Two decades of experience with thoracoscopic lobectomy in infants and children: standardizing techniques for advanced thoracoscopic surgery

Evaluation of Thoracoscopic Lobectomy in Infants for Congenital Lung Lesions: Earlier Is Better!

OBJECTIVES

This study evaluates the safety and efficacy of thoracoscopic lobectomy for congenital lung lesions in infants less then 4 months of age.

MATERIALS AND METHODS

From January 1997 to October 2022, 194 patients under 4 months of age and weight less then 5.6 Kg underwent video-assisted thoracoscopic lobe resection for CPAM, Sequestration, and CLE. All procedures were performed by or under the direct guidance of a single surgeon.

RESULTS

195 of 196 procedures were completed thoracoscopically. Operative times ranged from 25 min to 195 min (average, 82 min). There were 50 upper, 8 middle, and 136 lower lobe resections. There were 4 intraoperative complications (2.1 %), of which 1 (0.5 %) required conversion to an open thoracotomy. The postoperative complication rate was 3.1 % Hospital length of stay ranged from 1 to 8 days (Avg 1.8) for those admitted for surgery. There were no conversions to open or blood transfusions in the last 15 years.

CONCLUSIONS

Thoracoscopic lung resection congenital lung lesions in infants is a safe and efficacious technique and avoids the morbidity of a thoracotomy. Early intervention allows surgery before clinical infections or symptoms occur. Newer instrumentation and techniques allow the operation to be safely performed in the first few months of life with shorter operative times, fewer complications, and decreased hospital stays. The minimal morbidity of this procedure should be considered when considering non-operative management of these patients.

LEVEL OF EVIDENCE: 3

Congenital lung malformations

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.

Nationwide Outcomes After Thoracoscopic Versus Open Resection of Congenital Pulmonary Airway Malformations in Newborns

Purpose: Elective resection of congenital pulmonary airway malformations (CPAM) has been debated for decades and varies significantly between individual surgeons. However, few studies have compared outcomes and costs associated with thoracoscopic and open thoracotomy approaches on a national level. This study sought to compare nationwide outcomes and resource utilization in infants undergoing elective lung resection for CPAM. Materials and Methods: The Nationwide Readmission Database was queried from 2010 to 2014 for newborns who underwent elective surgical resection of CPAM. Patients were stratified by operative approach (thoracoscopic versus open). Demographics, hospital characteristics, and outcomes were analyzed using standard statistical tests. Results: A total of 1716 newborns with CPAM were identified. Elective readmission for pulmonary resection was performed in 12% (n = 198), with 63% of resections completed at a different hospital than the newborn stay. Most resections were thoracoscopic (75%), compared to only 25% via thoracotomy. Infants treated with thoracoscopic resection were more often male (78% versus 62% open, P = .040) and were older at the time of resection. Patients who had an open thoracotomy experienced a higher rate of serious complications (40% versus 10% thoracoscopic, P < .001), including postoperative hemorrhage, tension pneumothorax, and pulmonary collapse. Readmission costs were higher for infants treated via thoracotomy (P < .001). Conclusion: Thoracoscopic lung resection for CPAM is associated with lower cost and fewer postoperative complications than thoracotomy. Most resections are performed at different hospitals than the place of birth, which may affect long-term outcomes from single institutional studies. These findings may be used to address costs and improve future evaluations of elective CPAM resections.

Thoracoscopic Clockwise Lobectomy May Be a Stylized Procedure for Treating Children with Congenital Lung Malformations

Background: Thoracoscopic lobectomy is a challenging procedure in children with congenital lung malformations (CLMs). This study aims to evaluate the safety and efficacy of thoracoscopic clockwise lobectomy (TCL) in CLMs in children and its potential to be a stylized procedure. Methods: All patients with CLMs who received TCL from 2015 to 2019 in our hospital were retrospectively reviewed. Clinical information was extracted from medical records, including patient demographics, operative details, and outcomes. Results: A total of 184 patients with a median age of 6.8 months (range, 3-156) and a median weight of 9 kg (range, 6-45) received TCL. Lesions were all located in the lower lobe and included congenital pulmonary airway malformation (n = 133), intralobar sequestration (n = 44), bronchiectasis (n = 4), and congenital lobar emphysema (n = 3). The mean (±standard deviation [SD]) operating time was 46 ± 7.5 minutes (range, 35-113). The mean (±SD) blood loss was 3.5 ± 0.8 mL (range, 1-60). Three patients converted to thoracotomy, and 162 patients did not have a chest tube placed. The postoperative course was uneventful in all patients except 2 patients who developed air leaks and 23 patients who developed a mild fever. The median length of postoperative hospital stay was 2 days. A total of 163 patients were followed up for more than 1 year without any complications. Conclusion: TCL is suitable for lower lobectomy and is safe and effective in standard and complicated thoracoscopic lobectomy. It could be recommended as a stylized procedure in treating children with CLMs.

Arterial Embolization and Methylene Blue Injection into the Aberrant Artery in Two Infants with Intralobar Sequestration

Bronchopulmonary sequestration is a rare congenital lung dysplasia. An intralobar sequestration (ILS) is a nonfunctional mass within the lung parenchyma without bronchial communication and with aberrant systemic arterial blood supply. Surgical resection or close observation can be proposed in the management of asymptomatic and low-risk ILS, but there is a lack of consensus. Endovascular embolization before thoracoscopic resection of ILS has been described to limit perioperative bleeding. Another technique previously reported is the injection of methylene blue in the feeding artery to macroscopically mark the sequestration from the healthy lung. In that way, a nonanatomical resection can be performed instead of a lobectomy without the risk of leaving abnormal lung tissue in place. We describe the first two cases of these two techniques combined: a 3-year-old girl with an ILS in the right lower lobe with an artery originating from the abdominal aorta, and a 14-month-old girl with an ILS in the right lower lobe with an artery coming from the celiac trunk. The combination of embolization and injection of methylene blue in the aberrant artery leads to a clear macroscopic demarcation of the blue-colored ILS from the healthy lung parenchyma and allowed safe nonanatomical resection of the ILS without risk of bleeding or compromising normal lung tissue.

Comparison of Endobronchial Intubation Versus Bronchial Blockade for Elective Pulmonary Lobectomy of Congenital Lung Anomalies in Small Children

Purpose: Resection of many congenital lung lesions is commonly performed under single-lung ventilation, which helps collapse the lung being manipulated and enables a thoracoscopic approach in most cases. We set out to determine whether lung isolation achieved by either main stem intubation or usage of a bronchial blocker was associated with superior clinical outcomes. Materials and Methods: A retrospective review of all patients aged <2 years undergoing elective pulmonary lobectomy for congenital lung malformations at a tertiary-care pediatric hospital from 2011 through 2020 was performed. Demographic data, diagnosis type, type of lung isolation method employed, and perioperative outcomes were recorded. Continuous variables were analyzed with Student's t-tests, whereas categorical variables were analyzed with Fisher's exact tests and chi-square tests. Results: Thirty-two patients were analyzed-17 were managed with a bronchial blocker while 15 underwent main stem intubation. The most common diagnoses were congenital pulmonary airway malformations (53.1%) and intralobar bronchopulmonary sequestrations (34.4%). Patients managed with main stem intubation were slightly younger (P = .06) than those for which a bronchial blocker was used. Thirty-one (96.9%) resections were initiated thoracoscopically. Main stem intubation was associated with shorter operative times (P = .01), shorter anesthetic times (P = .02), and less blood loss (P = .04). No differences in length of stay (P = .64), conversation to thoracotomy (P = .35), intraoperative complications (P = .23), or postoperative complications (P = .49) were observed. Conclusion: Lung isolation through main stem intubation, when compared with bronchial blockers, is associated with shorter operative time, shorter anesthetic exposure, and diminished blood loss in pediatric patients undergoing lobectomy for congenital lung anomalies.

Comparison of single-port, multi-port video-assisted thoracoscopic and open lobectomy for children: a single-center experience

PURPOSE

The feasibility of single-port video-assisted thoracic surgery (SPVATS) for pediatric lobectomy has not been clearly established. We compared the feasibilities of single-port (SP), multi-port (MP) VATS and open lobectomy (OL) for surgical treatment of children with lung disease.

METHODS

In this study, we retrospectively analyzed and compared data for 22,19 and 30 pediatric lung disease patients who had been subjected to SP, MP and OL, respectively. These procedures were performed between March, 2012 and August, 2020 at the Second Affiliated Hospital of Wenzhou Medical University. Perioperative clinical indicators were analyzed.

RESULTS

Compared to OL, SP was associated with lower intraoperative blood loss (p = 0.008), lower postoperative thoracic drainage volume (p = 0.041), shorter chest drainage duration (p = 0.002) and hospital stay (p = 0.001). Operation time (p = 0.437), volume of estimated blood loss (p = 0.979), conversion rate to thoracotomy (p = 0.861), total thoracic drainage volume (p = 0.824), duration of chest tube drainage (p = 0.543), length of hospital stay (p = 0.812) and incidences of postoperative complications were comparable in MP and SP groups.

CONCLUSION

SPVATS is a safe and feasible approach for lobectomy in pediatrics, with comparable postoperative clinical outcomes to MPVATS and better outcomes relative to OL. However, studies with large sample sizes in multicenter should be performed to verify our findings.

Anesthesia for thoracic surgery in infants and children

The management of infants and children presenting for thoracic surgery poses a variety of challenges for anesthesiologists. A thorough understanding of the implications of developmental changes in cardiopulmonary anatomy and physiology, associated comorbid conditions, and the proposed surgical intervention is essential in order to provide safe and effective clinical care. This narrative review discusses the perioperative anesthetic management of pediatric patients undergoing noncardiac thoracic surgery, beginning with the preoperative assessment. The considerations for the implementation and management of one-lung ventilation (OLV) will be reviewed, and as will the anesthetic implications of different surgical procedures including bronchoscopy, mediastinoscopy, thoracotomy, and thoracoscopy. We will also discuss pediatric-specific disease processes presenting in neonates, infants, and children, with an emphasis on those with unique impact on anesthetic management.

Comprehensive assessment of the quality and reliability of the ten most-viewed YouTube videos on thoracoscopic lobectomy in children: a comparison from the available videos on a peer-reviewed platform

BACKGROUND

Surgery residents often consider learning from the operative videos on YouTube, however, the quality of these videos is questionable. We aim to compare the quality and reliability of operative videos on thoracoscopic lobectomy (TL) in children available on YouTube (YT) and WebSurg (WS).

METHODS

Using a defined search strategy, the most-viewed YT videos and all available WS videos on TL in children were identified. The quality and reliability of the two groups of videos were compared using the video popularity index (VPI), Journal of American Medical Association (JAMA) benchmark criteria, and LAP-VEGaS quality assessment tool. On the basis of the LAP-VEGaS score, the videos were divided into acceptable quality (score ≥ 11) or poor quality (score < 11).

RESULTS

Ten most-viewed YT videos were compared with six relevant videos on WS. The median %VPI among the WS and YT videos were 83.3 (range 71.5-404.4) and 49.4 (range 0-270), respectively (p = 0.017). The median JAMA score of the WS videos was also significantly higher than the YT videos (p = 0.0003). In terms of the LAP-VEGaS scores, all WS videos versus only three YT had an acceptable quality.

CONCLUSIONS

As compared to the WS videos, the quality and reliability of the YT videos on TL were significantly poorer.

Learning curve for total thoracoscopic lobectomy for treating pediatric patients with congenital lung malformation

BACKGROUND

Pediatric thoracoscopic lobectomy is a technically challenging procedure that may result in better pain control, better cosmetic results, and shorter hospital stay. However, data describing the learning curve of total thoracoscopic lobectomy (TTL) have yet to be obtained. To evaluate our learning curve for TTL in children, we reviewed the safety and efficiency of our initial experiences with TTL in pediatric patients with congenital lung malformation.

METHODS

This was a retrospective study of all pediatric patients undergoing TTL between March 2011 and January 2017. Cumulative summation (CUSUM) analysis of operative time (OT) was used.

RESULTS

One hundred patients were retrospectively analyzed and chronologically divided into three phases: the ascending (A), plateau (B), and descending (C) phases of CUSUM of OT. Phases A, B, and C comprised 35, 22, and 43 cases, respectively. OT decreased significantly from phases A to B (P = 0.035) and B to C (P = 0.019). Age and weight of patients both reduced significantly from phase A to B (p = 0.017 and p = 0.012, respectively), while the two measures did not vary from phase B to C (p = 0.987 and p = 0.874, respectively). Chest tube duration and length of hospital stay had similar trend. All complications occurred in five cases in phase A (5/35). Six cases were converted to open surgery (6%). Four conversions occurred within phase A and two in phase C (4/35 vs 2/43, p = 0.490). There were no mortalities.

CONCLUSIONS

Repeated standardized training plays a role in overcoming the learning curve for thoracoscopic lobectomy in children, and CUSUM_OT indicates that a learning curve of approximately 57 cases is required in our institute.

Thoracoscopic Lobectomy in Infants and Children

Indications for pulmonary lobectomy in infants and children include cystic pulmonary adenomatoid malformation, congenital lobar emphysema, chronic infection, and malignancy. These procedures can now all be done thoracoscopically avoiding the short- and long-term morbidity of an open thoracotomy. In this article we describe the technique of thoracoscopic lobectomy as well as the preoperative and postoperative care.

Computer-aided quantitative MSCT measurements may be useful for congenital lung malformations surgical approach selection

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 (V_lesion), the volume of the lesion-involved lobe (V_lobe), the volume of the lesion-involved lung (V_lung) and the volume of the total lung (V_{total lung}). The proportions of V_lesion to V_lobe (P_lesion/lobe), V_lesion to V_lung (P_lesion/lung), and V_lesion to V _{total lung} (P_{lesion/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. V_lesion (OR 1.51, 95% CI 1.09-2.07), P_lesion/lobe (OR 1.78, 95% CI 1.16-2.72), P_lesion/lung (OR 1.63, 95% CI 1.13-2.35), and P_{lesion/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.

Robotic lobectomy in children with severe bronchiectasis: A worthwhile new technology

BACKGROUND/PURPOSE

Lobectomy is required in children affected by non-responsive, symptomatic, localized bronchiectasis, but inflammation makes thoracoscopy challenging. We present the first published series of robotic-assisted pulmonary lobectomy in children with bronchiectasis.

METHODS

Retrospective analysis of all consecutive patients who underwent pulmonary lobectomy for severe localized bronchiectasis (2014-2019) via thoracoscopic versus robotic lobectomy. Four 5 mm ports were used for thoracoscopy; a four-arm approach was used for robotic surgery (Da Vinci Surgical Xi System, Intuitive Surgical, California).

RESULTS

Eighteen children were operated (robotic resection, n = 7; thoracoscopy, n = 11) with infected congenital pulmonary malformation, primary ciliary dyskinesia, and post-viral infection. There were no conversions to open surgery with robotic surgery, but five with thoracoscopy. Total operative time was significantly longer with robotic versus thoracoscopic surgery (mean 247 ± 50 versus 152 ± 57 min, p = 0.008). There were no significant differences in perioperative complications, length of thoracic drainage, or total length of stay (mean 7 ± 2 versus 8 ± 3 days, respectively). No blood transfusions were required. Two thoracoscopic patients had a type-3 postoperative complication.

CONCLUSIONS

Pediatric robotic lung lobectomy is feasible and safe, with excellent visualization and bi-manual hand-wrist dissection - useful properties in difficult cases of infectious pathologies. However, instrumentation dimensions limit use in smaller thoraxes.

Cerebral Oxygenation by Near-Infrared Spectroscopy in Infants Undergoing Thoracoscopic Lung Resection

Background: Thoracoscopic resection is the standard of care for congenital lung malformations (CLMs) in infants. However, there is rising concern that capnothorax may affect cerebral perfusion and oxygenation, carrying potential long-term effects on neurodevelopmental behavior. The aim of our study was to investigate, using near-infrared spectroscopy (NIRS), the regional cerebral oxygenation (CrSO₂) in infants undergoing thoracoscopic lung resection; the secondary aim was to assess the relationship between rSO₂ and standard monitoring. Methods: In this retrospective study, we reviewed all infants (<1 year old, ASA II) who underwent thoracoscopic CLM resection in double-lung ventilation under fixed capnothorax parameters (5 mmHg of pressure, 1 L/minute flow), standardized anesthetic protocol, standard monitoring, and multisite NIRS in our center. We focused our attention on 8 anesthetic and surgical maneuvers, potentially affecting tissue oxygen saturation. Results: Ten infants met the inclusion criteria. At surgery, median age was 5.5 (4-7) months, median weight 7.2 (6.6-8) kg, median operative time 110 (55-180) minutes, and median capnothorax duration 79 (34-168) minutes. No conversion to open surgery occurred. CrSO₂ values remained within clinically accepted values during thoracoscopy, beside a CrSO₂ drop >20% of basal value in 1 patient, during capnothorax induction. Renal NIRS added very little to standard monitoring, which appeared generally inadequate to consistently appraise end-organ perfusion. ETCO₂ best correlated with CrSO₂ variations, suggesting to be able to realistically predict them. Conclusions: The thoracoscopic treatment of CLMs under the given conditions appears well tolerated in infants, pending the continuous adjustment of ventilator settings by an experienced anesthetist, confident with NIRS technology.

Lung surgery in children and their post-operative risk of respiratory infection

PURPOSE

Pediatric surgeons at our institution are often asked by families about a theoretical increased risk of severe common upper respiratory infections in children status post lung resection. No data exist on this topic. We, therefore, aimed to examine the risk of severe respiratory infection in children after pulmonary resection.

METHODS

A chart review was conducted on all pediatric patients who underwent pulmonary resection between August 1st, 2009 and January 31st, 2019. Collected data included patient characteristics, operation, complications and any admission for respiratory infection.

RESULTS

Fifty-seven patients met inclusion criteria. Resections included lobectomy (45.6%), segmentectomy (14.0%), and wedge resection (40.4%). Twelve (21.1%) were immunocompromised and 6 (10.5%) had post-operative complications. Within 1 year of surgery, 2 (3.5%) patients were hospitalized for a viral upper respiratory illness (URI), 1 (1.8%) for bacterial pneumonia, and none due to influenza.

CONCLUSION

In the general pediatric population, the risk of admission for respiratory illness is 3-21%. At this institution, overall risk of respiratory infection after lung resection appears comparable to baseline community risk. Our findings could aid counseling pediatric patients and their families regarding the 1-year risk of infection after lung resection.

Thoracoscopic versus open resection for symptomatic congenital pulmonary airway malformations in neonates: a decade-long retrospective study

PURPOSE

The purpose of this study is to evaluate the potential advantages of thoracoscopic versus open resection for symptomatic congenital pulmonary airway malformation (CPAM) in neonates.

METHODS

A retrospective review of the medical records of neonates (age ≤ 28 days) who underwent surgery for symptomatic CPAM from 2010 to 2020.

RESULTS

Of the 24 patients, 14 patients underwent thoracoscopic resection and 10 patients underwent open resection. 4 patients with CPAM located in the upper or middle lobes underwent lobectomy, and 20 underwent lung-preserving wedge resection in the lower lobe. Between the two groups, there were no statistically significant differences in related preoperative variables, including gestational age at birth, body weight, head circumference, lesion size, cystic adenomatoid malformation volume ratio (CVR), and age at operation (P > .05). The differences in intraoperative variables were statistically significant. The length of the surgical incision was significantly shorter in thoracoscopic resection group than in open resection group (1.4 cm [1.3-1.8] vs. 6.0 cm [5.0-8.0], P = .000), along with significantly less operative blood loss (3 ml [1-6] vs. 5 ml [2-10], P = .030) but significantly longer operation time (159 min [100-220] vs. 110 min [70-170], P = .003). Regarding postoperative variables, ventilator days, duration of chest tube use and length of hospital stay were not statistically significant (P > .05).

CONCLUSION

Both thoracoscopic and open resection for symptomatic CPAM achieve good clinical outcomes, even in neonates. Thoracoscopic resection has minimal aesthetic effects and does not increase the risk of surgical or postoperative complications. Lung-preserving resection may be feasible for neonatal CPAM surgery.

Thoracoscopic Management of Pediatric Patients with Congenital Lung Malformations: Results of a European Multicenter Survey

Background: This study aimed to report a European multi-institutional experience about thoracoscopic management of children with congenital lung malformations. Methods: The records of 102 patients (49 girls and 53 boys) with median age at surgery of 1 year (range 6 months-1.5 years), who underwent thoracoscopic lobectomy in five European Pediatric Surgery units, were retrospectively collected. Indications for surgery included congenital pulmonary airway malformation (CPAM) (n = 47), intra- and extralobar pulmonary sequestration (n = 34), hybrid lesion (CPAM/intralobar sequestration) (n = 2), severe bronchiectasis (n = 9), congenital lobar emphysema (n = 8), and others (n = 2). The condition was asymptomatic in 77/102 (75.5%), whereas symptoms such as recurrent pneumonia and/or respiratory distress were present in 25/102 (24.5%). Results: Surgical procedures included 18 upper, 20 middle, and 64 lower lobe resections. No conversions to open were reported. A 3 mm sealing device and 5 mm stapler were adopted in the last 48/102 patients (47%). The median operative time was 92.2 minutes (range 74-141). The median operative time significantly decreased in patients in whom the vessel division and bronchial sealing were performed using sealing devices (75.5 minutes) compared with suture ligations (118.9 minutes) (P = .001). The median hospital stay was 3.7 days (range 2-6.2). Three/102 patients (2.9%) developed postoperative complications, including air leakage requiring pleural drainage (n = 1) (Clavien IIIb) and respiratory infection (n = 2) (Clavien II). A reoperation was required in one patient with residual pleuropulmonary blastoma (0.9%). All symptomatic patients reported resolution of symptoms postoperatively. Conclusions: Thoracoscopic lobectomy is a safe and effective procedure with excellent cosmetic outcome, in expert hands. Based upon our experience, we strongly recommend surgery in patients with congenital lung malformations by the first year of life, to reduce the risk of infection and make the procedure technically easier, despite the small patients' size. Surgeon's experience and use of miniaturized instruments and sealing devices remain key factors for successful outcome.

Mentoring in Pediatric Thoracoscopy: From Theory to Practice

Introduction: Thoracoscopy represents the most challenging area of pediatric minimally invasive surgery due to its technical difficulty. A standardized training program would be advisable. The aim of this study is to evaluate the results of our surgical training. Materials and Methods: A retrospective, single-center, cohort study was performed. The following four-step program was tested: (1) theoretical part; (2) experimental training; (3) training in centers of reference; (4) personal operative experience. Particular attention was focused on the choice of mentor. Times and modality of adherence to the program were evaluated. The effectiveness and safety of the training were evaluated according to the surgical results of esophageal atresia (EA/TEF) repair and resection of congenital lung malformations (CLM). The study was conducted from January 2014 to May 2020. Attending surgeons with previous experience in neonatal and pediatric laparoscopy were selected for the training program after being evaluated by the head of Department. Results: The training program was fully completed in 2 years. Twenty-four lobectomies, 9 sequestrectomies, 2 bronchogenic cyst resections and 20 EA/TEF repair were performed. Thoracoscopy was always feasible and effective, with no conversion. The operative times progressively decreased. Only three minor complications were recorded, all treated conservatively. Conclusions: A standardized training program is highly desirable to learn how to safely perform advanced pediatric thoracoscopy. The 4-steps design seems a valid educational option. The choice of the mentor is crucial. An experience-based profile for pediatric surgeons who may teach thoracoscopy is advisable.

Congenital Pulmonary Airway Malformation in Children: Advantages of an Additional Trocar in the Lower Thorax for Pulmonary Lobectomy

Aim: To present the use of an additional trocar (AT) in the lower thorax during thoracoscopic pulmonary lobectomy (TPL) in children with congenital pulmonary airway malformation. Methods: For a lower lobe TPL (LL), an AT is inserted in the 10th intercostal space (IS) in the posterior axillary line after trocars for a 5-mm 30° scope, and the surgeon's left and right hands are inserted conventionally in the 6th, 4th, and 8th IS in the anterior axillary line, respectively. For an upper lobe TPL (UL), the AT is inserted in the 9th IS, and trocars are inserted in the 5th, 3rd, and 7th IS, respectively. By switching between trocars (6th↔8th for the scope, 4th↔6th for the left hand, and 8th↔10th for the right hand during LL and 5th↔7th, 3rd↔5th, and 7th↔9th during UL, respectively), vital anatomic landmarks (pulmonary veins, bronchi, and feeding arteries) can be viewed posteriorly. The value of AT was assessed from blood loss, operative time, duration of chest tube insertion, requirement for post-operative analgesia, and incidence of perioperative complications. Results: On comparing AT+ (n = 28) and AT- (n = 27), mean intraoperative blood loss (5.6 vs. 13.0 ml), operative time (3.9 vs. 5.1 h), and duration of chest tube insertion (2.2 vs. 3.4 days) were significantly decreased with AT (p < 0.05, respectively). Differences in post-operative analgesia were not significant. There were three complications requiring conversion to open/mini-thoracotomy: AT- (n = 2; bleeding), AT+: (n = 1; erroneous stapling). Conclusions: An AT and switching facilitated posterior dissection during TPL in children with congenital pulmonary airway malformation enhancing safety and efficiency.

Thoracoscopy versus thoracotomy for congenital lung malformations treatment: A single center experience

INTRODUCTION

Our aim is to compare thoracoscopy to thoracotomy in the treatment of congenital lung malformations (CLM) in children.

MATERIALS AND METHODS

We report a retrospective monocentric cohort study. Patients treated at our Center for CLM (1991-2020) were divided in two groups: patients treated with video-assisted thoracoscopic surgery (VATS) and open thoracotomy (OT). Characteristics of the two groups were compared through statistical analysis (GraphPad Prism7). A p value less than .05 was considered statistically significant.

RESULTS

One hundred six patients were included: 58 in VATS group, 48 in OT group. Prenatal diagnosis was possible in 73.6%. The most frequent surgical procedures were lobectomy (43.4%) and sequestrectomy (22.6%). All VATS patients underwent lung exclusion, mostly by endobronchial blocker (69%). Mean operative time was 146.1 min (±52.04 SD) in VATS and 159.2 (±46.53 SD) in OT (p = .1973). Conversion to OT was necessary in 20.6% of VATS patients, but decreased in the last 5 years (6.2%). There were not any intraoperative complication. Respectively in VATS and OT group, length of stay (LOS) was 4.5 days ± 3.6 SD versus 7.7 ± 3.4 SD (p < .0001), chest tube duration 2.8 days ± 3.4 SD versus 3.7 ± 2.4 SD (p < .0001), antibiotic treatment duration 3.7 days ± 4.7 SD versus 5 ± 2.6 SD (p = .1196). Postoperative complications were described in 22.6%. The commonest histological diagnosis (40.6%) was congenital pulmonary airway malformation.

CONCLUSION

VATS resulted a feasible, effective and safe technique. Operative time and postoperative complications were similar in VATS and OT groups. VATS conversion rate decreased in time. VATS had a statistically significant shorter LOS and chest tube duration.

Thoracoscopic Resection of Congenital Lung Malformation: Looking for the Right Preoperative Assessment

INTRODUCTION

 Consensus on the best postnatal radiological evaluation of congenital lung malformations (CLMs) is still lacking. In recent years, the interest on magnetic resonance imaging (MRI) has grown, but its role is still unknown.

AIM

 The aim of the study was to identify the best preoperative diagnostic assessment for CLM.

MATERIALS AND METHODS

 All patients with a prenatal suspicion of CLM between January 2014 and February 2018 were studied. Asymptomatic newborns underwent MRI, during spontaneous sleep without contrast. Patients with a positive MRI were scheduled for computed tomography (CT) within the fourth month of life. Thoracoscopic resection was performed in cases with a pathological CT. MRI, CT, and surgical findings were compared based on dimension, localization, and features of the CLM using the Cohen's kappa test (K).

RESULTS

 A total of 20 patients were included (10 males). No difference was found in the diameter and site of the lesions always localized in the same side (K = 1) and in the same pulmonary lobe (K = 1). Infants who underwent thoracoscopic resection included: three congenital pulmonary airway malformations (CPAMs), five extralobar and eight intralobar sequestrations (bronchopulmonary sequestrations [BPSs]), three bronchogenic cysts, and one congenital emphysema. The concordance between MRI and CT and between radiological investigations and pathology was satisfactory for the greatest part of the studied variables. MRI showed sensitivity of 100%, specificity of 82%, positive predictive value of 50% and negative predictive value of 100% for CPAM and 77, 100, 100, and 80% for BPS, respectively.

CONCLUSION

 MRI proved to be a reliable diagnostic investigation for CLM with high sensitivity and specificity. Early MRI in spontaneous sleep without contrast and preoperative contrast CT scan is a valuable preoperatory assessment.

Combined non-intubated anaesthesia and paravertebral nerve block in comparison with intubated anaesthesia in children undergoing video-assisted thoracic surgery

BACKGROUND

This study is to investigate if non-intubated anaesthesia combined with paravertebral nerve block (PVNB) can enhance recovery in children undergoing video-assisted thoracic surgery (VATS).

METHODS

A randomized controlled trial including 60 patients aged 3 to 8 years old who underwent elective VATS was performed. They were randomly assigned to receive non-intubated anaesthesia combined with PVNB or general anaesthesia with tracheal intubation (1:1 ratio). The primary outcome was the length of postoperative in-hospital stay. The secondary outcomes included emergence time, the incidence of emergence delirium, time to first feeding, time to first out-of-bed activity, pain score and in-hospital complications.

RESULTS

The non-intubated group had shorter postoperative in-hospital stay than the control group (4 days [IQR, 4-6] vs 5 days [IQR, 5-8], 95% CI 0-2; P = .013). When compared to the control group, the incidence of emergence delirium (odds ratio [OR] 3.39, 95% CI 1.01-11.41; P = .043), emergence time, duration in the PACU, time to first eating food, first out-of-bed activity, pain score and consumption of sufentanil (at 6 and 12 hours after surgery) were decreased in the intervention group. In contrast, the incidence of airway complications was higher in the control than the intervention group (27.6% vs 6.9%, P = .037). There was no statistical significance in the occurrence of PONV, pneumothorax and other complications between the two groups.

CONCLUSIONS

Non-intubated anaesthesia combined with PVNB enhances recovery in paediatric patients for video-assisted thoracic surgery although further multi-centre study is needed.

Feasibility and safety of reduced-port video-assisted thoracoscopic surgery using a needle scope for pulmonary lobectomy- retrospective study

Background

This study aimed to determine the usefulness and limitations of videoassisted thoracoscopic (VATS) lobectomy using one-window and puncture method (1WPM).

Methods

This study involved 14 patients who underwent lobectomy using the 1WPM at our institute from 2008 to 2017.

Results

The study patients comprised of 3 men and 11 women with a median age of 10.5 years (range, 0-72 years). There were eight cases in children younger than 18 years old and the youngest patient was 9 days old. The diagnoses were congenital pulmonary cystic disease (n = 7), primary lung cancer (n = 4), metastatic lung tumor (n = 1), and others (n = 2). The 1WPM was successful in 9 of 14 patients (64.3%) and, in 5 cases (35.7%), needed conversion to either two-window method (TWM) using additional port (n = 3) or open thoracotomy (n = 2). The causes for conversion were need for additional bronchoplasty or lymph node dissection (n = 3), failure of one-lung ventilation (n = 1), and presence of a small thoracic cavity that made the procedure extremely difficult (n = 1). In the group that was successfully treated with 1WPM, the median values were as follows: operation time, 193 min (range, 112-480 min); blood loss, 0 ml (range, 0-90 ml); drainage duration, 1 day (range, 1-4 days); and postoperative hospital stay, 7 days (range, 4-13 days).

Conclusions

Lobectomy by 1WPM can be safely performed and has good postoperative course and this procedure can be applicable and effective in small infants.

•

This study describes the novel VATS lobectomy method: the one-window and puncture method (1WPM).

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1WPM is performed using 2–3 cm single incisions and a needle scope for intrathoracic access from other points.

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This retrospective study involved 14 patients who underwent lobectomy using the 1WPM.

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VATS lobectomy using 1WPM can be safely applied from adult cases to new born cases.

Application of an Extracorporeal-Assisted Intracorporeal Sliding Knot-Tying Technique in Minimally Invasive Surgery in Children

Background: A retrospective study was carried out to determine the feasibility and safety of an extracorporeal-assisted intracorporeal sliding knot-tying technique in minimally invasive surgery in children. Materials and Methods: From June 2009 to December 2017, a total of 333 cases of pediatric minimally invasive surgery were performed using the extracorporeal-assisted intracorporeal sliding knot-tying technique. Polyester, polyglactin, and polydioxanone sutures were used for suturing and knotting. The average time used for knotting was recorded during the surgery. The patients were followed up for unraveled knots and recurrence of the diseases. Results: All 333 surgical procedures were performed successfully, including 152 cases of thoracoscopic diaphragmatic hernia repair, 151 cases of thoracoscopic diaphragmatic plication, 7 cases of thoracoscopic esophageal anastomosis, and 23 cases of laparoscopic esophageal hiatal hernia fundoplication. No serious complications or mortalities were observed. Twelve-month to 9-year follow-up showed that all pediatric patients recovered well and no recurrence or unraveled knots were found. Conclusions: This new knot-tying technique is safe and feasible for various minimally invasive endoscopic surgeries, especially for suturing tissues under tension, such as thoracoscopic diaphragmatic hernia repair, laparoscopic esophageal hiatal hernia repair, and fundoplication. All types of sutures can be used for this knot-tying technique. It is easy to learn and can be quickly mastered by doctors with endoscopic surgery experience.

Culture of safety and error traps in pediatric thoracoscopy

Growing adoption of thoracoscopy by pediatric surgeons has resulted in increasingly complex operations being performed. Although common complications of these procedures have decreased with experience, surgeons are still at risk to fall into error traps where routine practice in uncommon situations results in unanticipated complications. A background culture of safety that rewards multidisciplinary communication, teamwork, openness and standardization of care can assist surgeons to recognize, address and report error traps when they arise. This article serves to encourage a culture of safety and raise awareness of error traps in pediatric thoracoscopy to minimize potential harm and improve quality of care.

Left extralobar pulmonary sequestration and a right aorto-to-pulmonary vein fistula in a newborn: a 3-mm thoracoscopic monolateral approach

An extralobar pulmonary sequestration (EPS) associated with a contralateral aorto-to-pulmonary vein fistula is rare. We report the case of a female newborn with left EPS fed by an artery originating from the distal thoracic aorta and, symmetrically on the controlateral side, an artery shunting in the inferior right pulmonary vein. Echocardiography showed dilatation of the left atrium. On the 34th day since birth (weight 4500 g), the patient was operated on thoracoscopically. The EPS was closed with a 3-mm sealing system, divided and removed. A window in the mediastinal pleura was created, and the origin of the fistula was identified and sealed. The postoperative course was uneventful. The patient was discharged on Day 4 with no echocardiographic signs of persistence of the fistula and of the congestive heart failure. This is the first case report of a thoracic large systemic circulation-to-pulmonary vein fistula causing heart failure associated with EPS. The thoracoscopic monolateral approach and the availability of 3-mm instruments guaranteed a maximum level of minimal invasiveness.

Cardiorespiratory effects of variable pressure thoracic insufflation in cats undergoing video-assisted thoracic surgery

OBJECTIVE

To evaluate the effects of intrathoracic insufflation on cardiorespiratory variables and working space in cats undergoing video-assisted thoracic surgery.

STUDY DESIGN

Prospective randomized study.

ANIMALS

Six healthy cats.

METHODS

Cats were anesthetized using a standardized protocol. A Swan-Ganz catheter was positioned in the pulmonary artery under fluoroscopic guidance for measurement of cardiac output. Intrathoracic pressures (ITP) of 0 (baseline), 3, and 5 mm Hg were induced with CO₂ and maintained for 30 minutes. Statistical comparison of cardiorespiratory variables was performed. After the procedures, all cats were recovered from anesthesia. Videos of thoracic working space at each ITP level were scored in a blinded fashion by 3 board-certified surgeons using a numerical scale from 0-10.

RESULTS

All cats tolerated insufflation with 3 and 5 mm Hg for 30 minutes without oxygen desaturation, although ventilatory levels had to be increased substantially to maintain eucapnia and oxygenation. Cardiac index was not significantly different from baseline after 30 minutes at 3 mm Hg but was significantly lower after 30 minutes at 5 mm Hg compared with 3 mm Hg. Oxygen delivery was unaffected by 3 or 5 mm Hg compared with baseline. Scores for working space increased between baseline and 3 and 5 mm Hg but were not different between 3 and 5 mm Hg.

CONCLUSION

CO₂ insufflation to 5 mm Hg seems well tolerated in healthy cats, provided ventilatory settings are substantially increased as ITP increases.

CLINICAL SIGNIFICANCE

Thoracic CO₂ insufflation of 3 mm Hg in cats during video-assisted thoracic surgery is associated with less hemodynamic perturbation than 5 mm Hg insufflation and may provide the benefit of improved working space compared with baseline.

Expression Analysis of ACSL5 and Wnt2B in Human Congenital Pulmonary Airway Malformations

BACKGROUND

The objective of this study was to determine acyl-CoA synthetase 5 (ACSL5) and Wnt2B expression patterns in human congenital pulmonary airway malformations (CPAMs) and to identify the possible roles of ACSL5 and Wnt2B in the pathogenesis of CPAM.

METHODS

Expression of ACSL5 and Wnt2B was evaluated by immunohistochemical staining, Western blotting, and quantitative real-time polymerase chain reaction, which were performed on surgical specimens of CPAM and adjacent normal lung tissues as controls.

RESULTS

Immunohistochemistry revealed that ACSL5 and Wnt2B immunopositive cells were predominantly detected in the mesenchymal cell nucleus, and there were lower expressions of ACSL5 and Wnt2B immunopositive cells in CPAM tissues than those in adjacent normal lung tissues. Western blotting and quantitative real-time polymerase chain reaction showed that ACSL5 and Wnt2B protein and mRNA expressions were significantly decreased in CPAM tissues as compared to the adjacent normal lung tissues (P < 0.05). In addition, there was a reduced level of ACSL5 relative to that of Wnt2B.

CONCLUSIONS

The decreased ACSL5 and Wnt2B expressions correlated with aberrations in pulmonary development and in the pathogenesis of CPAM, so downregulation of ACSL5 and Wnt2B could play an important role in the development of bronchial-alveolar structures in CPAM.

Minimal-invasive thoracic surgery in pediatric patients

During the last two decades, there was a tremendous development of video-assisted thoracoscopic surgery (VATS), especially in the field of video-assisted lung resections. This article describes the actually state of this surgical technique in the treatment of pediatric patients. The problems in practical application are illustrated as well as clinical results, like they are presented in literature.

Congenital pulmonary airway malformations: state-of-the-art review for pediatrician's use

Congenital pulmonary airway malformations or CPAM are rare developmental lung malformations, leading to cystic and/or adenomatous pulmonary areas. Nowadays, CPAM are diagnosed prenatally, improving the prenatal and immediate postnatal care and ultimately the knowledge on CPAM pathophysiology. CPAM natural evolution can lead to infections or malignancies, whose exact prevalence is still difficult to assess. The aim of this "state-of-the-art" review is to cover the recently published literature on CPAM management whether the pulmonary lesion was detected during pregnancy or after birth, the current indications of surgery or surveillance and finally its potential evolution to pleuro-pulmonary blastoma.

CONCLUSION

Surgery remains the cornerstone treatment of symptomatic lesions but the postnatal management of asymptomatic CPAM remains controversial. There are pros and cons of surgical resection, as increasing rate of infections over time renders the surgery more difficult after months or years of evolution, as well as risk of malignancy, though exact incidence is still unknown. What is known: • Congenital pulmonary airway malformations (CPAM) are rare developmental lung malformations mainly antenatally diagnosed. • While the neonatal management of symptomatic CPAM is clear and includes prompt surgery, controversies remain for asymptomatic CPAM due to risk of infections and malignancies. What is new: • Increased rate of infection over time renders the surgery more difficult after months or years of evolution and pushes for recommendation of early elective surgery. • New molecular or pathological pathways may help in the distinction of type 4 CPAM from type I pleuropulmonary blastoma.

Thoracoscopic Lobectomy for Congenital Lung Lesions

Congenital lung lesions (CLLs) comprise a heterogeneous group of developmental and histologic entities often diagnosed on screening prenatal ultrasound. Most fetuses with CLL are asymptomatic at birth; however, the risk of malignancy and infection drives the decision to prophylactically resect these lesions. The authors describe their approach to minimally invasive lobectomy in children with CLLs, postoperative care, and management of procedure-specific complications.

Medium Term Pulmonary Function Test After Thoracoscopic Lobectomy for Congenital Pulmonary Airway Malformation: A Comparative Study with Normal Control

INTRODUCTION

Congenital pulmonary airway malformation (CPAM) is a major indication of lobectomy in children. Early lobectomy had been proposed for the advantage of compensatory lung growth. Despite the increasing use of thoracoscopic lobectomy its effect on postoperative lung function was still not well established in the literature. This study was therefore performed to study the result of postoperative pulmonary function test (PFT) on a medium term basis.

MATERIALS AND METHODS

All patients who underwent thoracoscopic lobectomy for CPAM between 2006 and 2010 were recruited into the study. PFT was performed 5 years after the operation. Age-matched healthy individuals with similar body size were recruited for PFT as the control group. Demographic data and PFT results were extracted for statistical analysis. Test result less than 80% of predicted value was considered abnormal.

RESULTS

Fifteen consecutive patients were identified in the study period, 8 boys and 7 girls. The PFT was performed at a mean age of 9 years. None of the patients had respiratory symptoms. The forced vital capacity (FVC) (99.6% versus 97.0% predicted, P = .56), forced expiratory volume in 1 second (FEV1) (86.0% versus 89.1% predicted, P = .52), FEV1 to FVC ratio (96.6% versus 98.7% predicted, P = .60), total lung capacity (92.5% versus 94.5% predicted, P = .68), and alveolar volume adjusted diffusion capacity of carbon monoxide (106.4% versus 100.4% predicted, P = .35) showed no statistical difference from the control group.

CONCLUSION

Patients who underwent thoracoscopic lobectomy have normal lung function 5 years after the operation. Further study is necessary to confirm the long-term result.

Optimal age for elective surgery of asymptomatic congenital pulmonary airway malformation: a meta-analysis

Controversy exists on the optimal age for elective resection of asymptomatic congenital pulmonary airway malformation. Current recommendations vary widely, highlighting the overall lack of consensus. A systematic search of Embase, MEDLINE, CINAL, and CENTRAL was conducted in January 2016. Identified citations were screening independently in duplicate and consensus was required for inclusion. Results were pooled using inverse variance fixed effects meta-analysis. Meta-analysis results indicate no statistically significant differences for complications within the 3-month and 6-month age comparison groups [odds ratio (OR) 4.20, 95% confidence interval (CI) 0.78-22.77, I ² = 0%; OR 2.39, 95% CI 0.63-9.11, I ² = 0%, respectively]. Older patients were significantly favoured for 3-month and 6-month age comparison groups for length of hospital stay [mean difference (MD) 4.13, 95% CI 2.31-5.96, I ² = 0%; MD 3.38, 95% CI 0.44-6.31, I ² = 0%, respectively]. Borderline statistical significance was observed for chest tube duration in patients ≥6 months of age (MD 1.06, 95% CI 0.02-2.09, I ² = 0%). No mortalities were recorded. Surgical treatment appears to be safe at all ages, with no mortalities and similar rates of complications between age groups. The included evidence was not sufficient to make a conclusive recommendation on optimal age for elective resection.

Serial improvement of quality metrics in pediatric thoracoscopic lobectomy for congenital lung malformation: an analysis of learning curve

BACKGROUND

Video-assisted thoracic surgery (VATS) pulmonary resection in children is a technically demanding procedure that requires a relatively long learning period. This study aimed to evaluate the serial improvement of quality metrics according to case volume experience in pediatric VATS pulmonary resection of congenital lung malformation (CLM). Methods VATS anatomical resection in CLM was attempted in 200 consecutive patients. The learning curve for the operative time was modeled by cumulative sum analysis. Quality metrics were used to measure technical achievement and efficiency outcomes. Results The median operative time was 95 min. The median length of hospital stay and chest tube indwelling time was 4 and 2 days, respectively. The improvement of operation time was observed persistently until 200 cases. However, two cut-off points, the 50th case and 110th case, were identified in the learning curve for operative time, and the 110th case was the turning point for stable outcomes with short operation time. Significant reduction of length of hospital stay and chest tube indwelling time was observed after 50 cases (p = .002 and p = .021, respectively). The complication rate decreased but continued at a low rate for entire study period and the interval decrease was not statistically significant. Conversion rate decreased significantly (p = .001), and technically challenging procedures were performed more frequently in later cases. Conclusions Improvements of quality metrics in operation time, conversion rate, length of hospital stay, and chest tube indwelling time were observed in proportion to case volume. Minimum experience of 50 is necessary for stable outcomes of pediatric VATS pulmonary resection.

Thoracoscopic Lobectomy in Infants and Children Utilizing a 5 mm Stapling Device

PURPOSE

Thoracoscopic lobectomy for congenital cystic lung disease has become an accepted and in many institutions the preferred technique. However, the technical challenges are many. Previous endoscopic staplers (12 mm) used commonly in adults are too large for use in infants This study evaluates the safety and efficacy of using a 5 mm stapling device to seal and divide major pulmonary structures.

METHODS

From July 2014 to March 2016, 26 patients of age 6 weeks to 13 months underwent thoracoscopic lobectomy for CPAM or sequestration. Weights ranged from 3.2 to 11.4 kg. There were 7 upper lobectomies, 2 middle, and 17 lower lobectomies. In each case, the 5 mm stapler (Justright Surgical; Louisville, Colorado) was the primary device for vessel and bronchial sealing and division. It is 4.8 mm in diameter with an anvil length of 25 mm and lays down four rows of staples and divides between them. A 3 mm sealing device was used for dissection and to take smaller segmental vessels as necessary. Stump lines were evaluated for bleeding or air leak in all cases.

RESULTS

All procedures were accomplished successfully thoracoscopically. The stapler was used on the main lobar artery cases and vein in 24 cases, a large systemic sequestration vessel in 5 cases, and the bronchus in all 26. The stapler was also used to complete the minor fissure in 1 case and the major fissure in 1 case. A total of 96 staple loads were fired. Operative times ranged from 35 to 135 minutes. There was no significant bleeding of any vascular stump. In 1 case, the edge of the bronchial stump had to be reinforced, this was thought to be secondary to too much tissue being enclosed in the jaws. There were no postoperative complications.

CONCLUSION

The use of a 5 mm stapling device appears to be safe and effective in thoracoscopic lobectomy in infants. It allows for safe management of major pulmonary vessels and bronchi in the confined chest of an infant through a single 5 mm port.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Thoracoscopic Vs open resection of congenital cystic lung disease- utilization and outcomes in 1120 children in the United States

PURPOSE

To determine if utilization of thoracoscopic resection of congenital cystic lung disease (CLD) is increasing and if this approach is associated with improved outcomes using a large national sample.

METHODS

Children ≤20years old who underwent resection of a congenital cystic adenomatoid malformation, bronchopulmonary sequestration, or bronchogenic cyst were identified from the Healthcare Cost and Utilization Project Kids' Inpatient Database (2009, 2012) and Nationwide Inpatient Sample (2008, 2010-2011). Patient characteristics and outcomes were compared between thoracoscopic and open approaches using univariate and multivariable analyses stratified by magnitude of resection.

RESULTS

Thoracoscopic resection was used in 39.4% of 1120 children who underwent resection of CLD. Utilization of the thoracoscopic approach increased from 32.2% in 2008 to 48.2% in 2012. Use of thoracoscopy was lower in lobectomy than segmental resection (32.5 vs 48.4%, p<.001). Newborns, those with comorbid congenital conditions, and those with respiratory infections also had lower rates of thoracoscopy. After stratifying by magnitude of resection and adjusting for patient complexity, complication rates and postoperative length of stay were similar between thoracoscopic and open approaches.

CONCLUSION

Utilization of thoracoscopic resection for CLD in the United States is increasing with time. After adjusting for patient complexity, there is no difference in postoperative length of stay or complications between thoracoscopic and open lobectomy and sub-lobar resection.

The first 100 infant thoracoscopic lobectomies: Observations through the learning curve and comparison to open lobectomy

OBJECTIVE

The objective of the study is to describe our initial 100 attempted infant thoracoscopic lobectomies for asymptomatic, prenatally diagnosed lung lesions, and compare the results to contemporaneous age-matched patients undergoing open lobectomy.

BACKGROUND

Infant thoracoscopic lobectomy is a technically challenging procedure, which has only gained acceptance worldwide in recent years.

METHODS

This is a retrospective review of all patients undergoing thoracoscopic or open lung lobectomy between March 2005 and January 2014. Included were all asymptomatic infants younger than 4months. Excluded were patients undergoing emergent lobectomy and patients with isolated extralobar bronchopulmonary sequestrations.

RESULTS

A total of 100 attempted thoracoscopic lobectomies were compared with 188 open lobectomies. In the thoracoscopic group, mean age and weight at surgery were 7.3weeks and 4.8kg, mean operative time was 185minutes, and mean hospital stay was 3days. Twelve cases were converted to open (12%). Ten conversions occurred within the first third of the series and none in the last third. There were no mortalities. There were no differences between the thoracoscopic and open groups in perioperative complications or hospital stay. There was a significant difference in the operative time: 111minutes vs. 185minutes (open vs. thoracoscopic; p<0.001). There was a higher mean end-tidal carbon dioxide (ETCO2) and lower mean peripheral capillary oxygen saturation (SpO2) in the thoracoscopic group versus the open group (51.7 versus 38.6mmHg and 97.5 versus 99.1%, respectively).

CONCLUSION

In high volume centers, the learning curve of thoracoscopic lobectomy can be overcome and the procedure can be performed with equivalent outcomes and, in our opinion, superior cosmetic results to open lobectomy.