Research Article
Postoperative Outcome of Thoracotomy in ChildrenPostoperative Outcome of Thoracotomy in Children
Türkyılmaz Z*, Sönmez K and Karabulut R
Department of Pediatric Surgery, Gazi Medical Faculty, Turkey
*Corresponding author: Zafer Türkyılmaz, Department of Pediatric Surgery, Gazi Medical Faculty, Besevler, Ankara, Kızlarpınarı cad. No:31/10 06300 Keçiören Ankara, Türkiye
Published: 26 Aug, 2016
Cite this article as: Türkyılmaz Z, Sönmez K, Karabulut R. Postoperative Outcome of Thoracotomy in Children. Clin Surg. 2016; 1: 1086.
Abstract
Aim: This study aimed to examining the complications of thoracotomy and the factors affecting these complications in children.
Materials and Methods: The records of the patients who had undergone thoracotomies performed
in our clinic between 1998 and 2015 were retrospectively evaluated for age, gender, operation
duration, additional anomaly, diagnosis, type of wound and incision, complications, type of
analgesia, pulmonary lesions, nutritional status of the patients, and removal time of thoracic
tube. Kruskal-Wallis and Pearson Chi-square tests were used in statistical analyses. P <0.05 was
considered significant.
Results: 103 thoracotomies were performed. The gender distribution was 63% males and 37%
females, with a mean age of 37.1 months (1 day-16 years). The cases were esophagus atresia (n=40),
thoracic hydatid cyst (n=21) and other thoracic lesions (n=14). The mean operation duration was
115 minutes (40-240 min.). Thirty-two wounds were clean; 64 were clean-contaminated; and 7 were
contaminated. The main complications were atelectasis and wound infection. The postoperative
analgesic applications were intravenous (iv) dipyrone in 42 cases, local prilocaine in 3 cases, local
bupivacaine in 6 cases, epidural catheterization in 20 cases, local prilocaine - iv dipyrone in 17 cases,
and local bupivacaine -iv dipyrone in 15 cases.
Conclusion: After pediatric thoracotomies, the incidence of surgical infections is 16% and the
pulmonary functions of the patients are often declined. Operation time under 90 minutes and use
of local anesthetics for postoperative pain, preferably through epidural procedures, might decrease
the risk of pulmonary complications.
Keywords: Thoracotomy; Children; Complications
Introduction
Thoracotomies of pediatric population are often performed by both pediatric surgery and thoracic surgery departments. Litarature has many data about thoracotomy especially in the area of cardiac surgery since 1959. However, literature presents limited information on the experiences in pediatric thoracotomy procedures especially esophageal atresia and others. This study aimed to examining the complications of thoracotomy and the factors affecting these complications in children.
Materials and Methods
The records of the patients who had undergone thoracotomies performed in our clinic between 1998 and 2015 were retrospectively evaluated for the age, gender, operation duration, additional anomaly, diagnosis, type of wound and incision, complications, type of analgesia used, pulmonary lesions, nutritional status, and removal time of thoracic tube. The incisions, gender, complications, type of analgesia, pulmonary lesion and nutrition were compared statistically by Kruskal Wallis test and for the evaluation other parameters, Pearson Chi-Square test was used. P <0.05 was considered significant.
Results
103 thoracotomies were performed (Table 1). The study involved the evaluation of the records of 5 male (63%) and 38 female (37%) patients. The mean age of the patients was 37.1 months (1 day-16
years). The main pathologies of the patients were as follows: 40 patients (38.8%) esophagus atresia (3
patients, isolated atresia; 37 patients, proximal esophagus atresia-distal trachea-esophageal fistula);
21 patients (20%) thoracal hydayid cyst; and 14 patients (13.5%) thoracic mass. In all the cases,
crystallized penicillin, ampicillin or cephalosporin were used preoperative and postoperatively.
Low Birth Weight (LBW) was seen in 16 patients, malnutrition was
seen in 3 patient and chemotheraphy was given before the surgery in
10 patients (Pulmonary metastasis of Wilm’s tumor (4), lymphoma
(3), pulmonary blastoma (3). The mean operation duration was
115 minutes (40-240). While 4 patients with esophagus atresia had
accompanying anorectal malformation, omphalocele, Morgagni
hernia, and duadenal atresia, one patient with liver laceration had
sepsis findings preoperatively. The wound types of the patients
were 32 clean, 64 clean-contaminated, and 7 contaminated. The
thoracotomies were performed with right posterolateral (n=70), left
posterolateral (n=24), anterior (n=5), right anterolateral (n=3) and
right abdominothoracic incisions. When two methods of incision were
compared for complications, more complications had developed after
the left posterolateral thoracotomies (p <0.05). In the comparisons of
complications associated with type of wound, there was no difference
between the rates of clean wound and clean-contaminated wound,
while the differences between clean and clean-contaminated wounds
and between clean-contaminated and contaminated wounds were
statistically significant (p <0.05).
Postoperative complications were noted in 67 patients as
wound infections (n=13), salivary fistula (n=11) in the patients
with esophagus atresia, wound infection and salivary fistula (n=4),
atelectasis (n=30), atelectasis and wound infection (n=7), and
hydrothorax-atelectasis (n=2). The postoperative analgesia was
provided with intravenous (iv) dipyrone in 42 cases, local prilocaine
in 3 cases, local bupivacaine in 6 cases, epidural catheterization in 20
cases, local prilocaine - iv dipyrone in 17 cases, and local bupivacaine
-iv dipyrone in 15 cases. The comparisons of the complications
associated with the postoperative analgesia used revealed that the rate
of complications was higher in the group which was administered
dipyrone only than in the other groups except in the group whose
peripheral nerve block was achieved by prilocine administration
(p <0.05, for each group). There was no significant differences in
the incidence rate of complications between local bupivacaine and
prilocaine administration and epidural catheter use (p >0.05), while
the use of local anesthesia with long-term effectiveness (bupivacaine)
had significantly reduced the rate of complications compared to
the use of prilocaine alone or in dipyrone combination (p <0.05).
The infections in our series were all noted for those with operation
durations over 90 minutes; however, the operation durations did not
differ significantly with regard to post-operative complications (p
>0.05).
The preoperative pulmonary graphs of 26 patients had revealed
infiltration. While 4 patients did not require thoracic tube insertion,
the thoracic tubes of the other patients were removed at mean of 5.6th
day (2-18 days). The mean thoracic tube removal time of the patients
with esophagus atresia was 8.5 days (6-15 days), whereas it was 5.4
days for other interventions (2-18 days). Atelectasia was seen in the
patients especially the removal of chest tube over the 8th day (p <0.05).
Table 1
Discussion
More than 50% of thoracotomy patients develop postoperative
chronic pain in the surgical wound, and epidural analgesia is known
to reduce the need for analgesic drug use by 10-20 folds compared to
systemic analgesia [1]. The requirement of peripheral nerve blockage
for high dose analgesic agent is due to dense vascularization of the
area that leads to high systemic absorption, which results in reaching
the toxic dose in relatively short time. In addition, repeated injections
are both painful and not practical [1-4]. Insufficient pain relief
following thoracotomy reduces pulmonary compliance and leads
to deep inhalation, restricted cough, atelectasis due to retention of
secretions and pneumonia [2-6]. In our series, 30 patients developed
atelectasis. Four of these were among esophagus atresia cases, and the
remaining (n=26) were among the other cases. The lower incidence
of respiratory complications in the newborn (particularly in the
cases with esophagus atresia) may be due to postoperative mechanic
ventilation of at least 2-3 days and PEEP application. In older
children, however, these procedures are not preferred and the patient
is subjected to as many pulmonary exercises as possible. The incidence
rate of postoperative pulmonary complications has been reported
as 10-80 % for upper abdominal surgery and 20% for throcatomies
[7,8]. In our series, post-thoracotomy pulmonary complication rate
was 38%. The complications ratio was higher in the group which was
administered dipyrone only than in the other groups (except only
prilocaine administration (p <0.05) in this study. The right and left
posterolateral thoracotomies were the most common in this series.
When two methods of incision were compared for complications,
more complications had developed after the left posterolateral
thoracotomies (p <0.05).
Surgical wound infections cause major economic and health
problems. The incidence rate of surgical wound infections after all
operations accounts for 5-17%. Surgical wounds have been classified
as preoperatively clean, clean-contaminated, contaminated, and dirty
[9,10]. The possible incidence rate of wound infections for each of
the wounds has been reported as 1-2.7%, 2.9-10.5%, 7.9-13.5% and
6.3-30% respectively [11,12]. However, in thoracotomies, these rates
are not definite. In our series, the incidence rates of wound infection
were 11% for clean wounds, 14% for clean-contaminated wounds,
and 57% for contaminated wounds. The incidence rate of wound
infections for all the patients was 16% (n=17), more than half (n=
9) developing in the newborn population. Evaluation of 41 newborn
in the series revealed an incidence rate of 21% for wound infections.
This high rate may be associated with higher rate of esophagus atresia
and the development of salivary fistula among the newborn. In a
previous study evaluating postoperative surgical wound infections
in a series of newborn, the incidence rate of infections was reported
to be 11.7%. In other age groups, this rate was 12%. The incidence
rate for wound infections in some series after orthopedics surgery has
been reported as 1.9%; after gastroenterological surgery, 3.5%; and
after plastic surgery, 4.7% [10]. Nevertheless, literature reveals no
reports of wound infection rates after thoracic procedures.
In another study evaluating surgical wound infection and
operation duration in a series, the infection rate for the cases with
operation durations under 30 minutes was 4.7%; between 30 and
60 minutes, 14.8%; and over 2 hours, 15.8% [12]. The infections in
our series were all noted for those with operation durations over
90 minutes. In Adebo OA’s 10 esophageal atresia series 3 wound
infection (30%) had seen but our series was 22% [13]. Our study was
shown name of the disease has more effect on the development of
complications regarding to type of incision.
Most pediatric thoracotomies are performed to treat esophageal
atresia, thoracic hydatid cyst and thoracic lesions. Surgical
infections and disordered pulmonary functions are common in
the thoracotomies of this age group. Operation duration under 90
minutes and administration of local anesthetic and intravenous
analgesic agents to provide pain postoperative pain relief, particularly
through epidural procedures, may reduce pulmonary complication
to a minimum level.
References
- Soto RG, Fu ES. Acute pain management for patients undergoing thoracotomy. Ann Thorac Surg 2003; 75: 1349-1357.
- Esme H, Apiliogullari B, Duran FM, Yoldas B, Bekci TT. Comparison between intermittent intravenous analgesia and intermittent paravertebral subpleural analgesia for pain relief after thoracotomy. Eur J Cardiothorac Surg. 2012; 41: 10-13.
- Tetik O, İslamoglu F, Ayan E, Duran M, Buket S, Çekirdekçi A. Intermittent infusion of 0.25% bupivacaine through an intrapleural catheter for postthoracotomy pain relief. Ann Thorac Surg. 2004; 77: 284-288.
- Yeğin A, Erdoğan A, Kayacan N, Karslı B. Early postoperative pain management after thoracic surgery; pre- and postoperative versus postoperative epidural analgesia: a randomised study. Eur J Cardiothorac Surg. 2003; 24: 420-424.
- Grider JS, Mullet TW, Saha SP, Harned ME, Sloan PA. A randomized, double-blind trial comparing continuous thoracic epidural bupivacaine with and without opioid in contrast to a continuous paravertebral infusion of bupivacaine for post-thoracotomy pain. J Cardiothorac Vasc Anesth. 2012; 26: 83-89.
- Gonzalez KW, Dalton BG, Millspaugh DL, Thomas PG, St Peter SD. Epidural versus Patient-Controlled Analgesia after Pediatric Thoracotomy for Malignancy: A Preliminary Review. Eur J Pediatr Surg. 2016; 26: 340-343.
- Pereira ED, Fernandes AL, da Silva Ancao M, de Arauja Pereres C, Atallah AN, Faresin SM. Prospective assessment of the risk of postoperative pulmonary complications in patients submitted to upper abdominal surgery. Sao Paulo Med J. 1999; 117: 151-160.
- Leo F, Venissac N, Pop D, Anziani M, Leon ME, Mouroux J. Anticipating pulmonary complications after thoracotomy: the FLAM Score. J Cardiothorac Surg. 2006; 1: 34.
- Altemeier WA. Surgical infections: incisional wound. In: Bennett JV, Brachman PS, eds. Hospital infections. Boston. 1979: 287-306.
- Grogaard B, Kimsas E, Raeder J. Wound infection in day-surgery. Ambul Surg. 2001; 9: 109-112.
- Duque-Estrada EO, Duarte MR, Rodrigues DM, Raphael MD. Wound infections in pediatric surgery: a study of 575 patients in a university hospital. Pediatr Surg Int. 2003; 19: 436-438.
- Uludağ O, Rieu P, Niessen M, Voss A. Incidence of surgical site infections in pediatric patients: a 3-month prospective study in an academic pediatric surgical unit. Pediatr Surg Int. 2000; 16: 417-420.
- Adebo OA. Oesophageal atresia and tracheo-oesophageal fistula: review of a 10-year personal experience. West Afr J Med. 1990; 9: 164-169.