Thoracoscopy in pediatrics: Surgical perspectives

Pediatric thoracoscopic lung resections: a comprehensive analysis of congenital lesion cases

BACKGROUND

Congenital lung lesions in pediatric patients may be managed conservatively or by video assisted thoracoscopic surgery (VATS). This study aimed to determine the complications after VATS for congenital lung lesions in children.

METHODS

All children undergoing a lung resection between January 2009 and June 2022 were retrospectively identified. Children undergoing a primary open lobectomy or a resection other than a congenital lung lesion were excluded. Both early (<30 days) and late postoperative pulmonary complications were determined. The primary endpoint was postoperative complications within 30 days.

RESULTS

In total, 56 patients were included, with a median age of 13 months (IQR 9-37). A VATS lobectomy were performed in 46 patients (82%), an extralobar sequestration in 8 patients (14%), an wedge resection in 1 patient and a segment resection in 1 patient. During the COVID pandemic, fewer resections were performed with an increase in symptomatic patients. A conversion to open occurred in 6 patients (11%), of which a preoperative lung infection was associated with an increased risk thereof(p = 0.004). The median follow-up was 22 months (IQR 7-57) and all patients were alive. A postoperative complication (Clavien Dindo ≥3) occurred in 9 patients and complications without the need of intervention in 6 patients. During follow-up a pneumonia occurred in 11 patients.

CONCLUSION

There seems to be a shift towards delayed surgery with an increase in symptomatic congenital lung malformations, which might lead to an increase in postoperative complications.

Enhancing neonatal thoracoscopic surgical training with rabbit model

Background

Thoracoscopy, which has an increasing role in the treatment of indexed neonatal surgical conditions, requires adequate training. To support this, the current study aimed to evaluate the feasibility and effectiveness of using live rabbit models in neonatal thoracoscopic skills training among paediatric surgeons.

Methods

Following didactic lectures and demonstrations, the participants were given hands-on opportunities to perform thoracoscopic procedures. The feasibility and effectiveness of using live rabbit models in neonatal thoracoscopic skills training among paediatric surgeons were evaluated with pre-/post-course procedural confidence scores and a questionnaire.

Results

This study included 13 paediatric surgeons-2 (15 %) males and 11 (85 %) females-who were evenly distributed. There were four basic surgical trainees, five higher surgical trainees and four fellows in paediatric surgery (mean surgical practice experience: 4.5 ± 3.7 years). Most had experience assisting paediatric (70 %) and neonatal (62 %) thoracoscopic surgery. Only 30 % had experience as the chief surgeon of paediatric thoracoscopic surgery, with none on neonates. Significant improvement was seen in procedural confidence as the assistant and chief surgeon of all procedures post-workshop. The surgeons rated the model positively.

Conclusion

The procedural confidence level of paediatric surgeons improved significantly after workshop participation. This realistic and easily reproducible model can help perfect thoracoscopic skills. Therefore, its integration into paediatric surgical training would promote surgical skill proficiency and could improve surgeons' confidence in neonate operations.

Factors influencing the length of stay (LOS) undergoing robot-assisted thoracoscopic lung surgery in the setting of enhanced recovery after surgery (ERAS) protocol for pediatric patients: a retrospective study

Background

A prolonged length of stay (LOS) after surgery may result in higher hospital costs and hospital-acquired complications. This study aims to identify the risk factors associated with a prolonged hospital stay after robot-assisted thoracoscopic lung surgery for pediatric patients in the context of enhanced recovery after surgery.

Methods

The data for this retrospective study were collected from pediatric patients undergoing robot-assisted thoracoscopic lung surgery. Patients were divided into two subgroups based on median postoperative LOS (Group I: LOS > median 5 days and Group II: LOS ≤ median 5 days). Logistic regression analysis was used to identify the potential factors associated with increased LOS.

Results

This study included 241 patients, 71 (29.46%) with an LOS of >5 days. The proportion of older children was significantly higher in Group I than that in Group II (P=0.004). Patients in Group I were more likely to experience a longer duration of anesthesia and surgery (P<0.001). They also had significantly higher rates of pneumonia, pleural effusion, and liver function damage (P<0.05). Several factors were identified to be associated with an increased LOS after robot-assisted thoracoscopic lung surgery: age >6 years [odds ratio (OR) =3.214, 95% confidence interval (CI): 1.464-7.502, P=0.004], surgery duration >100 min (OR =2.138, 95% CI: 1.296-4.387, P=0.005), intra-albumin (OR =13.778, 95% CI: 1.470-129.116, P=0.022), and blood loss >5 mL (OR =2.184, 95% CI: 1.082-4.409, P=0.029).

Conclusions

The results revealed that older age, longer surgery duration, use of intra-albumin, and more blood loss predict longer postoperative hospital stay in pediatric patients with congenital lung lesions after robot-assisted thoracoscopic lung surgery.

Thoracotomy in Children: Review from a Low-Income Country

Background

Thoracotomy is indicated for several congenital and acquired disorders in children. It is among the surgical procedures which require a well-trained and dedicated surgical, anesthesia and critical care team which can be difficult to assemble in a low-income country setup. As the pattern and outcome of thoracotomy in children remained unreported from such setting, this study aims to shed light on this matter.

Methodology

A descriptive cross-sectional review was conducted. Children who have undergone thoracotomy for non-cardiac pathologies were included in the study. Demographic and clinical data were collected by chart review. Frequencies and percentages were used to describe categorical variables while mean, median, standard deviation and interquartile range were calculated for continuous variables.

Results

A total of 68 patients were operated on in the study period, out of which 44 (64.7%) were males. The mean ages of the children at the time of diagnosis and procedure were 4.05 ± 3.9 years and 4.14 ± 4.03 years, respectively. The most common indication for thoracotomy was pulmonary hydatid cyst (17; 25%) followed by congenital lobar emphysema (11; 16.2%). Muscle sparing posterolateral thoracotomy was the most common approach in 66 (97.1%) patients. The analgesic medications that were used in the post-operative period were paracetamol, diclofenac, ibuprofen, tramadol and morphine. Combined analgesics were administered in two-thirds of the patients while a single analgesic was used in the rest of the children. No regional blocks were administered post operatively as pediatric size catheters were not available. The morbidity and mortality rates were found to be 11.8% and 8.8%, respectively.

Conclusion

The most common indication for thoracotomy in this study was pulmonary hydatid cyst. The provision of post-thoracotomy analgesia in our institution is suboptimal as evidenced by no use of regional blocks and poor practice of administering multimodal analgesia. Thoracotomy was associated with fairly high morbidity and mortality.

Lung Ultrasound to Assess One Lung Ventilation: A Pediatric Case Series

Objectives: One lung ventilation (OLV) is the preferred ventilation technique for thoracoscopy as it provides a better exposure of the operative field and grants the protection of the healthy lung. Preoperative evaluation of lung exclusion is necessary and different methods are available. In recent years lung ultrasound (US) gained popularity and its use for monitoring the endotracheal tube position is widely reported. The existing evidence on adults addresses lung US as effective, yet only few data are available in children. Therefore, we present our experience with lung US as verification method for pediatric OLV. Methods: All patients undergoing OLV for video-assisted thoracoscopic surgery from January 2019 to May 2021 and for whom lung exclusion was confirmed through lung US were involved. Lung exclusion was considered effective when absence of lung motion and presence of lung pulse were encountered. When lung US did not match these criteria, repositioning of the endobronchial device followed by US verification was performed. When lung US met the exclusion criteria surgery was started and direct thoracoscopic observation was used to verify lung exclusion. Results: A total of 20 patients, accounting for 22 procedures, were involved. Absence of lung motion and presence of lung pulse were assessed in the operative-side lung for all patients. Lung exclusion was confirmed through thoracoscopy. Postoperative lung US proved the reappearance of lung motion in the previously excluded lung. Conclusions: In our center experience lung US resulted to be a safe, effective, and time-saving verification method for OLV. Further studies are needed to define its sensitivity and specificity.

Effect of different mechanical ventilation modes on cerebral blood flow during thoracoscopic surgery in neonates: A randomised controlled trial

Background and Aims:

Infants exposed to major surgery are at risk of injuries to the immature brain because of reduced arterial oxygen saturation. This study compared the effect of volume-controlled ventilation (VCV) versus pressure-controlled ventilation (PCV) on cerebral oxygenation in neonates subjected to repair of tracheoesophageal fistula (TEF) under video-assisted thoracoscopic surgery (VATS).

Methods:

This randomised controlled study included 30 full-term neonates scheduled for VATS for managing TEF under general anaesthesia. They were randomised to either VC group (n = 15), who received VCV, or PC group (n = 15), who received PCV. Cerebral oxygenation (rScO₂) was monitored throughout the surgery with documentation of episodes of cerebral desaturation. Peripheral oxygen saturation, partial pressure of carbon dioxide (PaCO₂), and end-tidal carbon dioxide were recorded at baseline, after induction of anaesthesia, and every 30 min till the end of the surgery.

Results:

rScO₂ was significantly higher in the PC group than the VC group at baseline and was significantly higher in the VC group after 15 min (P = 0.041). Later, it was comparable in both the groups up to 60 min after starting the surgery. Cerebral desaturation was significantly more common in the PC group (80%) compared to VC group (33.3%) (P = 0.010). PC group required higher fraction of inspired oxygen and positive end-expiratory pressure to prevent cerebral desaturation. PaCO₂ was significantly higher in the PC group than the VC group at 30 and 60 min (P = 0.005 and 0.029).

Conclusion:

VCV is safer than PCV for cerebral oxygenation during VATS in neonates.

Anesthesia for thoracic surgery in infants and children

The management of infants and children presenting for thoracic surgery poses a variety of challenges for anesthesiologists. A thorough understanding of the implications of developmental changes in cardiopulmonary anatomy and physiology, associated comorbid conditions, and the proposed surgical intervention is essential in order to provide safe and effective clinical care. This narrative review discusses the perioperative anesthetic management of pediatric patients undergoing noncardiac thoracic surgery, beginning with the preoperative assessment. The considerations for the implementation and management of one-lung ventilation (OLV) will be reviewed, and as will the anesthetic implications of different surgical procedures including bronchoscopy, mediastinoscopy, thoracotomy, and thoracoscopy. We will also discuss pediatric-specific disease processes presenting in neonates, infants, and children, with an emphasis on those with unique impact on anesthetic management.

Predictive Factors and Outcomes for Successful Thoracoscopic Lung Resection in Pediatric Patients

BACKGROUND

Less than 50% of children with congenital lung lesions are treated thoracoscopically. There are variable data regarding the benefits and limited information on factors contributing to successful thoracoscopic lobectomies in pediatric patients. We sought to identify predictive factors leading to safe and efficient thoracoscopic lung resection.

STUDY DESIGN

We performed a single-center, retrospective chart review of patients (age <18 y) who underwent lung resection between June 2009 and July 2020. Pulmonary wedge resection was excluded. Data collected included demographics, perioperative findings, such as symptoms or infection, and postoperative outcomes. Univariate, multivariate, and sensitivity analyses were performed.

RESULTS

Ninety-six patients were identified. Sixty-nine patients (72%) underwent initial thoracoscopy, with 15 (22%) converting to open thoracotomy (CTO). Forty-one (43%) patients had preoperative symptoms and 15 (15.6%) had an active infection. Among symptomatic patients, 18 (43.9%) underwent thoracotomy and 23 (56%) were attempted thoracoscopically, 13 (31%) of whom were completed thoracoscopically. On univariate analysis, age >1 year, infection, preoperative symptoms, and intraoperative adhesions were associated with CTO. Older age (odds ratio [OR] = 1.041) and estimated blood loss (EBL) (OR = 2.398) were significant prognostic factors of CTO on logistic regression. Thoracoscopy was significantly associated with decreased length of stay, opioid use, chest tube duration, blood loss and need for blood transfusion. There was no difference in operative time, 30-day readmission, or mortality.

CONCLUSIONS

Thoracoscopy has become a standard approach for pediatric lung resection. Our findings indicate that age < 1 year and the absence of active respiratory infection and preoperative symptoms may be predictive of successful completion of the thoracoscopic approach. Thoracoscopy offers significant advantages over the traditional open thoracotomy with regard to blood loss and opioid requirements, LOS, and chest tube duration.

Pleural lump after paragonimiasis treated by thoracoscopy: A case report

BACKGROUND

Paragonimiasis is a parasitic disease that has multiple symptoms, with pulmonary types being common. According to our clinical practices, the pleural effusion of our patients is full of fibrous contents. Drainage, praziquantel, and triclabendazole are recommended for the treatment, but when fibrous contents are contained in pleural effusion, surgical interventions are necessary. However, no related reports have been noted. Herein, we present a case of pulmonary paragonimiasis treated by thoracoscopy.

CASE SUMMARY

A 12-year-old girl presented to our outpatient clinic complaining of shortness of breath after exercise for several days. Enzyme-linked immunosorbent assay revealed positivity for antibodies against Paragonimus westermani, serological test showed eosinophilia, and moderate left pleural effusion and calcification were detected on computed tomography (CT). She was diagnosed with paragonimiasis, and praziquantel was prescribed. However, radiography showed an egg-sized nodule in the left pleural cavity during follow-up. She was then admitted to our hospital again. The serological results were normal except slight eosinophilia. CT scan displayed a cystic-like node in the lower left pleural cavity. The patient underwent a thoracoscopic mass resection. A mass with a size of 6 cm × 4 cm × 3 cm adhered to the pleura was resected. The pathological examination showed that the mass was composed of non-structured necrotic tissue, indicating a granuloma. The patient remainded asymptomatic and follow-up X-ray showed complete removal of the mass.

CONCLUSION

This case highlights that thoracoscopic intervention is necessary when fibrous contents are present on CT scan or chest roentgenogram to avoid later fibrous lump formation in patients with pulmonary paragonimiasis.

Single-port laparoscopic appendicectomy versus conventional three-port approach for acute appendicitis in children: a systematic review and meta-analysis

AIM

To evaluate comparative outcomes of single-port laparoscopic appendicectomy (SPLA) and conventional three-port laparoscopic appendicectomy (CLA) in the management of acute appendicitis in children.

METHODS

A comprehensive systematic review of randomised controlled trials (RCTs) with subsequent meta-analysis of outcomes were conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. Operative time, surgical site infection, intra-abdominal collection, incisional hernia, length of hospital stay (LOS), additional port/s and conversion to open were the evaluated outcome parameters.

RESULTS

Four RCTs reporting a total number of 520 patients who underwent SPLA (n = 260) or CLA (n = 260) were included. There was no difference between SPLA and CLA group in post-operative collection (risk difference (RD) - 0.00, P = 0.94), surgical site infection (RD 0.02, P = 0.25), incisional hernia (RD 0.00 P = 1), LOS (mean difference (MD) 0.73 P = 0.93), need for additional port/s (RD 0.04, P = 0.24) and conversion to open (RD 0.00, P = 1). However, there was a significantly longer operative time in the SPLA group (MD 9.80, P = 0.00001). The certainty of the evidence was judged to be moderate for all outcomes.

CONCLUSIONS

SPLA and CLA seem to have comparable efficacy and safety in children with acute appendicitis although the former may be associated with longer procedure time. Future high-quality RCTs with adequate sample sizes are required to provide stronger evidence in favour of an intervention.