Timing for Herniorrhaphy in Premature Infants: TiHPI study

Position du problème et objectif(s) de l’étude

Inguinal hernias (IH) occur more frequently in premature infants (10-30%) than in full-term infants (0.8-4%)Its repair is one of the most frequently performed procedures in pediatric surgery. Anesthesia in preterms is at high risk of complications. The optimal time for surgical management of inguinal hernias IHi in preterm patients is still unknown, opposing early management before 45 weeks corrected amenorrhea of age or before discharge from NICU versus later management. The aim of this study was to compare the incidence of postoperative complications in preterm infants with IH, following either early or late surgical management.

Matériel et méthodes

A national prospective non-randomized multicenter study included patients born prematurely (gestational age of less than 37 weeks), diagnosed with IH before the corrected age of 45 weeks. The early group of preterm infants was defined by a surgery up to and including 45 weeks of post-menstrual age and a late group after 45 weeks. The primary outcome was the number of children presenting at least one early (before 30 minutes) or late (between 30 minutes and 12 hours) apnea . The other outcomes were the difference between each group of the occurrence other anesthetic complications and peri-operative surgical complications (enterocolitis, early hernia recurrence, hematoma). The calculation of the required sample size using Fisher’s exact test (as one of the proportions is low), with an alpha risk of 0.05, a power of 80%, and a two-sided approach, results in a total of 216 subjects.To account for potential missing data, an additional 10% of subjects was planned to be recruited, bringing the total sample size to 238 patients. Parents or legal guardians received an information letter and an opposition form for each inclusion. The study was accepted by the local ethical committee and registered under number 2020PI069.

Résultats & Discussion

262 patients were included over a period of one and a half years in fourteen centers. The median postnatal age was 13 weeks, with a median gestational age at birth of 30 weeks. The median weight at the time of surgery was 4 kg. 132 patients in the early group and 130 patients in the late group. 25 patients (18.9%) presented at least one apnea in the twelve hours following the intervention in the early group versus 6 in the late group (4.6%) (p<0.0003). 39 patients (29.8%) had a per-operative respiratory complication in the early group vs. 23 patients (18%) in the late group (p<0.026). 49 patients (37.4%) had per-operative arterial hypotension vs. 17 patients (13.3%) in the late group (p<0.001).

Conclusion

The results of this study support delaying surgical management of inguinal hernias in preterm infants due to an increased risk of respiratory and hemodynamic complications during and after surgery when the time of surgery is before 35 weeks of post-menstrual age. But we still need more studies to confirm this strategy. However the optimal timing depends on multidsciplinary discussion for each case.

Auteurs

Mathilde DE QUEIROZ (1) , Nicolas BERTE (2), Amandine LUC (3), Pierre Louis VEROT (4) - (1)Hôpital Femme Mère Enfant Département D'anesthésie Réanimation Pédiatrique, Lyon, France, (2)Département De Chirurgie Pédiatrique, Nancy, France, (3)Département De Biostatistique, Nancy, France, (4)Département De Chirurgie Pédiatrique, Grenoble, France

Orateur(s)

Jean-Philippe SALAÜN (Caen)