Current concepts in surgical management of pediatric lung and chest wall diseases

Pectus deformities and their impact on pulmonary physiology

Pectus excavatum (PE) and pectus carinatum (PC) are the most common anomalies of the thoracic cage and they have been recognized since ancient times [1-3]. The two conditions differ in their appearance, and their effect on lung function. There is no direct correlation between the appearance of the deformities and the clinical symptoms. Whether, and when these deformities should be corrected as well as with which method (surgical or conservative) remain controversial. The following article reviews the current concepts regarding the pathophysiology of both conditions as well as the advances in their evaluation and management.

Video-assisted thoracoscopic surgery of childhood empyema: early referral improves outcome

BACKGROUND/AIM

Video-assisted thoracoscopic surgery (VATS) is considered a safe and effective option in the treatment of childhood empyema. The aim of this study was to assess the efficacy of early referral for primary VATS in childhood empyema.

METHOD

A cohort of 24 consecutive children (12 boys, 12 girls) from 2004 to 2009 with post-pneumonic empyema, as demonstrated by loculation on ultrasound, undergoing VATS at a single tertiary level institution, was reviewed. All cases of empyema were managed as per the local protocol of early referral for primary VATS.

RESULTS

Mean age of presentation was 54 months (5 months to 15 years). Mean duration of symptoms before presentation to our centre was 6.29 days (±2.74 days) (range 1-10 days) and mean time to referral to the paediatric surgical unit was 1.95 days (±2.57 days). VATS was performed in all patients with a mean operating time 113.7 min (±37.0 min), which included time for bronchoscopy (range 43-184 min). The mean duration of chest drainage was 4 days (±2.96 days) and post-operative hospitalisation was 6.88 days (±4.11 days).

CONCLUSION

Early primary VATS for post-pneumonic empyema in children demonstrated a higher success rate, lower conversion to open thoracotomy improved outcome and shorter hospitalisation.

Balloon-assisted single-port thoracoscopic debridement in children with thoracic empyema

PURPOSE

In this study, we evaluated the results of a balloon-aided single-port thoracoscopic debridement of late-stage thoracic empyema in children.

PATIENTS AND METHODS

We retrospectively reviewed age, gender, duration of prehospital illness, physical findings, surgical interventions, and the morbidity in 12 children with late-stage parapneumonic empyema. The diagnosis of pleural effusion was confirmed by a thoracocentesis before thoracoscopy. A balloon connected to a 12 F feeding tube was inserted into the thoracic cavity and inflated with air before the enterance of the thoracoscope. By this maneuver, a cavity was formed just under the enterance point. Thereafter, a routine debridement and chest irrigation was performed by thoracoscopy. Only one port was inserted in all but 1 patient, and the telescope was used as a dissecting tool. A thorax tube was inserted through the port site at the end of the procedure and left for the drainage.

RESULTS

The main symptoms of the patients were dyspnea, cough, and fever. The empyema was located on the right hemithorax in 5 patients and on the left side in 7 patients. A second port was necessary to enhance the dissection in 1 case. The chest tube was removed within 3-30 days (median, 11 days) after the surgical approach. No complication directly related to the procedure was seen. The only problems postoperatively were a self-limited and spontaneously resolved bronchopleural fistula in 4 patients, and we had to perform an additional thoracoscopy to resolve the remaining intrapleural adhesions in 1 child.

CONCLUSIONS

Thoracoscopic debridement in patients with late-stage thoracic empyema may be very beneficial, and this treatment method may provide any further thoracotomy. A balloon inflated in the thoracic cavity may achieve a wider field of vision for thorascopic surgery, and single-port thoracoscopy is sufficient and safe for the dissection.