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Management of congenital diaphragmatic hernia

Bösenberg, Adrian Ta; Brown, Robin Ab

Current Opinion in Anaesthesiology: June 2008 - Volume 21 - Issue 3 - p 323–331
doi: 10.1097/ACO.0b013e3282f9e214
Pediatric anesthesia: Edited by Bernard J. Dalens

Purpose of review To evaluate the impact of recent research on the management of congenital diaphragmatic hernia in the light of new theories on embryological development, earlier antenatal diagnosis, fetal and postnatal interventions together with advances in perinatal intensive care.

Recent findings The year 2007 provided in excess of 200 publications that address various aspects of congenital diaphragmatic hernia. The genetic basis and the causes of pulmonary hypoplasia at the molecular level are slowly being unravelled. Fetal MRI of lung volume, lung–head ratio, liver position and size of diaphragmatic defect have all been evaluated as early predictors of outcome and with a view to prenatal counselling. The impact of fetal interventions such as fetal endoluminal tracheal occlusion, the mode of delivery, the surgical techniques and agents for treating pulmonary hypertension were evaluated. The influence of associated anomalies and therapeutic interventions on the outcome and quality of life of survivors continue to be appraised.

Summary Deferred surgery after stabilization with gentle ventilation and reversal of pulmonary hypertension remain the cornerstones of management. Optimal presurgery and postsurgery ventilatory settings remain unproven. Continued improvement in neonatal intensive care raises the bar against which any intervention such as fetal endoluminal tracheal occlusion and extracorporeal membrane oxygenation will be judged.

aDepartment of Anaesthesia, Faculty of Health Sciences, South Africa

bDepartment of Paediatric Surgery, University of Cape Town, Red Cross Children's Hospital, Cape Town, South Africa

Correspondence to Adrian T. Bösenberg MBChB, FFA (SA), Department Anaesthesia, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa Tel: +27 21 829274343; e-mail: Adrian.Bosenberg@uct.ac.za

© 2008 Lippincott Williams & Wilkins, Inc.