Clinical profile and surgical outcome of patients with congenital diaphragamatic hernia - A Prospective study.

INTRODUCTION : The migration of abdominal viscera through a defect in the diaphragm into the chest results in a diaphragmatic hernia. The congenital form exists as three distinct anatomical types: (i) Herniation through the posterolateral foramen of Bochdalek (ii) Herniation through the substernal foramen of Morgagni ; and (iii) Herniation through the esophageal hiatus. The term 'congenital diaphragmatic hernia' (CDH) refers to the herniation of abdominal viscera through the posterolateral foramen of Bochdalek. Congenital diaphragmatic hernia remains one of the most difficult challenges in the paediatric surgery. The surgical aspects are relatively straight forward but the medical management of the associated pulmonary hypoplasia and pulmonary hypertension still eludes us. With each passing decade, new approaches to the medical and surgical management of this entity have been advocated but have not stood the test of time. The multitude of treatment options for CDH reflects our limited understanding of the pathophysiology and explains the relatively fixed mortality rate seen. AIMS AND OBJECTIVES : To find out the incidence of congenital Diaphragmatic Hernia in Government Rajaji Hospital, Madurai. To evaluate the clinical presentation. To find out the incidence of Congenital Diaphragmatic Hernia (CDH) diagnosed antenatally. Total numbers treated and follow up for 1 year. MATERIAL AND METHODS : All cases of congenital diaphragmatic hernia admitted in Govt. Rajaji Hospital, Madurai were studied. All cases were given adequate preoperative preparation and those surgically treated were followed up for a period of 1 year and their outcome was noted. Those cases which were not eligible for surgical treatment were analyzed and their outcome was noted. CONCLUSION : In our institution when newborn were admitted with a prenatal diagnosis of Congenital Diaphragmatic Hernia (CDH)or when CDH babies became symptomatic after birth a careful protocol of respiratory assistance was followed. Immediate postnatal intubation was done; mask ventilation was avoided; whenever ventilators were available smallvolume, high frequency and reduced peak pressure mechanical ventilation was started and continued till stabilization of the baby for surgical repair. Pre-ductal and post-ductal percutaneous oxygen saturation measurements helped in the assessment of fitness of the child for surgical intervention. Inotropic drugs were used as necessary and cardiac function and heart anomalies were carefully evaluated. The goal of the preoperative treatments was “stabilization” of the child - PaO2 > 40 mmHg and PaCO2 < 60 mmHg, good myocardial function and adequate renal clearance with reduced or withdrawn inotropic drugs. Surgical repair of CDH was undertaken only after cardiorespiratory functions were stabilized. A policy of “delayed” surgery coupled with gentle ventilation and was followed. Congenital Diaphragmatic Hernia (CDH) still continues to show a significant mortality in our institution. This condition continues to remain a significant challenge for obstetricians, pediatric surgeons, neonatologists, and pediatricintensivists