Open vs thorascopic surgical management of bronchogenic cysts

Video-Assisted Thoracoscopic or Conventional Thoracic Surgery in Infants and Children: Current Evidence

INTRODUCTION

 The pros and cons of video-assisted thoracoscopic versus conventional thoracic surgery in infants and children are still under debate. We assessed reported advantages and disadvantages of video-assisted thoracoscopy in pediatric surgical procedures, as well as the evidence level of the available data.

MATERIALS AND METHODS

 A systematic literature search was performed to identify manuscripts comparing video-assisted thoracoscopic and the respective conventional thoracic approach in classic operative indications of pediatric surgery. Outcome parameters were analyzed and graded for level of evidence (according to the Oxford Centre of Evidence-Based Medicine).

RESULTS

 A total of 48 comparative studies reporting on 12,709 patients, 11 meta-analyses, and one pilot randomized controlled trial including 20 patients were identified. More than 15 different types of advantages for video-assisted thoracoscopic surgery were described, mostly with a level of evidence 3b or 3a. Most frequently video-assisted thoracoscopic surgery was associated with shorter hospital stay, shorter postoperative ventilation, and shorter time to chest drain removal. Mortality rate and severe complications did not differ between thoracoscopic and conventional thoracic pediatric surgery, except for congenital diaphragmatic hernia repair with a lower mortality and higher recurrence rate after thoracoscopic repair. The most frequently reported disadvantage for video-assisted thoracoscopic surgery was longer operative time.

CONCLUSION

 The available data point toward improved recovery in pediatric video-assisted thoracoscopic surgery despite longer operative times. Further randomized controlled trials are needed to justify the widespread use of video assisted thoracoscopy in pediatric surgery.

Is thoracoscopy superior to thoracotomy in the treatment of congenital lung malformations? An updated meta-analysis

Background:

A meta-analysis was performed for a comparison of outcomes between video-assisted thoracoscopic surgery (VATS) and thoracotomy for congenital lung malformations (CLM).

Methods:

Electronic databases, including PubMed, Scopus, Embase, and the Cochrane Library were searched systematically for literature aimed mainly at reporting the therapeutic effects for CLM administrated by VATS and thoracotomy.

Results:

A total of 40 studies meeting the inclusion criteria were included, involving 2896 subjects. VATS was associated with fewer complications [odds ratio (OR) 0.54; 95% confidence interval (CI), 0.42–0.69], less use of epidural anesthesia (OR, 0.08; 95% CI, 0.03–0.23), shorter length of hospital stay [standard mean difference (SMD) −0.98; 95% CI, −1.4 to −0.55] and chest drainage (SMD, −0.43; 95% CI, −0.7 to −0.17), as compared with thoracotomy. However, thoracotomy showed superiority in reduced operative time (SMD, 0.44; 95% CI, 0.04–0.84). Pearson analysis (Pearson r = 0.85, 95% CI, 0.28 to 0.98, p = 0.01) and linear regression (R square 0.73) confirmed a positive correlation between percentage of symptomatic cases and conversion in patients using VATS.

Conclusion:

VATS is associated with fewer complications, less use of epidural anesthesia, shorter length of stay and length of chest drainage, but longer operative time, as compared with thoracotomy. Symptomatic patients with CLM using VATS may be prone to conversion to thoracotomy.

The reviews of this paper are available via the supplemental material section.

Foregut duplications in the superior mediastinum: beware of a common wall with the tracheo-bronchial tree

BACKGROUND

Foregut duplication cysts (FD) with a common muscular wall with the oesophagus are well recognised. Our case series highlights the existence of a common wall between superior mediastinal FD and the tracheo-bronchial tree.

MATERIALS AND METHODS

Over the last 15 years, we have thoracoscopically resected 41 FD. Five cases were identified to have a common wall with the tracheo-bronchial tree at operation. The clinical history, radiology, findings at operation and pathology were evaluated to highlight learning points.

RESULTS

Five superior mediastinal cysts with a common wall were identified, with two antenatally and three postnatally diagnosed. All three postnatal cases and one antenatal case presented with symptoms of respiratory compromise and stridor. Only one neonate was relatively asymptomatic before resection. CT similarities in all cases were: separation of trachea and oesophagus by the cyst, oesophageal deviation to the right or compression and compression of trachea/bronchus. Thoracoscopically, two cysts were resected without injury to the airway, while three had inadvertent tracheo-bronchial injury. Repair of the tracheal injury was possible in one case thoracoscopically, while two cases required conversions, as adequate oxygenation could not be maintained despite on-table endotracheal tube advancement beyond the injury and thoracoscopic manoeuvres. All cases had excellent outcomes at follow-up (median 25months, range 4-39months) with resolution of symptoms and no recurrences.

CONCLUSIONS

Our report highlights the existence of a common wall between the superior mediastinal FD and the tracheo-bronchial tree. Thoracoscopic resections are feasible including repair of inadvertent airway injury, provided adequate oxygenation can be maintained.

The Video-Assisted Thoracic Surgery for Mediastinal Bronchogenic Cysts: A Single-Center Experience

OBJECTIVE

The aim of this study was to evaluate the outcomes of video-assisted thoracic surgery (VATS) for mediastinal bronchogenic cyst (MBC) excision and investigate the surgical indication for MBC.

METHODS

We retrospectively reviewed all consecutive MBC patients who underwent surgical excision between April 2001 and June 2016. One hundred and nineteen patients were enrolled with a median age of 45.4 years and divided into two groups: anterior mediastinum group (n = 48), and middle and posterior mediastinum group (n = 71). VATS technique was initially performed for each patient. The cyst should be resected completely as far as possible. Follow-up was completed by telephone or outpatient clinic every year. The deadline of follow-up was June 2017.

RESULTS

One hundred and eighteen patients underwent VATS, and only one patient converted to open thoracotomy. The average operative time was 103.8 ± 41.6 min (40-360 min). The average intraoperative blood loss was 56.6 ± 86.6 ml (5-600 ml). The intraoperative complication rate was 3.4%, and the incomplete excision rate was 5.9%. The multivariate logistic analysis showed that maximal diameter >5 cm was significantly associated with risk of operation time extension (OR = 3.968; 95% CI 1.179-13.355, p = 0.026) and bleeding loss increasing (OR = 12.242; 95% CI 2.420-61.933, p = 0.002). No serious postoperative complications were observed. Follow-up was performed in 102 patients, and the mean follow-up time was 45 months (12-194 months). There was no local recurrence.

CONCLUSIONS

The maximal diameter >5 cm increased risk of operation time extension and bleeding loss increasing. Early surgical excision of MBC by VATS is recommended to establish histopathological diagnosis, relieve symptoms, and prevent surgery-related complications.

Comparison of video-assisted thoracoscopic surgery and thoracotomy in the treatment of mediastinal cysts

Background

This study aims to compare the results of videoassisted thoracoscopic surgery and thoracotomy in the treatment of mediastinal cystic lesions.

Methods

Sixty patients (28 males, 32 females; mean age 36.1±19.4 years; range, 2 days to 82 years) who were performed thoracotomy or video-assisted thoracoscopic surgery for mediastinal cyst treatment in our clinic between January 1997 and December 2016 were retrospectively evaluated. Chest radiography and thorax computed tomography were used in all participants for diagnosis. Magnetic resonance imaging was used additionally in 23 participants.

Results

Of the patients, mediastinal cysts were localized in anteriorsuperior mediastinum in 19 (31.7%), middle mediastinum in 19 (31.7%) and posterior mediastinum in 22 (36.6%). Histopathologically, 17 bronchogenic cysts, 15 hydatid cysts, 10 pericardial cysts, seven cystic teratomas, four enteric cysts, four thymic cysts, two lymphangiomas and one thoracic duct cyst were identified. While thoracotomy was performed in 34 patients (56.7%), video-assisted thoracoscopic surgery was performed in 26 patients (43.3%). Mean duration of thoracotomies and video-assisted thoracoscopic surgeries was 123.6±24.7 minutes and 87.4±17.6 minutes, respectively (p<0.01). Mean duration of hospital stay was 8.2±4.3 days after thoracotomy and 4.3±1.2 days after video-assisted thoracoscopic surgery (p<0.01). While postoperative complications developed in four patients (two pneumothoraxes, one pleural effusion, one chylothorax), no mortality was observed in any of them.

Conclusion

Main treatment method for mediastinal cysts is surgery. Thoracoscopic approach significantly reduces patient's duration of surgical procedure and postoperative duration of hospital stay. We believe that minimally invasive approaches will be administered more frequently compared to open surgeries for mediastinal cysts in the near future.

Does thoracoscopy have advantages over open surgery for asymptomatic congenital lung malformations? An analysis of 1626 resections

AIM

The apparent incidence of antenatally diagnosed congenital lung malformations (CLM) is rising (1 in 3000), and the majority undergo elective resection even if asymptomatic. Thoracoscopy has been popularized, but early series report high conversion rates and significant complications. We aimed to perform systematic review/meta-analysis of outcomes of thoracoscopic vs open excision of asymptomatic CLMs.

METHODS

A systematic review according to PRISMA guidelines was performed. Data were extracted for all relevant studies (2004-2015) and Rangel quality scores calculated. Analysis was on 'intention to treat' basis for thoracoscopy and asymptomatic lung lesions. Meta-analysis was performed using the addon package METAN of the statistical package STATA14™; p<0.05 was considered significant.

RESULTS

36 studies were eligible, describing 1626 CLM resections (904 thoracoscopic, 722 open). There were no randomized controlled trials. Median quality score was 14/45 (IQR 6.5) 'poor'. 92/904 (10%) thoracoscopic procedures were converted to open. No deaths were reported. Meta-analysis showed that regarding thoracoscopic procedures, the total number of complications was significantly less (OR 0.63, 95% CI 0.43, 0.92; p<0.02, 12 eligible series, 912 patients, 404 thoracoscopic). Length of stay was 1.4days shorter (95%CI 2.40, 0.37;p<0.01). Length of operation was 37 min longer (95% CI 18.96, 54.99; p<0.01). Age, weight, and number of chest tube days were similar. There was heterogeneity (I² 30%, p=0.15) and no publication bias seen.

CONCLUSIONS

A reduced total complication rate favors thoracoscopic excision over thoracotomy for asymptomatic antenatally diagnosed CLMs. Although operative time was longer, and open conversion may be anticipated in 1/10, the overall length of hospital stay was reduced by more than 1day.

LEVEL OF EVIDENCE

4 (based on lowest level of article analyzed in meta-analysis/systematic review).

Intramural esophageal bronchogenic cyst mimicking achalasia in a toddler

Bronchogenic cysts are congenital malformations of the tracheobronchial tree. We describe a 20-month-old male who presented with persistent non-bilious emesis; manometry and imaging were consistent with esophageal achalasia. During a planned laparoscopic Heller myotomy, an intramural bronchogenic cyst was discovered in the anterior esophagus at the level of the gastroesophageal junction and successfully resected with resolution of his symptoms.

Thoracoscopic resection of a bronchogenic cyst in a 17-year-old girl

Bronchogenic cysts comprise approximately 6% of mediastinal tumors in children. The treatment consists in surgical resection of the cyst. The authors present the case of a 17-year-old girl who was accidentally diagnosed with a mediastinal cyst. The patient was successfully treated with thoracoscopic surgery with good early and late clinical outcomes.

Resection of pediatric lung malformations: National trends in resource utilization & outcomes

PURPOSE

We sought to determine factors influencing survival and resource utilization in patients undergoing surgical resection of congenital lung malformations (CLM). Additionally, we used propensity score-matched analysis (PSMA) to compare these outcomes for thoracoscopic versus open surgical approaches.

METHODS

Kids' Inpatient Database (1997-2009) was used to identify congenital pulmonary airway malformation (CPAM) and pulmonary sequestration (PS) patients undergoing resection. Open and thoracoscopic CPAM resections were compared using PSMA.

RESULTS

1547 cases comprised the cohort. In-hospital survival was 97%. Mortality was higher in small vs. large hospitals, p<0.005. Survival, pneumothorax (PTX), and thoracoscopic procedure rates were higher, while transfusion rates and length of stay (LOS) were lower, in children ≥3 vs. <3months (p<0.001). Multivariate analysis demonstrated longer LOS for older patients and Medicaid patients (all p<0.005). Total charges (TC) were higher for Western U.S., older children, and Medicaid patients (p<0.02). PSMA for thoracoscopy vs. thoracotomy in CPAM patients showed no difference in outcomes.

CONCLUSION

CLM resections have high associated survival. Children <3months of age had higher rates of thoracotomy, transfusion, and mortality. Socioeconomic status, age, and region were independent indicators for resource utilization. Extent of resection was an independent prognostic indicator for in-hospital survival. On PSMA, thoracoscopic resection does not affect outcomes.

Video-assisted thoracic surgery compared with posterolateral thoracotomy for mediastinal bronchogenic cysts in adult patients

BACKGROUND

Mediastinal bronchogenic cyst (MBC) is the most common primary cystic lesion of the mediastinum. This study aimed to investigate the efficacy and safety of video-assisted thoracic surgery (VATS) compared with posterolateral thoracotomy (PLT) for the treatment of MBCs in a large series.

METHODS

Patients with MBCs who underwent surgical resection between August 2005 and December 2015 were identified from the electronic database of the Department of Thoracic Surgery, West China Hospital. The patient demographic characteristics, intraoperative findings, postoperative outcomes and follow-up information were reviewed and analyzed.

RESULTS

A total of 99 patients underwent cystectomy were enrolled for the present study. Of those patients, 65 underwent VATS cystectomy (VATS group) and 34 underwent PLT cystectomy (PLT group) during the same period. The VATS group had shorter operative time than the PLT group (108.77±47.81 vs. 144.62±55.16, P=0.001), less intraoperative blood loss (median 20 vs. 100 mL, P<0.001), and less pleural drainage of the first three days after surgery (median 240 vs. 400 mL, P=0.002). In addition, the length of postoperative hospital stay and duration of chest drainage for the VATS group was also shorter than those of the PLT group (4.94±2.01 vs. 8.64±5.52 days, P=0.001; 2.52±1.29 vs. 3.71±1.55 days, P<0.001, respectively). No statistical significance was revealed among the two groups with regard to the maximum diameter of the cysts, pleural atresia, incomplete resection, surgery-related complications, duration of intensive care unit stay, and postoperative complications.

CONCLUSIONS

Both VATS and PLT are reliable approaches for the surgical resection of MBCs. The VATS approach is superior to PLT with shorter operative time, shorter duration of chest drainage, shorter postoperative hospital stay, less intraoperative blood loss, and less pleural drainage of the first three days after surgery. We conclude that VATS should be the preferred approach for the treatment of MBCs.

Thoracoscopic excision of foregut duplication cyst: A case report and review of literature

Thoracoscopy has major advantages over thoracotomy. We report a successful management of foregut duplication cyst thoracoscopically in a child with review of literature.

Efficacy and Safety of Transbronchial Needle Aspiration in Diagnosis and Treatment of Mediastinal Bronchogenic Cysts: Systematic Review of Case Reports

BACKGROUND

Although surgical resection of mediastinal bronchogenic cysts is considered the treatment of choice, there is increasing interest in minimally invasive approaches of management. The purpose of this study was to review the literature on the role of transbronchial needle aspiration (TBNA), either conventional or endobronchial ultrasound (EBUS)-guided, in the diagnosis and management of bronchogenic cysts.

METHODS

We systematically searched the PubMed and EmBase databases for studies (until July 2014) reporting TBNA of bronchogenic cysts. Data were recorded on a standard data extraction form and is presented in a descriptive manner.

RESULTS

Our search yielded 26 studies (32 patients). The median age of the patients was 43 years. Most were men (n=15), symptomatic at presentation (n=19), and had cysts in the paratracheal location (n=14). Endosonography was performed on 16 patients. The EBUS appearance of the lesion was hypoechoic and anechoic in 11 and 5 patients, respectively. Thirty-one patients underwent TBNA (conventional: 16; EBUS-guided: 15). The intent of TBNA was therapeutic in 19 patients and diagnostic or symptomatic palliation in the others. Complications were reported in 5 (16.1%) patients [infective (n=4), bradycardia (n=1)] after TBNA; there were no deaths. The median duration of follow-up was 14 months and no recurrences were detected during the follow-up period.

CONCLUSIONS

Bronchoscopy is a useful tool in the diagnosis of bronchogenic cysts, both for confirmation of the cystic nature of the lesion by EBUS and diagnosis by TBNA (preferably EBUS-guided) of the cyst fluid. Therapeutic aspiration of the cyst may be an alternative to surgery in adults with mediastinal bronchogenic cysts.

Da Vinci Robotic System in the surgery for mediastinal bronchogenic cyst: a report on five patients

BACKGROUND

To present the results of the patients with mediastinal bronchogenic cysts that underwent robotic surgery using Da Vinci Robotic System in our institution.

METHODS

Five patients with mediastinal bronchogenic cyst undergoing robotic resection between October 2011 and September 2015 were retrospectively evaluated. Their pre-, peri- and post-operative results were investigated.

RESULTS

There were five patients (male/female: 3/2) with a mean age of 43±28 years. Three patients (60%) were asymptomatic. The lesions had been detected in the remaining two patients during the investigation of cough and abdominal pain. All the lesions were located at the posterior mediastinum. The mean diameter of lesion was 48±17 mm. One patient underwent robotic decortication in addition to robotic cystectomy. Operative times are outlined as: mean docking time 20±12 min, mean console time 63±32 min, and mean operating time 88±41 min. The mean length of stay was 3.6±2.2 days. There was no mortality or morbidity.

CONCLUSIONS

Bronchogenic cyst is among the commonest congenital lesions. The treatment is surgical resection, and mostly via thoracotomy and video-assisted thoracic surgery (VATS). There exist less than 15 patients who underwent robotic resection in the English literature, and most of them are presented as single case reports. Robotic resection of mediastinal bronchogenic cysts could be considered as a safe method.

Robotic excision of paraesophageal bronchogenic cyst in a 9-year-old child

Bronchogenic cysts are often asymptomatic and discovered as an incidental finding. They may become symptomatic due to esophageal compression as they increase in size or from development of infection. We report a case of a 9-year-old male with an asymptomatic bronchogenic cyst who underwent successful robotic assisted thoracoscopic excision.

Thoracoscopic excision of two bronchogenic cysts located in highest upper mediastinum: Report of two cases

Bronchogenic cysts are rare congenital malformation that need surgical removal. To date, bronchogenic cysts located in highest upper mediastinum excised by thoracoscopy have not been reported, though complete thoracoscopic extirpation of a bronchogenic cyst has been reported before. We excised two highest upper bronchogenic cysts by thoracoscopy successfully without any postoperative complication, demonstrating thoracoscopy could be a first-line therapeutic option even for highest upper mediastinum brochogenic cysts.

Surgical management of bronchopulmonary malformations

BACKGROUND

Bronchopulmonary malformations (BPM) are rare conditions, which typically arise below the carina and can result in significant morbidity (infection and/or hemorrhage) and mortality (respiratory failure).

MATERIALS AND METHODS

All children with BPM surgically treated from 2001-2014 at a tertiary care children's hospital were identified. Patient demographics, surgical indications, procedure type, estimated blood loss, pathology, perioperative complications, length of stay, and outcomes were analyzed.

RESULTS

A total of 41 BPM patients underwent surgery with 98% overall survival (one abdominal BPM expired) but 100% for thoracic lesions. Resections were performed thoracoscopically (37%), thoracoscopy converted to open (22%), and via thoracotomy (37%). Poor visualization (67%) or inability to tolerate single lung ventilation (33%) led to conversions. No conversions resulted from hemorrhage or received blood transfusions. Patients with prenatally diagnosed BPM were more likely to undergo thoracoscopic surgery (odds ratio [OR], 18.2) versus nonprenatally diagnosed, P = 0.002. Open/converted patients had longer chest tube days (6.2) versus thoracoscopic (2.9), P = 0.048. Additionally, respiratory distress was a more common indication in patients aged <4 mo (OR, 28.0) versus ≥4 mo and <6 kg (OR, 40.5) versus ≥6 kg, P < 0.001. Open resections were more common in patients aged <4 mo (OR, 26.3) versus ≥4 mo, P = 0.002. Operative time was shorter and estimated blood loss (mL/kg) was greater for <6 versus ≥6 kg, P < 0.05.

CONCLUSIONS

BPM resections have high overall survival. Chest tube days are shorter among thoracoscopic patients, but conversion to thoracotomy can avoid hemorrhage and need for transfusion. Size and respiratory distress limit use of thoracoscopy in young infants with BPM.

Videothoracoscopy in the treatment of mediastinal cysts

Introduction

Progress in the development of surgical techniques has led to the growing use of video-assisted thoracoscopic surgery (VATS) techniques in mediastinal cyst treatment.

Aim

To present our experience of treating mediastinal cysts with the minimally invasive technique.

Material and methods

Fifty patients with mediastinal cysts were treated from 2001 to 2011. There were 32 women and 18 men. The age of the patients ranged from 17 to 72, the mean age being 42 years. All patients underwent basic preoperative diagnostic tests of the chest: X-ray, computed tomography (CT), bronchoscopy and spirometry; 4 patients underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and 3 fine needle aspiration biopsy (FNAB) of the described lesions.

Results

The VATS was performed in each case. Conversion was carried out due to superior mediastinal location in 10 cases and pleural adhesions in 3 cases. The partial resection of a cyst was performed in 3 patients. One patient was treated conservatively due to heart failure. In that patient the transthoracic needle aspiration of a cyst under ultrasound guidance using alcoholisation with 76% ethanol with a good effect was performed twice. Cyst recurrence was observed in 1 case.

Conclusions

The surgical access depends on the location of a cyst. The VATS resection of a superior mediastinal cyst is not always feasible. Surgery of mediastinal cysts is both diagnostic and curative.

Minimal invasive surgery in the newborn: current status and evidence

The evolution of minimally invasive surgery (MIS) in the newborn has been delayed due to the limited working space and the unique physiology. With the development of smaller instruments and advanced surgical skills, many of the initial obstacles have been overcome. MIS is currently used in specialized centers around the world with excellent feasibility. Obvious advantages include better cosmesis, less trauma, and better postoperative musculoskeletal function, in particular after thoracic procedures. However, the aim of academic studies has shifted from proving feasibility to a critical evaluation of outcome. Prospective randomized trials and high-level evidence for the benefit of endoscopic surgery are still scarce. Questions to be answered in the upcoming years will therefore include both advantages and potential disadvantages of MIS, especially in neonates. This review summarizes recent developments of MIS in neonates and the evidence for its use.

Video-assisted thoracoscopic resection of recurrent intrapulmonary bronchogenic cyst after thoracotomy

Intrapulmonary bronchogenic cysts are typically treated surgically by lobectomy to completely excise the cyst to minimize risk for recurrence. Video-assisted thoracoscopic surgery is being used with increasing frequency to manage intrathoracic pathology. We present a patient who underwent resection of a bronchogenic cyst 20 years before. She developed a symptomatic recurrence, and video-assisted thoracoscopic surgery was used to lyse adhesions from her previous posterolateral thoracotomy and perform an intraparenchymal dissection to resect the pathologic lesion while sparing the remaining parenchyma of her right upper lobe. At 2 years of follow-up, the patient is without evidence of recurrence.

Resection of a bronchogenic cyst in the first decade of life with robotic surgery

The conventional surgical approach for the removal of bronchogenic cyst in children is thoracotomy. Video-assisted thoracoscopic surgery is still under debate with the concerns of incomplete removal and injury to major intrathoracic structures. In this case report, we present an 8-year old patient who was successfully treated with robotic surgery (Intuitive Surgical, Mountain View, CA, USA). Robotic technology enables precise dissection and complete resection of the thoracic bronchogenic cyst without violating the capsule and adjacent major intrathoracic structures. She was discharged on postoperative Day 2 and was active on Day 5.

Video-assisted thoracoscopic resection of a bronchogenic esophageal cyst

Bronchogenic cysts are lesions of congenital origin derived from the primitive foregut. The usual presentation of bronchogenic cyst in the mediastinum is related to cyst infection or adjacent organs compression. A case of a bronchogenic esophageal cyst presenting with progressive dysphagia in a 46-year-old man is described. A video-assisted thoracoscopic excision was performed successfully. Details of the procedure are discussed.

Bronchogenic cyst: Clinical course from antenatal diagnosis to postnatal thoracoscopic resection

PURPOSE:

The purpose of this study was to describe an approach to surgical management of bronchogenic cysts based on the natural course observed from the time of antenatal screening to surgical resection in patients treated at our institution and reported in the literature.

MATERIALS AND METHODS:

We retrospectively reviewed the clinical features of all children presenting bronchogenic cyst diagnosed antenatally from 2007 to 2010. A total of six children were included.

RESULTS:

Antenatal diagnosis was accurate in 62.5% of cases. In the first year of life, the size of the cyst remained stable in four patients, doubled in one, and increased 30% within six months in one. The indication for surgery was emphysema of the left bronchus in two patients and rapid growth in two patients. One patient is still awaiting surgery.

CONCLUSION:

Bronchogenic cysts grow slowly in the first months of life, but growth is exponential even in the absence of complications. We recommend complete resection before the age of two years to prevent infectious complications and facilitate surgery.

Thoracoscopic resection of congenital cystic lung lesions is associated with better post-operative outcomes

INTRODUCTION

The incidence of congenital cystic lung lesions has been increasing in recent years due to better antenatal detection. With the introduction and maturation of thoracoscopy, the operative management for these lesions has seen advancement in the last decade. In this study, we aimed to compare the post-operative outcomes of patients who had thoracoscopic resection with those who underwent open resection.

METHODS

A retrospective review of all patients who underwent surgery for congenital cystic lung lesions between January 1996 and June 2012 in a tertiary referral center was conducted. Patients' demographics, operative procedures and post-operative outcomes were analyzed.

RESULTS

Sixty-seven patients were identified over the past 15 years. Thirty-nine patients had thoracoscopic resections and 28 had open resections. Thirteen patients in the thoracoscopic group required conversion. Both groups had similar demographics in terms of age, body weight and laterality of lesions. The mean operative time and blood loss in the two groups were comparable. Patients in the thoracoscopic group had significantly shorter duration of chest tube drainage (4.3 vs. 6.9 days, p = 0.004), shorter intensive care unit stay (2.5 vs. 5.9 days, p = 0.003) and shorter hospital stay (6.9 vs. 12.0 days, p < 0.001). Post-operative complication rate was similar between the two groups. Patients with body weight less than 5 kg showed a significantly higher conversion to open surgery as compared to those with body weight more than 5 kg (62.5 vs. 25.8 %, p = 0.049).

CONCLUSION

Successful thoracoscopic resection for congenital cystic lung lesions results in better post-operative outcomes. However, this technique remains technically challenging in patients with body weight less than 5 kg.

Eleven-year experience in thoracoscopic excision of bronchogenic cyst

Objectives: bronchogenic cysts are uncommon congenital cystic lesions. Most are incidentally detected and require surgical excision for histological diagnosis, symptom relief, and to prevent complications. Video-assisted thoracoscopic resection is preferable in suitable patients. In this study, we reviewed the clinical presentation, diagnosis, and thoracoscopic treatment of bronchogenic cysts.

Methods: from January 2001 to December 2011, 14 patients with bronchogenic cyst underwent thoracoscopic surgery for excision of the cyst. Their mean age was 24 years. Twelve patients were symptomatic (85.71%).

Results: the average maximum diameter of the cysts was 6.7 cm. The most common location of the cyst was the mediastinum ( n = 10, 71.4%). All bronchogenic cysts were completely excised. In 7 cases, the procedure was converted to thoracotomy. The mean hospital stay following thoracoscopic surgery was 4 days. There was no recurrence on follow-up.

Conclusions: thoracoscopic excision of a bronchogenic cyst should be considered the first-line therapeutic option. Proper preoperative case selection can prevent conversion to thoracotomy due to major pleural adhesions. There should be a low threshold for conversion to thoracotomy if complete excision of the cyst is not possible, because this is the main goal of treatment to prevent recurrence.

Bronchogenic cyst: best time for surgery?

BACKGROUND

Bronchogenic cyst (BC) is a benign congenital mediastinal tumor whose natural course remains unclear. In adults, most BCs are removed by thoracotomy after complications. Currently, prenatal diagnosis is generally feasible and allows an early thoracoscopic intervention. The purpose of this retrospective study was to ascertain the best time for the operation.

METHODS

Reviewed were 36 patients (11 children, 25 adults) with a BC managed from 2000 to 2011. Clinical history, cyst size, duration of hospitalization, preoperative and postoperative complications, and detection of inflammatory elements were compared (Student t tests) between pediatric and adult patients.

RESULTS

In the pediatric group, diagnosis was made prenatally in 7 patients, during the neonatal period in 2, and later in 2. Nine were asymptomatic. In the adult group, 20 patients were treated for complications. Thoracotomy was performed in 2 children and thoracoscopy in 9 (no conversion). A thoracoscopic operation was performed in 9 adults (2 conversions), and 17 adults required additional procedures (4 pericardial and 9 lung resections, 3 bronchial, and 1 esophageal sutures). The average length of hospitalization was 4.45 days for children (3.33 days in the thoracoscopic subgroup) and 8 days for adults. Mean maximal cyst diameter was 2.2 cm in children and 6.5 cm in adults (p < 0.10). Pathologic study revealed inflammatory reaction in 2 children (18%) vs 21 adults (84%; p < 0.001).

CONCLUSIONS

Early surgical resection of BCs provides better conservation of pulmonary parenchyma, a lower incidence of inflammatory lesions, and a reduced rate of complications, and should be proposed after prenatal diagnosis, between the 6th and 12th month of life.

Thoracoscopic vs open resection of congenital lung lesions: a meta-analysis

BACKGROUND

Several comparative studies are published evaluating both the open and the minimally invasive approaches for congenital lung lesions with inconsistent results. Our objective was to compare both procedures using systematic review and meta-analysis methodology.

METHODS

All publications describing both interventions were reviewed. The statistical analysis was performed using RevMan 5 software (Cochrane library).

MAIN RESULTS

No randomized trials were identified. Six retrospective studies were identified and were included in this study. There was no significant difference in overall complication rates between both techniques. Lengths of hospital stay as well as days with chest tube in place were longer with the open approach. There was no difference in the duration of surgery. Postoperative pain management was heterogeneous between studies. No study looked at long-term follow-up. Subgroup analysis for congenital cystic adenomatoid malformation of the lung was done.

CONCLUSIONS

Our results suggest no differences between thoracotomy versus thoracoscopy for congenital lung lesions with respect to overall complications and the duration of surgery. However, length of hospital stay and days with chest tube in place were longer after the open approach. Thoracoscopic resection is a safe and feasible alternative to open resection of congenital lung lesions in experienced hands.

Thoracoscopic resection of mediastinal bronchogenic cysts in adults

OBJECTIVE

The aim of this study was to discuss the diagnosis and determine the optimal thoracoscopic surgical treatment of mediastinal bronchogenic cysts.

METHODS

From May 1996 to April 2008, 13 consecutive patients with mediastinal bronchogenic cysts underwent thoracoscopic surgery at our institution. There were eight men and five women aged 16-74 years (mean age, 41.5 years).

RESULTS

In the majority of patients (69.2%), there were no clinical symptoms and the lesions were found incidentally by chest radiography that was performed as part of physical screening. Lesions were found in the posterior mediastinum in five patients (38.5%) and in the upper mediastinum in four (30.8%). In the histopathological examinations, ciliary epithelium was observed in 13 patients (100.0%), bronchial cartilage in 7 patients (53.8%), bronchial glands in 6 patients (46.2%), and smooth muscle in 5 patients (38.5%). No serious postoperative complications were observed. In 3 patients (23.1%), conversion to open thoracotomy was necessary due to major pleural adhesions and intraoperative vascular injury.

CONCLUSION

Thoracoscopic resection of mediastinal bronchogenic cyst is minimally invasive and has no serious postoperative complications, and should therefore be considered as the primary therapeutic option.

Clinical characteristics and management of intrathoracic bronchogenic cysts: a single center experience

Background

The aim of this study is to investigate the clinical characteristics and management of intrathoracic bronchogenic cysts.

Materials and Methods

Twenty-four (n=24) patients with intrathoracic bronchogenic cysts were treated surgically between August 1990 and December 2009 at our institution. Patients were divided into two groups by bronchogenic cyst location: mediastinal or intrapulmonary. Symptoms at diagnosis, radiologic findings, locations, surgical methods, pathological findings, and surgical outcomes were investigated retrospectively from consecutive patient medical records.

Results

There were 12 females (50.0%). The mean age was 26.8 (range, 5 to 64) years. The mean follow-up period was 27.3 (range, 1 to 121) months. There were 15 (62.5%) mediastinal and 9 (37.5%) intrapulmonary bronchogenic cysts. Symptoms occurred in 8 patients with mediastinal bronchogenic cysts (53.3%) and 5 patients with intrapulmonary bronchogenic cysts (55.6%) (p=1.000). On computed tomography (CT), 7 patients (46.7%) showed homogenous solid masses in mediastinal bronchogenic cysts and five (55.6%) patients exhibited heterogeneous cystic masses with air-fluid levels in intrapulmonary bronchogenic cystic masses. Open thoracotomy was performed in 17 (70.8%) patients, and video-assisted thoracic surgery was performed in 7 (29.2%) patients. On pathological findings, there were 16 (66.7%) complicated cysts, and in 13 symptomatic patients, 11 (84.6%) patients had complicated cysts. There was no operative death in this study. During the follow-up period, no recurrence was detected.

Conclusion

Intrathoracic bronchogenic cysts have a wide variety of clinical characteristics and radiologic findings. Even though some patients do not experience symptoms and signs caused by bronchogenic cysts, serious symptoms and complications may develop with the passage of time.

Thoracoscopic resection of a paraaortic bronchogenic cyst

Bronchogenic mediastinal cysts (BMC) represent 18% of primitive mediastinal tumors and the most frequent cystic lesions in this area. Nowadays, BMC are usually treated by VATS. However, the presence of major adhesions to vital structures is often considered as an unfavourable condition for thoracoscopic treatment. The authors report the thoracoscopic treatment of a BMC having dense adhesions to the aortic arch. Diagnosis and surgical treatment is described. Review of the literature and surgical options on this topic are discussed.

Thoracoscopic repair of congenital diaphragmatic hernia in infancy

BACKGROUND

Minimally invasive surgical techniques, specifically the thoracoscopic approach, have been applied to congenital diaphragmatic hernia (CDH) with varying outcomes from selected centers. The aim of our study was to examine the rate of successful completion and compare outcomes between open and thoracoscopic approaches in CDH repair.

METHODS

We performed a retrospective analysis of infants with CDH repair (From February 2004 to January 2008). Patients were divided into thoracoscopic and open groups, based on operative approach. We analyzed demographic, clinical, and hospitalization characteristics to compare the completion rate and outcomes in these two groups.

RESULTS

Analysis of 31 infants with CDH (14 thorascocopic and 17 open) demonstrated no differences in sex (P = 0.132), age (P = 0.807), birthweight (P = 0.256), weight at operation (P = 0.647), pulmonary hypertension (P = 0.067), preoperative intensive care unit (ICU) days (P = 0.673), ventilator days (P = 0.944), or use of a patch (P = 0.999) between the groups. Seventy-nine percent of thoracoscopic operative approaches were completed successfully. There was a significant difference between the open and thoracoscopic groups with respect to estimated gestational age (39 versus 36.5 weeks; P = 0.006) and operating room time (70 versus 145 minutes; P = 0.004). The total (P = 0.662), ICU (P = 0.889), and postoperative (P = 0.619) length of stay and days on ventilator (P = 0.705), as well as days until initial enteral feeds (P = 0.092), were not significantly different between groups. There were no deaths and no evidence of recurrence, with a mean follow-up of 346 days.

CONCLUSIONS

In our early experience, the thoracoscopic approach for congenital diaphragmatic hernia repair was completed in 80% of our patient population with minimal exclusion criteria. Further study, with larger sample sizes, is needed to ascertain differences in outcomes, such as length of stay and initiation of enteral feeding.

Thoracoscopic versus open resection of congenital lung lesions: a case-matched study

PURPOSE

The purpose of the study was to compare the outcomes in children undergoing thoracoscopic versus open resection of congenital lung lesions.

METHODS

Retrospective review of 12 consecutive children (<3 years of age) undergoing thoracoscopic resection of a congenital lung lesion between 2004 and 2005 was performed. Intraoperative and early postoperative results were compared with randomly selected age- and sex-matched (2:1) patients undergoing thoracotomy between 2000 and 2005.

RESULTS

Twelve children underwent thoracoscopic resection and were compared with 24 that underwent thoracotomy. Seventy five percent of the lesions in both groups were congenital cystic adenomatoid malformations. There were no major intraoperative complications. Two thoracoscopic procedures were converted to a thoracotomy. Perioperative outcomes including operative time, length of stay, duration and volume of chest tube drainage, and dose and duration of intravenous opioids were similar for the procedures. However, children undergoing thoracoscopic procedures were less likely (odds ratio = 0.07) to have received adjunctive regional anesthesia. Overall morbidity was 33% thoracoscopic and 25% open (P = .70).

CONCLUSION

Thoracoscopic resection is a safe and feasible alternative to open resection of congenital lung lesions. Examination of long-term advantages of the thoracoscopic approach such as decreased risk of chest wall deformity and scoliosis and improved cosmesis will require longer follow-up.