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Dossche L, Kersten C, van Rosmalen J, Wijnen R, IJsselstijn H, Schnater J. Lower respiratory tract infections in children with congenital lung abnormalities. Pediatr Pulmonol 2024. [PMID: 38771198 DOI: 10.1002/ppul.27067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/08/2024] [Accepted: 05/07/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVE We aimed to determine if the incidence of lower respiratory tract infections (LRTI) among children with asymptomatic, observationally managed congenital lung abnormalities (CLA) differed from that of symptomatic patients who underwent surgery. Second, we sought to compare the pre- and post-resection incidence of LRTI in patients who underwent surgery. METHODS This retrospective cohort study included patients born between 1999 and 2021 with CLA confirmed by CT scan who were enrolled in a prospective longitudinal follow-up program. The LRTI incidence rates at 1, 2, 5, 8, and 12 years were compared between surgically and observationally managed patients using incidence rate ratios (IRR). Differences in pre- and post-resection LRTI incidence rates among patients who underwent CLA-related surgery were assessed through IRR. RESULTS Among 217 included patients, 81 (37%) had undergone surgery and 136 (63%) had been observationally managed. The LRTI incidence rates did not significantly differ at any follow-up moment between the surgical and observational groups. Among the children who underwent CLA-related surgery, the pre-resection LRTI incidence rates were significantly higher than the post-resection LRTI incidence rates (IRR of 3.57, 95% confidence interval: [2.00; 6.33], p < .001). CONCLUSION We could not demonstrate differences in LRTI incidence throughout childhood between patients with surgically and observationally managed CLA. We recommend discussing cases of LRTI in patients with CLA in a multidisciplinary setting, using additional diagnostics such as chest X-ray to screen for CLA involvement, enabling a well-considered decision on surgical resection of the lesion.
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Affiliation(s)
- Louis Dossche
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Casper Kersten
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Rene Wijnen
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Hanneke IJsselstijn
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Johannes Schnater
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
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Salvi PS, Canner JK, Coons B, Cowles RA, Engwall-Gill AJ, Kunisaki SM, Penikis AB, Schneider E, Sferra SR, Solomon DG. The impact of undergoing elective pediatric lung resection during respiratory syncytial virus peak season on patient outcomes: A nationwide retrospective analysis. Pediatr Pulmonol 2024; 59:1346-1353. [PMID: 38353176 DOI: 10.1002/ppul.26914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 01/18/2024] [Accepted: 02/01/2024] [Indexed: 04/30/2024]
Abstract
OBJECTIVES Observational data to support delaying elective pediatric thoracic surgery during peak respiratory viral illness season is lacking. This study evaluated whether lung surgery during peak viral season is associated with differences in postoperative outcomes and resource utilization. METHODS A retrospective observational cohort study was performed using the Pediatric Health Information System (PHIS). Patients with a congenital lung malformation (CLM) who underwent elective lung resection between 1 January 2016 and 29 February 2020 were included. Respiratory syncytial virus (RSV) incidence was used as a proxy for respiratory viral illness circulation. Monthly hospital-specific RSV incidence was calculated from PHIS data, and peak RSV season was defined by Centers for Disease Control data. Multivariable regression models were built to identify predictors of postoperative mechanical ventilation, which was the main outcome measure, as well as secondary outcomes including 30-day readmission after lung resection, postoperative length of stay (LOS) and hospital billing charges. RESULTS Of 1542 CLM patients identified, 344 (22.3%) underwent lung resection during peak RSV season. 38% fewer operations were performed per month during peak RSV season than during off-peak months (p < .001). Children who underwent surgery during peak RSV season did not differ from the off-peak group in terms of age at operation, race, or comorbid conditions (i.e., congenital heart disease, newborn respiratory distress, and preoperative pneumonia). There was no association between hospital-specific RSV incidence at the time of surgery and postoperative mechanical ventilation, postoperative LOS, 30-day readmission rate or hospital billing charges. DISCUSSION Performing elective lung surgery in children with CLMs during peak viral season is not associated with adverse surgical outcomes or increased utilization of healthcare resources.
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Affiliation(s)
- Pooja S Salvi
- Division of Pediatric Surgery, New Haven, Connecticut, USA
| | - Joseph K Canner
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Barbara Coons
- Division of Pediatric Surgery, New Haven, Connecticut, USA
| | | | | | | | | | - Eric Schneider
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Shelby R Sferra
- Division of General Pediatric Surgery, Baltimore, Maryland, USA
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Busti M, Zarfati A, Valfre L, Conforti A, Bagolan P. Respiratory and Musculoskeletal Long-Term Outcomes after Surgical Resection of Congenital Cystic Adenomatoid Malformation of the Lung in Newborns, Infants, and Toddlers. Eur J Pediatr Surg 2024; 34:63-68. [PMID: 37459887 DOI: 10.1055/a-2130-2564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
INTRODUCTION The long-term outcomes of children who underwent surgery for congenital cystic adenomatoid malformation of the lung (CCAML) are not well documented, particularly regarding orthopaedic and respiratory follow-up (FU). The aim of this study was to assess the long-term pulmonary and orthopaedic outcomes of surgically treated CCAML in newborns, infants, and toddlers. MATERIALS AND METHODS Retrospective examination of prospectively recorded data of consecutive patients with CCAML who underwent surgery at our tertiary referral institution from January 2000 to December 2015 (newborns, infants, and toddlers). Clinical, radiological, and surgical data, as well as FU data were revised. A multidisciplinary team followed the patients after discharge at scheduled time points. RESULTS Seventy-seven patients were included. After surgery, patients were followed for a median of 8 years (range: 1-19 years) until they reached a median age of 8 years (range: 2-19 years). Thirty patients (39%) developed wheezing and 21 (27%) had lower respiratory tract infections (LRTIs) within 4 years of age. However, more than 50% of patients with respiratory symptoms underwent complete remission in the following 4 years. Thirty-one patients (40%) developed at least one minimal musculoskeletal deformity. Eighteen (23%) had scoliosis, 17 (22%) thoracic asymmetry, 10 (12%) pectus excavatum, and 5 (6%) winged scapula. CONCLUSIONS Patients operated for CCAML had good overall outcomes despite pulmonary symptoms and musculoskeletal sequelae. Even though these issues are frequently paucisymptomatic, trying to use less-invasive procedures (such as minimally axillary open "muscle-sparing" thoracotomy or thoracoscopy) may reduce this burden. A structured multidisciplinary FU is required.
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Affiliation(s)
- Matteo Busti
- Newborn Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
- Department of Systems Medicine, University of "Tor Vergata," Rome, Italy
| | - Angelo Zarfati
- Newborn Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
- Department of Systems Medicine, University of "Tor Vergata," Rome, Italy
| | - Laura Valfre
- Newborn Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Andrea Conforti
- Newborn Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pietro Bagolan
- Newborn Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
- Department of Systems Medicine, University of "Tor Vergata," Rome, Italy
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Dougherty D, Diaconescu A, Shah NR, VanHulle R, Ladino-Torres M, Treadwell MC, Mychaliska GB, Perrone EE. Prenatal Measurements of Congenital Lung Malformations: Can They Predict Postnatal Size? J Surg Res 2024; 293:259-265. [PMID: 37804795 DOI: 10.1016/j.jss.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 10/09/2023]
Abstract
INTRODUCTION Prenatally diagnosed congenital lung malformations (CLMs) are monitored via ultrasound and measured by congenital pulmonary airway malformation volume ratios (CVRs) which can predict postnatal respiratory symptoms. This study compared CVR to postnatal lesion size to help guide prenatal counseling. METHODS A retrospective chart review evaluated the prenatal imaging and postnatal outcomes for patients who were prenatally diagnosed with CLMs and had a postnatal computed tomography (CT) scan at one institution. RESULTS Fifty-seven patients were included. Four had symptoms requiring urgent resection. The remaining were discharged and had clinic follow-up with CT scan to determine next steps: five had no identified lesions, eight had lesions whose diagnosis did not warrant an operation, and 40 had lesions whose diagnosis rendered size a factor in operative decision-making. Of these 40, 26/40 patients (65%) underwent elective resection (median maximum CVR 0.97; median lesion size 4 cm) and 14/40 patients (35%) were observed without resection (median maximum CVR 0.5; median lesion size 3 cm). There was a positive correlation between prenatal CVR and postnatal lesion size, with R-squared = 0.46. Maximum CVRs were better than last CVRs when predicting whether postnatal CT size would fall above or below our institution's level of recommended resection, with an area under the curve of 0.85 and a CVR cut-point of 0.61. CONCLUSIONS For newborns with asymptomatic CLMs, higher maximum CVRs correlated with larger size on postnatal CT. A maximum CVR ≤0.6 was correlated with a smaller postnatal CT size that may be eligible for nonoperative management. While these results are not intended to recommend surgery based on higher CVRs alone, this information could potentially be used to reassure expectant parents whose babies' prenatal imaging demonstrate lower maximum CVRs.
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Affiliation(s)
- Danielle Dougherty
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Nikhil R Shah
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan.
| | - Rachel VanHulle
- Department of Radiology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Maria Ladino-Torres
- Department of Radiology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Marjorie C Treadwell
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Michigan Medicine, University of Michigan, L4001 Women's Hospital, Ann Arbor, Michigan
| | - George B Mychaliska
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Erin E Perrone
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
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Alhamad M, Anand D. Congenital diaphragmatic hernia with associated broncho-pulmonary sequestration: A report of two cases and a literature review. J Neonatal Perinatal Med 2024; 17:123-131. [PMID: 38189715 DOI: 10.3233/npm-230042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND Congenital Diaphragmatic Hernia (CDH) is a severe congenital anomaly with significant morbidity and mortality. It can be isolated or can be associated with other congenital anomalies, including broncho-pulmonary sequestration (BPS). The association of CDH with BPS (CDH+BPS) is uncommon but has been previously reported, and it can complicate the course of the disease in patients with CDH. We report two cases of CDH+BPS that were recently treated at our CDH-Qatar (CDH-Q) program. METHODS We reviewed CDH-Q program registry to search for CDH+BPS and extracted the data for the identified cases. We also reviewed the previously published literature available on PubMed for similar cases. RESULTS Out of 53 cases of CDH referred to CDH-Q from January 2018 to December 2022, two cases of CDH+BPS were identified, with an estimated prevalence of 3.8% of this association in our CDH population. Both cases were born at term. Case 1 was diagnosed with CDH+BPS postnatally, while case 2 was diagnosed with CDH antenatally but BPS was diagnosed after birth. Both cases underwent a surgical repair of the CDH with resection of the associated BPS, and the histopathology of the resected lung tissue confirmed the presence of BPS in both. Both cases survived to discharge. CONCLUSION The association of CDH+BPS is uncommon; however, it can have significant consequences on the management and the prognosis of patients with CDH. Reporting these cases is important to provide a better understanding of this association and its impact on CDH patients.
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Affiliation(s)
- Moath Alhamad
- Sidra Medicine, Doha, Qatar
- Weill Cornell Medicine, Doha, Qatar
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Pederiva F, Rothenberg SS, Hall N, Ijsselstijn H, Wong KKY, von der Thüsen J, Ciet P, Achiron R, Pio d'Adamo A, Schnater JM. Congenital lung malformations. Nat Rev Dis Primers 2023; 9:60. [PMID: 37919294 DOI: 10.1038/s41572-023-00470-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 11/04/2023]
Abstract
Congenital lung malformations (CLMs) are rare developmental anomalies of the lung, including congenital pulmonary airway malformations (CPAM), bronchopulmonary sequestration, congenital lobar overinflation, bronchogenic cyst and isolated congenital bronchial atresia. CLMs occur in 4 out of 10,000 live births. Postnatal presentation ranges from an asymptomatic infant to respiratory failure. CLMs are typically diagnosed with antenatal ultrasonography and confirmed by chest CT angiography in the first few months of life. Although surgical treatment is the gold standard for symptomatic CLMs, a consensus on asymptomatic cases has not been reached. Resection, either thoracoscopically or through thoracotomy, minimizes the risk of local morbidity, including recurrent infections and pneumothorax, and avoids the risk of malignancies that have been associated with CPAM, bronchopulmonary sequestration and bronchogenic cyst. However, some surgeons suggest expectant management as the incidence of adverse outcomes, including malignancy, remains unknown. In either case, a planned follow-up and a proper transition to adult care are needed. The biological mechanisms through which some CLMs may trigger malignant transformation are under investigation. KRAS has already been confirmed to be somatically mutated in CPAM and other genetic susceptibilities linked to tumour development have been explored. By summarizing current progress in CLM diagnosis, management and molecular understanding we hope to highlight open questions that require urgent attention.
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Affiliation(s)
- Federica Pederiva
- Paediatric Surgery, "F. Del Ponte" Hospital, ASST Settelaghi, Varese, Italy.
| | - Steven S Rothenberg
- Department of Paediatric Surgery, Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Nigel Hall
- University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Hanneke Ijsselstijn
- Department of Paediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Kenneth K Y Wong
- Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Jan von der Thüsen
- Department of Pathology and Clinical Bioinformatics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Pierluigi Ciet
- Departments of Radiology and Nuclear Medicine and Respiratory Medicine and Allergology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Radiology, University of Cagliari, Cagliari, Italy
| | - Reuven Achiron
- Department of Obstetrics and Gynecology, Fetal Medicine Unit, The Chaim Sheba Medical Center Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adamo Pio d'Adamo
- Laboratory of Medical Genetics, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - J Marco Schnater
- Department of Paediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
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Liu C, Liu J, Yuan M, Cheng K, Luo D, Zeng L, Xu C. Pulmonary function after lobectomy in children: a systematic review and meta-analysis. BMJ Paediatr Open 2023; 7:e001979. [PMID: 37848263 PMCID: PMC10582896 DOI: 10.1136/bmjpo-2023-001979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/26/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND The influence of lobectomy on pulmonary function in children was still controversial. A systematic review and meta-analysis were essential to explore whether pulmonary function was impaired after lobectomy in children. METHODS PubMed, Embase and Web of Science were searched from 1 January 1946 to 1 July 2022. Forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), FEV1/FVC and total lung capacity were extracted from the studies as the primary analysis indicators. Subgroup analyses were performed between the congenital lung malformation (CLM) group and other diseases group, early surgery and late surgery group (1 year old as the dividing line). RESULTS A total of 5302 articles were identified through the search strategy; finally, 10 studies met the inclusion criteria. Through the meta-analysis, we found a mild obstructive ventilatory disorder in children who underwent lobectomy. However, a normal pulmonary function could be found in young children with CLM who underwent lobectomy, and the time of operation had no significant influence on their pulmonary function. CONCLUSIONS The overall result of pulmonary function after lobectomy in children was good. Surgeons may not need to be excessively concerned about the possibility of lung surgery affecting pulmonary function in children, particularly in patients with CLM. PROSPERO REGISTRATION NUMBER CRD42022342243.
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Affiliation(s)
- Chenyu Liu
- Department of Pediatric Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Jie Liu
- Department of Pediatric Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Miao Yuan
- Department of Pediatric Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Kaisheng Cheng
- Department of Pediatric Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Dengke Luo
- Department of Pediatric Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Li Zeng
- Department of Pediatric Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Chang Xu
- Department of Pediatric Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
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Dossche LWJ, Kersten CM, Zanen-van den Adel T, Wijnen RMH, Gischler SJ, IJsselstijn H, Rietman AB, Schnater JM. Long-term neurodevelopment in children with resected congenital lung abnormalities. Eur J Pediatr 2023; 182:3845-3855. [PMID: 37326640 PMCID: PMC10570195 DOI: 10.1007/s00431-023-05054-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/26/2023] [Accepted: 06/02/2023] [Indexed: 06/17/2023]
Abstract
To determine whether children who underwent resection of a congenital lung abnormality (CLA) are at higher risk for neurodevelopmental impairments than peers in the general population. The study population consisted of children born between 1999-2018 who underwent resection of a symptomatic CLA. Neurocognitive development (intelligence, memory, attention, visuospatial processing, executive functioning) and motor function of this population are monitored through our structured, prospective longitudinal follow-up program at the ages of 30 months, 5, 8, and 12 years. We compared study population scores with Dutch norm values using one-sample t-tests and one-sample binominal proportion tests. Forty-seven children were analyzed. The 8-year-olds showed significant impairments in sustained attention through the Dot Cancellation Test (mean z-scores -2.4; [-4.1; -0.8], p = 0.006 and -7.1; [-12.8; -1.4], p = 0.02 for execution speed and fluctuations respectively). Visuospatial memory was impaired at 8 years, though only in 1 out of 3 assessment tools (Rey Complex Figure Test z-scores (-1.0; [-1.5; -0.5], p < 0.001). Further neurocognitive outcomes were unimpaired at all tested ages. Regarding motor function outcomes, mean z-scores of total motor functioning were unimpaired across assessed ages. However, at 8 years, significantly more children than expected had definite motor problems (18% vs 5%, 95% CI [0.052; 0.403], p = 0.022). Conclusion: This evaluation reveals impairment in some subtests of sustained attention, visuospatial memory and motor development. However, globally, normal neurodevelopmental outcomes were found throughout childhood. We recommend testing for neurodevelopmental impairments in children who underwent surgery for CLA only if associated morbidities are present or if caregivers express doubts about their daily functioning. What is Known: • In general, surgically managed CLA cases seldom suffer from long-term surgery-related morbidity and show favorable lung function. What is New: • Long-term neurocognitive and motor function outcome appear unimpaired within surgically managed CLA cases. We recommend testing for neurodevelopmental impairments in children who underwent surgery for CLA only if associated morbidities are present or if caregivers express doubts about their daily functioning.
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Affiliation(s)
- Louis W J Dossche
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Casper M Kersten
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Tabitha Zanen-van den Adel
- Department of Orthopedics, Section of Physical Therapy, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - René M H Wijnen
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Saskia J Gischler
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Hanneke IJsselstijn
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Andre B Rietman
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC University Medical Center, 3015 CN, Rotterdam, the Netherlands
| | - J M Schnater
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
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Roshan MP, de Macedo Filho R, Sayegh K. Rare case of bilateral bronchopulmonary sequestration. Radiol Case Rep 2023; 18:3236-3239. [PMID: 37448606 PMCID: PMC10336350 DOI: 10.1016/j.radcr.2023.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/28/2023] [Accepted: 06/18/2023] [Indexed: 07/15/2023] Open
Abstract
Pulmonary sequestration is a rare congenital bronchopulmonary malformation with an estimated incidence of less than 6%. It is described as the abnormal formation of nonfunctional lung tissue that receives its blood supply from systemic circulation rather than the bronchial tree. Most are unilateral, while a miniscule proportion is bilateral. Delayed diagnosis can result in recurrent pneumonia, failure to thrive, regular hospital visits, morbidity and even fatality. Thus, it is important to raise awareness of this condition. Herein, we present a case of a 42-year-old patient with bilateral pulmonary sequestration (BPS) on a triple rule out CT angiography (TRO-CTA).
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Affiliation(s)
- Mona P. Roshan
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Robson de Macedo Filho
- Baptist Health of South Florida and Radiology Associates of South Florida, 8900 N Kendall Dr, Miami, FL, 33176 USA
| | - Karl Sayegh
- Baptist Health of South Florida and Radiology Associates of South Florida, 8900 N Kendall Dr, Miami, FL, 33176 USA
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10
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Elders BBLJ, Kersten CM, Hermelijn SM, Wielopolski PA, Tiddens HAWM, Schnater JM, Ciet P. Congenital lung abnormalities on magnetic resonance imaging: the CLAM study. Eur Radiol 2023; 33:4767-4779. [PMID: 36826502 PMCID: PMC10290040 DOI: 10.1007/s00330-023-09458-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 01/26/2023] [Accepted: 02/03/2023] [Indexed: 02/25/2023]
Abstract
OBJECTIVES Follow-up of congenital lung abnormalities (CLA) is currently done with chest computer tomography (CT). Major disadvantages of CT are exposure to ionizing radiation and need for contrast enhancement to visualise vascularisation. Chest magnetic resonance imaging (MRI) could be a safe alternative to image CLA without using contrast agents. The objective of this cohort study was to develop a non-contrast MRI protocol for the follow-up of paediatric CLA patients, and to compare findings on MRI to postnatal CT in school age CLA patients. METHODS Twenty-one CLA patients, 4 after surgical resection and 17 unoperated (mean age 12.8 (range 9.4-15.9) years), underwent spirometry and chest MRI. MRI was compared to postnatal CT on appearance and size of the lesion, and lesion associated abnormalities, such as hyperinflation and atelectasis. RESULTS By comparing school-age chest MRI to postnatal CT, radiological appearance and diagnostic interpretation of the type of lesion changed in 7 (41%) of the 17 unoperated patients. In unoperated patients, the relative size of the lesion in relation to the total lung volume remained stable (0.9% (range - 6.2 to + 6.7%), p = 0.3) and the relative size of lesion-associated parenchymal abnormalities decreased (- 2.2% (range - 0.8 to + 2.8%), p = 0.005). CONCLUSION Non-contrast-enhanced chest MRI was able to identify all CLA-related lung abnormalities. Changes in radiological appearance between MRI and CT were related to CLA changes, patients' growth, and differences between imaging modalities. Further validation is needed for MRI to be introduced as a safe imaging method for the follow-up of paediatric CLA patients. KEY POINTS • Non-contrast-enhanced chest MRI is able to identify anatomical lung changes related to congenital lung abnormalities, including vascularisation. • At long-term follow-up, the average size of congenital lung abnormalities in relation to normal lung volume remains stable. • At long-term follow-up, the average size of congenital lung abnormalities associated parenchymal abnormalities such as atelectasis in relation to normal lung volume decreases.
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Affiliation(s)
- Bernadette B L J Elders
- Department of Paediatric Pulmonology and Allergology, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Casper M Kersten
- Department of Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Sergei M Hermelijn
- Department of Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Piotr A Wielopolski
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Harm A W M Tiddens
- Department of Paediatric Pulmonology and Allergology, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - J Marco Schnater
- Department of Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Pierluigi Ciet
- Department of Paediatric Pulmonology and Allergology, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands.
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.
- Radiology Department, University of Cagliari, Cagliari, Italy.
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11
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Ten-year experience in the clinical management of intralobar pulmonary sequestration in children. Pediatr Pulmonol 2023; 58:1022-1027. [PMID: 36539260 DOI: 10.1002/ppul.26287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 12/01/2022] [Accepted: 12/18/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Intralobar pulmonary sequestration (ILS) is rare and its optimal clinical management remains ambiguous. This study aimed to introduce our 10-year experience in clinical management of ILS. And the application of our novel surgical method, thoracoscopic anatomical lesion resection (TALR) on ILS was introduced. MATERIALS AND METHODS Patients with ILS who received treatment between December 2010 and 2020 were included in this study, retrospectively. A binary logistic regression model was used to assess risk factors for preoperative symptoms. Intraoperative and postoperative outcomes were compared between the thoracoscopic lobectomy and lung-sparing surgery groups. RESULTS A total of 112 patients were included in this study. Age and maximum cyst diameter were risk factors for preoperative symptoms. Lung-sparing surgery proved to be safe and feasible with no residual lesions. CONCLUSIONS The overall prognosis of early thoracoscopic surgery for ILS was good. Lung-sparing surgery, especially TALR could be used as a first-line surgery for ILS. It may resolve the long-standing controversy over whether surgery for asymptomatic patients with ILS.
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12
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King A, Olutoye OO, Lee TC, Keswani SG. Surgical Management of Congenital Lung Malformations. Neoreviews 2023; 24:e84-e96. [PMID: 36720690 DOI: 10.1542/neo.24-2-e84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Congenital lung malformations (CLMs) are commonly diagnosed prenatal lesions with varied natural history. Prenatal diagnosis and monitoring help to guide fetal interventions, delivery planning, and need for urgent perinatal surgical interventions. All prenatally diagnosed CLMs should be evaluated postnatally, typically with cross-sectional imaging, because many lesions persist despite the appearance of complete 'regression' in utero. Management of CLMs in asymptomatic infants weighs the surgical and anesthetic risk of prophylactic resection against the risk of expectant management, including the possibility of infection, malignant degeneration, and more complicated surgical resection later with loss of compensatory lung growth.
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Affiliation(s)
- Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
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13
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Yang W, Gao Y, Li P, Eckman MH. Should asymptomatic patients with congenital lung malformations undergo surgery? A decision analysis. Pediatr Pulmonol 2023; 58:449-456. [PMID: 36251577 PMCID: PMC10092826 DOI: 10.1002/ppul.26206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 09/22/2022] [Accepted: 10/12/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Congenital lung malformations (CLMs) are being detected more frequently during pregnancy. There is controversy regarding the optimal treatment for an asymptomatic child with prenatally diagnosed CLMs. Due to the paucity of information from clinical trials, we developed decision analytic models to compare two treatment strategies for such patients-elective surgical resection versus expectant management. METHODS We built decision analytic models stratified by lesion size. We used data from English language literature identified through PubMed searches along with estimates from expert opinions of surgical colleagues. We analyzed results for two hypothetical asymptomatic 6-month-old children with CLMs; one has a large lesion occupying more than 50% of the involved lobe, while the other has a small lesion occupying less than 50% of the involved lobe. We used quality-adjusted life years (QALYs) to measure effectiveness. RESULTS For an asymptomatic child with a small or large lesion, expectant management resulted in a small gain of 0.09 or 0.15 QALYs, respectively. Sensitivity analyses showed that surgical resection would be preferred if the probability of remaining asymptomatic was low. CONCLUSIONS In contrast to current practice, expectant management may be a better alternative for asymptomatic children born with CLMs. More longitudinal studies are required to improve the accuracy of the model.
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Affiliation(s)
- Weili Yang
- Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Pediatric Surgery, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Ya Gao
- Department of Pediatric Surgery, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Peng Li
- Department of Pediatric Surgery, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Mark H Eckman
- Division of General Internal Medicine, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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14
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Gao Y, Xu W, Li W, Chen Z, Li Q, Liu Z, Liu H, Dai L. Epidemiology and prevalence of pulmonary sequestration in Chinese population, 2010-2019. BMC Pulm Med 2023; 23:8. [PMID: 36624419 PMCID: PMC9830928 DOI: 10.1186/s12890-023-02308-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Pulmonary sequestration (PS) is the second common congenital lung malformation and has been known for over 150 years. However, there is a scarcity of epidemiological studies on it. This study aimed to characterize the epidemiology of pulmonary sequestration in Chinese population in the recent decade by using a nationwide database. METHODS Using data from the Chinese Birth Defects Monitoring Network during 2010-2019, the prevalence rates for PS were calculated by birth year, maternal age, residence area, geographical region, and infant sex. Variations in prevalence and changes over time were further examined. Other variables of interest for analysis included the pregnancy outcomes of affected infants, the prenatal diagnosis, and the co-occurring anomalies of PS cases. RESULTS During the study period, we identified an average prevalence rate of 0.31, 0.11, and 0.42 per 10,000 live and still births for the isolated, non-isolated, and overall PS, respectively. An upward trend was observed for each category of PS. The prevalence rates varied significantly by maternal age (< 20 years, 0.34/10,000; 20-24 years, 0.33/10,000; 25-29 years, 0.45/10,000; 30-34 years, 0.46/10,000; ≥ 35 years, 0.36/10,000), residence area (urban vs. rural, 0.51/10,000 vs. 0.30/10,000), geographical region (western, 0.33/10,000; eastern, 0.49/10,000; central, 0.43/10,000), and by infant sex (male vs. female, 0.45/10,000 vs. 0.38/10,000). Non-isolated PS cases were more likely born prematurely than isolated cases (15.29% vs. 7.83%). 40.28% and 33.80% of non-isolated cases were accompanied by additional respiratory, and circulatory system malformations, respectively. CONCLUSIONS The study presents for the first time the prevalence of pulmonary sequestration in Chinese population. The rising prevalence and relatively poor perinatal outcome of affected fetuses or newborns indicate the necessity to improve perinatal management of PS.
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Affiliation(s)
- Yuyang Gao
- grid.13291.380000 0001 0807 1581National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, No.17 Section 3 Renminnanlu, Chengdu, 610041 Sichuan China ,grid.13291.380000 0001 0807 1581Pediatric Department, The Joint Laboratory for Pulmonary Development and Related Diseases, West China Institute of Women and Children’s Health, West China Second University Hospital, Sichuan University, No.17 Section 3 Renminnanlu, Chengdu, 610041 Sichuan China
| | - Wenli Xu
- grid.13291.380000 0001 0807 1581National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, No.17 Section 3 Renminnanlu, Chengdu, 610041 Sichuan China ,grid.13291.380000 0001 0807 1581Pediatric Department, The Joint Laboratory for Pulmonary Development and Related Diseases, West China Institute of Women and Children’s Health, West China Second University Hospital, Sichuan University, No.17 Section 3 Renminnanlu, Chengdu, 610041 Sichuan China
| | - Wenyan Li
- grid.13291.380000 0001 0807 1581National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, No.17 Section 3 Renminnanlu, Chengdu, 610041 Sichuan China
| | - Zhiyu Chen
- grid.13291.380000 0001 0807 1581National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, No.17 Section 3 Renminnanlu, Chengdu, 610041 Sichuan China
| | - Qi Li
- grid.13291.380000 0001 0807 1581National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, No.17 Section 3 Renminnanlu, Chengdu, 610041 Sichuan China
| | - Zhen Liu
- grid.13291.380000 0001 0807 1581National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, No.17 Section 3 Renminnanlu, Chengdu, 610041 Sichuan China
| | - Hanmin Liu
- Pediatric Department, The Joint Laboratory for Pulmonary Development and Related Diseases, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, No.17 Section 3 Renminnanlu, Chengdu, 610041, Sichuan, China. .,National Health Commission Key Laboratory of Chronobiology, Sichuan University, Chengdu, Sichuan, China. .,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China. .,NHC Key Laboratory of Chronobiology, Sichuan University, Chengdu, Sichuan, China.
| | - Li Dai
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, No.17 Section 3 Renminnanlu, Chengdu, 610041, Sichuan, China. .,Pediatric Department, The Joint Laboratory for Pulmonary Development and Related Diseases, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, No.17 Section 3 Renminnanlu, Chengdu, 610041, Sichuan, China. .,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China. .,Med-X Center for Informatics, Sichuan University, Chengdu, Sichuan, China. .,NHC Key Laboratory of Chronobiology, Sichuan University, Chengdu, Sichuan, China.
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Long-Term Results of Pediatric Congenital Pulmonary Malformation: A Population-Based Matched Case-Control Study with a Mean 7-Year Follow-Up. CHILDREN (BASEL, SWITZERLAND) 2022; 10:children10010071. [PMID: 36670622 PMCID: PMC9857330 DOI: 10.3390/children10010071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/20/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022]
Abstract
Symptomatic congenital pulmonary malformations (CPMs) are a group of anomalies involving the lungs. The long-term outcomes of these patients are not well known. The present research aimed to study the pulmonary function, respiratory morbidity, and health-related quality of life (QoL) of patients treated for CPMs. All children (<16 years of age) treated for CPMs in 2002−2012 (in Oulu University Hospital) were invited to the follow-up visit. Altogether, there were 22 patients, out of which 17 (77%) participated. The mean follow-up time was 6.6 (ranged from 3 to 16) years. Pulmonary function tests, diffusing capacity, respiratory morbidity, and QoL were determined as the primary outcomes. Potential residual malformations and lung anatomy were investigated using computer tomography (CT) imaging. The outcomes were compared to the age- and sex-matched healthy controls. The forced expiratory volume at 1 s (FEV1, Z-score) remained lower in operated patients compared to the healthy controls (−1.57 ± SD 1.35 vs. −0.39 ± SD −0.86, p-value 0.005). There were no differences in respiratory morbidity or QoL between the patients and the controls. The surgical approach (lobectomy vs. partial resection) did not affect lung function. A younger age (<1 year of age) at the time of the surgery seemed to result in a higher lung capacity, but the finding was not statistically significant. Patients with CPMs treated with surgery were satisfied with their wellbeing in the long-term. A lower lung function did not have an impact on their wellbeing. However, there was a slight decrease in lung function compared to the healthy controls, and a clinical follow-up of the patients was recommended.
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16
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Zanini A, Macchini F, Boito S, Morandi A, Ferrara G, Persico N, Leva E. Intrauterine Ultrasound-Guided Laser Coagulation as a First Step for Treatment of Prenatally Complicated Bronchopulmonary Sequestration: Our Experience and Literature Review. Eur J Pediatr Surg 2022; 32:536-542. [PMID: 35288883 DOI: 10.1055/s-0042-1744149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Prenatal ultrasound-guided laser coagulation (USLC) for complicated bronchopulmonary sequestrations has been described but a consensus on the procedure and on the following management is still lacking. We present our experience and provide a literature review. METHODS Retrospective review of patients treated in our center. Literature review and combined analysis of perinatal data were performed. RESULTS Five cases were treated at our center, all presenting with severe hydrothorax. Four met the criteria for fetal hydrops. Four cases underwent postnatal computed tomography (CT) scan: in one case, there was no evidence of persistent bronchopulmonary sequestration. The other three underwent thoracoscopic resection, in two, a viable sequestration was found. Including our series, 57 cases have been reported, with no mortality and a success rate of 94.7%. Mean gestational age (GA) at the procedure was 28 ± 3.4 weeks and mean GA at birth and birth weight (BW) were 38.6 ± 2.3 weeks and 3,276 ± 519.8 g, respectively. In 80.6% of the cases investigated postnatally, a residual mass was found, 50% of cases who showed prenatal arterial flow cessation had a persistent sequestration postnatally, and 26.3% of cases underwent postnatal sequestrectomy. Both patients in our series had pathology examination confirming a viable bronchopulmonary sequestration. CONCLUSION Prenatal USLC seems to be a valid option for bronchopulmonary sequestration complicated by severe hydrothorax and/or fetal hydrops. Authors believe that this procedure should aim to reverse fetal distress and allow pregnancy continuation, and it should not be considered a definitive treatment. The currently available data do not support changes of the common postnatal management.
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Affiliation(s)
- Andrea Zanini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Lombardia, Italy
| | - Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Lombardia, Italy
| | - Simona Boito
- Department of Fetal Medicine and Surgery Service, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Lombardia, Italy
| | - Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Lombardia, Italy
| | - Giuditta Ferrara
- Department of Fetal Medicine and Surgery Service, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Lombardia, Italy
| | - Nicola Persico
- Department of Fetal Medicine and Surgery Service, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Lombardia, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milano, Lombardia, Italy
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Lombardia, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milano, Lombardia, Italy
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Congenital lung malformations: Dysregulated lung developmental processes and altered signaling pathways. Semin Pediatr Surg 2022; 31:151228. [PMID: 36442455 DOI: 10.1016/j.sempedsurg.2022.151228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Congenital lung malformations comprise a diverse group of anomalies including congenital pulmonary airway malformation (CPAM, previously known as congenital cystic adenomatoid malformation or CCAM), bronchopulmonary sequestration (BPS), congenital lobar emphysema (CLE), bronchogenic cysts, and hybrid lesions. Little is known about the signaling pathways that underlie the pathophysiology of these lesions and the processes that may promote their malignant transformation. In the last decade, the use of transgenic/knockout animal models and the implementation of next generation sequencing on surgical lung specimens have increased our knowledge on the pathophysiology of these lesions. Herein, we provide an overview of normal lung development in humans and rodents, and we discuss the current state of knowledge on the pathophysiology and molecular pathways that are altered in each congenital lung malformation.
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18
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Karlsson M, Conner P, Ehren H, Bitkover C, Burgos CM. The natural history of prenatally diagnosed congenital pulmonary airway malformations and bronchopulmonary sequestrations. J Pediatr Surg 2022; 57:282-287. [PMID: 35431039 DOI: 10.1016/j.jpedsurg.2022.03.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The natural history of congenital pulmonary airway malformations (CPAM) and bronchopulmonary sequestrations (BPS) is not fully understood, and the management of the newborn with an asymptomatic lesion is a controversial issue. We aimed to study the natural history and outcome of CPAM/BPS at our institution with a policy of watchful waiting, and to investigate if any prognostic factors in the pre- and/or postnatal- period may predict the need for surgery. MATERIAL AND METHODS A retrospective review study was conducted of children prenatally diagnosed with CPAM and/or BPS during the 18-year period, from 2002 to 2020. Data from the pre and postnatal period was collected and analysed. RESULTS Sixty- six patients with prenatally observed lung lesions were entered in the study, with an overall survival rate of 94%. Fifty-six percent of the lesions decreased in size during gestation. Thirty-one percent had surgery and 69% could be managed conservatively with a median follow-up of 4 years. Nineteen percent developed symptoms after the neonatal period. Children with a presence of mediastinal shift on postnatal imaging (p = 0.003), with a high CVR (p = 0.005) and a large lesion size during gestation (p = 0.014) were significantly more likely to require surgery. CONCLUSION Prenatal regression is common among prenatally diagnosed CPAM/BPS and the majority of children that are asymptomatic beyond the neonatal period will remain asymptomatic throughout their childhood. Future analysis with a longer follow-up might give new insights in order to identify children at risk of developing symptoms. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Matilda Karlsson
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
| | - Peter Conner
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Center for Fetal Medicine Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Ehren
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Catarina Bitkover
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Carmen Mesas Burgos
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Early Features of Chronic Obstructive Pulmonary Disease in Patients with Asthma: Is there ACO before ACO? Immunol Allergy Clin North Am 2022; 42:549-558. [PMID: 35965044 DOI: 10.1016/j.iac.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The diagnosis of asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is considered when a patient presents features of both asthma and COPD, usually including a component of irreversible airway obstruction (IRAO). However, some patients with asthma, particularly smokers, may have various features typical of COPD in the absence of such component of IRAO. Features of early COPD can be found at a young age in such patients even with normal spirometry. More longitudinal studies should be conducted to determine steps needed to improve clinical outcomes of these patients including the early recognition of these changes and the application of preventative/therapeutic interventions.
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20
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Musculoskeletal deformities in children with congenital thoracic malformations: a population-based cohort study. Pediatr Surg Int 2022; 38:731-736. [PMID: 35235016 DOI: 10.1007/s00383-022-05101-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE It is unclear if musculoskeletal deformities observed in patients with congenital diaphragmatic hernia (CDH), congenital lung lesion (CLL) and esophageal atresia/tracheoesophageal fistula (EA/TEF) are associated with the anomaly or are a result of the surgery required to treat the anomaly. This study compared the prevalence of musculoskeletal deformities for: (1) children with congenital thoracic anomalies to controls; (2) CLL to EA/TEF both repaired via thoracotomy; and (3) CLL and EA/TEF to CDH repaired via laparotomy. METHODS We performed a retrospective study of children with CLL, CDH or EA/TEF between 1990 and 2016. Date-of-birth-matched control groups were generated from a population-based dataset. International Classification of Disease codes were used to identify scoliosis and pectus anomalies. We determined Hazard ratios (HR) for cases versus controls. RESULTS We included 167 cases (CDH n = 82; CLL n = 29; EA/TEF n = 56) and 1670 controls. EA/TEF had a greater risk of scoliosis (HR 5.52, 95%CI 1.49,13.73) and pectus deformities (HR 4.07, 95%CI 1.96,8.45). CDH showed more scoliosis (HR 5.03, 95%CI 1.99,12.74) but not pectus anomalies. Musculoskeletal deformities were not more common in CLL. CONCLUSION Children born with CDH or EA/TEF, but not CLL, had more musculoskeletal deformities than controls. The inconsistent association between musculoskeletal deformities and the surgical approach suggested a congenital predisposition.
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Congenital lung malformation patients experience respiratory infections after resection: A population-based cohort study. J Pediatr Surg 2022; 57:829-832. [PMID: 35151496 DOI: 10.1016/j.jpedsurg.2021.12.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/29/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE The benefit of elective resection of congenital lung malformations continues to be debated. Proponents of resection endorse a decreased risk of respiratory complications as one indication for surgery. Our study aimed to compare the prevalence of respiratory infections in cases, before and after resection of congenital lung malformations, to controls without a history of congenital lung malformation. METHODS We performed a retrospective cohort study of children born from 1991 to 2007 who underwent congenital lung malformation resection. Patients were identified from Winnipeg´s Surgical Database of Outcomes and Management (WiSDOM), and a 10:1 date-of-birth matched control group was generated from a population-based administrative data repository. International Classification of Disease codes were used to assess pulmonary infection outcomes. Relative rates (RR) were calculated to compare the frequency of pneumonia, respiratory infections and influenza between cases and controls. RESULTS We included 31 congenital lung malformation cases and 310 controls. Cases consisted of 14 (45.16%) congenital pulmonary airway malformations, 9 (29.03%) bronchopulmonary sequestrations and 8 (25.81%) hybrid lesions. Before resection, pneumonia was more common in cases than controls (RR 6.85; 95%CI 3.89, 11.9), while the risk of acute respiratory infections (RR 1.21; 95%CI 0.79, 1.79) and influenza (RR 0.46; 95%CI 0.01, 3.22) were similar to controls. Post-resection, the risk of pneumonia (RR 9.75; 5.06, 18.50) was still higher in cases than controls, and respiratory infections (RR 1.77; 95%CI 1.20, 2.53) and influenza (RR 3.98; 95%CI 1.48, 9.36) were more common in cases than controls. CONCLUSION Our study demonstrated that after resection of congenital lung malformations, children experience more frequent respiratory infections compared to the general population. Resection does not eliminate the increased risk of pneumonia.
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22
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Yang W, Shen C, Yu N, Guo Y, Pan W, Li P, Gao Y, Chen X, Cheng J. Computer-aided quantitative MSCT measurements may be useful for congenital lung malformations surgical approach selection. Pediatr Surg Int 2021; 37:1273-1280. [PMID: 34213588 DOI: 10.1007/s00383-021-04949-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To examine the association between the MSCT quantitative measurements of congenital lung malformations (CLM) and the selection of surgical approaches (lobectomy vs. lung-sparing surgery). METHODS This retrospective study evaluated CLM surgical cases at our institution from 2016 to 2018. MSCT quantitative measurements were generated by a semi-automated approach: the volume of the lesion (Vlesion), the volume of the lesion-involved lobe (Vlobe), the volume of the lesion-involved lung (Vlung) and the volume of the total lung (Vtotal lung). The proportions of Vlesion to Vlobe (Plesion/lobe), Vlesion to Vlung (Plesion/lung), and Vlesion to V total lung (Plesion/total lung) were calculated. We used Logistics regression to examine whether quantitative measurements were associated with the selection of surgical approaches. RESULTS 151 patients were included (median age at surgery 6 months). 82 patients underwent lung-sparing surgery, and 69 patients underwent lobectomy. Vlesion (OR 1.51, 95% CI 1.09-2.07), Plesion/lobe (OR 1.78, 95% CI 1.16-2.72), Plesion/lung (OR 1.63, 95% CI 1.13-2.35), and Plesion/total lung (OR 1.58, 95% CI 1.12-2.22) were positively associated with the selection of lobectomy. CONCLUSION The application of quantified MSCT analysis may provide insight into the quantitative characteristics of CLM, which could be potentially useful for surgical approach selection.
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Affiliation(s)
- Weili Yang
- Department of Pediatric Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, 157 West Five Road, Xi'an, 710004, Shaanxi, China
| | - Cong Shen
- Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Nan Yu
- Department of Medical Imaging, The Affiliated Hospital of Shaanxi Chinese Medicine University, Xianyang, 712000, Shaanxi, China
| | - Youmin Guo
- Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Weikang Pan
- Department of Pediatric Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, 157 West Five Road, Xi'an, 710004, Shaanxi, China
| | - Peng Li
- Department of Pediatric Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, 157 West Five Road, Xi'an, 710004, Shaanxi, China
| | - Ya Gao
- Department of Pediatric Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, 157 West Five Road, Xi'an, 710004, Shaanxi, China
| | - Xin Chen
- Department of Medical Imaging, The Second Affiliated Hospital of Xi'an Jiaotong University, 157 West Five Road, Xi'an, 710004, Xi'an, China.
| | - Jiwen Cheng
- Department of Pediatric Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, 157 West Five Road, Xi'an, 710004, Shaanxi, China.
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Zarfati A, Voglino V, Tomà P, Cutrera R, Frediani S, Inserra A. Conservative management of congenital bronchial atresia: The Bambino Gesù children's hospital experience. Pediatr Pulmonol 2021; 56:2164-2168. [PMID: 33760393 DOI: 10.1002/ppul.25385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 03/01/2021] [Accepted: 03/10/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Congenital bronchial atresia (CBA) is a rare airway malformation. No management guidelines exist because of limited evidence: treatment, surgical or conservative, is based on consensus and opinion. OBJECTIVE To review the experience of a pediatric tertiary center and provide additional data about nonsurgical management of CBA and its outcomes after a structured follow-up, and to help formulate appropriate evidence-based guidelines. METHODS A retrospective analysis of clinical, radiological, surgical, and pathological data of all pediatric patients with suspicion of CBA referred to the surgical department of the Bambino Gesù children's hospital of Rome between December 2013 and 2019, along with a review of the literature. RESULTS Among the 18 children initially included in the study, 2 were lost to follow-up after radiological diagnosis, 4 underwent surgery for radiological suspicion of other pulmonary malformations. The final population is composed of 12 conservatively managed patients. At the end of the follow-up (median: 29 months, range 3-61), 1 patient (8%) was symptomatic. CONCLUSION Conservative management for CBA appears to be safe. Surgery should be reserved for patients with symptomatic or complicated cases.
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Affiliation(s)
- Angelo Zarfati
- General and Thoracic Pediatric Surgery Unit, Bambino Gesù' Children Hospital, Rome, Italy
| | - Valerio Voglino
- General and Thoracic Pediatric Surgery Unit, Bambino Gesù' Children Hospital, Rome, Italy
| | - Paolo Tomà
- Pediatric Radiology Unit, Bambino Gesù' Children Hospital, Rome, Italy
| | - Renato Cutrera
- Pediatric Broncopneumology, Bambino Gesù' Children Hospital, Rome, Italy
| | - Simone Frediani
- General and Thoracic Pediatric Surgery Unit, Bambino Gesù' Children Hospital, Rome, Italy
| | - Alessandro Inserra
- General and Thoracic Pediatric Surgery Unit, Bambino Gesù' Children Hospital, Rome, Italy
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24
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Gardner JR, Navuluri S, Small M, Richter GT. Superabsorbent Gel Polymer Aspiration and Erosion Into Mediastinum. OTO Open 2021; 5:2473974X211023020. [PMID: 34179679 PMCID: PMC8202283 DOI: 10.1177/2473974x211023020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- James Reed Gardner
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Sriram Navuluri
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mariah Small
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Gresham Thomas Richter
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Division of Pediatric Otolaryngology, Arkansas Children's Hospital, Little Rock, Arkansas, USA
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25
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Regier PJ, Gallastegui A, Craft WF. Successful Treatment of Congenital Lobar Emphysema in Multiple Lung Lobes in an English Bulldog Puppy. J Am Anim Hosp Assoc 2021; 57:96-100. [PMID: 33450005 DOI: 10.5326/jaaha-ms-7088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2020] [Indexed: 11/11/2022]
Abstract
A 5 mo old male intact English bulldog was evaluated at a veterinary referral hospital for acute respiratory distress and chronic difficulty breathing. Thoracic radiographs revealed multifocal pulmonary hyperinflation and hyperlucency suspected in the left caudal and accessory lung lobes. A thoracic computed tomography scan identified severe diffuse enlargement of the caudal subsegment of the left cranial lung lobe and the dorsal process of the accessory lung lobe, with parenchymal hypoattenuation, rounded margins, and thin pulmonary vessels. Based on clinical signs and imaging findings, he was diagnosed with suspect congenital lobar emphysema in multiple lung lobes. A median sternotomy was performed, which revealed a hyperinflated, emphysematous left cranial lung lobe (caudal subsegment) and accessory lung lobe for which two lung lobectomies were performed. The remaining lung lobes were small and atelectatic. Histopathology revealed bronchial cartilage hypoplasia and aplasia and findings consistent with congenital lobar emphysema. The puppy recovered well from surgical treatment of congenital lobar emphysema, requiring multiple lung lobectomies, with subsequent computed tomography-evidenced re-expansion of the remaining lung lobes 3 mo after surgery. The patient is still alive 1 yr after surgery with a normal activity level and no evidence of respiratory compromise.
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26
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Cheng L, Duan J, Wang M, Lu D, Li H, Ma J, Liu J, Wang C, Zhang Y. Case Report: Prenatal and Postnatal Management for Fetal Bronchogenic Cysts During the COVID-19 Pandemic. Front Pediatr 2021; 9:675883. [PMID: 34307253 PMCID: PMC8292643 DOI: 10.3389/fped.2021.675883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/08/2021] [Indexed: 12/14/2022] Open
Abstract
Background: A fetal bronchogenic cyst (BC) is a rare congenital anomaly with an incidence of 0.147-0.238‰. The coronavirus disease 2019 (COVID-19) pandemic, as a particular situation, hindered pregnant women from receiving periodic prenatal checkups. Case Description: Until 34+6 weeks of gestation, a fetal case of the intrathoracic cyst was found by ultrasound examination. Further, MRI examination confirmed the diagnosis of the congenital mediastinal cystic lesion, probably a BC. Genetic testing was not conducted due to the COVID-19 pandemic. At 38+5 weeks of gestation with maternal COVID-19 testing negative, a live girl was delivered by cesarean section. Five months later, the child underwent bronchocystectomy, and the postoperative pathological lesions confirmed a (right upper mediastinum) BC. Conclusion: Herein, we reported the prenatal and postnatal management for a rare case of the congenital BC by multidisciplinary approaches during the COVID-19 pandemic. Fetal MRI and screening for fetal chromosomal abnormalities are especially recommended. This case contributes to the awareness that the COVID-19 pandemic interferes with regular follow-up schedules during pregnancy and may interfere with timely performed additional tests; which leads to more accurate genetic counseling. A combination of multidisciplinary approaches, including radiology, infection control, genetic counseling, obstetrics, and pediatric surgery, is pivotal for managing fetal BC during the COVID-19 pandemic.
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Affiliation(s)
- Lin Cheng
- Department of Obstetrics and Gynecology, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Clinical Research Center for Prenatal Diagnosis and Birth Health, Wuhan, China.,Wuhan Clinical Research Center for Reproductive Science and Birth Health, Wuhan, China
| | - Jie Duan
- Department of Obstetrics and Gynecology, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Clinical Research Center for Prenatal Diagnosis and Birth Health, Wuhan, China.,Wuhan Clinical Research Center for Reproductive Science and Birth Health, Wuhan, China
| | - Mei Wang
- Department of Obstetrics and Gynecology, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Clinical Research Center for Prenatal Diagnosis and Birth Health, Wuhan, China.,Wuhan Clinical Research Center for Reproductive Science and Birth Health, Wuhan, China
| | - Dan Lu
- Hubei Clinical Research Center for Prenatal Diagnosis and Birth Health, Wuhan, China.,Wuhan Clinical Research Center for Reproductive Science and Birth Health, Wuhan, China.,Department of Ultrasound Imaging, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Huan Li
- Hubei Clinical Research Center for Prenatal Diagnosis and Birth Health, Wuhan, China.,Wuhan Clinical Research Center for Reproductive Science and Birth Health, Wuhan, China.,Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jianhong Ma
- Department of Obstetrics and Gynecology, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Clinical Research Center for Prenatal Diagnosis and Birth Health, Wuhan, China.,Wuhan Clinical Research Center for Reproductive Science and Birth Health, Wuhan, China
| | - Juan Liu
- Department of Obstetrics and Gynecology, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Clinical Research Center for Prenatal Diagnosis and Birth Health, Wuhan, China.,Wuhan Clinical Research Center for Reproductive Science and Birth Health, Wuhan, China
| | - Cheng Wang
- Department of Obstetrics and Gynecology, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Clinical Research Center for Prenatal Diagnosis and Birth Health, Wuhan, China.,Wuhan Clinical Research Center for Reproductive Science and Birth Health, Wuhan, China
| | - Yuanzhen Zhang
- Department of Obstetrics and Gynecology, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Clinical Research Center for Prenatal Diagnosis and Birth Health, Wuhan, China.,Wuhan Clinical Research Center for Reproductive Science and Birth Health, Wuhan, China
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27
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ATS Core Curriculum 2020. Pediatric Pulmonary Medicine. ATS Sch 2020; 1:456-475. [PMID: 33870313 PMCID: PMC8015762 DOI: 10.34197/ats-scholar.2020-0022re] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine, in a 3- to 4-year recurring cycle of topics. These topics will be presented at the 2020 International Conference. Below is the pediatric pulmonary medicine core, including pediatric hypoxemic respiratory failure; modalities in noninvasive management of chronic respiratory failure in childhood; surgical and nonsurgical management of congenital lung malformations; an update on smoke inhalation lung injury; an update on vaporizers, e-cigarettes, and other electronic delivery systems; pulmonary complications of sarcoidosis; pulmonary complications of congenital heart disease; and updates on the management of congenital diaphragmatic hernia.
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Wong MCY, Faure Bardon V, Farmakis K, Berteloot L, Lapillonne A, Delacourt C, Sarnacki S, Ville Y, Khen-Dunlop N. Ultrasound detected prenatal hyperechoic lung lesions and concordance with postnatal findings: A common aspect for multiple diagnoses. Prenat Diagn 2020; 41:323-331. [PMID: 33111324 DOI: 10.1002/pd.5854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/20/2020] [Accepted: 10/23/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hyperechoic lung lesions are largely detected prenatally but their underlying etiology is still poorly defined. The aim of the study was to determine the concordance between pre and postnatal diagnosis of hyperechoic lung lesions. METHODS Prenatal ultrasound (US) evaluation was performed by a fetal medicine specialist. Postnatal diagnosis was based on CT-scan. Pre- and postnatal features were retrieved from medical charts. RESULTS Seventy five patients were included from January 2009 to December 2018. Main prenatal diagnoses were bronchopulmonary sequestrations (BPS) (n = 24%-32%), pulmonary cystic malformations (PCM) (n = 19%-25%), congenital lobar emphysemas (CLE) (n = 15%-20%). Mediastinal shift was observed in 18 cases (24%). The prenatal detection of a systemic arterial supply had a diagnostic accuracy of 90%, while the prenatal detection of a cystic component had a diagnostic accuracy of 76.5%. All 16 neonates with prenatal isolated mediastinal shift were asymptomatic at birth. Seven neonates showed respiratory distress that was not predicted prenatally. CONCLUSIONS Hyperechoic lung malformations reflect a heterogeneous group of lesions with a good concordance for bronchopulmonary sequestration, but not a satisfying prediction for cystic lesions.
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Affiliation(s)
- Michela Cing Yu Wong
- Department of Pediatric Surgery, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Valentine Faure Bardon
- Department of Obstetrics, Hôpital Necker-Enfants Malades, AP-HP, Paris, France.,Université de Paris, Paris, France
| | - Konstantinos Farmakis
- Department of Pediatric Surgery, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Laureline Berteloot
- Department of Pediatric Radiology, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Alexandre Lapillonne
- Université de Paris, Paris, France.,Department of Neonatal Intensive Care, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Christophe Delacourt
- Department of Pediatric Pulmonology, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Sabine Sarnacki
- Department of Pediatric Surgery, Hôpital Necker-Enfants Malades, AP-HP, Paris, France.,Université de Paris, Paris, France
| | - Yves Ville
- Department of Obstetrics, Hôpital Necker-Enfants Malades, AP-HP, Paris, France.,Université de Paris, Paris, France
| | - Naziha Khen-Dunlop
- Department of Pediatric Surgery, Hôpital Necker-Enfants Malades, AP-HP, Paris, France.,Université de Paris, Paris, France
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29
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Reyna JC, Zagory JA, Yallapragada S, Santiago-Munoz P, Schindel DT. Impact of Additional Anomalies on Postnatal Outcomes in Congenital Lung Malformations. J Surg Res 2020; 256:611-617. [PMID: 32810660 DOI: 10.1016/j.jss.2020.07.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/29/2020] [Accepted: 07/11/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Approximately 20% of fetuses diagnosed with congenital lung malformations (CLMs) are found to have additional anomalies. We aim to determine if additional anomalies have an impact on postnatal outcomes for patients with CLMs. METHODS After institutional review board approval, we performed a retrospective review of live-born patients with CLMs from 2008 to 2018. All patients were prenatally diagnosed with CLMs. Clinical information pertaining to additional congenital anomalies and outcomes was collected from the electronic health record and analyzed. RESULTS Of the 88 patients who had a prenatal diagnosis of CLMs, 20.5% had additional anomalies. Ten of the 18 patients (56%) were considered to have a major anomaly in addition to CLMs. Outcomes for patients electing nonoperative management of CLMs were similar between those with and without an additional anomaly. Although patients with an additional anomaly were more likely to have perinatal respiratory complications (44% versus 17%, P = 0.03), the number of preoperative clinic and emergency department visits, age at surgery, minimally invasive approach to surgical resection of CLM, estimated blood loss, length of hospital stay, intubation, duration of intubation, 30-day postoperative complications, and long term sequelae were not statistically different. This held true when stratified for major versus minor anomalies. CONCLUSIONS Twenty percent of fetuses diagnosed with CLM in our population have additional anomalies. Newborns with additional anomalies have a higher risk of pre-excision pulmonary complications. However, the overall outcomes of all patients with CLMs are similar.
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Affiliation(s)
- Juan C Reyna
- Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jessica A Zagory
- Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - David T Schindel
- Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
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30
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Saleh ME, Beshir H, Awad G, ElDerie A, Sanad M. Surgical outcomes for pediatric congenital lung malformation: 13 years' experience. Indian J Thorac Cardiovasc Surg 2020; 36:608-618. [PMID: 32837048 PMCID: PMC7418582 DOI: 10.1007/s12055-020-00977-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/21/2020] [Accepted: 05/27/2020] [Indexed: 12/15/2022] Open
Abstract
Background Congenital lung malformations (CLM) are a gamut of lesions that originate throughout the embryonic period and manifest in the neonatal or sporadically in the prenatal period, characteristically might stay well for some time, to be found inadvertently or to present with complications. In the 13 years from Jan. 2003 to Dec. 2015, this prospective cohort study included consecutive pediatric patients under 12 years old, who presented either emergently or electively with any variety of CLM. The lesions encompassed in this assortment were congenital lobar emphysema (CLE), congenital pulmonary airway malformation (CPAM), bronchogenic cysts (BC), and bronchopulmonary sequestration (BPS). Results Sixty-eight pediatric patients with CLM were operated at our institution; 18 CPAMs, 22 CLEs, 19 BPSs (17 intralobar and 2 extralobar), and 9 patients with BCs. The patients’ age ranged from 1 to 54 months (mean age of 10.73 ± 9.73 months), with overall male gender predominance (61.76%). Both CLE and CPAM had a male predominance, while BC and BPS had equivocal gender distribution. CLE patients had the earliest presentation at 2.89 ± 1.5 months and congenital cystic adenomatoid malformations (CCAM) had the latest presentation at 21.78 ± 15.6 months (F = 15.27, p < 0.0001). Lobectomy was the commonest procedure performed. Fifty-nine lobectomies were performed (21 LUL, 15 RLL, 14 LLL, 8 RUL, and 1 middle lobectomy). Six cystectomies were performed for BC. Twenty-three cases (33.8%) had postoperative complications that were mainly significant or prolonged air leak (13.24%), pneumonia (5.88%), 3 cases of hemothorax (4.4%), pulmonary atelectasis in 2 patients (2.94%), 1 patient developed effusion (1.47%), and there were 2 mortalities. Conclusions CLM must be in mind in the differential diagnoses of any case with repeated infection, respiratory distress, or radiological abnormalities. Surgery in the form of lobectomy or lesser resection is generally safe. Electronic supplementary material The online version of this article (10.1007/s12055-020-00977-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Hatem Beshir
- Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University, Mansoura, Egypt.,Department of Cardiothoracic Surgery, Egypt Ministry of Health and Population, Alexandria, Egypt
| | - Gehad Awad
- Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ahmad ElDerie
- Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohammed Sanad
- Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University, Mansoura, Egypt.,Department of Cardiothoracic Surgery, Egypt Ministry of Health and Population, Nasser Institute for Research and Treatment, Cairo, Egypt
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31
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Applications of Pediatric Body CT Angiography: What Radiologists Need to Know. AJR Am J Roentgenol 2020; 214:1019-1030. [DOI: 10.2214/ajr.19.22274] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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32
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Affiliation(s)
- Akshaya Vachharajani
- Department of Newborn Medicine, Washington University School of Medicine, St Louis, MO
| | - Maja Herco
- Department of Newborn Medicine, Washington University School of Medicine, St Louis, MO
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33
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Leith E, Aurora P, Wallis C. Images in paediatrics: An infant with a persistent cough and an unusual course of the nasogastric tube. Arch Dis Child 2020; 105:199. [PMID: 30120143 DOI: 10.1136/archdischild-2018-315524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2018] [Indexed: 11/04/2022]
Affiliation(s)
| | - Paul Aurora
- Respiratory Unit, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
| | - Colin Wallis
- Respiratory Unit, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
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34
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Cherian SV, Kumar A, Ocazionez D, Estrada -Y- Martin RM, Restrepo CS. Developmental lung anomalies in adults: A pictorial review. Respir Med 2019; 155:86-96. [PMID: 31326738 DOI: 10.1016/j.rmed.2019.07.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 06/03/2019] [Accepted: 07/05/2019] [Indexed: 11/16/2022]
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Abstract
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.
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Affiliation(s)
- Michael Zobel
- Fetal Treatment Center, Department of Surgery, University of California, San Francisco
| | - Rebecca Gologorsky
- Fetal Treatment Center, Department of Surgery, University of California, San Francisco
| | - Hanmin Lee
- Fetal Treatment Center, Department of Surgery, University of California, San Francisco
| | - Lan Vu
- Fetal Treatment Center, Department of Surgery, University of California, San Francisco.
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36
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Gopikrishna S, Henry A, Kaur S, Shand AW, Jiwane A, Dyer K, Welsh AW. A 9-year audit of fetal chest masses in an Australian maternal-fetal medicine cohort. Australas J Ultrasound Med 2019; 22:191-199. [PMID: 34760556 DOI: 10.1002/ajum.12161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/17/2019] [Accepted: 05/06/2019] [Indexed: 11/06/2022] Open
Abstract
Introduction To assess fetal vs. neonatal diagnoses, pregnancy outcomes and need for surgery in babies prenatally diagnosed with congenital pulmonary airway malformation (CPAM) or bronchopulmonary sequestration (BPS). Methods Retrospective single-centre cohort study of fetuses with a prenatal diagnosis of CPAM or BPS between 2006 and 2014. Data collected included serial antenatal ultrasound information and neonatal/infant diagnoses and outcomes. Results Initial ultrasound diagnosis (n = 63) was CPAM in 51 and BPS in 12: nineteen (30%) fetuses had mediastinal shift and 2 (3%) had hydrops. All neonates with known birth outcome (n = 56) were liveborn. Final diagnosis in 52 infants (83%) with neonatal imaging and/or histopathology confirmed CPAM in 17/44 (39%) and BPS in 6/9 (67%). Of 34 prenatally suspected but unconfirmed CPAM lesions: 10 had no lesion on neonatal imaging, one no neonatal imaging performed, five confirmed BPS, 11 other lung/thoracic lesions, seven were lost to follow-up. There was one infant death. 27/63 infants (43%) had post-natal surgery. More neonates requiring neonatal respiratory support/resuscitation had surgery compared to those who did not (67% vs. 29%, P = 0.008). Patients with suspected CPAM or BPS on both initial and final ultrasound were more likely to have post-natal surgical management than when a lesion was no longer visible on final antenatal ultrasound (68% vs. 23%, P = 0.001). Conclusions Over 50% of antenatally suspected CPAM/BPS either regressed or had an alternate post-natal diagnosis. Perinatal outcome was good, with the majority of neonates/infants conservatively managed. Persistently visible antenatal lesion and need for neonatal respiratory support predicted ultimate surgical management.
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Affiliation(s)
- Saranya Gopikrishna
- School of Women's & Children's Health, Faculty of Medicine University of New South Wales Randwick New South Wales Australia
| | - Amanda Henry
- School of Women's & Children's Health, Faculty of Medicine University of New South Wales Randwick New South Wales Australia.,Department of Maternal-Fetal Medicine Royal Hospital for Women Randwick New South Wales Australia.,Department of Obstetrics & Gynaecology St George Hospital Kogarah New South Wales Australia
| | - Simren Kaur
- Faculty of Medicine University of New South Wales Randwick New South Wales Australia
| | - Antonia W Shand
- School of Women's & Children's Health, Faculty of Medicine University of New South Wales Randwick New South Wales Australia.,Department of Maternal-Fetal Medicine Royal Hospital for Women Randwick New South Wales Australia.,Children's Hospital at Westmead Clinical School The University of Sydney Sydney New South Wales Australia
| | - Ashish Jiwane
- Department of Paediatric Surgery Sydney Children's Hospital Sydney New South Wales Australia
| | - Kate Dyer
- Department of Maternal-Fetal Medicine Royal Hospital for Women Randwick New South Wales Australia
| | - Alec W Welsh
- School of Women's & Children's Health, Faculty of Medicine University of New South Wales Randwick New South Wales Australia.,Department of Maternal-Fetal Medicine Royal Hospital for Women Randwick New South Wales Australia
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37
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Alebna PA, Kim DH, Chaudhary R, Tavares M. Pulmonary hypertension and congenital bronchial atresia: A time factor association. Respir Med Case Rep 2019; 28:100882. [PMID: 31297310 PMCID: PMC6597737 DOI: 10.1016/j.rmcr.2019.100882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 06/11/2019] [Accepted: 06/11/2019] [Indexed: 12/19/2022] Open
Abstract
Congenital bronchial atresia is rarely symptomatic in adults. Recurrent lung infection and pneumothorax are the feared complications of this otherwise benign condition. The objective of this article is to present a case of congenital bronchial atresia manifesting as pulmonary hypertension in a 66 year-old patient. While doing so, we highlight the relevant knowledge accrued in medical literature with regards this rare condition. Finally, with the revelation that congenital bronchial atresia may cause severe pulmonary hypertension later in life, perhaps a less conservative approach to management may be warranted in younger adults and children with this condition.
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Affiliation(s)
| | - David H. Kim
- George Washington University, Washington, DC, United States
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38
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Abstract
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.].
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39
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Phelps A, Tan C, Ahuja S, Kolnick D, Courtier J, MacKenzie JD. Visualization of pleural fissures in infants on computed tomography. WORLD JOURNAL OF PEDIATRIC SURGERY 2019. [DOI: 10.1136/wjps-2018-000034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PurposeFor infants with prenatally detected lung lesions, a chest CT is performed prior to surgery. The chest CT is performed as close to the surgery date as possible, because it is presumed that the visualization of lung fissures would be poor in the immediate neonatal setting. However, this presumption has never been formally studied. The purpose of this study is to assess differences in lung fissure visualization on chest CT in different infant age groups.MethodsThis was a retrospective study of clinically indicated chest CT approved by the institutional review board performed in infants of different ages. The visibility of pleural fissures was subjectively assessed by three pediatric radiologists who were blinded to age group.ResultsIn the 0–2 months age group, 80% of all fissure segments were visible versus 92% in the 5–6 months group (p=0.04) and 95% in the 7–9 months group (p=0.01).ConclusionsThe ability to visualize pleural fissures on CT increases with infant age. This observation should be taken into consideration when choosing the optimal timing of preoperative CT for asymptomatic congenital lung lesions.
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40
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Style CC, Cass DL, Verla MA, Cruz SM, Lau PE, Lee TC, Fernandes CJ, Keswani SG, Olutoye OO. Early vs late resection of asymptomatic congenital lung malformations. J Pediatr Surg 2019; 54:70-74. [PMID: 30366720 DOI: 10.1016/j.jpedsurg.2018.10.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 10/01/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE To examine postsurgical outcomes of a consecutive series of children treated with elective operations for congenital lung malformations (CLM). METHODS A retrospective review was performed on a prospectively collected dataset of all fetuses evaluated for a CLM between July 2001 and June 2016. Prenatal findings, operative treatment and postnatal outcomes were collected. Children having elective operations were divided in two groups based on age at time of surgery. RESULTS Of 220 fetuses, 143 had operations and follow-up at our center. Six had open fetal lobectomy, 17 had EXIT-to-resection, 16 infants had urgent resection for symptoms and 110 with asymptomatic lesions had elective resection. Of these 110, the median fetal maximum CVR was 0.8 [range 0.1-2.2], and median age at operation was 4 (1.5-60) months (58% had resection at ≤4 months). Overall complication rate, including air-leak and pleural effusion, was 15%. When comparing those having resection at ≤4 months to those >4 months, there were no significant differences in complication rates or length of stay. Operative time was shorter for patients with early resection (154 ± 59 vs 181 ± 89, p = 0.05). No infant having resection at ≤4 months was readmitted. Overall, children survived with good recovery. CONCLUSION Early elective resection of congenital lung malformations prior to 4 months of age is feasible and not associated with increased operative risk. TYPE OF STUDY Restropective study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Candace C Style
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | | | - Mariatu A Verla
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Stephanie M Cruz
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX
| | - Patricio E Lau
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Timothy C Lee
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | | | - Sundeep G Keswani
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Oluyinka O Olutoye
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX.
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Annunziata F, Bush A, Borgia F, Raimondi F, Montella S, Poeta M, Borrelli M, Santamaria F. Congenital Lung Malformations: Unresolved Issues and Unanswered Questions. Front Pediatr 2019; 7:239. [PMID: 31249823 PMCID: PMC6584787 DOI: 10.3389/fped.2019.00239] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 05/28/2019] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Federica Annunziata
- Division of Paediatrics, Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Andrew Bush
- Department of Paediatrics and Paediatric Respiratory Medicine, Imperial College and Royal Brompton Hospital, London, United Kingdom
| | - Francesco Borgia
- Divisions of Cardiology and Cardiothoracic Surgery, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Francesco Raimondi
- Division of Paediatrics, Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Silvia Montella
- Division of Paediatrics, Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Marco Poeta
- Division of Paediatrics, Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Melissa Borrelli
- Division of Paediatrics, Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Francesca Santamaria
- Division of Paediatrics, Department of Translational Medical Sciences, Federico II University, Naples, Italy
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