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Ann Thorac Surg 2000;69:591-596
© 2000 The Society of Thoracic Surgeons

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Original Articles

Postoperative recovery in children after minimum versus full-length sternotomy

^a Department of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA
^b Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
^c Department of Radiology, Harvard Medical School, Boston, Massachusetts, USA
^d Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
^e Departments of Anesthesia, Cardiac Surgery, Psychiatry, and Orthopedic Surgery, Children’s Hospital, Boston, Massachusetts, USA

Address reprint requests to Dr Laussen, Cardiac Anesthesia Service, Children’s Hospital 300 Longwood Ave, Boston, MA 02115
e-mail: laussen{at}al.tch.harvard.edu

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Minimal access incisions for pediatric cardiac surgery have been reported to hasten postoperative recovery. This prospective study compared recovery after a minimum versus full-length sternotomy for repair of atrial septal defects in children.

Methods. We studied 35 children undergoing atrial septal defect repair using a full-length sternotomy (n = 18) or ministernotomy (n = 17) according to the surgeon’s preference. All children were managed according to an established clinical practice guideline. Intraoperative comparisons included patient demographics, bypass and cross-clamp times, and, as a measure of stress response, epinephrine, norepinephrine, and lactate levels at six time intervals throughout the surgical procedure. Postoperative comparisons included pain scores at 6, 12, and 24 hours, frequency of emesis, analgesic requirements, respiratory rate and gas exchange, and length of intensive care unit and total hospital stay. Nurse and parent assessment scores of overall recovery were constructed using visual analog and Likert scales.

Results. No significant differences between mini- versus full-length sternotomy were detected for the measured outcome variables. No adverse outcomes were detected.

Conclusions. In this prospective study, a ministernotomy did not enhance postoperative recovery, and the primary advantage appears to be an improved cosmetic result.

	Introduction

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As the mortality and morbidity following pediatric congenital heart surgery has continued to decline, variables such as postoperative recovery time, pain and discomfort, total length of hospital stay, cost efficiency, and cosmetic result have become important markers of patient outcome. Minimal access cardiac surgery for both adults and children has been advocated over recent years in an effort to reduce costs related to intensive care unit (ICU) and hospital stay, and to improve cosmetic results. A shorter recovery time with less compromise of respiratory function and reduced pain also has been cited in reports, although there are no prospective studies to support this contention [1–4].

In congenital cardiac surgery, alternative minimal access techniques reported have included a right anterior thoracotomy and a transverse inframammary skin incision with either a vertical sternotomy or bilateral transverse anterior thoracotomy. At Children’s Hospital, Boston, a 4 to 5 cm midline transxiphoid incision with minimal sternal split is used to enable access to the heart for bicaval and aortic cannulation for tansatrial repair of atrial and ventricular septal defects. A previous report has documented the low risk associated with this approach [1]. This prospective study evaluates patient recovery after a minimal access midline transxiphoid incision compared with a full midline sternotomy in children undergoing atrial septal defect (ASD) repair.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
After Institutional Review Board approval, 35 patients undergoing ASD repair were studied. A power analysis indicated that 35 patients with approximately 17 in each group would provide 80% power to detect a difference of 1 standard deviation (SD) in each outcome variable using a two-tailed alpha level of 0.05 (Version 2.0, nQuery Advisor, Statistical Solutions, Boston, MA).

The decision for a mini- versus a full-length sternotomy was according to surgeon’s preference. Both groups were managed under the same clinical practice guideline (CPG) protocol established for ASD surgery at our institution, which includes patient admission on the same day of surgery, restriction of perioperative investigations and laboratory tests to reduce ancillary charges, early tracheal extubation, and early discharge from hospital.

Anesthetic management
All patients received an identical anesthetic technique, administered by the same anesthesiologist (P.C.L.), with the aim to extubate in the operating room. Patients were not premedicated and received either an inhalational induction with sevoflurane or intravenous (IV) induction with sodium thiopental or propofol. After pancuronium 0.15 mg/kg, the trachea was intubated and anesthesia prebypass maintained with IV fentanyl 5 µg/kg and inhaled isoflurane with oxygen and N₂O. The amount of isoflurane was titrated according to hemodynamic response. After induction, and before surgical incision, each patient received a single dose of caudal epidural morphine 75 µg/kg. On bypass, anesthesia was maintained using isoflurane 0.5 to 1% administered into the fresh gas flow of the bypass circuit and titrated according to perfusion pressure. Postbypass, anesthesia was continued with isoflurane, oxygen, and air. The wound was infiltrated with 0.25% bupivocaine before skin closure. At completion of surgery, neuromuscular blockade was reversed with neostigmine 50 µg/kg and glycopyrolate 20 µg/kg, and the trachea was extubated.

Operative technique
The technique for minimal access pediatric cardiac surgery at our institution using a perixyphoid incision has been described previously [1]. Briefly, it involves a 4 to 5 cm midline incision extending over the xyphoid process, starting from a point inferior to the level of the nipples. Access to the pericardium is achieved through a midline transxyphoid incision, and if necessary, the incision can be extended into the lower segment of the sternum. In the majority of small children undergoing ASD closure using this minimal access technique, aortic and vena cava cannulation can be achieved with a midline transxyphoid incision alone or with division of the sternum less than 2 cm. In older patients, aortic cannulation may be difficult using this minimal access approach and femoral arterial cannulation may be performed as an alternative. The artery is exposed through an incision in the groin crease and the cannula introduced through a transverse arteriotomy, which is then closed primarily on completion of the surgery.

Cephalad and anterior retraction of the sternum and rib cage is helpful using a fixed-arm retractor attached to the frame of the operating table. The pericardium is opened over the atrium and the incision extended over the ascending aorta to facilitate cannulation. Hypothermic cardioplegic arrest is used in all cases. After atriotomy, closure of the ASD is performed either by direct suture closure or with a patch of autologous pericardium. Air is removed from the left ventricle and atrium initially by passive filling of the heart on partial bypass, with lung inflation, immediately before closure of the ASD, and subsequently through the site of the cardioplegia once the aortic cross clamp has been removed, either passively or with applied suction to the cardioplegia needle according to surgeon preference. Once off bypass, a single chest tube or a Blake (Johnson & Johnson, Arlington, TX) silicone drain with bulb suction is used for drainage of the mediastinum, and a small pericardial window is left open over the right atrium to facilitate drainage of the pericardium.

Intraoperative evaluation
Patient demographics and bypass factors including duration of bypass and cross-clamp time were compared between the two groups. To evaluate whether the minimal access approach resulted in a reduced stress response, blood samples were drawn for epinephrine, norepinephrine, and lactate levels at six time intervals. These intervals were chosen to evaluate the response to surgical stress and bypass, and included: T1, immediately postinduction; T2, immediately after sternotomy; T3, postaortic cannulation; T4, at the nadir temperature on cardiopulmonary bypass; T5, rewarmed on bypass; and T6, at the time of chest drain insertion postbypass. Plasma epinephrine and norepinephrine were measured using a thin layer chromatographic technique.

Postoperative evaluation
The respiratory status of each patient after extubation was evaluated by respiratory rate and arterial blood gas on arrival to the cardiac ICU (CICU). Pain scores were evaluated at 6, 12, and 24 hours after surgery using a validated facial expression scale (0 = no pain, 5 = severe pain) [5]. The frequency of emesis, additional analgesic requirements, total length of ICU stay in hours, and total length of hospital stay in days were also compared.

Nurses in the ICU were asked two questions regarding their assessment of each patient’s pain level and overall recovery during the first night after surgery. Patients were graded on a 0 to 100 mm visual analog scale (0 = worst, 100 = best), and although the nurses were clearly not blinded as to the type of surgical incision, they were blinded as to the purpose of the study.

After transfer to the general cardiology ward, and immediately before discharge, nurses on the cardiology ward were asked five questions regarding their assessment of analgesia, mobility, sleeping, eating, and general recovery after surgery for each patient. Once again, patients were scored on a 0 to 100 mm visual analog scale and the responses to questions for each patient were averaged, providing a nurse assessment score (NAS). This score was constructed as a single clinical index of postoperative recovery, with the intent to examine the overall recovery rather than specific symptoms.

Similarly, a parent assessment score (PAS) was constructed by integrating a series of questions regarding each patient’s recovery. The scores to the questions were averaged to provide the PAS, with the intent to provide an overall measure rather than to analyze specific problem areas. Using a 5-point Likert scale (0 = no problems, 4 = severe problems), eight questions regarding behavior, mood, appetite, sleeping, mobility, and pain were given to the parents before discharge (lowest summated PAS of 0 = no problems, maximum summated PAS of 32 = severe problems). Seven questions were asked on follow-up telephone assessment, including questions relating to mood, behavior, appetite, sleeping, and school attendance (minimum summated PAS of 0 = no problems, maximum summated PAS of 28 = severe problems).

Data analysis
Full-length and ministernotomy techniques were compared with respect to each continuous variable of interest using two-sample Student’s t tests. Pain scores did not demonstrate significant departures from normality, as evaluated by the Wilk-Shapiro test, and therefore were also compared by Student’s t tests. Parent postoperative and home questionnaire data were compared with the nonparametric Wilcoxon rank-sum test. For evaluation of epinephrine, norepinephrine, lactate, and glucose levels, a two-tailed Bonferroni-corrected p value less than 0.01 was considered significant to adjust for the type I error for comparisons at multiple time points. Otherwise, p values less than or equal to 0.05 were considered statistically significant. Data are expressed as means ± SD, except for nurse and parental response data, in which medians and ranges are provided. Statistical analysis was performed using version 6.12 of the SAS software package (SAS Institute, Cary, NC).

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Patient demographics and intraoperative data including surgical procedure, cross-clamp time, and total pump time are shown in Table 1. Patients undergoing the ministernotomy procedure had a significantly shorter cardiopulmonary bypass (CPB) time (p = 0.05) and a significantly shorter aortic cross-clamp time (p = 0.01). All patients undergoing a ministernotomy had a secundum ASD repair, whereas 3 patients undergoing a full-length sternotomy had a primum ASD repair, 2 with a cleft in the mitral valve that was sutured, and 2 underwent closure of a sinus venosus defect, 1 requiring a Warden procedure. When these 5 patients were excluded from the analysis, there was no difference in the bypass or aortic cross-clamp times between the two groups (full-length sternotomy 20.8 ± 6.8 minutes versus ministernotomy 17.8 ± 6.4 minutes, p = not significant [NS]). No significant differences were detected in the time from skin incision to onset of CPB (full-length sternotomy 43.7 ± 13.5 minutes versus ministernotomy 50.0 ± 14.0 minutes, p = NS), nor time from end of CPB to skin closure (full-length sternotomy 40.0 ± 11.2 minutes versus ministernotomy 43.3 ± 7.5 minutes, p = NS).

The changes in epinephrine, norepinephrine, and lactate levels are shown in Figure 1. Although an increase in all levels during surgery was noted, there was no significant difference between the mini- and full-length sternotomy groups at any time point.

View larger version (38K): [in this window] [in a new window]   Fig 1. Changes in mean (± SD) plasma epinephrine (A), levels norepinephrine (B), and lactate (C) at each time point. (T1 = baseline postinduction; T2 = sternotomy; T3 = aortic cannulation; T4 = nadir temperature on cardiopulmonary bypass; T5 = rewarmed on cardiopulmonary bypass; T6 = chest drain placement.)

	Comment

Top Abstract Introduction Material and methods Results Comment References

Alternative access techniques for congenital cardiac surgery have been described primarily to improve cosmetic results [1–4, 6, 7]. These techniques have been recommended particularly for female patients older than 10 years of age as breast development is sufficient to delineate the extent of breast tissue. However, they have been applied to children of all ages including infants. Cosmetic results assessed in the immediate postoperative period have been satisfactory, although specific complications related to the incision have been reported. Phrenic nerve injury has been reported following ASD closure through an anterior right thoracotomy [8]. Pectoral muscle and breast maldevelopment have been reported after a transverse inframammary incision, along with paresthesia around breast tissue [9].

The advantages of a midline incision include avoidance of pericardial incisions near the phrenic nerve and the need to construct myocutaneous flaps, which could contribute to skin denervation. The disadvantage of a full midline sternotomy is primarily cosmetic, due to the length of the scar and possibly chest wall deformities, an important consideration for children as they grow and develop. Limiting the skin incision to 4 to 5 cm over the perixyphoid area enables adequate surgical access for transatrial repair of defects such as an ASD. No patient in our study required extension of the incision to improve surgical access, and the total operative time was identical between the mini- and full-length sternotomy groups. Results from this study, along with the previous report from our institution, indicate that a minimal access technique through a perixyphoid incision enables accurate repair of the intracardiac defect without increased patient morbidity.

Although data were collected prospectively, a limitation of this study is that patients were not randomized and the decision as to which incision to use was left to the surgeon. Due to the relative simplicity of the procedures and equal experience of the surgeons, it is unlikely that this factor had an influence on the outcome variables. Nevertheless, the longer duration of both total bypass and aortic cross-clamp times in the full-length sternotomy group was directly related to 5 patients in this group who underwent either repair of a primum ASD or sinus venosus defect. When these patients were excluded from analysis, there remained no significant difference between any of the outcome variables measured. The lack of randomization is also reflected in the higher number of female patients selected in the ministernotomy group.

An increase in plasma catecholamine levels during cardiac surgery is a consistent finding in adults and children [10–12]. This was also evident in our study. Surgical approach did not alter the stress response; there were no differences in the hormonal and metabolic stress responses between the full-length and ministernotomy groups despite similar patient demographics, bypass characteristics, and anesthetic management. Although the surgical incision is limited, significant anterior and cephalad retraction is necessary to facilitate surgical access.

All patients received an identical anesthetic technique. The surgical incision had no impact on anesthetic management nor the ability to extubate patients in the operating room after surgery. A mild respiratory acidosis following early extubation after congenital heart surgery has been reported previously [13, 14]. The reason for this has not been characterized, however, this study indicates that restriction to chest wall movement after a full midline sternotomy is not a factor. No differences in respiratory rate or arterial blood gas were detected between either surgical technique.

Similarly, the minimal access technique did not reduce postoperative pain. The age range for patients in this study was between 5 and 16 years, thereby permitting all patients to be assessed with a validated pain score in the immediate postoperative period. No significant difference between surgical technique was detected. Although the perixyphoid skin incision is small, anterior and cephalad retraction of the chest wall may stretch or disrupt costochondral joints, thereby contributing to postoperative pain. There were no differences in additional postoperative analgesic requirements or incidence of emesis between the two groups.

Although the sample size was small in this study, the amount of discomfort after a standard full midline sternotomy was not severe as assessed by pain scores and the postoperative nurse and parent scores. This may be related to the cartilaginous nature of the sternum, that sternal spreading makes use of the normal rib excursion as they hinge on the costovertebral facets, and that muscle is not divided or retracted. We have no objective data comparing pain scores for a complete sternotomy relative to a thoracotomy or abdominal incision in this age group. However, the relatively low level of discomfort seen in patients after a full-length sternotomy may make it difficult to demonstrate a specific advantage for a minimally invasive technique.

The CPG protocol for the surgical management of an ASD has been in place in the Cardiovascular Program at Children’s Hospital, Boston, since 1993. Although a formal cost analysis has not been undertaken, we have demonstrated a reduction in total hospital charges and the length of hospital stay [15]. All patients in the study were managed under the same CPG, which may account for the lack of differences between the surgical access techniques in terms of CICU and total hospital stay. No evaluation was made by medical or nursing staff as to whether patients after a minimally invasive technique met criteria for discharge from CICU or from hospital earlier. After surgery, all patients remained overnight in the ICU and we have been reluctant to transfer patients at a set time or during the night after surgery. We appreciate that after a minimally invasive technique, patients may be ready to leave the ICU and be discharged from the hospital earlier than those who receive a full midline incision, and that managing these patients under the same CPG may be inappropriate.

Although the nurses and parents were not blinded to the surgical approach, no significant difference in any of the postoperative questions was detected between the two groups. At 6-week follow-up, all patients had essentially returned to full activity and resumed school. Whether an assessment earlier after discharge could have detected differences between the two groups, however, is not known.

In summary, a transxyphoid approach to ASD surgery provides an improved cosmetic result, which is an important consideration for children and parents when planning elective cardiac surgery. There was no increased morbidity using a minimal access technique, however, we were unable to demonstrate shortened recovery or reduced hospital stay above and beyond that achieved by the CPG protocols in these patients.

	Acknowledgments

 
The authors acknowledge the assistance given by Richard A. Jonas, MD, and John E. Mayer, Jr, MD, with patient enrollment and manuscript preparation.

	Footnotes

 
This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/section/atsdiscussion/

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Del Nido P.J., Bichell D.P. Minimal access surgery for congenital heart defects. Semin Thorac Cardo Surg 1998;1:75-80.
2. Rosengart T.K., Stark J.F. Repair of atrial septal defect through a right thoracotomy. Ann Thorac Surg 1993;55:1138-1140.[Abstract]
3. Luciani G., Piccin C., Mazzuzzo A. Minimal access median sternotomy for repair of congenital heart defects. J Thorac Cardio Surg 1998;116:357-358.[Free Full Text]
4. Gundry S.I., Shattuck O.H., Razzouk A.J., del Rio M.J., Sardari F.F., Bailey L.L. Facile minimally invasive cardiac surgery via ministernotomy. Ann Thorac Surg 1996;65:1100-1104.[Abstract/Free Full Text]
5. Bieri D., Reeve R.A., Champion G.D., Addicoat L., Ziegler J.B. The Faces Pain Scale for self assessment of the severity of pain experienced by children. Pain 1990;41:139-150.[Medline]
6. Massetti M., Babatasi G., Rossi A., et al. Operation for atrial septal defect through a right anterolateral thoracotomy. Ann Thorac Surg 1996;62:1100-1103.[Abstract/Free Full Text]
7. Brutel de la Rivieri A., Brom A., Brom A.J. Horizontal sub-mammary skin incision for median sternotomy. Ann Thorac Surg 1981;32:101-104.[Abstract]
8. Helps B.A., Ross-Russell R.I., Dicks-Mireaux C., Elliot M.J. Phrenic nerve damage by a right thoracotomy in older children with secundum ASD. Ann Thorac Surg 1993;56:328-330.[Abstract]
9. Cherup L.L., Siewers R.K., Futerell J.W. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg 1986;41:492-497.[Abstract]
10. Sebel P.S., Bovill J.G., Schellekens A.P., Hawker C.D. Hormonal responses to high-dose fentanyl anaesthesia. A study in patients undergoing cardiac surgery. Br J Anaesth 1981;53:941-948.[Abstract/Free Full Text]
11. Anand K.J.S., Hansen D.D., Hickey P.R. Hormonal-metabolic stress responses in neonates undergoing cardiac surgery. Anesthesiology 1990;73:661-670.[Medline]
12. Lehot J.J., Villard J., Piriz H., et al. Hemodynamic and hormonal responses to hypothermic and normothermic cardiopulmonary bypass. J Cardiothorac Vasc Anesth 1992;6:132-139.[Medline]
13. Laussen P.C., Reid R.W., Stene R.A., et al. Tracheal extubation of children in the operating room after atrial septal defect repair as part of a clinical practice guideline. Anesth Analg 1996;82:988-993.[Abstract]
14. Burrows F.A., Taylor R.H., Hillier S.C. Early extubation of the trachea after repair of secundum type atrial septal defects in children. Can Anesth Soc J 1992;39:1041-1044.
15. Freed M.D., Pare D.S., Laussen P.C., et al. Clinical practice guidelines and the repair of congenital heart disease. Circulation 1995;95:A0570.

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This Article Abstract Full Text (PDF) Online Discussion Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Peter C. Laussen David P. Bichell Pedro J. del Nido Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Laussen, P. C. Articles by del Nido, P. J. Search for Related Content PubMed PubMed Citation Articles by Laussen, P. C. Articles by del Nido, P. J.