Hybrid video-assisted thoracoscopic surgery lobectomy of fissureless congenital cystic adenomatoid malformation: a case report

Preoperative delineation of pulmonary fissural anatomy at multi-detector computed tomography in children with congenital pulmonary malformations and impact on surgical complications and postoperative course

BACKGROUND

Delineation of the anatomy and integrity of the pulmonary fissures at CT is important because anomalous or incomplete fissures might increase the risk of surgery and of postoperative complications.

OBJECTIVE

To preoperatively evaluate the integrity of the pleural fissures in children with congenital lung malformations and determine whether anomalous fissural anatomy is a risk factor for a more complicated surgery and postoperative course.

MATERIALS AND METHODS

We reviewed preoperative multi-detector CT scans of consecutive children who underwent open or thoracoscopic resection of a congenital pulmonary malformation from 2008 to 2018, to determine the integrity of the fissural anatomy, and compared these findings with the surgical report. We correlated postoperative factors including operating room time, days in hospital and chest tube with the operating room documented fissural integrity.

RESULTS

We saw a significant association between the radiologically determined fissural integrity at CT and the operative findings independently for the right, left and both lungs combined (P<0.001). The sensitivity of CT to determine fissural integrity was 76.9%, specificity 95.2%, positive predictive value 95.2%, negative predictive value 76.9%, and accuracy 85.1%. There was a statistically significant association between size of the pulmonary malformation and the integrity of the fissure(s) (P=0.024). Larger lesions also resulted in a significantly longer hospitalization (P=0.024).

CONCLUSION

Chest CT showed high accuracy for delineating fissural anatomy in children with congenital pulmonary malformations, with a good interobserver correlation. Incomplete lung fissures were found more often in children with larger congenital pulmonary malformations. In addition, larger lesions were associated with longer hospital stays. Therefore, children with incomplete fissures may have a longer postoperative course. Analysis of the fissural anatomy should be included in the CT report.

Does fissure status affect the outcome of thoracoscopic pulmonary lobectomy?

PURPOSE

We studied fissure status and devices used to divide lung parenchyma during thoracoscopic pulmonary lobectomy (TPL).

METHODS

52 consecutive TPL indicated for congenital pulmonary airway malformation or interlobar pulmonary sequestration performed between 2009 and 2019 were reviewed prospectively to compare patients with absent fissure and no visible interlobar pulmonary artery (IPA) treated by stapling (group A; n = 10), incomplete fissure with partially visible IPA treated with an Enseal^® or LigaSure™ device (group I; n = 17), and complete fissure with fully visible IPA treated by electrocautery (group C; n = 25).

RESULTS

Patient demographics were similar. Mean age at TPL was 2.82 years (range 0.03-9.81). Mean duration of follow-up was 4.77 years (range 0.33-10.19). Operative time and duration of chest tube insertion were similar (p = NS). Intraoperative blood loss was significantly lower in group C compared with group I (p = 0.028). Complications were minor bronchial artery hemorrhage during anterior-to-posterior bronchial dissection (group A: n = 1; group I: n = 1), problematic single lung ventilation (group I: n = 1), and persistent postoperative air leak (group I: n = 1).

CONCLUSION

While fissure status does not appear to affect the outcome of TPL in children, the choice of device for dividing lung parenchyma relies specifically on fissure status.