Risk factors for postoperative pulmonary complications in children with severely compromised pulmonary function secondary to severe scoliosis.

OBJECTIVES: After corrective surgery for scoliosis, postoperative pulmonary complications lead to increases in morbidity, length of hospital stay (LOS) and mortality. This study aimed to identify associations with such respiratory complications, and to assess the utility of noninvasive ventilation (NIV) in children with severe scoliosis METHODS: This retrospective cohort study included all children aged ≤17 years who underwent spinal surgery for scoliosis between January 2009 and January 2012 at a quaternary pediatric hospital. Data were collated regarding polysomnography (PSG) and NIV use, before and after corrective surgery. Factors associated with severely compromised pulmonary function (SCPF) were established and correlations with the occurrence of postoperative pulmonary complications and LOS were identified. RESULTS: Altogether, 133 children had corrective surgery for scoliosis, aged 12.7 (range: 2-17) years at operation. Scoliosis causes were identified as: idiopathic (39.8%), neuromuscular disease (32.2%), syndrome (15.7%), and congenital (12%). Correlates with SCPF (forced vital capacity [FVC] <40% predicted, n = 10) included markers of sleep hypoventilation, including serum bicarbonate ≥29 mmol/L, morning pCO2 > 50mm Hg (P = .003), and overnight, episodic CO2 retention of >7 mm Hg. Using these parameters an additional eight children with SCPF were identified making a total of 18 out of 133 (13.5%) of the patients. Postoperative pulmonary complications were seen in 24 children (18%) and their occurrence correlated with higher Cobb angle (>90°), lower pulmonary function (FVC), higher serum bicarbonate and underlying neuromuscular disease. Amongst the 18 children with SCPF, regular use of NIV preoperatively was associated with reduced rate of postoperative pulmonary complications (P = .02) and reduced LOS by 6.4 days (P = .01). CONCLUSION: Nocturnal hypoventilation on PSG identifies children with SCPF. Use of NIV in children with SCPF was linked to fewer postoperative pulmonary complications and reduced duration of hospital stay.

Recurrent diaphragmatic hernia: Modifiable and non-modifiable risk factors.

RATIONALE: The risk of recurrence of Congenital Diaphragmatic Hernia (CDH) in an era of thoracoscopic surgery is unclear. OBJECTIVES: (1) estimate the incidence and (2) evaluate the perioperative factors associated with the symptomatic recurrence of CDH. METHODS: Medical records of CDH infants operated on in the neonatal period at a single-tertiary hospital between January 2000 and January 2013 were retrospectively reviewed. RESULTS: Of 119 infants with CDH, 34 (28.6%) were excluded: 17 (14.3%) died without recurrence and 17 (14.3%) presented beyond neonatal period or were followed elsewhere. Of 85 survivors, 71 infants had an open repair and 14 had a thoracoscopic repair. Eleven of 85 survivors (13%) developed a recurrence on average 19.8 weeks (range 15-34) after the initial repair. Of 11 recurrences, 6 had an initial thoracoscopic repair and 5 had an open repair (6/14 [43%] vs. 5/71 [7%]; P = 0.002). Two children had multiple recurrences. Statistically significant associations were found between recurrence and the presence of persistent pulmonary hypertension (PPHTN) (P = 0.006), severe PPHTN (P = 0.002), inhaled nitric oxide, or sildenafil use for treatment of PPHTN (P = 0.002), need for perioperative high frequency oscillatory ventilation (HFOV) (P = 0.0006), length of hospital stay (LOS) (P = 0.02), duration of ventilation (P = 0.016), and need for home oxygen (P = 0.003). In multivariate regression analysis both the closure type and home oxygen requirement were statistically significant, independent factors predicting a recurrence (P = 0.04 and 0.02, respectively) but the type of surgery (thoracoscopic vs. open) only approached significance (P = 0.052). The recurrence rate for the seven surgeons who performed at least 5 repairs ranged from 7% to 40%. CONCLUSIONS: A high survival rate of 85% with a 13% incidence of symptomatic CDH recurrence was demonstrated. Potentially, improved selection of cases for thoracoscopic repair and concentrating the thoracoscopic technique amongst a dedicated team of experienced thoracoscopic surgeons may reduce the rate of recurrence of CDH.