P2D321: Evaluating the Epidemiology and Regional Variations in Additional Surgical Interventions for Children with Congenital Diaphragmatic Hernia: A Multi-institutional Analysis

Background: Congenital diaphragmatic hernia (CDH) is a neonatal condition that is associated with multisystem co-morbidities and requires multidisciplinary care, including surgical procedures, in addition to the index CDH repair. This study aims to describe multi-center epidemiology and frequency of additional surgical interventions for concomitant surgical diagnoses in neonates with CDH.

Methods: We conducted a retrospective cohort study of children with CDH who underwent additional general surgical procedures using the Pediatric Health Information System (PHIS) database. Patients aged < 31 days with a primary repair of CDH were identified by querying ICD-9 and ICD-10 codes during an index encounter between September 2011 and September 2019. From this initial cohort, patients were included in the final study population if additional surgical interventions were completed either during the index encounter or within 1 year following discharge. Frequencies of the most common additional surgeries were compared by census region (West, South, Midwest, East) using chi-squared analysis with correction.

Results: We identified 2233 patients who had a neonatal CDH repair between September 2011 and September 2019. The cohort was 60.4% male with a mean gestational age of 37.5 weeks. 1047/2233 patients (47%) had at least one additional surgical procedure during their index hospitalization or within 1 year from discharge. The five most performed additional surgical procedures were gastrostomy tube insertion (25%), circumcision (23%), Nissen fundoplication (13%), abdominal wall defect repair (6%), and tracheostomy (6%) (figure 1).

Of the 2233 index patients, 394 (18%) lived in the West, 812 (36%) in the South, 617 (28%) in the Midwest, and 410 (18%) in the East as defined by PHIS census regions. Additional surgical procedures were performed in 33% of patients in the West, 46% in the South, 53% in the Midwest, and 53% in the East. Placement of gastrostomy tube to facilitate artificial feeding was consistent across regions and performed in 25% of the cohort. We observed significant regional differences (p < 0.05) in the frequency of abdominal wall defect repair, circumcision, and Nissen fundoplication (Figure 2).

Conclusion: This data is the first of its kind to examine the frequency of additional general surgical operations in patients with CDH repair on a national scale. In addition to their initial CDH repair, patients with CDH often undergo multiple other surgical procedures in the first year of life, contributing to their clinical picture of disease severity and resource utilization. CDH is a condition that results in multisystem co-morbidities, including feeding difficulties and chronic respiratory insufficiency, which is reflected in the rates of gastrostomy tube, fundoplication, and tracheostomy procedures. The impact and benefit of these additional surgical procedures on long-term outcomes needs to be examined.