Transcript Indications for Thoracocoscopy in Children

Indications for Thoracoscopy in
Children
George W. Holcomb, III, M.D., MBA
Children’s Mercy Hospital
Kansas City, Missouri
Indications for Thoracoscopic
Procedures in Children
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Lung Biopsy
Lobectomy
Sequestration resection
Excision bronchogenic cyst
Foregut duplication resection
Esophageal myotomy
Anterior spine fusion
Debridement/decortication
Diaphragmatic
hernia/plication - ?
• Spontaneous ptx
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PDA ligation
Thoracic duct ligation
Esophageal atresia repair
Aortopexy
Mediastinal mass exc/bx
Thymectomy
Sympathectomy
Pericardial window
Division of vascular ring
Nuss operation
Anterior spinal operations
Musculoskeletal Sequelae From
Thoracotomy
• Shoulder elevation
• Limitation shoulder movement
• Scoliosis
• Respiratory dysfunction
• Mammary maldevelopment
• Atrophy chest wall muscles
Post Thoracotomy Sequelae
1. 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
Thoracoscopy
Patient Positioning
Data Points
• Age
• Weight
• Gender
• Type of operation
• Indication for operation
• Final diagnosis
• Chest tube
• Complications
• Length of stay
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, 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
151
JLAST 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, 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 postoperative chest tubes
(JLAST 19: S23-S25, 2009)
Conclusion
• Safe and effective
• Primary diagnostic and therapeutic
application for most thoracic conditions at
CMH
Thoracoscopy - Empyema
Technique
• 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 - Empyema
Technique
• 3rd incision (10 mm),
9th or 10th ICS, MAL
• Site for chest tube
exteriorization
Thoracoscopy - Empyema
Technique
• Rotate instruments
among the three
incisions
• Can remove
canula, insert
curved ring
forceps
Thoracoscopy - Empyema
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Thoracoscopy - Duplication
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Thoracoscopy – Lymph Node Bx
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Thoracoscopy – Left Lower
Lobectomy
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Diagnosis of Malignancy
via Thoracoscopy
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Alveolar Soft-part Sarcoma
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Ewing’s Sarcoma
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Ganglioneuroma
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Lymphoma
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Neuroblastoma
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Rhabdomyosarcoma
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Schwannoma
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Wilms’ Tumor
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Yolk Sac Tumor
Thoracoscopic Repair
EA/TEF
EA/TEF
Preoperative 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 of Esophageal
Atresia and Tracheoesophageal
Fistula: A Multi-Institutional
Analysis
George W. Holcomb III, Steven S. Rothenberg,
Klaas MA Bax, Marcelo Martinez-Ferro, Craig
T. Albanese, Daniel J. Ostlie, David C. van der
Zee, C K Yeung
American Surgical Association, 2005
Ann Surg 242:422-430, 2005
Thoracoscopic Repair EA/TEF
104 Patients
Waterston A
62 Patients
Waterston B
30 Patients
Waterston C
12 Patients
Operation converted
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Operation staged
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Esophageal anastomotic leak
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Stricture (on initial esophagram)
3
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Patients needing only 1 dilation
7
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Patients needing 2 dilations
Patients needing 3 dilations
9
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2
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Patients needing >3 dilations
3
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Recurrent tracheoesophageal fistula
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Fundoplication
19
6
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Imperforate anus operations
4
4
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Duodenal atresia repairs
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Aortopexy
Death
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Waterston A: > 5.5 lb with no significant associated problems
Waterston B: 4-5.5 lbs. or higher weight with moderate pneumonia or congenital anomaly
Waterston C: weight < 4 lb or higher weight with severe pneumonia or congenital anomaly
Preoperative Bronchoscopy
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Port/Instrument Positions
EA/TEF
Why Thoracoscopy?
89 pts/16 yrs
• shoulder elevation:
24%
• chest deformity:
20%
• abduction limited:
100%
• spine deformities:
18%
• breast deformities:
27%
(3/11)
Jaureguizar E, et al: Morbid musculoskeletal sequelae of thoracotomy
for tracheo-esophageal fistula. J Pediatr Surg 20: 511-514, 1985
Thoracoscopic Repair EA/TEF
Fistula 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, 2007
Tips/Tricks
• Oscillating
ventilator
• U-clips
anterior
anastomosis
JLAST 21: 877-879, 2011
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How To Get Started
Not The Ideal Case
• 2 - 2.5 kg
• Very high upper pouch
• Complex single
ventricle physiology
• Prostaglandin
dependent
How To Get Started
Ideal 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
QUESTIONS
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