Historical evolution of thoracoscopic repair for congenital diaphragmatic hernia: an era-based systematic review and meta-analysis.

BACKGROUND: Thoracoscopic repair for congenital diaphragmatic hernia (CDH) has increasingly gained acceptance; however, earlier studies demonstrated higher recurrence rates than open repair. Because thoracoscopic CDH repair has evolved substantially over time, historical outcomes may not reflect contemporary practice. We evaluated temporal changes in outcomes after thoracoscopic repair through an era-based systematic review and meta-analysis. METHODS: Embase, MEDLINE/PubMed, Web of Science, and Cochrane Library databases were systematically searched for studies comparing thoracoscopic and open CDH repair. Random-effects meta-analyses, era-based subgroup analyses (pre-2015 vs post-2015), meta-regression analyses, and temporal trend analyses of conversion rates were performed. RESULTS: Twenty-seven studies involving 9,396 patients were included. Overall pooled analysis demonstrated significantly higher recurrence after thoracoscopic repair than open repair (RR 2.43, 95% CI 1.88-3.14, p < 0.001). However, recurrence rates became more comparable in post-2015 studies (RR 1.43, 95% CI 0.81-2.54). Meta-regression demonstrated a significant temporal reduction in recurrence disadvantage over time (p = 0.0059). Mortality was lower in the thoracoscopic group, although this finding likely reflected selection bias favoring physiologically stable patients. CONCLUSIONS: Although thoracoscopic repair remains associated with higher overall recurrence rates, its relative recurrence disadvantage has decreased substantially over time. Contemporary thoracoscopic repair may achieve recurrence outcomes approaching those of open repair in carefully selected patients treated at experienced centers.