Uniportal video-assisted thoracoscopy in pediatrics-initial experience

Background

It has become apparent that the endoscopic surgeries are rapidly developing, and they have become an essential part of every specialty of surgery. Single port thoracoscopic surgery is developing, enhancing the advantages of muti-portal video-assisted thoracoscopic surgery (VATS). Although becoming a well-recognised approach for adult patients, extremely limited literature exists concerning uniportal VATS among pediatric cases. This study aims to present our initial experience with this approach in a single tertiary hospital and extrapolate its feasibility and safety in this specific context.

Methods

Perioperative parameters and surgical outcomes for all pediatric patients who underwent an intercostal or subxiphoid uniportal VATS surgery in our department in 2 years retrospectively reviewed. The median length of follow-up was 8 months.

Results

Sixty-eight pediatric patients underwent different uniportal VATS operation for different types of pathology. The median age was (3.5 years). Median operating time was 116 minutes. Three cases converted to open. The mortality rate was zero. The median length of stay was 5 days. Three patients presented complications. Three patients lost from follow-up.

Conclusions

Despite literature data heterogeneity, these results provide support to the feasibility and applicability of uniportal VATS in the pediatric population. Further studies are required to explore the benefit of uniportal over multi-portal VATS (including chest wall deformities, cosmesis and quality of life).

Rare case of horseshoe lung associated with scimitar syndrome in Palestine: a case report

The caudal and basal parts of the lungs are fused together in a rare congenital bronchopulmonary anomaly known as horseshoe lung. The majority of horseshoe lung cases are associated with scimitar syndrome. Most patients present with nonspecific symptoms. Multidetector pneumoangiography can be used to diagnose horseshoe lung, which shows that the isthmus of the pulmonary parenchyma traverses the midline, connecting the two lungs together. Treatment and prognosis are usually determined depending on the presence of other concomitant anomalies and the degree of symptom severity.

Case Presentation

A 3-month-old-male patient presented with respiratory symptoms and a history of chest infection. Chest imaging revealed anomalous venous drainage from the right lower lobe of the lung, right lung hypoplasia with mediastinal shift, and a parenchymal isthmus extending between the two lungs. The patient was diagnosed with horseshoe lungs associated with scimitar syndrome. He was also found to have extralobar sequestration to the right lower lobe of the lung. The patient underwent surgical management in the form of tunneling of the anomalous vein into the left atrium using pericardium autograft ligation of the sequestration artery.

Clinical Discussion

Because of its common association with other congenital malformations such as scimitar syndrome and cardiovascular defects, clinicians should be meticulous in the investigation and workup process of patients with horseshoe lung in order not to miss any of these associated abnormalities.

Conclusion

Although it is very rare, horseshoe lung should be considered in the differential diagnosis of respiratory distress symptoms, especially in children younger than 1 year.

Uniportal video assisted thoracoscopy versus open surgery for pulmonary hydatid disease-a single center experience

Background

Although rare in the Western world, the incidence of hydatid disease is still prevalent and strikingly endemic among the Palestinians. Until 2017, surgical treatment of lung pathologies was performed through the traditional incision (open thoracotomy). Uniportal video-assisted thoracoscopic surgery (VATS) approach has recently been applied in the cases of the pulmonary hydatid cysts with very satisfactory results.

Methods

Between January 2010 and January 2019, 39 patients with pulmonary HC disease have been surgically treated. The cases divided into two cohorts: operations performed by thoracotomy classified as group A, (n=16). Operations performed by uniportal VATS classified as group B, (n=23). Prospectively collected data was analysed retrospectively, and the results compared between both groups.

Results

No significant statistical differences were noticed in terms of demographics and comorbidity. Laboratory tests were similar except haemoglobin level, which was higher in group A (P=0.001). Despite that, blood transfusion was higher in group A (P=0.016). Moreover, operation time was longer in group A (P=0.000). Chest drainage remained longer in group A (P=0.077). The level of postoperative pain was significantly higher in group A certainly in POD 1 (P=0.000). Patients in group B discharged earlier from the hospital (P=0.011) and experienced lower complications (P=0.060). No significant difference in length of ICU stay. Neither recurrence nor 30-day mortality recorded in either group.

Conclusions

Uniportal VATS can be safely applied for pulmonary hydatidosis. It also seems to have a preference in several aspects compared to open Thoracotomy approach.

Modified repair of interrupted aortic arch utilizing retroesophageal right subclavian artery based on a neonatal hybrid approach in hypoplastic left heart complex

OBJECTIVE

Interrupted aortic arch (IAA) combined with an aberrant right subclavian artery (ARSA) is frequently associated with a hypoplastic ascending aorta. Neonatal surgical therapy carries a high risk particularly for aortic arch obstructions during the further follow-up.

METHODS

We performed a modified reconstruction of the aortic arch utilizing the ARSA as a natural substitute in a staged surgical approach. In a novel approach, the distal part of the ARSA is reimplanted into the brachiocephalic trunk.

RESULTS

In three patients, a novel arch reconstruction was successfully performed during complete biventricular repair. In a follow-up of 60 to 87 months, the reconstructed aortic arch has grown without any signs of obstruction in all three patients.

CONCLUSION

Utilizing the ARSA for surgical aortic arch repair is a satisfactory solution, when postnatal borderline left heart obstruction associated with IAA and ARSA is postponed by an initial hybrid approach.

Influence of noninvasive positive pressure ventilation on inspiratory muscle activity in obese subjects

Noninvasive positive pressure ventilation (NPPV) can improve ventilation in obese subjects during the postoperative period after abdominal surgery. Compared to nasal continuous positive airway pressure (nCPAP), NPPV was superior in correcting blood gas abnormalities both during the night-time and during the daytime in a subgroup of patients with the obesity hypoventilation syndrome (OHS). However, as it is unknown, if and to what extent NPPV can unload the respiratory muscles in the face of the increased impedance of the respiratory system in obesity, this is what was investigated. Eighteen obese subjects with a body mass index > or = 40 kg x m(-2) were investigated during the daytime, which included five healthy controls (simple obesity (SO)), seven patients with obstructive sleep apnoea (OSA) and six patients with the obesity hypoventilation syndrome (OHS). Assisted PPV was performed with bi-level positive airway pressure (BiPAP), applied via a face mask. Inspiratory positive airway pressure (IPAP) was set to 1.2 or 1.6 kPa and expiratory positive airway pressure (EPAP) was set to 0.5 kPa. Inspiratory muscle activity was measured as diaphragmatic pressure time product (PTPdi). Comparison of spontaneous breathing with BiPAP ventilation showed no significant difference in breathing pattern, although there was a tendency towards an increase in tidal volume (VT) in all three groups and a decrease in respiratory frequency (fR) in patients with OSA and OHS. End-tidal carbon dioxide (PET,CO2) with BiPAP was unchanged in SO and OSA, but was decreased in OHS. In contrast, inspiratory muscle activity was reduced by at least 40% in each group. This was indicated by a decrease in PTPdi with BiPAP 1.2/0.5 kPa from mean+/-SD 39+/-5 to 20+/-9 kPa x s (p<0.05) in SO, from 42+/-7 to 21+/-8 kPa x s (p<0.05) in OSA, and from 64+/-20 to 38+/-17 kPa x s (p<0.05) in OHS. With BiPAP 1.6/0.5 kPa, PTPdi was further reduced to 17+/-6 kPa x s in SO, and to 17+/-6 kPa x s in OSA, but not in OHS (40+/-22 kPa x s). We conclude that noninvasive assisted ventilation unloads the inspiratory muscles in patients with gross obesity.

[Effect of noninvasive ventilation on work of breathing in obesity]

BACKGROUND

Noninvasive ventilation with nose- or face-masks has been increasingly used in the past. The objective of mechanical ventilation is in addition to improve gas exchange to reduce breathing work. While improvement on breathing work has been shown mainly on normal-weight patients with different respiratory diseases, there is no existing data about the effect of noninvasive ventilation on the breathing work of patients with massive obesity.

PATIENTS AND METHODS

Assisted mask-ventilation with bilevel positive airway pressure (BiPAP) was carried out on 5 overweight control subjects (overweight controls), 7 overweight patients with obstructive sleep apnea (OSA), 6 patients with obesitas-hypoventilation syndrome (OHS), and 7 overweight patients with chronic obstructive lung disease (COLD). Inspiratory pressure assist (IPAP) was set to 12 or 16 cm H2O, exspiratory pressure (EPAP) was set to 5 cm H2O. All, subjects were massive overweight (body mass index [BMI] 42.2 +/- 5.8; range 31.8 to 55.4 kg/m2). Respiratory muscle activity was measured as esophageal pressure change (delta Pes) and transdiaphragmatic pressure change (delta Pdi) and calculated as pressure time integral.

RESULTS

With noninvasive ventilation respiratory muscle activity was significantly (p < 0.05) reduced in all groups at least 40% compared to baseline values during spontaneous respiration.

CONCLUSIONS

Noninvasive ventilation via face masks can efficiently reduce work of breathing in subjects with massive obesity.