Surgical approaches for neonatal congenital diaphragmatic hernia: a systematic review and meta-analysis

Purpose The optimal surgical approach for neonatal congenital diaphragmatic hernia (CDH) remains unclear. We conducted a systematic review and meta-analysis of the effectiveness of endoscopic surgery (ES) for neonatal CDH. Methods A systematic literature search was conducted using MEDLINE and the Cochrane Library. Studies that compared surgical approaches for neonatal CDH were selected. Mortality and recurrence of herniation were analyzed as primary endpoints. Each study was evaluated following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Results Eight observational studies comparing ES and open surgery (OS) met the criteria. As compared with the OS group, the ES group showed both a significantly lower mortality rate [risk ratio (RR) 0.18, 95 % confidence interval (CI) 0.09–0.38, p < 0.0001] and a significantly higher recurrence rate (RR 3.10, 95 % CI 1.95–4.88, p < 0.00001). However, serious selection bias was seen in seven of the eight studies—because the indication of ES had been determined intentionally, the ES groups may have included less severe cases. Conclusion Although the evidence was insufficient, ES was clearly associated with more recurrence than was OS. Therefore, ES should not be the routine treatment for every neonate. It is crucially important to select suitable cases for ES.