Discussion
Nowadays, most CPAMs are diagnosed prenatally, with an 85.7% prenatal
diagnosis ate for CPAM15.The exact etiology and
pathogenesis of CPAM are still unclear, and current studies suggest that
some potential genes and expressions are related to the formation of
lung cysts. The difference of Thyroid Transcription Factor 1, Fibroblast
Growth Factor 7, Fibroblast Growth Factor 9, Clara cell marker 10, SOX
2, SOX10, COL2A1, Hoxb-5, hMSH-2 and other transcription factors and
expression appear to play a role in the pathogenesis of
CPAM16, 17.In addition, the positive rate of
Transcription Factor 1 in CPAM type I, II, and III is significantly
different, and it can be used as an important marker for CPAM tissue
typing18.In severe cases, the lesion continues to grow
and ultimately may cause severe lung compression, mediastinal shift,
hydrops fetalis, and/or fetal demise. Management options include
observation, maternal antenatal steroid administration, and fetal
surgical intervention19, 20{Aziz, 2021 #37;Loh, 2012
#38;Aziz, 2021 #35}.In children with symptoms after birth, it is
recommended to surgically remove the lesions as soon as possible. For
asymptomatic children with prenatal diagnosis of CPAM, most experts
still recommend early elective surgery, but the exact timing of surgery
is still controversial. Early surgical resection can help early
compensatory growth of the lung and reduce the possibility of repeated
infection and malignant transformation21, but some
doctors are concerned about the increased risk of surgical complications
and anesthesia sequelae in children8, 22.Therefore,
exploring the optimal timing of early surgery, that is, exploring the
timing of compensatory lung growth and reduction of lung-related
diseases in children with good tolerance to surgery and anesthesia is
very important to weigh the risks of surgery.
The purpose of this study was to evaluate the efficacy of surgery in
children of different ages,which is reflected in the indicators of
length of hospital stay, operative time, chest tube duration, length of
ventilation, number of deaths, number of major complications. We found
that the indicators of length of hospital stay, operative time, the
length of ventilation and number of major complications contain
statistical significance.
Notably, some researchers23 used surgical time as a
proxy for technical difficulty, which means the shorter duration of
surgery reflects fewer problems and accidents during surgery. In
addition, studies24, 25 have shown that shortening
surgical time can shorten the length of hospital stay, as well as
reducing the incidence of surgical site infection within 30 days after
surgery, the use of air drainage tube, the possibility of readmission
and reoperation23. Especially for children, shorter
procedures mean less time spent on anesthetics, which can stunt brain
development and damage the nervous system26. In
addition, shortening the operation time can enable children to resume
normal eating time earlier27, which is of great
significance to help the early recovery of growth and development of
children.
Some studies have shown that mechanical ventilation is associated with
the occurrence of complications, and the incidence of complications
increases with the duration of respiratory support28.
Shortening the length of ventilation can not only reduce pulmonary
complications28, 29, such as postoperative pneumonia,
atelectasis, pulmonary edema, acute respiratory failure, tension
pneumothorax, and also can reduce extrapulmonary complications, such as
gastric insufflation, fistula, anastomotic leakage, bleeding, hospital
infection, mask discomfort, damaged skin, eye irritation, sinus
congestion, oronasal drying, and patient‐ventilator
asynchrony30, 31. It is worth noting that several
studies have shown that mortality associated with lung disease is
largely related to complications of postoperative re-intubation and
mechanical ventilation. This means that reducing the duration of
ventilation can reduce postoperative mortality by reducing the incidence
of ventilator-related complications32. In particular,
children’s lung development is not yet perfect, and changes in forced
ventilation, normal pulmonary respiration physiology and respiratory
mechanics will lead to respiratory dysfunction and decreased airway
clearance ability. Therefore, shortening mechanical ventilation time is
of great significance for children’s postoperative
recovery33.
Interestingly, one study34 found that the incidence of
complications increased with the age of the patient at the time of
surgery, and most of the complications were related to pleural problems,
mainly including air leakage and fluid accumulation35.
Air leakage at the surgical site can lead to surgical emphysema and
pneumothorax, while fluid accumulation can lead to chylothorax, and in
severe cases they may lead to accidental re-intubation or even
reoperation.
In addition, major complications include transient unilateral phrenic
nerve palsy, hemorrhage, pneumonia, deep incision or inter-organ space
infection, deep wound dehiscence, pulmonary embolism, renal failure or
insufficiency, sepsis, and deep venous thrombosis. Minor complications
include superficial surgical site infection, superficial wound rupture,
and urinary tract infection. In particular, musculoskeletal
complications including breast deformity, rib fusion,chest wall
asymmetry,pterygoid scapulae and scoliosis are the major long-term
complications of thoracotomy36, which have a bad
effect on children in skeletal development during
growth35. A cohort study published by Markel M et al
demonstrated that compared with the general population, children
experience more frequent respiratory infections after resection of
congenital lung malformations, and Resection does not eliminate the
increased risk of pneumonia37.
Extubation time is also one of the perioperative indicators. Ko HK et
al. believed that delayed extubation after surgery was significantly
associated with a higher proportion of other pulmonary complications,
reintubation, mortality, and prolonged intensive care unit and hospital
stays38. Studies also have shown that early extubation
is beneficial to reduce the pain and stress response of patients,
promote early activities, and speed up postoperative recovery, and it is
feasible and safe39.However, the clinical extubation
time mainly depends on the amount of postoperative thoracic hemorrhage
and the surgeon’s assessment, which has individual differences and a
certain degree of subjectivity. Our study shows no meaningful difference
in extubation time by surgical age.
Postoperative mortality is an important indicator for evaluating the
postoperative prognosis of children. Postoperative death may be caused
by complications such as heart failure, respiratory failure, infection,
etc., which are closely related to the surgical skill of the operator
and the conditions of the medical institution. But deaths from lung
resections are rare. In center with expertise and experience, CPAM
lesions can be safely resect with virtually no
mortality40, 41. However, due to the lack of data that
can be included at present, larger multi-center clinical trials are
needed to further improve the conclusions, and more comprehensively
assess the effect of age on clinical outcomes.