Video-Assisted Thoracoscopic Surgery for Pulmonary Sequestration in Children

Abundant hemoptysis revealing an aneurysm of an aberrant systemic artery to the left lower pulmonary lobe: A case report

Pulmonary sequestration (PS) is a congenital anomaly characterized by a lung region that is isolated from its normal bronchial and vascular connections. It typically receives blood supply from an aberrant systemic artery. An aneurysm of that aberrant artery is extremely rare. We report the case of a 55-year-old female patient who was incidentally diagnosed with intralobar PS after experiencing severe hemoptysis. The diagnosis was set by a chest contrast-enhanced computed tomography (CT), which also revealed an aneurysm of the aberrant systemic artery. A left lower lobectomy was successfully performed which confirmed the diagnosis. PS is characterized by a mass of lung tissue that lacks connection to the normal bronchial tree and is supplied with blood from the systemic circulation. There are 2 primary types: intralobar (ILS), located within a lung lobe, and extralobar (ELS), situated outside the lobes with abnormal vascular connections typically originating from the thoracic or abdominal aorta. In ILS, drainage usually occurs through pulmonary veins, whereas ELS often drains via the azygos or portal venous system. CT and magnetic resonance imaging (MRI) are preferred for diagnosing PS. They can also reveal complications such as an aneurysm of the aberrant artery, as in our case. PS is a rare yet significant anomaly to consider in cases of recurrent pneumonia or persistent consolidative opacities, especially when involving the lower lobe of the left lung. CT and MRI are highly valuable for pinpointing the lesion and identifying the feeder blood vessel associated with it.

Interlobar pulmonary sequestration with celiac aberrant artery in an elderly patient treated with combined endovascular and video-assisted thoracoscopic approach

Pulmonary sequestration is a rare congenital pulmonary anomaly where a portion of the lung parenchyma is supplied by an anomalous systemic artery, usually originating from the thoracic or abdominal aorta. Traditionally surgical resection and ligation of the aberrant feeding vessel are the gold standard treatments of this disease. Hybrid operations consisting in endovascular arterial embolization and surgical resection is a promising treatment option. We report a case of a 69-years-old man with symptomatic intralobular sequestration successfully treated by hybrid approach.

The clinical management of extralobar pulmonary sequestration in children

INTRODUCTION

The treatment of extralobar pulmonary sequestration (ELS) remains divergent. This study aims to demonstrate the characters of ELS in children for optimal clinical management in the future.

MATERIAL AND METHODS

A retrospective analysis was conducted for ELS patients' treatment in our center from January 2013 to April 2020.

RESULTS

In total, 85 patients were included, containing 70 upper-diaphragmatic, 7 intra-diaphragmatic, and 8 infra-diaphragmatic ELS. Eight patients' pathology results showing inflammation without symptoms preoperation and two patients had chest pain for torsion. All the upper-diaphragmatic and intra-diaphragmatic ELS patients accepted thoracoscopic surgery resection. The intraoperative operation time and blood loss volume of intra-diaphragmatic ELS were significantly more than that of the upper-diaphragmatic (40.14 ± 9.92  vs. 23.07 ± 6.79 min; 9.29 ± 3.45  vs. 3.18 ± 4.94 ml; all p < .05). No chest tubes were inserted in both subgroups. No complications were found in the postoperative follow-up of operative ELS patients at least 3 months. A total of eight infra-diaphragmatic ELS patients except for one (7/8) had conservative therapy and follow-up by the outpatient clinic or phone call eventually. There were no symptoms occurring and no size increasing of observation infra-diaphragmatic ELS.

CONCLUSIONS

The ELS has the potential risk of infection and torsion in this study. Thoracoscopic surgery might be optimal management of upper-diaphragmatic ELS for its minimal invasion and low perioperative risks, which could be developed into a day operation with safe and quick recovery. The intra-diaphragmatic and infra-diaphragmatic ELS need a larger sample size and multiple center data to get a better management approach.

Clinical Outcomes of Transarterial Embolization in the Treatment of Pulmonary Sequestration

PURPOSE

To assess the safety and efficacy of transarterial embolization (TAE) for pulmonary sequestration (PS).

METHODS

A single-center, retrospective study was conducted from March 2013 and December 2020. Patient characteristics, laboratory/imaging, complications, and the TAE procedure were reviewed.

RESULTS

We report 11 symptomatic patients with PS successfully treated by TAE. The aberrant supplying arteries were embolized, and there were no immediate complications. One to three days after TAE, patients complained of mild chest pain (n = 4), moderate chest pain (n = 3), and low-grade fever (n = 1). Chest pain symptoms were completely resolved after 2-4 days. One patient with PS and bronchiectasis required thoracoscopic resection due to continued symptoms. The remaining 10 patients showed disappearance of chest pain and hemoptysis and decreased lesion size at 2 weeks and 3 months, with a clinical success rate of 90.9%.

CONCLUSIONS

TAE may be a feasible alternative treatment for pulmonary sequestration.

Development of patient specific, realistic, and reusable video assisted thoracoscopic surgery simulator using 3D printing and pediatric computed tomography images

Herein, realistic and reusable phantoms for simulation of pediatric lung video-assisted thoracoscopic surgery (VATS) were proposed and evaluated. 3D-printed phantoms for VATS were designed based on chest computed tomography (CT) data of a pediatric patient with esophageal atresia and tracheoesophageal fistula. Models reflecting the patient-specific structure were fabricated based on the CT images. Appropriate reusable design, realistic mechanical properties with various material types, and 3D printers (fused deposition modeling (FDM) and PolyJet printers) were used to represent the realistic anatomical structures. As a result, the phantom printed by PolyJet reflected closer mechanical properties than those of the FDM phantom. Accuracies (mean difference ± 95 confidence interval) of phantoms by FDM and PolyJet were 0.53 ± 0.46 and 0.98 ± 0.55 mm, respectively. Phantoms were used by surgeons for VATS training, which is considered more reflective of the clinical situation than the conventional simulation phantom. In conclusion, the patient-specific, realistic, and reusable VATS phantom provides a better understanding the complex anatomical structure of a patient and could be used as an educational phantom for esophageal structure replacement in VATS.

Pulmonary sequestration: What the radiologist should know

Pulmonary sequestration consists of a nonfunctioning mass of lung tissue, either sharing the pleural envelope of the normal lung (intralobar) or with its own pleura (extralobar), lacking normal communication with the tracheobronchial tree and receiving its arterial supply by one or more systemic vessels. It is the second most common congenital lung anomaly according to pediatric case series, but its real prevalence is likely to be underestimated, and imaging plays a key role in the diagnosis and treatment management of the condition and its potential complications. We will give a brief overview of the pathophysiology, clinical presentation and imaging findings of intra- and extralobar pulmonary sequestration, with particular reference to multidetector computed tomography as part of a powerful and streamlined diagnostic approach.

Coil embolization of intralobar pulmonary sequestration - an alternative to surgery: a case report

BACKGROUND

Pulmonary sequestration is a congenital lung disease characterized by nonfunctioning pulmonary tissue that lacks normal communication with the bronchial tree and is supplied by a nonpulmonary systemic artery. Symptomatic bronchopulmonary sequestration is uncommon, seen more frequently in the pediatric population than in adults. It has traditionally been treated with surgical resection; however, a limited but growing number of cases have been treated with angiographic embolization. Given the inherent risks of cardiothoracic surgery, embolization of the anomalous vessel is an enticing alternative treatment. We present a case of a 56-year-old woman with known, symptomatic, intralobar pulmonary sequestration that was successfully treated with coil embolization.

CASE PRESENTATION

A 56-year-old Pacific Islander woman with a history of chronic myeloid leukemia was admitted to the hospital with an episode of hemoptysis. Computed tomography of the chest demonstrated left lower lobe intralobar pulmonary sequestration fed by a large tortuous vessel branching off of the descending thoracic aorta. Surgical resection of the sequestration is the current standard treatment strategy of symptomatic intralobar pulmonary sequestration. The cardiothoracic surgeon noted that given the size and location of arterial blood supply, intervention would involve thoracotomy and lobectomy. The interventional radiologist offered embolization of the lesion as an alternative to surgery. Multiple coils, 6-13 mm in size, were used to embolize the sequestration. No considerable flow distal to the coils was noted postembolization.

CONCLUSIONS

Intralobar pulmonary sequestration is a rare condition that typically requires surgical management. This case demonstrates the efficacy of coil embolization as an alternative management strategy. To date, limited case reports of adults treated with endovascular embolization exist. Treatment of symptomatic pulmonary sequestration with embolization can be considered as an alternative to surgical resection.

Clinical presentation and characteristics of 25 adult cases of pulmonary sequestration

BACKGROUND

Pulmonary sequestration (PS) is a rare congenital abnormality of lung tissue. Only few series of adult cases are reported. The aim was to describe clinical characteristics in adult cases of PS and to compare outcomes in different clinical situations.

METHODS

Using MSD engine we searched for cases of PS that have been diagnosed between Jan 1st, 2005 and Dec 31st, 2015. Clinical data was retrospectively gathered. Statistica v.12 (StatSoft, Inc.) was used for statistical analyses.

RESULTS

We found 25 cases (18 females, 7 males), which underwent surgery and were histologically proven. There were 22 cases of intralobar PS. 7 cases were asymptomatic, 12 had infectious history (including 3 cases of lung abscess and pleural empyema), 4 presented with hemoptysis, 2 with chest pain. The average age to undergo surgery was 38.24, in the asymptomatic group 34, in symptomatic 39.89. In the latter the symptoms preceded the surgery for 2.45-year. Great majority of sequestrations was located in lower lobes (96%), 52% on the left. Symptomatic cases were at higher than expected risk of surgical complications, comparing to asymptomatic (chi², P=0.04). In most cases there were surgical and histological signs of infection, only in 9 cases etiological factor was determined: in 5 cases it was A. fumigatus. A 0.53-day longer post-surgical hospital stay was observed in the symptomatic group, no statistical significance was found (U-test, P=0.45).

CONCLUSIONS

Surgical treatment of symptomatic cases of PS is characterized by slightly longer post-surgical hospital stay and higher risk of surgical complications. Fungal infections are the most likely to occur in PS.

Does thoracoscopy have advantages over open surgery for asymptomatic congenital lung malformations? An analysis of 1626 resections

AIM

The apparent incidence of antenatally diagnosed congenital lung malformations (CLM) is rising (1 in 3000), and the majority undergo elective resection even if asymptomatic. Thoracoscopy has been popularized, but early series report high conversion rates and significant complications. We aimed to perform systematic review/meta-analysis of outcomes of thoracoscopic vs open excision of asymptomatic CLMs.

METHODS

A systematic review according to PRISMA guidelines was performed. Data were extracted for all relevant studies (2004-2015) and Rangel quality scores calculated. Analysis was on 'intention to treat' basis for thoracoscopy and asymptomatic lung lesions. Meta-analysis was performed using the addon package METAN of the statistical package STATA14™; p<0.05 was considered significant.

RESULTS

36 studies were eligible, describing 1626 CLM resections (904 thoracoscopic, 722 open). There were no randomized controlled trials. Median quality score was 14/45 (IQR 6.5) 'poor'. 92/904 (10%) thoracoscopic procedures were converted to open. No deaths were reported. Meta-analysis showed that regarding thoracoscopic procedures, the total number of complications was significantly less (OR 0.63, 95% CI 0.43, 0.92; p<0.02, 12 eligible series, 912 patients, 404 thoracoscopic). Length of stay was 1.4days shorter (95%CI 2.40, 0.37;p<0.01). Length of operation was 37 min longer (95% CI 18.96, 54.99; p<0.01). Age, weight, and number of chest tube days were similar. There was heterogeneity (I² 30%, p=0.15) and no publication bias seen.

CONCLUSIONS

A reduced total complication rate favors thoracoscopic excision over thoracotomy for asymptomatic antenatally diagnosed CLMs. Although operative time was longer, and open conversion may be anticipated in 1/10, the overall length of hospital stay was reduced by more than 1day.

LEVEL OF EVIDENCE

4 (based on lowest level of article analyzed in meta-analysis/systematic review).

Congenital pulmonary airway malformation and sequestration: Two standpoints for a single condition

In adults, congenital pulmonary malformations are candidates for surgery due to symptoms. A pre-natal diagnosis is simple and effective, and allows an early thoracoscopic surgical treatment. A retrospective study was performed to assess management in two different populations of adults and children to define the best strategy.

Utility of preoperative visualization for intrapulmonary sequestration in video-assisted thoracoscopic surgery

We herein report the case of a 59-year-old male suffering from severe cough. The patient had previously experienced several episodes of pneumonia beginning in childhood. A three dimensional multidetector computed tomography (3D-MDCT) scan revealed pulmonary sequestration with a left gastric artery blood supply, and clearly revealed the other pulmonary vessels. The patient underwent video-assisted thoracoscopic surgery, in which the anomalous tissue was resected safely. Preoperative visualization of the vessels may be helpful for the safe treatment of a pulmonary sequestration, and the VATS approach is a suitable operation under corrective surgical planning.

Malformações pulmonares congênitas

As malformações congênitas do pulmão são raras e variam muito na sua forma de apresentação clínica e gravidade, dependendo principalmente do grau de envolvimento pulmonar e de sua localização na cavidade torácica. Elas podem se manifestar em qualquer idade e podem ser fonte de importante morbidade e mortalidade em lactentes e crianças. Os indivíduos com malformações congênitas do pulmão podem apresentar sintomas respiratórios ao nascimento, enquanto outros podem permanecer assintomáticos por longos períodos. Atualmente, com o uso rotineiro da ultrassonografia pré-natal, vem ocorrendo um aumento no diagnóstico mais precoce dessas malformações. A manifestação clínica dessas malformações varia desde uma disfunção respiratória pós-natal imediata a um achado acidental na radiografia de tórax. O diagnóstico precoce e o tratamento imediato oferecem a possibilidade de um desenvolvimento pulmonar absolutamente normal. Quando assintomáticos, a conduta para o tratamento dos pacientes com malformações pulmonares ainda é controversa, uma vez que o prognóstico dessas afecções é imprevisível. O manejo dessas lesões depende do tipo de malformação e de sintomas. Devido ao risco de complicação, a maioria dos autores sugere a ressecção da lesão no momento em que essa é identificada. A lobectomia é o procedimento de escolha, fornecendo excelentes resultados a longo prazo. Este artigo descreve as principais malformações pulmonares congênitas, seu diagnóstico e controvérsias quanto o tratamento.

[Persistent pleuropneumopathy in a young woman]

Bronchopulmonary sequestration is a rare malformation characterized by lung tissue fed by one or several aberrant systemic arteries. The authors present the case of a 35-year-old woman in whom extralobar sequestration was fortuitously detected at the time of persistent pleuropneumopathy. Computed tomography was used in the diagnosis of pulmonary sequestration. The most common and recommended treatment is the surgical removal of the pulmonary sequestration.

Advantage of absorbable suture material for pulmonary artery ligation

PURPOSE

The applicability of absorbable materials as ligatures of pulmonary vessels has not been described. The present study compares tissue reactions around sites of pulmonary arteries ligated with absorbable material (Vicryl) and with nonabsorbable material (silk).

METHODS

Beagle dogs underwent thoracotomy and the pulmonary artery branches were ligated with silk or Vicryl under general anesthesia. The ligated arterial tissues were obtained at 4 and 8 weeks after thoracotomy and processed for pathological analysis.

RESULTS

The arteries ligated using Vicryl or silk were clinically completely sealed at 4 weeks after ligation. More inflammation and granuloma were evident at tissues surrounding ligations made with silk than with Vicryl at 8 weeks. Hyperplasia of the arterial intima continued at 8 weeks after ligation with both Vicryl and silk sutures, although some hyperplasia similar to that in nonligated arterial intima appeared at 4 weeks after ligation.

CONCLUSION

Less inflammation and granuloma are caused at arterial tissues around ligations accomplished with absorbable Vicryl than those done with nonabsorbable silk sutures, although both are equally effective. Absorbable sutures might be suitable for ligating pulmonary arteries.

Video assisted thoracic surgery sublobar resection of intralobar pulmonary sequestration after preoperative embolization of systemic blood supply

Intralobar pulmonary sequestration is abnormal lung tissue of embryonic origin that receives arterial blood supply from the systemic arterial circulation from the abdominal aorta. The arterial blood supply traverses the diaphragm and courses through the inferior pulmonary ligament. Intralobar pulmonary sequestrations are usually treated by anatomic lobar or sublobar resections via an open thoracotomy. Recent reports suggest the utility of a video assisted thoracic surgery (VATS) pulmonary resection. However, the presence of the feeding systemic artery often makes VATS resection difficult or impossible, due to the risk of injury to the feeding vessel, and subsequent retraction below the diaphragm. We present procedural video recordings describing a multidisciplinary procedure, where precedent coil embolization of the feeding systemic vessel allows for relative risk-free VATS sublobar resection of the intralobar pulmonary sequestration.

Recent advances and controversies in pediatric laparoscopic surgery

Children represent a unique group of patients who are likely to greatly benefit from minimally invasive surgery (MIS). The promise of less postoperative pain, smaller scars, shorter hospital stays, and a faster return to school continues to drive growth in this area. The development of pediatric-specific techniques and documentation of improved outcomes form a critical gateway to widespread application of pediatric MIS. A brief perspective on current approaches to MIS for pediatric congenital and acquired disease is provided in this report. Technical departures from standardized adult MIS and the rationale for their modification are highlighted.

Thoracoscopic right middle lobar bronchus reimplantation for iatrogenic injury in infant: is it a good option?

We report the first case in the literature of thoracoscopic bronchial reimplantation in 5 month-old boy. The child was born with congenital cystic adenomatoid malformation of the right lower lobe associated with lower intralobar pulmonary sequestration diagnosed prenatally. An iatrogenic middle lobar bronchus injury was detected per-operatively during thoracoscopic lobectomy. Management and follow-up were exposed.

Minimally invasive surgery of the lung: lung biopsy, treatment of spontaneous pneumothorax, and pulmonary resection

Thoracoscopy of pediatric patients has evolved from diagnostic lung biopsy to a myriad of both diagnostic and therapeutic procedures. In this chapter, we discuss those procedures related to the child's lung which are most commonly performed: lung biopsy; resection of bronchogenic cysts, pulmonary sequestrations, and pulmonary lobes; and the treatment of spontaneous pneumothorax.

Thoracoscopic versus open resection for congenital cystic adenomatoid malformations of the lung

PURPOSE

This study evaluated the potential advantages of thoracoscopy compared to thoracotomy for resection of congenital cystic adenomatoid malformations (CCAM).

METHODS

We conducted a retrospective chart review of consecutive cases of CCAM resection at University of California San Francisco Children's Hospital from January 1996 to December 2006.

RESULTS

Thirty-six cases of postnatal CCAM resections were done over the past 10 years; 12 patients had thoracoscopic resections, whereas 24 patients had open resections. Patients in the thoracoscopic group had significantly longer operative time (mean difference of 61.3 minutes; 95% confidence interval [CI], 30.5-92.1) but shorter postoperative hospital stay (mean difference of 5.7 days; 95% CI, 0.9-10.4) and duration of tube thoracostomy (mean difference of 2.6 days; 95% CI, 0.7-4.5) and lower odds of postoperative complications (odds ratio of 9.0 x 10(-4); 95% CI, 8.0 x 10(-6)-0.1). In the subgroup analysis of only asymptomatic patients, the thoracoscopy group still had a significantly shorter hospital stay (mean difference of 2.8 days; 95% CI, 0.7-4.8). There was also a pattern for reduced complications in the thoracoscopy group (OR, 0.13; 95% CI, 0.02-1.0; P = .05). The average hospital costs were similar in both groups. With a conversion rate of 33% (6/18), patients with a history of preoperative respiratory symptoms had a higher incidence of conversion than those who were asymptomatic (66.7% vs 0%, P = .005). These four patients had a history of pneumonia.

CONCLUSION

Minimally invasive resection of CCAM results in longer operative time but shorter hospital stay, potentially reduced complications, and no additional hospital costs. Thoracoscopic lobectomy in patients with a history of pneumonia is challenging and a risk factor for conversion to thoracotomy.

Pulmonary sequestration: a single-institutional series composed of 27 cases

OBJECTIVE

Large series about pulmonary sequestration from a single institute are rare in the literature. In this study, we aimed to evaluate diagnosis, treatment, and outcomes of pulmonary sequestration in a single institute.

METHODS

Records of patients with pulmonary sequestration between January 1982 and January 2006 were reviewed retrospectively. Age, sex, symptoms, diagnostic procedures, operative findings, operative techniques, postoperative complications, and follow-up results were evaluated.

RESULTS

Twenty-seven patients, 17 male and 10 female, with an average age of 23.3 were operated on for pulmonary sequestration. Twenty patients had preoperative symptoms including recurrent pneumonia attacks, chest pain, hemoptysis, and shortness of breath. Chest radiography, thoracic computed tomography, aortography, magnetic resonance imaging, and bronchoscopy were used as diagnostic methods. Of the cases, 19 (70%) were intralobar pulmonary sequestration and 8 (30%) were extralobar pulmonary sequestration. Surgical procedures were lower lobectomy in 18 and segmentectomy in 1 of the patients with intralobar pulmonary sequestration and simple mass excision in all of those with extralobar pulmonary sequestration. Postoperative histopathologic examinations excluded any other alternative diagnosis. Furthermore, it detected an aspergilloma ball in 1 of the intralobar pulmonary sequestration specimens. Two patients had a postoperative complication (prolonged air leak in 1 patient and empyema in the other). During the follow-up period (mean 2.3 years), none of the patients presented a problem. No mortality was encountered.

CONCLUSION

Owing to the potentially severe complications they can cause, pulmonary sequestrations should be removed whenever they are diagnosed. Since careful dissection provides sufficient surgical comfort, preoperative identification of the aberrant vessels is not a rule for the success of the operation.

Thoracoscopic Resection of an Apical Extralobar Pulmonary Sequestration in an Infant

Pulmonary sequestration is a form of bronchopulmonary-foregut malformation that is treated with surgical resection, either via a thoracotomy or the thoracoscopic approach. Apical extralobar pulmonary sequestrations are rare. We report a case of an apical pulmonary sequestration in an infant that was amenable to thoracoscopic resection. An 8-month-old girl, weighing 10.3 kg, with a left apical extralobar pulmonary sequestration underwent thoracoscopic resection. The pulmonary sequestration was identified and dissected free from surrounding tissue. The vascular peduncle was secured with an endo-GIA loaded with 2-mm vascular staples. The infant was discharged on postoperative day two without complications. In spite of the patient's small size and the apical nature of the sequestration, the operation was easily performed via a thoracoscopic approach. Thoracoscopic resection of an apical extrapulmonary sequestration in a small infant is feasible and may minimize the morbidity of this procedure.

[Sequestration of the posterobasal segment of the right lower pulmonary lobe]

Pulmonary sequestration is a rare congenital malformation that receives its blood supply from a systemic artery. We report a case of pulmonary sequestration treated by ligature of the anomalous artery without pulmonary resection. Pulmonary sequestration must be treated surgically before the occurrence of severe complications.