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Invited Commentary |

Improved Survival in Congenital Diaphragmatic Hernia With Evolving Therapeutic Strategies—Invited Commentary

Robert E. Cilley, MD
Arch Surg. 1998;133(5):503. doi:10.1001/archsurg.133.5.503.
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Weber and colleagues have presented their extensive institutional experience in the treatment of infants with CDH at the Cardinal Glennon Children's Hospital. There is much to be gleaned from this report on more than 200 patients that spans 27 years. Carefully considered historical reviews, such as this one, have much to offer us. The institutional experience reported here is compatible with trends in other children's hospitals caring for infants with CDH.

The implications of these observations leave a number of unanswered questions. These include: (1) Should CDH repair ever be performed at institutions where ECMO is not available? (2) Should all women known to be carrying a fetus with CDH plan to deliver in such centers? (3) Is it ever appropriate to operate immediately after birth on an infant with CDH? (4) May repair be delayed for longer periods than the 2 to 5 days that the authors suggest? (5) In high-risk patients who require immediate ECMO support, must CDH repair always be performed while the patient is receiving ECMO as the authors have practiced, or may CDH repair be delayed until ECMO treatment has been completed? (6) Are there any infants with CDH who are "too sick" to survive and for whom no therapy should be offered? (7) With reports of improved survival rates using conventional postnatal therapy, what, if any, is the role of fetal therapy in the treatment of CDH?

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