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Rothenberg S, Shipman K, Lai S, Kay S. Evaluation of Thoracoscopic Lobectomy in Infants for Congenital Lung Lesions: Earlier Is Better! J Pediatr Surg 2024; 59:368-371. [PMID: 37973421 DOI: 10.1016/j.jpedsurg.2023.10.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 10/24/2023] [Indexed: 11/19/2023]
Abstract
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
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Affiliation(s)
| | | | - Sarah Lai
- The Rocky Mountain Hospital for Children Denver, CO, USA
| | - Saundra Kay
- The Rocky Mountain Hospital for Children Denver, CO, USA
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2
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He T, Sun X, Luo D, Dai S, Yuan M, Yang G, Cheng K, Xu C. Absorbable Clips Applied in Thoracoscopic Anatomical Lung Resection in Younger Children. World J Surg 2023; 47:3394-3399. [PMID: 37851068 DOI: 10.1007/s00268-023-07193-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2023] [Indexed: 10/19/2023]
Abstract
OBJECTIVES This study aims to evaluate the feasibility and safety of a 5-mm absorbable clips applied in thoracoscopic anatomical lung resection in younger children. METHODS Demographic data and intra- and postoperative parameters of the two groups (Abs-o-lock® group and Hem-o-lok® group) were reviewed. In the Abs-o-lock® group, 5-mm absorbable clips were used in thoracoscopic anatomical lung resection on all patients from January 2020 to March 2021. In the Hem-o-lok® group, 5-mm Hem-o-lok® clips were used from January to December 2019. The primary outcomes were the one-time success rate of ligation, major bleeding rate, intraoperative dislodgement rate and operative time, which were compared between the two groups. RESULTS There were 224 patients involved in this study, of whom 103 were in the Abs-o-lock® group and 121 were in the Hem-o-lok® group. The one-time success rate of ligation was 96.5% in the Abs-o-lock® group and 98.9% in the Hem-o-lok® group (p < 0.05). No major bleeding occurred in either group. The intraoperative dislodgement rate did not significantly differ between the two groups (p = 1.0). The operative time consumed in the Abs-o-lock® group was much longer than that in the Hem-o-lok® group for subgroups of resection of extralobar sequestration (p < 0.05), lobectomy (p < 0.05) and segmentectomy (p < 0.05). CONCLUSIONS Compared to Hem-o-lok® clips, it is feasible and safe to apply 5-mm absorbable clips for vessel sealing during thoracoscopic anatomical lung resection in younger children.
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Affiliation(s)
- Taozhen He
- Department of Pediatric Surgery, West China Hospital of Sichuan University, NO. 37 GUOXUE Lane, Chengdu, 610041, Sichuan Province, China
| | - Xiaoyan Sun
- Health Management Centre, West China Hospital of Sichuan University, NO. 37 GUOXUE Lane, Chengdu, 610041, China
| | - Dengke Luo
- Department of Pediatric Surgery, West China Hospital of Sichuan University, NO. 37 GUOXUE Lane, Chengdu, 610041, Sichuan Province, China
| | - Shiyi Dai
- Department of Pediatric Surgery, West China Hospital of Sichuan University, NO. 37 GUOXUE Lane, Chengdu, 610041, Sichuan Province, China
| | - Miao Yuan
- Department of Pediatric Surgery, West China Hospital of Sichuan University, NO. 37 GUOXUE Lane, Chengdu, 610041, Sichuan Province, China
| | - Gang Yang
- Department of Pediatric Surgery, West China Hospital of Sichuan University, NO. 37 GUOXUE Lane, Chengdu, 610041, Sichuan Province, China
| | - Kaisheng Cheng
- Department of Pediatric Surgery, West China Hospital of Sichuan University, NO. 37 GUOXUE Lane, Chengdu, 610041, Sichuan Province, China
| | - Chang Xu
- Department of Pediatric Surgery, West China Hospital of Sichuan University, NO. 37 GUOXUE Lane, Chengdu, 610041, Sichuan Province, China.
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Pederiva F, Rothenberg SS, Hall N, Ijsselstijn H, Wong KKY, von der Thüsen J, Ciet P, Achiron R, Pio d'Adamo A, Schnater JM. Congenital lung malformations. Nat Rev Dis Primers 2023; 9:60. [PMID: 37919294 DOI: 10.1038/s41572-023-00470-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 11/04/2023]
Abstract
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.
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Affiliation(s)
- Federica Pederiva
- Paediatric Surgery, "F. Del Ponte" Hospital, ASST Settelaghi, Varese, Italy.
| | - Steven S Rothenberg
- Department of Paediatric Surgery, Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Nigel Hall
- University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Hanneke Ijsselstijn
- Department of Paediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Kenneth K Y Wong
- Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Jan von der Thüsen
- Department of Pathology and Clinical Bioinformatics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Pierluigi Ciet
- Departments of Radiology and Nuclear Medicine and Respiratory Medicine and Allergology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Radiology, University of Cagliari, Cagliari, Italy
| | - Reuven Achiron
- Department of Obstetrics and Gynecology, Fetal Medicine Unit, The Chaim Sheba Medical Center Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adamo Pio d'Adamo
- Laboratory of Medical Genetics, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - J Marco Schnater
- Department of Paediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
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Zeng G, Zhang Q, Song B, Feng X, Sun J, Mo X, Wu KH. Clinical Symptoms Affect Treatment and Prognosis in Pediatric Patients with Congenital Pulmonary Airway Malformation: A Propensity Score Matching Retrospective Cohort Study. J Pediatr Surg 2023; 58:1963-1968. [PMID: 36658074 DOI: 10.1016/j.jpedsurg.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/31/2022] [Accepted: 11/22/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES Surgery for asymptomatic congenital pulmonary airway malformation patients is still debatable at this time. This study aims to investigate the safety and efficacy of surgery for asymptomatic patients, as well as the factors influencing the symptoms of this group of patients. METHODS An institutional database was sampled for congenital pulmonary airway malformation patients. Patients were divided into the symptomatic group and the asymptomatic group. Propensity score matching (PSM) analysis selected patients in each group to compare perioperative outcomes. A multivariable logistic regression analysis was performed to investigate the potential influences on symptomatic lesions. RESULTS The asymptomatic group had better perioperative results than the symptomatic group, including shorter operating times (119.39 ± 49.42 min vs 100.73 ± 23.09 min, P = 0.031), shorter postoperative mechanical ventilation (2 h [0.5-46] vs 1 h [0.5-5], P = 0.002), shorter chest tube durations (4d [2-29] vs 3d [2-10], P = 0.007), and shorter postoperative hospital stays (10d [6-36] vs 8d [6-16], P < 0.001). With the conversion to thoracotomy and postoperative complications, there was no statistically significant difference between the two PSM-matched groups (P > 0.05). Age (p = 0.037), postnatal diagnosis (p = 0.018), and maximum cyst diameter (p = 0.032) were found to be independent variables associated with symptomatic lesions by multivariable logistic regression. CONCLUSIONS Patients with congenital pulmonary airway malformation appear to have better perioperative outcomes before the beginning of symptoms. Symptomatic pulmonary lesions were associated with age, postnatal diagnosis, and maximum cyst diameter. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Guowei Zeng
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
| | - Qi Zhang
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
| | - Binqian Song
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
| | - Xinghui Feng
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
| | - Jian Sun
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
| | - Xuming Mo
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
| | - Kai-Hong Wu
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210008, China.
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5
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He T, Sun X, Liu C, Yuan M, Yang G, Cheng K, Dai S, Xu C. Learning curve for total thoracoscopic segmentectomy in treating pediatric patients with congenital lung malformation. Surg Endosc 2023:10.1007/s00464-023-09987-8. [PMID: 36941411 DOI: 10.1007/s00464-023-09987-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 02/25/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Total thoracoscopic segmentectomy (TTS) is a technically challenging procedure in children but results in more parenchyma preservation, better pain control, better cosmetic results, and a shorter hospital stay. However, definitive data describing the learning curve of TTS has yet to be obtained. Here, we review the safety and efficiency of our initial experiences with pediatric TTS and evaluate our learning curve. METHODS This was a retrospective study of all pediatric patients undergoing TTS between December 2016 and January 2020. Pediatric patients who underwent TTS were included, while those undergoing lobectomy or wedge resection were excluded. RESULTS One hundred and twelve patients were retrospectively analyzed to evaluate the learning curve and were divided chronologically into three phases, the ascending phase (A), plateau phase (B) and descending phase (C), through cumulative summation (CUSUM) of the operative time (OT). Phases A, B, and C comprised 28, 51, and 33 cases, respectively. OT decreased significantly from phases A to B (p < 0.001) and from phase B to C (p = 0.076). No significant differences were observed in the demographic factors among the three phases. The conversion rate was zero, and the complication rate was 0.9%. Differences in technical parameters, such as length of stay and chest tube duration, were statistically insignificant between phases A and B or B and C. There were no mortalities. CONCLUSION CUSUMOT indicates that the learning curve of at least 79 cases is required for TTS in our institute. We emphasize that the learning curve should be cautiously interpreted because many factors in different institutions may influence the exact parabola and actual learning curve.
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Affiliation(s)
- Taozhen He
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Xiaoyan Sun
- Health Management Centre, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Chenyu Liu
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Miao Yuan
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Gang Yang
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Kaisheng Cheng
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Shiyi Dai
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Chang Xu
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China.
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6
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Macchini F, Mazzoleni S, Cavallaro G, Persico N, Borzani I, Leva E. Combined Pre- and Postnatal Minimally Invasive Approach to a Complex Symptomatic Congenital Pulmonary Airway Malformation. European J Pediatr Surg Rep 2023; 11:e36-e39. [PMID: 37502275 PMCID: PMC10370641 DOI: 10.1055/a-2107-0409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 02/08/2023] [Indexed: 07/29/2023] Open
Abstract
Congenital pulmonary airway malformation (CPAM) is a rare congenital lung lesion that usually remains asymptomatic during the fetal and neonatal period. However, it can occasionally cause prenatal cardiocirculatory failure and fetal hydrops, requiring a thoraco-amniotic shunt (TAS) placement. In other cases, it can also cause symptoms at birth (such as respiratory distress) and may require urgent surgical intervention. Thoracoscopic lobectomy for neonates is rarely reported. Here, we report a case of right macrocystic CPAM causing fetal hydrops at 27 weeks of gestation. The fetus was treated with a TAS placement that successfully resolved the hydrops. At 39 weeks of gestation, a male neonate was born (weight 2,850 g). The TAS spontaneously displaced during delivery, causing an open pneumothorax (PNX), initially treated with a drainage. His condition gradually worsened, requiring ventilatory support. Computed tomography (CT) scan showed different giant cysts in the context of the right lower lobe, left mediastinal shift, and compression of the rest of the lung. An urgent surgical management was required. A thoracoscopic right lower lobectomy was performed at 10 days of life (weight 2,840 g). The postoperative course was uneventful; the child remained totally asymptomatic and showed a good recovery. To the best of our knowledge, this is the first reported case of open iatrogenic PNX following TAS positioning and the second of neonatal thoracoscopic lobectomy in a newborn weighting less than 3 kg. The purpose of this report is to indicate that minimally invasive surgery is feasible, safe, and effective for the resection of CPAM, even in small newborns.
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Affiliation(s)
- Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Lombardia, Italy
| | - Stefano Mazzoleni
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Lombardia, Italy
| | - Giacomo Cavallaro
- Department of Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Lombardia, Italy
| | - Nicola Persico
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Lombardia, Italy
| | - Irene Borzani
- Department of Pediatric Radiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Lombardia, Italy
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Lombardia, Italy
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7
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Luo D, Fu X, Wang Q, Cheng K, Lv Y, Yuan M, Xu C, He T, Yang G, Wang Y, Jia R, Liu C. Thoracoscopic Clockwise Lobectomy May Be a Stylized Procedure for Treating Children with Congenital Lung Malformations. J Laparoendosc Adv Surg Tech A 2022; 32:1293-1298. [PMID: 36257641 DOI: 10.1089/lap.2022.0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Thoracoscopic lobectomy is a challenging procedure in children with congenital lung malformations (CLMs). This study aims to evaluate the safety and efficacy of thoracoscopic clockwise lobectomy (TCL) in CLMs in children and its potential to be a stylized procedure. Methods: All patients with CLMs who received TCL from 2015 to 2019 in our hospital were retrospectively reviewed. Clinical information was extracted from medical records, including patient demographics, operative details, and outcomes. Results: A total of 184 patients with a median age of 6.8 months (range, 3-156) and a median weight of 9 kg (range, 6-45) received TCL. Lesions were all located in the lower lobe and included congenital pulmonary airway malformation (n = 133), intralobar sequestration (n = 44), bronchiectasis (n = 4), and congenital lobar emphysema (n = 3). The mean (±standard deviation [SD]) operating time was 46 ± 7.5 minutes (range, 35-113). The mean (±SD) blood loss was 3.5 ± 0.8 mL (range, 1-60). Three patients converted to thoracotomy, and 162 patients did not have a chest tube placed. The postoperative course was uneventful in all patients except 2 patients who developed air leaks and 23 patients who developed a mild fever. The median length of postoperative hospital stay was 2 days. A total of 163 patients were followed up for more than 1 year without any complications. Conclusion: TCL is suitable for lower lobectomy and is safe and effective in standard and complicated thoracoscopic lobectomy. It could be recommended as a stylized procedure in treating children with CLMs.
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Affiliation(s)
- Dengke Luo
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoying Fu
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Qinghai Wang
- Department of Pediatric Surgery, Guangyuan Central Hospital, Guangyuan, China
| | - Kaisheng Cheng
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yong Lv
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Miao Yuan
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chang Xu
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Taozhen He
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Gang Yang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yao Wang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ru Jia
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chenyu Liu
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
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Weller JH, Peter SDS, Fallat ME, Saito JM, Burns CR, Deans KJ, Fraser JD, Gadepalli SK, Helmrath MA, Hirschl RB, Kabre R, Lal DR, Landman MP, Leys CM, Mak GZ, Minneci PC, Wright TN, Kunisaki SM. Thoracoscopic versus open lobectomy in infants with congenital lung malformations: A multi-institutional propensity score analysis. J Pediatr Surg 2021; 56:2148-2156. [PMID: 34030879 DOI: 10.1016/j.jpedsurg.2021.04.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 03/18/2021] [Accepted: 04/15/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Jennine H Weller
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Johns Hopkins Children's Center, Baltimore, MD, United States
| | | | - Mary E Fallat
- Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville, Norton Children's Hospital, Louisville, KY, United States
| | - Jacqueline M Saito
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Cartland R Burns
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Katherine J Deans
- Center for Surgical Outcomes Research, the Research Institute and Department of Surgery, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH, United States
| | - Jason D Fraser
- Children's Mercy Hospital, Kansas City, MO, United States
| | - Samir K Gadepalli
- University of Michigan and Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, MI, United States
| | - Michael A Helmrath
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Ronald B Hirschl
- University of Michigan and Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, MI, United States
| | - Rashmi Kabre
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Dave R Lal
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Matthew P Landman
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin, Madison, WI, United States
| | - Grace Z Mak
- Section of Pediatric Surgery, Department of Surgery, Comer Children's Hospital, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Peter C Minneci
- Center for Surgical Outcomes Research, the Research Institute and Department of Surgery, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH, United States
| | - Tiffany N Wright
- Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville, Norton Children's Hospital, Louisville, KY, United States
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Johns Hopkins Children's Center, Baltimore, MD, United States.
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9
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He T, Sun X, Yang Y, Yuan M, Yang G, Cheng K, Xu C. Learning curve for total thoracoscopic lobectomy for treating pediatric patients with congenital lung malformation. Asian J Surg 2021; 45:1383-1388. [PMID: 34635410 DOI: 10.1016/j.asjsur.2021.08.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/12/2021] [Accepted: 08/29/2021] [Indexed: 02/08/2023] Open
Abstract
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 CUSUMOT indicates that a learning curve of approximately 57 cases is required in our institute.
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Affiliation(s)
- Taozhen He
- Department of Pediatric Surgery, West China Hospital of Sichuan University, NO. 37 GUOXUE Lane, Chengdu, 610041, China
| | - Xiaoyan Sun
- Health Management Centre, West China Hospital of Sichuan University, NO. 37 GUOXUE Lane, Chengdu, 610041, China
| | - Yang Yang
- Department of Pediatric Surgery, West China Hospital of Sichuan University, NO. 37 GUOXUE Lane, Chengdu, 610041, China
| | - Miao Yuan
- Department of Pediatric Surgery, West China Hospital of Sichuan University, NO. 37 GUOXUE Lane, Chengdu, 610041, China
| | - Gang Yang
- Department of Pediatric Surgery, West China Hospital of Sichuan University, NO. 37 GUOXUE Lane, Chengdu, 610041, China
| | - Kaisheng Cheng
- Department of Pediatric Surgery, West China Hospital of Sichuan University, NO. 37 GUOXUE Lane, Chengdu, 610041, China
| | - Chang Xu
- Department of Pediatric Surgery, West China Hospital of Sichuan University, NO. 37 GUOXUE Lane, Chengdu, 610041, China.
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10
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Rothenberg SS. Thoracoscopic Lobectomy in Infants and Children. J Laparoendosc Adv Surg Tech A 2021; 31:1157-1161. [PMID: 34609926 DOI: 10.1089/lap.2021.0454] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Steven S Rothenberg
- Department of Pediatric Surgery, Rocky Mountain Hospital for Children, Denver, Colorado, USA
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11
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An P, Xiao X, Zhao Y, Zhou J, Li X, Xiong Y. Prenatal ultrasound measurements of mild congenital pulmonary airway malformation and long-term prognosis: A retrospective cohort study. Int J Gynaecol Obstet 2021; 157:327-332. [PMID: 34101166 DOI: 10.1002/ijgo.13778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 05/22/2021] [Accepted: 06/07/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To investigate the relationship between mild congenital pulmonary airway malformation (CPAM) and its long-term prognosis in childhood and to explore whether surgery is necessary. METHODS We conducted a retrospective cohort of fetuses with mild CPAM diagnosed prenatally with available long-term outcomes in childhood from 2004 to 2016. The patients were divided into two groups according to the fetal CPAM-to-volume ratio (CVR) of less than 1.0 and 1.0-1.6. The primary outcome was a postnatal composite outcome including CPAM-associated respiratory symptoms and surgical resection of the lesion. The secondary outcomes included neonatal asphyxia, perinatal morbidity and mortality. RESULTS Forty-two fetuses were identified as having CVR <1.0 or CVR-1.0-1.6 respectively (n = 37 vs n = 5; 88.1% vs 11.9%), with the median duration of follow up 2.15 years (0.3-10.8 years). Of 42 patients, 32 (76%) remained asymptomatic without recurrent respiratory symptoms or surgical resection; the other 10 with CVR <1.0 had respiratory symptoms. Of 10 symptomatic cases, five recovered after expectant treatment, and five underwent resection, for an increase in lesion size and recurrent respiratory infection. CONCLUSION Patients with CVR <1.0 still need to be closely observed after birth. Conservative management is a reasonable option in asymptomatic cases, but surgery might be necessary in some.
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Affiliation(s)
- Ping An
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Xirong Xiao
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Ying Zhao
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Jizi Zhou
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Xiaotian Li
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China.,Institute of Biomedical Sciences of Fudan University, Shanghai, China
| | - Yu Xiong
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
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12
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Abstract
This article reviews the contemporary diagnosis and management of antenatally diagnosed congenital lung lesions. These anomalies, which include congenital pulmonary airway malformation (CPAM) (formerly congenital cystic adenomatoid malformation), bronchopulmonary sequestration (BPS), bronchogenic cyst, and congenital lobar emphysema (CLE), are relatively rare but are increasingly encountered by clinicians because of the improved resolution and enhanced sensitivity of fetal ultrasound. Serial assessment of these lesions throughout pregnancy remains the norm rather than the exception. Perinatal management strategies may differ based on initial size and growth patterns of these masses until delivery. Fetal magnetic resonance imaging and other diagnostic testing can sometimes be helpful in providing additional prognostic information. Over the last decade, maternal steroids have become standard of care in the management of larger lesions at risk for nonimmune hydrops. As a result, fetal surgical procedures, including open resection, thoracoamniotic shunting, and ex utero intrapartum treatment (EXIT), are less uncommonly performed. Decisions regarding whether delivery of these fetuses should occur in a tertiary care center with pediatric surgery coverage versus delivery at a local community hospital are now highly relevant in most prenatal counseling discussions with families. Large lung malformations may require urgent surgical removal in the early postnatal period because of respiratory distress. Other complications, such as recurrent pneumonia, pneumothorax, and cancer, are indications for postnatal lung resection on an elective basis. Many children are good candidates for minimally invasive (thoracoscopic) surgical approaches as an alternative to resection by thoracotomy. In the vast majority of cases, the overall prognosis remains excellent.
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Affiliation(s)
- Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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13
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Video-Assisted Thoracoscopic Surgery (VATS) in a 20-Day-Old Newborn With Empyema Thoracis. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2174-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Prasad D, Pennell C, Arthur LG, Prasad R. Preoperative Embolization Facilitates Segmental Resection of Pulmonary Sequestration in an Infant. European J Pediatr Surg Rep 2021; 9:e1-e4. [PMID: 33532170 PMCID: PMC7840227 DOI: 10.1055/s-0040-1721043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 08/18/2020] [Indexed: 11/25/2022] Open
Abstract
The most common congenital lung malformations are congenital pulmonary airway malformations and pulmonary sequestrations. Many surgeons advocate resection to prevent complications of infection, malignancy, and pneumothorax. The standard of care is lobectomy, but segmentectomy and embolization alone have been reported. These methods avoid the complications of lobectomy but are not widely practiced due to concerns about incomplete resection or involution of the lesion. We present a novel approach to the treatment of a pulmonary sequestration in a 7-month-old male using preoperative embolization followed by a sublobar pulmonary resection. The embolization clearly demarcated the affected lung intraoperatively, thereby facilitating complete removal of the lesion with a segmental lung resection rather than complete lobectomy.
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Affiliation(s)
- Dilan Prasad
- Department of Pediatric General, Thoracic, and Minimally Invasive Surgery, Saint Christopher's Hospital for Children, Philadelphia, Pennsylvania, United States
| | - Christopher Pennell
- Department of Pediatric General, Thoracic, and Minimally Invasive Surgery, Saint Christopher's Hospital for Children, Philadelphia, Pennsylvania, United States
| | - Lindsay Grier Arthur
- Department of Pediatric General, Thoracic, and Minimally Invasive Surgery, Saint Christopher's Hospital for Children, Philadelphia, Pennsylvania, United States
| | - Rajeev Prasad
- Department of Pediatric General, Thoracic, and Minimally Invasive Surgery, Saint Christopher's Hospital for Children, Philadelphia, Pennsylvania, United States
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15
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Esposito C, Bonnard A, Till H, Leva E, Khen-Dunlop N, Zanini A, Montalva L, Sarnacki S, Escolino M. Thoracoscopic Management of Pediatric Patients with Congenital Lung Malformations: Results of a European Multicenter Survey. J Laparoendosc Adv Surg Tech A 2021; 31:355-362. [PMID: 33428520 DOI: 10.1089/lap.2020.0596] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Ciro Esposito
- Pediatric Surgery Unit, "Federico II" University of Naples, Naples, Italy
| | - Arnaud Bonnard
- Pediatric Surgery Unit, Robert Debrè Hospital, Paris, France
| | - Holger Till
- Pediatric Surgery Unit, Medical University of Graz, Graz, Austria
| | - Ernesto Leva
- Pediatric Surgery Unit, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Andrea Zanini
- Pediatric Surgery Unit, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milan, Italy
| | - Louise Montalva
- Pediatric Surgery Unit, Robert Debrè Hospital, Paris, France
| | - Sabine Sarnacki
- Pediatric Surgery Unit, Necker Enfants Malades Hospital, Paris, France
| | - Maria Escolino
- Pediatric Surgery Unit, "Federico II" University of Naples, Naples, Italy
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16
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Xie J, Wu Y, Wu C. Is thoracoscopy superior to thoracotomy in the treatment of congenital lung malformations? An updated meta-analysis. Ther Adv Respir Dis 2020; 14:1753466620980267. [PMID: 33308023 PMCID: PMC7739138 DOI: 10.1177/1753466620980267] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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17
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Macchini F. Thoracoscopic resection of congenital pulmonary airway malformations: timing and technical aspects. J Thorac Dis 2020; 12:3944-3948. [PMID: 32944305 PMCID: PMC7475558 DOI: 10.21037/jtd.2020.03.109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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18
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Kunisaki SM, Leys CM. Surgical Pulmonary and Pleural Diseases in Children: Lung Malformations, Empyema, and Spontaneous Pneumothorax. Adv Pediatr 2020; 67:145-169. [PMID: 32591058 DOI: 10.1016/j.yapd.2020.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins University, Johns Hopkins University School of Medicine, 1800 Orleans Street, Suite 7353, Baltimore, MD 21287, USA.
| | - Charles M Leys
- Division of Pediatric Surgery, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, 600 Highland Avenue, H4/740 CSC, Madison, WI 53792-7375, USA
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19
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Romnek MJ, Diefenbach K, Tumin D, Tobias JD, Kim S, Thung A. Postoperative Clinical Course and Opioid Consumption Following Repair of Congenital Diaphragmatic Hernia: Open Versus Thoracoscopic Techniques. J Laparoendosc Adv Surg Tech A 2020; 30:590-595. [PMID: 32267796 DOI: 10.1089/lap.2019.0510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: Minimally invasive surgical (MIS) approaches for thoracic procedures in adults result in an improved postoperative course with less pain, but there are limited data on similar procedures in neonates. We aimed to evaluate postoperative opioid consumption and pain management practices in neonates and infants following MIS versus open repair of congenital diaphragmatic hernia (CDH). Materials and Methods: This was an IRB approved, retrospective study from 2012 to 2016. Demographic data, intraoperative analgesic regimen, total 7-day postoperative opioid consumption, and use of adjunctive pain medications were compared by surgery type (open versus MIS). Secondary measures included time to tracheal extubation, oral feeds, and discharge home. Results: The study cohort included 28 patients (13 female, median age 5 days, average gestational age 39 weeks, and weight 3 kg). MIS was performed in 8 patients. In the first 7 postoperative days, the median postoperative opioid consumption was 0.3 mg/kg of oral morphine equivalents (interquartile range [IQR] 0.2, 18.3) in the MIS group versus 32.3 mg/kg (IQR 9.9, 53.6) in the open group (95% CI of differences in medians: 8.2-42.9; P = .006). No difference was noted in intraoperative opioid administration. Among secondary outcomes, length of stay was significantly longer in the open group. Conclusions: Although several factors may impact the hospital course of neonates with CDH, we found that patients had a more than 100-fold difference in median opioid consumption following repair with MIS versus an open approach. The study also noted significant variation in analgesic regimens suggesting other avenues for improved care of postsurgical neonates.
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Affiliation(s)
- Mary J Romnek
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Karen Diefenbach
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology and Pain Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Stephani Kim
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Arlyne Thung
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology and Pain Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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20
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Bawazir OA. Congenital lobar emphysema: Thoracotomy versus minimally invasive surgery. Ann Thorac Med 2020; 15:21-25. [PMID: 32002043 PMCID: PMC6967143 DOI: 10.4103/atm.atm_203_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/03/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND: Congenital lobar emphysema (CLE) is a rare developmental malformation of the lung but can be associated with high morbidity and mortality. The objective of this study is to review our experience with 45 patients with CLE highlighting clinical features, aspects of diagnosis, and management. METHODS: The medical records of all patients diagnosed with CLE in our center were reviewed. Patients age at the time of diagnosis, sex, clinical presentation, associated anomalies, the lobes affected, treatment modality, and outcome were described. A comparison was made between those who had lobectomy via open thoracotomy and those treated thoracoscopically. RESULTS: From January 2000 to December 2018, a total of 45 infants with CLE were presented to our institution. There were 30 male and 15 female, and the mean age at presentation was 3.35 months. Twenty-five patients presented with respiratory distress. Nine patients presented immediately after birth, and two of them had surgery within the 1st week of life. Twenty patients were presented with repeated chest infections. Left upper lobe was affected in 27 patients, right middle lobe in 13, and right upper lobe in 5 patients. Forty-four patients had a lobectomy, and one was managed conservatively. One patient had a postoperative bronchopleural fistula. Nine patients had a thoracoscopic lobectomy, and two of them were converted to open thoracotomy because of persistent air leak. The operative time and hospital stay were nonsignificantly longer in thoracoscopic lobectomy (P = 0.5 and 0.4, respectively). There was no operative mortality in both groups. CONCLUSIONS: CLE is a rare malformation with variable presentation. Infants presenting with respiratory distress or recurrent chest infection should be evaluated for the possibility of CLE. Lobectomy is the treatment of choice, and rarely, the patients may be managed conservatively. Thoracoscopic lobectomy is a safe procedure with the possibility of air leak and conversion to open lobectomy.
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Affiliation(s)
- Osama Abdullah Bawazir
- Department of Surgery, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia.,Department of Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
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21
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Ito A, Takao M, Shimamoto A, Kaneda S, Matsushita K, Inoue M, Uchida K. Introduction of thoracoscopic surgery for congenital pulmonary airway malformation in infants: review of 13 consecutive surgical cases. J Thorac Dis 2019; 11:5079-5086. [PMID: 32030224 DOI: 10.21037/jtd.2019.12.14] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Although complete video-assisted thoracic surgery (C-VATS) has been demonstrated to have several advantages compared with conventional thoracotomy, there are few reports on the clinical feasibility of C-VATS for CPAM in infants. Methods We retrospectively evaluated 13 consecutive patients (neonates 4; infants 9) surgically treated for congenital pulmonary airway malformation (CPAM) from 1 January 2008 to 31 March 2017. Results In the group of neonates, all 4 cases were prenatally diagnosed and they underwent semi-emergent surgery after birth due to respiratory failure. In the group of 9 infants, 5 cases were prenatally diagnosed and 4 cases were diagnosed at age >2.5 years due to symptoms associated with pulmonary cystic infection. Pulmonary resection consisted of the following: 8 lobectomies, 1 segmentectomy, 2 wedge resection, 1 fractionated lung resection and 1 lobectomy with segmentectomy. Overall, there were 9 thoracotomy and 4 thoracoscopic surgeries. Mean operation time was 162 min (range, 67-290 min) and blood loss was 21 mL (range, 0-74 mL) on average. There were no complications such as thoracic deformity or respiratory failure, however in 2 of those who underwent segmentectomy the cystic remnant remained. No statistically significant differences were observed between the thoracotomy Group and C-VATS group in terms of age and height at intervention, operation time, blood loss, postoperative day of drain removal, and length of hospital stay after surgery. However, only the average body weight was heavier in C-VATS group (P=0.03). Conclusions Since early surgical resection of asymptomatic CPAM is often recommended for the prevention of infections and the development of lung malignancy, we recommend performing surgery after the age of 1 year if the patient's condition is stable. Furthermore, C-VATS lobectomy may be feasible if they are older than 18 months or weigh more than 10 kg.
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Affiliation(s)
- Atsushi Ito
- Department of Thoracic and Cardiovascular Surgery Mie University School of Medicine, Tsu, Japan
| | - Motoshi Takao
- Department of Thoracic and Cardiovascular Surgery Mie University School of Medicine, Tsu, Japan
| | - Akira Shimamoto
- Department of Thoracic and Cardiovascular Surgery Mie University School of Medicine, Tsu, Japan
| | - Shinji Kaneda
- Department of Thoracic and Cardiovascular Surgery Mie University School of Medicine, Tsu, Japan
| | - Kohei Matsushita
- Department of Gastrointestinal and Pediatric Surgery, Mie University School of Medicine, Tsu, Japan
| | - Mikihiro Inoue
- Department of Gastrointestinal and Pediatric Surgery, Mie University School of Medicine, Tsu, Japan
| | - Keiichi Uchida
- Department of Gastrointestinal and Pediatric Surgery, Mie University School of Medicine, Tsu, Japan
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22
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Abstract
Thoracoscopic surgery and other minimally invasive approaches in children achieved marked advancement and expanded to include several disciplines in the last decade. The new armamentarium of the minimally invasive surgery including the smaller instruments and better magnification led to the application of this technology in the small infants and neonates. Currently, thoracoscopy is considered the preferred surgical approach for various conditions in neonates and infants over the standard thoracotomy, and thoracoscopic training is included in the surgical training curriculum for the residents in many institutes worldwide. Children are different from adults, and technique modifications are required when using thoracoscopy in children. Thoracoscopy showed satisfactory results in several operations including pulmonary resections, mediastinal tumors biopsies or resections, repair of the diaphragmatic hernias, decortication, and tracheoesophageal fistula. This review aims to address the unique aspects of thoracoscopic surgery in children, identify its potential technical and anatomical challenges, and the proposed solutions. A literature search for latest and relevant publications was done using the keywords (thoracoscopy; pediatric; lung biopsy; decortication; lobectomy; mediastinum; esophagus; and diaphragmatic hernia).
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Affiliation(s)
- Osama A Bawazir
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
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23
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Lau CT, Wong KKY. Long-term pulmonary function after lobectomy for congenital pulmonary airway malformation: is thoracoscopic approach really better than open? J Pediatr Surg 2018; 53:2383-2385. [PMID: 30249357 DOI: 10.1016/j.jpedsurg.2018.08.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 08/25/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Congenital pulmonary airway malformation (CPAM) is the most common lung pathology diagnosed antenatally. Thoracoscopic lobectomy has shown increasing popularity, but the long-term result is still lacking. In this study we compared long -term pulmonary function after thoracoscopic and open lobectomy. METHODS All CPAM patients with lobectomy between 2000 and 2008 were recruited into the study. Pulmonary function test (PFT) was performed at least 7 years after operation. Demographic data and PFT results were analyzed. Comparison was made between the thoracoscopic and open group. RESULTS Twelve patients were included in each group. PFT was performed at a mean age of 9.8 (thoracoscopic) and 12.2 years (open), respectively (p = 0.17). The thoracoscopic group showed better performance in forced vital capacity (FVC) (98.9 vs 84.3% predicted, p = 0.03), forced expiratory volume in 1 s (FEV1) (88.5 vs 76.1% predicted, p = 0.04), and alveolar volume adjusted diffusion capacity of carbon monoxide (106.4 vs 91.4% predicted, p = 0.03). FEV1 to FVC ratio, total lung capacity, and residual volume showed no statistical difference. CONCLUSION The long term PFT result following thoracoscopic lobectomy is better than open lobectomy. This may be due to impaired respiratory musculature after thoracotomy. Further study with larger sample size is necessary to determine this hypothesis. LEVEL-OF-EVIDENCE III.
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Affiliation(s)
- Chin-Tung Lau
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Kenneth K Y Wong
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong.
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24
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Nylund AM, Höglund OV, Fransson BA. Thoracoscopic‐assisted lung lobectomy in cat cadavers using a resorbable self‐locking ligation device. Vet Surg 2018; 48:563-569. [DOI: 10.1111/vsu.13109] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/23/2018] [Accepted: 09/04/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Adam M. Nylund
- College of Veterinary MedicineWashington State University Pullman Washington
| | - Odd V. Höglund
- Department of Clinical SciencesSwedish University of Agricultural Sciences Uppsala Sweden
| | - Boel A. Fransson
- College of Veterinary MedicineWashington State University Pullman Washington
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25
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Criss CN, Musili N, Matusko N, Baker S, Geiger JD, Kunisaki SM. Asymptomatic congenital lung malformations: Is nonoperative management a viable alternative? J Pediatr Surg 2018; 53:1092-1097. [PMID: 29576400 DOI: 10.1016/j.jpedsurg.2018.02.065] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 02/27/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION The purpose of this study was to evaluate clinical outcomes in children with asymptomatic congenital lung malformations (CLM) who were initially managed nonoperatively. METHODS An IRB-approved retrospective review was performed on all CLMs at a single tertiary care referral center (Jan 2006-Dec 2016, n=140). Asymptomatic cases that did not undergo elective resection were evaluated for subsequent CLM-related complications based on clinical records and a telephone quality of life survey. RESULTS Out of 39 (27.9%) who were initially managed nonoperatively, 13 (33%) developed CLM-related symptoms and underwent surgical intervention at a median age of 6.8years (range, 0.7-19.8years). The most common indication for conversion to operative management was pneumonia (78%). Larger lesions, as measured by CT scan, were significantly associated with the need for subsequent surgical intervention (mean maximal diameter, 5.7 vs. 2.9cm; p=0.005). Based on survey data with a median follow up of 3.9years (range, 0.2-13.2years), 17% developed chronic pulmonary symptoms, including cough (11%) and asthma requiring bronchodilators (12%). CONCLUSION Although these data support nonoperative management as a viable alternative to surgical resection, at least one-third of CLM children eventually develop pneumonia or other pulmonary symptoms. Larger lesions are correlated with an increased risk for eventual surgical resection. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Cory N Criss
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, C.S. Mott Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI.
| | - Ninette Musili
- Michigan State University College of Human Medicine, Lansing, MI
| | - Niki Matusko
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Scott Baker
- Department of Radiology, Michigan Medicine, C.S. Mott Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI
| | - James D Geiger
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, C.S. Mott Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI
| | - Shaun M Kunisaki
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, C.S. Mott Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI
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Wong KKY, Flake AW, Tibboel D, Rottier RJ, Tam PKH. Congenital pulmonary airway malformation: advances and controversies. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:290-297. [PMID: 30169300 DOI: 10.1016/s2352-4642(18)30035-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 11/23/2017] [Accepted: 11/28/2017] [Indexed: 02/07/2023]
Abstract
Advances in antenatal screening have provided evidence that the prevalence of congenital pulmonary airway malformation is higher than previously thought. This means that, on a global scale, more congenital pulmonary airway malformations will be diagnosed and seen by clinicians across many different specialties. This increase poses new controversies and challenges for clinicians in terms of prenatal and postnatal management. Important and exciting research has begun to emerge in the past decade. This Review describes current understanding of the disease, the latest surgical developments, and highlights management issues and controversies, including the rationale and timing of surgical intervention, the choice of surgical approach, and long-term functional outcomes. In doing so, we attempt to provide a balanced management algorithm for readers.
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Affiliation(s)
- Kenneth K Y Wong
- Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong, China.
| | - Alan W Flake
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dick Tibboel
- Department of Paediatric Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Robbert J Rottier
- Department of Paediatric Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Paul K H Tam
- Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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Abstract
Congenital lung lesions (CLLs) comprise a heterogeneous group of developmental and histologic entities often diagnosed on screening prenatal ultrasound. Most fetuses with CLL are asymptomatic at birth; however, the risk of malignancy and infection drives the decision to prophylactically resect these lesions. The authors describe their approach to minimally invasive lobectomy in children with CLLs, postoperative care, and management of procedure-specific complications.
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Affiliation(s)
- Jarrett Moyer
- Department of Surgery, University of CA - San Francisco, 513 Parnassus Avenue, S-321, San Francisco, CA 94143, USA.
| | - Hanmin Lee
- Professor of Surgery, Division of Pediatric Surgery, Dept of Surgery, Universty of CA - San Francisco, San Francisco, CA
| | - Lan Vu
- Assistant Professor of Surgery, Division of Pediatric Surgery, Dept of Surgery, University of CA - San Francisco, San Francisco, CA
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Treatment of congenital pulmonary airway malformations: a systematic review from the APSA outcomes and evidence based practice committee. Pediatr Surg Int 2017; 33:939-953. [PMID: 28589256 DOI: 10.1007/s00383-017-4098-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2017] [Indexed: 01/15/2023]
Abstract
PURPOSE Variation in management characterizes treatment of infants with a congenital pulmonary airway malformation (CPAM). This review addresses six clinically applicable questions using available evidence to provide recommendations for the treatment of these patients. METHODS Questions regarding the management of a pediatric patient with a CPAM were generated. English language articles published between 1960 and 2014 were compiled after searching Medline and OvidSP. The articles were divided by subject area and by the question asked, then reviewed and included if they specifically addressed the proposed question. RESULTS 1040 articles were identified on initial search. After screening abstracts per eligibility criteria, 130 articles were used to answer the proposed questions. Based on the available literature, resection of an asymptomatic CPAM is controversial, and when performed is usually completed within the first six months of life. Lobectomy remains the standard resection method for CPAM, and can be performed thoracoscopically or via thoracotomy. There is no consensus regarding a monitoring protocol for observing asymptomatic lesions, although at least one chest computerized tomogram (CT) should be performed postnatally for lesion characterization. An antenatally identified CPAM can be evaluated with MRI if fetal intervention is being considered, but is not required for the fetus with a lesion not at risk for hydrops. Prenatal consultation should be offered for infants with CPAM and encouraged for those infants in whom characteristics indicate risk of hydrops. CONCLUSIONS Very few articles provided definitive recommendations for care of the patient with a CPAM and none reported Level I or II evidence. Based on available information, CPAMs are usually resected early in life if at all. A prenatally diagnosed congenital lung lesion should be evaluated postnatally with CT, and prenatal counseling should be undertaken in patients at risk for hydrops.
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Optimal age for elective surgery of asymptomatic congenital pulmonary airway malformation: a meta-analysis. Pediatr Surg Int 2017; 33:665-675. [PMID: 28293700 DOI: 10.1007/s00383-017-4079-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2017] [Indexed: 10/24/2022]
Abstract
Controversy exists on the optimal age for elective resection of asymptomatic congenital pulmonary airway malformation. Current recommendations vary widely, highlighting the overall lack of consensus. A systematic search of Embase, MEDLINE, CINAL, and CENTRAL was conducted in January 2016. Identified citations were screening independently in duplicate and consensus was required for inclusion. Results were pooled using inverse variance fixed effects meta-analysis. Meta-analysis results indicate no statistically significant differences for complications within the 3-month and 6-month age comparison groups [odds ratio (OR) 4.20, 95% confidence interval (CI) 0.78-22.77, I 2 = 0%; OR 2.39, 95% CI 0.63-9.11, I 2 = 0%, respectively]. Older patients were significantly favoured for 3-month and 6-month age comparison groups for length of hospital stay [mean difference (MD) 4.13, 95% CI 2.31-5.96, I 2 = 0%; MD 3.38, 95% CI 0.44-6.31, I 2 = 0%, respectively]. Borderline statistical significance was observed for chest tube duration in patients ≥6 months of age (MD 1.06, 95% CI 0.02-2.09, I 2 = 0%). No mortalities were recorded. Surgical treatment appears to be safe at all ages, with no mortalities and similar rates of complications between age groups. The included evidence was not sufficient to make a conclusive recommendation on optimal age for elective resection.
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Abstract
Thoracoscopic pulmonary lobectomy (TPL) techniques in infants and children are presented practically with concise descriptions and numerous illustrations. TPL is the treatment of choice for congenital pulmonary airway malformation and intralobar pulmonary sequestration, both now commonly diagnosed prenatally. Timing of surgery is somewhat controversial in asymptomatic cases with small isolated lesions. Incomplete fissures and history of chest infections are most problematic. Thorough understanding of anatomic relations preoperatively is vital for successful outcome and thin-slice computed tomography with 3D reconstruction of vessels is valuable. Judicious placement of trocars and switching instruments between trocars improves visualization and safety. Specific techniques for all commonly performed TPL are included.
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Does thoracoscopy have advantages over open surgery for asymptomatic congenital lung malformations? An analysis of 1626 resections. J Pediatr Surg 2017; 52:247-251. [PMID: 27889066 DOI: 10.1016/j.jpedsurg.2016.11.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 11/08/2016] [Indexed: 11/23/2022]
Abstract
AIM The apparent incidence of antenatally diagnosed congenital lung malformations (CLM) is rising (1 in 3000), and the majority undergo elective resection even if asymptomatic. Thoracoscopy has been popularized, but early series report high conversion rates and significant complications. We aimed to perform systematic review/meta-analysis of outcomes of thoracoscopic vs open excision of asymptomatic CLMs. METHODS A systematic review according to PRISMA guidelines was performed. Data were extracted for all relevant studies (2004-2015) and Rangel quality scores calculated. Analysis was on 'intention to treat' basis for thoracoscopy and asymptomatic lung lesions. Meta-analysis was performed using the addon package METAN of the statistical package STATA14™; p<0.05 was considered significant. RESULTS 36 studies were eligible, describing 1626 CLM resections (904 thoracoscopic, 722 open). There were no randomized controlled trials. Median quality score was 14/45 (IQR 6.5) 'poor'. 92/904 (10%) thoracoscopic procedures were converted to open. No deaths were reported. Meta-analysis showed that regarding thoracoscopic procedures, the total number of complications was significantly less (OR 0.63, 95% CI 0.43, 0.92; p<0.02, 12 eligible series, 912 patients, 404 thoracoscopic). Length of stay was 1.4days shorter (95%CI 2.40, 0.37;p<0.01). Length of operation was 37 min longer (95% CI 18.96, 54.99; p<0.01). Age, weight, and number of chest tube days were similar. There was heterogeneity (I2 30%, p=0.15) and no publication bias seen. CONCLUSIONS A reduced total complication rate favors thoracoscopic excision over thoracotomy for asymptomatic antenatally diagnosed CLMs. Although operative time was longer, and open conversion may be anticipated in 1/10, the overall length of hospital stay was reduced by more than 1day. LEVEL OF EVIDENCE 4 (based on lowest level of article analyzed in meta-analysis/systematic review).
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Lau CT, Kan A, Shek N, Tam P, Wong KKY. Is congenital pulmonary airway malformation really a rare disease? Result of a prospective registry with universal antenatal screening program. Pediatr Surg Int 2017; 33:105-108. [PMID: 27770196 DOI: 10.1007/s00383-016-3991-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Congenital pulmonary airway malformation (CPAM) is an increasingly recognized disease with potential mortality. Owing to limited published studies, the true incidence is yet to be determined. We carried out this prospective study with the aim to estimate its true incidence on a population basis. METHODS An antenatal ultrasonography program was implemented since 2009. Fetuses with suspected intra-thoracic lesions were monitored by regular follow-ups. Antenatal course, postnatal outcomes, and other demographics were compared to those of patients with CPAM in the previous decades (1989-2008). The incidence of CPAM was calculated in different periods. RESULTS 66 CPAM patients were identified between 2009 and 2014 with 62 patients being detected by antenatal scan. In contrast, 45 patients were identified between 1989 and 2008 with 27 patients being detected antenatally. The incidence rate during the past and recent period was estimated as ~1 in 27,400 and ~1 in 7200 live births, respectively (p = 0.024). CONCLUSION With increasing awareness of clinicians and the universal use of latest ultrasound technology, it is likely that more CPAM cases will be detected in the future. Here, we presented our best estimated incidence rate of CPAM, yet only a larger scale study can reveal its true incidence.
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Affiliation(s)
- C T Lau
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong SAR, China.
| | - A Kan
- Department of Obstetrics and Gynaecology, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong SAR, China
| | - N Shek
- Department of Obstetrics and Gynaecology, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong SAR, China
| | - P Tam
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong SAR, China
| | - K K Y Wong
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong SAR, China.
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Rothenberg S. Thoracoscopic Lobectomy in Infants and Children Utilizing a 5 mm Stapling Device. J Laparoendosc Adv Surg Tech A 2016; 26:1036-1038. [PMID: 27705088 PMCID: PMC5165674 DOI: 10.1089/lap.2016.0334] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Thoracoscopic lobectomy for congenital cystic lung disease has become an accepted and in many institutions the preferred technique. However, the technical challenges are many. Previous endoscopic staplers (12 mm) used commonly in adults are too large for use in infants This study evaluates the safety and efficacy of using a 5 mm stapling device to seal and divide major pulmonary structures. METHODS From July 2014 to March 2016, 26 patients of age 6 weeks to 13 months underwent thoracoscopic lobectomy for CPAM or sequestration. Weights ranged from 3.2 to 11.4 kg. There were 7 upper lobectomies, 2 middle, and 17 lower lobectomies. In each case, the 5 mm stapler (Justright Surgical; Louisville, Colorado) was the primary device for vessel and bronchial sealing and division. It is 4.8 mm in diameter with an anvil length of 25 mm and lays down four rows of staples and divides between them. A 3 mm sealing device was used for dissection and to take smaller segmental vessels as necessary. Stump lines were evaluated for bleeding or air leak in all cases. RESULTS All procedures were accomplished successfully thoracoscopically. The stapler was used on the main lobar artery cases and vein in 24 cases, a large systemic sequestration vessel in 5 cases, and the bronchus in all 26. The stapler was also used to complete the minor fissure in 1 case and the major fissure in 1 case. A total of 96 staple loads were fired. Operative times ranged from 35 to 135 minutes. There was no significant bleeding of any vascular stump. In 1 case, the edge of the bronchial stump had to be reinforced, this was thought to be secondary to too much tissue being enclosed in the jaws. There were no postoperative complications. CONCLUSION The use of a 5 mm stapling device appears to be safe and effective in thoracoscopic lobectomy in infants. It allows for safe management of major pulmonary vessels and bronchi in the confined chest of an infant through a single 5 mm port.
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Affiliation(s)
- Steven Rothenberg
- 1 Columbia University College of Physicians and Surgeons , New York, New York.,2 Rocky Mountain Hospital for Children , Denver, Colorado
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Sueyoshi R, Koga H, Suzuki K, Miyano G, Okawada M, Doi T, Lane GJ, Yamataka A. Surgical intervention for congenital pulmonary airway malformation (CPAM) patients with preoperative pneumonia and abscess formation: "open versus thoracoscopic lobectomy". Pediatr Surg Int 2016; 32:347-51. [PMID: 26661941 DOI: 10.1007/s00383-015-3848-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/03/2015] [Indexed: 11/24/2022]
Abstract
AIM Thoracoscopic lobectomy (TL) and open lobectomy (OL) were compared for treating congenital pulmonary airway malformation (CPAM) with preoperative complications, specifically pneumonia/abscess formation (PA). METHODS The medical records of 46 CPAM patients treated by lobectomy at our institution from 1990 to 2014 were reviewed retrospectively. Four groups, TL for patients without PA (n = 17; TL-), TL for patients with PA (n = 8; TL+), OL for patients without PA (n = 16; OL-), and OL for patients with PA (n = 5; OL+) were compared for operative time, intra/postoperative complications, blood loss, duration of chest tube insertion, postoperative analgesia, pre: postoperative white blood cell (WBC) ratio, and duration of hospitalization. RESULTS Operative time for TL+ was longest, but not statistically significant. Incidences of intra/postoperative complications were similar in all groups. Blood loss was significantly less for TL+ versus OL+ (p < .05). WBC ratio was significantly lower in TL+ versus OL+ (p < .05), similar for TL+ and TL-, and significantly higher in OL+ versus OL- (p < .01). Chest tube insertion was significantly longer in OL- versus TL- (p < .01). CONCLUSION PA would not appear to be a contraindication to perform TL in CPAM. TL is associated with less surgical stress than OL despite longer operative time.
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Affiliation(s)
- Ryo Sueyoshi
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, 113-8421, Japan.
| | - Hiroyuki Koga
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, 113-8421, Japan
| | - Kenji Suzuki
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Go Miyano
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, 113-8421, Japan
| | - Manabu Okawada
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, 113-8421, Japan
| | - Takashi Doi
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, 113-8421, Japan
| | - Geoffrey J Lane
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, 113-8421, Japan
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, 113-8421, Japan
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Laje P, Pearson EG, Simpao AF, Rehman MA, Sinclair T, Hedrick HL, Adzick NS, Flake AW. The first 100 infant thoracoscopic lobectomies: Observations through the learning curve and comparison to open lobectomy. J Pediatr Surg 2015; 50:1811-6. [PMID: 26100691 DOI: 10.1016/j.jpedsurg.2015.05.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/22/2015] [Accepted: 05/26/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of the study is to describe our initial 100 attempted infant thoracoscopic lobectomies for asymptomatic, prenatally diagnosed lung lesions, and compare the results to contemporaneous age-matched patients undergoing open lobectomy. BACKGROUND Infant thoracoscopic lobectomy is a technically challenging procedure, which has only gained acceptance worldwide in recent years. METHODS This is a retrospective review of all patients undergoing thoracoscopic or open lung lobectomy between March 2005 and January 2014. Included were all asymptomatic infants younger than 4months. Excluded were patients undergoing emergent lobectomy and patients with isolated extralobar bronchopulmonary sequestrations. RESULTS A total of 100 attempted thoracoscopic lobectomies were compared with 188 open lobectomies. In the thoracoscopic group, mean age and weight at surgery were 7.3weeks and 4.8kg, mean operative time was 185minutes, and mean hospital stay was 3days. Twelve cases were converted to open (12%). Ten conversions occurred within the first third of the series and none in the last third. There were no mortalities. There were no differences between the thoracoscopic and open groups in perioperative complications or hospital stay. There was a significant difference in the operative time: 111minutes vs. 185minutes (open vs. thoracoscopic; p<0.001). There was a higher mean end-tidal carbon dioxide (ETCO2) and lower mean peripheral capillary oxygen saturation (SpO2) in the thoracoscopic group versus the open group (51.7 versus 38.6mmHg and 97.5 versus 99.1%, respectively). CONCLUSION In high volume centers, the learning curve of thoracoscopic lobectomy can be overcome and the procedure can be performed with equivalent outcomes and, in our opinion, superior cosmetic results to open lobectomy.
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Affiliation(s)
- Pablo Laje
- Department of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erik G Pearson
- Department of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Allan F Simpao
- Department of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mohammed A Rehman
- Department of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tiffany Sinclair
- Department of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Holly L Hedrick
- Department of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- Department of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alan W Flake
- Department of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Lieber J, Urla CI, Baden W, Schäfer J, Kirschner HJ, Fuchs J. Experiences and challenges of thorcoscopic lung surgery in the pediatric age group. Int J Surg 2015; 23:169-75. [PMID: 26475091 DOI: 10.1016/j.ijsu.2015.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 09/12/2015] [Accepted: 10/04/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND We report a single-center study of minimally invasive thoracoscopic lung surgery with pediatric patients. METHODS We performed a retrospective analysis of patients who underwent thoracoscopic lung surgery between 2004 and 2013. The procedures were divided into anatomic and non-anatomical lung resections. RESULTS Seventy-six patients with a mean age of 6.5 years (range: 7 days-17 years) and a mean weight of 11 kg (range: 2.6-56.0 kg) received thoracoscopic lung surgery for tumor metastases (n = 20), sequestration/congenital adenomatoid malformation (19), cysts (12), aspergillomas (7), bullae (5), middle lobe syndrome (3), bronchiectasis (3), emphysema (2), and other reasons (5). Twenty-nine anatomical lung resections (Group I: lobectomies, segmentectomies) and 47 non-anatomical lung resections (Group II: wedge resections, lung tissue-sparing surgery) were performed. In 6 cases, preoperative CT-guided coiling was used to localize the lung lesions. Specimen removal was achieved using a widened (2 cm) trocar site. The operating times of Group I patients were longer compared than those of Group II patients (means: 154 and 68 min, respectively); conversion rates (8 versus 2), chest tube insertion rates (100% versus 51%), and postoperative ventilation (48% versus 13%) also differed. CONCLUSION Thoracoscopic anatomical lung resections appear to be safe and effective in infants and children. In congenital lung diseases, the key to success is the intraoperative destruction of space-occupying lesions. Limitations exist in cases with infectious adhesions. Non-anatomical lung resections are technically easier and should remain standard in pediatric surgery. Limitations exist in cases of metastases, which are deep within the parenchyma and are not visible on the lung surface.
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Affiliation(s)
- Justus Lieber
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Hoppe-Seyler-Strasse 1, D-72076 Tübingen, Germany.
| | - Cristian Ioan Urla
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Hoppe-Seyler-Strasse 1, D-72076 Tübingen, Germany.
| | - Winfried Baden
- Department of Pediatric Cardiology and Pulmonology, University Children's Hospital, Hoppe-Seyler-Strasse 1, D-72076 Tübingen, Germany.
| | - Jürgen Schäfer
- Department of Diagnostic Radiology, University Hospital, Hoppe-Seyler-Strasse 1, D-72076 Tübingen, Germany.
| | - Hans-Joachim Kirschner
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Hoppe-Seyler-Strasse 1, D-72076 Tübingen, Germany.
| | - Jörg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Hoppe-Seyler-Strasse 1, D-72076 Tübingen, Germany.
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Kulaylat AN, Engbrecht BW, Hollenbeak CS, Safford SD, Cilley RE, Dillon PW. Comparing 30-day outcomes between thoracoscopic and open approaches for resection of pediatric congenital lung malformations: Evidence from NSQIP. J Pediatr Surg 2015; 50:1716-21. [PMID: 26144284 DOI: 10.1016/j.jpedsurg.2015.06.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 06/04/2015] [Accepted: 06/08/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE Thoracoscopic surgery has been increasingly utilized in treating pediatric congenital lung malformations (CLM). Comparative studies evaluating 30-day outcomes between thoracoscopic and open resection of CLM are lacking. METHODS There were 258 patients identified in pediatric NSQIP with a CLM and pulmonary resection in 2012-2013. Comparisons of patient characteristics and outcomes between surgical approaches were made using standard univariate statistics. In addition, a propensity score match was performed to evaluate outcomes in similar patient cohorts. RESULTS One-hundred twelve patients (43.4%) received thoracoscopic resections and 146 patients (56.6%) received open resections. Patients undergoing open resections were more likely to be less than 5 months of age and have a comorbidity/preoperative condition (47.3% vs. 25.0%, p<0.001). The extent of resection was a lobectomy in 84.8% of thoracoscopic and 92.5% of open resection patients. Median operative time was similar between both groups (thoracoscopic 172 vs. open 153.5 minutes). On univariate analysis, thoracoscopic resection was associated with decreased postoperative complications (9.8% vs. 25.3%, p=0.001) and LOS (3 vs. 4 days, p<0.001). However, after adjusting for similar patient and operative characteristics, no significant differences were encountered between techniques. CONCLUSIONS Thoracoscopic and open resection provide comparable 30-day outcomes and safety in the management of congenital lung malformations.
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Affiliation(s)
- Afif N Kulaylat
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, United States
| | - Brett W Engbrecht
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, United States
| | - Christopher S Hollenbeak
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, United States; Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA, United States
| | - Shawn D Safford
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, United States
| | - Robert E Cilley
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, United States
| | - Peter W Dillon
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, United States.
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Mahida JB, Asti L, Pepper VK, Deans KJ, Minneci PC, Diefenbach KA. Comparison of 30-Day Outcomes Between Thoracoscopic and Open Lobectomy for Congenital Pulmonary Lesions. J Laparoendosc Adv Surg Tech A 2015; 25:435-40. [DOI: 10.1089/lap.2014.0298] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Justin B. Mahida
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Lindsey Asti
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Victoria K. Pepper
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Katherine J. Deans
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Peter C. Minneci
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Karen A. Diefenbach
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
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Wagenaar AE, Tashiro J, Hirzel A, Rodriguez LI, Perez EA, Hogan AR, Neville HL, Sola JE. Surgical management of bronchopulmonary malformations. J Surg Res 2015; 198:406-12. [PMID: 25918001 DOI: 10.1016/j.jss.2015.03.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 02/22/2015] [Accepted: 03/26/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Bronchopulmonary malformations (BPM) are rare conditions, which typically arise below the carina and can result in significant morbidity (infection and/or hemorrhage) and mortality (respiratory failure). MATERIALS AND METHODS All children with BPM surgically treated from 2001-2014 at a tertiary care children's hospital were identified. Patient demographics, surgical indications, procedure type, estimated blood loss, pathology, perioperative complications, length of stay, and outcomes were analyzed. RESULTS A total of 41 BPM patients underwent surgery with 98% overall survival (one abdominal BPM expired) but 100% for thoracic lesions. Resections were performed thoracoscopically (37%), thoracoscopy converted to open (22%), and via thoracotomy (37%). Poor visualization (67%) or inability to tolerate single lung ventilation (33%) led to conversions. No conversions resulted from hemorrhage or received blood transfusions. Patients with prenatally diagnosed BPM were more likely to undergo thoracoscopic surgery (odds ratio [OR], 18.2) versus nonprenatally diagnosed, P = 0.002. Open/converted patients had longer chest tube days (6.2) versus thoracoscopic (2.9), P = 0.048. Additionally, respiratory distress was a more common indication in patients aged <4 mo (OR, 28.0) versus ≥4 mo and <6 kg (OR, 40.5) versus ≥6 kg, P < 0.001. Open resections were more common in patients aged <4 mo (OR, 26.3) versus ≥4 mo, P = 0.002. Operative time was shorter and estimated blood loss (mL/kg) was greater for <6 versus ≥6 kg, P < 0.05. CONCLUSIONS BPM resections have high overall survival. Chest tube days are shorter among thoracoscopic patients, but conversion to thoracotomy can avoid hemorrhage and need for transfusion. Size and respiratory distress limit use of thoracoscopy in young infants with BPM.
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Affiliation(s)
- Amy E Wagenaar
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Jun Tashiro
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Alicia Hirzel
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Luis I Rodriguez
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Eduardo A Perez
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Anthony R Hogan
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Holly L Neville
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Juan E Sola
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida.
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Rothenberg SS, Middlesworth W, Kadennhe-Chiweshe A, Aspelund G, Kuenzler K, Cowles R, Bodenstein L, Kay S, Shipman K, Rothenberg C, Stolar C, Stylianos S. Two decades of experience with thoracoscopic lobectomy in infants and children: standardizing techniques for advanced thoracoscopic surgery. J Laparoendosc Adv Surg Tech A 2015; 25:423-8. [PMID: 25560086 DOI: 10.1089/lap.2014.0350] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES This study evaluates the safety and efficacy of thoracoscopic lobectomy in infants and children. MATERIALS AND METHODS From January 1994 to November 2013, 347 patients underwent video-assisted thoracoscopic lobe resection at two institutions. All procedures were performed by or under the direct guidance of a single surgeon. Patients' ages ranged from 1 day to 18 years, and weights ranged from 2.8 to 78 kg. Preoperative diagnosis included sequestration/congenital pulmonary airway malformation (n=306), severe bronchiectasis (n=24), congenital lobar emphysema (n=13), and malignancy (n=4). RESULTS Of the 347 procedures, 342 were completed thoracoscopically. Operative times ranged from 35 minutes to 240 minutes (average, 115 minutes). Average operative time when a trainee was the primary surgeon was 160 minutes. There were 81 upper, 25 middle, and 241 lower lobe resections. There were four intraoperative complications (1.1%) requiring conversion to an open thoracotomy. The postoperative complication rate was 3.3%, and 3 patients required re-exploration for a prolonged air leak. Hospital length of stay (LOS) ranged from 1 to 16 days (average). In patients <5 kg and <3 months of age, the average operative time was 90 minutes, and the LOS was 2.1 days. CONCLUSIONS Thoracoscopic lung resection is a safe and efficacious technique. With proper mentoring it is an exportable technique, which can be performed by pediatric surgical trainees. The procedures are safe and effective even when performed in the first 3 months of life. Early resection avoids the risk of later infection and malignancy.
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Affiliation(s)
- Steven S Rothenberg
- 1 Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons and Morgan Stanley Children's Hospital of New York-Presbyterian , New York, New York
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41
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Hilar closure using staplers or Hem-o-lok clips in a rabbit model. J Surg Res 2014; 192:616-20. [DOI: 10.1016/j.jss.2014.07.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 07/10/2014] [Accepted: 07/23/2014] [Indexed: 11/21/2022]
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Abstract
The management of congenital lung malformations is controversial both in the prenatal and postnatal periods. This article attempts to inform best practice by reviewing the level of evidence with regard to prenatal diagnosis, prognosis, and management and postnatal management, including imaging, surgical indication, surgical approach, and risk of malignancy. We present a series of clinically relevant statements along those topics and analyze the evidence for each. In the end, we make a plea for an adequate description of the lesions, both before and after birth, which will allow future comparisons between management options and the initiation of prospective registries.
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Affiliation(s)
- Robert Baird
- Department of Pediatric Surgery, McGill University, Montreal Children׳s Hospital, McGill University Health Center, Montreal, QC, Canada
| | - Pramod S Puligandla
- Department of Pediatric Surgery, McGill University, Montreal Children׳s Hospital, McGill University Health Center, Montreal, QC, Canada; Department of Pediatrics, McGill University, Montreal Children׳s Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Jean-Martin Laberge
- Department of Pediatric Surgery, McGill University, Montreal Children׳s Hospital, McGill University Health Center, Montreal, QC, Canada.
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Koga H, Suzuki K, Nishimura K, Okawada M, Doi T, Lane GJ, Inada E, Okazaki T, Yamataka A. Comparison of the value of tissue-sealing devices for thoracoscopic pulmonary lobectomy in small children: a first report. Pediatr Surg Int 2014; 30:937-40. [PMID: 25074733 DOI: 10.1007/s00383-014-3567-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2014] [Indexed: 10/25/2022]
Abstract
Accurate division and sealing of lung parenchyma particularly in cases of total or near total incomplete fissure are crucial for preventing air leakage following thoracoscopic pulmonary lobectomy (TPL). However, conventional endoscopic stapling devices cannot be used during TPL in small children because of limited space. Consequently, Ligasure (LS) and Enseal (ES) devices are being used instead. We are the first to compare LS and ES for efficacy and efficiency during TPL. Of 26 TPL (6 upper, 3 middle, and 17 lower) performed for congenital adenomatoid malformation (n = 16) and sequestration (n = 10), incomplete fissure was found in 14. TPL (LS = 11; ES = 15) was performed conventionally in the lateral decubitus position with single lung ventilation using four 5 mm trocars. All cases had a chest tube inserted intraoperatively that was left in situ. Patient demographics, location of pathology, incidence of incomplete fissure, mean age/weight at TPL, mean blood loss, and mean operative time were all similar. However, duration of chest tube insertion was significantly shorter in ES because there was less postoperative air leakage (1.3 vs. 3.9 days; p < 0.05). ES would appear to seal lung parenchyma more effectively during TPL based on the shorter duration of chest tube insertion.
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Affiliation(s)
- Hiroyuki Koga
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, 113-8421, Japan,
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Rothenberg SS, Shipman K, Kay S, Kadenhe-Chiweshe A, Thirumoorthi A, Garcia A, Czauderna P, Kravarusic D, Freud E. Thoracoscopic Segmentectomy for Congenital and Acquired Pulmonary Disease: A Case for Lung-Sparing Surgery. J Laparoendosc Adv Surg Tech A 2014; 24:50-4. [DOI: 10.1089/lap.2013.0337] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Steven S. Rothenberg
- The Rocky Mountain Hospital for Children, Denver, Colorado
- Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Saundra Kay
- The Rocky Mountain Hospital for Children, Denver, Colorado
| | | | - Arul Thirumoorthi
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Alejandro Garcia
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Piotr Czauderna
- Department of Surgery and Urology for Children and Adolescents, Medical University of Gdansk, Gdansk, Poland
| | - Dragan Kravarusic
- Schneider Children's Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Enrique Freud
- Schneider Children's Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Thoracoscopic vs open lobectomy in infants and young children with congenital lung malformations. J Am Coll Surg 2013; 218:261-70. [PMID: 24315887 DOI: 10.1016/j.jamcollsurg.2013.10.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 10/21/2013] [Accepted: 10/23/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND Although thoracoscopic lobectomy is a widely accepted surgical procedure in adult thoracic surgery, its role in small children remains controversial. The purpose of this study was to evaluate perioperative outcomes after thoracoscopic and open lobectomy in infants and young children with congenital lung malformations at a single academic referral center. STUDY DESIGN A cohort study of 62 consecutive children who underwent elective pulmonary lobectomy for a congenital lung lesion between 2001 and 2013 was performed. Patient demographics and perioperative outcomes were evaluated in univariate and logistic regression analyses. RESULTS Forty-nine patients underwent thoracoscopy and 13 had a thoracotomy. Six children undergoing thoracoscopy required conversion to thoracotomy (conversion 12.2%). Perioperative outcomes, including median blood loss (2.0 vs 1.1 mL/kg; p = 0.34), chest tube duration (3 vs 3 days; p = 0.33), hospital length of stay (3 vs 3 days; p = 0.42), and morbidity as defined by the Accordion Grading Scale (30.6% vs 30.8%; p = 0.73), were similar between thoracoscopy and thoracotomy, respectively. Although thoracoscopy was associated with increased operative duration compared with thoracotomy (239.9 vs 181.2 minutes, respectively; p = 0.03), thoracoscopy operative times decreased with increasing institutional experience (p = 0.048). Thoracoscopic lobectomy infants younger than 5 months of age had a 2.5-fold higher rate of perioperative adverse outcomes compared with older children (p = 0.048). CONCLUSIONS In small children undergoing pulmonary lobectomy, both thoracoscopy and thoracotomy are associated with similar perioperative outcomes. The cosmetic and musculoskeletal benefits of the thoracoscopic approach must be balanced against institutional expertise and a potentially higher risk for complications in younger patients.
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Tanaka Y, Uchida H, Kawashima H, Sato K, Takazawa S, Masuko T, Deie K, Iwanaka T. Complete Thoracoscopic Versus Video-Assisted Thoracoscopic Resection of Congenital Lung Lesions. J Laparoendosc Adv Surg Tech A 2013; 23:719-22. [DOI: 10.1089/lap.2013.0110] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yujiro Tanaka
- Department of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroshi Kawashima
- Department of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Kaori Sato
- Department of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Shinya Takazawa
- Department of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Takayuki Masuko
- Department of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Kyoichi Deie
- Department of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Tadashi Iwanaka
- Department of Pediatric Surgery, University of Tokyo Hospital, Tokyo, Japan
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Fascetti-Leon F, Gobbi D, Pavia SV, Aquino A, Ruggeri G, Gregori G, Lima M. Sparing-lung surgery for the treatment of congenital lung malformations. J Pediatr Surg 2013; 48:1476-80. [PMID: 23895957 DOI: 10.1016/j.jpedsurg.2013.02.098] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 01/16/2013] [Accepted: 02/20/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE Congenital lung malformations (CLM) are traditionally treated by pulmonary lobectomy. The foremost indication for surgery is that these lesions predispose to respiratory tract infections and to malignancy. Owing to the improvement of prenatal diagnosis, most patients are operated in a timely manner and prophylactically. In this context, lung-sparing surgery (LS) has gained interest as a lung preservation strategy, especially for asymptomatic patients. In the present study, we evaluated both thoracoscopic and open lung-preserving resections as an alternative to lobectomy for CLM resection. METHODS We retrospectively reviewed all patients who underwent lung-sparing resection (segmentectomy and atypical resection) for CLM from 2001 to 2010. Data were collected regarding preoperative diagnostic workup, type of intervention, and follow up. RESULTS Fifty-four patients received LS for CLM during the study period. Twenty-six were approached thoracoscopically, with 18 cases requiring open conversion for a complete resection. There were six postoperative complications: three asymptomatic pneumothoraces that resolved without intervention, one tension pneumothorax that required replacement of a drainage catheter, and three instances of intra-operative bleeding requiring blood transfusion. Mean duration of follow-up was 65.2 months. Two patients experienced pneumonia during the follow-up period. A third patient had a cystic lung lesion on postoperative computed tomography (CT) which required a second-look surgery. CONCLUSIONS LS for CLM is a safe and effective means of lung parenchymal preservation in pediatric patients. Complication rates are comparable to that of traditional lobectomy. In our experience, this type of lung surgery does not carry a higher risk of residual disease and recurrence if accurately planned in selected patients, i.e., those with small asymptomatic lesions. The complication rate is acceptable and apparently not affected by preoperative symptoms. The thoracoscopic approach is recommended, although open conversion should be advocated to avoid too long operative times.
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Affiliation(s)
- Francesco Fascetti-Leon
- Department of Paediatric Surgery, Paediatric Surgery Unit, University of Bologna, Via Massarenti, 11, 40138, Bologna, Italy.
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Lau CT, Leung L, Chan IHY, Chung PHY, Lan LCL, Chan KL, Wong KKY, Tam PKH. Thoracoscopic resection of congenital cystic lung lesions is associated with better post-operative outcomes. Pediatr Surg Int 2013; 29:341-5. [PMID: 23292534 DOI: 10.1007/s00383-012-3243-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The incidence of congenital cystic lung lesions has been increasing in recent years due to better antenatal detection. With the introduction and maturation of thoracoscopy, the operative management for these lesions has seen advancement in the last decade. In this study, we aimed to compare the post-operative outcomes of patients who had thoracoscopic resection with those who underwent open resection. METHODS A retrospective review of all patients who underwent surgery for congenital cystic lung lesions between January 1996 and June 2012 in a tertiary referral center was conducted. Patients' demographics, operative procedures and post-operative outcomes were analyzed. RESULTS Sixty-seven patients were identified over the past 15 years. Thirty-nine patients had thoracoscopic resections and 28 had open resections. Thirteen patients in the thoracoscopic group required conversion. Both groups had similar demographics in terms of age, body weight and laterality of lesions. The mean operative time and blood loss in the two groups were comparable. Patients in the thoracoscopic group had significantly shorter duration of chest tube drainage (4.3 vs. 6.9 days, p = 0.004), shorter intensive care unit stay (2.5 vs. 5.9 days, p = 0.003) and shorter hospital stay (6.9 vs. 12.0 days, p < 0.001). Post-operative complication rate was similar between the two groups. Patients with body weight less than 5 kg showed a significantly higher conversion to open surgery as compared to those with body weight more than 5 kg (62.5 vs. 25.8 %, p = 0.049). CONCLUSION Successful thoracoscopic resection for congenital cystic lung lesions results in better post-operative outcomes. However, this technique remains technically challenging in patients with body weight less than 5 kg.
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Affiliation(s)
- C T Lau
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong SAR, China
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Koga H, Suzuki K, Nishimura K, Okazaki T, Lane GJ, Inada E, Yamataka A. Traction sutures allow endoscopic staples to be used safely during thoracoscopic pulmonary lobectomy in children weighing less than 15 kg. J Laparoendosc Adv Surg Tech A 2012; 23:81-3. [PMID: 23216408 DOI: 10.1089/lap.2012.0063] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE During thoracoscopic pulmonary lobectomy (TPL) in larger children (>15 kg), an endoscopic stapler (ES) and endoscopic clipper (EC) are used during dissection and division of the pulmonary vessels (PVs) and bronchus. However, in smaller children (<15 kg), ES/EC cannot be used because of limited space. We report our technique for thoracoscopic dissection and division of the PVs and bronchus in smaller children. SUBJECTS AND METHODS Fifteen cases of sequestration/congenital cystic adenomatoid malformation weighing less than 15 kg (range, 8-15 kg; mean, 11 kg) were the subjects for this review. With the patient under single-lung ventilation in the lateral decubitus position, four ports ranging from 5 to 12 mm were placed. After the PVs and bronchus were exposed, thick silk was used to encircle them as a traction suture. By applying traction, the PVs and bronchus could be exposed, and ES/EC were used safely by applying countertraction. RESULTS All cases had uneventful TPL (upper in 3 patients, middle in 3 patients, and lower in 9 patients). ES/EC were easy to use. Mean operative time was 220 minutes. CONCLUSIONS Our technique allows the PVs and bronchus in children weighing less than 15 kg to be divided safely using ES/EC. We strongly recommend our technique, although simple, be used during TPL in smaller children.
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Affiliation(s)
- Hiroyuki Koga
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan.
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50
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Seong YW, Yoo BS, Kim JT, Park IK, Kang CH, Kim YT. Video-Assisted Thoracoscopic Lobectomy in Children: Safety and Efficacy Compared with the Conventional Thoracotomy Approach. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2012; 7:394-8. [DOI: 10.1177/155698451200700604] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective There have been only small numbers of reports for video-assisted thoracoscopic surgery (VATS) lobectomy in children because of its technically demanding aspects. This study was performed to evaluate the safety and the efficacy of the VATS lobectomy compared with the conventional lobectomy by thoracotomy and to investigate the risk factors of thoracotomy conversion. Methods From May 2005 to October 2010, a total of 37 pediatric patients underwent VATS lobectomy and 28 pediatric patients underwent conventional lobectomy. The VATS lobectomy group consisted of relatively older patients compared with the thoracotomy group. Clinical outcomes from the two groups were analyzed and compared. Results Of the 37 patients in the VATS group, 8 patients (23%) required thoracotomy conversion and 29 patients (77%) were successfully operated on thoracoscopically. There were no in-hospital mortalities in both groups. Annual thoracotomy conversion rate has decreased from 50% in 2005 to 9% in 2010. There were no significant differences in the outcome between the VATS group and the thoracotomy group. Morbidities in the VATS group included prolonged drainage longer than 7 days (two patients), prolonged air leakage (two patients), and bleeding (one patient). There was no difference in the incidence of morbidities between the two groups. Univariate analyses revealed failure of single-lung ventilation (P = 0.007) and history of pneumonia (P = 0.001) to be risk factors of thoracotomy conversion. Conclusions Video-assisted thoracoscopic surgery lobectomy in children is a safe and effective treatment modality, with results comparable with those of conventional lobectomy. In the univariate analysis, failure of single-lung ventilation and history of pneumonia were the two factors related to thoracotomy conversion.
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Affiliation(s)
- Yong Won Seong
- Department of Thoracic and Cardiovascular Surgery, and Seoul National University Hospital, Seoul, Republic of Korea
| | - Byung Su Yoo
- Department of Thoracic and Cardiovascular Surgery, and Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin Tae Kim
- Department of Anesthesiology, Clinical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - In Kyu Park
- Department of Thoracic and Cardiovascular Surgery, and Seoul National University Hospital, Seoul, Republic of Korea
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, and Seoul National University Hospital, Seoul, Republic of Korea
| | - Young Tae Kim
- Department of Thoracic and Cardiovascular Surgery, and Seoul National University Hospital, Seoul, Republic of Korea
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