A survey of musculoskeletal and aesthetic abnormalities after thoracotomy in pediatric patients

Progression of infantile scoliosis after thoracotomy and sternotomy for the treatment of congenital cardiac abnormalities

PURPOSE

To determine whether the rate of progression of scoliosis is higher following thoracotomies and sternotomies in children.

METHODS

We undertook a retrospective review of 1744 patients from a tertiary paediatric referral unit who had sternotomies or thoracotomies from 2005 to 2010 to identify those with scoliosis and to determine where possible, the pre- and post-operative rate of scoliosis progression. A secondary objective was to assess the risk factors for progression after surgery through Chi-square analysis.

RESULTS

1419/1744 (81.4%) patients (55% M, 45% F) had post-op chest X-rays. 25% had a thoracotomy, and 75% had a sternotomy. 5.8% had scoliosis at their most recent chest X-ray (mean Cobb angle 20° (range 11-63°)). There was no significant difference for rates of scoliosis for those who had sternotomies vs thoracotomies (6.3% vs. 4.6% P = 0.258) but a significant difference for those who had primary vs revision sternotomies (5.1% vs. 9.9% P = 0.008). Pre- and post-op progression calculations were possible in 30 patients. The mean time from surgery to the start of the progression was 12 months (range 0-93 months). There was no significant difference between the rates of progression pre-op vs post-op: 1.0 vs. 0.5 deg/month, P = 0.228. There was no significant difference between the rates of post-op progression for those who had a sternotomy versus a thoracotomy (0.5 vs. 0.5 deg/month P = 0.503).

CONCLUSION

Thoracotomies and sternotomies do not appear to increase the rate of progression of scoliosis in these patients.

LEVEL OF EVIDENCE

III. Radiographs illustrating scoliosis progression.

Musculoskeletal and Esthetic Complications after Neonatal Thoracotomy: Revisited

AIM

The aim is to study the complications of neonatal thoracotomy and its preventive measures.

METHODS

We retrospectively reviewed 53 neonates who underwent thoracotomy from January 2017 to December 2019 for a period of 3 years. Patient demographic data, primary disease for which they underwent thoracotomy, postoperative complications (immediate and delayed) during follow-up were documented.

RESULTS

During 3-year period, 53 neonates underwent thoracotomy for various surgical pathologies. The indications were esophageal atresia with tracheoesophageal fistula (n = 49), eventration of diaphragm (n = 3), congenital lobar emphysema of left upper lobe of lung (n = 1). Most of them were right posterolateral thoracotomies (n = 48, 90.56%) and left posterolateral thoracotomy was done in only 5 cases (9.43%). Associated anomalies were seen in 22 cases, such as cardiac (n = 19), renal (n = 4) and gastrointestinal (n = 5). Associated comorbidities seen in 14 cases; preterm (n = 4), low birth weight (n = 13), delayed presentation (n = 6). Early postoperative complications such as pneumonia (34%, n = 18) and wound infection (11.3%, n = 6) were noted. Delayed complications include musculoskeletal abnormalities (n = 19, 35.8%) and esthetic complications such as asymmetry of chest (5.6%).

CONCLUSION

Neonatal thoracotomy is associated with complications such as pneumonia, wound infections, and musculoskeletal abnormalities such as asymmetry of chest and scoliosis. These can be prevented by adequate postoperative pain relief, muscle-sparing thoracotomies, avoiding tight closures, and nerve injuries. Long-term follow-up is required because these complications may manifest later on also. Early detection and institution of physiotherapy may help.

Comparison of thoracoscopy vs. thoracotomy on musculoskeletal outcomes of children with congenital pulmonary airway malformation (CPAM)

BACKGROUND

It has been postulated that video-assisted thoracoscopic surgery (VATS) is superior than conventional thoracotomy for resection of congenital pulmonary airway malformation (CPAM) in terms of shorter hospital length of stay, reduced post-operative complication and better long-term pulmonary outcome. However, there is limited available data concerning the effect of VATS and conventional thoracotomy on musculoskeletal aspects in patients with CPAM. This study aims to compare the long-term effects of both surgical techniques on musculoskeletal outcomes in this group of patients.

METHODS

Thirty-five patients with mean age of 11.38 years old who underwent VATS or conventional thoracotomy for CPAM resection were recruited in this study. The mean follow-up time was 10.42 years (5.48 to 17.71 years). Musculoskeletal examination included screening of musculoskeletal deformities (elevation of shoulder, asymmetry of nipple level, breast/ pectoral muscle maldevelopment, winging of scapula, scoliosis), measurement of bilateral chest wall in relation to anatomical parameter, and testing of shoulder range of motion and power.

RESULTS

The prevalence of winged scapula was significantly lower in patients who underwent VATS than thoracotomy (13% vs 58%, p = 0.008). There is also a smaller reduction in operated-side chest wall vertical distance in VATS patients (0.982 vs 0.956, p = 0.058). There were no significant difference in prevalence of other musculoskeletal deformities, other chest wall measurements, shoulder range of motion and power between two groups.

CONCLUSION

Thoracoscopy decreases the incidence of scapular winging but has no effect on effect on other musculoskeletal deformities.

Winged scapula following axillary thoracotomy with long thoracic nerve preservation

Winged scapula is a rare condition caused by injuries to the long thoracic nerve (LTN) and accessory nerves. A 69-year-old man underwent surgery for right lung cancer. Video-assisted thoracic surgery was converted to axillary thoracotomy at the fourth intercostal space. The latissimus dorsi was protected, and the serratus anterior was divided on the side anterior to the LTN. Two months after discharge, he presented with difficulty in elevating his right arm and protrusion of the scapula from his back. Active forward flexion of the right shoulder was limited to 110° and abduction to 130°. He was diagnosed with winged scapula. After 6 months of occupational therapy, the symptoms improved. The LTN may have been overstretched or damaged by the electric scalpel. We recommend an increased awareness of the LTN, and to divide the serratus anterior at a site as far as possible from the LTN to avoid postoperative winged scapula.

Pericarditis in a Child with an Intrapericardial Bronchogenic Cyst

Background An intrapericardial bronchogenic cyst (IBC) is a rare congenital malformation seemingly asymptomatic in most subjects.

Case Description A 9-year-old boy presented with persistent chest pain and fever. Imaging revealed a large pericardial effusion with a tumor located at the left atrial appendage extending behind the great vessels. Mass rupture with scattered mucoid debris was found intra-operatively. The tumor was excised and the IBC was confirmed by immunohistochemistry. A postcardiotomy syndrome occurred four weeks post-operative. It was treated conservatively. Since then, follow-up visits have remained uneventful.

Conclusion IBCs are a scarce, but serious cause of persistent inflammation in children.

[Embolization of pulmonary arteriovenous malformation causing hypoxemia in a 7-year-old child]

Pulmonary arteriovenous fistulas are abnormal vessels joining the right pulmonary artery to the pulmonary veins. They lead to an extracardiac right-to-left shunt with refractory hypoxemia. We report the case of a 7-year-old girl with a large pulmonary arteriovenous fistula discovered with refractory hypoxemia diagnosed during general anesthesia for adenoidectomy. Radio-opacity was observed on the upper lobe of the right lung. The diagnosis was made using thoracic angiotomography. The proximal arterial vessel arose from the lobar pulmonary artery. The fistula had developed in the entire right upper lobe and drained into two veins flowing into the right superior pulmonary artery. Given the marked hypoxemia, the potential risks of pulmonary hemorrhage and pulmonary infection, an occlusion of the fistula was indicated. After discussion between surgeons and interventional cardiologists, catheterization was indicated. The occlusion of the fistula was successful at the second attempt after release of a vascular plug in the main proximal vessel. This case illustrates the clinical circumstances of diagnosis of arteriovenous fistula, the diagnostic algorithm for refractory hypoxemia and the therapeutic options, with discussion of the benefits and drawbacks of a catheterization procedure.