Diagnosis and management of intradiaphragmatic extralobar pulmonary sequestration: a report of 11 cases

Imaging Diagnosis for Intradiaphragmatic Pulmonary Sequestration: A Pilot Study

OBJECTIVES

Extrapulmonary sequestration (EPS) within the diaphragm (ID-EPS) is rare and requires additional procedures such as incision or detachment of the diaphragm from the lesion for diagnosis. This study aimed to describe the imaging findings and evaluate the diagnostic accuracy of ultrasonography and computed tomography (CT) for ID-EPS.

MATERIAL AND METHODS

Split diaphragm sign, shape of lesion edge, drainage vein into intra-abdomen on ultrasound and CT, and lesion characteristics on ultrasound were compared between patients with ID-EPS and with above-diaphragm EPS (AD-EPS) using Fisher's exact test.

RESULTS

Three and nine patients were diagnosed with ID-EPS and AD-EPS, respectively. Significant differences were observed between the two groups in the split diaphragm sign on ultrasound (presence/absence in patients with ID-EPS vs AD-EPS, 2/1 vs 0/9, P = .046), shape of lesion edge on ultrasound/CT (round/beak in patients with ID-EPS vs AD-EPS, 3/0 vs 0/9, P = .005 on both CT and ultrasound), lesion characteristics on ultrasound (presence/absence of cystic area within lesion in patients with ID-EPS vs AD-EPS, 0/3 vs 7/2, P = .046), and the drainage vein into the abdomen on CT (presence/absence in patients with ID-EPS vs AD-EPS; 2/1 vs 0/9, P = .046). No drainage veins were visualized in the abdomen on ultrasonography and no significant differences in the presence/absence of the split-diagram sign on CT (presence/absence in patients with ID-EPS vs AD-EPS and ID-EPS; 0/3 vs 0/9, P > .999; 1/2 vs 0/9, P = .250) were observed between the two groups.

CONCLUSION

A combination of postnatal ultrasonography and CT was useful in predicting EPS located within the diaphragm.

Intradiaphragmatic pulmonary sequestrations: a surgical challenge. Case series

Bronchopulmonary sequestrations (BPSs) are rare congenital anomalies characterized by non-functioning embryonic lung tissue receiving anomalous blood supply. They are most commonly located within the thorax (supradiaphragmatic) or into the abdominal cavity (infradiaphragmatic). Intradiaphragmatic extralobar BPs (IDEPS) are an exceptionally rare finding, representing a diagnostic and operative challenge. We report three cases of IDEPS and their surgical management, describing our experience and approach to such rare clinical entities. From 2016 to 2022, we treated 3 cases of IDEPS. Surgical techniques, histopathological findings and clinical outcomes were retrospectively evaluated for each case and compared. Three different surgical techniques were used to approach each lesion, from open thoracotomy to a combined laparoscopic and thoracoscopic approach. Histopathological analysis of the specimens revealed hybrid pathological features, proper of both congenital pulmonary airway malformation (CPAM) and extralobar pulmonary sequestration. IDEPS represent a surgical challenge for pediatric surgeons, given their complex surgical planning. In our experience, the thoracoscopic approach is safe and feasible when performed by trained surgeons, even though a combined thoracoscopic-laparoscopic approach allows for optimal vessels control. The presence of CPAM elements within the lesions supports their surgical removal. Additional studies are required to better characterize IDEPS and their management.

Thoracoscopic repair of neonatal left diaphragmatic hernia with sac combined with both extralobar pulmonary sequestration and congenital pulmonary airway malformation

Intradiaphragmatic extralobar pulmonary sequestration (IDEPS) is considered to be very rare among extralobar pulmonary sequestration (EPS), and IDEPS combined with congenital diaphragmatic hernia (CDH) with sac is extremely rare. The patient was a neonatal girl. Left-sided CDH with a hernia sac was diagnosed based on computed tomography (CT). Thoracoscopic repair was planned for the 5th day after birth. Left CDH with sac was recognized on the posterolateral side and isolated EPS was recognized on the sac. The hernia sac, including the EPS, was resected, and the diaphragm defect was closed. The resected specimen consisted of fibrous connective tissue and pulmonary sequestration (PS) connected with the sac. It was diagnosed as the hybrid form, with features of both type 2 congenital pulmonary airway malformation (CPAM) and EPS. The postoperative course was uneventful. At 1 year and 9 mo after the operation, no recurrence of herniation or laterality of the diaphragm was recognized.

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.

The clinical management of extralobar pulmonary sequestration in children

INTRODUCTION

The treatment of extralobar pulmonary sequestration (ELS) remains divergent. This study aims to demonstrate the characters of ELS in children for optimal clinical management in the future.

MATERIAL AND METHODS

A retrospective analysis was conducted for ELS patients' treatment in our center from January 2013 to April 2020.

RESULTS

In total, 85 patients were included, containing 70 upper-diaphragmatic, 7 intra-diaphragmatic, and 8 infra-diaphragmatic ELS. Eight patients' pathology results showing inflammation without symptoms preoperation and two patients had chest pain for torsion. All the upper-diaphragmatic and intra-diaphragmatic ELS patients accepted thoracoscopic surgery resection. The intraoperative operation time and blood loss volume of intra-diaphragmatic ELS were significantly more than that of the upper-diaphragmatic (40.14 ± 9.92  vs. 23.07 ± 6.79 min; 9.29 ± 3.45  vs. 3.18 ± 4.94 ml; all p < .05). No chest tubes were inserted in both subgroups. No complications were found in the postoperative follow-up of operative ELS patients at least 3 months. A total of eight infra-diaphragmatic ELS patients except for one (7/8) had conservative therapy and follow-up by the outpatient clinic or phone call eventually. There were no symptoms occurring and no size increasing of observation infra-diaphragmatic ELS.

CONCLUSIONS

The ELS has the potential risk of infection and torsion in this study. Thoracoscopic surgery might be optimal management of upper-diaphragmatic ELS for its minimal invasion and low perioperative risks, which could be developed into a day operation with safe and quick recovery. The intra-diaphragmatic and infra-diaphragmatic ELS need a larger sample size and multiple center data to get a better management approach.

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.

Bronchopulmonary sequestration: Improving practice by evaluating for a missed diagnosis

Bronchopulmonary sequestration (BPS) is a lung mass that does not communicate with the tracheobronchial tree or the pulmonary arterial vasculature, and thus does not play a role in oxygenation. This article discusses the etiology of BPS, as well as its pathophysiology, signs and symptoms, imaging studies used to diagnose, and treatment options in both pediatric and adult patients.