Postnatal care setting and survival after fetoscopic tracheal occlusion for severe congenital diaphragmatic hernia: A systematic review and meta-analysis

Background: Fetoscopic endoluminal tracheal occlusion (FETO) was recently shown to improve postna-tal survival in a multicenter, randomized controlled trial of infants with severe congenital diaphragmatic hernia (CDH). However, the external validity of this study remains unclear given a lack of standardiza-tion in postnatal management approaches. The purpose of this study was to evaluate the impact of an integrated prenatal and postnatal care setting on survival outcomes in severe CDH after FETO.Study design: A systematic review, meta-analysis, and individual participant analysis of FETO outcomes in severe CDH were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The primary outcome was survival to discharge. Subgroup analyses of patients managed in integrated versus nonintegrated settings were performed to identify predictors of outcome.Results: The review generated five studies ( n = 192) for the meta-analysis of FETO versus expectant pre-natal management. These data revealed a significant survival benefit after FETO that was restricted to an integrated setting (OR 2.97, 95% Confidence Interval 1.69-4.26). There were nine studies ( n = 150) for the individual participant analysis, which showed that FETO managed in an integrated setting had sig-nificantly increased survival rates when compared to FETO treated in a nonintegrated setting (70.7% vs. 45.7%, p = 0.003). Multi-level logistic regression identified increased availability of extracorporeal mem-brane oxygenation (ECMO) as the strongest determinant of postnatal survival (OR = 18.8, p = 0.049).Conclusion: This systematic review shows that institutional integration of prenatal and postnatal care is associated with the highest overall survival in children with severe CDH. These data highlight the importance of a standardized, multidisciplinary approach, including access to ECMO, as a critical postnatal component in optimizing FETO outcomes in CDH.(c) 2022 Elsevier Inc. All rights reserved.

Automated summary

This study evaluated the impact of an integrated prenatal and postnatal care setting on survival outcomes in severe congenital diaphragmatic hernia (CDH) after fetoscopic endoluminal tracheal occlusion (FETO). The results showed that institutional integration of prenatal and postnatal care is associated with the highest overall survival in children with severe CDH.