Indications for thoracocoscopy in children brazil 2014
Transcript of Indications for thoracocoscopy in children brazil 2014
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