indications for thoracoscopy in children cipesur meeting november 2011 george w. holcomb, iii, m.d.,...
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Indications for Thoracoscopy in Indications for Thoracoscopy in ChildrenChildren
CIPESUR Meeting CIPESUR Meeting November 2011November 2011
George W. Holcomb, III, M.D., MBA
Children’s Mercy Hospital
Kansas 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• Anterior spinal operations
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
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, 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 at CMH
Thoracoscopy - EmpyemaTechnique
• 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
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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
• Alveolar Soft-part Sarcoma
• Ewing’s Sarcoma
• Ganglioneuroma
• Lymphoma
• Neuroblastoma
• Rhabdomyosarcoma
• Schwannoma
• Wilms’ Tumor
• Yolk Sac Tumor
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 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, 2005American Surgical Association, 2005
Ann Surg 242:422-430, 2005Ann Surg 242:422-430, 2005
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
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Port/Instrument Positions
EA/TEF
89 pts/16 yrs
• shoulder elevation: 24%
• chest deformity: 20%
• abduction limited: 100%
• spine deformities: 18%
• breast deformities: 27% (3/11)
Why Thoracoscopy?
Jaureguizar E, et al: Morbid musculoskeletal sequelae of thoracotomy Jaureguizar E, et al: Morbid musculoskeletal sequelae of thoracotomy for tracheo-esophageal fistula. J Pediatr Surg 20: 511-514, 1985for tracheo-esophageal fistula. J Pediatr Surg 20: 511-514, 1985
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
Tips/Tricks
• Oscillating ventilator
• U-clips anterior anastomosis
JLAST 21: 877-879, JLAST 21: 877-879, 20112011
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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
www.cmhmis.com
QUESTIONS