Prior thoracic surgery has a limited impact on the feasibility of consecutive thoracoscopy in children: a prospective study on 228 procedures

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.

Serial improvement of quality metrics in pediatric thoracoscopic lobectomy for congenital lung malformation: an analysis of learning curve

BACKGROUND

Video-assisted thoracic surgery (VATS) pulmonary resection in children is a technically demanding procedure that requires a relatively long learning period. This study aimed to evaluate the serial improvement of quality metrics according to case volume experience in pediatric VATS pulmonary resection of congenital lung malformation (CLM). Methods VATS anatomical resection in CLM was attempted in 200 consecutive patients. The learning curve for the operative time was modeled by cumulative sum analysis. Quality metrics were used to measure technical achievement and efficiency outcomes. Results The median operative time was 95 min. The median length of hospital stay and chest tube indwelling time was 4 and 2 days, respectively. The improvement of operation time was observed persistently until 200 cases. However, two cut-off points, the 50th case and 110th case, were identified in the learning curve for operative time, and the 110th case was the turning point for stable outcomes with short operation time. Significant reduction of length of hospital stay and chest tube indwelling time was observed after 50 cases (p = .002 and p = .021, respectively). The complication rate decreased but continued at a low rate for entire study period and the interval decrease was not statistically significant. Conversion rate decreased significantly (p = .001), and technically challenging procedures were performed more frequently in later cases. Conclusions Improvements of quality metrics in operation time, conversion rate, length of hospital stay, and chest tube indwelling time were observed in proportion to case volume. Minimum experience of 50 is necessary for stable outcomes of pediatric VATS pulmonary resection.

Thoracoscopic resection of congenital pulmonary malformations in infants: is the feasibility related to the size of the lesion?

BACKGROUND

The size of congenital pulmonary malformation (CPM) in infants might interfere with the feasibility of thoracoscopic resection. This study was undertaken to evaluate the impact of the size of CPM on the applicability of video-assisted thoracic surgery (VATS) in infants.

METHODS

Twenty-two infants were operated on for CPM from November 2000 to June 2009. The intra- and postoperative course was analyzed retrospectively from patient charts. Preoperative scans were evaluated blindly by a radiologist to calculate the relation between the maximum size of the lesion and the thoracic diameter in VATS and open procedures.

RESULTS

VATS was performed in 14 (64%) of the 22 patients and thoracotomy in 8. VATS was successfully performed in 11 (79%) of the 14 patients, whereas VATS was converted to thoracotomy due to lack of overview in 3 (21%). The mean relative size of CPM at preoperative imaging was 0.34 ± 0.05 (range: 0.3-0.4) in patients who received successful VATS, 0.57 ± 0.06 (range: 0.5-0.6) in converted cases, and 0.68 ± 0.10 (range: 0.5-0.8) in infants who underwent thoracotomy. The relative CPM size was significantly lower in successful VATS than in cases of conversion (P<0.01) and thoracotomy (P<0.01).

CONCLUSIONS

The relative size of CPM at preoperative imaging might be useful information for a decision-making on the use of VATS in infants. A relative CPM size below 0.5, which is less than half of the thoracic diameter, indicates a good feasibility for thoracoscopic resection of CPM. A larger size may indicate that VATS might be technically difficult.

[Minimally invasive pediatric surgery]

In recent years minimally invasive surgical techniques in children have made substantial progress. The feasibility and safety of a wide spectrum of laparoscopic and thoracoscopic procedures have been confirmed in numerous studies. Moreover, it was reported that minimally invasive pediatric surgery is associated with lower morbidity, a shorter hospital stay, lower costs, better cosmetics and clinical results similar to those achieved by open surgery. The present article reviews information on established as well as feasible but not yet established surgical procedures. The discussion of potential hemodynamic, respiratory and organ perfusion effects of the CO(2) pneumoperitoneum and the notation of special logistic aspects should support the reader in the process of decision-making to schedule infants and children for minimally invasive surgery.