Resection of pediatric lung malformations: National trends in resource utilization & outcomes

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 versus thoracotomy lobectomy in children with congenital lung lesions: a systematic review and meta-analysis

BACKGROUND

Thoracoscopic lobectomy is always compared with open thoracotomy in congenital lung lesions with no definitive results. This systematic review and meta-analysis compared the clinical outcomes of thoracoscopic versus thoracotomy lobectomy in children.

METHODS

The electronic databases MEDLINE, EMBASE, and PubMed were searched. A meta-analysis was used to analyse and compare the operating time, length of hospital stay, and postoperative complications, such as wound infections and respiratory issues, in thoracoscopic and thoracotomy lobectomy.

RESULTS

Two thousand and ninety five paediatric patients were analysed over 17 studies (1 ambidirectional cohort study and 16 retrospective studies). Of these patients, 903 and 1192 had undergone thoracoscopic lobectomy and thoracotomy, respectively. There was a significant lower incidence of overall and respiratory complications and longer operative time for thoracoscopic lobectomy compared with thoracotomy in children; however, pooling the results for the two methods revealed no significant difference in wound infection or length of hospital stay.

CONCLUSION

Thoracoscopic lobectomy offers the benefit of having fewer overall and respiratory complications than thoracotomy. It did not, however, clearly outperform open surgery in terms of operative time, wound infection, or postoperative hospitalization.

Sublobar Pulmonary Resection in Children With Congenital Lung Abnormalities: A Systematic Review

BACKGROUND

Lobectomy is currently the advised resection for symptomatic congenital lung abnormalities (CLA). Sublobar surgery is suggested as an alternative that enables to conserve healthy lung parenchyma. This systematic review aims to explore the outcomes of sublobar surgery in CLA patients as well as the corresponding surgical terminology and techniques.

METHODS

A systematic literature search was performed in adherence to PRISMA-P guidelines. The target population consists of children undergoing sublobar pulmonary resection for CLA. All studies were independently assessed by two reviewers, and evaluated by a third reviewer in case of disagreement.

RESULTS

The literature search yielded 901 studies of which 18 studies were included, comprising 1167 cases. The median chest tube insertion duration was 3.6 days (range 2.0-6.9 days), the median hospital admission was 4.9 days (range 2.0-14.5 days), and residual disease was diagnosed in 2% - leading to re-operation in 70%. The median incidence of postoperative complications was 15% (range 0-67%). Follow-up imaging was standard-of-care in 2/3 of studies. Due to the absence of standardised terminology, operative details and specification of resection type did not typically relate between studies.

CONCLUSIONS

Sublobar resection of CLA lesions could be a viable alternative to lobectomy in certain cases, with the advantage of conserving healthy lung parenchyma. Peri- and postoperative complications are comparable with those reported for conventional lobectomy. The incidence of residual disease following sublobar surgery appears to be lower than commonly stated. To improve comparability between studies, we recommend reporting perioperative characteristics in a structured format.

LEVEL OF EVIDENCE

Level IV.

Introduction of pediatric thoracoscopic lung resections in a low-volume center - feasibility, outcome and cost analysis

BACKGROUND

Early series of pediatric thoracoscopic surgery have reported high conversion rates and significant complications. This study investigated the introduction of pediatric thoracoscopic lung resections in a low-volume center with reference to corresponding open thoracotomy procedures with regards to operative times, length of stay, cost of admission, and outcomes.

METHODS

A single surgeon series. Data from the first 10 consecutive thoracoscopic lung resections were compared to a cohort of 10 consecutive open lung resections performed before the introduction of the thoracoscopic technique. All operations were performed between December 2015 and October 2021. The median follow-up was 34 months (range 4-65).

RESULTS

The cohort included 14 lobectomies (8 thoracoscopic and 6 open) for congenital pulmonary airway malformation (CPAM), and 6 resections (mainly non-anatomic) of pulmonary sequestration (2 thoracoscopic and 4 open). One lobectomy required conversion to thoracotomy, and one patient required reinsertion of a chest drain after open lobectomy due to persistent air leak. No other complications were recorded. All patients were asymptomatic at their follow-up. There was no significant difference in the mean age, mean weight, operative times, and intraoperative blood loss between open and minimally invasive procedures. Thoracoscopic technique was associated with significantly shorter stay at pediatric intensive care unit and shorter overall inpatients stay.

CONCLUSION

Thoracoscopic lung resections can be safely introduced in a low-volume center with comparable cost, operative time, and results and significantly shorter inpatient stay.

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.

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.

Anesthesia for thoracic surgery in infants and children

The management of infants and children presenting for thoracic surgery poses a variety of challenges for anesthesiologists. A thorough understanding of the implications of developmental changes in cardiopulmonary anatomy and physiology, associated comorbid conditions, and the proposed surgical intervention is essential in order to provide safe and effective clinical care. This narrative review discusses the perioperative anesthetic management of pediatric patients undergoing noncardiac thoracic surgery, beginning with the preoperative assessment. The considerations for the implementation and management of one-lung ventilation (OLV) will be reviewed, and as will the anesthetic implications of different surgical procedures including bronchoscopy, mediastinoscopy, thoracotomy, and thoracoscopy. We will also discuss pediatric-specific disease processes presenting in neonates, infants, and children, with an emphasis on those with unique impact on anesthetic management.

Thoracoscopic surgery for congenital lung cysts: an attempt to limit pulmonary resection in cases of lesions involving multiple lobes

PURPOSE

Although we generally perform thoracoscopic lobectomy for congenital lung cysts (CLCs), we recently began performing thoracoscopic-limited pulmonary resection (segmentectomy or small partial lung resection) on relatively small lesions and on lesions involving multiple lobes. Our study aimed to determine the therapeutic outcomes of thoracoscopic CLC surgery.

METHODS

We retrospectively reviewed patients aged ≤ 18 years who underwent their first CLC surgery at our facility between 2013 and 2020.

RESULTS

A comparison between patients < 4 months old and those ≥ 4 months old showed no significant difference in operating time or incidence of complications. Blood loss volume (mL/kg) was significantly greater in patients < 4 months old and in patients who had undergone semi-urgent or urgent surgery. Operating time and postoperative complications were not increased in semi-urgent or urgent surgeries. There was no significant difference in operating time, blood loss volume, or postoperative complications between patients with a preoperative history of pneumonia and patients with no such history.

CONCLUSION

In most patients, thoracoscopic surgery for CLC was safely performed. Limited pulmonary resection is considered difficult to perform thoracoscopically in children, but can be safely performed using new devices and navigation methods.

LEVEL OF EVIDENCE

III.

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.

Development of a multi-institutional registry for children with operative congenital lung malformations

INTRODUCTION

The purpose of this study was to develop a multi-institutional registry to characterize the demographics, management, and outcomes of a contemporary cohort of children undergoing congenital lung malformation (CLM) resection.

METHODS

After central reliance IRB approval, a web-based, secure database was created to capture retrospective cohort data on pathologically-confirmed CLMs performed between 2009 and 2015 within a multi-institutional research collaborative.

RESULTS

Eleven children's hospitals contributed 506 patients. Among 344 prenatally diagnosed lesions, the congenital pulmonary airway malformation volume ratio was measured in 49.1%, and fetal MRI was performed in 34.3%. One hundred thirty-four (26.7%) children had respiratory symptoms at birth. Fifty-eight (11.6%) underwent neonatal resection, 322 (64.1%) had surgery at 1-12 months, and 122 (24.3%) had operations after 12 months. The median age at resection was 6.7 months (interquartile range, 3.6-11.4). Among 230 elective lobectomies performed in asymptomatic patients, thoracoscopy was successfully utilized in 102 (44.3%), but there was substantial variation across centers. The most common lesions were congenital pulmonary airway malformation (n = 234, 47.3%) and intralobar bronchopulmonary sequestration (n = 106, 21.4%).

CONCLUSION

This multicenter cohort study on operative CLMs highlights marked disease heterogeneity and substantial practice variation in preoperative evaluation and operative management. Future registry studies are planned to help establish evidence-based guidelines to optimize the care of these patients.

LEVEL OF EVIDENCE

Level II.

Sex differences in surgically correctable congenital anomalies: A systematic review

PURPOSE

This study aims to compare the prevalence and outcomes of surgically correctable congenital anomalies between sexes.

METHODS

Upon registration on PROSPERO (CRD42019120165), a librarian aided in conducting a systematic review using PRISMA guidelines. The five largest relevant studies were included for each anomaly. Cumulative prevalence differences and confidence intervals were calculated, and the Cochran-Mantel-Haenszel test was performed.

RESULTS

Of 42,722 identified studies, 68 were included in our analysis. All included anomalies had greater than 1000 patients except duodenal atresia (n = 787) and intestinal duplication (n = 148). Males had a significantly higher prevalence than females in 10/14 anomalies (Hirschsprung's disease, omphalomesenteric duct, congenital diaphragmatic hernia, anorectal malformation, malrotation, esophageal atresia, congenital pulmonary airway malformation, intestinal atresia, omphalocele, and gastroschisis; p < 0.001). There was no difference in the prevalence of duodenal atresia or intestinal duplication between sexes (p = 0.88 and 0.65, respectively). Females had a significantly higher prevalence of biliary anomalies (atresia and choledochal cyst).

CONCLUSION

Our study indicates that males have higher prevalence rates of most congenital anomalies. Further investigations are required to illuminate the embryology underlying this sex distribution and whether sex influences outcomes.

TYPE OF STUDY

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Prognostic study, level II.

Extrapulmonary sequestration with a left internal thoracic arterial feeding vessel in an infant treated with video-assisted Thoracoscopic resection: a case report

Background

Congenital lung malformations exist along a spectrum of pathogenesis and disease severity. Extrapulmonary sequestration (EPS), in which nonfunctional lung tissue develops without connection to the tracheobronchial tree, is one rare manifestation of this disease. Atypical vascular anatomy with a systemic feeding vessel characterizes these lesions.

Case presentation

A 3 day old, 37 week gestation infant underwent chest X-ray for confirmation of umbilical catheter placement and was found to have an elevated left hemidiaphragm consistent with eventration versus congenital diaphragmatic hernia. He remained asymptomatic and was evaluated as an outpatient at the age of 9 months, where CT angiogram demonstrated extrapulmonary versus intrapulmonary sequestration with a systemic feeding vessel from the left internal mammary artery.

Conclusions

It is exceedingly rare for the feeding artery to arise from the internal mammary; two such cases have been reported to date, both in adult patients. Here we present a third case of EPS with arterial supply from the internal mammary successfully treated with video-assisted thoracoscopic resection in a 9 month old infant.

Long-term lung function in children following lobectomy for congenital lung malformation

BACKGROUND/PURPOSE

To date, the optimal management of asymptomatic congenital lung malformations (CLMs) is still debated. There is still scant and controversial information regarding the long-term assessment of pulmonary function (PF) after lobectomy in children. The aim of this study is to evaluate PF in children who underwent lobectomy for CLM in infancy, hypothesizing that patients operated during the first year of life retain a normal lung function.

METHODS

Children operated between 2005 and 2016 at our institution underwent PF evaluation through spirometry/whole-body plethysmography, forced oscillation technique, and multiple-breath inert gas wash-out.

RESULTS

Out of 85 patients who underwent lobectomy at a median age of 5months, 50 met the inclusion criteria, and 28 patients were tested. More than 80% of patients had normal FEV₁ and FVC. The mean FEV₁, FVC, FEF_25-75% values were higher in the patients operated before reaching one year of age.

CONCLUSIONS

The long-term outcome after lobectomy was excellent for most patients, as they retained a normal long-term PF. Therefore, for asymptomatic patients, a surgical approach before one year of age to avoid complications such as malignancy and to ensure an optimal PF catch-up could be beneficial.

LEVEL OF EVIDENCE

III - Treatment Studies.

Outcomes following elective resection of congenital pulmonary airway malformations are equivalent after 3 months of age and a weight of 5 kg

PURPOSE

Resection of congenital pulmonary airway malformations (CPAMs) is often performed to reduce the risk of recurrent infection and malignant transformation. However, there is substantial variation in the timing of resection. This study was performed to determine the association of age and weight on outcomes following elective resection of CPAMs.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program-Pediatric database from 2012 to 2014 was queried for infants undergoing elective resection of a CPAM. Infants were categorized based on age (0-3months, 3-6months, 6-9months, 9-12months, and >12months) and weight (0-5kg, 5-10kg, and >10kg). Groups were compared for baseline characteristics and outcomes including a morbidity composite of pneumonia, reintubation, ventilator days >0, reoperation, readmission, hospital length of stay >7days, and mortality.

RESULTS

A total of 311 infants met study criteria. The morbidity composite was significantly more common among infants <3months of age compared to infants >3months of age (31.3% vs. 15.6%, p=0.01) and among infants <5kg as compared to infants >5kg (37.5% vs. 15.8%, p<0.01).

CONCLUSIONS

Infants should be observed until three months of age and a weight of five kilograms prior to elective resection of CPAMs.

LEVEL OF EVIDENCE

Level III.