Thoracoscopy versus thoracotomy improves midterm musculoskeletal status and cosmesis in infants and children

A modern approach to multiple pulmonary resections in children with recurrent metastatic pulmonary disease

Implications of repeated resections of pulmonary metastasis (PM) are not well documented in the modern era. Fifteen children underwent two (n = 8), three (n = 3), or four or more (n = 3) resections (total = 38 procedures), most commonly for osteosarcoma (71%). Operative approach included muscle-sparing thoracotomy (71%), non-muscle-sparing thoracotomy (18%), and video-assisted thoracoscopy (11%). Median resected nodules per procedure was four (range = 1-95). Prolonged air leaks were the most common postoperative complication (29%). Median hospital stay was 4 days, and no children were discharged with or have required oxygen. Event-free survival is 67% at median follow-up time of 54 months, with an overall survival rate of 64%. Repeat resection of PM appears to be well tolerated, without prolonged hospital stays or compromised pulmonary function.

Thoracic Musculoskeletal Deformities Following Surgical Treatment of Esophageal Atresia - Thoracoscopic Versus Open Approach: A Retrospective Two Centers Cohort Study

INTRODUCTION

Thoracic musculoskeletal deformities are significant complications following open correction of esophageal atresia (EA) during long-term follow-up. We aimed to compare the frequency and severity of thoracic musculoskeletal deformities after open and thoracoscopic repair of EA. We hypothesized that fewer deformities would occur following the less invasive thoracoscopic approach.

METHODS

This retrospective study analyzed patients treated at two pediatric surgery departments in Poland between 2005 and 2021. The patient groups differed in surgical approach, operative techniques, indications for multi-staged surgery, and postoperative complications. The study encompassed all types of EA/TEF. The first group comprised 68 patients who underwent thoracoscopic esophageal atresia repair (Wroclaw), while the second group involved 44 patients who underwent open repair (Warsaw). Clinical data were retrospectively reviewed, with results considered significant at p < 0.05.

RESULTS

The median age at examination was 6 years in the thoracoscopy group and 5.5 years in the thoracotomy group. In the thoracoscopy group, 53 out of 68 patients (77.9%) and in the thoracotomy group - 35 out of 44 patients (79.5%) were treated in one stage. The incidence of thoracic musculoskeletal deformities was significantly lower in the thoracoscopy group (1.5%) compared to the thoracotomy group (34.1%, p < 0.001). Scoliosis occurred significantly more often after thoracotomy (13.6% vs 1.5%, p = 0.016). There was no rib fusion (0% vs 37.1%, p < 0.001) and no scoliosis of =>20° (0% vs 6.8%, p = 0.058) after thoracoscopy. The coincidence of rib fusion and scoliosis was significant (9.1%, p = 0.022) for the open approach. In the thoracotomy group, multi-staged surgery and more frequent reoperations due to major complications were significantly associated with an increased occurrence of deformities. None of the patients after thoracoscopic multi-stage or complicated EA/TEF repair developed scoliosis.

CONCLUSIONS

The frequency and severity of thoracic musculoskeletal deformities were significantly lower after the thoracoscopic approach. Thoracoscopy may be a more advantageous and preferred surgical approach for the EA/TEF treatment, although further randomized, controlled studies are necessary. Post-thoracotomy scoliosis may progress to a severity requiring surgery.

Birth weight and thoracoscopic approach for patients with esophageal atresia and tracheoesophageal fistula-a retrospective cohort study

BACKGROUND

This study aimed to analyze the results, feasibility and safety of the thoracoscopic approach for patients with esophageal atresia with tracheoesophageal fistula (EA/TEF) depending on the patient's birth weight.

METHODS

The study involved only type C and D EA/TEF. Among the analyzed parameters were the patients' characteristics, surgical treatment and post-operative complications: early mortality, anastomosis leakage, anastomosis strictures, chylothorax, TEF recurrence, and the need for fundoplication or gastrostomy.

RESULTS

145 consecutive newborns underwent thoracoscopic EA with TEF repair. They were divided into three groups-A (N = 12 with a birth weight < 1500 g), B (N = 23 with a birth weight ≥ 1500 g but < 2000 g), and C-control group (N = 110 with a birth weight ≥ 2000 g). Primary one-stage anastomosis was performed in 11/12 (91.7%) patients-group A, 19/23 (82.6%)-group B and 110 (100%)-group C. Early mortality was 3/12 (25%)-group A, 2/23 (8.7%)-group B, and 2/110 (1.8%)-group C and was not directly related to the surgical repair. There were no significant differences in operative time and the following complications: anastomotic leakage, recurrent TEF, esophageal strictures, and chylothorax. There were no conversions to an open surgery. Fundoplication was required in 0%-group A, 4/21 (19.0%)-group B, and 2/108 (1.9%)-group C survivors. Gastrostomy was performed in 1/9 (11.1%)-group A, 3/21 (14.3%)-group B and 0%-group C.

CONCLUSION

In an experienced surgeon's hands, even in the smallest newborns, the thoracoscopic approach may be safe, feasible, and worthy of consideration. Birth weight seems to be not a direct contraindication to the thoracoscopic approach.

Are Low Weight or Cardiopathy Contraindications for Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula?

BACKGROUND

 Thoracoscopic repair of esophageal atresia (EA) with tracheoesophageal fistula (TEF) is becoming an increasingly widespread technique; there is still controversy about its indication in certain patients. Our objective is to analyze if potential risk factors such as major congenital heart disease (CHD) or low birth weight (LBW) are a limitation to this approach.

METHODS

 Retrospective study (2017-2021) of patients with EA and distal TEF who underwent thoracoscopic repair were included. Patients with LBW less than 2,000 g or major CHD were compared with the rest.

RESULTS

 Twenty-five patients underwent thoracoscopic surgery. Nine patients (36%) had major CHD. Five of them (20%) were LBW less than 2,000 g, and only 8% (2/25) presented both risk factors. There were no differences in terms of operative time, conversion rate, tolerance evaluated with gasometric parameters (pO2, pCO2, pH) or complications (anastomotic leak and stricture, both early or during follow-up) in patients with major CHD and LBW (1,473 ± 319 vs. 2,664 ± 402 g). One conversion to thoracotomy was performed in a neonate weighing 1,050 g due to anesthetic intolerance. There was no recurrence of TEF. One patient died at the age of 9 months, due to major uncorrectable heart disease.

CONCLUSION

 Thoracoscopic repair of EA/TEF is feasible technique in patients with CHD or LBW, with similar results to other patients. The complexity of this technique warrants individualizing the indication in each case.

LEVEL OF EVIDENCE

 IV.

Pediatric thoracoscopic lung resections: a comprehensive analysis of congenital lesion cases

BACKGROUND

Congenital lung lesions in pediatric patients may be managed conservatively or by video assisted thoracoscopic surgery (VATS). This study aimed to determine the complications after VATS for congenital lung lesions in children.

METHODS

All children undergoing a lung resection between January 2009 and June 2022 were retrospectively identified. Children undergoing a primary open lobectomy or a resection other than a congenital lung lesion were excluded. Both early (<30 days) and late postoperative pulmonary complications were determined. The primary endpoint was postoperative complications within 30 days.

RESULTS

In total, 56 patients were included, with a median age of 13 months (IQR 9-37). A VATS lobectomy were performed in 46 patients (82%), an extralobar sequestration in 8 patients (14%), an wedge resection in 1 patient and a segment resection in 1 patient. During the COVID pandemic, fewer resections were performed with an increase in symptomatic patients. A conversion to open occurred in 6 patients (11%), of which a preoperative lung infection was associated with an increased risk thereof(p = 0.004). The median follow-up was 22 months (IQR 7-57) and all patients were alive. A postoperative complication (Clavien Dindo ≥3) occurred in 9 patients and complications without the need of intervention in 6 patients. During follow-up a pneumonia occurred in 11 patients.

CONCLUSION

There seems to be a shift towards delayed surgery with an increase in symptomatic congenital lung malformations, which might lead to an increase in postoperative complications.

Association of Operative Approach With Postoperative Outcomes in Neonates Undergoing Surgical Repair of Esophageal Atresia and Tracheoesophageal Fistula

INTRODUCTION

Minimally invasive surgery (MIS) is gaining traction as a first-line approach to repair congenital anomalies. This study aims to evaluate outcomes for neonates undergoing open versus MIS repairs for esophageal atresia/tracheoesophageal fistula (EA/TEF).

METHODS

In this retrospective study, neonates undergoing EA/TEF repair from 2013 to 2020 were identified using the National Surgical Quality Improvement Program-Pediatric database. Proportions of operative approach (open vs. MIS) over time were analyzed. A propensity score-matched analysis using preoperative characteristics was performed and outcomes were compared including composite morbidity and reintervention rates (overall, major [thoracoscopy, thoracotomy], and minor [chest/feeding tube placement, endoscopy]) between operative approaches. Pearson's chi-square or Fisher's exact tests were used as appropriate.

RESULTS

We identified 1738 neonates who underwent EA/TEF repair. MIS utilization increased over time. Pre-match, neonates undergoing open repair were more likely to be premature, lower weight, ventilator dependent, and have cardiac risk factors with higher severity. Post-match, the groups were similar and included 340 neonates per group. MIS repair was associated with longer median operative time (209 vs. 174 min, p < 0.001) and increased overall post-operative intervention rates (7.6% vs. 2.9%, p = 0.01). There were no differences in composite morbidity (24.4% vs. 25.0%, p = 0.86) outside of reintervention.

CONCLUSION

MIS approach for neonates with EA/TEF appears to be associated with a higher rate of reinterventions. Further studies evaluating MIS approaches for the repair of EA/TEF are needed to better define short- and long-term outcomes.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Thoracoscopic Excision of Mediastinal Bronchogenic Cysts in Children: A Case Series

Background: Bronchogenic cysts result from a congenital anomalous budding of the tracheobronchial tree. Resection is usually recommended to avoid complications. Mediastinal bronchogenic cysts present a unique challenge due to their proximity to vital structures. The purpose of this study is to review our experience with mediastinal bronchogenic cysts. Methods: A single-institution retrospective review evaluated all mediastinal bronchogenic cyst excisions between January 2012 and November 2022. Patient demographics were assessed, including age at diagnosis, presenting symptoms, imaging workup, and cyst characteristics. Operative approach, complications, and surgical pathology were reported. Results: Five patients were identified. Age at diagnosis ranged from 18 to 27 months. No patient was diagnosed prenatally. All patients had symptoms at the time of diagnosis, including cough, wheezing, and respiratory distress. Three cysts were paratracheal, and two were paraesophageal. Age at surgery ranged from 26 to 30 months. All bronchogenic cysts were successfully resected thoracoscopically. Individual technical challenges included narrowing of the mainstem bronchus preventing lung isolation, significant mediastinal inflammation, the necessity for cyst evacuation to delineate the extent of the cyst, adherence of cyst wall to bronchus or trachea requiring cold dissection, and a stalk of tissue with an intimate connection to the carina that was amputated. No intraoperative or postoperative complication occurred. Surgical pathology was consistent with a bronchogenic cyst in all cases. Median length of hospital stay was two days. Conclusion: Thoracoscopy is a safe and effective procedure for mediastinal bronchogenic cyst excision in children. Certain technical maneuvers are highlighted, which may facilitate resection.

Evaluation of Thoracoscopic Lobectomy in Infants for Congenital Lung Lesions: Earlier Is Better!

OBJECTIVES

This study evaluates the safety and efficacy of thoracoscopic lobectomy for congenital lung lesions in infants less then 4 months of age.

MATERIALS AND METHODS

From January 1997 to October 2022, 194 patients under 4 months of age and weight less then 5.6 Kg underwent video-assisted thoracoscopic lobe resection for CPAM, Sequestration, and CLE. All procedures were performed by or under the direct guidance of a single surgeon.

RESULTS

195 of 196 procedures were completed thoracoscopically. Operative times ranged from 25 min to 195 min (average, 82 min). There were 50 upper, 8 middle, and 136 lower lobe resections. There were 4 intraoperative complications (2.1 %), of which 1 (0.5 %) required conversion to an open thoracotomy. The postoperative complication rate was 3.1 % Hospital length of stay ranged from 1 to 8 days (Avg 1.8) for those admitted for surgery. There were no conversions to open or blood transfusions in the last 15 years.

CONCLUSIONS

Thoracoscopic lung resection congenital lung lesions in infants is a safe and efficacious technique and avoids the morbidity of a thoracotomy. Early intervention allows surgery before clinical infections or symptoms occur. Newer instrumentation and techniques allow the operation to be safely performed in the first few months of life with shorter operative times, fewer complications, and decreased hospital stays. The minimal morbidity of this procedure should be considered when considering non-operative management of these patients.

LEVEL OF EVIDENCE: 3

Congenital lung malformations: a nationwide survey on management aspects by the Italian Society of Pediatric Surgery

INTRODUCTION

Over the years, congenital lung malformations (CLM) management remains a controversial topic in pediatric thoracic surgery. The Italian Society of Pediatric Surgery performed a national survey to study the current management variability among centers, trying to define national guidelines and a standardized approach of children with congenital lung malformations.

METHODS

Following a National Society approval, an electronic survey including 35 items on post-natal management was designed, focusing on surgical, anesthesiology, radiology and pneumology aspects. The survey was conducted contacting all pediatric surgical units performing thoracic surgery.

RESULTS

39 pediatric surgery units (97.5%) participated in the study. 13 centers (33.3%) were classified as high-volume (Group A), while 26 centers (66.7%) were low volume (Group B). Variances in diagnostic imaging protocols were observed, with Group A performing fewer CT scans compared to Group B (p = 0.012). Surgical indications favored operative approaches for asymptomatic CLM and pulmonary sequestrations in both groups, while a wait-and-see approach was common for congenital lobar emphysema. Surgical timing for asymptomatic CLM differed significantly, with most high-volume centers operating on patients younger than 12 months (p = 0.02). Thoracoscopy was the preferred approach for asymptomatic CLM in most of centers, while postoperative long-term follow-up was not performed in most of the centers.

CONCLUSION

Thoracoscopic approach seems uniform in asymptomatic CLM patients and variable in symptomatic children. Lack of uniformity in surgical timing and preoperative imaging assessment has been identified as key areas to establish a common national pattern of care for CLM.

Thoracoscopic Stage Internal Traction Repair Reduces Time to Achieve Esophageal Continuity in Long Gap Esophageal Atresia

OBJECTIVE

 Management of long gap esophageal atresia (LGOA) is controversial. This study aims at comparing the management of LGOA between two high-volume centers.

METHODS

 We included patients with LGOA (type A and B) between 2008 and 2022. Demographics, surgical methods, and outcomes were collected and compared.

RESULTS

 The study population involved 28 patients in center A and 24 patients in center B. A surgical approach was thoracoscopic in center A, only for one patient was open for final procedure. In center B, 3 patients were treated only thoracoscopically, 2 converted to open, and 19 as open surgery. In center A primary esophageal anastomosis concerned 1 case, two-staged esophageal lengthening using external traction 1 patient, and 26 were treated with the multistaged internal traction technique. In 24 patients a full anastomosis was achieved: in 23 patients only the internal traction technique was used, while 1 patient required open Collis-Nissen procedure as final management. In center B primary anastomosis was performed in 7 patients, delayed esophageal anastomosis in 8 patients, esophageal lengthening using external traction in 1 case, and 9 infants required esophageal replacement with gastric tube. Analyzed postoperative complications included: early mortality, 2/28 due to accompanied malformations (center A) and 0/24 (center B); anastomotic leakage, 4/26 (center A) treated conservatively-all patients had a contrast study-and 0/24 (center B), 1 case of pleural effusion, but no routine contrast study; recurrent strictures, 13/26 (center A) and 7/15 (center B); and need for fundoplication, 5/26 (center A) and 2/15 (center B). Age at esophageal continuity was as a median of 31 days in center A and 110 days in center B. Median time between initial procedure and esophageal anastomosis was 11 days in center A and 92 days in center B.

CONCLUSION

 Thoracoscopic internal traction technique reduces time to achieve esophageal continuity and the need for esophageal substitution while maintaining a similar early complication rate.

Musculoskeletal deformities after thoracoscopic versus conventional open repair for esophageal atresia

BACKGROUND

The superiority of thoracoscopic repair (TR) over conventional open repair (COR) for esophageal atresia, especially in terms of long-term outcomes, remains to be investigated. The aim of this study was to compare short- and long-term results between TR and COR group.

METHODS

Patients who underwent TR or COR for esophageal atresia without other predispositions to musculoskeletal deformities (2003-2016) and had been followed up for a minimum of 5 years were retrospectively reviewed. Musculoskeletal deformities (e.g., scoliosis, chest wall asymmetry, and rib deformities) were mainly evaluated based on the most recent chest radiographs.

RESULTS

Nine and eight patients were included in the TR and COR groups, respectively; the mean follow-up period was 8.7 and 11.5 years, respectively (p = 0.14). These groups had similar epidemiological characteristics and rates of postoperative complications. Musculoskeletal deformities developed significantly less frequently in the TR group versus the COR group (11 % vs. 88 %, p < 0.05; scoliosis: 0 % vs. 38 %, p = 0.08; chest wall asymmetry: 11 % vs. 50 %, p = 0.14; and rib deformities: 11 % vs. 88 %, p < 0.05, respectively).

CONCLUSION

TR was associated with a decreased incidence of musculoskeletal deformities and comparable complication rates versus COR for esophageal atresia repair. TR may achieve better long-term outcomes in this setting.

Videothoracoscopic surgery in children

Video-assisted thoracic surgery (VATS) is now being used with increasing frequency for a wide variety of indications in pediatric patients. Although there is no high level of evidence for the advantages of VATS in the pediatric patient group, the proven benefits of this method in the adult patient group have encouraged thoracic surgeons to perform VATS in this patient population. In this study, the procedures performed in pediatric patients under 18 years of age and their results were reviewed with the help of articles obtained as a result of searches using relevant keywords in the English literature (PubMed, Web of Science, EMBASE, and Cochrane). The frequency, indications, and results of the procedures performed differed according to age groups.

Thoracoscopic Surgery in the Management of Idiopathic Scoliosis: Systematic Literature Review according to the Prisma Protocol

Idiopathic scoliosis is characterized by a three-dimensional deformity of the spine with axial rotation and lateral inclination with an angle greater than 10° according to the Cobb method. Its approach can be conservative or surgical, depending on the degree of angulation, musculoskeletal development and age of the affected child or adolescent, or even depending on the functional impairment resulting from the condition. The aim of this study was to analyze the impact of videoassisted thoracoscopic surgery in the management of idiopathic scoliosis. This is a systematic literature review, built according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and registered with PROSPERO under number CRD42022351466. The search for studies was performed between August 2022 and September of the same year, in bibliographic databases including MEDLINE, The Cochrane Library and Web of Science. The technique is a minimally invasive alternative to thoracotomy that has shown great evolution in recent years. The main advantages include less blood loss during the procedure, shorter hospital stay and improved post-surgical esthetics. One of the disadvantages mentioned by the authors is the greater complexity and technological requirement, longer surgical time and the need for careful selection of patients, according to degrees of vertebral deviation. The use of analgesics and anti-inflammatory drugs had no significant difference between traditional procedures (thoracotomy) or thoracoscopic surgery.

Congenital lung malformations

Congenital lung malformations (CLMs) are rare developmental anomalies of the lung, including congenital pulmonary airway malformations (CPAM), bronchopulmonary sequestration, congenital lobar overinflation, bronchogenic cyst and isolated congenital bronchial atresia. CLMs occur in 4 out of 10,000 live births. Postnatal presentation ranges from an asymptomatic infant to respiratory failure. CLMs are typically diagnosed with antenatal ultrasonography and confirmed by chest CT angiography in the first few months of life. Although surgical treatment is the gold standard for symptomatic CLMs, a consensus on asymptomatic cases has not been reached. Resection, either thoracoscopically or through thoracotomy, minimizes the risk of local morbidity, including recurrent infections and pneumothorax, and avoids the risk of malignancies that have been associated with CPAM, bronchopulmonary sequestration and bronchogenic cyst. However, some surgeons suggest expectant management as the incidence of adverse outcomes, including malignancy, remains unknown. In either case, a planned follow-up and a proper transition to adult care are needed. The biological mechanisms through which some CLMs may trigger malignant transformation are under investigation. KRAS has already been confirmed to be somatically mutated in CPAM and other genetic susceptibilities linked to tumour development have been explored. By summarizing current progress in CLM diagnosis, management and molecular understanding we hope to highlight open questions that require urgent attention.

Thoracoscopic Versus Open Repair of Esophageal Atresia: A Systematic Review of Surgical Outcomes

Introduction: Esophageal atresia (EA) is a rare defect in the continuity of the esophagus, with the absent portion forming an upper and lower segment. Despite both thoracoscopic and conventional open repair (OR) techniques being well established worldwide, the literature remains unclear as to the comparison of surgical outcomes and efficacy of each procedure. Aim: To conduct a systematic review to determine which technique for EA repair, thoracoscopic or open, has the better outcome. Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) compliant literature search returned 14 full text articles for analysis of demographic information and surgical outcomes. Results: Major comorbidities were more likely in the OR group (P < .05) with all other surgical outcomes comparable between the two groups. Conclusion: Overall, this systematic review highlights that the surgical outcomes of patients undergoing thoracoscopic repair for EA are comparable with those of the conventional OR.

Neonate with congenital pulmonary airway malformation concurrent with enteric duplication cyst: a case report of a rare anomaly

A congenital pulmonary airway malformation (CPAM) occurring concurrently with an enteric duplication cyst is a rare anomaly. Definitive management for both abnormalities is usually surgical resection. We present the uncommon case of a neonate with a CPAM and ileal duplication cyst, including pre-natal and post-natal workup. The patient was brought to the operating room for laparoscopic duplication cyst excision at 3 months of age. The patient returned to the operating room for a thoracoscopic right lower lobectomy at five months of age. This case presents a rare congenital anomaly with the concurrent presentation of a CPAM and enteric duplication cyst, with both being successfully excised minimally invasively.

Nationwide Outcomes After Thoracoscopic Versus Open Resection of Congenital Pulmonary Airway Malformations in Newborns

Purpose: Elective resection of congenital pulmonary airway malformations (CPAM) has been debated for decades and varies significantly between individual surgeons. However, few studies have compared outcomes and costs associated with thoracoscopic and open thoracotomy approaches on a national level. This study sought to compare nationwide outcomes and resource utilization in infants undergoing elective lung resection for CPAM. Materials and Methods: The Nationwide Readmission Database was queried from 2010 to 2014 for newborns who underwent elective surgical resection of CPAM. Patients were stratified by operative approach (thoracoscopic versus open). Demographics, hospital characteristics, and outcomes were analyzed using standard statistical tests. Results: A total of 1716 newborns with CPAM were identified. Elective readmission for pulmonary resection was performed in 12% (n = 198), with 63% of resections completed at a different hospital than the newborn stay. Most resections were thoracoscopic (75%), compared to only 25% via thoracotomy. Infants treated with thoracoscopic resection were more often male (78% versus 62% open, P = .040) and were older at the time of resection. Patients who had an open thoracotomy experienced a higher rate of serious complications (40% versus 10% thoracoscopic, P < .001), including postoperative hemorrhage, tension pneumothorax, and pulmonary collapse. Readmission costs were higher for infants treated via thoracotomy (P < .001). Conclusion: Thoracoscopic lung resection for CPAM is associated with lower cost and fewer postoperative complications than thoracotomy. Most resections are performed at different hospitals than the place of birth, which may affect long-term outcomes from single institutional studies. These findings may be used to address costs and improve future evaluations of elective CPAM resections.

Short-term outcomes of thoracoscopic versus open lobectomy for congenital lung malformations

PURPOSE

Thoracoscopic and open approaches for the management of congenital lung malformations (CLM) has been debated. The aim of this study is to compare 30-day outcomes for non-emergent lobectomies in children.

METHODS

The National Surgical Quality Improvement Program-Pediatric database was queried for patients undergoing CLM resection from 2013 to 2020. Outcomes were compared by operative technique in an intention-to-treat model and then propensity matched.

RESULTS

2157 patients met inclusion criteria and underwent non-emergent pulmonary lobectomy for CLM. The intended operative approach was thoracoscopic in 57.7% of patients. Patients in the open group compared to the thoracoscopic were more likely to be born premature, have chronic lung disease, require preoperative oxygen support, and be ventilator dependent. After propensity matching, there was no statistically significant difference in 30-day mortality, unplanned readmission, and other complications between the thoracoscopic and open groups. Thoracoscopic approach was associated with a shorter length of stay. The proportion of cases approached via thoracoscopy increased over time from 48.8% in 2013 to 69.9% in 2020.

CONCLUSIONS

This large multicenter retrospective matched analysis demonstrates thoracoscopic lobectomy in children has similar favorable 30-day outcomes and shorter length of stay for the non-emergent management of CLM, compared to open thoracotomy.

LEVEL OF EVIDENCE

Level III.

Thoracogenic scoliosis: coronal deformity progression in paediatric patients

PURPOSE

To assess the risk of developing thoracogenic scoliosis (THS) in paediatric patients, depending on the side of lateral thoracotomy (LT) and of spine deviation in the coronal plane by means of logistic regression and scoliosis-free survival analyses.

METHODS

A total of 307 consecutive patients undergoing LT were retrospectively reviewed; 32 patients met the inclusion criteria: 1) underwent LT and developed THS; 2) age < 15 years at LT; 3) clinical and radiographic follow-up ≥ 5 years. Patients were divided into ipsilateral group (convexity ipsilateral to LT) and contralateral group (convexity contralateral to LT).

RESULTS

The mean follow-up was 10 ± 4.7 in the ipsilateral group (n = 13) and 12 ± 4.8 years in the contralateral group (n = 19). The contralateral group underwent LT at a younger age (4.4 vs 6.4 years, p = 0.55), developed more severe coronal deformity (27.8° vs 18.9°, p = 0.15), had higher rate of THS > 20° (47.5% vs 38.4%; p = 0.34) and > 45° (21.1% vs 0%; p = 0.99). The mean time from LT to THS diagnosis was 4.2 ± 2.9 in ipsilateral group and 5.5 ± 4.2 years in contralateral group. Left-side LT (p = 0.03) and age > 5 years (p = 0.01) showed a lower risk of THS diagnosis. The group variable had a statistically significant effect on the risk of developing THS > 45° (p = 0.03).

CONCLUSION

In this series, children that developed THS with a convexity contralateral to the side of LT had more severe and progressive coronal spine deformity.

LEVEL OF EVIDENCE

III.

Arterial Embolization and Methylene Blue Injection into the Aberrant Artery in Two Infants with Intralobar Sequestration

Bronchopulmonary sequestration is a rare congenital lung dysplasia. An intralobar sequestration (ILS) is a nonfunctional mass within the lung parenchyma without bronchial communication and with aberrant systemic arterial blood supply. Surgical resection or close observation can be proposed in the management of asymptomatic and low-risk ILS, but there is a lack of consensus. Endovascular embolization before thoracoscopic resection of ILS has been described to limit perioperative bleeding. Another technique previously reported is the injection of methylene blue in the feeding artery to macroscopically mark the sequestration from the healthy lung. In that way, a nonanatomical resection can be performed instead of a lobectomy without the risk of leaving abnormal lung tissue in place. We describe the first two cases of these two techniques combined: a 3-year-old girl with an ILS in the right lower lobe with an artery originating from the abdominal aorta, and a 14-month-old girl with an ILS in the right lower lobe with an artery coming from the celiac trunk. The combination of embolization and injection of methylene blue in the aberrant artery leads to a clear macroscopic demarcation of the blue-colored ILS from the healthy lung parenchyma and allowed safe nonanatomical resection of the ILS without risk of bleeding or compromising normal lung tissue.

Long-Term Outcomes and Health-Related Quality of Life in a Swiss Patient Group with Esophageal Atresia

INTRODUCTION

 Surgical treatment of esophageal atresia (EA) has markedly improved, allowing the focus to shift from short-term complications and mortality to long-term complications and quality of life. Health-related quality of life (HRQoL) is variable and reported to range from reduced to unimpaired in patients with repaired EA. We assessed the HRQoL, determined the prevalence of long-term complications and their possible impact on the HRQoL in patients who had correction of EA in Switzerland. Further, we also investigated in the general well-being of their parents.

MATERIALS AND METHODS

 Patients with EA repair in Switzerland between 1985 and 2011 were enrolled. Long-term complications were assessed by enquiring disease-related symptoms, standardized clinical examinations, and analysis of radiographs. HRQoL was inquired using different validated questionnaires (KIDSCREEN-27, World Health Organization [WHO]-5, and Gastrointestinal Quality of Life Index [GIQLI]). Patients were grouped according to their age. In underage patients, general well-being of the parents was assessed using the WHO-5 questionnaire.

RESULTS

 Thirty patients were included with a mean age of 11.3 ± 5.7 years. Long-term complications were present in 63% of all patients. HRQoL in underage patients was comparable to the provided reference values and rated as good, while adult patients reported a reduced HRQoL. The presence of gastroesophageal reflux disease symptoms was associated with reduced HRQoL in underage patients. Parents of underage patients stated a good general well-being.

CONCLUSION

 Long-term complications among patients with repair of EA in Switzerland are common. HRQoL in underage patients is good and general well-being of their parents is unimpaired. Adult patients reported a reduced HRQoL, consistent with other reports. As long-term complications may manifest only later in life, a structured follow-up of patients with an EA repair during childhood and adolescence is needed.

Thoracogenic scoliosis: a retrospective review of 129 pediatric patients with a mean follow-up of 10 years

PURPOSE

To determine the midterm outcome of lateral thoracotomy (LT) in skeletally immature patients concerning thoracogenic scoliosis development and lung parenchyma resection (LPR) extent.

METHODS

In total, 129 children met the inclusion criteria: (1) LT during the study period; (2) skeletally immature at the time of LT; (3) clinical and radiographic follow-up of at least 3 years; and (4) no spinal or thoracic deformity on radiographs before LT. Patients were grouped according to their underlying disease, age at LT, and LPR extent. Radiographic parameters were assessed. Kaplan-Meier survival curves and univariate and multivariate analysis were performed.

RESULTS

Of 129, 108 patients underwent pneumonectomy (9; 9.1%), lobectomy (79; 61.2%), segmentectomy (20; 15.5%) and 21 patients LT without LPR. The mean age at LT and at last radiological follow-up was 5.5 years (birth-17.8) and 15.2 years (3.4-33.2). The mean follow-up was 10 years (3-28.1). Scoliosis developed on average 5.3 years after LT. The mean Cobb angle was 22.1° (11-90°); > 10° in 37/129 patients (28.7%), of whom 5/129 (3.9%) had > 45°. The average vertebral rotation was 16.2° (2-43°; grade 0-II). RVAD was 26.5° (8°-33°) and 15.3° (2-43°) in patients with Cobb > 45° and ≤ 45°. Gender, age at surgery, and extent of LPR were not risk factors for post-thoracotomy scoliosis (p > 0.05), although younger patients developed a more severe deformity.

CONCLUSION

Although post-thoracotomy scoliosis is not associated with significant rotation, the risk of curve progression > 45° is relatively high. Regular follow-up is required as scoliosis may develop several years after LT with or without LPR.

Lung Ultrasound to Assess One Lung Ventilation: A Pediatric Case Series

Objectives: One lung ventilation (OLV) is the preferred ventilation technique for thoracoscopy as it provides a better exposure of the operative field and grants the protection of the healthy lung. Preoperative evaluation of lung exclusion is necessary and different methods are available. In recent years lung ultrasound (US) gained popularity and its use for monitoring the endotracheal tube position is widely reported. The existing evidence on adults addresses lung US as effective, yet only few data are available in children. Therefore, we present our experience with lung US as verification method for pediatric OLV. Methods: All patients undergoing OLV for video-assisted thoracoscopic surgery from January 2019 to May 2021 and for whom lung exclusion was confirmed through lung US were involved. Lung exclusion was considered effective when absence of lung motion and presence of lung pulse were encountered. When lung US did not match these criteria, repositioning of the endobronchial device followed by US verification was performed. When lung US met the exclusion criteria surgery was started and direct thoracoscopic observation was used to verify lung exclusion. Results: A total of 20 patients, accounting for 22 procedures, were involved. Absence of lung motion and presence of lung pulse were assessed in the operative-side lung for all patients. Lung exclusion was confirmed through thoracoscopy. Postoperative lung US proved the reappearance of lung motion in the previously excluded lung. Conclusions: In our center experience lung US resulted to be a safe, effective, and time-saving verification method for OLV. Further studies are needed to define its sensitivity and specificity.

Comparison of single-port, multi-port video-assisted thoracoscopic and open lobectomy for children: a single-center experience

PURPOSE

The feasibility of single-port video-assisted thoracic surgery (SPVATS) for pediatric lobectomy has not been clearly established. We compared the feasibilities of single-port (SP), multi-port (MP) VATS and open lobectomy (OL) for surgical treatment of children with lung disease.

METHODS

In this study, we retrospectively analyzed and compared data for 22,19 and 30 pediatric lung disease patients who had been subjected to SP, MP and OL, respectively. These procedures were performed between March, 2012 and August, 2020 at the Second Affiliated Hospital of Wenzhou Medical University. Perioperative clinical indicators were analyzed.

RESULTS

Compared to OL, SP was associated with lower intraoperative blood loss (p = 0.008), lower postoperative thoracic drainage volume (p = 0.041), shorter chest drainage duration (p = 0.002) and hospital stay (p = 0.001). Operation time (p = 0.437), volume of estimated blood loss (p = 0.979), conversion rate to thoracotomy (p = 0.861), total thoracic drainage volume (p = 0.824), duration of chest tube drainage (p = 0.543), length of hospital stay (p = 0.812) and incidences of postoperative complications were comparable in MP and SP groups.

CONCLUSION

SPVATS is a safe and feasible approach for lobectomy in pediatrics, with comparable postoperative clinical outcomes to MPVATS and better outcomes relative to OL. However, studies with large sample sizes in multicenter should be performed to verify our findings.

Need for transition medicine in pediatric surgery – health related quality of life in adolescents and young adults with congenital malformations

Survival rates of patients with visceral congenital malformations have increased considerably. However, long-term morbidity in these patients is high. In the last decades, these circumstances have led to a shift in goals of caretakers and researchers with a new focus on patients’ perspectives and long-term morbidity. Health-related quality of life (HrQoL) is the most commonly used patient-reported outcome measure to assess the impact of chronic symptoms on patients’ everyday lives. Most pediatric surgical conditions can cause a significantly decreased HrQoL in affected patients compared to the healthy population. In order to guarantee life-long care and to minimize the impact on HrQoL a regular interdisciplinary follow-up is obligatory. The period of transition from child-centered to adult-oriented medicine represents a critical phase in the long-term care of these complex patients. This scoping review aims to summarize relevant pediatric surgical conditions focusing on long-term-morbidity and HrQoL assessment in order to demonstrate the necessity for a well-structured and standardized transition for pediatric surgical patients.

[Current Treatment of Oesophageal Atresia]

Oesophageal atresia is a rare congenital malformation occurring in 1 : 3000/1 : 4000 neonates. Surgical correction is always required. Perioperative management concepts depend on the type of malformation. Postoperative results are closely related to postsurgical complications. Interdisciplinary management should extend from prenatal diagnosis, birth and perinatal care to neonatal intensive care and paediatric surgical therapy with specialised pediatric anaesthesia. Other areas that should be available are logopedia, paediatric gastroenterology and paediatric pulmonology. Long-term care should include systematic aftercare and transition programs to adult medicine.

Association of operative approach with outcomes in neonates with esophageal atresia and tracheoesophageal fistula

PURPOSE

We sought to evaluate the impact of thoracoscopic repair on perioperative outcomes in infants with esophageal atresia and tracheoesophageal fistula (EA/TEF).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program pediatric database from 2014 to 2018 was queried for all neonates who underwent operative repair of EA/TEF. Operative approach based on intention to treat was correlated with perioperative outcomes, including 30-day postoperative adverse events, in logistic regression models.

RESULTS

Among 855 neonates, initial thoracoscopic repair was performed in 133 (15.6%) cases. Seventy (53%) of these cases were converted to open. Those who underwent thoracoscopic repair were more likely to be full-term (p = 0.03) when compared to those in the open repair group. There were no significant differences in perioperative outcome measures based on surgical approach except for operative time (thoracoscopic: 217 min vs. open: 180 min, p<0.001). A major cardiac comorbidity (OR 1.6, 95% CI 1.2-2.1; p = 0.003) and preoperative ventilator requirement (OR 1.4, 95% CI 1.0-1.9; p = 0.034) were the only risk factors associated with adverse events.

CONCLUSIONS

Thoracoscopic neonatal repair of EA/TEF continues to be used sparingly, is associated with high conversion rates, and has similar perioperative outcomes when compared to open repair.

LEVEL OF EVIDENCE

III.

Thoracoscopic versus open lobectomy in infants with congenital lung malformations: A multi-institutional propensity score analysis

PURPOSE

The impact of thoracoscopic surgery on outcomes in children with congenital lung malformations (CLM) remains controversial. The purpose of this study was to determine the effect of operative approach on perioperative outcomes in infants undergoing lobectomy for an asymptomatic CLM.

METHODS

After IRB approval, a retrospective cohort study was conducted on 506 children with a CLM resected at one of eleven children's hospitals over a seven-year period. Infants undergoing elective lobectomy were identified, and covariates were balanced based on operative approach using propensity scores with full matching. Outcomes were analyzed based on intention to treat with weighted conditional regression.

RESULTS

One hundred seventy-five infants met inclusion criteria. There were 67 (38.3%) open, 89 (50.9%) thoracoscopic, and 19 (10.9%) thoracoscopic-converted-to-open lobectomies. Thoracoscopic lobectomy was associated with significantly longer operative times (26 min, 95% CI 6-47 min, p = 0.012) but used less epidural anesthesia (OR 0.02, 95% CI 0.004-0.11, p<0.001) when compared to open lobectomy. There were no significant differences in intraoperative blood loss, postoperative complications, chest tube duration, or length of stay.

CONCLUSIONS

Thoracoscopy has become the most common operative approach for elective lobectomy in infants with asymptomatic CLMs. The non-inferiority of thoracoscopic lobectomy in postoperative outcomes supports its continued use as an alternative to open lobectomy.

LEVEL OF EVIDENCE

Treatment study, Level III.

Novel Device for Endoluminal Esophageal Atresia Repair: First-in-Human Experience

Thoracoscopic esophageal atresia (EA) repair affords many benefits to the patient; however, intracorporeal suturing of the anastomosis is technically challenging. Esophageal magnetic compression anastomosis (EMCA) is a compelling option for endoluminal EA repair, but available EMCA devices have prohibitive rates of recalcitrant stricture. Connect-EA is a new endoluminal EMCA device system that employs 2 magnetic anchors with a unique mating geometry designed to reliably create a robust anastomosis and decrease rates of leak and stricture. We describe our first-in-human experience with this novel endoluminal device for staged EA repair in 3 patients (Gross type A, B, and C) at high risk for conventional surgical repair. First, the esophageal pouches were approximated thoracoscopically. After acute tension subsided, the device anchors were endoscopically placed in the esophageal pouches and mated. Anchors were spontaneously excreted in 2 cases. Endoscopic repositioning and retrieval of the anchors were required in 1 patient because of narrowed esophageal anatomy. There were no perioperative complications. Patients were managed for 14 to 18 months. The strictures that developed in the patients were membranous and responded well to dilation alone, resolving after 4 to 5 outpatient dilations. Gastrostomies were closed between 6 and 11 months and all patients are tolerating full oral nutrition. Early experience with this new endoluminal EMCA device system is highly favorable. The device offers considerable benefit over conventional handsewn esophageal anastomosis and anastomotic outcomes are superior to available EMCA devices.

Learning curve for total thoracoscopic lobectomy for treating pediatric patients with congenital lung malformation

BACKGROUND

Pediatric thoracoscopic lobectomy is a technically challenging procedure that may result in better pain control, better cosmetic results, and shorter hospital stay. However, data describing the learning curve of total thoracoscopic lobectomy (TTL) have yet to be obtained. To evaluate our learning curve for TTL in children, we reviewed the safety and efficiency of our initial experiences with TTL in pediatric patients with congenital lung malformation.

METHODS

This was a retrospective study of all pediatric patients undergoing TTL between March 2011 and January 2017. Cumulative summation (CUSUM) analysis of operative time (OT) was used.

RESULTS

One hundred patients were retrospectively analyzed and chronologically divided into three phases: the ascending (A), plateau (B), and descending (C) phases of CUSUM of OT. Phases A, B, and C comprised 35, 22, and 43 cases, respectively. OT decreased significantly from phases A to B (P = 0.035) and B to C (P = 0.019). Age and weight of patients both reduced significantly from phase A to B (p = 0.017 and p = 0.012, respectively), while the two measures did not vary from phase B to C (p = 0.987 and p = 0.874, respectively). Chest tube duration and length of hospital stay had similar trend. All complications occurred in five cases in phase A (5/35). Six cases were converted to open surgery (6%). Four conversions occurred within phase A and two in phase C (4/35 vs 2/43, p = 0.490). There were no mortalities.

CONCLUSIONS

Repeated standardized training plays a role in overcoming the learning curve for thoracoscopic lobectomy in children, and CUSUM_OT indicates that a learning curve of approximately 57 cases is required in our institute.

Thoracoscopic Lobectomy in Infants and Children

Indications for pulmonary lobectomy in infants and children include cystic pulmonary adenomatoid malformation, congenital lobar emphysema, chronic infection, and malignancy. These procedures can now all be done thoracoscopically avoiding the short- and long-term morbidity of an open thoracotomy. In this article we describe the technique of thoracoscopic lobectomy as well as the preoperative and postoperative care.

Support for Introduction of Pediatric Endosurgery in Nepal as Global Pediatric Surgery: Preliminary Needs Assessment Survey

Background: Endosurgery provides several advantages over open surgery in the context of global surgery; however, there are several barriers to its introduction. The preliminary assessment of needs and barriers is essential for carrying out effective support as Global Surgery. However, no report has described the initiation of support for endosurgery based on a preliminary survey of the needs and barriers. The present survey study aimed at determining the needs and barriers of pediatric endosurgery in Nepal. Materials and Methods: A needs assessment survey was conducted among all pediatric surgeons in Nepal via an online platform. This was followed by workshop on pediatric endosurgical skills in Nepal. To assess the skills of participants and effectiveness of the workshop, the skill evaluation tests and the questionnaire survey were conducted. Results: Fourteen pediatric surgeons (response rate: 60.9%) responded to the needs assessment survey. More than 70% of the participants did not have any experience with advanced endosurgical procedures. However, advanced endosurgical procedures were strongly needed. A lack of training was indicated as a major barrier for the introduction of pediatric endosurgery. Fifteen participants completed the workshop. Participants' confidence in their endosurgical skills improved significantly after the workshop. The skill evaluation tests revealed that participants' endosurgical skills also improved significantly after the workshop, although even after the workshop, participants still took an average of 415.6 seconds to place and knot one suture. Conclusions: The needs assessment survey and workshop for Nepalese pediatric surgeons helped clarify their needs for endosurgery and the barriers to its introduction.

Comparison of thoracoscopy vs. thoracotomy on musculoskeletal outcomes of children with congenital pulmonary airway malformation (CPAM)

BACKGROUND

It has been postulated that video-assisted thoracoscopic surgery (VATS) is superior than conventional thoracotomy for resection of congenital pulmonary airway malformation (CPAM) in terms of shorter hospital length of stay, reduced post-operative complication and better long-term pulmonary outcome. However, there is limited available data concerning the effect of VATS and conventional thoracotomy on musculoskeletal aspects in patients with CPAM. This study aims to compare the long-term effects of both surgical techniques on musculoskeletal outcomes in this group of patients.

METHODS

Thirty-five patients with mean age of 11.38 years old who underwent VATS or conventional thoracotomy for CPAM resection were recruited in this study. The mean follow-up time was 10.42 years (5.48 to 17.71 years). Musculoskeletal examination included screening of musculoskeletal deformities (elevation of shoulder, asymmetry of nipple level, breast/ pectoral muscle maldevelopment, winging of scapula, scoliosis), measurement of bilateral chest wall in relation to anatomical parameter, and testing of shoulder range of motion and power.

RESULTS

The prevalence of winged scapula was significantly lower in patients who underwent VATS than thoracotomy (13% vs 58%, p = 0.008). There is also a smaller reduction in operated-side chest wall vertical distance in VATS patients (0.982 vs 0.956, p = 0.058). There were no significant difference in prevalence of other musculoskeletal deformities, other chest wall measurements, shoulder range of motion and power between two groups.

CONCLUSION

Thoracoscopy decreases the incidence of scapular winging but has no effect on effect on other musculoskeletal deformities.

Minimally invasive surgery for neuroblastic tumours: A SIOPEN multicentre study: Proposal for guidelines

INTRODUCTION

Surgery plays a key role in the management of Neuroblastic tumours (NB), where the standard approach is open surgery, while minimally invasive surgery (MIS) may be considered an option in selected cases. The indication(s) and morbidity of MIS remain undetermined due to small number of reported studies. The aim of this study was to critically address the contemporary indications, morbidity and overall survival (OS) and propose guidelines exploring the utility of MIS for NB.

MATERIALS & METHODS

A SIOPEN study where data of patients with NB who underwent MIS between 2005 and 2018, including demographics, tumour features, imaging, complications, follow up and survival, were extracted and then analysed.

RESULTS

A total of 222 patients from 16 centres were identified. The majority were adrenal gland origin (54%) compared to abdominal non-adrenal and pelvic (16%) and thoracic (30%). Complete and near complete macroscopic resection (>95%) was achieved in 95%, with 10% of cases having conversion to open surgery. Complications were reported in 10% within 30 days of surgery. The presence of IDRF (30%) and/or tumour volume >75 ml were risk factors for conversion and complications in multivariate analysis. Overall mortality was 8.5%.

CONCLUSIONS

MIS for NB showed that it is a secure approach allowing more than 95% resection. The presence of IDRFs was not an absolute contraindication for MIS. Conversion to open surgery and overall complication rates were low, however they become significant if tumour volume >75 mL. Based on these data, we propose new MIS guidelines for neuroblastic tumours.

Case reports of one-lung ventilation using Fuji Uniblocker bronchial blockers for infants under one-year-old in uniportal video-assisted thoracoscopic surgery

INTRODUCTION

Uniportal video-assisted thoracoscopic surgery (VATS) for various pulmonary diseases provides advantages of less postoperative pain and earlier post-operative recovery over traditional open surgery. The inherent limitation of this surgical modality in manipulation of surgical instruments renders intra-operative one-lung ventilation a requisite to increase the substantially restricted working space and thus visibility of the surgical filed.

PATIENT CONCERNS

Patient 1, an 8-month-old, 9-kg, and 70 cm-in-height male infant was diagnosed as congenital pulmonary airway malformation (CPAM) over left lower lobe.Patient 2, a 9-month-old, 8-kg and 72 cm-in-height male infant was diagnosed as CPAM over right lower lobe.Patient 3, an 8-month-old, 8-kg and 67 cm-in-height female infant was diagnosed as CPAM over left lower lobe.This facilitating one-lung ventilation yet was rarely conducted in infants under one year of age for the extremely small body size, the unavailability of dedicated tools, and therein the very tough techniques demanded.

DIAGNOSIS

Infants with congenital cystic adenomatoid malformation.

INTERVENTIONS

Here we report three infants of less than one year of age in whom one-lung ventilation was successfully achieved by intraluminal use of 5-Fr Fuji Uniblocker Bronchial Blocker devices and in turn assisted the completion of uniportal VATS for congenital cystic adenomatoid malformation in unilateral lungs.

OUTCOMES

Three infants received VATS under uniblocker smoothly. Patient 1 had two episode of balloon dislodgement and desaturation and solved by re-insertion. And he had subglottic tracheal stenosis which treatment with laser coagulation. Patient 2 had overall blood loss 80 ml. Patient 3 had one episode of desaturation after stapling the bronchus and fiberoptic bronchoscope revealed obstruction by blood and secretion which solved by suction.

CONCLUSION

In conclusion, OLV in infants undergoing uniportal VATs could be successfully achieved by Fuji 5 Fr Uniblocker bronchial blockers for as long as 4 hours, as exemplified by our three cases, and balloon poor sealing and dislodgment can be immediately solved by bronchoscope-guided re-positioning without compromising surgical proceeding or outcome.

Video-Assisted Thoracoscopic or Conventional Thoracic Surgery in Infants and Children: Current Evidence

INTRODUCTION

 The pros and cons of video-assisted thoracoscopic versus conventional thoracic surgery in infants and children are still under debate. We assessed reported advantages and disadvantages of video-assisted thoracoscopy in pediatric surgical procedures, as well as the evidence level of the available data.

MATERIALS AND METHODS

 A systematic literature search was performed to identify manuscripts comparing video-assisted thoracoscopic and the respective conventional thoracic approach in classic operative indications of pediatric surgery. Outcome parameters were analyzed and graded for level of evidence (according to the Oxford Centre of Evidence-Based Medicine).

RESULTS

 A total of 48 comparative studies reporting on 12,709 patients, 11 meta-analyses, and one pilot randomized controlled trial including 20 patients were identified. More than 15 different types of advantages for video-assisted thoracoscopic surgery were described, mostly with a level of evidence 3b or 3a. Most frequently video-assisted thoracoscopic surgery was associated with shorter hospital stay, shorter postoperative ventilation, and shorter time to chest drain removal. Mortality rate and severe complications did not differ between thoracoscopic and conventional thoracic pediatric surgery, except for congenital diaphragmatic hernia repair with a lower mortality and higher recurrence rate after thoracoscopic repair. The most frequently reported disadvantage for video-assisted thoracoscopic surgery was longer operative time.

CONCLUSION

 The available data point toward improved recovery in pediatric video-assisted thoracoscopic surgery despite longer operative times. Further randomized controlled trials are needed to justify the widespread use of video assisted thoracoscopy in pediatric surgery.

Thoracoscopic Management of Pediatric Patients with Congenital Lung Malformations: Results of a European Multicenter Survey

Background: This study aimed to report a European multi-institutional experience about thoracoscopic management of children with congenital lung malformations. Methods: The records of 102 patients (49 girls and 53 boys) with median age at surgery of 1 year (range 6 months-1.5 years), who underwent thoracoscopic lobectomy in five European Pediatric Surgery units, were retrospectively collected. Indications for surgery included congenital pulmonary airway malformation (CPAM) (n = 47), intra- and extralobar pulmonary sequestration (n = 34), hybrid lesion (CPAM/intralobar sequestration) (n = 2), severe bronchiectasis (n = 9), congenital lobar emphysema (n = 8), and others (n = 2). The condition was asymptomatic in 77/102 (75.5%), whereas symptoms such as recurrent pneumonia and/or respiratory distress were present in 25/102 (24.5%). Results: Surgical procedures included 18 upper, 20 middle, and 64 lower lobe resections. No conversions to open were reported. A 3 mm sealing device and 5 mm stapler were adopted in the last 48/102 patients (47%). The median operative time was 92.2 minutes (range 74-141). The median operative time significantly decreased in patients in whom the vessel division and bronchial sealing were performed using sealing devices (75.5 minutes) compared with suture ligations (118.9 minutes) (P = .001). The median hospital stay was 3.7 days (range 2-6.2). Three/102 patients (2.9%) developed postoperative complications, including air leakage requiring pleural drainage (n = 1) (Clavien IIIb) and respiratory infection (n = 2) (Clavien II). A reoperation was required in one patient with residual pleuropulmonary blastoma (0.9%). All symptomatic patients reported resolution of symptoms postoperatively. Conclusions: Thoracoscopic lobectomy is a safe and effective procedure with excellent cosmetic outcome, in expert hands. Based upon our experience, we strongly recommend surgery in patients with congenital lung malformations by the first year of life, to reduce the risk of infection and make the procedure technically easier, despite the small patients' size. Surgeon's experience and use of miniaturized instruments and sealing devices remain key factors for successful outcome.

The Role of Video-Assisted Thoracoscopic Surgery in Pediatric Oncology: Single-Center Experience and Review of the Literature

Aim: Video-assisted thoracoscopic surgery (VATS) has been widely used in the last decades. Nevertheless, the pros and cons of thoracoscopy vs. open surgery in pediatric oncology are still under debate. In literature, VATS has been applied for both diagnostic and ablative surgery to treat neurogenic tumors, thymic neoplasms, lung tumors and metastases, germ cell tumors, lymphoproliferative diseases, and other rare tumors. Recent reviews described excellent outcomes in pediatric oncology as well as in the treatment of adult lung cancer, with a significantly higher rate of mortality and complication in thoracotomy compared to VATS. We reviewed our experience on thoracoscopy in pediatric malignancy and compared it to the literature. Materials and Methods: This was a retrospective cohort-study of pediatric oncological patients who underwent VATS at our institution from 2007 to 2020, and a review of the recent literature on the topic. Results: A total of 43 procedures were performed on 38 oncological patients (18 males, 20 females). Median age was years 7.72 (0.35-18.6). Diagnosis: 10 neurogenic tumors, nine hematological diseases, five metastases, four lypoblastomas, three thymic pathologies, three germ cell tumors, two pleuropneumoblastomas, two myofibroblastic tumors, one myoepithelial carcinoma, one liposarcoma, and three suspected oncological mass. In three cases, a 3D model was elaborated to better plan the surgical approach. Diagnostic biopsies were 22 (51.1%), and ablative surgeries, 21 (48.9%). One neurogenic tumor was resected with the Da Vinci Robot. Median operative time was 120 min (30-420). A drain was left in place in 20 (46.5%) for a median of 4 days. Median length of hospitalization was 5 days (1-18). One case (2.3%) was converted (intraoperative bleeding). There were three post-operative complications (7.0%): one pneumonia, one pleural effusion, and one diaphragmatic paralysis (need for plication). Results were compared to recent literature, and morbidity and conversion rate were comparable to reviewed publications. Conclusion: VATS represents a valuable tool for diagnostic and therapeutic procedures in pediatric oncology. Nonetheless, it is a challenging technique that should be performed by expert surgeons on oncological and mini-invasive surgery. Three-dimensional reconstruction can optimize the pre-operative planning and guarantee a safer and more targeted treatment. Finally, the advent of robotics-assisted surgery represents a new challenge that may further implement the advantages of VATS.

Musculoskeletal deformities after thoracic surgery in children: An observational long-term follow-up study

PURPOSE

This study reports the incidence, severity, and predictors of musculoskeletal deformities (MD), including scoliosis and chest wall anomalies, following thoracic procedures in children.

METHODS

Children younger than 14 years who had thoracic surgery between 1997 and 2012 and had no other predispositions to MD, underwent longitudinal follow-ups with dedicated musculoskeletal examination performed in an esophageal atresia, orthopedic, or research clinic. Incidence of MD was calculated, and logistic regression methods were used to determine independent predictors, including sex, gestational age, age at procedure, serratus anterior muscle division, and chest tube placement.

RESULTS

The study cohort consisted of 104 patients followed for a median of 10.8 years (range 3-21). A total of 56 MD developed in 41 patients (39%), including scapular winging (24; 23%), scoliosis (17; 16%), and chest wall anomalies (15; 14%). The majority of MD were subclinical, with only 8 patients [8% (6 thoracotomies, 2 thoracoscopies)] requiring intervention. Among patients who underwent thoracotomies (93, 89%), serratus anterior muscle division was the only significant predictor of the development of MD [OR 8.9; 95% CI 2.8-32.6].

CONCLUSION

Musculoskeletal deformities develop in a significant proportion of children following thoracic surgery, but most are subclinical. A muscle-sparing technique decreases the incidence of these deformities.

TYPE OF STUDY

Prospective Cohort Study.

LEVEL OF EVIDENCE

Level II.

Congenital Pulmonary Airway Malformation in Children: Advantages of an Additional Trocar in the Lower Thorax for Pulmonary Lobectomy

Aim: To present the use of an additional trocar (AT) in the lower thorax during thoracoscopic pulmonary lobectomy (TPL) in children with congenital pulmonary airway malformation. Methods: For a lower lobe TPL (LL), an AT is inserted in the 10th intercostal space (IS) in the posterior axillary line after trocars for a 5-mm 30° scope, and the surgeon's left and right hands are inserted conventionally in the 6th, 4th, and 8th IS in the anterior axillary line, respectively. For an upper lobe TPL (UL), the AT is inserted in the 9th IS, and trocars are inserted in the 5th, 3rd, and 7th IS, respectively. By switching between trocars (6th↔8th for the scope, 4th↔6th for the left hand, and 8th↔10th for the right hand during LL and 5th↔7th, 3rd↔5th, and 7th↔9th during UL, respectively), vital anatomic landmarks (pulmonary veins, bronchi, and feeding arteries) can be viewed posteriorly. The value of AT was assessed from blood loss, operative time, duration of chest tube insertion, requirement for post-operative analgesia, and incidence of perioperative complications. Results: On comparing AT+ (n = 28) and AT- (n = 27), mean intraoperative blood loss (5.6 vs. 13.0 ml), operative time (3.9 vs. 5.1 h), and duration of chest tube insertion (2.2 vs. 3.4 days) were significantly decreased with AT (p < 0.05, respectively). Differences in post-operative analgesia were not significant. There were three complications requiring conversion to open/mini-thoracotomy: AT- (n = 2; bleeding), AT+: (n = 1; erroneous stapling). Conclusions: An AT and switching facilitated posterior dissection during TPL in children with congenital pulmonary airway malformation enhancing safety and efficiency.

Is thoracoscopy superior to thoracotomy in the treatment of congenital lung malformations? An updated meta-analysis

Background:

A meta-analysis was performed for a comparison of outcomes between video-assisted thoracoscopic surgery (VATS) and thoracotomy for congenital lung malformations (CLM).

Methods:

Electronic databases, including PubMed, Scopus, Embase, and the Cochrane Library were searched systematically for literature aimed mainly at reporting the therapeutic effects for CLM administrated by VATS and thoracotomy.

Results:

A total of 40 studies meeting the inclusion criteria were included, involving 2896 subjects. VATS was associated with fewer complications [odds ratio (OR) 0.54; 95% confidence interval (CI), 0.42–0.69], less use of epidural anesthesia (OR, 0.08; 95% CI, 0.03–0.23), shorter length of hospital stay [standard mean difference (SMD) −0.98; 95% CI, −1.4 to −0.55] and chest drainage (SMD, −0.43; 95% CI, −0.7 to −0.17), as compared with thoracotomy. However, thoracotomy showed superiority in reduced operative time (SMD, 0.44; 95% CI, 0.04–0.84). Pearson analysis (Pearson r = 0.85, 95% CI, 0.28 to 0.98, p = 0.01) and linear regression (R square 0.73) confirmed a positive correlation between percentage of symptomatic cases and conversion in patients using VATS.

Conclusion:

VATS is associated with fewer complications, less use of epidural anesthesia, shorter length of stay and length of chest drainage, but longer operative time, as compared with thoracotomy. Symptomatic patients with CLM using VATS may be prone to conversion to thoracotomy.

The reviews of this paper are available via the supplemental material section.

Thoracoscopic versus conventional open repair of tracheoesophageal fistula in neonates: A short-term comparative study

PURPOSE

Esophageal atresia with or without a tracheo-esophageal fistula is a challenging anomaly in neonates. Thoracoscopic repair is gaining popularity now in pediatric surgery community. The present study aims at comparing the short term outcomes of thoracoscopy versus classic thoracotomy for repair of such conditions.

METHODS

Thirty neonates with tracheoesophageal fistula were randomly divided into two equal groups (n=15) after excluding patients with birth weight <2000g, multiple associated anomalies and cardiorespiratory instability. One group had conventional open repair while the other had thoracoscopic repair. Demographic data, intraoperative result and post-operative findings were recorded and compared between both groups.

RESULTS

Both groups showed similar results regarding demographic and patients' characteristics. Thoracoscopic repair had relatively longer, yet non-significant operative time but with highly significant difference in preserving azygos vein. There was low conversion rate with thoracoscopy (6.66%). Open repair resulted in a longer hospital stay (11.73±5.68 vs 9.2±2.95). Complication rate was comparable in both groups; however, thoracoscopy was associated with better cosmetic results as reported by parents and surgeons (p=0.00).

CONCLUSION

Compared to thoracotomy, thoracoscopic repair offers a less invasive, effective and safe technique with similar short term outcomes, but with superior cosmetic results and better ability to spare azygos vein.

TYPE OF STUDY

Therapeutic/Treatment study LEVEL OF EVIDENCE: Level II.

Thoracoscopy vs thoracotomy for the management of metastatic osteosarcoma: A Pediatric Surgical Oncology Research Collaborative Study

Complete surgical resection of pulmonary metastatic disease in patients with osteosarcoma is crucial to long-term survival. Open thoracotomy allows palpation of nodules not identified on imaging but the impact on survival is unknown. The objective of this study was to compare overall survival (OS) and pulmonary disease-free survival (DFS) in children who underwent thoracotomy vs thoracoscopic surgery for pulmonary metastasectomy. A multi-institutional collaborative group retrospectively reviewed 202 pediatric patients with osteosarcoma who underwent pulmonary metastasectomy by thoracotomy (n = 154) or thoracoscopy (n = 48). Results were analyzed by Kaplan-Meier survival estimates and multivariate Cox proportional hazard regression models. With median follow-up of 45 months, 135 (67.5%) patients had a pulmonary relapse and 95 (47%) patients were deceased. Kaplan-Meier analysis showed no significant difference in 5-year pulmonary DFS (25% vs 38%; P = .18) or OS (49% vs 42%, P = .37) between the surgical approaches of thoracotomy and thoracoscopy. In Cox regression analysis controlling for other factors impacting outcome, there was a significantly increased risk of mortality (HR 2.11; P = .027; 95% CI 1.09-4.09) but not pulmonary recurrence (HR 0.96; P = .90; 95% CI 0.52-1.79) with a thoracoscopic approach. However, in the subset analysis limited to patients with oligometastatic disease, thoracoscopy had no increased risk of mortality (HR 1.16; P = .62; 0.64-2.11). In conclusion, patients with metastatic osteosarcoma and limited pulmonary disease burden demonstrate comparable outcomes after thoracotomy and thoracoscopy for metastasectomy. While significant selection bias in these surgical cohorts limits the generalizability of the conclusions, clinical equipoise for a randomized clinical trial in patients with oligometastatic disease is supported.

Is thoracoscopic esophageal atresia repair safe in the presence of cardiac anomalies?

BACKGROUND

Esophageal atresia (EA) is often associated with congenital heart disease (CHD). Repair of EA by the thoracoscopic approach places physiological stress on a newborn with CHD. This paper reviews the outcomes of infants with CHD who had undergone thoracoscopic EA repair, comparing their outcomes to those without CHD.

METHODS

This was a review of infants who underwent thoracoscopic EA repair from 2009 to 2017 at one institution. Operative time and outcomes were analyzed in relation to CHD status.

RESULTS

Twenty five infants underwent thoracoscopic EA repair during the study period. Seventeen (68%) had associated anomalies of whom 9 (36%) had cardiac anomalies. The mean operative time was 217 min. There was no difference in operative time between CHD and non-CHD cases (estimate 20 min longer operative time in the presence of a cardiac anomaly [95% CI -20 to 57]). Two cases were converted to open thoracotomy; both were non-CHD. There was no difference in the time to feeding, time in intensive care unit or time in hospital between CHD and non-CHD cases. Five patients developed an anastomotic leak (two CHD and three non-CHD) of which two were clinical; all were managed conservatively. There was no case of recurrent fistula.

CONCLUSIONS

This pilot study did not find evidence that thoracoscopic EA repair compromised outcomes in children with congenital heart disease. A prospective multicenter study with long-term follow-up is recommended to confirm whether thoracoscopic repair in CHD is truly equivalent to the open operation.

TYPE OF STUDY

Therapeutic.

LEVEL OF EVIDENCE

Level III.

Scoliosis after thoracotomy repair of esophageal atresia: a systematic review

Standard surgical repair of esophageal atresia/tracheoesophageal fistula (EA/TEF) is via a right posterolateral thoracotomy. A recognized complication is the later development of scoliosis. The prevalence and pathogenesis of secondary scoliosis are poorly understood. We, therefore, conducted a systematic review on this topic. All English language articles reporting incidence, outcomes and/or interventions for scoliosis in children after EA repair via thoracotomy were identified. Fourteen relevant articles published between 1969 and 2019 reporting 1338 children were included in the analysis. The aggregate prevalence of scoliosis among 937 children without congenital vertebral anomalies was 13%, but this figure varied widely between studies. Severity of scoliosis was documented in 181 children; eight children had a Cobb angle > 40° and 10 had undergone spinal surgery. The spinal curvature in affected individuals was dominantly or exclusively convex to the left. In conclusion, the reported prevalence of scoliosis varies widely but on average affects about one in eight children after open repair of EA/TEF. Most cases are mild and do not require intervention. It is currently uncertain whether secondary scoliosis is preventable by using meticulous thoracotomy techniques or thoracoscopic repair.Level of evidence IV.