THE USE of less invasive thoracic surgery has gained

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1 Efficacy of Primary and Secondary Video-Assisted Thoracic Surgery in Children By Frederick J. Rescorla, Karen W. West, Cynthia A. Gingalewski, Scott A. Engum, L.R. Scherer III, and Jay L. Grosfeld Indianapolis, Indiana Background/Purpose: Video-assisted thoracic surgery (VATS) is used commonly for diagnostic and therapeutic procedures in children. The purpose of this study was to determine the accuracy, efficacy, and complications associated with primary and secondary VATS in children. Methods: Eighty-seven infants, children, and adolescents underwent 104 VATS procedures between March 1993 and April There were 47 boys and 40 girls with an age range of 6 months to 19 years. VATS was performed for excision of pulmonary nodule (n 51), biopsy of infiltrate (n 14), excision or biopsy mediastinal mass (n 12), decortication of empyema (n 16), pleurodesis and bleb excision for pneumothorax (n 5), pleurolysis for P32 administration (n 3), esophageal myotomy (n 2), and thymectomy (n 1). In 6 children a contralateral thoracic procedure was performed along with VATS (3 VATS, 3 thoracotomies). Secondary VATS was performed in 20 after prior thoracic procedures. Results: VATS was efficacious for diagnostic or therapeutic purposes in 93 cases. Overall, 11 (11%) VATS required conversion to open thoracotomy. Average length of thoracostomy tube drainage (CTD) was 2.2 days, and average length of stay (LOS) was 3.7 days. Complications included prolonged air leak ( 7 days) in 3 (2 empyema, 1 nodule). Two children with malignancy and pulmonary infiltrates died within 30 days of progressive respiratory failure. There were no bleeding complications or deaths related to VATS. Conclusions: VATS is a safe and effective primary and secondary procedure in children resulting in a short length of CTD and LOS. Duration of CTD and LOS are prolonged if empyema is associated with a bronchopleural fistula, and VATS may not be of value in this setting. J Pediatr Surg 35: Copyright 2000 by W.B. Saunders Company. INDEX WORDS: Thoracoscopy, video-assisted thoracic surgery. THE USE of less invasive thoracic surgery has gained increased acceptance over the past decade coincident with the increasing popularity of minimally invasive abdominal surgery. Thoracoscopy or video-assisted thoracic surgery (VATS) involves performance of intrathoracic procedures through several small thoracostomy openings without a thoracotomy. Reported advantages include less pain, lower postoperative narcotic requirement, shorter hospital stay, and smaller incisions with resultant improved cosmesis. 1,2 Disadvantages include concern for missing pulmonary lesions because of inability to manually palpate the lung parenchyma, the potential of port site seeding with tumor cells with removal of malignant nodules, and incomplete decortication when From the Section of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. Presented at the 46th Annual International Congress of the British Association of Paediatric Surgeons, Liverpool, England, July 21-24, Address reprint requests to Frederick J. Rescorla, MD, JW Riley Hospital for Children, 702 Barnhill Dr, Room 2500, Indianapolis, IN Copyright 2000 by W.B. Saunders Company /00/ $03.00/0 treating empyema. 1,3,4 The purpose of this report is to review diagnostic and therapeutic thoracoscopy at a single pediatric institution and to determine the accuracy, efficacy, and complications associated with primary and secondary VATS in children. MATERIALS AND METHODS Eighty-seven infants, children, and adolescents underwent 104 VATS procedures between March 1993 and April 1999 at the J.W. Riley Hospital for Children, Indianapolis, Indiana (Table 1). There were 47 boys and 40 girls with an age range of 6 months to 19 years (average, 10.6 years). Ten patients who had 27 procedures accounted for all of the multiple procedures. Children were selectively considered for VATS based on the superficial location of pulmonary lesions. Six children underwent simultaneous contralateral thoracic procedure consisting of 3 VATS and 3 thoracotomies. Eighty-four of the procedures were primary VATS, and in 20, VATS was a secondary procedure after prior thoracotomy in 8, prior VATS in 11, and both prior VATS and thoracotomy in 1. Technique All children received a general anesthetic. Selective ventilation of the right or left bronchus was used in some older children to allow ipsilateral lung collapse. The patient was positioned laterally (Fig 1) similar to that for thoracotomy. A 5-mm or 10-mm skin incision was made and the subcutaneous tissue divided. A clamp was used to spread the chest wall and intercostal muscles and penetrate the parietal pleura. A reusable or disposable trocar was introduced into the thoracic space. Carbon dioxide ( 10 mm Hg) was used selectively as needed to 134 Journal of Pediatric Surgery, Vol 35, No 1 (January), 2000: pp

2 VIDEO-ASSISTED THORACIC SURGERY 135 Table 1. Indications for VATS Nodule 51 Infiltrate 14 Mediastinal mass 12 Empyema 16 Pneumothorax 5 Pleurolysis P32 3 Esophageal myotomy 2 Myasthenia gravis 1 provide lung collapse. Two additional working ports were used generally. In cases in which a lung biopsy was performed, an atraumatic mechanical grasper elevated the lung adjacent to the nodule, and the lung was divided using a stapling device (Endo-GIA Stapler, United States Surgical Corp, Norwalk, CT). The lung specimen was delivered into the largest trocar and withdrawn from the chest without contact with the chest wall. In patients with empyema requiring decortication (Fig 2), thin fluid was aspirated with suction catheters, and more solid fragments were removed with graspers. The pleural space was debrided and lung expansion confirmed before closing the chest. In children with pneumothorax, blebs if present, were excised and a parietal pleurodesis performed with dry sponges and gauze pads held by graspers. Eosphageal myotomy was performed through the left chest. The inferior pulmonary ligament was divided and a myotomy performed with aid of an intraesophageal endoscope. Tube thoracostomy was used selectively. In children with pneumothorax, tubes were left in place for at least 4 to 7 days to allow formation of pleural adhesions. RESULTS VATS was efficacious for diagnostic or therapeutic purposes in 93 cases. Eleven children (11%) required conversion to open thoracotomy because of inability to visualize a tumor nodule in 6, a nodule located too close to a hilar vessel in 1, extensive pleural adhesions from prior thoracotomy in 1, a mediastinal mass too large to Fig 1. Technique of VATS. remove in 1, and inability to perform adequate decortication in 2. The conversion rates of primary and secondary VATS were similar (Table 2). Eight of 51 children with suspicious nodules on computed tomography (CT) required conversion to open thoracotomy. Twenty-eight of the remaining 43 had metastatic disease confirmed by VATS, and, in 15, the histology findings showed a benign process. Nine mediastinal procedures were performed to obtain biopsy specimens from mediastinal lymph nodes or tumors. Two children had masses (esophageal duplication cyst and bronchogenic cyst) resected, and 1 patient with a large thymic tumor required conversion to an open thoracotomy because of the size of the mass. Average duration of thoracostomy tube drainage was 2.2 days (range, 0 to 14) and average length of stay was 3.7 days (range, 1 to 17; Table 3). The only postoperative complication was prolonged air leak in 3 patients. In 2 children with empyema it was felt that a bronchopleural fistula was inadequately managed, and, in 1 with a deep tumor nodule, the depth of excision resulted in an air leak for 11 days. Two children with malignancy and persistent pulmonary infiltrates died of respiratory insufficiency within 30 days of VATS. One child with an esophageal myotomy for achalasia required esophageal balloon dilatation 16 months after surgery because of recurrent symptoms. There were no bleeding complications or deaths related to VATS. DISCUSSION Video-assisted thoracic surgery has gained increasing popularity over the past decade. Rodgers et al 5 and others 6 reported early experience with thoracoscopy in children in the 1970s and 1980s; however, most reports have followed the more recent advances in minimally invasive surgery in the early 1990s. VATS has been used for biopsy of pulmonary infiltrates, excision of tumor nodules, biopsy or excision of mediastinal masses, decortication of empyema, pleurodesis and blebectomy for pneumothorax, lung resection, thymectomy, esophageal myotomy, evaluation of thoracic trauma, and closure of patent ductus arteriosus. 2,7-9 Cancer was the most common indication for diagnostic or therapeutic VATS in the current study. The technique for VATS usually requires 3 separate incisions (a camera port and 2 working ports). The incisions are planned carefully to allow visualization of the desired site and removal of the nodule. Although most surgeons use rigid equipment, Yamamoto et al 10 have used a flexible bronchoscope within a scope guide passed through a single incision alongside a grasper and a stapling device. 10 We generally enter the pleural space with a hemostat and then pass a trocar; however, Rothenbergetal 11 reported use of the Veres needle and infusion of CO 2 at 4 mm Hg pressure to collapse the lung. Selective contralateral bronchial intubation permits ipsi-

3 136 RESCORLA ET AL Fig 2. Empyema treated with VATS. Chest radiograph (A) and CT (B) show a loculated empyema with lung collapse. Re-expansion on chest radiograph (C) 6 days and (D) 23 days after VATS decortication. lateral lung collapse and improves visualization of the thoracic cavity. Ipsilateral lung collapse also is useful in identifying more deeply located tumor nodules. Caution should be exercised in cases of an obliterated pleural cavity secondary to previous empyema or thoracotomy. The current study had a similar conversion rate with primary and secondary VATS procedures indicating that this technique is useful selectively on a repeat basis. Although some investigators 12 have used endoloops and endosuturing techniques and avoid stapling devices, we have preferred the security and efficacy of stapled Table 2. Conversion Rate for Primary and Secondary VATS No. Conversion (%) Primary VATS 84 9 (10.7) Secondary VATS 20 2 (10.5) closure. The stapling instruments usually are passed directly into the chest without a trocar. Complications with VATS have been relatively rare but have included failure to visualize the desired lesion, inadequate decorti- Table 3. Results Based on Indication Diagnosis No. Conversion Chest Tube Drainage, d (range) Length of Stay, d (range) Nodule (0-11) 1.9 (1-11) Infiltrate (0-6) 2.5 (1-7) Empyema (2-14) 8.6 (4-17) Mediastinal mass (0-3) 2.0 (1-3) Pneumothorax (2-7) 7 (4-10) Pleurolysis for P (0-1) 3.3 (1-5) Thymectomy Esophageal myotomy

4 VIDEO-ASSISTED THORACIC SURGERY 137 cation for empyema, failure to identify and treat a bronchopleural fistula, intercostal artery injury, 12 and exceedingly long procedural times. Occasionally, if the port selection is appropriate, a finger may be inserted to aid in palpation and identification of a deeper nodule. 13 Holcomb et al 14 described a multiinstitutional series concerning 63 thoracoscopic procedures in children with malignancy and noted a conversion rate of 10% (adhesions, inability to identify lesion, bleeding) and no mortality. In those patients in whom a biopsy could be obtained thoracoscopically, diagnostic tissue was obtained in 98%. Rothenberg et al 11 reported 36 consecutive thoracoscopic lung biopsy cases with no conversion and identified histology on 30. Chest tubes were placed in 21 patients and were removed after 24 hours in 15. Several concerns have been raised regarding this technique in children with malignancy including ability to identify deep lesions, possibility of missing small lesions not identified by CT scan but otherwise identifiable by manual palpation at thoracotomy, and malignant seeding of the port site. If the procedure is used only to establish the diagnosis such as in a child with Wilms tumor and several bilateral nodules, VATS is efficacious. Pleural-based or superficial lesions ideally are suited for VATS. In these cases VATS may be used for diagnosis with postoperative adjuvant chemotherapy and radiation managing the bulk of the pulmonary disease. In other tumor types such as osteosarcoma, the VATS procedure is therapeutic and is not followed by administration of chemotherapy. The current study does not address the concern raised by others regarding failure to identify small lesions in cases of osteosarcoma using VATS. To answer this question accurately, thoracoscopy with removal of lesions would have to be followed by immediate thoracotomy and manual palpation. Chest CT scans often underestimate the actual number of lesions, 4 and in view of this observation, some clinicians have advocated initial thoracotomy to permit identification and removal of all nodules. One might conclude that if ipsilateral non-ct detected pulmonary nodules are identified, they most likely exist on the contralateral side, and bilateral thoracotomies would be required. Port site seeding has been observed rarely with VATS. Sartorelli et al 3 reported a port site recurrence after resection of 2 osteogenic sarcoma nodules and recommended the use of the endoscopic specimen retrieval bag. We have not used bags but are careful to avoid tumor disruption and deliver the biopsy specimen through a rigid trocar, thus avoiding direct tumor contact with the port tract in the chest wall. The management of empyema ranges from antibiotics alone or in combination with thoracentesis or closed chest tube thoracostomy to more invasive debridement and decortication accomplished by thoracotomy or VATS. The pleural fluid can range from the thin parapneumonic fluid with or without loculation to a thick exudate, which can progress to a thick constricting rind. Tube thoracostomy and antibiotics often are successful with thin fluid but less successful with thick pleural fluid and exudate. Successful resolution of empyema with VATS has ranged from 60% to 100% and is probably related to the degree of pleural rind and lung entrapment as well as the presence of a bronchopleural fistula. One early adult series 15 of 30 patients noted complete resolution in 18 (60%) with secondary resolution from further procedures in 8 and death in 4. They noted lower success in the presence of a bronchopleural fistula. Klena et al 16 recommended VATS within 1 week of the diagnosis of a loculated parapneumonic empyema to clear the chest before the development of thicker pleural fluid and pulmonary restriction. VATS usually has been recommended for persistent fever, leukocytosis, oxygen requirement, pleural opacification, or persistent loculation on CT. 1,16,17 In the current series, adequate decortication usually was possible; however, inadequate closure of an associated bronchopleural fistula resulted in prolonged air leak. Michel et al 8 reported successful thoracoscopic management of 18 of 21 children with a variety of mediastinal cysts including bronchogenic cysts, pleuropericardial cysts, esophageal duplication, and cystic hygroma. In 3 cases of bronchogenic cyst, a thoracotomy was used because of difficult dissection and 1 had a postoperative esophageal leak. Thymectomy for myasthenia gravis with use of VATS has been reported widely in the literature with reports of lower analgesic requirement and shortened hospital stay compared with median sternotomy. 9,18 The management of pneumothorax with parietal pleurectomy and blebectomy also has been reported previously with VATS. Arta et al 18 in a review of 10 VATS and 10 thoracotomies for recurrent pneumothorax showed the safety of VATS; however, they described 1 instance of recurrence with VATS. One child in our series had undergone a previous VATS procedure at another institution and was treated successfully with a secondary VATS procedure. Although the current study and several other studies describe relatively short thoracostomy tube duration and length of stay with VATS, few have directly compared VATS with thoracotomy. A retrospective study comparing thoracotomy with thoracoscopy identified a lower complication rate (7.6% v 16.2%), shorter intensive care unit (0 v 2 days) and hospital (5.5 v 8 days) stay, and shorter duration of pleural drainage (0 v 2 days) with

5 138 RESCORLA ET AL thoracoscopy. 2 The rate of conversion to thoracotomy in this study was 27%, however, because of poor visualization. Video-assisted thoracic surgery is a valuable technique in the management of selective thoracic conditions. Close attention must be directed to closure of bronchopleural fistula associated with empyema, and in this situation thoracotomy may be advisable. The issue of non-ct detected nodules in cases of therapeutic VATS for malignancy remains unresolved. 1. Patton RM, Abrams RS, Gauderer MWL: Is thoracoscopically aided pleural debridement advantageous in children? Am Surg 65:69-72, Weatherford DA, Stephenson JE, Taylor SM, et al: Thoracoscopy versus thoracotomy: Indication and advantages. Am Surg 61:83-86, Sartorelli KH, Partrick S, Meagher DP: Port-site recurrence after thoracoscopic resection of pulmonary metastasis owing to osteogenic sarcoma. J Pediatr Surg 31: , Downey RJ: Surgical treatment of pulmonary metastases. Thorac Surg Oncol 8: , Rodgers BM, Moazam F, Talbert JL: Thoracoscopy in children. Ann Surg 189: , Janik JS, Naguraj HS, Groff DB: Thoracoscopic evaluation of intrathoracic lesions in children. J Thorac Cardiovasc Surg 83: , Carrillo EH, Schmacht DC, Gable DR, et al: Thoracoscopy in the management of posttraumatic persistent pneumothorax. J Am Coll Surg 186: , Michel JL, Revillion Y, Montupet P, et al: Thoracoscopic treatment of mediastinal cysts in children. J Pediatr Surg 33: , Yim APC, Kay RLC, Ho JKS: Video-assisted thoracoscopic thymectomy for myasthenia gravis. Chest 108: , 1995 REFERENCES 10. Yamamoto H, Okada M, Takada M, et al: Video-assisted thoracic surgery through a single skin incision. Arch Surg 133: , Rothenberg SS, Wagner JS, Chang JHT, et al: The safety and efficacy of thoracoscopic lung biopsy for diagnosis and treatment in infants and children. J Pediatr Surg 31: , Schier F, Waldschmidt J: Thoracoscopy in children. J Pediatr Surg 31: , Yim APC, Low JM, Ng SK, et al: Video-assisted thoracoscopic surgery in the paediatric population. J Paediatr Child Health 31: , Holcomb GW, Tomita SS, Haase GM, et al: Minimally invasive surgery in children with cancer. Cancer 76: , Ridley PD, Braimbridge MV: Thoracoscopic debridement and pleural irrigation in the management of empyema thoracis. Ann Thorac Surg 51: , Klena JW, Cameron BH, Langer JC, et al: Timing of videoassisted thoracoscopic debridement for pediatric empyema. J Am Coll Surg 187: , Mineo TC, Pompeo E, Ambrogi V, et al: Adjuvant pneumomediastinum in thoracoscopic thymectomy for myasthenia gravis. Ann Thorac Surg 62: , Arta HM, Latouf O, Moore JE, et al: Thoracotomy versus video-assisted thoracoscopic pleurectomy for spontaneous pneumothorax. Amer Surg 63: , 1997