Embolization versus surgical resection of pulmonary sequestration: clinical experiences with a thoracoscopic approach

A Rare Case of Extralobar Bronchopulmonary Sequestration

Bronchopulmonary sequestration is a rare developmental abnormality of the pulmonary system. It is a pulmonary malformation and is defined as lung tissue without connection to the tracheobronchial tree with a systemic blood supply. We present a case of an eight-month-old infant with prenatally diagnosed bronchopulmonary sequestration. At six months of age, an extralobar sequestration with a feeding vessel from truncus coeliacus and venous drainage to vena thoracica interna sinistra was diagnosed from a CT scan of the lung. Thoracoscopy was performed with the identification of intradiaphragmatic sequestration, conversion to thoracotomy with resection of the lesion, and repair of the diaphragm. Postoperative follow-up revealed no complications. Intradiaphragmatic bronchopulmonary sequestration is an extremely rare congenital anomaly. The gold standard for diagnostic clarification is computed tomography. The preferred approach for surgical treatment is transthoracic.

Untreated pulmonary sequestration with recurrent superinfection -supporting COPD development in a 42 year old male patient

BACKGROUND

Pulmonary sequestration is a congenital malformation in which nonfunctional lung tissue develops without connection to the bronchial system. The main complication is the occurrence of recurrent pneumonia.

CASE PRESENTATION

We describe the case of a patient who was incidentally diagnosed with PS as part of the diagnostic algorithm for community-acquired pneumonia. Due to the relatively late diagnosis, the recurrent bronchopulmonary was conducive to the development of COPD and pulmonary emphysema. For prognostic reasons, surgical resection was performed by posterolateral thoracotomy.

CONCLUSIONS

Although cigarette smoking is the main risk factor for developing COPD, recurring lung infections may have a synergistic effect. Sometimes recurrent infections are caused by a congenital malformation. Especially in adults who have had recurrent pneumonia since childhood.

Neonatal and Infant Lung Disorders: Glossary, Practical Approach, and Diagnoses

A multitude of lung disorders ranging from congenital and genetic anomalies to iatrogenic complications can affect the neonate or the infant within the first year of life. Neonatal and infant chest imaging, predominantly by plain radiography and computed tomography, is frequently employed to aid in diagnosis and management; however, these disorders can be challenging to differentiate due to their broad-ranging, and frequently overlapping radiographic features. A systematic and practical approach to imaging interpretation which includes recognition of radiologic patterns, utilization of commonly accepted nomenclature and classification, as well as interpretation of imaging findings in conjunction with clinical history can not only assist radiologists to suggest the diagnosis, but also aid clinicians in management planning. The contents of this article were endorsed by the leadership of both the World Federation of Pediatric Imaging (WFPI), and the International Society of Pediatric Thoracic Imaging (ISPTI).

Unexpected pulmonary sequestration in a pregnant patient

A pregnant woman in her early 30s, at 20 weeks of gestational age, presented with recurrent haemoptysis, pleuritic chest pain and a productive cough of 6 months duration. She underwent CT pulmonary angiogram which demonstrated right pulmonary sequestration and right-sided consolidation. Pre-existing pulmonary comorbidities such as chronic inflammation, structural abnormalities or weakened blood vessels within the lungs can encourage the growth of abnormal blood vessels. During pregnancy, these dynamics can be further aggravated by increasing cardiac output to promote blood flow to the placenta and increasing oxygen delivery to the developing foetus. These changes likely cause increased blood flow to the pulmonary sequestration, resulting in haemoptysis. The patient was treated conservatively for community-acquired pneumonia with a course of oral amoxicillin 500 mg three times a day for 5 days, and she is doing well on follow-up.

Case report: A unique quadruple coexisting anomaly-scimitar syndrome, atrial septal defect, vascular ring, and pulmonary sequestration

The article describes a successful clinical outcome in the case of a 5-month old female with a diagnosis of incomplete vascular ring of aberrant right subclavian artery and ostium secundum atrial septal defect associated with partial anomalous pulmonary venous return of scimitar syndrome type, coexisting with right pulmonary sequestration. During hospitalization, surgical correction of the heart defect and resection of the lung sequestration were performed. To the best of our knowledge, described constellation of defects is a unique phenomenon, posing a challenge for complex treatment and disease management.

Management of Congenital Lung Malformations

Congenital lung malformations represent a spectrum of lesions, each with a distinct cause and tailored clinical approach. This article will focus on the following malformations: congenital pulmonary airway malformations, formally known as congenital cystic adenomatoid malformations, bronchopulmonary sequestration, congenital lobar emphysema, and bronchogenic cyst. Each of these malformations will be defined and examined from an embryologic, pathophysiologic, and clinical management perspective unique to that specific lesion. A review of current recommendations in both medical and surgical management of these lesions will be discussed as well as widely accepted treatment algorithms.

Intralobular pulmonary sequestration in the middle lobe supplied by a right internal mammary artery: a case report

Background

Pulmonary sequestration (PS) is a rare congenital malformation that is more common in the left lower lobe, and the thoracic aorta is the most common arterial supply.

Case presentation

We describe a case of a 67-year-old man with a chief complaint of intermittent cough and hemoptysis who had been diagnosed by multidetector computed tomography angiography with right middle lobe intralobular pulmonary sequestration supplied by a right internal mammary artery. Finally, he underwent middle pulmonary lobectomy with normal postoperative recovery.

Discussion

This is a rare intralobular pulmonary sequestration case for a feeding artery from the right internal mammary. Multidetector computed tomography angiography should be performed for diagnosis and preoperative evaluation once pulmonary sequestration is suspected.

Video-assisted thoracoscopic surgery lobectomy for giant intralobar pulmonary sequestration: A case report

RATIONALE

Pulmonary sequestration, which can be divided into 2 main types: intralobar pulmonary sequestration (IPS) and extralobar pulmonary sequestration, is an uncommon congenital condition for which surgical resection is usually indicated. Video-assisted thoracoscopic surgery, as compared with open thoracotomy, has increasingly become the preferred operative procedure in the treatment of PS, owing to less postoperative pain and faster recovery. This report describes a rare and challenging case with a giant IPS undergoing video-assisted thoracic lobectomy.

PATIENT CONCERNS

A 39-year old woman suffered from recurrent pneumonia for nearly 3 years. An enhanced computed tomography scan performed in our hospital revealed a 12.0 cm × 10.0 cm-sized IPS in the left lower lobe, supplied by an 8-mm aberrant artery originating from the descending thoracic aorta.

DIAGNOSIS

Histology of the resected lobe confirmed the diagnosis of giant intralobar pulmonary sequestration associated with infection.

INTERVENTIONS

Thoracoscopic left lower lobectomy was performed.

OUTCOMES

The patient has been discharged from the hospital on the ninth day after surgery with an uneventful recovery, she was in good health after a 1-year follow-up.

LESSONS

Although full of challenges, thoracoscopic lobectomy for giant IPS is a safe and feasible surgical procedure associated with reduced surgical trauma and postoperative pain as well as improved cosmetic results compared with traditional thoracotomy.

Adult Presentation of Anomalous Pulmonary Artery from the Descending Aorta: A Rare Cause of Exertional Chest Pain

Case Presentation: A 20-year-old female presented to the emergency department for evaluation of exertional, right-sided chest pain. The patient underwent a computed tomography angiogram of her chest as part of her workup, demonstrating the right lower-lobe pulmonary artery arising from the abdominal aorta. Discussion: Anomalous pulmonary arterial supply is exceedingly rare. In adult patients, it is likely to be found incidentally during workup for more common medical conditions. Symptoms may include chest pain, exertional dyspnea, or hemoptysis. The high pressure of systemic blood in a low-pressure pulmonary system can result in right heart strain, pulmonary hypertension, and high-output cardiac failure.

Ten cases of intradiaphragmatic extralobar pulmonary sequestration: a single-center experience

Background

Intradiaphragmatic extralobar pulmonary sequestration (IDEPS) is a rare type of pulmonary sequestration (PS). The purpose of this study is to assess diagnosis and operative treatment of IDEPS.

Methods

Patients with PS who were diagnosed and treated in our center from January 2015 to December 2020 were analyzed retrospectively to identify patients with IDEPS.

Results

Totally, 215 patients with PS were treated surgically, including 10 cases with IDEPS. Prenatal ultrasounds and postnatal-enhanced CT showed the presence of IDEPS in four cases and in seven cases, respectively. The three-dimensional (3D) reconstruction software was performed perfectly to identify the location of the lesions in 10 cases. The surgeries were performed smoothly by laparoscopic surgery in one case, video-assisted thoracic surgery (VATS) in five cases and Da Vinci robot-assisted thoracoscopic surgery (DVRATS) in four cases. In the VATS group, the average operative duration, intraoperative blood loss volume, length of stay after operation, and postoperative thoracic catheter indwelling duration were 48 min, 3.8 mL, 6.4 days and 2.2 days, respectively. That of the DVRATS group were 80 min, 3.5 mL, 4.3 days and 1.5 days, respectively. No side effects had appeared.

Conclusions

The 3D reconstruction software was proven to be capable in assisting the assessment of IDEPS. We suggested early surgery to treat IDEPS, and the best path was accessing the mass from the chest. Both DVRATS and VATS for the treatment of an IDEPS are safe, feasible, and effective. Furthermore, DVRATS provides a 3D magnified view, more flexibility and precision.

Debating the embolization of a large aberrant systemic artery for pulmonary sequestration using an Amplatzer duct occluder: a case report and literature review

Here, we report two rare cases of pulmonary sequestration that were fed by large systemic arteries and embolized with a large Amplatzer duct occluder and their 3-year follow-up, and we discuss the efficacy and safety of the embolization of a large aberrant systemic artery to pulmonary sequestration using an Amplatzer duct occluder. A 9-year-old boy complained of chest pain for 1 month, and a 6-year-old boy initially complained of recurrent cough for 3 months. A series of examinations was launched to evaluate any possible malformation or abnormalities in the patients. Chest CT and CTA identified a right lower pulmonary sequestration with infection. After admission, transcatheter device occlusion was planned after essential antibiotic treatment, and postoperative infection prevention and anti-inflammatory treatment were given. In the following 2 years of follow-up, neither of the children had recurrent chest pain, cough or other related symptoms. However, the CT follow-up demonstrated that a residual mass was visible in both patients. The same chest scan section revealed slight reductions in lung lesions from 38.344 cm2 to 37.119 cm2 (3% reduction) and 14.243 cm2 to 13.178 cm2 (7.5% reduction) for each patient. No follow-up data demonstrated the long-term clinical outcomes of the residual lesion. We do not recommend that embolization be performed for large pulmonary sequestration lesions with an aberrant artery larger than 6 mm that is planned to receive a device larger than 10 mm, as their outcomes showed a higher possibility of rebuilding the vascularization network feeding the pulmonary sequestration, indicating a higher risk for long-term complications.

Intralobar Pulmonary Sequestration Presenting as Hemothorax Secondary to Spontaneous Pneumothorax: Case Report and Literature Review

INTRODUCTION

Patients with pulmonary sequestration (PS), a rare congenital lung malformation, are mostly asymptomatic. Recurrent localized infection is a major complication, while sudden hemothorax is extremely rare. We present a case of intralobar PS presenting as hemothorax secondary to spontaneous pneumothorax and comprehensively review the relevant literature.

CASE REPORT

A 16-year-old male presented with chest pain after strenuous exercise. Chest X-ray showed a moderate pneumothorax. After admission and conservative treatment, he developed dizziness, amaurosis, and urinary incontinence. Bedside chest X-ray suggested a massive pleural effusion, and hemothorax was further identified via catheter drainage. Contrast-enhanced computed tomography was performed, and no abnormal blood vessels or leakage of contrast agent were observed. As the hemoglobin level continued to drop, exploratory thoracoscopic surgery was performed immediately. The abnormal systemic artery supplying the lung tissue was found to be ruptured; therefore, ligation of the abnormal artery with resection of the diseased lung tissue was performed. Pathological examination revealed non-specific manifestations of PS. He was followed up for 1 year without related complications.

CONCLUSION

Our case suggests that the abnormal supply vessels of PS are unstable, which may cause sudden hemothorax. Therefore, patients with PS should undergo surgery promptly after diagnosis. In patients with hemothorax, we should consider the diagnosis of PS; however, contrast-enhanced computed tomography or angiography cannot confirm the diagnosis in all cases. Surgical intervention is recommended in emergency settings.

Elevated tumor markers in a benign lung disease

BACKGROUND

This study aimed to determine the underlying pathophysiologic mechanism of elevated carbohydrate antigen 19-9 (CA19-9) in pulmonary sequestration (PS) patients.

MATERIALS AND METHODS

Four pulmonary sequestration patients, 12 pneumonia patients and 12 healthy adult volunteers were prospectively studied. Specimens from another 34 pulmonary sequestration patients were retrospectively analyzed. Serum CA19-9 levels of 4 patients were tested before and 1 week, 1 month and 3 months after surgery. The CA19-9 levels of 12 pneumonia patients and 12 healthy adult volunteers were tested as controls. The expression and localization of CA19-9 in diseased lesions and corresponding normal lung tissues were analyzed by Immunohistochemical (IHC). Hematoxylin-eosin (HE) staining was performed to observe the pathological changes in pulmonary sequestration tissues.

RESULTS

Serum CA19-9 levels were significantly higher in the 4 patients (797.3 ± 316 IU/ml) than in the pneumonia patients (10.07 ± 5.01 IU/ml) and healthy volunteers (9.85 ± 4.12 IU/ml). In addition, serum CA19-9 levels decreased dramatically after the focus was removed. Positive staining of CA19-9 was found in 70% (24/34) of pulmonary sequestration tissues, and CA19-9 was mainly expressed in the bronchial mucus. In the 4 diseased lesions, deformed alveolar structure and inflammatory cell infiltration were observed, and the degree of damage was positively correlated with serum CA19-9 levels.

CONCLUSIONS

CA19-9 could be generated by abnormal columnar epithelia in pulmonary sequestration tissues and was transported into circulation after alveoli damage. CA19-9 could serve as an adjuvant diagnostic marker in pulmonary sequestration.

Intralobar Pulmonary Sequestration with Anomalous Artery Arising from the Celiac Trunk

Pulmonary saequestration is a rare congenital malformation characterized by a dysplastic portion of lung parenchyma supplied by an anomalous artery originating from the aorta or its branches. The worldwide incidence of pulmonary sequestration among all congenital lung malformations in children ranges from 1.5% to 6.4%. There are two main types of pulmonary sequestration according to the localization of the malformation, i.e., intrapulmonary sequestration (dysplastic tissue located inside a lobe of the normal lung) and extrapulmonary sequestration. Our case presentation aims to make physicians aware of this rare anomaly which may be difficult to diagnose because of its oligosymptomatic course prior to first presentation. We present the case of a 10-year-old girl who suffered from a second episode of prolonged pneumonia of the left lower lobe. Contrast-enhanced-computed-tomography (CT) scan of the thoraco-abdominal segment of the aorta and its branches revealed intrapulmonary sequestration localized at the left lower lobe of the lung. The intrapulmonary sequester was perfused by a large artery arising from the celiac trunk. The girl underwent open surgery with ligation of the anomalous feeding artery and atypical pulmonary resection of the affected area of the left lower lobe. Postoperatively, the child recovered without any complications.

Preoperative Embolization Facilitates Segmental Resection of Pulmonary Sequestration in an Infant

The most common congenital lung malformations are congenital pulmonary airway malformations and pulmonary sequestrations. Many surgeons advocate resection to prevent complications of infection, malignancy, and pneumothorax. The standard of care is lobectomy, but segmentectomy and embolization alone have been reported. These methods avoid the complications of lobectomy but are not widely practiced due to concerns about incomplete resection or involution of the lesion. We present a novel approach to the treatment of a pulmonary sequestration in a 7-month-old male using preoperative embolization followed by a sublobar pulmonary resection. The embolization clearly demarcated the affected lung intraoperatively, thereby facilitating complete removal of the lesion with a segmental lung resection rather than complete lobectomy.

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.

Congenital lung lesions

Diagnosis and management of congenital lung malformations has evolved dramatically over the past several decades. Advancement in imaging technology has enabled earlier, more definitive diagnoses and, consequently, more timely intervention in utero or after birth, when indicated. These advancements have increased overall survival rates to around 95% from historical rates of 60%. However, further refinement of diagnostic technique and standardization of treatment is needed, particularly as the increased sensitivity of diagnostic imaging results in more frequent diagnoses. In this article, we provide an updated review of the diagnostic strategies, management, and prognosis of congenital lung malformations.

Congenital Lung Malformations

Congenital lung malformations (CLM) comprise a spectrum of anatomical anomalies of the lungs and respiratory tree. The prenatal growth pattern of CLMs is unpredictable with larger lesions causing life-threatening complications, such as hydrops fetalis, and smaller lesions remaining asymptomatic and potentially regressing. The most common CLMs are congenital pulmonary adenomatoid malformations, bronchopulmonary sequestrations, congenital lobar emphysema, and bronchogenic cysts. All these lesions have clinically similar presentations when symptomatic, but pathophysiologic differences that must be considered when evaluating and treating. This article reviews the most common CLMs, their pathophysiology, clinical presentation, diagnostic considerations, and current literature on the controversies surrounding CLM management. [Pediatr Ann. 2019;48(4):e169-e174.].

[Pulmonary intralobar sequestration in adults: Evolution of surgical treatment]

BACKGROUND

Until now, the traditional procedure to treat intralobar pulmonary sequestration (ILS) in adults has been a lobectomy performed by open thoracotomy. We have reviewed our data to observe if the surgical management of these lesions has evolved over the last years.

METHODS

We retrospectively reviewed the records of the patients who were operated for an ILS either by posterolateral thoracotomy (PLT group), or by thoracoscopy (TS group) between 2000 and 2016.

RESULTS

Eighteen patients were operated for a SIL during this period. Prior to 2011, all resections were performed by thoracotomy (n=6) and after 2011 the surgical approach was either a thoracotomy (n=5) or a thoracoscopy (n=7). There was one conversion because of dense pleural adhesions and this patient was integrated in the PLT group for further analysis. ILS were more frequently encountered on the left side (n=12, 66.6 %) than on the right one (n=6, 33.3 %) and exclusively in the lower lobes. All patients of the PLT group underwent a lobectomy. In the TS group, 5 patients underwent a sublobar resection (2 segmentectomiesS⁹⁺¹⁰, 1 basilar segmentectomy and 2 atypical resections). There was no mortality. In the PLT group, 5 patients (45 %) had complications versus one patient (14 %) in the TS group. The mean hospital stay was 7.4 days in the PLT group versus 5.4 days in the TS group.

CONCLUSIONS

These data confirm that ILS can be safely treated by a sublobar resection that should be performed, whenever possible, thoracoscopically.

Congenital Lung Malformations: Unresolved Issues and Unanswered Questions

Advances in prenatal and postnatal diagnosis, perioperative management, and postoperative care have dramatically increased the number of scientific reports on congenital thoracic malformations (CTM). Nearly all CTM are detected prior to birth, generally by antenatal ultrasound. After delivery, most infants do well and remain asymptomatic for a long time. However, complications may occur beyond infancy, including in adolescence and adulthood. Prenatal diagnosis is sometimes missed and detection may occur later, either by chance or because of unexplained recurrent or persistent respiratory symptoms or signs, with difficult implications for family counseling and substantial delay in surgical planning. Although landmark studies have been published, postnatal management of asymptomatic children is still controversial and needs a resolution. Our aim is to provide a focused overview on a number of unresolved issues arising from the lack of an evidence-based consensus on the management of patients with CTM. We summarized findings from current literature, with a particular emphasis on the vigorous controversies on the type and timing of diagnostic procedures, treatments and the still obscure relationship between CTM and malignancies, a matter of great concern for both families and physicians. We also present an algorithm for the assessment and follow-up of CTM detected either in the antenatal or postnatal period. A standardized approach across Europe, based on a multidisciplinary team, is urgently needed for achieving an evidence-based management protocol for CTM.

Congenital pulmonary vascular anomalies

Congenital pulmonary vascular anomalies are typically found in infancy or early childhood however, some may remain silent and present in adult patients. Anomalies may be separated into anatomic categories based on involvement of the pulmonary arteries, pulmonary veins or both with or without involvement of the lung parenchyma. Association with congenital heart disease and other syndromes is very common. Computed tomography (CT) and magnetic resonance imaging (MRI) are both invaluable at assessment of these anomalies allowing for both diagnosis and detailed treatment planning. This article will focus primarily on the use of CT, as the high resolution evaluation of the lung parenchyma is also important in many of these conditions. In young patients especially, rapid heart rate and concerns of radiation exposure are important considerations when performing CT. This article will discuss scan techniques as well as clinical diagnostic considerations and basic endovascular treatment of congenital pulmonary vascular anomalies.

Intralobar pulmonary sequestration originating from the intercostal arteries treated with surgical resection

Intralobar pulmonary sequestration originating from the intercostal arteries is rarely reported. Herein, we report an unusual case of a 56‐year‐old male patient with intralobar pulmonary sequestration supplied from the intercostal arteries on the left lower lobe who presented after a month of a repeated cough and massive hemoptysis. Although transcatheter arterial embolization was performed three times, the patient's symptoms were not relieved. A left lower lobectomy was performed with video‐assisted thoracic surgery. At the six‐month follow‐up after surgery, the patient had recovered well without any hemoptysis. Therefore, surgical resection with lobectomy may be a better alternative to transcatheter arterial embolization for the treatment of intralobar pulmonary sequestrations arising from the intercostal arteries. To our knowledge, this is the second reported case of intralobar pulmonary sequestration arising from the intercostal arteries.

Adult pulmonary intralobar sequestrations: changes in the surgical management

Background

Until now, the traditional procedure to treat intralobar pulmonary sequestration (ILS) in adults has been a lobectomy performed by open chest surgery. We have reviewed our data to determine whether the surgical management of these lesions has evolved over the last years.

Methods

We retrospectively reviewed the records of patients who were operated on for an ILS by either posterolateral thoracotomy (PLT group), or by thoracoscopy (TS group) between 2000 and 2016.

Results

Eighteen patients were operated on for a ILS during this period. Before 2011, all resections were performed by thoracotomy (n=6) and after 2011 the approach was either a thoracotomy (n=5) or a thoracoscopy (n=7). There was one conversion because of dense pleural adhesions and this patient was integrated in the PLT group for further analysis. ILS presented more frequently on the left side (n=12, 66.7%) than on the right one (n=6, 33.3%) and exclusively in the lower lobes. All the PLT group patients underwent a lobectomy. In the TS group, five patients underwent a sublobar resection (2 segmentectomies S9+10, 1 basilar segmentectomy and 2 atypical resections). There was no mortality. In the PLT group, 5 patients (45%) had complications versus one patient (14%) in the TS group. The mean hospital stay was 7.4 days in the PLT group versus 5.4 days in the TS group.

Conclusions

These data confirm that ILS can be safely treated by a sublobar resection that should be performed, whenever possible, without opening the chest.

Retrospective review of the diagnosis and treatment of pulmonary sequestration in 28 patients: surgery or endovascular techniques?

Background

Pulmonary sequestration (PS) is a rare congenital pulmonary malformation. In this study, we aimed to retrospect and evaluate the diagnosis, treatment, and outcomes of PS in 28 patients at our institute.

Methods

The files of 28 patients with PS who were treated with surgery (21 cases) or endovascular intervention (7 cases) between May 2005 and June 2016 from a single institute were retrospectively reviewed. The following data of all patients were analyzed: age, sex, clinical symptoms, diagnostic methods, operative techniques, and treatment outcomes.

Results

Twenty-eight patients, 15 male and 13 female, with a median age of 42.5 underwent operative intervention for PS. Twenty-one patients showed preoperative symptoms including cough, expectoration, hemoptysis, chest and/or back pain, and fever. General chest computed tomography (CT) scanning; percutaneous needle biopsy, bronchoscopy, enhanced CT scanning, and CT angiography (CTA) were used as diagnostic methods. Twenty-one patients were diagnosed preoperatively by enhanced CT scanning and CTA; seven patients were confirmed by surgery. Twenty-one patients underwent surgery (15 cases via thoracotomy and 6 cases via video-assisted thoracic surgery), seven patients underwent interventional therapy (three cases via endovascular embolization and four cases via thoracic aortic endovascular stent-graft exclusion). Three patients had a complication in surgery group (intraoperative hemorrhage in two patients and postoperative hydropneumothorax in one patient) and two patients had post-embolization syndrome in interventional group (fever and pain at embolism site). During the follow-up period ranging from 6 to 84 months, no recurrences or further complications were observed in two groups.

Conclusions

Enhanced CT or CTA may be a potential approach for the diagnosis of PS. Surgical resection for PS is the major treatment approach. Endovascular embolization of PS could be considered when pulmonary lesion is small-sized. Endovascular exclusion could be used to treat combined arterial aneurysm and dissection of PS.

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).

Congenital Lung Malformations: Shifting from Open to Thoracoscopic Surgery

BACKGROUND

Over the years the need for surgical treatment, timing of intervention, and the type of surgical approach have been discussed, but the treatment of congenital lung malformations remains controversial. The aim of this study was to compare the thoracotomy approach with the thoracoscopic technique by evaluating different surgical outcomes (duration of surgery, postoperative hospital stay, and complications).

METHODS

All patients operated from January 2011 to March 2015 for suspected congenital cystic lung were included in the study. Patients treated for congenital lobar emphysema and tracheobronchial neoplasms were excluded from the study.

RESULTS

In the analyzed period, 31 asymptomatic patients were treated: 18 lung resections were performed with thoracotomy (Group A) and 13 with the thoracoscopic approach (Group B). No significant differences were observed between the age and weight at surgery, length of the procedures, complications, and the need for postoperative intensive care between the two groups. The postoperative hospital stay in Group A was twice that for Group 2 (p = 0.0009).

CONCLUSION

Comparing thoracoscopic surgery with the traditional open approach, we confirmed the superiority of minimally invasive treatment in terms of postoperative hospital stay. Common technical recommendations can help pediatric centers to develop the thoracoscopic approach for the treatment of congenital pulmonary malformations.

Use of Amplatzer Vascular Plugs for the treatment of combined extralobar and intralobar pulmonary sequestration in a 5-year-old child

Pulmonary sequestration is a rare congenital anomaly that can be asymptomatic or present with recurrent infections, respiratory symptoms, or rarely heart failure. Sequestration is classified as intralobar or extralobar on the basis of whether there is separation from normal lung tissue by its own visceral pleura. Classically, patients are treated with surgical resection. We present a case of multivessel, combined intralobar and extralobar pulmonary sequestration treated with transcatheter embolisation.

Endovascular embolization prior to surgical resection of symptomatic intralobar pulmonary sequestration in an adult

Intralobar pulmonary sequestration is a rare congenital malformation, conventionally managed by surgical resection. Recently, the endovascular embolization has been proposed for the definite treatment of this disease. Additionally, preoperative embolization of aberrant arteries to minimize the risk of serious intraoperative haemorrhage has also been described. We report the case of 43-year old female patient who presented with cough and haemoptysis, and was successfully treated with endovascular embolization followed by a Video-assisted thoracoscopic wedge resection.

Congenital cystic lesions of the lung

Congenital cystic lesions of the lung are present in 1 in 10,000-35,000 births and present as a spectrum of anomalies. Majority of these cystic lesions comprise congenital cystic adenomatoid malformations, pulmonary sequestrations, congenital lobar emphysema, and bronchogenic cysts. Most of these lesions are nowadays detected antenatally, however some will present either in the newborn or during later childhood. A review of the aetiology, classification, natural history, investigations, and treatment of congenital cystic lung lesions is discussed.

Uncommon etiology of chest pain: pulmonary sequestration

Chest pain is a common presenting symptom in the emergency department. After ruling out emergent causes, emergency physicians need to identify and manage less commonly encountered conditions. Pulmonary sequestration (PS) is a rare congenital condition involving pulmonary parenchyma. In PS, a portion of non-functional lung tissue receives systemic blood supply from an anomalous artery. While most individuals with PS present in early life with symptoms of difficulty feeding, cyanosis, and dyspnea, some present later with recurrent pneumonia, hemoptysis, or productive cough. In this report, we present a case of PS in an adult with acute onset pleuritic chest pain.

A rare case of bilateral pulmonary sequestration managed with embolization and surgical resection in a patient

In this article, we report a rare case of a 22-year-old male with bilateral pulmonary sequestration, treated with embolization and surgical resection. The initial plan involved staged bilateral lobectomy for both lungs and prophylactic embolization of feeding vessels for preventing unexpected hemorrhage during operation. Symptomatic right lower lobe was resected with video-assisted thoracic surgery after embolization, and the patient refused surgery of left lower lobe upon symptomatic relief. The two-year follow-up examination revealed that the patient was healthy and had no relevant discomfort.