Perioperative outcome of patients with congenital diaphragmatic hernia undergoing open versus minimally invasive surgery.

PURPOSE: The aim of this study was to evaluate outcome of patients with congenital diaphragmatic hernia (CDH) undergoing open versus minimally invasive surgery. SUBJECTS AND METHODS: Patient records of 33 children undergoing surgery for CDH between March 2002 and September 2008 were reviewed. Patient data were compared regarding operating time, intraoperative maximum CO(2) partial pressure (pCO(2 max)) values, postoperative ventilation time, complications, and recurrences. RESULTS: Median age at time of operation was 4 days (range, 0-1017 days), and median weight was 3800 g (range, 2000-13,200 g). Laparotomy was performed in 12 children. Seventeen patients underwent thoracoscopic repair, and four children had a laparoscopic approach. Operating time was significantly longer (P=.004) in the minimally invasive group. Median values of pCO(2 max) during operation were not significantly different (P=.25) in the minimally invasive surgery group. The pCO(2 max) values in the postoperative course were significantly lower (P=.013) in the minimally invasive group, whereas median ventilation times postoperatively were significantly longer (P=.024) in the open surgery group. CONCLUSIONS: Median values of pCO(2 max) in the postoperative course were significantly lower in the minimally invasive surgery group. In addition, postoperative ventilation time was shorter when children underwent minimally invasive surgery. In conclusion, minimally invasive surgery seems to offer advantages for selected patients with CDH.

Perioperative outcome of patients with esophageal atresia and tracheo-esophageal fistula undergoing open versus thoracoscopic surgery.

INTRODUCTION: Thoracoscopic approach for repair of esophageal atresia (EA) and tracheo-esophageal fistula (TEF) has become a standard procedure in many pediatric surgical centers. Thoracoscopic surgery in a newborn is demanding from both the surgeon and the patient. The potential benefits for the newborn are still discussed by neonatologists, pediatric intensive care physicians, and also parents. The aim of our investigation was to clearly define perioperative outcome and complication rates in children undergoing thoracoscopic versus open surgery for EA and TEF repair. PATIENTS AND METHODS: We reviewed the records of 68 newborns undergoing surgery for EA and TEF between March 2002 and February 2010. Patient data of open versus thoracoscopic approach were compared regarding operating time, intraoperative as well as postoperative pCO(2)max values, postoperative ventilation time, and complications. Specific patient data are reported with the median and range. Data analysis was done with the JMP(®) 7.0.2 statistical software (SAS Institute, Cary, NC). RESULTS: For the 68 patients, the mean gestational age was 35 weeks (28-41), the median birth weight was 2720 g (1500-3510 g) in the thoracoscopic group and 2090 g (780-3340 g) in the open group. There were 36 girls and 32 boys. Thirty-two children had associated anomalies. Twenty-five children were undergoing a thoracoscopic procedure. In 8 cases, the operation was converted to open thoracotomy. Another 32 children received a thoracotomy. In 11 newborns, a cervical esophagostomy was performed because of long-gap EA and these patients were excluded from the study. Operating time was 141 minutes (77-201 minutes) in the thoracoscopic group and 106 minutes (48-264 minutes) in the thoracotomy group, with significant difference (P=.014). Values of pCO(2)max during operation were 62 mm Hg (34-101 mm Hg) in the thoracoscopic group and 48 mm Hg (28-89 mm Hg) in the open group, with significant difference (P=.014). Postoperative ventilation time was 3 days (1-51 days) in all groups, with no significant difference (P=.79). Early complications were noticed in 9 children undergoing thoracoscopy and in 8 patients of the thoracotomy group, again with no significant difference (P>.05). CONCLUSION: Thoracoscopic repair of EA with TEF is justified because of a comparable perioperative outcome to open surgery, competitive operating times, decreased trauma to the thoracic cavity, and improved cosmesis despite skeptical considerations. Complication rates are not higher than in children operated on through a thoracotomy. However, a learning curve has to be taken into account and large experience in minimal invasive surgery is mandatory for this procedure. Larger series have to be expected for a more objective evaluation of perioperative as well as long-term outcomes. To our opinion, the thoracoscopic approach appears to be favorable and could be a future standard.