Review Article
Surgical versus conservative management of congenital pulmonary airway malformation in children: A systematic review and meta-analysis

https://doi.org/10.1016/j.jpedsurg.2015.11.022Get rights and content

Abstract

Background

The ideal management of infants born with asymptomatic congenital pulmonary airway malformation (CPAM) is controversial. We performed a systematic review and meta-analysis comparing elective resection versus expectant management.

Methods

We searched CENTRAL, MEDLINE, EMBASE, CINAHL, and PubMed for studies describing the management of asymptomatic CPAM and reporting on postoperative morbidity, mortality, and length of hospital stay (LOS). We performed meta-analyses when possible and provide a narrative summary of results.

Results

One nonrandomized prospective and eight retrospective studies met our inclusion criteria. Out of 168 patients, 70 underwent surgery before symptoms developed with seven experiencing postoperative complications (10.0%); 63 developed symptoms while being managed expectantly and subsequently underwent surgery with 20 complications (31.8%). Thirty-five patients continued to be followed nonsurgically (three months to nine years of follow-up). Morbidity was higher with surgery after symptom development (6 studies; odds ratio 4.59, 95% confidence interval (CI) 1.40 to 15.11, P < 0.01); there was no difference in LOS (3 studies; mean difference 4.96, 95% CI − 1.75 to 11.67, P = 0.15). There were no related deaths.

Conclusions

Elective resection of asymptomatic CPAM lesions is safe and prevents the risk of symptom development, which may result in a more complicated surgery and recovery.

Section snippets

Selection of study topic

We used a Dephi-like method [17] to determine the issues of greatest concern to pediatric surgeons regarding the surgical management of CPAM.

Studies included

Our electronic search yielded 342 studies. After applying our exclusion criteria to titles and abstracts, 63 studies remained. Full-text review resulted in eight of these studies being included, while an additional one was identified from hand-searching the reference sections of included articles; nine studies were ultimately included [10], [11], [12], [14], [23], [24], [25], [26], [27]. Seven of these were amenable to inclusion in meta-analyses [10], [11], [12], [14], [23], [24], [25] (Fig. 1).

Summary and comparison with the literature

With the wide use of antenatal ultrasound, CPAM is often diagnosed before birth, and may remain asymptomatic for years. Whether asymptomatic children should undergo elective lung resection is disputed [6], [7]. We have attempted to compare patients who underwent resection of CPAM lesions while asymptomatic to those who were managed expectantly and had surgery only upon the development of symptoms, in terms of morbidity and length of stay in hospital.

We identified nine studies reporting on a

Conclusions

Based on our results, we recommend elective resection of asymptomatic CPAM lesions, rather than expectant management. Lung resection in an asymptomatic patient is quite safe, prevents the risk of symptom development later in life, and may help prevent the development of malignancy. The ideal timing of elective resection will be the topic of a future review.

Acknowledgments

The University of Ottawa Summer Studentship program provided financial support for this project. We thank Colin Way for his help quality assessing included articles and Katrina Sullivan for proof-reading the manuscript.

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