Scoliosis after thoracotomy for esophageal atresia

Outcome of long gap esophageal atresia at 6 years: A prospective case control cohort study

BACKGROUND DATA

EA is the most frequent congenital esophageal malformation. Long gap EA remains a therapeutic challenge for pediatric surgeons. A case case-control prospective study from a multi-institutional national French data base was performed to assess the outcome, at age of 1 and 6 years, of long gap esophageal atresia (EA) compared with non-long gap EA/tracheo-esophageal fistula (TEF). The secondary aim was to assess whether initial treatment (delayed primary anastomosis of native esophagus vs. esophageal replacement) influenced mortality and morbidity at ages 1 and 6 years.

METHODS

A multicentric population-based prospective study was performed and included all patients who underwent EA surgery in France from January 1, 2008 to December 31, 2010. A comparative study was performed with non-long gap EA/TEF patients. Morbidity at birth, 1 year, and 6 years was assessed.

RESULTS

Thirty-one patients with long gap EA were compared with 62 non-long gap EA/TEF patients. At age 1 year, the long gap EA group had longer parenteral nutrition support and longer hospital stay and were significantly more likely to have complications both early post-operatively and before age 1 year compared with the non-long gap EA/TEF group. At 6 years, digestive complications were more frequent in long gap compared to non-long gap EA/TEF patients. Tracheomalacia was the only respiratory complication that differed between the groups. Spine deformation was less frequent in the long gap group. There were no differences between conservative and replacement groups at ages 1 and 6 years except feeding difficulties that were more common in the native esophagus group.

CONCLUSIONS

Long gap strongly influenced digestive morbidity at age 6 years.

Progression of infantile scoliosis after thoracotomy and sternotomy for the treatment of congenital cardiac abnormalities

PURPOSE

To determine whether the rate of progression of scoliosis is higher following thoracotomies and sternotomies in children.

METHODS

We undertook a retrospective review of 1744 patients from a tertiary paediatric referral unit who had sternotomies or thoracotomies from 2005 to 2010 to identify those with scoliosis and to determine where possible, the pre- and post-operative rate of scoliosis progression. A secondary objective was to assess the risk factors for progression after surgery through Chi-square analysis.

RESULTS

1419/1744 (81.4%) patients (55% M, 45% F) had post-op chest X-rays. 25% had a thoracotomy, and 75% had a sternotomy. 5.8% had scoliosis at their most recent chest X-ray (mean Cobb angle 20° (range 11-63°)). There was no significant difference for rates of scoliosis for those who had sternotomies vs thoracotomies (6.3% vs. 4.6% P = 0.258) but a significant difference for those who had primary vs revision sternotomies (5.1% vs. 9.9% P = 0.008). Pre- and post-op progression calculations were possible in 30 patients. The mean time from surgery to the start of the progression was 12 months (range 0-93 months). There was no significant difference between the rates of progression pre-op vs post-op: 1.0 vs. 0.5 deg/month, P = 0.228. There was no significant difference between the rates of post-op progression for those who had a sternotomy versus a thoracotomy (0.5 vs. 0.5 deg/month P = 0.503).

CONCLUSION

Thoracotomies and sternotomies do not appear to increase the rate of progression of scoliosis in these patients.

LEVEL OF EVIDENCE

III. Radiographs illustrating scoliosis progression.

Thoracogenic scoliosis: a retrospective review of 129 pediatric patients with a mean follow-up of 10 years

PURPOSE

To determine the midterm outcome of lateral thoracotomy (LT) in skeletally immature patients concerning thoracogenic scoliosis development and lung parenchyma resection (LPR) extent.

METHODS

In total, 129 children met the inclusion criteria: (1) LT during the study period; (2) skeletally immature at the time of LT; (3) clinical and radiographic follow-up of at least 3 years; and (4) no spinal or thoracic deformity on radiographs before LT. Patients were grouped according to their underlying disease, age at LT, and LPR extent. Radiographic parameters were assessed. Kaplan-Meier survival curves and univariate and multivariate analysis were performed.

RESULTS

Of 129, 108 patients underwent pneumonectomy (9; 9.1%), lobectomy (79; 61.2%), segmentectomy (20; 15.5%) and 21 patients LT without LPR. The mean age at LT and at last radiological follow-up was 5.5 years (birth-17.8) and 15.2 years (3.4-33.2). The mean follow-up was 10 years (3-28.1). Scoliosis developed on average 5.3 years after LT. The mean Cobb angle was 22.1° (11-90°); > 10° in 37/129 patients (28.7%), of whom 5/129 (3.9%) had > 45°. The average vertebral rotation was 16.2° (2-43°; grade 0-II). RVAD was 26.5° (8°-33°) and 15.3° (2-43°) in patients with Cobb > 45° and ≤ 45°. Gender, age at surgery, and extent of LPR were not risk factors for post-thoracotomy scoliosis (p > 0.05), although younger patients developed a more severe deformity.

CONCLUSION

Although post-thoracotomy scoliosis is not associated with significant rotation, the risk of curve progression > 45° is relatively high. Regular follow-up is required as scoliosis may develop several years after LT with or without LPR.

Comparison of thoracoscopy vs. thoracotomy on musculoskeletal outcomes of children with congenital pulmonary airway malformation (CPAM)

BACKGROUND

It has been postulated that video-assisted thoracoscopic surgery (VATS) is superior than conventional thoracotomy for resection of congenital pulmonary airway malformation (CPAM) in terms of shorter hospital length of stay, reduced post-operative complication and better long-term pulmonary outcome. However, there is limited available data concerning the effect of VATS and conventional thoracotomy on musculoskeletal aspects in patients with CPAM. This study aims to compare the long-term effects of both surgical techniques on musculoskeletal outcomes in this group of patients.

METHODS

Thirty-five patients with mean age of 11.38 years old who underwent VATS or conventional thoracotomy for CPAM resection were recruited in this study. The mean follow-up time was 10.42 years (5.48 to 17.71 years). Musculoskeletal examination included screening of musculoskeletal deformities (elevation of shoulder, asymmetry of nipple level, breast/ pectoral muscle maldevelopment, winging of scapula, scoliosis), measurement of bilateral chest wall in relation to anatomical parameter, and testing of shoulder range of motion and power.

RESULTS

The prevalence of winged scapula was significantly lower in patients who underwent VATS than thoracotomy (13% vs 58%, p = 0.008). There is also a smaller reduction in operated-side chest wall vertical distance in VATS patients (0.982 vs 0.956, p = 0.058). There were no significant difference in prevalence of other musculoskeletal deformities, other chest wall measurements, shoulder range of motion and power between two groups.

CONCLUSION

Thoracoscopy decreases the incidence of scapular winging but has no effect on effect on other musculoskeletal deformities.

Prevalence of and Risk Factors for Sagittal Posture Abnormalities in Children Born With Esophageal Atresia: A Prospective Cohort Study

Introduction: Scoliosis is a well-described complication of esophageal atresia (EA) caused by the associated spine malformations and/or thoracotomy. However, the sagittal posture abnormalities in patients with EA have not been described. The aim of this study was to evaluate the prevalence of and risk factors for sagittal posture abnormalities at the age of 6 years in patients operated on for EA. Methods: A prospective cohort of 123 patients with EA was examined by the same rehabilitation doctor at the time of a multidisciplinary visit scheduled at the age of 6 years. Children presenting with scoliosis (n = 4) or who missed the consultation (n = 33) were excluded. Univariate and multivariate logistic regression models with Firth's penalized-likelihood approach were used to identify risk factors associated with sagittal posture anomalies. Candidate risk factors included neonatal characteristics, associated malformations, atresia type, postoperative complications, psychomotor development retardation, orthopedic abnormalities, and neurological hypotonia. Results: The prevalence rates of sagittal posture abnormalities were 25.6% (n = 22; 95% CI, 16.7-36.1%). Multivariate analysis showed that minor orthopedic abnormalities (OR: 4.02, 95% CI: 1.29-13.43, P = 0.021), and VACTERL (OR: 3.35, 95% CI: 1.09-10.71, P = 0.042) were significant risk factors for sagittal posture abnormalities. Conclusion: This study shows that sagittal posture anomalies occur frequently in children operated on at birth for EA and are not directly linked to the surgical repair. These children should be screened and treated using postural physiotherapy, especially those with VACTERL and minor orthopedic abnormalities.

Prevalence of Tracheoesophageal Anomaly Cases among Neonates Undergoing Surgery in a Tertiary Care Children’s Hospital

INTRODUCTION

Tracheo-oesophageal anomaly is the abnormal communication between trachea and oesophagus. The most common type of tracheo-oesophageal anomaly is oesophageal atreasia with distal tracheo oesophageal fistula. Tracheo-oesophageal anomaly is a common neonatal problem requiring an urgent surgery. Tracheo-oesophageal anomaly can be diagnosed as an isolated malformation or as part of polymalformative syndrome with possible vertebrae anomalies also known as Vacterl syndrome. The aim of the study is to find out the prevalence of tracheo-oesophageal anomaly cases among neonates undergoing surgery in a tertiary care childrens hospital in Nepal.

METHODS

This is a descriptive cross sectional study conducted in a tertiary care children’s hospital in Nepal taking into account the medical records from period of 01 Jan, 2018 to Dec 31, 2019. Study population included the infants undergoing operative procedure in the operation theatre of Kanti Children’s Hospital. The calculated sample size was 306. Data was collected by retrospective chart review technique and listed in performa. Consecutive sampling technique was used. Thus collected data was entered in SPSS version 20 and necessary calculations were done.

RESULTS

The prevalence of tracheo-oesophageal anomalies was found out to be 30 (9.8%) at 95% confidence interval. The most common problem, with which infants were brought to Kanti Children’s Hospital, that required urgent neonatal surgical intervention was anorectal malformation constituting 94 (30.72%) of the surgeries followed by intestinal obstruction 76 (24.84%) which included duodenal atresia, jujunal atresia and ileal atresia.

CONCLUSIONS

Tracheo-oesophageal anomaly constitutes a major portion of neonatal disease condition requiring surgery in Nepal.

Scoliosis after thoracotomy repair of esophageal atresia: a systematic review

Standard surgical repair of esophageal atresia/tracheoesophageal fistula (EA/TEF) is via a right posterolateral thoracotomy. A recognized complication is the later development of scoliosis. The prevalence and pathogenesis of secondary scoliosis are poorly understood. We, therefore, conducted a systematic review on this topic. All English language articles reporting incidence, outcomes and/or interventions for scoliosis in children after EA repair via thoracotomy were identified. Fourteen relevant articles published between 1969 and 2019 reporting 1338 children were included in the analysis. The aggregate prevalence of scoliosis among 937 children without congenital vertebral anomalies was 13%, but this figure varied widely between studies. Severity of scoliosis was documented in 181 children; eight children had a Cobb angle > 40° and 10 had undergone spinal surgery. The spinal curvature in affected individuals was dominantly or exclusively convex to the left. In conclusion, the reported prevalence of scoliosis varies widely but on average affects about one in eight children after open repair of EA/TEF. Most cases are mild and do not require intervention. It is currently uncertain whether secondary scoliosis is preventable by using meticulous thoracotomy techniques or thoracoscopic repair.Level of evidence IV.

The role of 22q11.2 deletion syndrome in the relationship between congenital heart disease and scoliosis

BACKGROUND CONTEXT

For over four decades, clinicians and researchers have suggested a relationship between congenital heart disease (CHD) and scoliosis, attributed to either the disease itself or to the long-term effects of cardiac surgery on the immature thoracic cage. However, no study has yet accounted for 22q11.2 deletion syndrome (22q11.2DS), the second most common cause of CHD after Down syndrome. 22q11.2DS has a scoliosis risk of 50%, but within 22q11.2DS a previous report found no significant association between scoliosis and CHD. We, therefore, hypothesized that scoliosis within a CHD cohort would be related to an underlying 22q11.2 deletion.

PURPOSE

To determine the prevalence of scoliosis in CHD patients with and without 22q11.2DS.

STUDY DESIGN/SETTING

Cross-sectional.

PATIENT SAMPLE

A well-characterized existing database of 315 adults with CHD (primarily tetralogy of Fallot), with (n=86) and without (n=229) 22q11.2DS, matched by sex and CHD severity, and excluding other known syndromic diagnoses. We compared the scoliosis prevalence of patients with 22q11.2DS and CHD patients to the prevalence of scoliosis in a cohort of adults with 22q11.2DS without CHD based on medical records.

OUTCOME MEASURES

Presence of scoliosis (Cobb angle ≥10°).

METHODS

We systematically determined the presence of scoliosis in all included patients using chest radiographs, blind to genetic diagnosis. Besides 22q11.2DS, we analyzed other suspected risk factors for scoliosis using a regression model: thoracotomy before the age of 12 years, severe CHD type and sex.

RESULTS

The prevalence of scoliosis in adults with CHD and 22q11.2DS (n=46, 53.5%) was significantly greater than in those without 22q11.2DS (n=18, 7.9%, p<.0001). The presence of a 22q11.2 deletion (odds ratio [OR] 25.4, 95% confidence interval [95% CI] 11.2-57.4, p<.0001), a history of thoracotomy before the age of 12 years (OR 3.5, 95% CI 1.6-8.1, p=.0027) and most complex CHD class (OR 2.3, 95% CI 1.1-4.7, p=.0196), but not sex, were significant independent predictors of scoliosis. In the 22q11.2DS group, a right-sided aortic arch was associated with a left thoracic scoliotic curve (p=.036).

CONCLUSIONS

The prevalence of scoliosis in those with CHD but without a 22q11.2 deletion approximates that of the general population. However, in the CHD population with a 22q11.2 deletion, the prevalence of scoliosis approximates that of others with 22q11.2DS. The pediatric surgical approach and severity of CHD were weaker independent contributors as compared to the 22q11.2 deletion. The results support the importance of a genetic diagnosis of 22q11.2DS to the risk of developing scoliosis in individuals with CHD. The 22q11.2 deletion may represent a common etiopathogenetic pathway for both CHD and scoliosis, possibly involving early laterality mechanisms.

Chylous Leak During Posterior Approach to Juvenile Scoliosis Surgery: A Case Report

CASE

We report the first documented case of chylous leak recognized intraoperatively during posterior spinal instrumentation and fusion for juvenile scoliosis in a female patient with a history of thoracotomy and decortication for an empyema.

CONCLUSIONS

Thoracic duct injury can lead to severe morbidity and mortality because of chylothorax formation. Although chylous leaks are a well-documented complication of the anterior approach to spine surgery, leaks during the posterior approach are rarely reported. When these chylous leaks are recognized intraoperatively, the likelihood of serious complications may be minimized by drain placement before closure.

Prevalence and natural history of scoliosis and associated congenital vertebral anomalies in patients operated for esophageal atresia with or without tracheoesophageal fistula

BACKGROUND

Scoliosis has been reported after repair of esophageal atresia with or without tracheoesophageal fistula (EA-TEF). This study aims to investigate the prevalence and natural history of scoliosis and associated congenital vertebral anomalies in patients operated for EATEF.

METHODS

A retrospective review of patients operated for EA-TEF with radiological examination for the presence of scoliosis or associated spine congenital anomalies was done on 106 patients (ages 5-19 years).

RESULTS

Scoliosis was found in 53 patients (49%) for which 46 of these were in the thoracic region and 33 were right-thoracic curves. After a follow-up ranging from 5 to 14 years, four patients (3.7%) out of 106 were operated for scoliosis. Right-sided thoracotomy (RST) was the identifiable risk factor for scoliosis development; all patients with scoliosis had their EA repaired through RST. Congenital vertebral anomalies were found in 8 of those patients (7.5%). After a median follow-up of 6.5 years, no patients progressed enough to require operation.

CONCLUSION

Scoliosis affects one of every two patients operated for EA; it may progress to the indication of surgery. RST was the identifiable risk factor for scoliosis development.

The 22q11.2 deletion syndrome as a model for idiopathic scoliosis - A hypothesis

Adolescent idiopathic scoliosis (AIS), defined as a lateral deviation of the spine of at least ten degrees, is a classic enigma in orthopaedics and affects 1-4% of the general population. Despite (over) a century of intensive research, the etiology is still largely unknown. One of the major problems in all existing AIS research is the fact that most patients come to medical attention after onset of the curve. Therefore, it is impossible to know whether current investigated parameters are causative, or an effect of the scoliosis. Moreover, up until now there is no known animal model that captures the core features of AIS. In order to identify causal pathways leading to AIS we propose another approach, which has been of great value in other medical disciplines: To use a subset of the population, with a higher risk for a certain disease as a "model" for the general population. Such a "model" may allow the identification of causative mechanisms that might be applicable to the general population. The 22q11.2 deletion syndrome (22q11.2DS) is the most common microdeletion syndrome and occurs in ∼1:3000-6000 children and 1:1000 pregnancies. Nearly half of the population of patients with 22q11.2DS develop a scoliosis that in most cases resembles AIS as far as age at onset and curve pattern. We postulate that within 22q11.2DS certain causal pathways leading to scoliosis can be identified and that these are applicable to the general population.

Posterior Spinal Fusion in a Scoliotic Patient With Congenital Heart Block Treated With Pacemaker: An Intraoperative Technical Difficulty

STUDY DESIGN

Case report.

OBJECTIVE

To describe the technical difficulties on performing posterior spinal fusion (PSF) on a pacemaker-dependent patient with complete congenital heart block and right thoracic scoliosis.

SUMMARY OF BACKGROUND DATA

Congenital complete heart block requires pacemaker implantation at birth through thoracotomy, which can result in scoliosis. Corrective surgery in this patient was challenging. Height gain after corrective surgery may potentially cause lead dislodgement. The usage of monopolar electrocautery may interfere with the function of the implanted cardiac device.

METHODS

A 17-year-old boy was referred to our institution for the treatment of right thoracic scoliosis of 70°. He had underlying complete congenital heart block secondary to maternal systemic lupus erythematosus. Pacemaker was implanted through thoracotomy since birth and later changed for four times. PSF was performed by two attending surgeons with a temporary pacing inserted before the surgery. The monopolar electrocautery device was used throughout the surgery.

RESULTS

The PSF was successfully performed without any technical issues and complications. Postoperatively, his permanent pacemaker was functioning normally. Three days later, he was recovering well and was discharged home from hospital.

CONCLUSION

This case indicates that PSF can be performed successfully with thoughtful anticipation of technical difficulties on a pacemaker-dependent patient with underlying congenital heart block.

LEVEL OF EVIDENCE

5.

Thoracic skeletal anomalies following surgical treatment of esophageal atresia. Lessons from a national cohort

INTRODUCTION

Thoracotomy as surgical approach for esophageal atresia treatment entails the risk of deformation of the rib cage and consequently secondary thoracogenic scoliosis. The aim of our study was to assess these thoracic wall anomalies on a large national cohort and search for factors influencing this morbidity.

MATERIALS AND METHODS

Pediatric surgery departments from our national network were asked to send recent thoracic X-ray and operative reports for patients born between 2008 and 2010 with esophageal atresia. The X-rays were read in a double-blind manner to detect costal and vertebral anomalies.

RESULTS

Among 322 inclusions from 32 centers, 110 (34.2%) X-rays were normal and 25 (7.7%) displayed thoracic malformations, including 14 hemivertebrae. We found 187 (58.1%) sequelae of surgery, including 85 costal hypoplasia, 47 other types of costal anomalies, 46 intercostal space anomalies, 21 costal fusions and 12 scoliosis, with some patients suffering from several lesions. The rate of patients with these sequelae was not influenced by age at intervention, weight at birth, type of atresia, number of thoracotomy or size of the center. The rate of sequelae was higher following a classical thoracotomy (59.1%), whatever the way that thoracotomy was performed, compared to nonconverted thoracoscopy (22.2%; p=0.04).

CONCLUSION

About 60 % of the patients suffered from a thoracic wall morbidity caused by the thoracotomy performed as part of surgical treatment of esophageal atresia. Minimally invasive techniques reduced thoracic wall morbidity. Further studies should be carried out to assess the potential benefit of minimally invasive approaches to patient pulmonary functions and on the occurrence of thoracogenic scoliosis in adulthood.

LEVELS OF EVIDENCE

Level III retrospective comparative treatment study.

Thoracoscopic surgery for esophageal atresia

This review centers on the thoracoscopic management of esophageal atresia (EA) and distal tracheoesophageal fistula (TEF). The first thoracoscopic repair of EA was performed by Rothenberg and Lobe in Berlin in 1999 just prior to an IPEG meeting. Since that time, the largest report describing the use of thoracoscopy for EA/TEF repair came in 2005 with a multi-national, multi-institutional retrospective review from six institutions around the world. The outcomes reported were quite good and very comparable to large series of open operations that had been previously reported. This review will describe a single surgeon's technique for thoracoscopic repair of EA/TEF. In addition, further controversies regarding the usefulness of preoperative bronchoscopy, ligation of the distal TEF, and type of suture used for the esophageal anastomosis will also be discussed. Finally, there is a discussion on the advantages and disadvantages of the thoracoscopic approach.

Complications in the surgical management of children with malignant solid tumors

With improvement in the outcomes for children with cancer has come an increasing focus on minimizing the morbidity from therapeutic interventions, including surgical procedures, while continuing to have a high likelihood of cure. Thus, an appreciation for the potential complications of surgery, both acute and long term, is critical when considering the risks and benefits of any procedure performed on a child with cancer. Although not meant to be an exhaustive review, here we discuss the most common and significant surgical complications that may occur when performing diagnostic, therapeutic, or supportive procedures in children with the most common malignant solid tumors.

Long-term Complications of Congenital Esophageal Atresia, Single Institution Experience

OBJECTIVE

To evaluate general health condition of children operated for esophageal atresia, including complications from gastrointestinal tract and skeletal defects.

METHODS

Between 1990 and 2005, 77 patients were operated for esophageal atresia in the Polish Mothers Health Memorial Hospital. The study was based on retrospective analysis of medical case records of all children with esophageal atresia. All living patients (n=51) were invited for follow-up studies.

RESULTS

Pathological gastroesophageal reflux was found in 46.7% of children. Scoliosis was diagnosed in 20 patients. Chest deformations were observed in 43.3% children.

CONCLUSION

The absence of clinical symptoms does not exclude the presence of gastroesophageal reflux in children operated for esophageal atresia. Children operated for esophageal atresia should be followed up regularly by a multispecialistic medical team.

Current Practice and Outcomes of Thoracoscopic Esophageal Atresia and Tracheoesophageal Fistula Repair: A Multi-institutional Analysis in Japan

BACKGROUND

In order to better understand the current practice and outcomes of thoracoscopic repair of esophageal atresia (EA)/tracheoesophageal fistula (TEF), a multi-institutional analysis was conducted among seven Japanese institutes.

MATERIALS AND METHODS

A survey was sent to the seven institutes regarding the surgical technique, postoperative management, and outcomes of thoracoscopic repair of EA/TEF.

RESULTS

The operation was uniformly performed via an intrapleural approach in the 0-45° prone position. The TEF was occluded with suture ligature in four (57.1%) institutes and clips in the remaining three (42.9%) institutes. Anastomosis was performed using the extracorporeal knot-tying technique in four institutes and the intracorporeal technique in three institutes. Patients were routinely left intubated and paralyzed for 3-7 days postoperatively in four institutes. In total, 58 patients underwent thoracoscopic repair of EA/TEF. Fifty-two (89.7%) of the patients underwent successful thoracoscopic repair. Six (10.3%) operations were converted to open thoracotomy because of a long gap (n=4), right aortic arch (n=1), and intraoperative instability (n=1). The body weight at operation ranged from 1.2 to 4.6 kg, and the operative time ranged from 115 to 428 minutes. There were no major intraoperative complications. Eleven patients (19.0%) suffered from anastomotic leakage. Twenty-eight patients (48.3%) developed anastomotic stricture. One patient died during the postoperative period because of an unrelated disease. Recurrent TEF developed in three patients (5.2%). Thirteen patients (22.4%) later required fundoplication.

CONCLUSIONS

The outcome of thoracoscopic repair of EA/TEF was comparable to that of the open procedure. As considerable variability was observed among the seven institutes with respect to the surgical technique and management, standardizing the surgical management may improve the outcome.

Prognostic risk factors for the development of scoliosis after chest wall resection for malignant tumors in children

BACKGROUND

Surgical resection of a malignant tumor of the chest wall in children may result in the development of progressive scoliosis. The aim of this study was to identify the risk factors associated with scoliosis following resection of a tumor of the chest wall and to evaluate the prevalence and characteristics of the scoliosis.

METHODS

Forty children who underwent resection of a malignant tumor of the chest wall from 1984 to 2005 were included in a multicenter, retrospective cohort study. The mean age of the patients at the time of surgery was 9.8 years (range, 0.2 to nineteen years). Resections were classified with the use of the following scheme: the number of resected ribs was noted in Roman numerals, and the level of the resection was identified by dividing the thorax into three sectors (A [anterior], B [lateral], and C [posterior]) in the horizontal plane. One to five ribs (mean, 2.3 ribs) were resected. Patients with scoliosis were compared with patients who did not have scoliosis through the use of univariate and multivariate analyses. The mean duration of follow-up was 8.5 years (range, three to twenty-three years).

RESULTS

Patients who had a tumor resection during a rapid-growth period (patient age of less than six years or between twelve and fifteen years) had a 5.8 times higher risk of scoliosis. The resection of three or more ribs in the posterior sector (C) was the primary risk factor for scoliosis, with an odds ratio of 18.9. Seventeen (43%) of the children developed scoliosis, which was convex toward the resection side without vertebral rotation in all of them.

CONCLUSIONS

The risk of scoliosis following the resection of a primary malignant tumor of the chest wall in children was shown to be higher when resection was performed during a rapid-growth period and when the resection involved three or more ribs in the posterior sector.

A survey of musculoskeletal and aesthetic abnormalities after thoracotomy in pediatric patients

OBJECTIVE

To study the incidence and type of musculoskeletal and aesthetic abnormalities after thoracotomy in children.

MATERIALS AND METHODS

Children below 12 years of age who had undergone thoracotomy for any condition and have at least 2 years follow up were included in the study. Detailed assessment of the patients included: history and general examination, clinical examination of chest and musculoskeletal system, X-ray chest including bilateral shoulders [antero-posterior (AP), lateral, oblique], X-ray whole spine (AP, lateral, right and left side bending AP view).

RESULTS

Fifty-two pateints were recruited. The incidences of various clinically and radiologically assessed musculoskeletal and aesthetic abnormalities observed were: winging of scapula (5.7%), ipsilateral elevation of shoulder (5.7%), fixation of skin cicatrix to bony thorax (7.7%), maldevelopment of pectoral muscles (11.5%), asymmetry of the level of nipples (1.9%), rib fusion (5.7%), crowding of ribs (9.6%), mediastinal shift (3.8%), decreased space available for lungs (3.8%), Scoliosis with Cobb's angle >10(0) (1.9%).

CONCLUSIONS

The incidences of musculoskeletal and aesthetic abnormalities after posterolateral thoracotomies in children were low. Longer follow up of patients after thoracotomy is needed to pick up these abnormalities as the children grow.

Rib osteoblastoma as an incidental finding in a patient with adolescent idiopathic scoliosis: a case report

The purpose of this article is to present an unreported case of rib osteoblastoma associated with progressive adolescent idiopathic scoliosis and to discuss thoracogenic scoliosis as a potential cause of curve progression after tumor resection. An 11-year and 8-month-old girl with adolescent idiopathic scoliosis was referred with an incidental finding of an expansile lesion in the posterior left seventh rib. A computed tomography-guided needle biopsy established the diagnosis of benign osteoblastoma. Transarterial embolization was performed followed by wide resection. Sixteen months after surgery the patient underwent posterior spinal fusion to address her scoliosis progression during the growth spurt. Forty-one and 25 months after rib resection and spinal fusion, respectively, the patient remains asymptomatic, without local tumor recurrence, and with excellent correction of her spinal deformity. Although scoliosis secondary to rib osteoblastoma has been described in the literature, rib osteoblastoma may coexist with idiopathic scoliosis. In such a case, surgical management of osteoblastoma should not interfere with treatment of idiopathic scoliosis.

Scoliosis after chest wall resection

BACKGROUND DATA

There has been an increased focus on the role of rib abnormalities in the development of scoliosis. Rib resection may influence the development of scoliosis. Although scoliosis has been identified in patients after thoracotomy, most of the currently available information is from case reports.

METHODS

We examined records of 37 patients who underwent a chest wall or rib resection for rib lesions at our institution during the period of 1992 to 2005. Adequate data was available in 21 patients. We gathered data on demographic information, location of resection, and changes in curvature after resection based on radiograph or scout CT films at the latest follow-up appointment.

RESULTS

Fourteen of 21 patients developed scoliosis with a mean Cobb angle of 25.8° (10°-70°). Eleven of these 14 patients had a progressive spinal deformity after chest wall resection with an average change in curvature of 29° (10°-70°). Eight of those 11 developed a convex toward the resection, while 3/11 developed a convex away from the resection. Seven of the eight patients with resections that included a rib superior to the sixth rib developed scoliosis, while four of 13 with resections below the sixth rib developed scoliosis.

CONCLUSION

Patients who have had a rib or chest wall resection are at risk for developing scoliosis, particularly if the resection is performed above the sixth rib.

Paediatric thoracoscopic surgery

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

Pediatric minimally invasive surgery: laparoscopy and thoracoscopy in infants and children

This article discusses the potential benefits and challenges of minimally invasive surgery for infants and small children, and discusses why pediatric minimally invasive surgery is not yet the surgical default or standard of care. Minimally invasive methods offer advantages such as smaller incisions, decreased risk of infection, greater surgical precision, decreased cost of care, reduced length of stay, and better clinical information. But none of these benefits comes without cost, and these costs, both monetary and risk-based, rise disproportionately with the declining size of the patient. In this review, we describe recent progress in minimally invasive surgery for infants and children. The evidence for the large benefits to the patient will be presented, as well as the considerable, sometimes surprising, mechanical and physiological challenges surgeons must manage.

Natural history of spinal anomalies and scoliosis associated with esophageal atresia

OBJECTIVE

Clinical characteristics of spinal deformities that commonly occur in patients with esophageal atresia (EA) are unclear. The objective of this study was to assess the incidence and natural history of spinal anomalies and scoliosis in patients with EA.

METHODS

A population-based cohort of 100 adults who had an operation for EA in our hospital were examined clinically and radiographically for spinal deformities. The results were compared with data obtained from normal population-based controls.

RESULTS

Vertebral anomalies were observed in 45 patients, predominating in the cervical spine in 38 patients. Any additional anomaly was the most significant risk factor (odds ratio [OR]: 27 [95% confidence interval (CI): 8-100]) for the occurrence of vertebral anomalies. Scoliosis of >10 degrees was observed in 56 patients, >20 degrees in 11 patients, and >45 degrees in 1 patient. The risk for scoliosis of >10 degrees was 13-fold (OR: 13 [95% CI: 8.3-21]), and the risk for scoliosis of >20 degrees was 38-fold (OR: 38 [95% CI: 14-106]) compared with those in the normal population. Thoracotomy-induced rib fusions (OR: 3.6 [95% CI: 0.7-19]) and other associated anomalies (OR: 2.1 [95% CI: 0.9-2.9]) were the strongest predictive factors for scoliosis. The general clinical course of spinal deformities was mild, and none of the patients had undergone spinal surgery.

CONCLUSIONS

The risk of scoliosis is 13-fold after repair of EA in relation to general population. Nearly half of the patients have vertebral anomalies predominating in the cervical spine. Most of these deformities were not diagnosed primarily or during growth. Spinal surgery is rarely indicated.

Scoliosis in patients with aortic coarctation and patent ductus arteriosus: does standard posterolateral thoracotomy play a role in the development of the lateral curve of the spine?

The aim of this study was to determine the influence of lateral thoracotomy on the development of scoliosis in subjects undergoing repair of coarctation of the aorta (CoA) and patent ductus arteriosus (PDA). A group of 133 patients with CoA and PDA was evaluated. Forty-five patients with CoA and 38 with PDA underwent surgery using standard posterolateral thoracotomy (operative group), whereas 12 patients with CoA and 31 with PDA were treated using balloon dilatation and stent or coil implantation (nonoperative group). A spinal examination, together with the evaluation of chest and spinal roentgenograms, was conducted. Among the operated patients, 62% of those with CoA and 55% of those with PDA had clinical scoliosis. In the nonoperated patients, scoliosis was present in only 25% of those with CoA and 16% of those with PDA. Scoliosis ranged between 10 degrees and 42 degrees . In 89% of the operated patients with CoA and 76% of those with PDA the curve was thoracic; in 46% of the CoA group and 57% of the PDA group the curve was left-sided. All curves were right-sided in nonoperated subjects. Scoliosis in the operated group was higher in male than in female subjects (63% vs. 60% in CoA and 86% vs. 37% in PDA). The prevalence of scoliosis after standard posterolateral thoracotomy was significantly higher than after nonsurgical treatment methods in the CoA and PDA groups as well as in the general population. The rate of single thoracic and the rate of left-sided thoracic curves in patients after thoracotomy is higher than in nonoperated patients or in those with idiopathic scoliosis. The rate of scoliosis after thoracotomy is higher in male than female patients, especially after thoracotomy for PDA.

Complication of surgery for scoliosis in children with surgically corrected congenital cardiac malformations

INTRODUCTION

There is a high incidence of scoliosis in patients who have undergone cardiothoracic surgery for correction of congenital cardiac disease, this risk being 10 times higher than in the general population.

MATERIALS AND METHODS

So as to analyse the surgical and postoperative complications, we designed a retrospective study to include every child who underwent spinal orthopaedic surgery, and who had previously undergone cardiothoracic surgery because of a congenital cardiac malformation. We excluded those patients who had syndromes associated with the development of scoliosis.

RESULTS

We identified 18 patients with surgically treated congenital cardiac disease who had undergone surgery for scoliosis over a period of 7 years. This group came from a total number of 87 patients undergoing spinal fusion over the same period. Of those with congenitally malformed hearts, 61% had acyanotic lesions, with ventricular septal defect being the most frequent single lesion, present in 40%. All the patients needed blood transfusions during the surgery, with aprotinin used in 73% to reduce the bleeding, and inotropes needed for 4 children. During the immediate postoperative period, 1 patient died in the first 24 hours, while 7 (39%) had different complications, pneumonia in 4, pleural effusions in 2, and rhabdomyolysis in the other, as opposed to a rate of complications of 27% in patients without heart disease.

CONCLUSION

The surgical and postoperative complications in these patients depend on the specific cardiac lesion. A multidisciplinary team with experience in the treatment of congenitally malformed hearts is essential for appropriate management of these patients.

Thoracoscopy versus thoracotomy improves midterm musculoskeletal status and cosmesis in infants and children

BACKGROUND

It has been postulated that video-assisted thoracoscopic surgery (VATS) achieves a better biometric and aesthetic outcome than conventional thoracic surgery (CTS), but data are lacking. We aimed to compare the midterm effects of both approaches in children.

METHODS

Sixty-two infants and children, who underwent VATS (34; 55%) or CTS (28; 45%) for benign thoracic conditions, were evaluated at follow-up after a mean of 3.8 years (1 to 7 years). The patients underwent standardized clinical assessment of the skeletal system and function. The intercostal spaces were investigated for rib fusion by ultrasound. Patients (+/- parents) themselves, as well as clinicians, subsequently assessed the scars.

RESULTS

Comparing the operated versus nonoperated sides, chest asymmetry was significantly less frequent after VATS versus CTS in the horizontal plane (mean relative difference 0.996 +/- 0.003 vs 0.964 +/- 0.008, p < 0.001) and in nipple location (mean relative difference 0.985 +/- 0.008 vs 0.949 +/- 0.013, p = 0.047). The ranges of motion of the shoulder joints did not differ significantly. However, the incidence of scoliosis was lower in VATS patients (9% vs 54%, p < 0.001) and the intercostal spaces of the operated hemithoraces were narrower after CTS (p < 0.001). The Manchester scar assessment scores were in favor of VATS (mean 7.5 vs 13.1, p < 0.001). The visual analog scale scores recorded by patients-parents and independent observers were also significantly better after VATS. Patient satisfaction was less with CTS as 10% wanted to have the scar revised, compared with none in the VATS group.

CONCLUSIONS

The thoracoscopic versus conventional approach to the thoracic cavity in children is associated with significantly less midterm musculoskeletal sequelae and a better cosmetic outcome.

Retrospective study on the development of spinal deformities following sternotomy for congenital heart disease

STUDY DESIGN

Retrospective review with a minimum of 3 years of follow-up.

OBJECTIVE

We hypothesize that following median sternotomy there may be an increase incidence of both sagittal and coronal spinal deformity. We also think that heart size and a cyanotic cardiac condition are also risk factors for development of spinal deformity. The purpose of this study was to determine the incidence and characteristics of spinal deformity in patients following sternotomy for congenital heart disease.

SUMMARY OF BACKGROUND DATA

Patients with congenital heart disease are at an increased risk to develop scoliosis.

METHODS

A total of 108 patients underwent a median sternotomy for the treatment of congenital heart disease and met inclusion criteria. The medical record was reviewed to gather demographic data and medical and surgical history. Serial chest and spine radiographs were reviewed.

RESULTS

Scoliosis developed in 28% of the patients (10 males, 20 females). The mean follow-up was 13 years (range, 3-26 years). The mean coronal Cobb angle was 25 degrees (range, 11 degrees-88 degrees). Of these, 7 patients presented with curves of > or = 30 degrees. The mean age at diagnosis of scoliosis was 14 years (range, 2-33 years). A kyphotic deformity developed in 22% (24 patients). In patients with scoliosis, the mean sagittal kyphosis was 34 degrees (range, 2 degrees-73 degrees). Patients with a cyanotic cardiac condition had a trend toward severe scoliosis. There was no correlation between the development of scoliosis or kyphosis and the age at time of procedures, number of surgeries, gender, or heart size.

CONCLUSION

The risk of developing scoliosis in children with congenital heart disease is more than 10 times that of idiopathic scoliosis. Spinal deformities, including scoliosis and/or kyphosis, were found in 34% of the patients. The sagittal alignment in scoliosis patients tends toward kyphosis.

Spinal deformity after combined thoracotomy and sternotomy for congenital heart disease

Patients with congenital heart disease are at an increased risk to develop scoliosis. The purpose of this study was to determine the incidence of spinal deformity in patients after thoracotomy and sternotomy for congenital heart disease.

METHODS

Sixty-eight patients underwent thoracotomy followed by a sternotomy and met inclusion criteria. The medical records were reviewed to gather demographic data and medical and surgical history. Serial radiographs were reviewed.

RESULTS

Scoliosis developed in 26% of the patients (10 boys, 8 girls). The mean Cobb angle was 40 degrees (range, 15-78 degrees). The mean age at diagnosis of scoliosis was 10.7 years (range, 2.9-17 years). The mean follow-up was 14.9 years (range, 5-20 years). Twelve percent (8 patients) required posterior spinal fusion. A kyphotic deformity developed in 21% (14 patients). In patients with scoliosis, the mean kyphosis was 38 degrees (range, 2-88 degrees). Patients with a cyanotic cardiac condition had a 4-fold incidence of scoliosis. There was no correlation between the development of scoliosis or kyphosis and the age at time of procedures, number of surgeries, sex, heart size, or side of the aortic arch.

CONCLUSIONS

The risk of developing scoliosis in children with congenital heart disease is more than 10 times that of idiopathic scoliosis. Spinal deformities, including scoliosis and/or hyperkyphosis, were found in 38% of the patients. Curves develop at a younger age, which increases the risk of progression. The sagittal alignment in scoliosis patients tends toward hyperkyphosis. The thoracic spine receives a "double hit" when both procedures are combined.

Scoliosis after median sternotomy in children with congenital heart disease

STUDY DESIGN

A retrospective review of spinal deformity in patients with congenital heart disease surgically treated through a median sternotomy before the age of 8 years. Assessment was done on chest roentgenograms at skeletal maturity.

OBJECTIVES

To determine if patients surgically treated through a median sternotomy present a higher prevalence of spinal deformity.

SUMMARY OF BACKGROUND DATA

Congenital heart disease is associated with a higher prevalence of scoliosis. The etiology of scoliosis in this group of patients is unknown. Thoracotomy causes scoliosis, but median sternotomy has not been identified as a causal agent in these patients.

METHODS

Chest roentgenograms were done after skeletal maturity in 128 patients to assess for the presence of a spinal deformity in the sagittal or coronal plane as a result of a median sternotomy for treatment of congenital heart disease before the age of 8 years in patients without any prior radiographic evidence of spinal or costal deformity before surgery.

RESULTS

Forty-four (34.3%) of these patients had scoliosis greater than 10 degrees , 16 of them (12.5%) had curves greater than 20 degrees , and 33 (25.8%) had thoracic kyphosis lesser than 20 degrees . Patients operated before the age of 18 months had a significantly increased risk of developing scoliosis than those operated at a later age (odds ratio = 3.5; confidence interval = 1.3-9.6; P = 0.016). The presence of scoliosis was not related to the type of congenital heart disease.

CONCLUSIONS

There is a high prevalence of scoliosis in patients with congenital heart disease surgically treated through a median sternotomy. The prevalence of scoliosis increases in patients operated at an earlier age.

Progression of idiopathic thoracolumbar scoliosis after breast reconstruction with a latissimus dorsi flap: a case report

STUDY DESIGN

A report of a patient in whom progressive symptomatic thoracolumbar scoliosis developed after breast reconstruction with a latissimus dorsi myocutaneous flap.

OBJECTIVES

To present the first reported case of progressive symptomatic scoliosis after breast reconstruction with a latissimus dorsi myocutaneous flap and to suggest that latissimus flap harvest may be contraindicated in patients with preexisting scoliosis.

SUMMARY OF BACKGROUND DATA

Latissimus dorsi myocutaneous flap harvest incorporated into several surgical operations including breast reconstruction has been presented as a relatively benign procedure without significant biomechanical consequence. Nevertheless, various anatomic and animal studies have suggested an important role for balanced latissimus function in terms of proper spinal alignment. Long-term follow-up evaluation of patients after latissimus flap harvest is insufficient and fails to address the specific issue of spinal deformity.

METHODS

Postoperative radiographs demonstrated significant progression of the patient's thoracolumbar scoliosis as compared with radiographs taken before her latissimus harvest. Curve progression accompanied by development of severe and disabling back pain were considered indications for surgical curve correction and stabilization.

RESULTS

At the time of 1-year follow-up assessment after posterolateral spinal fusion and instrumentation, the patient had experienced complete relief from her back pain and satisfactory spinal fusion.

CONCLUSIONS

Although a cause and effect relation cannot be established, this case study suggests that latissimus harvest may have a destabilizing effect on the thoracolumbar spine in the long term, especially in patients with preexisting scoliosis. Alternative procedures should be considered in these patients.

Video-assisted thoracoscopic surgery for the treatment of congenital cardiac defects in the pediatric population

Recent technologic advances have contributed to a renewed interest in thoracoscopic surgery. In our institution, thoracoscopy through video-assisted technology has been successfully applied to congenital heart surgery. We reviewed the charts of 45 consecutive patients (ASA physical status 11-IV) who underwent video-assisted thoracoscopic surgery (VATS) for various congenital heart defects. The mean age of the patients was 2.65 yr and the mean weight was 11.78 kg. The surgical procedures included patent ductus arteriosus interruption (n = 28) and vascular ring division (n = 8), and 9 patients had miscellaneous procedures. The most commonly used anesthetic regimen consisted of isoflurane, pancuronium, fentanyl, air, and oxygen. Seven patients were managed with one-lung ventilation, the remainder by two-lung ventilation with surgical lung retraction. Intraoperative desaturation occurred in 12 patients (26.7%) but resolved quickly with brief reexpansion of the lungs. Postoperative complications included: pleural effusions (n = 3), chylothorax (n = 2), right upper lobe atelectasis (n = 1), small pneumothorax (n = 1), and vocal cord paralysis (n = 1). Seven patients (15.5%) required conversion to a thoracotomy for insufficient exposure (n = 4) or due to concern over bleeding (n = 3). This experience with VATS in pediatric patients with congenital heart disease may provide a database for comparison with others who work with the VATS technique.

Transoesophageal echocardiography detects residual ductal flow during video-assisted thoracoscopic patent ductus arteriosus interruption

This report describes transoesophageal echocardiographic (TEE) monitoring in a one-year-old boy undergoing patent ductus arteriosus (PDA) interruption. After application of a first vascular clip, echocardiographic monitoring detected incomplete interruption of ductal flow, prompting the surgeon to add a second clip to the ductus. The procedure was performed via a new surgical technique: video-assisted thoracoscopic surgery (VATS). This innovative approach offers many advantages to patient care including reduced postoperative pain and better preservation of pulmonary function. We conclude that the use of TEE monitoring during PDA interruption via the VATS procedure may improve the surgical result, and eliminate reintervention and the complications associated with residual ductal flow.

Spinal deformity in patients born with oesophageal atresia and tracheo-oesophageal fistula

Spinal deformity was present in 58 (19%) of 302 patients born with oesophageal atresia and fistula when examined at review. This was present in 24 (47%) of 51 patients with vertebral anomalies and 34 (14%) of 251 patients with normal vertebrae. Scoliosis was present in 21 patients with vertebral anomalies, torticollis in two, and lordosis in one. Two thirds of the patients with congenital scoliosis have had or are likely to require operation, compared with five patients with non-congenital scoliosis. Scoliosis associated with mixed vertebral anomalies in the lower thoracic spine had the worst prognosis. The medical records of a further 64 patients who had survived operation but who could not be traced were reviewed, and indicated that four had had congenital vertebral anomalies but none had a spinal deformity. We recommend early detection of vertebral anomalies in this group and careful follow up of patients with these abnormalities.

Chest wall deformity in patients with repaired esophageal atresia

Chest wall deformities developed after thoracotomy for esophageal atresia, in 77 of 232 patients (33%) who did not have a congenital vertebral anomaly. Anterior chest wall asymmetry was present in 47, scoliosis in 18 and a combination of both in 12 patients. Scoliosis was convex away from the incision in two thirds of those affected. Anterior chest wall deformity was more common in patients greater than 25 years of age, and scoliosis was more common in patients who had had multiple thoracotomies. Breast surgery to minimize inequality was required in three female patients, and spinal surgery in one patient. Twenty-two of 53 patients with a congenital vertebral anomaly developed scoliosis, eight of whom required surgery. The scoliosis was probably the result of the vertebral anomaly in these patients, who are particularly at risk for progressive deformity.