Downloaded from http://fn.bmj.com/ on March 29, 2015 - Published by group.bmj.com
ADC-FNN Online First, published on February 20, 2015 as 10.1136/archdischild-2012-302964 Leading article
Inguinal hernia repair in premature infants: more questions than answers Eileen M Duggan,1 Vikram P Patel,2 Martin L Blakely3 Inguinal hernia (IH) repair in term infants and older children is associated with very low morbidity and little controversy. However, this procedure has a different risk profile in premature infants. It is the most common major operative procedure in this population and has much higher morbidity than in term infants and older children.1–3 The morbidity (and some mortality) is not appreciated by many outside the paediatric surgery and neonatology fields.4 The incidence of IH is reported to be 13%–15% in premature infants—though the true incidence may be higher—and is inversely related to gestational age.5 6 Despite the frequency of IH, there is no consensus regarding many aspects of its management. The controversial aspects of IH repair in premature infants that we will address include timing of repair, anaesthetic mode, and the potential of long-term neurocognitive impairment related to anaesthetic agents.
CARDIOPULMONARY CONCERNS Many premature infants have cardiac or respiratory comorbidities and remain on oxygen at the time of IH repair. Severe apnoea and the need for ventilator support after operation are major concerns.7 Postoperative apnoea is known to be associated with a prior history of apnoea, prematurity and low postmenstrual age (PMA) at operation.3 8 9 In a case series with 47 premature infants, all of whom had IH repair prior to neonatal intensive care unit (NICU) discharge, 34% needed postoperative assisted ventilation, 23% had apneas/bradycardia and 4% required postoperative reintubation.10 Another review of 57 preterm infants showed that 8.8% either failed extubation or were unable to be extubated immediately postoperatively.11 Another case series 1
Department of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; 2 Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA; 3 Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA Correspondence to Dr Martin L Blakely, Department of Pediatric Surgery, Vanderbilt University Medical Center, 7100 Doctors’ Office Tower, 2200 Children’s Way, Nashville, Tennessee 37232, USA; [email protected]
of 126 preterm infants with IH repair reported a 5% apnoea rate; all of these infants had a prior history of apnoea.12 A fairly recent study showed that 13% of 45 premature infants who had IH repair before NICU discharge required intubation for >48 h after operation.3 Other factors can potentially contribute to cardiopulmonary issues, including the use of opioids or muscle relaxants during the procedure, type of anaesthesia, and duration of the operation. Unfortunately, the ability to predict postoperative respiratory problems for individual patients remains elusive.9
INCARCERATION Delaying IH repair is associated with a longer time period of exposure to hernia-related adverse events, especially incarceration and its attendant risks. Accurately identifying the rate of incarceration in this population has proven difficult due to the varying definitions of incarceration. In a series of 100 premature infants from Riley Children’s hospital, 31% had incarceration and two of these patients had gonadal infarction.13 In a series of 908 infants undergoing IH repair, 9.4% presented with incarceration.14 Successful reduction was accomplished in 84% of these patients. In the patients with incarceration, significant complications occurred in 31% including gonadal infarction and the need for bowel resection. Other studies of preterm infants showed 5% and 13% incarceration rate.3 15 Testicular atrophy rates after IH repair in premature infants have been reported from 2% to 30%.15 16
RECURRENCE Most surgeons believe that the effectiveness of IH repair, defined as lack of recurrence, does not vary significantly with regard to timing of repair. However, published data calls into question this consensus opinion, with recurrence rates ranging from 1% to over 8%.2 4 5 In one of the few long-term studies of children undergoing IH repair, ∼8% had a repeat IH operation and 3% had chronic inguinal pain into adulthood.13 This ongoing morbidity rate is higher than many paediatric surgeons would likely estimate.
ANAESTHESIA Providing anaesthesia to premature infants subjects them to risk of apnoea/bradycardia, prolonged assisted ventilation, temperature imbalance, exacerbation of preexisting disease (ie, oxygen need, bronchopulmonary dysplasia) and prolonged hospitalisation.17 18 A greater number of premature children receives general anaesthesia for IH repair than regional anaesthesia. Performing regional anaesthesia (ie, spinal and/or epidural) with or without sedation has risks of multiple and/or failed attempts and conversion to general anaesthesia during the procedure with its associated risks. With limited duration conferred with regional anaesthesia (in face of complex IH repair), specialised expertise is needed for the entire team to achieve satisfactory repair of IH. The benefit of regional anaesthesia regarding less postoperative apnoea has not been proven and initial hospitalisation is still needed for infants with PMA55 weeks PMA)
Apnoea and/or bradycardia Prolonged mechanical ventilation Increased technical difficulty Prolonged hospital stay
Hernia incarceration Frequent emergency department visits Unplanned readmissions Lost to follow-up
IH, inguinal hernia; NICU, neonatal intensive care unit; PMA, postmenstrual age.
F2
SUMMARY This review shows that there are many single institution studies reviewing outcomes of premature infants with IH. However, the numbers of patients in these studies are often small and most studies were retrospective, therefore, these studies were subject to the limitations inherent to observational studies for identifying best treatment methods. Nevertheless, the studies show that risks are high in this population and that outcomes may vary with the timing of repair. There have been calls for multicentre randomised trials comparing early versus later IH repair from all over the world and for a very long time.1 7 Yet, despite the frequency of IH repair in premature infants, this issue remains unstudied in a high-quality manner. A large, multicentre randomised trial is currently underway to address the effect of timing on the short-term and long-term safety and efficacy of IH repair in this population so that we may be able to deliver safe surgical care to this vulnerable population.30
9
10
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12
13
14
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Wang KS, Committee on Fetus and Newborn, American Academy of Pediatrics, Section on Surgery, American Academy of Pediatrics. Assessment and management of inguinal hernia in infants. Pediatrics 2012;130:768–73. Rescorla FJ, Grosfeld JL. Inguinal hernia repair in the perinatal period and early infancy: Clinical considerations. J Pediatr Surg 1984;19:832–7. Lee SL, Gleason JM, Sydorak RM. A critical review of premature infants with inguinal hernias: optimal timing of repair, incarceration risk, and postoperative apnea. J Pediatr Surg 2011;46:217–20. Phelps S, Agrawal M. Morbidity after neonatal inguinal herniotomy. J Pediatr Surg 1997;32:445–7. Rajput A, Gauderer MWL, Hack M. Inguinal hernias in very low birth weight infants: Incidence and timing of repair. J Pediatr Surg 1992;27:1322–4. Yeo CL, Gray PH. Inguinal hernia in extremely preterm infants. J Paediatr Child Health 1994;30: 412–3. Misra D. Inguinal hernias in premature babies: wait or operate? Acta Paediatr 2001;90:370–1. Jevtovic-Todorovic V, Hartman RE, Izumi Y, et al. Early exposure to common anesthetic agents causes widespread neurodegeneration in the developing rat brain and persistent learning deficits. J Neurosci 2003;23:876–82. Bell C, Dubose R, Seashore J, et al. Infant apnea detection after herniorrhaphy. J Clin Anesth 1995;7:219–23. Gollin G, Bell C, Dubose R, et al. Predictors of postoperative respiratory complications in premature infants after inguinal herniorrhaphy. J Pediatr Surg 1993;28:244–7. Allen GSG, Cox CSC, White NN, et al. Postoperative respiratory complications in ex-premature infants after inguinal herniorrhaphy. J Pediatr Surg 1998;33:1095–8. Murphy JJ, Swanson T, Ansermino M, et al. The frequency of apneas in premature infants after inguinal hernia repair: do they need overnight monitoring in the intensive care unit? J Pediatr Surg 2008;43:865–8. Zendejas B, Zarroug AE, Erben YM, et al. Impact of childhood inguinal hernia repair in adulthood: 50 years of follow-up. J Am Coll Surg 2010;211:762–8. Stylianos S, Jacir NN, Harris BH. Incarceration of inguinal hernia in infants prior to elective repair. J Pediatr Surg 1993;28:582–3. Misra D, Hewitt G, Potts SR, et al. Inguinal herniotomy in young infants, with emphasis on premature neonates. J Pediatr Surg 1994;29:1496–8. Walc L, Bass J, Rubin S, et al. Testicular fate after incarcerated hernia repair and/or orchiopexy performed in patients under 6 months of age. J Pediatr Surg 1995;30:1195–7. Steward DJ. Preterm infants are more prone to complications following minor surgery than are term infants. Anesthesiology 1982;56:304–6.
Duggan EM, et al. Arch Dis Child Fetal Neonatal Ed Month 2015 Vol 0 No 0
Downloaded from http://fn.bmj.com/ on March 29, 2015 - Published by group.bmj.com
Leading article 18
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Liu LM, Coté CJ, Goudsouzian NG, et al. Life-threatening apnea in infants recovering from anesthesia. Anesthesiology 1983;59:506–10. Craven PD, Badawi N, Henderson-Smart DJ, et al. Regional (spinal, epidural, caudal) versus general anaesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy. Cochrane Database Syst Rev 2003:CD003669. Coté CJ, Zaslavsky A, Downes JJ, et al. Postoperative apnea in former preterm infants after inguinal herniorrhaphy. A combined analysis. Anesthesiology 1995;82:809–22. Welborn LG, Hannallah RS, Fink R, et al. High-dose caffeine suppresses postoperative apnea in former preterm infants. Anesthesiology 1989;71:347–9.
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Sun L. Early childhood general anaesthesia exposure and neurocognitive development. Br J Anaesth 2010;105(Suppl 1):i61–8. Nemergut ME, Aganga D, Flick RP. Anesthetic neurotoxicity: what to tell the parents? Paediatr Anaesth 2014;24:120–6. Consensus Statement on the Use of Anesthetics and Sedatives in Children. http://www.smarttots.org/ resources/consensus.html (accessed 12 May 2014). Swenson O. Diagnosis and treatment of inguinal hernia. Pediatrics 1964;34:412–14. Wiener ES, Touloukian RJ, Rodgers BM, et al. Hernia survey of the Section on Surgery of the American Academy of Pediatrics. J Pediatr Surg 1996;31:1166–9. Antonoff MB, Kreykes NS, Saltzman DA, et al. American Academy of Pediatrics Section on Surgery
Duggan EM, et al. Arch Dis Child Fetal Neonatal Ed Month 2015 Vol 0 No 0
28
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hernia survey revisited. J Pediatr Surg 2005;40: 1009–14. Lautz TB, Raval MV, Reynolds M. Does timing matter? A national perspective on the risk of incarceration in premature neonates with inguinal hernia. J Pediatr 2011;158:573–7. Blakely ML, Neville HL, Mehall JR, et al. A comparison of early versus delayed inguinal hernia repair in premature infants. Pacific Association of Pediatric Surgeons, 2002. Timing of Inguinal Hernia Repair in Premature Infants. In: ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2000- [cited 2015 Jan 17]. http://clinicaltrials.gov/show/ NCT01678638 NLM Identifier: NCT01678638.
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Downloaded from http://fn.bmj.com/ on March 29, 2015 - Published by group.bmj.com
Inguinal hernia repair in premature infants: more questions than answers Eileen M Duggan, Vikram P Patel and Martin L Blakely Arch Dis Child Fetal Neonatal Ed published online February 20, 2015
Updated information and services can be found at: http://fn.bmj.com/content/early/2015/02/20/archdischild-2012-302964
These include:
References
This article cites 26 articles, 4 of which you can access for free at: http://fn.bmj.com/content/early/2015/02/20/archdischild-2012-302964 #BIBL
Email alerting service
Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Topic Collections
Articles on similar topics can be found in the following collections Epidemiologic studies (851) Child health (1397) Infant health (775) Neonatal health (841) Neonatal and paediatric intensive care (299) Neonatal intensive care (217) Pain (neurology) (173)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
ADC-FNN Online First, published on February 20, 2015 as 10.1136/archdischild-2012-302964 Leading article
Inguinal hernia repair in premature infants: more questions than answers Eileen M Duggan,1 Vikram P Patel,2 Martin L Blakely3 Inguinal hernia (IH) repair in term infants and older children is associated with very low morbidity and little controversy. However, this procedure has a different risk profile in premature infants. It is the most common major operative procedure in this population and has much higher morbidity than in term infants and older children.1–3 The morbidity (and some mortality) is not appreciated by many outside the paediatric surgery and neonatology fields.4 The incidence of IH is reported to be 13%–15% in premature infants—though the true incidence may be higher—and is inversely related to gestational age.5 6 Despite the frequency of IH, there is no consensus regarding many aspects of its management. The controversial aspects of IH repair in premature infants that we will address include timing of repair, anaesthetic mode, and the potential of long-term neurocognitive impairment related to anaesthetic agents.
CARDIOPULMONARY CONCERNS Many premature infants have cardiac or respiratory comorbidities and remain on oxygen at the time of IH repair. Severe apnoea and the need for ventilator support after operation are major concerns.7 Postoperative apnoea is known to be associated with a prior history of apnoea, prematurity and low postmenstrual age (PMA) at operation.3 8 9 In a case series with 47 premature infants, all of whom had IH repair prior to neonatal intensive care unit (NICU) discharge, 34% needed postoperative assisted ventilation, 23% had apneas/bradycardia and 4% required postoperative reintubation.10 Another review of 57 preterm infants showed that 8.8% either failed extubation or were unable to be extubated immediately postoperatively.11 Another case series 1
Department of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; 2 Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA; 3 Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA Correspondence to Dr Martin L Blakely, Department of Pediatric Surgery, Vanderbilt University Medical Center, 7100 Doctors’ Office Tower, 2200 Children’s Way, Nashville, Tennessee 37232, USA; [email protected]
of 126 preterm infants with IH repair reported a 5% apnoea rate; all of these infants had a prior history of apnoea.12 A fairly recent study showed that 13% of 45 premature infants who had IH repair before NICU discharge required intubation for >48 h after operation.3 Other factors can potentially contribute to cardiopulmonary issues, including the use of opioids or muscle relaxants during the procedure, type of anaesthesia, and duration of the operation. Unfortunately, the ability to predict postoperative respiratory problems for individual patients remains elusive.9
INCARCERATION Delaying IH repair is associated with a longer time period of exposure to hernia-related adverse events, especially incarceration and its attendant risks. Accurately identifying the rate of incarceration in this population has proven difficult due to the varying definitions of incarceration. In a series of 100 premature infants from Riley Children’s hospital, 31% had incarceration and two of these patients had gonadal infarction.13 In a series of 908 infants undergoing IH repair, 9.4% presented with incarceration.14 Successful reduction was accomplished in 84% of these patients. In the patients with incarceration, significant complications occurred in 31% including gonadal infarction and the need for bowel resection. Other studies of preterm infants showed 5% and 13% incarceration rate.3 15 Testicular atrophy rates after IH repair in premature infants have been reported from 2% to 30%.15 16
RECURRENCE Most surgeons believe that the effectiveness of IH repair, defined as lack of recurrence, does not vary significantly with regard to timing of repair. However, published data calls into question this consensus opinion, with recurrence rates ranging from 1% to over 8%.2 4 5 In one of the few long-term studies of children undergoing IH repair, ∼8% had a repeat IH operation and 3% had chronic inguinal pain into adulthood.13 This ongoing morbidity rate is higher than many paediatric surgeons would likely estimate.
ANAESTHESIA Providing anaesthesia to premature infants subjects them to risk of apnoea/bradycardia, prolonged assisted ventilation, temperature imbalance, exacerbation of preexisting disease (ie, oxygen need, bronchopulmonary dysplasia) and prolonged hospitalisation.17 18 A greater number of premature children receives general anaesthesia for IH repair than regional anaesthesia. Performing regional anaesthesia (ie, spinal and/or epidural) with or without sedation has risks of multiple and/or failed attempts and conversion to general anaesthesia during the procedure with its associated risks. With limited duration conferred with regional anaesthesia (in face of complex IH repair), specialised expertise is needed for the entire team to achieve satisfactory repair of IH. The benefit of regional anaesthesia regarding less postoperative apnoea has not been proven and initial hospitalisation is still needed for infants with PMA55 weeks PMA)
Apnoea and/or bradycardia Prolonged mechanical ventilation Increased technical difficulty Prolonged hospital stay
Hernia incarceration Frequent emergency department visits Unplanned readmissions Lost to follow-up
IH, inguinal hernia; NICU, neonatal intensive care unit; PMA, postmenstrual age.
F2
SUMMARY This review shows that there are many single institution studies reviewing outcomes of premature infants with IH. However, the numbers of patients in these studies are often small and most studies were retrospective, therefore, these studies were subject to the limitations inherent to observational studies for identifying best treatment methods. Nevertheless, the studies show that risks are high in this population and that outcomes may vary with the timing of repair. There have been calls for multicentre randomised trials comparing early versus later IH repair from all over the world and for a very long time.1 7 Yet, despite the frequency of IH repair in premature infants, this issue remains unstudied in a high-quality manner. A large, multicentre randomised trial is currently underway to address the effect of timing on the short-term and long-term safety and efficacy of IH repair in this population so that we may be able to deliver safe surgical care to this vulnerable population.30
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Wang KS, Committee on Fetus and Newborn, American Academy of Pediatrics, Section on Surgery, American Academy of Pediatrics. Assessment and management of inguinal hernia in infants. Pediatrics 2012;130:768–73. Rescorla FJ, Grosfeld JL. Inguinal hernia repair in the perinatal period and early infancy: Clinical considerations. J Pediatr Surg 1984;19:832–7. Lee SL, Gleason JM, Sydorak RM. A critical review of premature infants with inguinal hernias: optimal timing of repair, incarceration risk, and postoperative apnea. J Pediatr Surg 2011;46:217–20. Phelps S, Agrawal M. Morbidity after neonatal inguinal herniotomy. J Pediatr Surg 1997;32:445–7. Rajput A, Gauderer MWL, Hack M. Inguinal hernias in very low birth weight infants: Incidence and timing of repair. J Pediatr Surg 1992;27:1322–4. Yeo CL, Gray PH. Inguinal hernia in extremely preterm infants. J Paediatr Child Health 1994;30: 412–3. Misra D. Inguinal hernias in premature babies: wait or operate? Acta Paediatr 2001;90:370–1. Jevtovic-Todorovic V, Hartman RE, Izumi Y, et al. Early exposure to common anesthetic agents causes widespread neurodegeneration in the developing rat brain and persistent learning deficits. J Neurosci 2003;23:876–82. Bell C, Dubose R, Seashore J, et al. Infant apnea detection after herniorrhaphy. J Clin Anesth 1995;7:219–23. Gollin G, Bell C, Dubose R, et al. Predictors of postoperative respiratory complications in premature infants after inguinal herniorrhaphy. J Pediatr Surg 1993;28:244–7. Allen GSG, Cox CSC, White NN, et al. Postoperative respiratory complications in ex-premature infants after inguinal herniorrhaphy. J Pediatr Surg 1998;33:1095–8. Murphy JJ, Swanson T, Ansermino M, et al. The frequency of apneas in premature infants after inguinal hernia repair: do they need overnight monitoring in the intensive care unit? J Pediatr Surg 2008;43:865–8. Zendejas B, Zarroug AE, Erben YM, et al. Impact of childhood inguinal hernia repair in adulthood: 50 years of follow-up. J Am Coll Surg 2010;211:762–8. Stylianos S, Jacir NN, Harris BH. Incarceration of inguinal hernia in infants prior to elective repair. J Pediatr Surg 1993;28:582–3. Misra D, Hewitt G, Potts SR, et al. Inguinal herniotomy in young infants, with emphasis on premature neonates. J Pediatr Surg 1994;29:1496–8. Walc L, Bass J, Rubin S, et al. Testicular fate after incarcerated hernia repair and/or orchiopexy performed in patients under 6 months of age. J Pediatr Surg 1995;30:1195–7. Steward DJ. Preterm infants are more prone to complications following minor surgery than are term infants. Anesthesiology 1982;56:304–6.
Duggan EM, et al. Arch Dis Child Fetal Neonatal Ed Month 2015 Vol 0 No 0
Downloaded from http://fn.bmj.com/ on March 29, 2015 - Published by group.bmj.com
Leading article 18
19
20
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Liu LM, Coté CJ, Goudsouzian NG, et al. Life-threatening apnea in infants recovering from anesthesia. Anesthesiology 1983;59:506–10. Craven PD, Badawi N, Henderson-Smart DJ, et al. Regional (spinal, epidural, caudal) versus general anaesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy. Cochrane Database Syst Rev 2003:CD003669. Coté CJ, Zaslavsky A, Downes JJ, et al. Postoperative apnea in former preterm infants after inguinal herniorrhaphy. A combined analysis. Anesthesiology 1995;82:809–22. Welborn LG, Hannallah RS, Fink R, et al. High-dose caffeine suppresses postoperative apnea in former preterm infants. Anesthesiology 1989;71:347–9.
22
23
24
25 26
27
Sun L. Early childhood general anaesthesia exposure and neurocognitive development. Br J Anaesth 2010;105(Suppl 1):i61–8. Nemergut ME, Aganga D, Flick RP. Anesthetic neurotoxicity: what to tell the parents? Paediatr Anaesth 2014;24:120–6. Consensus Statement on the Use of Anesthetics and Sedatives in Children. http://www.smarttots.org/ resources/consensus.html (accessed 12 May 2014). Swenson O. Diagnosis and treatment of inguinal hernia. Pediatrics 1964;34:412–14. Wiener ES, Touloukian RJ, Rodgers BM, et al. Hernia survey of the Section on Surgery of the American Academy of Pediatrics. J Pediatr Surg 1996;31:1166–9. Antonoff MB, Kreykes NS, Saltzman DA, et al. American Academy of Pediatrics Section on Surgery
Duggan EM, et al. Arch Dis Child Fetal Neonatal Ed Month 2015 Vol 0 No 0
28
29
30
hernia survey revisited. J Pediatr Surg 2005;40: 1009–14. Lautz TB, Raval MV, Reynolds M. Does timing matter? A national perspective on the risk of incarceration in premature neonates with inguinal hernia. J Pediatr 2011;158:573–7. Blakely ML, Neville HL, Mehall JR, et al. A comparison of early versus delayed inguinal hernia repair in premature infants. Pacific Association of Pediatric Surgeons, 2002. Timing of Inguinal Hernia Repair in Premature Infants. In: ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2000- [cited 2015 Jan 17]. http://clinicaltrials.gov/show/ NCT01678638 NLM Identifier: NCT01678638.
F3
Downloaded from http://fn.bmj.com/ on March 29, 2015 - Published by group.bmj.com
Inguinal hernia repair in premature infants: more questions than answers Eileen M Duggan, Vikram P Patel and Martin L Blakely Arch Dis Child Fetal Neonatal Ed published online February 20, 2015
Updated information and services can be found at: http://fn.bmj.com/content/early/2015/02/20/archdischild-2012-302964
These include:
References
This article cites 26 articles, 4 of which you can access for free at: http://fn.bmj.com/content/early/2015/02/20/archdischild-2012-302964 #BIBL
Email alerting service
Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Topic Collections
Articles on similar topics can be found in the following collections Epidemiologic studies (851) Child health (1397) Infant health (775) Neonatal health (841) Neonatal and paediatric intensive care (299) Neonatal intensive care (217) Pain (neurology) (173)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
