Schlager Avraham, Arps Kelly, Siddharthan Ragavan, Glenn Ian, Hill Sarah J, Wulkan Mark L, Keene Sarah D, Clifton Matthew S
1 Akron Children's Hospital , Akron, Ohio.
2 Department of Surgery, Emory University/Children's Healthcare of Atlanta , Atlanta, Georgia .
J Laparoendosc Adv Surg Tech A. 2018 Jun;28(6):774-779. doi: 10.1089/lap.2016.0583. Epub 2018 Mar 12.
Thoracoscopic repair of congenital diaphragmatic hernia (CDH) has been associated with faster recovery, earlier extubation, and decreased morbidity. Nevertheless, thoracoscopic repair is rarely attempted in the post-extracorporeal membrane oxygenation (ECMO) patient. Commonly cited reasons for not attempting thoracoscopy include concerns that the patients' respiratory status is too tenuous to tolerate insufflation pressures or that presumed defect size is so large that it precludes thoracoscopic repair. Our purpose is to review our experience with post-ECMO thoracoscopic CDH repair and evaluate the success of this approach.
We performed retrospective analysis of attempted thoracoscopic CDH repairs after ECMO decannulation at our institution from 2001 to 2015. Primary outcome was rate of conversion. Secondary outcomes were intraoperative end-tidal CO, time to extubation, and rate of recurrence.
We identified 21 post-ECMO patients in whom thoracoscopic CDH repair was attempted. Thoracoscopic repair was successfully completed in 28%. No patients had reported intolerance to insufflation at 3-7 mmHg. Average end-tidal CO at 15 operative minutes was 36.9 mmHg in the thoracoscopic group versus 50.7 mmHg in the open group and at 60 minutes was 34.25 mmHg versus 45.6 mmHg, respectively. One patient in the thoracoscopic group died and 1 experienced a large pneumothorax. In the converted group there was one clinically significant pneumothorax and three pleural effusions. Survivors after thoracoscopy were extubated an average of 5.6 ± 2.6 days after surgery versus 19.4 ± 10 days in the converted group (P < .05). Recurrence rates at last follow-up were equal between the two groups at 20%.
Thoracoscopic CDH repair is both safe and feasible after ECMO with no increase in operative morbidity or mortality. Insufflation pressures of 3-7 mmHg are well tolerated without undue increase in end-tidal CO When compared to conversion cases, thoracoscopic repair is associated with significantly decreased time to extubation with no difference in recurrence.
先天性膈疝（CDH）的胸腔镜修复与更快的恢复、更早的拔管以及发病率降低相关。然而，体外膜肺氧合（ECMO）治疗后的患者很少尝试胸腔镜修复。不尝试胸腔镜检查的常见原因包括担心患者的呼吸状况过于脆弱，无法耐受充气压力，或者推测缺损尺寸过大，无法进行胸腔镜修复。我们的目的是回顾我们在ECMO治疗后胸腔镜CDH修复方面的经验，并评估这种方法的成功率。
我们对2001年至2015年在我们机构进行ECMO拔管后尝试胸腔镜CDH修复的患者进行了回顾性分析。主要结局是中转率。次要结局是术中呼气末二氧化碳分压（EtCO₂）、拔管时间和复发率。
我们确定了21例ECMO治疗后的患者，尝试对其进行胸腔镜CDH修复。28%的患者成功完成了胸腔镜修复。没有患者报告对3-7mmHg的充气压力不耐受。胸腔镜组在手术15分钟时的平均呼气末二氧化碳分压为36.9mmHg，而开放组为50.7mmHg；在60分钟时，胸腔镜组为34.25mmHg，开放组为45.6mmHg。胸腔镜组有1例患者死亡，1例出现大量气胸。中转组有1例临床上显著的气胸和3例胸腔积液。胸腔镜检查后的幸存者术后平均5.6±2.6天拔管，而中转组为19.4±10天（P<0.05）。两组在最后一次随访时的复发率均为20%。
ECMO治疗后胸腔镜CDH修复既安全又可行，手术发病率或死亡率没有增加。3-7mmHg的充气压力耐受性良好，呼气末二氧化碳分压不会过度升高。与中转病例相比，胸腔镜修复与拔管时间显著缩短相关，复发率无差异。
