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There is little consensus on optimal management for congenital diaphragmatic hernia extracorporeal membrane oxygenation (CDH ECMO) patients. Meaningful comparisons of the various approaches have been limited due to the low number of cases in institutions. In addition, the multidisciplinary reliance and rigid institutional framework of ECMO serve to further limit exposure to alternative practices. The goal of this study is to survey the international pediatric surgery community to describe the current practice trends.A survey was electronically distributed to the international pediatric surgical community. The results were evaluated using statistical analysis.A total of 123 pediatric surgeons completed the survey, of whom 89% work at institutions offering both venoatrial (VA) and venovenous (VV) ECMO. Although 69% perform VA ECMO for CDH, only 46% felt VA was the "optimal method." Among VV proponents, 21% believe the rate of VV to VA conversion to be5% and 16% believe it to be30% compared with 0% and 40% in VA proponents. Distribution of timing of repair: 46% post-ECMO repair, 22% early ECMO repair, 15% whenever stabilized on ECMO, and 14% late ECMO repair. Sixty-four percent (71/111) would perform an ECMO CDH repair in the unweanable patient and 27% (30/111) report successful decannulation after repair of a patient who was unweanable on ECMO for 2 weeks. Ninety-two percent do not perform exit-to-ECMO.There are significant practice variations in the management of CDH ECMO. Majority of pediatric surgeons perform VA ECMO in CDH patients; however, a significant percentage of those believe VV to be more optimal. This discrepancy is not accounted for by the VA-only institutions. Although post-ECMO CDH repair is the most common approach, the majority would perform a repair "on ECMO" if the patient was unweanable. In addition, although many pediatric surgeons believe the "last ditch repair" for the unweanable patient to be futile, 27% have reported success. Exit-to-ECMO for CDH remains a minority practice.

We previously developed a porcine model of long gap pure esophageal atresia (EA) to aid in the creation of novel devices and techniques for treatment of EA. Shortcomings of the model included difficulty decompressing the proximal esophageal pouch (leading to recurrent aspiration) and a requirement for gastrostomy tube (G-tube) feeds. Therefore, we sought to create a porcine model with a bifurcated esophagus wherein one portion of the esophageal lumen retained patency and the other part mimicked EA.After G-tube placement, thoracotomy was performed with subsequent partial stapled transection of the esophagus in a transverse manner, followed by longitudinal, partial stapled transection of the esophagus proximally and distally. Magnets were placed in the esophageal pouches.Proximal and distal esophageal pouches were created while preserving a parallel, narrower segment of continuous esophagus. G-tube feeds were used initially, but the animal ultimately tolerated full nutrition by mouth. The magnets successfully restored esophageal continuity. The animal regained much of the initial weight lost and survived to planned euthanasia. Necropsy revealed anastomosis formation without evidence of leak.A bifurcated porcine esophagus model was successfully devised, simulating EA while allowing the animal to receive oral feeds and clear oral secretions. This model is anticipated to promote animal well-being and ease of care during future investigations, as well as a platform for the safe development of new therapies for EA.

Although recurrence remains one of the most feared complications following congenital diaphragmatic hernia (CDH) repair, there are minimal data on the optimal surgical approach to these complex situations. The purpose of this study was to survey the international pediatric surgery community to ascertain practice patterns for both minimally invasive (MIS) and open approaches for recurrent CDH.A survey was e-mailed to members of an online community of pediatric surgeons. The questionnaire elicited surgeons' clinical experience, the continent in which they practice, and their surgical approach (laparotomy, thoracotomy, laparoscopy, or thoracoscopy) to five clinical cases, including initial and recurrent Bochdalek hernias. Fisher's exact test and chi-square test were used for statistical analysis.Two-hundred eighty pediatric surgeons responded to the survey. In total, 52.1% of surgeons chose an MIS approach for an initial repair of left CDH with the younger surgeons more likely to use an MIS approach. For the recurrence scenarios, 42.5%-55.5% of these surgeons would attempt an MIS repair after a recurrence. Specifically, thoracoscopy was favored over laparoscopy following both prior laparotomy (30.0% versus 7.5%) and prior right thoracoscopy (26.4% versus 10.0%), less favored following thoracotomy (9.3% versus 18.9%), and relatively similar proportions following prior left thoracoscopy (17.5% versus 16.4%). Laparotomy was the preferred open approach both for initial presentation and all recurrence scenarios. Among surgeons who would treat initial CDH with an open procedure, between 10.4% and 17.9% would switch to an MIS approach, most commonly after prior failed laparotomy.Approximately half surgeons who approach initial left CDH in an MIS manner would attempt an MIS approach for recurrence. The tendency to approach CDH recurrence from the opposite body cavity as the initial repair clearly impacted the surgical approach. This was particularly pronounced for MIS repairs, whereas for open approach, laparotomy remained, by far, the most popular in all scenarios.

While adult bowel anastomoses are typically performed with staplers, neonatal small bowel anastomoses have traditionally been performed in a hand-sewn manner due to the large size of surgical staplers. The purpose of this study was to compare stapled anastomosis using a newly available, 5-mm laparoscopic stapler to a hand-sewn anastomosis in an open animal model.Twenty anastomoses were performed by two general surgery residents (10 stapled and 10 hand-sewn) in an adult New Zealand white rabbit. The small bowel was divided with a scalpel. Surgical technique was alternated between single-layer hand-sewn and stapled anastomoses. Each anastomosis was resected for ex vivo testing. Measurements collected were outer diameter of the bowel before division, time to perform the anastomosis, anastomosis inner diameter (ID), and leak test. IDs were measured by cutting the anastomosis in cross-section, taking a photograph, and measuring the diameter by computer software. In addition, the surgeons qualitatively evaluated the anastomoses for hemostasis and overall quality. Statistical significance was determined using the Student's t-test.There were statistically significant differences between stapled and hand-sewn anastomosis, respectively, for average operative time (4 minutes 2 seconds versus 16 minutes 6 seconds, P .01) and anastomosis ID (8.2 versus 3.7 mm, P .01). There was one leak in the stapled group, which occurred at overlapping staple lines closing the enterotomy. A second stapled anastomosis required suture reinforcement, again at the enterotomy closure, due to operator error. Starting diameter, leak rate, hemostasis, and anastomosis quality were not statistically significant.In a neonatal open animal model, a 5-mm stapled anastomosis is an acceptable alternative to hand-sewn small bowel anastomosis. The stapler is faster and creates a larger diameter anastomosis, however, there was one leak when closing the enterotomy in the stapled group and overlapping staple lines should be avoided.