Liver position in fetal congenital diaphragmatic hernia retains a prognostic value in the era of lung-protective strategy

Yoshihiro Kitano, Satoshi Nakagawa, Tatsuo Kuroda, Toshiro Honna, Yushi Itoh, Tomoo Nakamura, Nobuyuki Morikawa, Naoki Shimizu, Kyoko Kashima, Satoshi Hayashi, Haruhiko Sago

Research output: Contribution to journalArticlepeer-review

90 Citations (Scopus)


Background/Purpose: The aims of this study were to analyze the outcomes of fetuses with congenital diaphragmatic hernia (CDH) treated by a lung-protective strategy using high-frequency oscillatory ventilation (HFOV) in a single center with a perinatology service and extracorporeal membrane oxygenation (ECMO) capability and to define the natural history of CDH in the era of lung-protective ventilation. Methods: A retrospective chart review of 30 neonates with CDH seen between April 2002 and October 2004 was conducted. All fetuses with a prenatal diagnosis were evaluated by fetal magnetic resonance imaging to define the liver position, and those with a significant volume of the liver in the chest were regarded as liver-up. Patients were managed by a lung-protective strategy using pressure-limited (maximum mean airway pressure [MAP], 18 cm H2O) HFOV. The patients were initially placed on HFOV with a fraction of inspired oxygen (Fio2) of 1.0 and a MAP of 12 cm H2O. Hypercapnea and preductal saturation as low as 85% were accepted. Inhaled nitric oxide and ECMO were introduced when the baby could not be oxygenated with a MAP of 18 cm H2O. Results: Twenty-six neonates (22 inborns with prenatal diagnosis and 4 outborns) were treated with this protocol. Four cases were not treated or died in utero because of severe associated anomalies. Thirteen of the 14 liver-down cases survived without ECMO and were discharged home (93% survival). On the contrary, 4 of 12 liver-up cases survived (33% survival). ECMO was required for initial stabilization in 5 cases with 1 survivor. Conclusions: Liver-down CDH babies have a good chance for survival without ECMO by a planned delivery and the lung-protective strategy using HFOV. Liver herniation demonstrated by prenatal magnetic resonance imaging retains a poor prognostic value even with this approach.

Original languageEnglish
Pages (from-to)1827-1832
Number of pages6
JournalJournal of Pediatric Surgery
Issue number12
Publication statusPublished - 2005 Dec
Externally publishedYes


  • Congenital diaphragmatic hernia
  • Fetus
  • Gentle ventilation
  • Lung-protective strategy

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Surgery


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