Clinical analysis of different surgical modalities for the treatment of congenital diaphragmatic hernia: a single-center retrospective study

doi:10.3877/cma.j.issn.1673-5250.2024.01.003

Objective

To explore the clinical effect of different surgical methods in the treatment of congenital diaphragmatic hernia (CDH).

Methods

From January 2013 to August 2023, retrospectively analysis was performed for the clinical data of 158 hospitalized children with CDH admitted to the Children′s Hospital of Chongqing Medical University. According to different surgical methods and approaches, they were divided into thoracotomy group-1 (n=7), laparotomy group-1 (n=61), thoracoscopic group-1 (n=85) and laparoscopic group-1 (n=5). 12 patients underwent endoscopic conversion and 7 died after surgery. Excluding 19 patients with CDH who died after the first CDH repair and underwent endoscopy conversion, 139 children with CDH were further divided into thoracotomy group-2 (n=6), laparotomy group-2 (n=58), thoracoscopic group-2 (n=71) and laparoscopic group-2 (n=4). The above groups were compared with regards to age of operation, operation time, intraoperative blood loss, incidence of blood transfusion, retention time of postoperative thoracic drainage tube, duration of postoperative ventilator use, hospitalization days, postoperative pulmonary complications and CDH recurrence by retrospective analysis with Kruskal-Wallis H test and chi-square test. The procedures followed in this study have been approved by the Ethics Committee of our hospital (Approval No. 2024-39).

Results

The overall mortality rate of CDH patients was 5.1% (8/158). 12 cases converted open surgery, including 3 cases converted to thoracotomy and 8 cases converted to laparotomy in thoracoscopic group-1, and 1 case converted to laparotomy in laparoscopic group-1. The operative time and intraoperative blood loss were compared among thoracotomy group-2, laparotomy group-2, thoracoscopic group-2 and laparoscopic group-2, and the differences were statistically significant (P<0.05). There was no significant difference in the incidence of intraoperative blood transfusion, the duration of postoperative ventilator use, retention time of postoperative thoracic drainage tube and the days of hospitalization among those four groups (P>0.05). Pulmonary complications were observed in 9 cases (6.5%), including pneumothorax (4 cases in laparotomy group-2 and 5 cases in thoracoscopic group-2). There were 3 cases (2.2%) of chylothorax (1 case in laparotomy group-2 and 2 cases in thoracoscopic group-2). 2 cases (1.4%) of atelectasis were in laparotomy group-2. The differences of incidence rates of pneumothorax, chylothorax, and atelectasis among those four group all were not statistically significant (P>0.05). Follow-up results showed that there were 7 cases (5.0%) of CDH recurrence, and there was no statistical significance among those four groups in incidence of CDH recurrence (P>0.05).

Conclusions

Different operative methods for children with CDH are safe and effective, and each has its own advantages and disadvantages. The choice of operative methods should take into account the patient′s condition, the surgeon′s technical characteristics and the operative conditions. Open surgery still plays an important role in treatment of CDH children, but thoracoscopic minimally invasive surgery has become the preferred method for CDH children.

Key words: Hernias, diaphragmatic, congenital, Thoracotomy, Laparotomy, Thoracoscopes, Laparoscope, Surgical procedures, operative, Child

表1 开胸组-1、开腹组-1、胸腔镜组-1、腹腔镜组-1 CDH患儿手术时月龄、死亡率及中转开放手术率比较

组别	例数	手术时月龄[月，M(Q₁，Q₃)]	死亡率[例数(%)]	中转开放手术率[例数(%)]
开胸组-1	7	0.2(0.1，8.3)	1(14.3)	－^a
开腹组-1	61	0.7(0.1，8.2)	3(4.9)	－^a
胸腔镜组-1	85	5.7(0.2，12.8)	4(4.7)	11(12.9)
腹腔镜组-1	5	17.0(11.0，22.0)	0(0)	1(20.0)
统计量		H＝14.07	χ²＝1.22	χ²＝0.20
P值		0.003	0.638	0.520

表1 开胸组-1、开腹组-1、胸腔镜组-1、腹腔镜组-1 CDH患儿手术时月龄、死亡率及中转开放手术率比较

组别	例数	手术时月龄[月，M(Q₁，Q₃)]	死亡率[例数(%)]	中转开放手术率[例数(%)]
开胸组-1	7	0.2(0.1，8.3)	1(14.3)	－^a
开腹组-1	61	0.7(0.1，8.2)	3(4.9)	－^a
胸腔镜组-1	85	5.7(0.2，12.8)	4(4.7)	11(12.9)
腹腔镜组-1	5	17.0(11.0，22.0)	0(0)	1(20.0)
统计量		H＝14.07	χ²＝1.22	χ²＝0.20
P值		0.003	0.638	0.520

表2 开胸组-2、开腹组-2、胸腔镜组-2、腹腔镜组-2 CDH患儿手术相关情况比较

组别	例数	手术时间[min，M(Q₁，Q₃)]	术中出血量[mL，M(Q₁，Q₃))	术中输血率[例数(%)]	术后胸腔引流管留置时间[d，M(Q₁，Q₃)]	术后呼吸机使用时间[d，M(Q₁，Q₃)]	住院天数[d，M(Q₁，Q₃)]
开胸组-2	6	82.5(71.7，95.0)	6.3(3.5，10.0)	0(0)	0.5(0.2，1.0)	0.5(0.2，1.0)	15.5(13.0，20.0)
开腹组-2	58	85.9(72.5，101.0)	5.0(3.1，8.9)	5(8.6)	5.4(3.1，10.5)	1.0(0.6，4.0)	17.2(13.4，22.2)
胸腔镜组-2	71	64.4(50.2，86.1)	2.1(1.3，3.2)	4(5.6)	5.0(3.4，8.1)	1.0(0.2，3.2)	15.3(12.3，20.4)
腹腔镜组-2	4	110.0(70.0，243.3)	7.5(3.0，15.0)	0(0)	0(0，0)	0.5(0.4，0.7)	15.0(5.0，17.7)
统计量		H＝21.15	H＝36.42	χ²＝0.77	H＝3.85	H＝5.81	H＝2.41
P值		<0.001	<0.001	0.865	0.278	0.121	0.492

表2 开胸组-2、开腹组-2、胸腔镜组-2、腹腔镜组-2 CDH患儿手术相关情况比较

组别	例数	手术时间[min，M(Q₁，Q₃)]	术中出血量[mL，M(Q₁，Q₃))	术中输血率[例数(%)]	术后胸腔引流管留置时间[d，M(Q₁，Q₃)]	术后呼吸机使用时间[d，M(Q₁，Q₃)]	住院天数[d，M(Q₁，Q₃)]
开胸组-2	6	82.5(71.7，95.0)	6.3(3.5，10.0)	0(0)	0.5(0.2，1.0)	0.5(0.2，1.0)	15.5(13.0，20.0)
开腹组-2	58	85.9(72.5，101.0)	5.0(3.1，8.9)	5(8.6)	5.4(3.1，10.5)	1.0(0.6，4.0)	17.2(13.4，22.2)
胸腔镜组-2	71	64.4(50.2，86.1)	2.1(1.3，3.2)	4(5.6)	5.0(3.4，8.1)	1.0(0.2，3.2)	15.3(12.3，20.4)
腹腔镜组-2	4	110.0(70.0，243.3)	7.5(3.0，15.0)	0(0)	0(0，0)	0.5(0.4，0.7)	15.0(5.0，17.7)
统计量		H＝21.15	H＝36.42	χ²＝0.77	H＝3.85	H＝5.81	H＝2.41
P值		<0.001	<0.001	0.865	0.278	0.121	0.492

表3 开胸组-2、开腹组-2、胸腔镜组-2、腹腔镜组-2 CDH患儿术后肺部相关并发症发生率及CDH复发率比较

组别	例数	肺不张[例数(%)]	气胸[例数(%)]	乳糜胸[例数(%)]	CDH复发[例数(%)]	CDH复发时间间隔[M(Q₁，Q₃)]
开胸亚组-2	6	0(0)	0(0)	0(0)	0(0)	－^a
开腹亚组-2	58	2(3.45)	4(6.9)	1(1.7)	0(0)	－^a
胸腔镜亚组-2	71	0(0)	5(7.0)	2(2.8)	7(9.9)	5.0(2.0，7.0)
腹腔镜亚组-2	4	0(0)	0(0)	0(0)	0(0)	－^a
χ²值		4.20	0.34	1.72	6.75	－^a
P值		0.312	0.952	0.632	0.068	－^a

表3 开胸组-2、开腹组-2、胸腔镜组-2、腹腔镜组-2 CDH患儿术后肺部相关并发症发生率及CDH复发率比较

组别	例数	肺不张[例数(%)]	气胸[例数(%)]	乳糜胸[例数(%)]	CDH复发[例数(%)]	CDH复发时间间隔[M(Q₁，Q₃)]
开胸亚组-2	6	0(0)	0(0)	0(0)	0(0)	－^a
开腹亚组-2	58	2(3.45)	4(6.9)	1(1.7)	0(0)	－^a
胸腔镜亚组-2	71	0(0)	5(7.0)	2(2.8)	7(9.9)	5.0(2.0，7.0)
腹腔镜亚组-2	4	0(0)	0(0)	0(0)	0(0)	－^a
χ²值		4.20	0.34	1.72	6.75	－^a
P值		0.312	0.952	0.632	0.068	－^a

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