Dermatology Online Journal

Risk factors in pediatric dermatologic surgery
Fernando Alfageme Roldan¹, Cristina Ciudad Blanco¹, Minia Campos Dominguez¹, Ricardo Suárez Fernández¹, José Manuel Hernanz Hermosa², Pablo Lázaro Ochaita¹
Dermatology Online Journal 15 (9): 2

1. Dermatology Services Hospital Gregorio Marañón
2. Hospital Infanta Leonor
Madrid, Spain. feralfarol@yahoo.es

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Abstract

BACKGROUND: Specific risk factors for complications in pediatric dermatologic surgery have not been studied in previous reports. OBJECTIVES: Analyze complications of a cohort of children for anesthetic and surgical complications and determine specific risk factors for surgical complications. METHODS: Retrospective collection of data from 210 consecutive children having operations over 6 years. Bivariate and logistic regression statistical analysis of complications and risk factors was conducted for single step interventions. RESULTS: General anesthesia complications were observed in 10.07 percent of the cases: Agitation and stridor were the most common anesthetic complications. Surgical complications were observed in 22.63 percent of the cases. Scar stretching followed by infection were the most prevalent complications. Complication rates, both anesthetic (9.09%) and surgical (13.63%) of multiple step interventions were similar to single step surgery. Intradermal absorbable suture in upper closure (p=0.028) and in limb (p=0.014) location were independently associated with complications. CONCLUSION: General anesthesia is safe in pediatric dermatology in the hands of experienced pediatric anesthetists. The most frequent surgical complication was scar stretching. Limb location and use of absorbable continuous intradermal suture in the upper closures should be taken into account as possible risk factors when informing parents and performing these procedures.

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Introduction

Pediatric dermatologic surgery is performed every day by more and more pediatric dermatologists [1]. These procedures must be tailored to both the child and parent. Special conditions for children and required when considering details about the surgical personnel, consultation, operating room and postoperative care. Data on specific risks, both anesthetic and surgical, are sparse and analysis of risk factors for specific complications are lacking. This information would be helpful for both parents and dermatologic surgeons performing these procedures.

Methods

Two hundred ten consecutive surgical procedures between 2001 and 2007 were reviewed from clinical charts. All procedures were performed in an operation theatre assisted by a pediatric anesthetist. Patients were examined one week after procedures for stitch removal and to assess any early complications. A second visit was scheduled three months after to observe forlate complications. Analysis of data concerning demographic variables, size, nature and location of the lesions, operative anesthesia type, surgical techniques, and suture techniques and materialswas performed. Complications, both anesthetic and surgical, in the immediate and late postoperative period were also collected.

Statistic analysis of variables possibly related to the absence or presence of complications was performed. χ² and Fischer exact tests were used for discrete variables. In the case of normal-distributed continuous variables t-Student mean comparation was used. Logistic regression analysis for presence or absence of complications for same variables was also performed. A bitailed statistic significance level of 95 percent was required. SPSS 15.0© software was used for both analyses.

Results

Demographic and lesion data

From 2001 to 2007, 190 single step (ss) surgical procedures on190 lesions and 22 procedures on 8 large congenital nevi requiring excisions in multiple steps (ms) were performed.

Analysis of the sex and age distribution of the children showed 92 boys and 98 girls between 3 months and 16 years of age, with a mean age of 8.56 ± 4.14 years. The histologic diagnoses of the lesions excised are presented in Table 1. The most frequent excised lesions were congenital melanocytic nevi (CMN), followed by sebaceus nevi (SN) and acquired menlanocytic nevi (AN). Clinical-pathological correlation was more difficult in neural and fibroepithelial lesions. Mean size of the lesions was 20.9 ± 16.8 mm (excluding multiple step CMN) with a minimum of 4 mm and a maximum of 100 mm. Location of the lesions excised is summarized in Table 2.

Surgery and anesthesia

General anesthesia (GA) was given in 79 percent of the procedures (139) and conscious sedation with local anesthesia (LA) in the rest of the procedures. The mean age for GA was 11.3 years and 7.5 years for LA. The age difference between local and general anesthesia was statistically significant (p=0.04).

The mean surgical time was 13.80 ± 23.3 minutes and the total time including anesthesia was 47.20 ± 15.3 minutes. The mean postoperative stay in a specialized anesthesia recovery room was 38 ± 27.54 min. Children were then transferred to day hospital facilities until oral tolerance was confirmed.

Surgical closure was direct in most cases. Two A-T flaps and one graft were the only exceptions. Interrupted subcutaneous absorbable sutures were used in 79.7 percent of the cases. Surface suture techniques included continuous intradermal absorbable sutures in 46.2 percent of the cases and interrupted non-absorbable stitches in 49.7 percent of cases. Acrylic bioglues were used in 8 cases after subcutaneous secured absorbable interrupted stitches were placed.

Complications

General anesthesia complications were observed in 14 patients (10.07%) (Table 3). The most frequent complication was agitation followed by nausea. No cardiac arrest or need of re-intubation was reported. Surgical complications were observed in 22.63 percent of the cases (Table 4). The most frequent surgical complication was scar stretching followed by hypertrophic scar, keloid, and infection. Antibiotics (topical or oral) were required in 4 patients and re-intervention was also needed in 5 cases (3 hypertrophic scars, one suture dehiscence, and a recurrence).

Multiple step (ms) surgeries

A total of 8 children were operated upon in multiple steps for excision of large melanocytic congenital nevi, for a total of 22 interventions. Table 5 is a compilation of the demographic data, including lesion size, location, and complications for this type of surgery. Two anesthetics (9 %) and three surgical complications (13%) occurred. As other risk factors could intervene in these surgeries, these were excluded from general statistic analysis.

Bivariate risk analysis of surgical complications

In the bivariate statistical analysis of the variables with respect to the presence or absence of complications, limb location of the lesions and the use of intradermal superficial sutures were associated with an increase in complication rate (Table 6). Statistical dependence of these two variables was excluded (p=0.3). Age groups were also analyzed for complications; although there was an increased proportion of complications in older age children, this did not prove to be statistically significant. Other variables, such as sex, other locations (back or face), or size of the lesion were not statistically significant.

Multivariate risk analysis of surgical complications

Logistic regression for the presence or absence of complications was also statistically significant for limb location and intradermal absorbable suture in upper closure (Table 7). Other tested variables such as back location, size, or age weren't significant in the logistic regression analysis.

Conclusions

Whether the dermatologic surgeon or plastic surgeon should perform surgical dermatologic procedures is an undecided debate [2]. In the case of children this debate hasn't even started. It's reasonable that, after proper surgical training, the very same specialist who diagnoses these conditions could also perform these procedures.

Analysis of results is mandatory when sufficient experience has been accumulated to identify problems and improve results. The lack of previous reports regarding complications in this type of surgery in this age group makes this report of special interest. When compared with other reports on complications in dermatologic surgery or pediatric surgery the incidence of both anesthetic and surgical complications is similar.

With respect to complications in children's general anesthesia, Tiret [3] in a multicentric study, rates the general anesthetic risk for major complications in this age group, including major surgery, as 0.7 per 1000 interventions, with a cardiac arrest or death risk of 0.21 per 1000 interventions. With respect to general anesthesia in minor skin surgery/lasers in children, Cunningham et al. reports a 10 percent complication rate in a multicentric study [4]. Emesis was the most common complication with no major complications; no cardiac arrest was recorded. In this article, it is also demonstrated that those children on general anesthesia generally do not have an increased rate of complications.

Regarding surgical complications, the rate of immediate postoperative complications in prospective studies in skin surgery in adults is similar to ours. Amici et al. [5] in a prospective survey of 3788 skin surgeries in a single center in adults reports a risk of infection of 2 percent. No reports on scar stretching incidence have been published to date in adults or children. This was the most common complication in our study, and may be due to the special features of the skin and activity of children.

Scar stretching and dehiscence are complications with a direct relationship to avoidingtensile force until scar formation is instituted [6]. In an experimental report on the influence of sutures and tension in minipigs [7], the scar width correlated exponentially with tension on the suture line; tension was linearly correlated with resection. No difference was noted between intradermal, continuous, or interrupted suture with either absorbable or non-absorbable sutures.

Theoretically, the mechanical stretch force of intradermal absorbable sutures is inferior to interrupted sutures in mobile areas [7, 8]. According to Orozco-Covarrubias [9] in the areas such as face and neck (low tension areas) the use of intradermal absorbable sutures or interrupted non-absorbable sutures yield similar esthetic results. Other studies favor the use of intradermal absorbable sutures in comparison with non-absorbable interrupted stitches [10, 11].

The results of our study show that limb location, independent of suture type, is more prone to surgical complications. Increased mobility of limbs could be a reason for this increased complication rate within this location. Whether continuous absorbable intradermal sutures should or should not be used in these regions has not been elucidated in our study. With respect to age, the tendency of more complications in older children could be also related to increased activity in this age group. However, this has not proved to be statistically significant in this study. Neither sex nor size of lesions were relevant with respect to surgical complications, even though one might postulate that boys are more active or that, as experimentally demonstrated, larger resections may have higher stretch forces [8].

Despite the few cases of multiple step surgeries performed (n=22), the surgical complication rate was not higher than in single step surgery (13.63% in ms vs 22.63% in ss). The idea of cumulative risk for general anesthesia in these multiple interventions is not sustained in our short series in which both complication rates were quite similar (9.09% in ms vs. 10.03% in ss).

The main limitation of this study is its retrospective nature. Underreported complication is a possible bias that has to be taken into account when interpreting these data. However, as previously stated, similar complication rates have been published in previous prospective dermatologic surgery studies, although these were different in patient age and type of surgery. Another limitation to this study is that follow up reviews were limited to 90 days in cases that showedno complications. Scar remodelling is a long process that sometimes can be favorable or unfavorable for the cosmetics of the scar.

This is to our knowledge, the first report on complications, both anesthetic and surgical, in this type of surgical procedure, performed by dermatologists in children. Regardless of its retrospective nature, it adds information about complications that should be useful in deciding upon procedures and in counseling parents.

Acknowledgments: I would like to thank all the staff, and present and past residents of Hospital Gregorio Marañon who in fact operated on these children with wholehearted care and professionalism towards their patients and their families. Special acknowledgments are for Prof Almudena Bermejo (Economy Department Universidad Carlos III) and Dr. Jose Maria Bellón (Statistics Department Hospital Gregorio Marañón for statistic review and proposals and Mrs. Concepción García and Mrs. Paloma Fernandez for their help with data collection.

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