Abstracts
Objective:
To identify risk factors for respiratory complications after adenotonsillectomy in children ≤ 12 years of age with obstructive sleep apnea who were referred to the pediatric ICU (PICU).
Methods:
A cross-sectional historical cohort study analyzing 53 children after adenotonsillectomy who met predetermined criteria for PICU referral in a tertiary level teaching hospital. The Student's t-test, Mann-Whitney test, and chi-square test were used to identify risk factors.
Results:
Of the 805 children undergoing adenotonsillectomy between January of 2006 and December of 2012 in the teaching hospital, 53 were referred to the PICU. Twenty-one children (2.6% of all those undergoing adenotonsillectomy and 39.6% of those who were referred to the PICU) had respiratory complications. Of those 21, 12 were male. The mean age was 5.3 ± 2.6 years. A high apnea-hypopnea index (AHI; p = 0.0269), a high oxygen desaturation index (ODI; p = 0.0082), a low SpO2 nadir (p = 0.0055), prolonged orotracheal intubation (p = 0.0011), and rhinitis (p = 0.0426) were found to be independent predictors of respiratory complications. Some of the complications observed were minor (SpO2 90-80%), whereas others were major (SpO2 ≤ 80%, laryngospasm, bronchospasm, acute pulmonary edema, pneumonia, and apnea).
Conclusions:
Among children up to 12 years of age with OSA, those who have a high AHI, a high ODI, a low SpO2 nadir, or rhinitis are more likely to develop respiratory complications after adenotonsillectomy than are those without such characteristics.
Postoperative complications; Tonsillectomy; Sleep apnea, obstructive
Objetivo:
Identificar fatores de risco para complicações respiratórias após adenotonsilectomia em crianças ≤ 12 anos com apneia obstrutiva do sono encaminhadas à UTI pediátrica (UTIP).
Métodos:
Estudo de coorte histórica com corte transversal que analisou 53 crianças após adenotonsilectomia que preencheram os critérios pré-estabelecidos para encaminhamento à UTIP em um hospital escola de nível terciário. Foram utilizados o teste t de Student, o teste de Mann-Whitney e o teste do qui-quadrado para identificar os fatores de risco.
Resultados:
Das 805 crianças submetidas à adenotonsilectomia entre janeiro de 2006 e dezembro de 2012 no hospital escola, 53 foram encaminhadas à UTIP. Vinte e uma crianças (2,6% do total de submetidas à adenotonsilectomia e 39,6% das que foram encaminhadas à UTIP) apresentaram complicações respiratórias, sendo 12 do gênero masculino e a idade média de 5,3 ± 2,6 anos. Maior índice de apneia-hipopneia (IAH; p = 0,0269), maior índice de dessaturação de oxigênio (IDO; p = 0,0082), baixo nadir da SpO2 (p = 0,0055), maior tempo de intubação orotraqueal (p = 0,0011) e rinopatia (p = 0,0426) foram preditores independentes de complicações respiratórias. Foram observadas complicações respiratórias menores (SpO2 entre 90-80%) e maiores (SpO2 ≤ 80%, laringoespasmos, broncoespasmos, edema agudo de pulmão, pneumonia e apneia).
Conclusões:
Em crianças de até 12 anos e com apneia obstrutiva do sono, aquelas que têm maior IAH, maior IDO, menor nadir da SpO2 e/ou rinopatia são mais predispostas a desenvolver complicações respiratórias após adenotonsilectomia do que aquelas sem essas características.
Complicações pós-operatórias; Tonsilectomia; Apneia do sono tipo obstrutiva
Introduction
Obstructive sleep apnea (OSA) affects approximately 4% of the pediatric
population(
11. Baugh RF, Archer SM, Mitchell RB, Rosenfeld RM, Amin R, Burns JJ, et
al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck
Surg. 2011;144(1 Suppl):S1-30.
http://dx.doi.org/10.1177/0194599810389949
http://dx.doi.org/10.1177/01945998103899...
) and is associated with significant medical problems, including
cardiopulmonary abnormalities(
22. Goldbart AD, Levitas A, Greenberg-Dotan S, Ben Shimol S, Broides A,
Puterman M, et al. B-type natriuretic peptide and cardiovascular function in young
children with obstructive sleep apnea. Chest. 2010;138(3):528-35.
http://dx.doi.org/10.1378/chest.10-0150
http://dx.doi.org/10.1378/chest.10-0150...
,
33. Cohen S, Springer C, Perles Z, Koplewitz BZ, Avital A, Revel-Vilk S.
Cardiac, lung, and brain thrombosis in a child with obstructive sleep apnea. Pediatr
Pulmonol. 2010;45(8):836-9. http://dx.doi.org/10.1002/ppul.21256
http://dx.doi.org/10.1002/ppul.21256...
) and failure to thrive.(
44. Freezer NJ, Bucens IK, Robertson CF. Obstructive sleep apnoea
presenting as failure to thrive in infancy. J Paediatr Child Health.
1995;31(3):172-5.
http://dx.doi.org/10.1111/j.1440-1754.1995.tb00779.x
http://dx.doi.org/10.1111/j.1440-1754.19...
)
OSA is characterized by increased upper airway resistance leading to disordered sleep.
Adenotonsillectomy has become the most common approach in the treatment of pediatric
OSA, increasing from 0% in 1978(
55. Rosenfeld RM, Green RP. Tonsillectomy and adenoidectomy: changing
trends. Ann Otol Rhinol Laryngol. 1990;99(3 Pt 1):187-91.
) to approximately 77% in 2005,(
66. Erickson BK, Larson DR, St Sauver JL, Meverden RA, Orvidas LJ.
Changes in incidence and indications of tonsillectomy and adenotonsillectomy,
1970-2005. Otolaryngol Head Neck Surg. 2009;140(6):894-901.
http://dx.doi.org/10.1016/j.otohns.2009.01.044
http://dx.doi.org/10.1016/j.otohns.2009....
) because it significantly improves disordered sleep, physical and emotional
symptoms,(
77. Tran KD, Nguyen CD, Weedon J, Goldstein NA. Child behavior and
quality of life in pediatric obstructive sleep apnea. Arch Otolaryngol Head Neck
Surg. 2005;131(1):52-7. http://dx.doi.org/10.1001/archotol.131.1.52
http://dx.doi.org/10.1001/archotol.131.1...
) and systemic inflammation secondary to OSA,(
22. Goldbart AD, Levitas A, Greenberg-Dotan S, Ben Shimol S, Broides A,
Puterman M, et al. B-type natriuretic peptide and cardiovascular function in young
children with obstructive sleep apnea. Chest. 2010;138(3):528-35.
http://dx.doi.org/10.1378/chest.10-0150
http://dx.doi.org/10.1378/chest.10-0150...
) and because it can reverse cor pulmonale. (
33. Cohen S, Springer C, Perles Z, Koplewitz BZ, Avital A, Revel-Vilk S.
Cardiac, lung, and brain thrombosis in a child with obstructive sleep apnea. Pediatr
Pulmonol. 2010;45(8):836-9. http://dx.doi.org/10.1002/ppul.21256
http://dx.doi.org/10.1002/ppul.21256...
)
Adenotonsillectomy is not risk-free; there is the possibility of hemorrhage,
dehydration, nausea, vomiting, pain,(
88. Brigger MT, Brietzke SE. Outpatient tonsillectomy in children: a
systematic review. Otolaryngol Head Neck Surg. 2006;135(1):1-7.
http://dx.doi.org/10.1016/j.otohns.2006.02.036
http://dx.doi.org/10.1016/j.otohns.2006....
) and need for additional airway support postoperatively.(
99. Rosen GM, Muckle RP, Mahowald MW, Goding GS, Ullevig C. Postoperative
respiratory compromise in children with obstructive sleep apnea syndrome: can it be
anticipated? Pediatrics. 1994;93(5):784-8.
10. McColley SA, April MM, Carroll JL, Naclerio RM, Loughlin GM.
Respiratory compromise after adenotonsillectomy in children with obstructive sleep
apnea. Arch Otolaryngol Head Neck Surg. 1992;118(9):940-3.
http://dx.doi.org/10.1001/archotol.1992.01880090056017
http://dx.doi.org/10.1001/archotol.1992....
-
1111. Wilson K, Lakheeram I, Morielli A, Brouillette R, Brown K. Can
assessment for obstructive sleep apnea help predict postadenotonsillectomy
respiratory complications? Anesthesiology. 2002;96(2):313-22.
http://dx.doi.org/10.1097/00000542-200202000-00015
http://dx.doi.org/10.1097/00000542-20020...
) In children undergoing adenotonsillectomy for OSA, the rate of respiratory
complications requiring medical intervention ranges from 21% to 36%.(
99. Rosen GM, Muckle RP, Mahowald MW, Goding GS, Ullevig C. Postoperative
respiratory compromise in children with obstructive sleep apnea syndrome: can it be
anticipated? Pediatrics. 1994;93(5):784-8.
,
1010. McColley SA, April MM, Carroll JL, Naclerio RM, Loughlin GM.
Respiratory compromise after adenotonsillectomy in children with obstructive sleep
apnea. Arch Otolaryngol Head Neck Surg. 1992;118(9):940-3.
http://dx.doi.org/10.1001/archotol.1992.01880090056017
http://dx.doi.org/10.1001/archotol.1992....
) OSA is commonly associated with risk factors for respiratory complications.
It is important to identify those factors that can increase the risk of postoperative
respiratory complications in children with OSA to ensure better quality of care and for
safety reasons.
There is a consensus that children with severe OSA should be observed
postoperatively.(
11. Baugh RF, Archer SM, Mitchell RB, Rosenfeld RM, Amin R, Burns JJ, et
al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck
Surg. 2011;144(1 Suppl):S1-30.
http://dx.doi.org/10.1177/0194599810389949
http://dx.doi.org/10.1177/01945998103899...
) However, there is disagreement over the safest place for clinical
observation after surgery: an outpatient setting; a pediatric ward; or a pediatric ICU
(PICU). Because of the paucity of evidence-based guidelines and studies for enabling
better clinical practice, the objective of this study was to identify risk factors for
possible respiratory complications after adenotonsillectomy in children ≤ 12 years of
age with OSA who were referred to the PICU.
Methods
This was a cross-sectional historical cohort study analyzing 53 children after adenotonsillectomy who met predetermined criteria for PICU referral in a tertiary level teaching hospital.
This study was approved by the Research Ethics Committee of the São Paulo State University Botucatu School of Medicine (Protocol no. CEP 4336-2012).
We included all male and female children 1 to 12 years of age, with adenotonsillar hypertrophy, admitted to the PICU after adenotonsillectomy, between January of 2006 and December of 2012. We excluded children with cardiac, pulmonary, neuromuscular, or chromosomal abnormalities and children with craniofacial anomalies, as well as children concurrently undergoing other surgical procedures associated with adenotonsillectomy, such as myringotomy, insertion of ventilation tubes, and/or diagnostic laryngoscopy. Referral to the ICU was based on clinical and/or polysomnographic criteria, which included age < 3 years, obesity, underweight, asthma, and/or polysomnographic changes (SpO2 nadir ≤ 80%, AHI ≥ 10 events/h).
All patients were evaluated by a single researcher during the perioperative period. Preoperative data were collected with a standardized history-taking questionnaire regarding age, gender, body mass index (BMI), presence of comorbidities-obesity (as defined on the basis of age-specific and gender-specific BMI percentile curves adopted by the World Health Organization [2007], with BMI percentiles ≥ 97 being a criterion of obesity), asthma, rhinitis, and upper respiratory tract infection (URTI)-adenoid size (as determined by examination with a 2.4-mm-diameter rigid endoscope with a 0-degree lens, on the basis of the adenoid/nasopharyngeal ratio), and tonsil size (as measured by Brodsky's scale)
Cardiorespiratory monitoring to confirm the diagnosis of OSA was performed on an inpatient basis, through the Department of Otolaryngology, for up to 6 months before adenotonsillectomy. The children underwent type I polysomnography (Alice(r); Phillips Respironics, Murrysville, PA, USA), or type III polysomnography (Stardust II(r); Phillips Respironics), or overnight oximetry to record SpO2 (PV 4000 LCD; Protec Equipamentos Médico-Hospitalares, São Paulo, Brazil). The respiratory parameters analyzed were as follows: apnea-hypopnea index (AHI); hypopnea index (HI); oxygen desaturation index (ODI); and SpO2 nadir. Data were recorded by the software of each device and were scored by a single rater. Oximetry was used to determine SpO2 nadir. Obstructive apnea was defined as a greater than 90% drop in nasal pressure excursions for at least 2 respiratory cycles, associated with thoracic and/or abdominal effort. Central apnea was defined as an absence of inspiratory effort throughout the event, with the event being ≥ 20 seconds in duration or lasting 2 respiratory cycles and being associated with an arousal or ≥ 3% oxygen desaturation. Hypopnea was characterized by a decrease of at least 50% in nasal pressure excursions, associated with ≥ 3% oxygen desaturation. The ODI was defined as the number of episodes of oxyhemoglobin desaturation ≥ 3% from baseline SpO2 per hour of sleep and ≥ 10 seconds in duration. SpO2 nadir was defined as the lowest SpO2 value, regardless of duration. OSA was classified as mild (AHI of 1 to 4.9 events/h), moderate (AHI of 5 to 9.9 events/h), or severe (AHI ≥ 10 events/h), and events were scored according to the recommended rules by the American Academy of Sleep Medicine (2007).
All surgical procedures were supervised, which allowed standardization of the surgical technique and the use of a standardized anesthetic protocol for children with OSA. Tonsillectomies and adenoidectomies were performed with the standard cold technique and a combination of intravenous (propofol [3mg/kg] and alfentanil [50mg/kg]) and inhalational (sevoflurane and/or N2O/O2 50:50) anesthesia. After surgery, all children were referred, intubated, to the PICU, where they remained intubated for up to 6 h and where they stayed for a minimum of 24 h, in accordance with the guidelines of the facility for children with severe apnea. The children were divided into two groups on the basis of absence of presence of respiratory complications after adenotonsillectomy.
Postoperative respiratory complications were divided into major complications (SpO2 ≤ 80%, laryngospasm, bronchospasm, apnea, pneumonia [confirmed by chest X-ray, leukocytosis with a left shift, and fever], and post-obstructive acute pulmonary edema [confirmed by chest X-ray or use of loop diuretics and reintubation]) and minor complications (SpO2between 90% and 80% requiring airway repositioning). In addition, we assessed duration of orotracheal intubation (OTI) after adenotonsillectomy as well as medical interventions (need for airway repositioning, use of positive pressure devices [continuous positive airway pressure or bilevel positive airway pressure], and reintubation).
Statistical analysis
Normality of data was tested with the Kolmogorov-Smirnov test, which was applied to all continuous variables in each group. The Student's t-test, Mann-Whitney test, and chi-square test were used for between-group comparisons of the study variables. Multiple linear regression analysis was performed to determine which variables correlated most closely with an increased risk of respiratory complications after adenotonsillectomy.
All tests were performed with Statistica, version 6.0 (StatSoft Inc., Tulsa, OK, USA), and the level of significance was set at 5%.
Results
Between January of 2006 and December of 2012, 805 adenotonsillectomies were performed in children with OSA in the teaching hospital, and 53 of those children were referred to the PICU. The reasons for referral to the PICU were age < 2 years (n = 2); obesity and/or asthma with an SpO2 nadir ≤ 80% (n = 10); an SpO2 nadir ≤ 75% (n = 4); mild OSA with an SpO2 nadir ≤ 70% (n = 1); moderate OSA associated with comorbidities (n = 5) or an SpO2 nadir ≤ 80% (n = 2); and severe OSA (n = 29). Respiratory parameters were recorded by type I polysomnography (n = 7), type III polysomnography (n = 30), and oximetry (n = 6).
Among the comorbidities assessed, rhinitis was the most common, occurring more frequently in the children with respiratory complications than in those without (Table 1). The children with respiratory complications had a higher AHI, a higher ODI, a lower SpO2 nadir, and a longer duration OTI than did those without complications (Table 2). After multiple linear regression analysis, the following independent variables were found to contribute to increasing the risk of respiratory complications after adenotonsillectomy: AHI; ODI; SpO2 nadir; rhinitis; and duration of OTI [p(R2) = 0.0099]; although, individually, no variable showed a close association with the clinical outcome (Table 3).
Of the 53 children studied, 21 (39.6%) had respiratory complications after adenotonsillectomy. The children were divided into two groups on the basis of absence of presence of respiratory complications (Table 1). The group without complications consisted of 32 children, 16 of whom were male, and the mean age was 6.1 ± 3.1 years (range, 1.6-12 years). The group with complications consisted of 21 children, 12 of whom were male, and the mean age was 5.3 ± 2.6 years (range, 2.4-12 years).
Seven children had minor respiratory complications (SpO2 90-80%), and 14 children had major respiratory complications (SpO2 ≤ 80% [n = 2]; laryngospasm [n = 9]; bronchospasm [n = 5]; intraoperative bronchospasm [n = 2]; apnea [n = 1]; pneumonia [n = 1]; and acute pulmonary edema [n = 3]; Table 4). The group with respiratory complications remained in the PICU for ≥ 24 h, and the main medical interventions were antibiotic therapy (n = 1) for pneumonia, use of loop diuretics (n = 3) for acute pulmonary edema, continuous administration of nebulized bronchodilator or adrenaline (n = 12) for bronchospasm and laryngospasm, and reintubation (n = 3) for acute pulmonary edema and severe bronchospasm in the presence of URTI (Table 4). The postoperative mortality rate was zero, and the children with and without respiratory complications remained hospitalized for 3 ± 1 days and 5 ± 2 days, respectively.
The respiratory complications observed after adenotonsillectomy are described individually in Table 4.
Discussion
Of the 805 children undergoing adenotonsillectomy between January of 2006 and December
of 2012 in the teaching hospital, 21 (2.6%) had postoperative respiratory complications.
This finding is similar to the results of other studies, in which the rate of
respiratory complications ranged from 1.3% to 13.4%.(
1212. Tweedie DJ, Bajaj Y, Ifeacho SN, Jonas NE, Jephson CG, Cochrane LA,
et al. Peri-operative complications after adenotonsillectomy in a UK pediatric
tertiary referral centre. Int J Pediatr Otorhinolaryngol. 2012;76(6):809-15.
http://dx.doi.org/10.1016/j.ijporl.2012.02.048
http://dx.doi.org/10.1016/j.ijporl.2012....
13. Biavati MJ, Manning SC, Phillips DL. Predictive factors for
respiratory complications after tonsillectomy and adenoidectomy in children. Arch
Otolaryngol Head Neck Surg. 1997;123(5):517-21.
http://dx.doi.org/10.1001/archotol.1997.01900050067009
http://dx.doi.org/10.1001/archotol.1997....
14. Kalra M, Buncher R, Amin RS. Asthma as a risk factor for respiratory
complications after adenotonsillectomy in children with obstructive breathing during
sleep. Ann Allergy Asthma Immunol. 2005;94(5):549-52.
http://dx.doi.org/10.1016/S1081-1206(10)61132-5
http://dx.doi.org/10.1016/S1081-1206(10)...
15. Jaryszak EM, Shah RK, Vanison CC, Lander L, Choi SS.
Polysomnographic variables predictive of adverse respiratory events after pediatric
adenotonsillectomy. Arch Otolaryngol Head Neck Surg. 2011;137(1):15-8.
http://dx.doi.org/10.1001/archoto.2010.226
http://dx.doi.org/10.1001/archoto.2010.2...
-
1616. Suen JS, Arnold JE, Brooks LJ. Adenotonsillectomy for treatment of
obstructive sleep apnea in children. Arch Otolaryngol Head Neck Surg.
1995;121(5):525-30.
http://dx.doi.org/10.1001/archotol.1995.01890050023005
http://dx.doi.org/10.1001/archotol.1995....
) Analysis of the children at high risk for complications who were referred
to the PICU (n = 53) revealed that the rate of respiratory complications was 39.6%,
which is also consistent with the findings of other studies, in which rates ranged from
25% to 60%. (
1111. Wilson K, Lakheeram I, Morielli A, Brouillette R, Brown K. Can
assessment for obstructive sleep apnea help predict postadenotonsillectomy
respiratory complications? Anesthesiology. 2002;96(2):313-22.
http://dx.doi.org/10.1097/00000542-200202000-00015
http://dx.doi.org/10.1097/00000542-20020...
,
1717. Hill CA, Litvak A, Canapari C, Cummings B, Collins C, Keamy DG, et
al. A pilot study to identify pre- and peri-operative risk factors for airway
complications following adenotonsillectomy for treatment of severe pediatric OSA. Int
J Pediatr Otorhinolaryngol. 2011;75(11):1385-90.
http://dx.doi.org/10.1016/j.ijporl.2011.07.034
http://dx.doi.org/10.1016/j.ijporl.2011....
18. McCormick ME, Sheyn A, Haupert M, Thomas R, Folbe AJ. Predicting
complications after adenotonsillectomy in children 3 years old and younger. Int J
Pediatr Otorhinolaryngol. 2011;75(11):1391-4.
http://dx.doi.org/10.1016/j.ijporl.2011.07.035
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2121. Ruboyianes JM, Cruz RM. Pediatric adenotonsillectomy for obstructive
sleep apnea. Ear Nose Throat J. 1996;75(7):430-3.
) It is of note that none of the children who had post-adenotonsillectomy
follow-up in the pediatric ward had any major respiratory complications requiring
transfer to the PICU.
The postoperative referral of the 53 children to the PICU was motivated by the presence
of OSA associated with one or more risk factors. According to the literature, children
with OSA aged < 2 years (
99. Rosen GM, Muckle RP, Mahowald MW, Goding GS, Ullevig C. Postoperative
respiratory compromise in children with obstructive sleep apnea syndrome: can it be
anticipated? Pediatrics. 1994;93(5):784-8.
,
1111. Wilson K, Lakheeram I, Morielli A, Brouillette R, Brown K. Can
assessment for obstructive sleep apnea help predict postadenotonsillectomy
respiratory complications? Anesthesiology. 2002;96(2):313-22.
http://dx.doi.org/10.1097/00000542-200202000-00015
http://dx.doi.org/10.1097/00000542-20020...
,
1717. Hill CA, Litvak A, Canapari C, Cummings B, Collins C, Keamy DG, et
al. A pilot study to identify pre- and peri-operative risk factors for airway
complications following adenotonsillectomy for treatment of severe pediatric OSA. Int
J Pediatr Otorhinolaryngol. 2011;75(11):1385-90.
http://dx.doi.org/10.1016/j.ijporl.2011.07.034
http://dx.doi.org/10.1016/j.ijporl.2011....
,
1818. McCormick ME, Sheyn A, Haupert M, Thomas R, Folbe AJ. Predicting
complications after adenotonsillectomy in children 3 years old and younger. Int J
Pediatr Otorhinolaryngol. 2011;75(11):1391-4.
http://dx.doi.org/10.1016/j.ijporl.2011.07.035
http://dx.doi.org/10.1016/j.ijporl.2011....
) or < 3 years(
2121. Ruboyianes JM, Cruz RM. Pediatric adenotonsillectomy for obstructive
sleep apnea. Ear Nose Throat J. 1996;75(7):430-3.
) and presenting with obesity,(
99. Rosen GM, Muckle RP, Mahowald MW, Goding GS, Ullevig C. Postoperative
respiratory compromise in children with obstructive sleep apnea syndrome: can it be
anticipated? Pediatrics. 1994;93(5):784-8.
,
1212. Tweedie DJ, Bajaj Y, Ifeacho SN, Jonas NE, Jephson CG, Cochrane LA,
et al. Peri-operative complications after adenotonsillectomy in a UK pediatric
tertiary referral centre. Int J Pediatr Otorhinolaryngol. 2012;76(6):809-15.
http://dx.doi.org/10.1016/j.ijporl.2012.02.048
http://dx.doi.org/10.1016/j.ijporl.2012....
,
1515. Jaryszak EM, Shah RK, Vanison CC, Lander L, Choi SS.
Polysomnographic variables predictive of adverse respiratory events after pediatric
adenotonsillectomy. Arch Otolaryngol Head Neck Surg. 2011;137(1):15-8.
http://dx.doi.org/10.1001/archoto.2010.226
http://dx.doi.org/10.1001/archoto.2010.2...
,
2222. Nafiu OO, Green GE, Walton S, Morris M, Reddy S, Tremper KK. Obesity
and risk of peri-operative complications in children presenting for
adenotonsillectomy. Int J Pediatr Otorhinolaryngol. 2009;73(1):89-95.
http://dx.doi.org/10.1016/j.ijporl.2008.09.027
http://dx.doi.org/10.1016/j.ijporl.2008....
23. Fung E, Cave D, Witmans M, Gan K, El-Hakim H. Postoperative
respiratory complications and recovery in obese children following adenotonsillectomy
for sleep-disordered breathing: a case-control study. Otolaryngol Head Neck Surg.
2010;142(6):898-905. http://dx.doi.org/10.1016/j.otohns.2010.02.012
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2424. Gleich SJ, Olson MD, Sprung J, Weingarten TN, Schroeder DR, Warner
DO, et al. Perioperative outcomes of severely obese children undergoing
tonsillectomy. Paediatr Anaesth. 2012;22(12):1171-8.
http://dx.doi.org/10.1111/j.1460-9592.2012.03905.x
http://dx.doi.org/10.1111/j.1460-9592.20...
) underweight,(
99. Rosen GM, Muckle RP, Mahowald MW, Goding GS, Ullevig C. Postoperative
respiratory compromise in children with obstructive sleep apnea syndrome: can it be
anticipated? Pediatrics. 1994;93(5):784-8.
,
2121. Ruboyianes JM, Cruz RM. Pediatric adenotonsillectomy for obstructive
sleep apnea. Ear Nose Throat J. 1996;75(7):430-3.
) asthma,(
1111. Wilson K, Lakheeram I, Morielli A, Brouillette R, Brown K. Can
assessment for obstructive sleep apnea help predict postadenotonsillectomy
respiratory complications? Anesthesiology. 2002;96(2):313-22.
http://dx.doi.org/10.1097/00000542-200202000-00015
http://dx.doi.org/10.1097/00000542-20020...
,
1414. Kalra M, Buncher R, Amin RS. Asthma as a risk factor for respiratory
complications after adenotonsillectomy in children with obstructive breathing during
sleep. Ann Allergy Asthma Immunol. 2005;94(5):549-52.
http://dx.doi.org/10.1016/S1081-1206(10)61132-5
http://dx.doi.org/10.1016/S1081-1206(10)...
) polysomnographic changes (SpO2 nadir ≤ 80%(
1111. Wilson K, Lakheeram I, Morielli A, Brouillette R, Brown K. Can
assessment for obstructive sleep apnea help predict postadenotonsillectomy
respiratory complications? Anesthesiology. 2002;96(2):313-22.
http://dx.doi.org/10.1097/00000542-200202000-00015
http://dx.doi.org/10.1097/00000542-20020...
) or < 72%,(
99. Rosen GM, Muckle RP, Mahowald MW, Goding GS, Ullevig C. Postoperative
respiratory compromise in children with obstructive sleep apnea syndrome: can it be
anticipated? Pediatrics. 1994;93(5):784-8.
,
1515. Jaryszak EM, Shah RK, Vanison CC, Lander L, Choi SS.
Polysomnographic variables predictive of adverse respiratory events after pediatric
adenotonsillectomy. Arch Otolaryngol Head Neck Surg. 2011;137(1):15-8.
http://dx.doi.org/10.1001/archoto.2010.226
http://dx.doi.org/10.1001/archoto.2010.2...
,
1919. Shine NP, Coates HL, Lannigan FJ, Duncan AW. Adenotonsillar surgery
in morbidly obese children: routine elective admission of all patients to the
intensive care unit is unnecessary. Anaesth Intensive Care.
2006;34(6):724-30.
) AHI ≥ 24 events/h,(
1717. Hill CA, Litvak A, Canapari C, Cummings B, Collins C, Keamy DG, et
al. A pilot study to identify pre- and peri-operative risk factors for airway
complications following adenotonsillectomy for treatment of severe pediatric OSA. Int
J Pediatr Otorhinolaryngol. 2011;75(11):1385-90.
http://dx.doi.org/10.1016/j.ijporl.2011.07.034
http://dx.doi.org/10.1016/j.ijporl.2011....
) high HI and/or high AHI),(
1515. Jaryszak EM, Shah RK, Vanison CC, Lander L, Choi SS.
Polysomnographic variables predictive of adverse respiratory events after pediatric
adenotonsillectomy. Arch Otolaryngol Head Neck Surg. 2011;137(1):15-8.
http://dx.doi.org/10.1001/archoto.2010.226
http://dx.doi.org/10.1001/archoto.2010.2...
) CO2 pressure > 45 mmHg and SpO2 <
86%,(
2121. Ruboyianes JM, Cruz RM. Pediatric adenotonsillectomy for obstructive
sleep apnea. Ear Nose Throat J. 1996;75(7):430-3.
) intraoperative laryngospasm,(
1717. Hill CA, Litvak A, Canapari C, Cummings B, Collins C, Keamy DG, et
al. A pilot study to identify pre- and peri-operative risk factors for airway
complications following adenotonsillectomy for treatment of severe pediatric OSA. Int
J Pediatr Otorhinolaryngol. 2011;75(11):1385-90.
http://dx.doi.org/10.1016/j.ijporl.2011.07.034
http://dx.doi.org/10.1016/j.ijporl.2011....
) or systemic comorbidities (neuromuscular abnormalities,(
99. Rosen GM, Muckle RP, Mahowald MW, Goding GS, Ullevig C. Postoperative
respiratory compromise in children with obstructive sleep apnea syndrome: can it be
anticipated? Pediatrics. 1994;93(5):784-8.
,
1111. Wilson K, Lakheeram I, Morielli A, Brouillette R, Brown K. Can
assessment for obstructive sleep apnea help predict postadenotonsillectomy
respiratory complications? Anesthesiology. 2002;96(2):313-22.
http://dx.doi.org/10.1097/00000542-200202000-00015
http://dx.doi.org/10.1097/00000542-20020...
,
2020. Brown KA, Morin I, Hickey C, Manoukian JJ, Nixon GM, Brouillette RT.
Urgent adenotonsillectomy: an analysis of risk factors associated with postoperative
respiratory morbidity. Anesthesiology. 2003;99(3):586-95.
http://dx.doi.org/10.1097/00000542-200309000-00013
http://dx.doi.org/10.1097/00000542-20030...
) craniofacial anomalies,(
99. Rosen GM, Muckle RP, Mahowald MW, Goding GS, Ullevig C. Postoperative
respiratory compromise in children with obstructive sleep apnea syndrome: can it be
anticipated? Pediatrics. 1994;93(5):784-8.
,
1111. Wilson K, Lakheeram I, Morielli A, Brouillette R, Brown K. Can
assessment for obstructive sleep apnea help predict postadenotonsillectomy
respiratory complications? Anesthesiology. 2002;96(2):313-22.
http://dx.doi.org/10.1097/00000542-200202000-00015
http://dx.doi.org/10.1097/00000542-20020...
,
2020. Brown KA, Morin I, Hickey C, Manoukian JJ, Nixon GM, Brouillette RT.
Urgent adenotonsillectomy: an analysis of risk factors associated with postoperative
respiratory morbidity. Anesthesiology. 2003;99(3):586-95.
http://dx.doi.org/10.1097/00000542-200309000-00013
http://dx.doi.org/10.1097/00000542-20030...
) cardiac abnormalities,(
1111. Wilson K, Lakheeram I, Morielli A, Brouillette R, Brown K. Can
assessment for obstructive sleep apnea help predict postadenotonsillectomy
respiratory complications? Anesthesiology. 2002;96(2):313-22.
http://dx.doi.org/10.1097/00000542-200202000-00015
http://dx.doi.org/10.1097/00000542-20020...
,
1212. Tweedie DJ, Bajaj Y, Ifeacho SN, Jonas NE, Jephson CG, Cochrane LA,
et al. Peri-operative complications after adenotonsillectomy in a UK pediatric
tertiary referral centre. Int J Pediatr Otorhinolaryngol. 2012;76(6):809-15.
http://dx.doi.org/10.1016/j.ijporl.2012.02.048
http://dx.doi.org/10.1016/j.ijporl.2012....
,
2020. Brown KA, Morin I, Hickey C, Manoukian JJ, Nixon GM, Brouillette RT.
Urgent adenotonsillectomy: an analysis of risk factors associated with postoperative
respiratory morbidity. Anesthesiology. 2003;99(3):586-95.
http://dx.doi.org/10.1097/00000542-200309000-00013
http://dx.doi.org/10.1097/00000542-20030...
,
2525. Kalra M, Kimball TR, Daniels SR, LeMasters G, Willging PJ, Rutter M,
et al. Structural cardiac changes as a predictor of respiratory complications after
adenotonsillectomy for obstructive breathing during sleep in children. Sleep Med.
2005;6(3):241-5. http://dx.doi.org/10.1016/j.sleep.2004.10.004
http://dx.doi.org/10.1016/j.sleep.2004.1...
) and chromosomal abnormalities)(
1111. Wilson K, Lakheeram I, Morielli A, Brouillette R, Brown K. Can
assessment for obstructive sleep apnea help predict postadenotonsillectomy
respiratory complications? Anesthesiology. 2002;96(2):313-22.
http://dx.doi.org/10.1097/00000542-200202000-00015
http://dx.doi.org/10.1097/00000542-20020...
,
1212. Tweedie DJ, Bajaj Y, Ifeacho SN, Jonas NE, Jephson CG, Cochrane LA,
et al. Peri-operative complications after adenotonsillectomy in a UK pediatric
tertiary referral centre. Int J Pediatr Otorhinolaryngol. 2012;76(6):809-15.
http://dx.doi.org/10.1016/j.ijporl.2012.02.048
http://dx.doi.org/10.1016/j.ijporl.2012....
) have increased rates of respiratory complications after adenotonsillectomy.
However, after this study's analyses of the results for postoperative respiratory
complications, the local department of otolaryngology discontinued the routine practice
of referring patients < 12 years of age with OSA and/or risk factors to the PICU
after adenotonsillectomy. What is recommended is that a sleep study be performed to
determine the severity of the respiratory disorder and a thorough clinical history be
taken to identify risk factors. For patients with severe OSA associated with severe
comorbidities (chromosomal, cardiac, and neuromuscular abnormalities, as well as
craniofacial anomalies) and/or children < 2 years of age, the recommendation for
postoperative observation in the PICU still applies.
The risk factors that could predict respiratory complications after adenotonsillectomy were polysomnographic parameters (high AHI [mean of 28.6 events/h]; high ODI [mean of 29.8 episodes/h]; and low SpO2 nadir [mean of 64.4%]), presence of rhinitis, and prolonged postoperative OTI (Table 2).
A higher AHI, a higher ODI, and a lower SpO2 nadir on the preoperative sleep
study translate to a higher prevalence of respiratory complications in children. Our
results were similar to those found in other studies that correlated polysomnographic
findings with postoperative respiratory complications and medical
interventions.(
1010. McColley SA, April MM, Carroll JL, Naclerio RM, Loughlin GM.
Respiratory compromise after adenotonsillectomy in children with obstructive sleep
apnea. Arch Otolaryngol Head Neck Surg. 1992;118(9):940-3.
http://dx.doi.org/10.1001/archotol.1992.01880090056017
http://dx.doi.org/10.1001/archotol.1992....
,
1111. Wilson K, Lakheeram I, Morielli A, Brouillette R, Brown K. Can
assessment for obstructive sleep apnea help predict postadenotonsillectomy
respiratory complications? Anesthesiology. 2002;96(2):313-22.
http://dx.doi.org/10.1097/00000542-200202000-00015
http://dx.doi.org/10.1097/00000542-20020...
,
1515. Jaryszak EM, Shah RK, Vanison CC, Lander L, Choi SS.
Polysomnographic variables predictive of adverse respiratory events after pediatric
adenotonsillectomy. Arch Otolaryngol Head Neck Surg. 2011;137(1):15-8.
http://dx.doi.org/10.1001/archoto.2010.226
http://dx.doi.org/10.1001/archoto.2010.2...
,
1717. Hill CA, Litvak A, Canapari C, Cummings B, Collins C, Keamy DG, et
al. A pilot study to identify pre- and peri-operative risk factors for airway
complications following adenotonsillectomy for treatment of severe pediatric OSA. Int
J Pediatr Otorhinolaryngol. 2011;75(11):1385-90.
http://dx.doi.org/10.1016/j.ijporl.2011.07.034
http://dx.doi.org/10.1016/j.ijporl.2011....
,
2626. Schroeder JW Jr, Anstead AS, Wong H. Complications in children who
electively remain intubated after adenotonsillectomy for severe obstructive sleep
apnea. Int J Pediatr Otorhinolaryngol. 2009;73(8):1095-9.
http://dx.doi.org/10.1016/j.ijporl.2009.04.007
http://dx.doi.org/10.1016/j.ijporl.2009....
) Schroeder et al.(
2626. Schroeder JW Jr, Anstead AS, Wong H. Complications in children who
electively remain intubated after adenotonsillectomy for severe obstructive sleep
apnea. Int J Pediatr Otorhinolaryngol. 2009;73(8):1095-9.
http://dx.doi.org/10.1016/j.ijporl.2009.04.007
http://dx.doi.org/10.1016/j.ijporl.2009....
) observed that 43% of the children with an AHI > 25 events/h required
some intervention as a result of respiratory complications. Another study showed that a
higher AHI (mean of 31.8 events/h), a higher HI (mean of 22.6 events/h), and a lower
SpO2 nadir (mean of 71.7%) translate to a stronger correlation with
respiratory complications, and that desaturation events were the ones most commonly
requiring oxygen supplementation. (
1515. Jaryszak EM, Shah RK, Vanison CC, Lander L, Choi SS.
Polysomnographic variables predictive of adverse respiratory events after pediatric
adenotonsillectomy. Arch Otolaryngol Head Neck Surg. 2011;137(1):15-8.
http://dx.doi.org/10.1001/archoto.2010.226
http://dx.doi.org/10.1001/archoto.2010.2...
) Therefore, it is clear that determining apnea severity via a sleep study
(polysomnography) before surgery is important in predicting the risk of possible
postoperative respiratory complications.
Among the comorbidities assessed, only rhinitis was found to be statistically
significant in the group with respiratory complications. Because children with severe
OSA have greater airway collapsibility(
2727. Gozal D, Burnside MM. Increased upper airway collapsibility in
children with obstructive sleep apnea during wakefulness. Am J Respir Crit Care Med.
2004;169(2):163-7. http://dx.doi.org/10.1164/rccm.200304-590OC
http://dx.doi.org/10.1164/rccm.200304-59...
,
2828. Marcus CL, McColley SA, Carroll JL, Loughlin GM, Smith PL, Schwartz
AR. Upper airway collapsibility in children with obstructive sleep apnea syndrome. J
Appl Physiol (1985). 1994;77(2):918-24.
) and are more susceptible to the respiratory-depressant effects of
anesthetics and opioids,(
2929. Brown KA, Laferrière A, Moss IR. Recurrent hypoxemia in young
children with obstructive sleep apnea is associated with reduced opioid requirement
for analgesia. Anesthesiology. 2004;100(4):806-10; discussion 5A.
,
3030. Waters KA, McBrien F, Stewart P, Hinder M, Wharton S. Effects of
OSA, inhalational anesthesia, and fentanyl on the airway and ventilation of children.
J Appl Physiol (1985). 2002;92(5):1987-94.
) it is possible that rhinitis associated with increased secretions and upper
airway edema can contribute to greater resistance and, consequently, to an increased
likelihood of perioperative respiratory complications.
Although several studies in the literature have demonstrated that age < 2
years(
99. Rosen GM, Muckle RP, Mahowald MW, Goding GS, Ullevig C. Postoperative
respiratory compromise in children with obstructive sleep apnea syndrome: can it be
anticipated? Pediatrics. 1994;93(5):784-8.
,
1111. Wilson K, Lakheeram I, Morielli A, Brouillette R, Brown K. Can
assessment for obstructive sleep apnea help predict postadenotonsillectomy
respiratory complications? Anesthesiology. 2002;96(2):313-22.
http://dx.doi.org/10.1097/00000542-200202000-00015
http://dx.doi.org/10.1097/00000542-20020...
,
1717. Hill CA, Litvak A, Canapari C, Cummings B, Collins C, Keamy DG, et
al. A pilot study to identify pre- and peri-operative risk factors for airway
complications following adenotonsillectomy for treatment of severe pediatric OSA. Int
J Pediatr Otorhinolaryngol. 2011;75(11):1385-90.
http://dx.doi.org/10.1016/j.ijporl.2011.07.034
http://dx.doi.org/10.1016/j.ijporl.2011....
,
1818. McCormick ME, Sheyn A, Haupert M, Thomas R, Folbe AJ. Predicting
complications after adenotonsillectomy in children 3 years old and younger. Int J
Pediatr Otorhinolaryngol. 2011;75(11):1391-4.
http://dx.doi.org/10.1016/j.ijporl.2011.07.035
http://dx.doi.org/10.1016/j.ijporl.2011....
) or < 3 years,(
2121. Ruboyianes JM, Cruz RM. Pediatric adenotonsillectomy for obstructive
sleep apnea. Ear Nose Throat J. 1996;75(7):430-3.
) obesity,(
99. Rosen GM, Muckle RP, Mahowald MW, Goding GS, Ullevig C. Postoperative
respiratory compromise in children with obstructive sleep apnea syndrome: can it be
anticipated? Pediatrics. 1994;93(5):784-8.
,
1212. Tweedie DJ, Bajaj Y, Ifeacho SN, Jonas NE, Jephson CG, Cochrane LA,
et al. Peri-operative complications after adenotonsillectomy in a UK pediatric
tertiary referral centre. Int J Pediatr Otorhinolaryngol. 2012;76(6):809-15.
http://dx.doi.org/10.1016/j.ijporl.2012.02.048
http://dx.doi.org/10.1016/j.ijporl.2012....
,
1515. Jaryszak EM, Shah RK, Vanison CC, Lander L, Choi SS.
Polysomnographic variables predictive of adverse respiratory events after pediatric
adenotonsillectomy. Arch Otolaryngol Head Neck Surg. 2011;137(1):15-8.
http://dx.doi.org/10.1001/archoto.2010.226
http://dx.doi.org/10.1001/archoto.2010.2...
,
2222. Nafiu OO, Green GE, Walton S, Morris M, Reddy S, Tremper KK. Obesity
and risk of peri-operative complications in children presenting for
adenotonsillectomy. Int J Pediatr Otorhinolaryngol. 2009;73(1):89-95.
http://dx.doi.org/10.1016/j.ijporl.2008.09.027
http://dx.doi.org/10.1016/j.ijporl.2008....
23. Fung E, Cave D, Witmans M, Gan K, El-Hakim H. Postoperative
respiratory complications and recovery in obese children following adenotonsillectomy
for sleep-disordered breathing: a case-control study. Otolaryngol Head Neck Surg.
2010;142(6):898-905. http://dx.doi.org/10.1016/j.otohns.2010.02.012
http://dx.doi.org/10.1016/j.otohns.2010....
-
2424. Gleich SJ, Olson MD, Sprung J, Weingarten TN, Schroeder DR, Warner
DO, et al. Perioperative outcomes of severely obese children undergoing
tonsillectomy. Paediatr Anaesth. 2012;22(12):1171-8.
http://dx.doi.org/10.1111/j.1460-9592.2012.03905.x
http://dx.doi.org/10.1111/j.1460-9592.20...
) and asthma(
1111. Wilson K, Lakheeram I, Morielli A, Brouillette R, Brown K. Can
assessment for obstructive sleep apnea help predict postadenotonsillectomy
respiratory complications? Anesthesiology. 2002;96(2):313-22.
http://dx.doi.org/10.1097/00000542-200202000-00015
http://dx.doi.org/10.1097/00000542-20020...
,
1414. Kalra M, Buncher R, Amin RS. Asthma as a risk factor for respiratory
complications after adenotonsillectomy in children with obstructive breathing during
sleep. Ann Allergy Asthma Immunol. 2005;94(5):549-52.
http://dx.doi.org/10.1016/S1081-1206(10)61132-5
http://dx.doi.org/10.1016/S1081-1206(10)...
) are related to a greater likelihood of respiratory complications after
adenotonsillectomy, this study found no statistically significant differences among
these variables in terms of the occurrence of respiratory events (Table 1). It may be that this lack of significance is due to the
small sample size, to the fact that this was a group of children at increased risk for
respiratory complications, and to the fact that the children were similar in terms of
comorbidities.
Duration of OTI (Table 2) was statistically
longer in patients with respiratory complications, corroborating Schroeder Jr. et
al.,(
2626. Schroeder JW Jr, Anstead AS, Wong H. Complications in children who
electively remain intubated after adenotonsillectomy for severe obstructive sleep
apnea. Int J Pediatr Otorhinolaryngol. 2009;73(8):1095-9.
http://dx.doi.org/10.1016/j.ijporl.2009.04.007
http://dx.doi.org/10.1016/j.ijporl.2009....
) who demonstrated that delaying extubation can increase the likelihood of
respiratory complications in a group who is already at high risk. Therefore, children
undergoing adenotonsillectomy for OSA associated with comorbidities who remained
intubated after surgery had increased complication rates and, consequently, prolonged
hospital stays.
This study was limited by its small sample size, surgeons' varied preferences of where
postoperative observation should occur, and a possible bias in selecting children for
polysomnography. A prospective study with a larger sample size is needed to determine
possible risk factors associated with an increased likelihood of respiratory
complications after adenotonsillectomy.(
1717. Hill CA, Litvak A, Canapari C, Cummings B, Collins C, Keamy DG, et
al. A pilot study to identify pre- and peri-operative risk factors for airway
complications following adenotonsillectomy for treatment of severe pediatric OSA. Int
J Pediatr Otorhinolaryngol. 2011;75(11):1385-90.
http://dx.doi.org/10.1016/j.ijporl.2011.07.034
http://dx.doi.org/10.1016/j.ijporl.2011....
)
The results of the present study indicate that, among children up to 12 years of age diagnosed with OSA, those who have a high AHI, a high ODI, and a low SpO2 nadir on preoperative polysomnography, as well as rhinitis, are more likely to develop respiratory complications after adenotonsillectomy than are those without such characteristics.
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» http://dx.doi.org/10.1001/archotol.1992.01880090056017 -
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» http://dx.doi.org/10.1097/00000542-200202000-00015 -
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» http://dx.doi.org/10.1016/S1081-1206(10)61132-5 -
15Jaryszak EM, Shah RK, Vanison CC, Lander L, Choi SS. Polysomnographic variables predictive of adverse respiratory events after pediatric adenotonsillectomy. Arch Otolaryngol Head Neck Surg. 2011;137(1):15-8. http://dx.doi.org/10.1001/archoto.2010.226
» http://dx.doi.org/10.1001/archoto.2010.226 -
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17Hill CA, Litvak A, Canapari C, Cummings B, Collins C, Keamy DG, et al. A pilot study to identify pre- and peri-operative risk factors for airway complications following adenotonsillectomy for treatment of severe pediatric OSA. Int J Pediatr Otorhinolaryngol. 2011;75(11):1385-90. http://dx.doi.org/10.1016/j.ijporl.2011.07.034
» http://dx.doi.org/10.1016/j.ijporl.2011.07.034 -
18McCormick ME, Sheyn A, Haupert M, Thomas R, Folbe AJ. Predicting complications after adenotonsillectomy in children 3 years old and younger. Int J Pediatr Otorhinolaryngol. 2011;75(11):1391-4. http://dx.doi.org/10.1016/j.ijporl.2011.07.035
» http://dx.doi.org/10.1016/j.ijporl.2011.07.035 -
19Shine NP, Coates HL, Lannigan FJ, Duncan AW. Adenotonsillar surgery in morbidly obese children: routine elective admission of all patients to the intensive care unit is unnecessary. Anaesth Intensive Care. 2006;34(6):724-30.
-
20Brown KA, Morin I, Hickey C, Manoukian JJ, Nixon GM, Brouillette RT. Urgent adenotonsillectomy: an analysis of risk factors associated with postoperative respiratory morbidity. Anesthesiology. 2003;99(3):586-95. http://dx.doi.org/10.1097/00000542-200309000-00013
» http://dx.doi.org/10.1097/00000542-200309000-00013 -
21Ruboyianes JM, Cruz RM. Pediatric adenotonsillectomy for obstructive sleep apnea. Ear Nose Throat J. 1996;75(7):430-3.
-
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» http://dx.doi.org/10.1016/j.ijporl.2008.09.027 -
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*
Study carried out in the Department of Ophthalmology, Otolaryngology and Head and Neck Surgery, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - FMB-UNESP, São Paulo State University Botucatu School of Medicine - Botucatu, Brazil.
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Financial support: None.
Publication Dates
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Publication in this collection
18 Apr 2015 -
Date of issue
May-Jun 2015
History
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Received
05 Sept 2014 -
Accepted
03 Feb 2015