Paediatric thoracoscopic surgery

Thoracoscopic Patch Repair of Congenital Diaphragmatic Hernia: Can Smaller Incisions Treat Larger Defects?

INTRODUCTION

Thoracoscopic CDH repair is increasingly performed for Type A and small Type B defects that are amenable to primary repair. However, the thoracoscopic approach is controversial for larger defects necessitating a patch due to technical complexity, intraoperative acidosis, and recurrence risk. We aim to compare clinical outcomes between thoracoscopic and open patch repair of Type B/C defects, using a standardized technique.

METHODS

This is a single-center retrospective review of thoracoscopic and open CDH patch repairs January 2017-December 2021. We excluded primary repairs, Type D hernias, repairs on ECMO, recurrent repairs. Various preoperative, intraoperative, and postoperative variables were compared. Primary outcome was recurrence rate. Secondary outcomes included intraoperative pH and pCO2, operative time, and complication rates.

RESULTS

Twenty-nine patients met inclusion criteria (open = 13, thoracoscopic = 16). The open cohort had lower o/e total fetal lung volume (29 vs 41.2%, p = 0.042), higher preoperative peak inspiratory pressures (24 vs 20 cm H2O, p = 0.007), were more frequently Type C defects (92.3 vs 31%, p = 0.002) and had liver "up" in left-sided hernias (46 vs 0%, p < 0.0001). Intraoperatively, median lowest pH and highest pCO2 did not differ; neither did overall median pH or pCO2. Operative times were similar (153 vs 194 min, p = 0.113). No difference in recurrence rates was identified, however postoperative complications were higher in the open group. There were no mortalities.

CONCLUSIONS

Although we demonstrate higher disease severity of patients undergoing open repair, thoracoscopic patch repair for Type B/C defects is safe and effective in patients with favorable physiologic status, alleviating concerns for intraoperative acidosis, operative length, and risk of recurrence.

LEVEL OF EVIDENCE

II.

A Surgical Approach to Pulmonary Metastasis in Children

Decisions regarding the role of surgery in pulmonary metastasis need to take into account histology and biology of the cancer. Response to chemotherapy and radiotherapy, balanced with toxicities, factors into decisions about metastasectomy. The less sensitive the tumor is to adjuvant therapy, the more likely that metastasectomy may be beneficial. Broad principles include the following: the aims of resection are localized resections with clear margins, with the aim of preserving adequate lung volume; unnecessary toxic therapy sometimes is avoided with accurate diagnosis; tumor type is of utmost importance; and number of metastases and the disease-free interval are not contraindications to metastasectomy.

Thoracoscopy vs. thoracotomy for the repair of esophageal atresia and tracheoesophageal fistula: a systematic review and meta-analysis

Esophageal atresia (EA) and tracheoesophageal fistula (TEF) require emergency surgery in the neonatal period to prevent aspiration and respiratory compromise. Surgery was once exclusively performed via thoracotomy; however, there has been a push to correct this anomaly thoracoscopically. In this study, we compare intra- and post-operative outcomes of both techniques. A systematic review and meta-analyses was performed. A search strategy was developed in consultation with a librarian which was executed in CENTRAL, MEDLINE, and EMBASE from inception until January 2017. Two independent researchers screened eligible articles at title and abstract level. Full texts of potentially relevant articles were then screened again. Relevant data were extracted and analyzed. 48 articles were included. A meta-analysis found no statistically significant difference between thoracoscopy and thoracotomy in our primary outcome of total complication rate (OR 0.98, [0.29, 3.24], p = 0.97). Likewise, there were no statistically significant differences in anastomotic leak rates (OR 1.55, [0.72, 3.34], p = 0.26), formation of esophageal strictures following anastomoses that required one or more dilations (OR 1.92, [0.93, 3.98], p = 0.08), need for fundoplication following EA repair (OR 1.22, [0.39, 3.75], p = 0.73)-with the exception of operative time (MD 30.68, [4.35, 57.01], p = 0.02). Considering results from thoracoscopy alone, overall mortality in patients was low at 3.2% and in most cases was due to an associated anomaly rather than EA repair. Repair of EA/TEF is safe, with no statistically significant differences in morbidity when compared with an open approach.Level of evidence 3a systematic review of case-control studies.

Thoracoscopy Versus Open Surgery for Persistent Ductus Arteriosus and Vascular Ring Anomaly in Neonates and Infants

BACKGROUND

The aim of our study was to report our experience in thoracoscopy in infants and neonates for vascular surgical conditions in neonates and infants and to compare our results to open surgery regarding the short-term outcome.

PATIENTS AND METHODS

We retrospectively reviewed all the patients operated in a single institution from 1997 to 2016 for persistent ductus arteriosus (PDA) and vascular ring (VR) anomalies. We compared our thoracoscopic series to a historical control group operated by open surgery. Data collection from charts and office notes included age and weight at surgery, cardiac ultrasound data for PDA, preoperative clinical symptoms for VR, type of surgery, operating time, analgesic treatment requirements, ventilation status during postoperative course, and early complications.

RESULTS

The thoracoscopic group included 13 PDA (median age and weight at surgery: 34 days and 1800 g) and 11 VR (median age and weight at surgery: 8 months and 7000 g). The thoracoscopic group did not differ in preoperative symptoms and work-up, operating time, ventilation status, length of hospital-stay, and postoperative complications with the group operated on by thoracotomy, for either PDA or VR.

CONCLUSION

Our short-term results in thoracoscopic PDA closure and VR anomalies surgery in neonates and infants are comparable to open surgery. Thoracoscopy seems to provide less pain especially for neonates and premature babies and allows to decrease the risk for postoperative chest wall deformities. Long-term outcome is mandatory to confirm these preliminary results.