Epidemiology and Regional Variation in Additional Surgical Interventions for Children With Congenital Diaphragmatic Hernia: A Multi-institutional Analysis.

Abstract

To determine practice variation in the surgical management of comorbidities in pediatric patients with congenital diaphragmatic hernia (CDH). A higher percentage of patients with CDH are surviving to discharge, accompanied by an increase in morbidity requiring surgical interventions, such as tracheostomy and gastrostomy tube insertion. The frequency, trends, and regional variations in operative management of these comorbidities in this population are unclear. Neonates who underwent CDH repair between 2012 and 2022 in the United States Pediatric Health Information System database were identified. Multivariable regression identified predictive factors for additional surgical morbidity after CDH repair, defined by an additional surgical intervention during the index hospitalization or within 1 year after discharge. To narrow the spectrum of severity of the disease, only patients with an intensive care unit admission on index hospitalization were included. Secondary analysis compared the frequency of operations and hospital resource utilization by region. A total of 4003 patients underwent CDH repair and were discharged from their index hospitalization. Of the total, 1939 (48%) underwent at least one additional surgical procedure after the index CDH repair. Most performed surgeries were gastrostomy tube (28%), fundoplication (13%), and tracheostomy (5%). Covariates associated with additional surgical morbidity included: prematurity [odds ratio (OR): 1.38; 95% CI: 1.20-1.59], cardiac comorbidity (OR: 1.31; 95% CI: 1.14-1.49), and chromosomal anomalies (OR: 1.76, 95% CI: 1.30-2.40). Northeast (OR: 2.43; 95% CI: 1.42-3.52), Midwest (OR: 2.11; 95% CI: 1.45-3.07), and South (OR: 1.45, 95% CI: 1.02-2.12) regions were associated with additional surgical morbidity. Patients who required additional surgical procedures had longer initial inpatient length of stays (71 vs 31 days) and higher associated costs ($357,000 vs $161,000). Surgical morbidity exists in patients with CDH after initial CDH repair. Counseling families on these outcomes is important in establishing expectations for management. Establishing guidelines for optimal surgical management will require continued reporting from multi-institutional studies.