) and winter (OR: 1.11; 95% CI: 1.03-1.20) were at higher odds for perforation at presentation. Patients with Medicaid (OR: 1.22; 95% CI: 1.03-1.43) and those uninsured (OR: 1.50; 95% CI: 1.16-1.93) were more likely to present with perforation. CONCLUSION: Perforated appendicitis was more likely to present on Mondays in US children. Although appendicitis is most common in summer months, rates of perforated appendicitis were highest in fall and winter.

Necrotizing enterocolitis in 20,822 infants: analysis of medical and surgical treatments.

Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency of the neonate. Previous information about this disease has largely been gathered from limited series. We analyzed 13 years of the National Inpatient Sample (NIS) and 3 years of the Kids' Inpatient Database (KID; 1997, 2000, 2003) to generate the most comprehensive profile of outcomes to date of medically versus surgically treated NEC. We identified 20 822 infants with NEC, of whom 15,419 (74.1%) and 5403 (25.9%) were undergoing medical and surgical management, respectively. Overall, surgical patients had greater length of stay, total hospital charges, and mortality. Among infants dying during admission, there was no significant difference in length of stay or charges between the medical and surgical groups. These findings highlight the need for developing a clinically relevant risk stratification tool to identify NEC patients at high risk for death.

Report of 2,087,915 surgical admissions in U.S. children: inpatient mortality rates by procedure and specialty.

BACKGROUND: Mortality rates for eight surgical procedures have been endorsed by the Agency for Healthcare Research and Quality as part of the Inpatient Quality Indicators developed to assist hospitals in identifying potential problem areas and as an indirect measure of quality for inpatient adult surgical care. Little to no broad information relating to the overall mortality relating to the surgical care of children is available. An analysis providing national data on the most common procedures performed in children and their associated mortality would be useful in beginning to create benchmarks for standards of surgical care in the pediatric patient. METHODS: A total of 93 million admissions from the National Inpatient Sample (NIS) file from the years 1988-1996, 1998, 1999, 2001, 2002, 2004-2005 and the Kids Inpatient Database (KID) from 1997, 2000, 2003 were screened to identify surgical admissions in children under the age of 18 years. Variables such as gender, race, age at admission, length of hospital stay, total hospital charges, insurance status, and inpatient mortality were analyzed. Diagnosis related group (DRG) codes were used to provide inpatient mortality rates for 147 different procedures and 15 surgical subspecialties. RESULTS: Over the 18-year period considered, a total of 2,087,915 surgical admissions in U.S. children were identified. Most of the patients were white (60.92%), male (54.64%), and were treated in urban, teaching hospitals (60.36%). Overall inpatient mortality was 0.85%, with a median hospital stay of 3 days. Procedures with the highest mortality were craniotomies for trauma (26.27%), liver and/or intestinal transplants (11.12%), heart transplants (10.94%), and other procedures for multiple significant trauma (10.69%). When analyzed by surgical subspecialty, gastrointestinal or general pediatric surgery saw the highest volume of patients, followed by orthopedic and ear, nose, and throat surgery (534,053 vs. 352,228 vs. 257,118 total procedures, respectively). CONCLUSIONS: Pediatric surgical literature has classically focused on disease-based outcomes. However, such data do not provide a comprehensive profile of pediatric surgical outcomes by procedure or subspecialty. The present study provides nationwide data relating to inpatient pediatric surgical outcomes in U.S. hospitals by procedure and pediatric subspecialty.

Congenital diaphragmatic hernia: outcome review of 2,173 surgical repairs in US infants.

Congenital diaphragmatic hernia (CDH) remains one of the most challenging conditions to treat within the pediatric surgical and medical communities. In spite of modern treatment modalities, including extracorporeal membrane oxygenation (ECMO) and improved ventilatory support, mortality remains high. The present study analyzes a US database containing information from nearly 93 million discharges in the US. Infants with congenital diaphragmatic hernia who underwent surgical repair were identified by ICD-9 procedure code and inclusion criteria including an age at admission of less than 1 year. Variables of gender, race, age, geographic region, co-existing diagnoses and procedures, hospital type, hospital charges adjusted to 2006 dollars, length of stay, and inpatient mortality were collected. A total of 89% of patients were either treated initially or rapidly transferred to urban teaching hospitals for definitive treatment of CDH. The inpatient mortality rate was 10.4% with a median length of stay of 20 days (interquartile range of 9-40 days). The median inflation-adjusted total hospital charge was $116,210. Respiratory distress was the most common co-existing condition (68.8%) followed by esophageal reflux (27.8%). The most common concomitant procedures performed were ECMO (17.8%) and fundoplication (17.6%). This study, which represents the largest characterization of US infants who have undergone CDH repair using data from a nationally representative non-voluntary database, demonstrates that surgical repair is associated with significant mortality and morbidity.