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Background: Higher recurrence rates have been reported for thoracoscopic repair (TR) of neonatal congenital diaphragmatic hernia (CDH) compared to open repair. Our centre initiated changes in surgical management following a quality review in order to improve outcome., Methods: A retrospective review of TR patients from 2000 to 2011 at a single institution was performed. A review was done in 2007, and changes were implemented to decrease recurrence rates. These included use of pledgets, an extracorporeal corner stitch, liberal prosthetic patch use, lower insufflation pressures, and TR was limited to two experienced surgeons. Outcome data before and after this quality improvement process were compared. Non-TR patients from the same time period served as controls. Data are quoted as median (range) and non-parametric tests used to compare. P<0.05 was regarded as significant., Results: There were 23 neonatal TR patients with median follow-up of 3.6 (range 0.4-7) years. Median age at repair was 2 (range 0-21) days. There were 5 patch repairs (22%), all after 2008. There were 9 recurrences (39%) at a median time of 162 days after TR, compared to 13 (10%) recurrences in the control cohort. For primary TR, there was a trend towards a decreased recurrence rate from 50% prior to 2008 to 25% after 2008 (P=0.26)., Conclusions: Systematic quality review was modestly effective in decreasing the recurrence rate for neonatal TR, but further outcome data are required., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Introduction: To date, there is no comparative study of thoracoscopic repair (TR) vs conventional open repair (COR) for tracheoesophageal fistula (TEF). The aim of the study was to compare the 2 techniques in neonates with TEF., Methods: A multi-institutional case-control study of cases of TEF was undertaken. The minimum follow-up was 6 months. Patients were considered for TR based on surgeon's preference. Cases were frequency matched on a 1:1 ratio based on gestational age and weight. Outcomes of interest were operative time, postoperative leaks, and postoperative stricture development. Statistical analysis using univariate analysis was performed., Results: Twenty-three neonates underwent TR. There were no differences between TR and COR groups with regard to weight and gestational age. The distribution of associated anomalies was similar in both groups. The mean operative time was 149.4 and 179 minutes in TR and COR, respectively (P = .18). Three patients were converted to COR. There were 4 leaks in TR and 3 in COR (P = .728). Inversely, 2 patients in the TR group developed a stricture necessitating dilation as compared with 4 patients in the COR group (P = .414)., Conclusion: Thoracoscopic repair of TEF is safe and comparable with conventional open repair.

Technically expedient repair of CDH defects is desirable. With increasing trend toward thoracoscopic repair, herein we examine physiologic predictors for the need for patch closure (PC) versus primary closure. All neonates who underwent surgical repair of CDH defects in a geographically defined region between 1992 and 2002 were included (n = 210). Two groups of patients were compared, primary repair (PR) versus PC. The 25th quartile was used as a cut off point for continuous variables. Univariate and multivariate logistic regression were performed. One hundred and fifty neonates underwent open PR (71.43%) versus 28.57% had PC. On univariate analyses the following variables were significantly associated with the need for PC: prenatal diagnosis, birth weight <2.7 kg, gestational age <37 weeks, APGAR at 5 min <6, immediate postnatal PCO(2) >34, Immediate oxygen saturation <93%, use of Nitric oxide and the need for high frequency oscillation (HFO). On multivariate analyses, only a PCO(2) >34 and the need for HFO were significantly associated with PC. Neonates with an initial PCO(2) >34 or need HFO pre-operatively should be excluded from attempts to repair the CDH thoracoscopically based on their higher potential need for PC with its entailed technical difficulty and increased operative time. [ABSTRACT FROM AUTHOR]

Abstract: Background/Purpose: Tube thoracostomy is a standard method of treating pediatric parapneumonic collections. Despite recent work denoting thoracoscopy as a superior method of treatment, few studies have looked at factors predictive of tube thoracostomy failure. We reviewed parapneumonic collections initially treated with tube thoracostomy to identify such factors. Methods: Nontuberculous parapneumonic collections treated initially with tube thoracostomy over a 10-year period were reviewed. A “failed primary tube thoracostomy” was defined as the presence of worsening clinicoradiological signs requiring a further chest procedure (ie, thoracoscopy, thoracotomy, or second thoracostomy). Results: Fifty-eight patients were identified. Forty-three percent failed primary tube thoracostomy. Within group F (failure group), 32% of patients had a concomitant medical condition (P < .001). Sixty percent of group F patients had duration of symptoms for more than 1 week compared with only 24% of group S (successful group) (P < .001). Conclusions: Our results suggest that primary treatment of parapneumonic collections with tube thoracostomy is likely to be unsuccessful in patients who are symptomatic for more than a week or who have a concomitant medical condition. A more aggressive primary surgical intervention is suggested for this group. [ABSTRACT FROM AUTHOR]