Association between surgical repair timing and mortality in neonates with congenital diaphragmatic hernia: a systematic review and meta-analysis

Congenital diaphragmatic hernia (CDH) is a rare congeni tal anomaly whose management involves a complex interplay between medical and surgical treatments.Sta bilization prior to surgery is vital.However, the optimal timing of surgical repair and its relationship with mor tality remain unknown.Hence, this metaanalysis aimed to evaluate the association between repair timing and mortality in neonates with CDH.A systematic review and metaanalysis were conducted in accordance with PRISMA (Preferred Reporting Items for Systematic re views and Metaanalyses) guidelines.The PubMed, NCBI, Cochrane CENTRAL, Google Scholar, CINHAL, Ovid, Scopus, Web of Science, and Epistemonikos databases were searched for articles published through April 2026.Forty studies, including 2 randomized controlled trials, 3 prospective observational studies, and 35 retrospective studies, were included in the metaanalysis.Newborns operated on within 24 hours of life had significantly higher mortality (relative risk [RR], 2.54; 95% confidence interval [CI], 1.76-3.66;P<0.001) than those operated on at or after 24 hours.This association persisted in a subgroup analysis restricted to contemporary studies published since 2000 (RR, 2.57; 95% CI, 1.00-6.62;P<0.001).Additional subgroup analyses demonstrated significantly higher mortality in neonates who underwent repair within 24 hours than in those who underwent repair at 24-48 hours (P<0.001),whereas mortality did not differ significantly between those who underwent repair at 24-48 hours and those who underwent repair after 48 hours (P=0.65).Surgical timing did not significantly alter mortality in a specific subset of newborns requiring ECMO support.In conclusion, a brief period of stabilization of at least 24 hours significantly improved survival among neonates with CDH, whereas delaying surgical repair beyond 48 hours conferred no additional survival benefits.