Saundra Kay

Thoracoscopic Lobectomy in Infants Less Than 10 kg with Prenatally Diagnosed Cystic Lung Disease

PURPOSE Thoracoscopic lobectomy for congenital cystic lung lesions is an accepted technique in pediatric surgery. Since an increasing number of these lesions are detected prenatally, the safety and efficacy of infant resections have been questioned. We reviewed our experience over a 10-year period to evaluate early resection of these lesions. METHODS From January 2001 to August 2009, 75 patients under 1 year of age and weighing <10 kg underwent thoracoscopic lobectomy at two institutions. Patients carried the following diagnoses: 52 had congenital cystic adenomatoid malformation, 20 had bronchopulmonary sequestration, and 3 had congenital lobar emphysema. All lesions were confirmed after birth by computed tomography scan. Patient age at operation ranged from 4 days to 11 months and patient weight from 3.1 to 10 kg. RESULTS Seventy-four of 75 lobectomies were thoracoscopically completed. There were 16 upper lobectomies, 1 middle lobectomy, and 55 lower lobectomies. Operative time ranged from 45 to 225 minutes. Hospital length of stay ranged from 1 to 5 days. A subset of 26 patients had surgery younger than 3 months of age and <5 kg, despite being asymptomatic. Their operative time averaged 90 minutes, and mean length of hospital stay was 1.5 days. CONCLUSION Thoracoscopic lobectomy is safe for infants <10 kg and avoids the morbidity associated with thoracotomy. Operating early on younger patients may avoid the inflammatory changes associated with both clinically apparent and subclinical infections, even in patients weighing <5 kg. This may make the procedures less technically challenging and may result in lower complication and conversion rates.

Laparoscopic duodenoduodenostomy in the neonate

BACKGROUND Minimally invasive procedures are performed in neonates for an ever-expanding list of congenital anomalies. The laparoscopic repair of duodenal atresia and stenosis in the neonate is one such indication. METHOD We report our experience with the laparoscopic duodenoduodenostomy for duodenal atresia and stenosis in the neonate over the past 4 years. A retrospective chart review was conducted on all cases of duodenal atresia and stenosis diagnosed at our center between January 2004 and January 2008. RESULTS Seventeen neonates underwent laparoscopic duodenoduodenostomy successfully during the period. Patient weight at surgery ranged from 1.35 to 3.75 kg. Most were operated on within the first week of life. Many had associated anomalies. There were no conversions to an open procedure, no intraoperative complications, and no anastomotic leaks observed. Time to full feeds averaged 12 days. CONCLUSIONS Laparoscopic duodenoduodenostomy in the neonate can be safely and successfully performed with excellent short-term outcome.

Use of Antenatal Steroids to Counteract the Negative Effects of Tracheal Occlusion in the Fetal Lamb Model

Tracheal occlusion (TO) in fetal lambs induces pulmonary hyperplasia but has negative effects on type II cells. The purpose of this study was to determine whether antenatal steroids could reverse the adverse effects of TO on lung maturation in fetal lambs. Sixteen time-dated pregnant ewes (term, 145 d) and 24 of their fetuses were divided into six groups:1) TO at 117 d gestation;2) TO at 117 d with a single maternal intramuscular injection of 0.5 mg/kg betamethasone 24 h before delivery;3) TO at 117 d and release of the occlusion 2 d before delivery;4) TO and release of the occlusion with maternal steroids;5) unoperated controls without antenatal steroid treatment; and 6) unoperated controls, littermates of groups 1–4, treated with antenatal steroids. All fetuses were killed at 137 d gestation. Outcome measurements consisted of lung weight-to-body weight ratio; lung morphometry determined by mean terminal bronchial density; and assessment of type II pneumocytes by in situ hybridization to the mRNA of surfactant proteins B and C. Lung weight-to-body weight ratio and mean terminal bronchial density were significantly different among groups with TO and controls, indicating increased lung growth and structural maturation. The density of type II pneumocytes was markedly decreased by TO. Release 2 d before sacrifice significantly increased the density and surfactant activity of type II pneumocytes, but to levels still far from controls. Steroids alone had an effect similar to release. An additive effect was noted with steroids and 2-d release resulting in type II cell density comparable to controls. After fetal TO, a single maternal intramuscular dose of 0.5 mg/kg of betamethasone 24 h before delivery allows partial recuperation of the type II pneumocytes, an effect that is potentiated by 2-d release.

Revisiting the role of routine retropleural drainage after repair of esophageal atresia with distal tracheoesophageal fistula

PURPOSE The aim of this study was to review routine retropleural drainage in esophageal atresia with distal tracheoesophageal fistula (TEF). METHODS The charts of 52 patients diagnosed with TEF between 1987 and 1997 were reviewed. Data collected included gestational age, birth weight, associated congenital anomalies, respiratory status, operative technique and timing, size of gap, tension on the anastomosis, complications related to the drain, and esophageal anastomotic leak (incidence, diagnosis, and treatment). RESULTS A total of 52 cases of TEF were identified. Data on sex, gestation age, birth weights, and malformations are summarized. Forty-seven patients underwent a single-stage extrapleural repair. Only one leak was identified in the single-stage group on routine day 7 esophagogram: a Waterson C patient who was clinically well with minimal drainage. The only other leak was in a class C patient who had undergone a staged repair because of an initial long gap. None of the favorable Waterston class patients suffered a leak. CONCLUSIONS A routine retropleural drain placed near the anastomosis may not be necessary in all cases of TEF. Good prognosis patients (Waterston class A and B) who undergo an uncomplicated extrapleural repair without undue tension do not appear to benefit from having a chest drain in place, and there is potential for complications. In complicated cases, however, retropleural drainage remains a reasonable adjunct.

Thoracoscopic Segmentectomy for Congenital and Acquired Pulmonary Disease: A Case for Lung-Sparing Surgery

PURPOSE Over the last 15 years thoracoscopic lobectomy for congenital and acquired lesions has become an accepted modality in pediatric thoracic surgery. There is still debate about the need to perform a complete lobectomy for some of these lesions, and some advocate observation rather than resection, despite possible long-term complications of untreated lesions. High-resolution computed tomography (CT) scans and physical findings at the time of surgery, along with new advanced techniques, now allow for discrete partial anatomic resections, which may preserve normal lung. This study evaluates the feasibility and early results using these techniques in selected cases. PATIENTS AND METHODS With institutional review board approval, the records of all patients undergoing thoracoscopic lung resection were reviewed. From January 2006 to December 2012, 23 patients, ranging from 1 month to 16 years of age and weighing 3.8-42 kg, underwent thoracoscopy for planned resection. Pathology was congenital cystic lung disease in 19 patients, bronchiectasis in 3 patients, and arteriovenous malformation in 1 patient. In each case findings on CT scan and at the time of surgery warranted consideration of lung-preserving surgery. Procedures were performed through three ports using single lung ventilation and CO2 insufflation to achieve lung collapse. The LigaSure™ device (Covidien, Norwalk, CT) was the primary instrument used to seal and divide the lung parenchyma and seal vessels. RESULTS All procedures were completed successfully thoracoscopically. An anatomic segmental resection was achieved in 22 of 23 cases. Operative time ranged from 30 to 300 minutes (mean, 120 minutes). Segmental resections included the left upper lobe apical/posterior (n=4), lingula (n=3), left lower lobe superior (n=5), medial or posterior basal (n=3), right middle lobe medial (n=1), right upper lobe apical (n=1), right lower lobe superior (n=4), and posterior basal (n=2). Two patients had more than one segment excised. Chest tubes were left in for 24 hours in 16 cases, 48 hours in 4 cases, and 5 days in 1 case. Hospital stay ranged from 1 to 6 days (mean, 2 days). Follow-up CT scans obtained at 1-6 years (mean, 28 months) show no residual disease in 20 of 21 patients. One patient underwent a nonanatomic resection and had evidence of recurrent congenital pulmonary airway malformation at the 4-year follow-up. This patient underwent a secondary thoracoscopic resection. CONCLUSIONS Thoracoscopic lung-conserving therapy is technically feasible and safe in infants and children. The magnification provided by a thoracoscopic approach makes identification of segmental anatomic planes easier, aiding in safe dissection and resection. Anatomic resection appears to be associated with a low morbidity. It may be appropriate in the case of bilateral or extensive disease or in cases where the diseased tissue is clearly limited to an anatomic segment. Continued long-term follow-up is needed.

Pericardial hemangioma presenting as thoracic mass in utero.

Pericardial hemangiomas are rare lesions. We present the case of an infant who was referred to our fetal diagnosis and treatment group for the presence of a left thoracic mass, pleural effusion, and mediastinal shift on fetal ultrasound. The characteristics of the lesion suggested the presence of a pulmonary sequestration. A chest radiograph done at birth was normal. At 2 weeks of age, an enhancing lesion of the left pericardium was identified on chest CT. A cardiac MRI demonstrated enhancement of the mass on T2-weighted images. The patient underwent thoracoscopic assessment of the mass for diagnostic purposes. Multiple lesions were identified along the left pericardium and diaphragm. A frozen section biopsy revealed a hemangioma. The natural history for hemangiomas is gradual regression; however, they may increase acutely in size and cause symptoms prior to involution. Investigations should be performed to identify the involvement of other organs. This case illustrates the need to closely follow all patients with prenatally diagnosed thoracic masses with CT imaging, even when they are asymptomatic and have a normal chest radiograph at birth.

Fetal Tracheal Occlusion : Antenatal Steroid Potentiates the Effect of Occlusion Release on Lung Maturation

Fetal Tracheal Occlusion : Antenatal Steroid Potentiates the Effect of Occlusion Release on Lung Maturation