Thoracoscopic Resection of Congenital Lung Malformation: Looking for the Right Preoperative Assessment

Diagnostic accuracy of imaging compared to histology in congenital lung malformations

INTRODUCTION

The aim of this study was to evaluate the accuracy of imaging tests (prenatal ultrasound [US] and postnatal computed tomography [CT]) in comparison to histology for diagnosis of congenital lung malformations (CLMs).

MATERIAL AND METHODS

Retrospective study of patients with a prenatal diagnosis of CLM whose postnatal follow-up included thoracic CT scan and histological examination of the lesion. We collected data on demographic variables, gestational age at diagnosis, US findings and the history of multiple gestation. We used the kappa coefficient to determine the level of agreement between the findings of prenatal US and postnatal tests (CT and histology).We analysed paired data on the size of the lesion, its location and the presence or absence of systemic arterial vascularization.

RESULTS

The sample included 56 patients with 57 lesions. The mean gestational age at diagnosis was 22.42 weeks (SD, 3.94) and 57% were male. Malformations most frequently involved the left lung and the lower lobes. The agreement between CT and histology in the detection of cystic lesions was moderate (κ = 0.55) but stronger compared to the agreement between US and histology (κ = 0.10). The agreement between CT and histology was substantial (κ = 0.66) in the detection of systemic vascularization of the lesion and stronger compared to the agreement between US and histology. Both imaging methods were highly accurate in the identification of the location of the pulmonary lesions.

CONCLUSIONS

postnatal CT offers a substantial concordance with histological findings, especially in the detection of systemic vascularization, and an accurate prediction of the anatomy of the lesion.

Intrauterine Ultrasound-Guided Laser Coagulation as a First Step for Treatment of Prenatally Complicated Bronchopulmonary Sequestration: Our Experience and Literature Review

INTRODUCTION

 Prenatal ultrasound-guided laser coagulation (USLC) for complicated bronchopulmonary sequestrations has been described but a consensus on the procedure and on the following management is still lacking. We present our experience and provide a literature review.

METHODS

 Retrospective review of patients treated in our center. Literature review and combined analysis of perinatal data were performed.

RESULTS

 Five cases were treated at our center, all presenting with severe hydrothorax. Four met the criteria for fetal hydrops. Four cases underwent postnatal computed tomography (CT) scan: in one case, there was no evidence of persistent bronchopulmonary sequestration. The other three underwent thoracoscopic resection, in two, a viable sequestration was found. Including our series, 57 cases have been reported, with no mortality and a success rate of 94.7%. Mean gestational age (GA) at the procedure was 28 ± 3.4 weeks and mean GA at birth and birth weight (BW) were 38.6 ± 2.3 weeks and 3,276 ± 519.8 g, respectively. In 80.6% of the cases investigated postnatally, a residual mass was found, 50% of cases who showed prenatal arterial flow cessation had a persistent sequestration postnatally, and 26.3% of cases underwent postnatal sequestrectomy. Both patients in our series had pathology examination confirming a viable bronchopulmonary sequestration.

CONCLUSION

 Prenatal USLC seems to be a valid option for bronchopulmonary sequestration complicated by severe hydrothorax and/or fetal hydrops. Authors believe that this procedure should aim to reverse fetal distress and allow pregnancy continuation, and it should not be considered a definitive treatment. The currently available data do not support changes of the common postnatal management.

Analysis of Pulmonary Surgery in Children and Adolescents in Germany: Who Is doing What?

INTRODUCTION

 In Germany, pediatric surgery is organized in a decentralized manner. A nationwide clinical registry does not exist. The aim of this research is to analyze the current status of pulmonary surgery in the country in respect of children and adolescents.

MATERIALS AND METHODS

 Claims data have been extracted from two health insurance databases representing 34% of the German population. Operative diagnoses and procedures, as well as patients' characteristics, were recorded from 2016 to 2019.

RESULTS

 The incidence of the four index diagnoses investigated matched the current literature in three of four entities. The main indications <8 years were congenital lung malformations (61%) and spontaneous pneumothorax at age 8 to 17 years (77%). Furthermore, 1,668 pediatric pulmonary procedures (0-17 years) were identified (668 pulmonary resections). Two age peaks were identified: 13% of patients were operated on before 1 year old and 50% of patients were between 15 and 17 years old. Video-assisted-thoracoscopic-surgery (VATS) for pulmonary resections was applied in 62% of cases. 96% of pulmonary resections in patients <1 year and 70% of pulmonary resections in children between 1 and 14 years were performed by pediatric surgeons. Of patients between 15 and 17 years old, only 14% were operated on in pediatric surgery. The estimated average pulmonary resection caseload was 3.2 cases per year and per institution for pediatric surgery and 1.5 for adult surgery.

CONCLUSION

 Indications for pulmonary surgery in children arise from rare diagnoses. In total, 66% of lung resections are performed in patients <1 year and >14 years. The majority of lung resections are performed as VATS. Patients ≤14 years are predominantly operated on by pediatric surgeons. The accessibility of pediatric pulmonary surgery is acceptable, but there is a low caseload per center.

Mentoring in Pediatric Thoracoscopy: From Theory to Practice

Introduction: Thoracoscopy represents the most challenging area of pediatric minimally invasive surgery due to its technical difficulty. A standardized training program would be advisable. The aim of this study is to evaluate the results of our surgical training. Materials and Methods: A retrospective, single-center, cohort study was performed. The following four-step program was tested: (1) theoretical part; (2) experimental training; (3) training in centers of reference; (4) personal operative experience. Particular attention was focused on the choice of mentor. Times and modality of adherence to the program were evaluated. The effectiveness and safety of the training were evaluated according to the surgical results of esophageal atresia (EA/TEF) repair and resection of congenital lung malformations (CLM). The study was conducted from January 2014 to May 2020. Attending surgeons with previous experience in neonatal and pediatric laparoscopy were selected for the training program after being evaluated by the head of Department. Results: The training program was fully completed in 2 years. Twenty-four lobectomies, 9 sequestrectomies, 2 bronchogenic cyst resections and 20 EA/TEF repair were performed. Thoracoscopy was always feasible and effective, with no conversion. The operative times progressively decreased. Only three minor complications were recorded, all treated conservatively. Conclusions: A standardized training program is highly desirable to learn how to safely perform advanced pediatric thoracoscopy. The 4-steps design seems a valid educational option. The choice of the mentor is crucial. An experience-based profile for pediatric surgeons who may teach thoracoscopy is advisable.

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.