Abdulhai Sophia, Glenn Ian C, McNinch Neil L, Ponsky Todd A, Schlager Avraham
Department of Pediatric Surgery, Akron Children's Hospital , Akron, Ohio.
J Laparoendosc Adv Surg Tech A. 2018 May;28(5):606-609. doi: 10.1089/lap.2017.0296. Epub 2017 Dec 13.
There is little consensus on optimal management for congenital diaphragmatic hernia extracorporeal membrane oxygenation (CDH ECMO) patients. Meaningful comparisons of the various approaches have been limited due to the low number of cases in institutions. In addition, the multidisciplinary reliance and rigid institutional framework of ECMO serve to further limit exposure to alternative practices. The goal of this study is to survey the international pediatric surgery community to describe the current practice trends.
A survey was electronically distributed to the international pediatric surgical community. The results were evaluated using statistical analysis.
A total of 123 pediatric surgeons completed the survey, of whom 89% work at institutions offering both venoatrial (VA) and venovenous (VV) ECMO. Although 69% perform VA ECMO for CDH, only 46% felt VA was the "optimal method." Among VV proponents, 21% believe the rate of VV to VA conversion to be <5% and 16% believe it to be >30% compared with 0% and 40% in VA proponents. Distribution of timing of repair: 46% post-ECMO repair, 22% early ECMO repair, 15% whenever stabilized on ECMO, and 14% late ECMO repair. Sixty-four percent (71/111) would perform an ECMO CDH repair in the unweanable patient and 27% (30/111) report successful decannulation after repair of a patient who was unweanable on ECMO for 2 weeks. Ninety-two percent do not perform exit-to-ECMO.
There are significant practice variations in the management of CDH ECMO. Majority of pediatric surgeons perform VA ECMO in CDH patients; however, a significant percentage of those believe VV to be more optimal. This discrepancy is not accounted for by the VA-only institutions. Although post-ECMO CDH repair is the most common approach, the majority would perform a repair "on ECMO" if the patient was unweanable. In addition, although many pediatric surgeons believe the "last ditch repair" for the unweanable patient to be futile, 27% have reported success. Exit-to-ECMO for CDH remains a minority practice.
对于先天性膈疝体外膜肺氧合（CDH ECMO）患者的最佳管理方式，目前几乎没有达成共识。由于各机构的病例数量较少，对各种方法进行有意义的比较受到限制。此外，ECMO的多学科依赖和严格的机构框架进一步限制了对替代做法的接触。本研究的目的是对国际小儿外科界进行调查，以描述当前的实践趋势。
通过电子方式向国际小儿外科界分发了一份调查问卷。使用统计分析对结果进行评估。
共有123名小儿外科医生完成了调查，其中89%在同时提供静脉-心房（VA）和静脉-静脉（VV）ECMO的机构工作。虽然69%的医生对CDH患者进行VA ECMO治疗，但只有46%的人认为VA是“最佳方法”。在支持VV的人中，21%认为VV转换为VA的比例<5%，16%认为该比例>30%，而支持VA的人中这两个比例分别为0%和40%。修复时机的分布情况为：46%在ECMO支持后进行修复，22%在早期进行ECMO支持下的修复，15%在ECMO支持下病情稳定时随时进行修复，14%在晚期进行ECMO支持下的修复。64%（71/111）的医生会对无法撤机的患者进行ECMO支持下的CDH修复，27%（30/111）的医生报告称，对一名在ECMO支持下两周仍无法撤机的患者进行修复后成功撤机。92%的医生不进行从手术室到ECMO的操作。
在CDH ECMO的管理方面存在显著的实践差异。大多数小儿外科医生对CDH患者进行VA ECMO治疗；然而，相当一部分人认为VV更优。仅开展VA治疗的机构并不能解释这种差异。虽然ECMO支持后进行CDH修复是最常见的方法，但如果患者无法撤机，大多数医生会在“ECMO支持下”进行修复。此外，虽然许多小儿外科医生认为对无法撤机的患者进行“最后一搏的修复”是徒劳的，但27%的医生报告取得了成功。对CDH患者进行从手术室到ECMO的操作仍然是少数做法。
