Department of Surgery, Division of General Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
Department of Gynecology and Obstetrics, Johns Hopkins Center for Fetal Therapy, Johns Hopkins University School of Medicine, 600N. Wolfe Street, Baltimore 21287, MD, United States.
J Pediatr Surg. 2022 Dec;57(12):819-825. doi: 10.1016/j.jpedsurg.2022.05.011. Epub 2022 May 19.
Fetoscopic endoluminal tracheal occlusion (FETO) was recently shown to improve postnatal survival in a multicenter, randomized controlled trial of infants with severe congenital diaphragmatic hernia (CDH). However, the external validity of this study remains unclear given a lack of standardization in postnatal management approaches. The purpose of this study was to evaluate the impact of an integrated prenatal and postnatal care setting on survival outcomes in severe CDH after FETO.
A systematic review, meta-analysis, and individual participant analysis of FETO outcomes in severe CDH were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The primary outcome was survival to discharge. Subgroup analyses of patients managed in integrated versus nonintegrated settings were performed to identify predictors of outcome.
The review generated five studies (n = 192) for the meta-analysis of FETO versus expectant prenatal management. These data revealed a significant survival benefit after FETO that was restricted to an integrated setting (OR 2.97, 95% Confidence Interval 1.69-4.26). There were nine studies (n = 150) for the individual participant analysis, which showed that FETO managed in an integrated setting had significantly increased survival rates when compared to FETO treated in a nonintegrated setting (70.7% vs. 45.7%, p = 0.003). Multi-level logistic regression identified increased availability of extracorporeal membrane oxygenation (ECMO) as the strongest determinant of postnatal survival (OR=18.8, p = 0.049).
This systematic review shows that institutional integration of prenatal and postnatal care is associated with the highest overall survival in children with severe CDH. These data highlight the importance of a standardized, multidisciplinary approach, including access to ECMO, as a critical postnatal component in optimizing FETO outcomes in CDH.
经阴道内镜腔内气管阻塞术（FETO）最近在一项多中心、随机对照试验中显示可提高严重先天性膈疝（CDH）患儿的出生后存活率。然而，鉴于缺乏标准化的产后管理方法，该研究的外部有效性仍不清楚。本研究的目的是评估产前和产后综合护理环境对 FETO 后严重 CDH 存活结局的影响。
根据系统评价和荟萃分析的首选报告项目（PRISMA）指南，对 FETO 治疗严重 CDH 的结果进行了系统评价、荟萃分析和个体参与者分析。主要结局是出院时的存活率。对在综合与非综合环境中管理的患者进行亚组分析，以确定结局的预测因素。
该综述产生了五项研究（n=192），用于 FETO 与预期产前管理的荟萃分析。这些数据显示 FETO 后有显著的生存获益，且仅限于综合环境（OR 2.97，95%置信区间 1.69-4.26）。有九项研究（n=150）进行了个体参与者分析，结果表明，与非综合环境中接受 FETO 治疗的患者相比，在综合环境中接受 FETO 治疗的患者的存活率显著提高（70.7%比 45.7%，p=0.003）。多水平逻辑回归确定体外膜肺氧合（ECMO）的可用性增加是出生后存活率的最强决定因素（OR=18.8，p=0.049）。
本系统评价表明，产前和产后护理的机构整合与严重 CDH 患儿的总体存活率最高相关。这些数据强调了标准化、多学科方法的重要性，包括获得 ECMO，作为优化 CDH 中 FETO 结局的关键产后组成部分。
