Indications for Thoracoscopy in Indications for Thoracoscopy in Infants and ChildrenInfants and Children

50th Meeting of the Brazilian 50th Meeting of the Brazilian Association of Pediatric SurgeonsAssociation of Pediatric Surgeons

George W. Holcomb, III, M.D., MBASurgeon-in-Chief

Children’s Mercy HospitalKansas City, Missouri

Indications for Thoracoscopic Procedures in Children

• Lung Biopsy• Lobectomy• Sequestration resection• Excision bronchogenic cyst• Foregut duplication resection• Esophageal myotomy• Anterior spine fusion• Debridement/decortication • Diaphragmatic

hernia/plication

• Spontaneous ptx

• PDA ligation• Thoracic duct ligation• Esophageal atresia repair• Aortopexy• Mediastinal mass exc/bx• Thymectomy• Sympathectomy• Pericardial window• Division of vascular ring• Nuss operation

Musculoskeletal Sequelae From Thoracotomy

• Shoulder elevation

• Limitation shoulder movement

• Scoliosis

• Respiratory dysfunction

• Mammary maldevelopment

• Atrophy chest wall muscles

Post Thoracotomy Sequelae1. Durning RP, et al: J Bone Joint Am 62, 1980

2. Gilsanz V, et al: AJR Am J Roentgenol 1983

3. Jaureguizar E, et al: J Pediatr Surg 1985

4. Chetcuti P, et al: J Pediatr Surg 1989

5. Goodman P, et al: J Comput Assist Tomogr 1993

6. Frola C, et al: AJR Am J Roentgenol 1995

ThoracoscopyPatient Positioning

Children’s Mercy Experience

• Jan 2000 – June 2007

• 230 patients = 231 thoracoscopic operations

• Age = 9.6 ± 6.1 years

• Weight = 36.6 ± 24.1 kg

• 115 boys : 115 girls

JLAST 18:131-135, 2008JLAST 18:131-135, 2008

Thoracoscopic Operations Children’s Mercy Experience (2000-2007)

Diagnostic No. of Patients

Wedge biopsy of solitary lung lesions 37

Biopsy and excision of mediastinal masses 26

Wedge biopsy of diffuse parenchymal disease 15

Evaluation of penetrating thoracic trauma

1

Total 79

Therapeutic

Pleural decortication for empyema 79

Exposure for scoliosis 26

Bullae resection for pneumothorax 25

Lobectomy 9

Repair of esophageal atresia and fistula 8

Evacuation of hemothorax and pleural effusion 3

Repair of bronchopleural fistula 1

Total 151JLAST 18:131-135, 2008JLAST 18:131-135, 2008

Complications

• No intra-operative complications

• 3 conversions to open during lobectomy• 2 right upper lobectomies (visualization)• 1 left lower lobectomy

(infection/inflammation)

• 1 persistent pneumothorax after bleb resection

JLAST 18:131-135, 2008JLAST 18:131-135, 2008

Results

Length of stay = 3.8 ± 4.0 days • Excluding esophageal atresia

and scoliosis

Chest tubes in 211 patients (91%)• 2.9 ± 2.0 days (excluding esophageal atresia and

scoliosis)• 93 traditional chest tubes• 118 soft drains• 20 patients without post-

operative chest tubes

(JLAST 19: S23-S25, 2009)

Conclusion

• Safe and effective

• Primary diagnostic and therapeutic application for most thoracic conditions

Thoracoscopy - EmpyemaTechnique

• Three 10 mm incisions (triangle)

• Initial incision 4th or 5th ICS, AAL

• Use telescope to compress lung and create working space

• 2nd incision opposite 1st one, PAL

• 10 mm cannulas,insufflation to 6-8 torr 10 mm angled telescope

Thoracoscopy - EmpyemaTechnique

• 3rd incision (10 mm), 9th or 10th ICS, MAL

• Site for chest tube exteriorization

Thoracoscopy - EmpyemaTechnique

• Rotate instruments among the three incisions

• Can remove canula, insert curved ring forceps

Thoracoscopy - Empyema

Patient Variables at ConsultationPatient Variables at Consultation

WBC WBC 20.820.8 19.719.7 0.71 0.71

Weight (kg) Weight (kg) 24.624.6 20.720.7 0.52 0.52

Age (Years) Age (Years) 4.8 4.8 5.2 5.2 0.770.77

Days of SymptomsDays of Symptoms 9.0 9.0 10.610.6 0.320.32

VATSVATS tPAtPA P ValueP Value

O2 support (L/min)O2 support (L/min) 0.81 0.81 0.79 0.79 0.96 0.96

Study Results

ER/PCP visits ER/PCP visits 2.9 2.9 2.7 2.7 0.69 0.69

J Pediatr Surg 44:106-111, 2009J Pediatr Surg 44:106-111, 2009

OutcomesOutcomes

16.6% failure rate for fibrinolysis16.6% failure rate for fibrinolysis

VATSVATS tPAtPA P ValueP Value

PO Fever (Days)PO Fever (Days) 3.1 3.1 3.8 3.8 0.46 0.46

O2 tx (Days) O2 tx (Days) 2.25 2.25 2.33 2.33 0.89 0.89

LOS (Days)LOS (Days) 6.89 6.89 6.83 6.83 0.960.96

Patient ChargesPatient Charges $11,660 $11,660 $7,575$7,575 0.010.01

Analgesic dosesAnalgesic doses 22.322.3 21.421.4 0.90 0.90

Study Results

J Pediatr Surg 44:106-111, 2009J Pediatr Surg 44:106-111, 2009

London Prospective TrialVATS v Fibrinolysis w/UrokinaseVATS v Fibrinolysis w/Urokinase

• No difference in LOS (6 v 6 days)

• No difference in 6 month CXR

• VATS more expensive ($11.3K v $9.1K)

• 16 % failure rate for fibrinolysis

Am J Respir Crit Care Med 174:221-227, Am J Respir Crit Care Med 174:221-227, 20062006

Current Management2008 - 2011

• Fibrinolysis has been our initial therapy

• 4 mg tPA in 40 cc saline for 3 days through a 12 Fr chest tube

• 102 consecutive patients

• 15.7% failure rate

• Mean hospitalization after initiation of fibrinolysis – 6.1 d +/- 2.5

• Mean O.R. time after failed fibrinolysis – 65 min

• Mean hospitalization after thoracoscopy – 5.9 d +/- 3.7

Thoracoscopy - Duplication

Thoracoscopy – Lymph Node Bx

Thoracoscopic Lobectomy

• Intralobar sequestration

• CCAM

• Bronchiectesis

• Lobar emphysema

• Other lobar conditions

Principles

• Single lung ventilation

• Double lumen ETT

• Contralateral mainstem intubation

• Bronchial blocker

Principles

• Lateral patient position

• Monitor over patient’s shoulder

• Surgeon/assistant on anterior side of patient

• Work medial to lateral; do not flip lung over

• Do not hesitate to convert

Thoracoscopy – Left Lower Lobectomy

Thoracoscopic RepairEA/TEF

EA/TEFPreoperative Evaluation

• Echocardiogram – assess cardiac anomalies

• Renal US – assess kidneys

• CXR/spine films – assess vertebral anomalies

• PE – assess limb, anorectal anomalies

• US great vessels – assess location of aortic arch

Thoracoscopic Repair EA/TEF

Thoracoscopic Repair EA/TEF104 Patients

Waterston A: > 5.5 lb with no significant associated problemsWaterston B: 4-5.5 lbs. or higher weight with moderate pneumonia or congenital anomalyWaterston C: weight < 4 lb or higher weight with severe pneumonia or congenital anomaly

Waterston A 62 Patients

Waterston B 30 Patients

Waterston C 12 Patients

Operation converted 2 2 1

Operation staged 1 - -

Esophageal anastomotic leak 2 3 3

Stricture (on initial esophagram) 3 1 -

Patients needing only 1 dilation 7 5 -

Patients needing 2 dilations 9 1 2

Patients needing 3 dilations - 3 1

Patients needing >3 dilations 3 2 -

Recurrent tracheoesophageal fistula 1 1 -

Fundoplication 19 6 1

Imperforate anus operations 4 4 2

Duodenal atresia repairs - 2 2

Aortopexy 6 1 -

Death 1 - 2

Preoperative Bronchoscopy

Port/Instrument Positions

Thoracoscopic Repair EA/TEFFistula Ligation

• Metal clip

• Weck clip

• Tie (x2 ?)

• Suture ligature (x2 ?)

• Suture closure – tracheal side

Tips/Tricks

• Surgisis placed b/w

esophagus & tracheal

suture line to help

prevent recurrent TEF

J LAST 17:380-382, 2007J LAST 17:380-382, 2007

How To Get StartedNot The Ideal Case

• 2 - 2.5 kg

• Very high upper pouch

• Complex single ventricle physiology

• Prostaglandin dependent

How To Get StartedIdeal Case

• Baby – 2.5-3 kg; no other anomalies

• Esophageal segments close together (CXR, Bronchoscopy)

• Start thoracoscopically – Go as far as comfortable

• Try it again

Summary• Thoracoscopy can

be done safely and effectively in infants and children

• Patient selection always important

• Distinct advantages, esp avoidance of musculoskeletal sequelae

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QUESTIONS