Impact of fetal intervention on postnatal management of congenital diaphragmatic hernia

We report our experience in the postnatal management of congenital diaphragmatic hernia (CDH) after fetal endoluminal balloon tracheal occlusion (FETO). Material and Methods: Out of 19 CDH fetuses diagnosed since December 2005, 13 had a lung-to-head ratio (LHR) < 1.1 (0.86 ± 0.11) and underwent FETO at a mean gestational age (GA) of 27.9 weeks. The balloon was removed in 3 cases through puncture in EXIT (ex utero intrapartum treatment); there were 3 trans-utero punctures, 3 fetoscopies and 3 balloons deflated spontaneously. One patient died from bleeding during the FETO procedure. Six patients were not subjected to FETO: 3 had a LHR ≥ 1.4 and 3 did not come to consultation prenatally. Results: Twelve babies were born after FETO at 34.9 ± 1.7 weeks GA; 3 died before surgery from refractory hypoxia. Six needed high frequency oscillatory ventilation (HFOV), and inhaled nitric oxide (NO), one progressing to extracorporeal membrane oxygenation (ECMO), and 3 needed conventional ventilation. CDH was repaired in 9: 2 with direct sutures and 7 with prosthetic patches. Extubation was at median of 5 days (range: 2-40), discharge was at 30.4 ± 16.4 days. Early complications were 1 reherniation and 2 intestinal occlusions. Two patients died after CDH repair: the ECMO case at 15 days, and an infant discharged on oxygen at home, at age 4 months. Of the non-FETO patients, four needed HFOV and NO. CDH repair was performed in 5: 3 had direct repair and 2 had prosthetic patches. Extubation was at 13.4 ± 12.9 days and discharge was at 43.8 ± 26.5 days. One patient died before surgery from severe cardiac malformation. Early complications were 1 reherniation and 1 hiatus hernia. Late complication was 1 reherniation at 5 months of life. There was no postoperative mortality. One patient needs oxygen at home. Conclusion: CDH patients with a poor prognosis undergoing FETO had postnatal outcomes similar to non-prenatally studied cases and good prognosis cases.