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Hypercapnia and Acidosis During Open and Thoracoscopic Repair of Congenital Diaphragmatic Hernia and Esophageal Atresia: Results of a Pilot Randomized Controlled Trial

Bishay, Mark MB, ChB, MRCS*; Giacomello, Luca MD*; Retrosi, Giuseppe MD*; Thyoka, Mandela MB, BS*; Garriboli, Massimo MD*; Brierley, Joe FRCPCH*; Harding, Louise FRCA; Scuplak, Stephen FRCA; Cross, Kate M. FRACS; Curry, Joe I. FRCS; Kiely, Edward M. FRCS; De Coppi, Paolo MD, PhD*; Eaton, Simon PhD; Pierro, Agostino MD, FRCS*

doi: 10.1097/SLA.0b013e31828fab55
Randomized Controlled Trials

Objective: We aimed to evaluate the effect of thoracoscopy in neonates on intraoperative arterial blood gases, compared with open surgery.

Background: Congenital diaphragmatic hernia (CDH) and esophageal atresia with tracheoesophageal fistula (EA/TEF) can be repaired thoracoscopically, but this may cause hypercapnia and acidosis, which are potentially harmful.

Methods: This was a pilot randomized controlled trial. The target number of 20 neonates (weight > 1.6 kg) were randomized to either open (5 CDH, 5 EA/TEF) or thoracoscopic (5 CDH, 5 EA/TEF) repair. Arterial blood gases were measured every 30 minutes intraoperatively, and compared by multilevel modeling, presented as mean and difference (95% confidence interval) from these predictions.

Results: Overall, the intraoperative PaCO2 was 61 mm Hg in open and 83 mm Hg [difference 22 mm Hg (2 to 42); P = 0.036] in thoracoscopy and the pH was 7.24 in open and 7.13 [difference −0.11 (−0.20 to −0.01); P = 0.025] in thoracoscopy. The duration of hypercapnia and acidosis was longer in thoracoscopy compared with that in open. For patients with CDH, thoracoscopy was associated with a significant increase in intraoperative hypercapnia [open 68 mm Hg; thoracoscopy 96 mm Hg; difference 28 mm Hg (8 to 48); P = 0.008] and severe acidosis [open 7.21; thoracoscopy 7.08; difference −0.13 (−0.24 to −0.02); P = 0.018]. No significant difference in PaCO2, pH, or PaO2 was observed in patients undergoing thoracoscopic repair of EA/TEF.

Conclusions: This pilot randomized controlled trial shows that thoracoscopic repair of CDH is associated with prolonged and severe intraoperative hypercapnia and acidosis, compared with open surgery. These findings do not support the use of thoracoscopy with CO2 insufflation and conventional ventilation for the repair of CDH, calling into question the safety of this practice. The effect of thoracoscopy on blood gases during repair of EA/TEF in neonates requires further evaluation. (ClinicalTrials.gov Identifier: NCT01467245)

This pilot randomized controlled trial shows that neonatal thoracoscopy, particularly thoracoscopic repair of congenital diaphragmatic hernia, is associated with prolonged and severe intraoperative hypercapnia and acidosis, compared with open surgery. This calls into question the safety of this practice.

*UCL Institute of Child Health and Great Ormond Street Hospital for Children, London, United Kingdom

Great Ormond Street Hospital for Children, London, United Kingdom

UCL Institute of Child Health, London, United Kingdom.

Reprints: Agostino Pierro MD, FRCS, FAAP Division of General and Thoracic Surgery, Hospital for Sick Children, Toronto, Canada. E-mail: agostino.pierro@sickkids.ca/catherine.day@sickkids.ca.

The authors are grateful to the Mittal Paediatric Surgery Research Fund for supporting this work. SE and PDC are supported by the Great Ormond Street Hospital Children's Charity.

Disclosure: No sponsors played any role in study design; in the collection, analysis, or interpretation of the data; in the writing of the report; or in the decision to submit the paper for publication. The authors declare no conflicts of interest.

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© 2013 by Lippincott Williams & Wilkins.