Safety Assessment for Thoracoscopic Day Case Surgery in Children with Congenital Pulmonary Malformation

Abstract

Background:

No data exist evaluating the utilization and safety of outpatient thoracoscopy in children. The aim of this study was to investigate the safety of outpatient thoracoscopy and to assess parental opinions on the advantages and disadvantages of a pediatric thoracoscopy outpatient setting.

Methods:

A retrospective review of data from patients treated by thoracoscopy for congenital pulmonary malformation between 2013 and 2016 was performed. Study focused on patients who underwent outpatient thoracoscopy. All were placed in a flank position and underwent a three-port (5-mm optical trocar and two 5-mm trocars) thoracoscopy. Insufflation pressure required was 5 mmHg with bilateral lung ventilation. Pain control was provided with multimodal postoperative analgesia and the use of paravertebral block for regional analgesia. No drain was inserted. Outcomes of interest included 30-day overall morbidity, readmission, reoperation, and parental opinions through a phone call questionnaire.

Results:

A total of 37 thoracoscopies were identified; 11 (30%) with a median age of 5.3 months (4.2–12.3) were performed as an outpatient procedure (10 sequestration, 1 bronchogenic cyst). Median operating time was 51 minutes (34–87). No conversion and no transfusion occurred. No complications occurred (no morbidity, no readmission, and no reoperation). According to parents' view the outpatient setting has no disadvantages.

Conclusion:

This first analysis of a small monocentric dataset demonstrates that pediatric patients can safely undergo thoracoscopy, an outpatient procedure, with a high rate of parental satisfaction.

Introduction

Congenital lung malformations (CLM) are relatively rare with estimates of about 1 in 10,000 to 1 in 35,000 pregnancies^1–5; however, the incidence has recently risen because of growing recognition of these lesions on the 16–20 week prenatal ultrasound.^4–10

The most common CLM are congenital pulmonary airway malformations (CPAM), pulmonary sequestration (PS), and mixed/hybrid lesions.⁹

The treatment of such malformations is surgical and it is the resection of the malformation, wedge resection, or lobectomy depending on the lesion.

Enhanced Recovery After Surgery (ERAS) protocols aim to optimize perioperative care in patients undergoing major surgical procedures by maintaining physiologic homeostasis and reducing surgical stress to improve recovery, reduce postoperative morbidity, and decrease overall costs.^11,12 General tenets of ERAS include perioperative patient education, shortened preoperative fasting durations, minimally invasive surgical techniques, opioid-sparing analgesia, early postoperative oral feeding and mobilization, and minimal use of surgical drains and catheters.¹³

Feasibility of the process would have to pass through a collaboration with the anesthesia care team and the elaboration of an analgesia protocol that would allow a prompt return home.

In a previous article, it was demonstrated how the use of a thoracoscopy reduces the length of stay in the hospital.¹⁴

The objective of our study was to show the feasibility of thoracoscopy in outpatient settings for some pulmonary lesions and to evaluate the results and the satisfaction of the parents by a survey conducted through phone.

Materials and Methods

The data relative to the patients operated on with thoracoscopy in our institution between January 2013 and December 2016 were reviewed, and we analyzed those who received an outpatient intervention.

Demographics including prenatal diagnosis, surgical technique used, postoperative care, and complications (including morbidity at 30 days, further interventions and hospitalizations) classified according to the Clavien Dindo score¹⁵ were collected.

The study focused on a satisfaction survey administered to parents; they were called at home 3–6 months after intervention. The questionnaire was designed specifically for this purpose, and its construction followed the procedures of other validated questionnaires in the literature.^16–19

Eligibility criteria for outpatient setting surgery and release criteria

Patients eligible for outpatient surgery were selected through different criteria that can be grouped as follows.

Presurgical criteria

Prenatal counseling is available for all families to be able to explain the type of malformation, surgical strategy, and age of surgery. The anticipation of the therapeutic journey is key to patients' care, explaining the full plan to the parents and especially highlighting the criteria necessary to allow discharge from hospital care. Hospital staff on their side must take care into judging if the family socioeconomic conditions are appropriate and whether the distance from their house to the hospital is adapted.

Intra-surgical evaluation, operative technique, and postoperative management

Children were welcomed the same day of the scheduled intervention.

They were all positioned in a lateral position for a three or four instrument insertion (a 5 mm camera and two or three 5 mm trocars).

The insufflation pressure was 5 mmHg without single lung ventilation.

The case included and described in the clinic were sequestrations and bronchogenic cysts.

For the extralobar sequestrations, a simple mass excision was performed after a control of the feeding vessels using a ligature in Vicryl and completion with LigaSure.

For the intralobar sequestrations (ILSs) control of the vessels was the same as that performed in the extralobar ones, but followed by a wedge resection of the lesion. The bronchogenic cysts were removed.

No drainage was used, and the postsurgery analgesia was performed following a multimodal analgesia protocol. A paravertebral catheter was inserted with a landmark percutaneous approach under thoracoscopic vision at the end of the surgical procedure (Tuohy epidural kit; Perifix ONE Paed set 20^®): from within the thorax the needle tip can be seen to appear in the thoracic paravertebral space as it tents the parietal pleura. An indwelling catheter was placed under direct vision, and a single injection of local anesthetic (Levobupivacaine 0.25 mL/kg) was performed with intravenous adjunct drugs (clonidine or dexamethasone) before removal of the catheter and removal of tracheal intubation in the operating room. These drug adjuncts were used in purpose of improving the quality and duration of the block, according to a multimodal analgesia protocol.^20–23

Criteria required to hospital discharge

Discharge criteria were a correct hemodynamic state (blood pressure, oxygen saturation, and respiratory rate) and a per oral satisfying pain control.

The measure of pain and the necessity of any treatment were measured with a FLACC score (Face Legs Activity Cry Consolability).^24–26

A postoperative chest thoracic X-ray was obtained for all patients and required to be normal, or with a minimal pleural effusion or minimal residual pneumothorax (considered as compatible with the postsurgery state). The children were discharged from the hospital the same day with a prescription for pain medication (Paracetamol and Ibuprofen) alternated systematically during the first 48–72 hours after surgery.

Next day nurse phone call

The day after the surgery all families received a phone call by one of the nurses of the day care to collect postsurgical data, following the table with the questions asked to the parents (Table 1).

Table 1.

Postoperative Telephone Call from the Nurse

Robert Debré Children's University Hospital–DAY SURGERY -
NAME: Date of birth: TEL NUMBER:	INTERVENTION Date Type of intervention Type of anesthesia
INFORMATION AFTER HOSPITAL DISCHARGE
Please, see attached paper with general information
Type of release: □ home □ care facility □ other
Means of transport: □ own vehicle □ taxi □ ambulance □ public transport □ by foot
Was child accompanied by parents? Yes/No
AT HOME
Your child experienced? Vomiting, fever, difficulties moving around or standing up, other? Did the child feel pain? At the level of (0–10) If treatment administered, which one? Was it effective?
Treated area: did you observe?
Blood or discharge□ Not much □ a lot □ heavy	If yes:• Was it necessary to redo the bandage?• Did you observe the presence of edema or hematoma?• Other
PROBLEM(S) ENCOUNTERED
People contactedType of information communicatedMeasure to be taken
Date of phone call: Time of phone call:Interview by:Interview with: □ father □ motherInterview not released

The evaluation of pain is done with mechanical visual analog and simple numerical rating scales, normally used for adults,²⁷ who in this specific case as the parents are the intermediaries and the access way to the children through phone. The parents stated pain levels orally using a score between 0 and 10.^29,30

Satisfaction survey

Parents were subjected to a satisfaction survey, 3–6 months after surgery, voted to collect information about hospital stay, respect of the dosage and administration schedule, pain management, and the recovery postsurgery at home.

Following is a template of the survey (Table 2):

Table 2.

Parent Satisfaction Survey

Questions	Kind	Available	Score
(1) Reception staff was…?	Yes, completely	Yes, completely	4
1-	Yes, enough	Yes, enough	3
1-	Not really	Not really	2
1-	Not at all	Not at all	1
(2) Intervention time has been respected?	Yes, completely		4
	Yes, enough		3
	Not really		2
	Not at all		1
(3) Would you say the surgeon was…?	Yes, completely	Yes, completely	4
	Yes, enough	Yes, enough	3
	Not really	Not really	2
	Not at all	Not at all	1
(4) Pain of your child was taken in charge	Very efficiently		4
	Efficiently enough		3
	Not efficiently enough		2
	Not efficiently		1
	Not applicable		0
(5) At the moment of leaving the hospital, how did you feel regarding going back home?	Happy to go back		4
	Anxious, but in the end fine		3
	Very anxious		2
	I did not want to go back		1
(6) Was pain management at home effective?	Very effective		4
	Effective enough		3
	Not effective enough		2
	Not effectively		1
	Not applicable		0
(7) If in need of a new procedure, would you accept to do it in day care again?	Yes, absolutely		4
	Yes, somewhat		3
	Not really		2
	Not at all		1
(8) Would you recommend day care to others?	Yes, absolutely		4
	Yes, somewhat		3
	Not really		2
	Not at all		1
(9) Did you encounter any problems along the procedure?	No
	Yes
	If yes, which one?

Every question is evaluated according to a scale from 1 to 4, and the scores were summed to obtain an objective satisfaction score.

Results

In total 37 thoracoscopies were identified for lung malformations, 24 (65%) males and 13 (35%) females (Table 3).

Table 3.

Characteristics of Patients

	Patients on day surgery
Number of patients	11
Median gestation age	40 weeks (range 34–41.5 weeks)
Age at surgery	5.3 months (range 4.2–12.3 months)
Diagnosis	10 sequestrations; 1 bronchogenic cyst
Other associated malformations	1/11 monosomy X
Operations	11/11 VATs excision of malformation
Mean time of operation	51 minutes (range 34–87 minutes)
Complications	1/11 hospitalization for infected malformation

VATs, thoracoscopic excision.

Eleven patients underwent an intervention under outpatient settings (30%), 8 (72%) males, all with a prenatal diagnosis of lung malformation.

Only one needed a conventional hospital stay. Ten patients were discharged on day of surgery.

The median gestation age was 40 weeks (range 34 weeks–41.5 weeks) with a median birth weight of 3150 g (range 2210–3845 g). No respiratory distress or other symptoms related to the pathology were encountered at the moment of birth.

One patient was affected by monosomy X, and for the remaining there were no associated pathologies.

Median age at the time of surgery was 5.3 months (range 4.2 and 12.3 months).

10 presented sequestrations (3 intralobar, one intradiaphragmatic, and 6 extralobar) and 1 a bronchogenic cyst.

Median surgery time was 51 minutes (range 34–87 minutes), and no conversion or blood transfusion was necessary.

No complications were encountered.

One patient required hospitalization for an infected ILS discovered during the surgery. The postoperative follow-up revealed a hybrid lesion, and the patient was reoperated for a thoracoscopic lobectomy, after 3 months.

Patients were seen in outpatient clinic in median at 37.5 days after the surgery (range 7–95 days), with a chest X-ray for all. In one (10%) a rib fracture was found, most likely linked to the surgery, but totally asymptomatic.

Median follow-up for the first cases is 3.5 months (range 2.1–8.5).

Satisfaction survey showed excellent results.

All the families (10/10) completed the postoperative survey.

We gave a score of 1 to 4 for each answer. The median score about all the questions was 39/40. High satisfaction rate was observed due to an excellent pain control and absence of postoperative complications.

The only responses with a lower score (2) were due to administrative problems: in one case a delay of the procedure (2 points) and in the other a delay in obtaining the medical charts which generated dissatisfaction. The other questions all recorded very high scores especially regarding reception, explanation, the availability of medical staff, and finally the perfect tolerance of the children during their hospital stay and homestay.

Discussion

To our knowledge, this is the first series reporting thoracoscopic procedure for CPAM as a day case surgery without postoperative complication and a good parent satisfaction.

The shortening of hospital stays after surgeries is a reality for adults: recent studies showed the feasibility and the security of an early release in thoracic surgery,^28–30 and this attitude is starting to spread in pediatric surgery.^31,32

There are however no studies describing day care thoracoscopy interventions in children. We introduced such procedure for all thoracic surgeries that did not need a drain while evaluating feasibility and parental satisfaction.

Several pediatric series demonstrated that low-invasive surgery is characterized by lower postsurgical pain and consequently by a faster recovery and resuming of everyday activities.^6,8

The nonhospitalization surely shows benefits for both the child and the whole family in the long run. Parents, even if skeptical at first, really appreciated the method declaring being very satisfied and especially happy to go home the same day and seeing the child recover his/her activities just a few hours after waking up from anesthesia.

The surgical intervention and the day of the surgery are only a part of the journey of the patient who is already taken into care during pregnancy with prenatal diagnosis. The family and the family environment are evaluated to optimize all the steps of the treatment journey, and every consultation before the intervention has the objective of preparing the parents by explaining the surgery and all possible complications together with all the possible accidents that could change the treatment process into a traditional hospital stay.

The only patient who was hospitalized after intervention already had a respiratory infection before surgery, and during the intervention purulent secretions were encountered at the moment of dissection. The parents were therefore already aware of such possibility.

A proper analgesia was at the root of the success of a quick rehabilitation, and it guarantees easier follow-up at home. The choice of introducing a paravertebral catheter under control of the surgeon allows a process of selective analgesia that finally makes the whole procedure less invasive given it will be removed at the end of the Bupivacaine injection.^33,34

The analgesia protocol at home is composed of nonsteroidal anti-inflammatory medications (Paracetamol and Ibuprofen), this reduces the use of opioid derivates; the positive responses of parents demonstrate their efficacy; moreover, what allows a same-day release after the intervention is not introducing a thoracic drainage system.

The postsurgery thoracic X-rays performed immediately after the intervention did not show pneumothorax or pathological effusion, and the only remark a month after the intervention was a broken rib that resulted completely asymptomatic, which is a very encouraging result for the type of malformation we treated.

Different issues regarding the feasibility of day care thoracic surgery are linked to the possible complications after the surgery: the present research showed a complete absence of complications in this short series.

Another key point that helps the success of the day care setting is the phone call the day after intervention; a nurse is dedicated solely to the collection of a list of the interventions carried out during the day and to call the parents the next day to assess the condition of the patient. The families returned home with their own vehicles and they were given explanations on how to deal with their children and to recognize the warning signals that would need hospitalization.

Most of the concerns were clarified following the phone call, confirming again the importance of the viewpoint of the care team³⁵; in fact even with written instructions and with the exhaustive explanation the day of the surgery, the survey showed the efficacy of the phone call with respect to their doubts.³⁶ The questions parents might need to ask can develop after the intervention and the first moments of recovery, receiving a phone call the next day will not only serve as both emotional and didactic support but also will give the parents an opportunity to ask those questions that have matured until then.^37,38

Many studies have shown the importance of a phone follow-up in the pediatric population.^39,40

The second questionnaire, the one for investigation satisfaction, is a tool that allows discovering any malfunction of the system and the problems relative to an inefficient take into the charge of the patients.^41,42

In conclusion, our results demonstrated how parents, long after the surgery, have a good memory of the process and claim of being promoters with other families of the day care surgery. It is mainly the surprise of being able to go home soon with a child in a general normal condition that leads to a sense of confidence toward the care team.

Next step to make this type of care grow would probably be to enlarge the number of pulmonary malformations treated in such a way. For now, the length of hospitalization of patients undergoing a lobectomy in our service has considerably decreased, with an average of 24 hours and a thoracic drainage kept for the 24 hours or not used.

Objective is also to increase the number of pathologies treatable in outpatient settings.

In the present study, we showed a first evaluation of the feasibility of the thoracoscopy in an outpatient setting and the satisfaction of the parents. This technique, with the help of multimodal analgesia, could be extended to other thoracic surgeries, provided that the surgery is brief and that it shows a low morbidity rate in a regular hospitalization setting.

Such surgeries however must be of quick execution and must be carried out in facilities adapted to this type of patients and with a low morbidity rate.

Footnotes

Disclosure Statement

No competing financial interests exist.

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