Refractory tension pneumothorax as a result of an internally displaced thoracoamniotic shunt in an infant with a congenital pulmonary airway malformation

Management dilemma in Thoracoamniotic Shunt Migrations

Shunt migration is a rare but significant complication of thoracoamniotic shunting, an intervention widely used for fetal pleural effusion. We describe a case of a term infant noted antenatally to have fetal hydrothorax that was managed with thoracoamniotic shunting but complicated by shunt migration. We also present the current literature on risk factors, complications and management of intrathoracic shunt migration. The majority of shunt migration cases are managed conservatively with no untoward postnatal sequelae, but surgical removal of the migrated shunt has been used for associated clinical complications, if visceral damage is suspected or if postnatal thoracic surgery is indicated for other reasons. We advocate an approach of conservative management for asymptomatic infants, where possible, to avoid unnecessary surgical and anaesthetic risks to very young, often already compromised children. However, further studies are still required to determine optimal management after shunt migration has occurred to ensure the best outcome.

Combined Pre- and Postnatal Minimally Invasive Approach to a Complex Symptomatic Congenital Pulmonary Airway Malformation

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.

Intrathoracic shunt displacement with massive pleural effusion after successful shunt placement in a hydropic fetus with multilocular macrocystic congenital pulmonary airway malformation

We successfully performed shunting for a fetus with a multilocular macrocystic lung mass with hydrops at 22 weeks' gestation. Complete resolution of hydrops was achieved; however, at 35 weeks' gestation, the fetus developed acute massive pleural effusion. Fetal ultrasound examination revealed that one end of the shunting tube had migrated downward in the thoracic cavity, which led to fluid draining from the lung cyst. The baby was delivered at term and was discharged following neonatal intensive care management. Intrathoracic displacement of the shunt can occur, followed by massive pleural effusion due to drainage of cystic fluid.

Thoracoscopic removal of a displaced thoracoamniotic shunt in a newborn with antenatal pleural effusion-a case report

Thoracoamniotic shunt has been considered as a treatment for antenatal pleural effusion and complication is rare. In majority of cases, the shunt can be removed uneventfully. In this article, we reported a rare complication of shunt migration resulting in the need of thoracoscopic removal at newborn period. The patient born at 39+3 weeks of gestation suffered from antenatal chylothorax detected at 28 weeks and was managed by intrauterine thoracoamniotic shunt insertion. This was complicated by shunt displacement, which caused respiratory distress after birth requiring ventilatory support and progressive pleural effusion in this patient. To prevent further neonatal compromise, thoracoscopic removal of the retained shunt was done on day 7 of life followed by post-op chest drain insertion. Post-op condition was stable with resolution of respiratory distress, and the patient was discharge on post-op day 16. We would like to remind clinicians about this potential complication of thoracoaminotic shunt, which can pose a potential risk of severe neonatal compromise, and that it can be managed by minimal invasive surgery even in the newborn period.