High-risk congenital diaphragmatic hernia: how long should surgery be delayed?

Over recent years, the management of babies with congenital diaphragmatic hernia (CDH) in our unit has evolved from immediate surgery (group 1 1969–1982, n = 62) through early surgery (within 24 h) following medical stabilisation (group 2 1982–1987, n = 42) to surgery delayed (median 96 h IQR 45–144) until stable on < 40% oxygen (group 3 1987–1992, n = 23). Two poor prognostic indicators were identified: respiratory distress requiring positive-pressure ventilation <4 h after birth (alpha babies), and the presence of an intra-thoracic stomach (ITS). The outcome in these high-risk infants was compared between the groups. The mortality of alpha infants in group 1 was 80% (n = 39), decreased in group 2 (57%, n = 26), and was significantly lower in group 3 (39%, P < 0.01). Mortality in alpha infants with ITS was 75% in group 2 (n = 15) and 42% in group 3 (n = 11). Significant persistent fetal circulation (PFC) requiring vasodilator treatment fell from 86% of alpha babies in group 2 to 53% in group 3 (P < 0.05). Delayed surgery appears to reduce mortality and the incidence of significant PFC compared to immediate and early surgery in babies with high-risk CDH. A randomised multi-centre trial of delayed surgery in CDH is required to confirm this.