Morbidity after thoracoscopic resection of congenital pulmonary airway malformations (CPAM): single center experience over a decade.

PURPOSE: Video-assisted thoracoscopic (VATS) resection of CPAM in children is an established, albeit controversial strategy for its management. We report a 10-year single center experience. METHODS: All children underwent VATS (2008-2017) and their current status was reviewed. Patients were grouped: 'symptomatic-P' (if parents reported recurrent lower respiratory tract infections etc.) or 'symptomatic-S' (neonates presenting with respiratory distress/difficulty) or 'asymptomatic'. RESULTS: 73 children, aged 10 m (4d-14yrs) underwent VATS; a neonate as an emergency ('symptomatic-S') and all others electively. The lesion was unilateral in all but one case. Histologically none were malignant. Of the elective 72 cases, 7 (10%) required conversion to open thoracotomy. Twenty (27.7%) were 'symptomatic-P' and the duration of surgery when compared to 'asymptomatic' children was longer 269 (range 129-689) versus 178 (range 69-575) minutes (P = 0.01). Post operatively, 8 children (11%) had a grade III/IV (Clavien-Dindo) complication; persistent air leak/pneumothorax (n = 5), chylothorax (n = 1), pleural effusion (n = 1) and seizure/middle cerebral artery thrombosis (n = 1). There was no mortality. Twenty-four children (33.3%) were reported 'symptomatic-P' post-surgery after a median follow up of 2.18 years. The surgical intervention had no impact on 'symptomatic-P' status (P = 0.46). CONCLUSION: The risks of surgery may outweigh benefit in asymptomatic children. CLINICALTRIALS. GOV IDENTIFIER: NCT04449614.

When to abandon single-lung anesthesia during video-assisted thoracoscopic surgery (VATS) in infants and young children: A case-based review.

Video-assisted thoracoscopic surgery (VATS) in infants and young children increasingly require one-lung anesthesia. However, the maintenance of norms of gas exchange is difficult during one-lung anesthesia in some infants. A combination of factors including added dead space of HME and the circle Y piece, intrathoracic inflation of CO2 and its pressure, airway resistance and bilateral lung disease contribute. Seeping blood from the operating lung soiling the endobronchial tube causes airway narrowing and obstruction adding to this difficulty especially during prolonged thoracoscopy. We report two cases: hypoxemia in one and hypercapnia in the other. Guidance on safe limits of permissive hypoxemia or hypercarbia in this scenario is vague. Therefore, irreversible hypoxemia and hypercarbia with changes in acid-base status should be considered as indications for swift conversion to open thoracotomy and abandon one-lung ventilation.