Minimal access thoracic surgery in the pediatric population

Error traps in pediatric one-lung ventilation

With the advent of thoracoscopic surgery, the benefits of lung isolation in children have been increasingly recognized. However, because of the small airway dimensions, equipment limitations in size and maneuverability, and limited respiratory reserve, one-lung ventilation in children remains challenging. This article highlights some of the most common error traps in the management of pediatric lung isolation and focuses on practical solutions for their management. The error traps discussed are as follows: (1) the failure to take into consideration relevant aspects of tracheobronchial anatomy when selecting the size of the lung isolation device, (2) failure to execute correct placement of the device chosen for lung isolation, (3) failure to maintain lung isolation related to surgical manipulation and isolation device movement, (4) failure to select appropriate ventilator strategies during one-lung ventilation, and (5) failure to appropriately manage and treat hypoxemia in the setting of one-lung ventilation.

Thoracoscopy vs. thoracotomy for the repair of esophageal atresia and tracheoesophageal fistula: a systematic review and meta-analysis

Esophageal atresia (EA) and tracheoesophageal fistula (TEF) require emergency surgery in the neonatal period to prevent aspiration and respiratory compromise. Surgery was once exclusively performed via thoracotomy; however, there has been a push to correct this anomaly thoracoscopically. In this study, we compare intra- and post-operative outcomes of both techniques. A systematic review and meta-analyses was performed. A search strategy was developed in consultation with a librarian which was executed in CENTRAL, MEDLINE, and EMBASE from inception until January 2017. Two independent researchers screened eligible articles at title and abstract level. Full texts of potentially relevant articles were then screened again. Relevant data were extracted and analyzed. 48 articles were included. A meta-analysis found no statistically significant difference between thoracoscopy and thoracotomy in our primary outcome of total complication rate (OR 0.98, [0.29, 3.24], p = 0.97). Likewise, there were no statistically significant differences in anastomotic leak rates (OR 1.55, [0.72, 3.34], p = 0.26), formation of esophageal strictures following anastomoses that required one or more dilations (OR 1.92, [0.93, 3.98], p = 0.08), need for fundoplication following EA repair (OR 1.22, [0.39, 3.75], p = 0.73)-with the exception of operative time (MD 30.68, [4.35, 57.01], p = 0.02). Considering results from thoracoscopy alone, overall mortality in patients was low at 3.2% and in most cases was due to an associated anomaly rather than EA repair. Repair of EA/TEF is safe, with no statistically significant differences in morbidity when compared with an open approach.Level of evidence 3a systematic review of case-control studies.

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: 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.

Thoracoscopy in pediatrics: Surgical perspectives

Thoracoscopic surgery and other minimally invasive approaches in children achieved marked advancement and expanded to include several disciplines in the last decade. The new armamentarium of the minimally invasive surgery including the smaller instruments and better magnification led to the application of this technology in the small infants and neonates. Currently, thoracoscopy is considered the preferred surgical approach for various conditions in neonates and infants over the standard thoracotomy, and thoracoscopic training is included in the surgical training curriculum for the residents in many institutes worldwide. Children are different from adults, and technique modifications are required when using thoracoscopy in children. Thoracoscopy showed satisfactory results in several operations including pulmonary resections, mediastinal tumors biopsies or resections, repair of the diaphragmatic hernias, decortication, and tracheoesophageal fistula. This review aims to address the unique aspects of thoracoscopic surgery in children, identify its potential technical and anatomical challenges, and the proposed solutions. A literature search for latest and relevant publications was done using the keywords (thoracoscopy; pediatric; lung biopsy; decortication; lobectomy; mediastinum; esophagus; and diaphragmatic hernia).

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.

Paediatric thoracoscopic surgery

Thoracoscopic surgery is now an integral part of paediatric practice. The evolution of instrumentation, optics and haemostatic devices have enabled even the most complex procedures to be carried out thoracoscopically. Although randomised studies are limited in children, thoracoscopic surgery appears to offer outcomes at least equivalent to that of open operations with less post-operative pain, less scarring and a more rapid recovery. Furthermore many of the long term musculo-skeletal deformities associated with a thoracotomy are avoided. There are however several surgical and anaesthetic challenges that make the widespread application of these techniques beyond that of specialised centres difficult.

[Minimally invasive pediatric surgery]

In recent years minimally invasive surgical techniques in children have made substantial progress. The feasibility and safety of a wide spectrum of laparoscopic and thoracoscopic procedures have been confirmed in numerous studies. Moreover, it was reported that minimally invasive pediatric surgery is associated with lower morbidity, a shorter hospital stay, lower costs, better cosmetics and clinical results similar to those achieved by open surgery. The present article reviews information on established as well as feasible but not yet established surgical procedures. The discussion of potential hemodynamic, respiratory and organ perfusion effects of the CO(2) pneumoperitoneum and the notation of special logistic aspects should support the reader in the process of decision-making to schedule infants and children for minimally invasive surgery.

Prior thoracic surgery has a limited impact on the feasibility of consecutive thoracoscopy in children: a prospective study on 228 procedures

BACKGROUND

This study aimed to determine the impact of prior thoracic surgery on consecutive ipsilateral thoracoscopic surgery in children.

METHODS

We prospectively analyzed 228 thoracic procedures, which were performed in 190 children (99 male,91 female; mean age, 5.1 years; range, 1 day to 18 years) over a 7-year period (January 2000 to August 2007).Of these, 137 were thoracoscopies and 91 conventional operations. A panel of pediatric pulmonologists, anesthetists,and pediatric surgeons decided whether a thoracoscopy or a conventional approach was indicated. The endpoints were conversion rate, intraoperative events, and complications in subsequent thoracoscopies with regard to the type of prior thoracic surgery. In addition, the reasons for exclusion from thorascopy of those patients,who had a previous thoracic operation, should be identified.

RESULTS

Thirty-two patients (14%) had prior ipsilateral thoracic surgery; 20 of these underwent thoracoscopy,12 after prior thoracotomy and 8 after prior thoracoscopy. The type of initial approach had no significant impact on the conversion rate of subsequent thoracoscopy (1/12 after thoracotomy vs. 0/8 after thoracoscopy; not significant). The conversion rate was not significantly different in patients with or without prior surgery (1/20 vs. 19/117; not significant). However, there was a higher number of reconstructive procedures in patients without prior surgery, which was reflected in conversions due to lack of overview (n 12), bleeding (n 3), tension during reconstruction of a diaphragmatic defect (n 2) and esophageal atresia (n 2), and intraoperative respiratory problems (n 1). Twelve patients with a prior operation underwent thoracotomy due to limited respiratory capacity (n 5), advanced tumor stage, prior sternotomy (n 6), and limited visibility, leading to conversion during initial thoracoscopy (n 1).

CONCLUSIONS

Prior thoracic operation has, independent of the initial approach, a limited impact on the feasibility of ipsilateral consecutive thoracoscopic surgery in children. The feasibility of thoracoscopy after prior operation is excellent.

Recent advances and controversies in pediatric laparoscopic surgery

Children represent a unique group of patients who are likely to greatly benefit from minimally invasive surgery (MIS). The promise of less postoperative pain, smaller scars, shorter hospital stays, and a faster return to school continues to drive growth in this area. The development of pediatric-specific techniques and documentation of improved outcomes form a critical gateway to widespread application of pediatric MIS. A brief perspective on current approaches to MIS for pediatric congenital and acquired disease is provided in this report. Technical departures from standardized adult MIS and the rationale for their modification are highlighted.

Prior thoracic surgery has a limited impact on the feasibility of consecutive thoracoscopy in children: a prospective study on 228 procedures

BACKGROUND

This study aimed to determine the impact of prior thoracic surgery on consecutive ipsilateral thoracoscopic surgery in children.

METHODS

We prospectively analyzed 228 thoracic procedures, which were performed in 190 children (99 male,91 female; mean age, 5.1 years; range, 1 day to 18 years) over a 7-year period (January 2000 to August 2007).Of these, 137 were thoracoscopies and 91 conventional operations. A panel of pediatric pulmonologists, anesthetists,and pediatric surgeons decided whether a thoracoscopy or a conventional approach was indicated. The endpoints were conversion rate, intraoperative events, and complications in subsequent thoracoscopies with regard to the type of prior thoracic surgery. In addition, the reasons for exclusion from thorascopy of those patients,who had a previous thoracic operation, should be identified.

RESULTS

Thirty-two patients (14%) had prior ipsilateral thoracic surgery; 20 of these underwent thoracoscopy,12 after prior thoracotomy and 8 after prior thoracoscopy. The type of initial approach had no significant impact on the conversion rate of subsequent thoracoscopy (1/12 after thoracotomy vs. 0/8 after thoracoscopy; not significant). The conversion rate was not significantly different in patients with or without prior surgery (1/20 vs. 19/117; not significant). However, there was a higher number of reconstructive procedures in patients without prior surgery, which was reflected in conversions due to lack of overview (n 12), bleeding (n 3), tension during reconstruction of a diaphragmatic defect (n 2) and esophageal atresia (n 2), and intraoperative respiratory problems (n 1). Twelve patients with a prior operation underwent thoracotomy due to limited respiratory capacity (n 5), advanced tumor stage, prior sternotomy (n 6), and limited visibility, leading to conversion during initial thoracoscopy (n 1).

CONCLUSIONS

Prior thoracic operation has, independent of the initial approach, a limited impact on the feasibility of ipsilateral consecutive thoracoscopic surgery in children. The feasibility of thoracoscopy after prior operation is excellent.

Thoracoscopic biopsy in children with diffuse parenchymal lung disease

Lung biopsy is necessary for establishing the diagnosis in patients with otherwise unclassified diffuse or localized parenchymal lung disease. This study aimed to assess the safety and accuracy of video-assisted thoracoscopic (VATS) lung biopsy in children with diffuse parenchymal lung disease (DPLD). In addition we aimed to evaluate the value of this technique with respect to the spectrum of diseases encountered, correlating histological diagnosis with treatment decisions and subsequent clinical outcome. Data from all patients (n = 21) who underwent surgical lung biopsy for suspected DPLD between March 2001 and August 2006 were collected prospectively. Median age was 3 years, 8 months (range 11 days to 15 years, 2 months). All lung biopsies were performed by VATS under general anesthesia. Median operative time was 45 min (range 25-100 min). Conversion to minithoracotomy due to cardiorespiratory difficulties was necessary in two young infants. There were no further intraoperative complications. In 8/21 children, a chest tube was inserted postoperatively for a median of 2 days (range 1-5 days). In one patient, prolonged air-leakage was managed thoracoscopically on postoperative day 9. There were no other postoperative complications. The specimens were of adequate volume and quality and a histopathological diagnosis was obtained for all patients. There was a broad spectrum of different diagnoses which led to specific therapeutic decisions. Subsequent medical treatment was beneficial in the majority of the patients. In conclusion, VATS is a safe and effective procedure for diagnosis of children with suspected DPLD. Diagnostic accuracy is high, morbidity rates are low, and patients may benefit from avoiding thoracotomy.

Survey of childhood empyema in Asia: implications for detecting the unmeasured burden of culture-negative bacterial disease

Background

Parapneumonic empyema continues to be a disease of significant morbidity and mortality among children despite recent advances in medical management. To date, only a limited number of studies have assessed the burden of empyema in Asia.

Methods

We surveyed medical records of four representative large pediatric hospitals in China, Korea, Taiwan and Vietnam using ICD-10 diagnostic codes to identify children <16 years of age hospitalized with empyema or pleural effusion from 1995 to 2005. We also accessed microbiology records of cultured empyema and pleural effusion specimens to describe the trends in the epidemiology and microbiology of empyema.

Results

During the study period, we identified 1,379 children diagnosed with empyema or pleural effusion (China, n = 461; Korea, n = 134; Taiwan, n = 119; Vietnam, n = 665). Diagnoses of pleural effusion (n = 1,074) were 3.5 times more common than of empyema (n = 305), although the relative proportions of empyema and pleural effusion noted in hospital records varied widely between the four sites, most likely because of marked differences in coding practices. Although pleural effusions were reported more often than empyema, children with empyema were more likely to have a cultured pathogen. In addition, we found that median age and gender distribution of children with these conditions were similar across the four countries. Among 1,379 empyema and pleural effusion specimens, 401 (29%) were culture positive. Staphylococcus aureus (n = 126) was the most common organism isolated, followed by Streptococcus pneumoniae (n = 83), Pseudomonas aeruginosa (n = 37) and Klebsiella (n = 35) and Acinetobacter species (n = 34).

Conclusion

The age and gender distribution of empyema and pleural effusion in children in these countries are similar to the US and Western Europe. S. pneumoniae was the second leading bacterial cause of empyema and pleural effusion among Asian children. The high proportion of culture-negative specimens among patients with pleural effusion or empyema suggests that culture may not be a sufficiently sensitive diagnostic method to determine etiology in the majority of cases. Future prospective studies in different countries would benefit from standardized case definitions and coding practices for empyema. In addition, more sensitive diagnostic methods would improve detection of pathogens and could result in better prevention, treatment and outcomes of this severe disease.

Current application of thoracoscopy in children

BACKGROUND

The safety and efficacy of thoracoscopy for thoracic lesions and conditions in children is evolving. Our experience with thoracoscopy has expanded in recent years. Therefore, we reviewed our most recent 7-year experience to examine the current applications for thoracoscopy in children.

METHODS

A retrospective review of all patients undergoing a thoracoscopic operation at Children's Mercy Hospital (Kansas City, MO) between January 1, 2000, and June 18, 2007, was performed. Data points reviewed included patient demographics, type of operation, final diagnosis, complications, and recovery.

RESULTS

During the study period, 230 children underwent 231 thoracoscopic procedures. The mean age was 9.6 +/- 6.1 years with a mean weight of 36.6 +/- 24.1 kg. Fifty percent of the patients were male. The thoracoscopic approach was used for decortication and debridement for empyema in 79 patients, wedge resection for lung lesions in 37, exposure for correction of scoliosis in 26, excision or biopsy of an extrapulmonary mass in 26, operation for spontaneous pneumothorax in 25, lung biopsy for a diffuse parenchymal process in 15, lobectomy in 9, repair of esophageal atresia with a tracheoesophageal fistula (EA-TEF) in 8, clearance of the pleural space for hemothorax or effusion in 3, diagnosis for trauma in 1, and repair of bronchopleural fistula in 1. Conversion was required in 3 patients, all of whom were undergoing a lobectomy. Two of these were right upper lobectomies and the other was a left lower lobectomy with severe infection and inflammation. The mean time of chest tube drainage (excluding scoliosis and EA-TEF patients) was 2.9 +/- 2.0 days. There were no major intraoperative thoracoscopic complications. A correct diagnosis was rendered in all patients undergoing a biopsy. One patient required a second thoracoscopic biopsy to better define a mediastinal mass. Two patients developed postoperative atelectasis after scoliosis procedures. One patient had a small persistent pneumothorax after a bleb resection for a spontaneous pneumothorax. This subsequently resolved.

CONCLUSIONS

In pediatric patients with thoracic pathology, thoracoscopy is highly effective for attaining the goal of the operation, with a low rate of conversion and complications.

Minimally invasive surgery of the lung: lung biopsy, treatment of spontaneous pneumothorax, and pulmonary resection

Thoracoscopy of pediatric patients has evolved from diagnostic lung biopsy to a myriad of both diagnostic and therapeutic procedures. In this chapter, we discuss those procedures related to the child's lung which are most commonly performed: lung biopsy; resection of bronchogenic cysts, pulmonary sequestrations, and pulmonary lobes; and the treatment of spontaneous pneumothorax.