Video-assisted thoracoscopic lobectomy in children: safety, efficacy, and risk factors for conversion to thoracotomy.

ABSTRACT

BACKGROUND: Video-assisted thoracoscopic lobectomy in small children has not been widely performed because of difficulties in single-lung ventilation and surgical technique. This study assessed the feasibility, outcomes, and risk factors for conversion to thoracotomy of thoracoscopic lobectomy in children. METHODS: From 2005 to 2011, thoracoscopic lobectomy was tried in 50 consecutive pediatric patients. The median age was 3.2 years and the median body weight was 16 kg. Congenital cystic adenomatoid malformation (CCAM) (78%) and pulmonary sequestration (18%) were the most common diagnoses. Prenatal diagnosis by ultrasonography was made in 34% of patients (17 of 50), and a previous history of pneumonia was present in 46% (23 of 50). The most commonly used single-lung ventilation modality was endobronchial blocking by balloon catheter through a single-lumen endotracheal tube. The use of a stapler was minimized, with endoscopic clipping devices and energy-based cutting instruments used instead. RESULTS: Thoracoscopic lobectomy without conversion was accomplished in 82% of patients (41 of 50). There was no in-hospital mortality and 1 major morbidity (2%) with postoperative bleeding. Comparison with a group from an earlier period (∼2009) and a group from a later period (2010-2011) determined that thoracotomy conversion rates, mean operation times, and mean hospital days were 27% and 8%, 190±85 and 133±40 minutes, and 11.0±6.7 and 5.2±2.2 days, respectively. In univariate analysis, lower body weight (p=0.010), operations in the earlier period (p=0.040), single-lung ventilation failure (p=0.004), and a previous history of pneumonia (p<0.001) were related to conversion to thoracotomy. Multivariate analysis revealed a previous history of pneumonia to be the only independent risk factor for conversion to thoracotomy (p=0.0179). CONCLUSIONS: Thoracoscopic lobectomy in small children is a safe and effective treatment modality. Close cooperation with the anesthesiologist, use of adequate instruments, and selection of proper patients are important for the success of thoracoscopic lobectomy in small children. A previous history of pneumonia was an independent risk factor for conversion to thoracotomy.