Postnatal Management of Lung Lesions Part II: Pediatric Thoracic Surgery...

And this is another pulmonary venous drain. And I'll show this one just to show some of the abnormal CT patterns. That'll be a tip off to you of what you're dealing with. So, you can see this sequestration there. You can see this very abnormal, uh, vessel that goes through the pulmonary parenchyma up into a pulmonary vein. Think the other thing is, you mentioned you didn't initially see anything. A number of these lesions, I'm amazed at how often they're misdiagnosed. They're either intra diaphragmatic or sub diaphragmatic. Um-hum. And they're thought to be in the chest. And so, it's really worth looking over these very well because there are times where certainly some of the infratic ones will approach laparoscopically. And then there are this new class that I've seen 3 or 4 of in the last year that are actually sort of in the lead, The muscle of the diaphragm and that you have to open the diaphragm in order to get at them. Yeah, between the leaves of the diaphragm. Right. And they're often in the GE junction as well. Right. Uh, or at the, uh, esophageal hiatus. And, and you can get oesophageal obstructive symptomatology. Right. Related to these. So again, here's a sequestration. And here's this big venous channel that you saw on the CT that's coming out of it and, uh, ascending up to the pulmonary vein. Again, just an arteriovenous fistula. This is an interesting one. This is a, uh, anatomic, Uh, extra pleural, or, uh, uh, extra lobar sequestration that has huge systemic arterial inflow, as you can see on the, uh, CT image there. And distal azygous outflow. Now, this is a left sided lesion and the, uh, the venous outflow actually goes across the chest and into the azygous vein. Hopefully it's, Present here. You can see this is completely, Separately invested by pleura. It has completely CCA histology and macrocystic abnormality on the CT scan. And, uh, there's, there's no bronchus whatsoever there. And you can see this, uh, There's no parenchymal connection. And here's this uh massive venous drainage that actually goes up. And then takes a right turn. Um, Out of the field and across the chest into the distal lazygu vein. You can see the, the big arterial inflow here. Coming off the aorta. So anyway, just a whole variety of different manifestations. And here's what Steve was referring to. Here's an infra diaphragmatic BPS. And you can see this thing, it's actually down under the diaphragm there. You can see the feeding vessels, which were, there were a bunch of them, and coming off the celiac axis, you can see the blush in the vascular reconstruction there. That is the BPS. And, uh, this was causing, uh, uh, obstruction to swallowing. So, the kid had a lot of secretions, um, And regurgitation of feedings and slow feeding. You can see the cysts in the middle of this, and this turned out to have CPAM histology again. So, an infra diaphragmatic BPS with CCAM, Uh, CPAM histology and, uh, esophageal obstruction. And I think that's video 14. See that I gave you in the new, in the new folder. Like, uh, it's, this is my fault cause I made a bunch of last minute changes. It's worth taking. It's worth it though. To see these. So it's, it's, yeah. Just wanted to give you an idea of the variety of these things. And this is, this is not it. This is a bronchial atresia. Um, a bronchial atresia with a, he said bronchogenic cysts that was 14. Did we try 13? Uh, let me see 13. Yeah, I think I want 13, actually. Sorry. Uh, yeah, this is it. OK, so, that's the spleen on the right. So, I'm taking a laparoscopic approach, cause I could see this was under the diaphragm. Although it clearly went up into the esophageal hiatus and some of it extended up to the chest. And you can see this is a big mass. It's not small. And it's very adherent to surrounding structures. So, this didn't come off the stomach easily. It didn't come off the GE junction easily. Actually went up into the esophageal hiatus there. And, uh, there's the pancreas underneath it. Actually, I found that the majority of these I approached through the abdomen do go up through the hiatus. Um-hum. There's some component, even if it doesn't look like it on CT. And often you can get a dumbbell lesion, which has a significant component on both sides. Yep. This had some fairly, uh, difficult vasculature coming off the celiac axis. You can see a big vascular pedicle there. Um, here's a, uh, a big vessel coming right out from underneath. You've been able to complete the procedure from the abdomen, not have to enter the chest? Yeah. Yeah, you can just sort of the hiatus. Follow it up and tease it up. And this, I'll show you the hiatus at the end. And I actually ended up putting some sutures to close the hiatus after I finished, um, Some of these vessels are. They're pretty substantial, as you can see. And then this had a, a cystic thing. I actually thought it, I had gone into the stomach or there was a connection to the stomach, but, um, There were mucoid cysts within this thing that were, Very adherent to the stomach. And then we're going up in the hiatus here. I try to fish it out. Opening the expanded fronto esophageal ligament here. But you can see how these can obstruct swallowing and uh. As Steve said, when, when you see them in this position, they're almost always in the hiatus and abutting the esophagus. I found the intra intra diaphragmatic ones, the ones with a leaf on each side are also frequently associated with the hiatus. So, there's the, uh, left cruise you just saw. There's another big vascular pedicle that goes up to it. So this was, it was a pretty tedious lesion to remove. It was amazingly adherent to everything around it, even in this, uh, 5 week old kid. And there's sort of the blown out hiatus. You can see there with the, The left cruise. Yeah, and then I, I think it's just a brief thing on, uh, bronchogenic cysts. They can be, uh, alone or they can be associated with a bronchial obstruction. You often see hyperplastic, uh, growth of the distal lobe, when they're associated with the bronchial atresia. And these can be, uh, huge prenatally, and actually, in the, the PowerPoint, we didn't show on the prenatal, I actually showed a fetal case where we had to, uh, resect a lobe that was causing eye drops, didn't respond to steroids, and it was related to, uh, bronchial atresia. So, they, you can have massive growth of even a lobe, um, lobar, uh, bronchial atresia. And then postnatally, you often just see a hyperplastic distal lobe, uh, with the, either the bronchial cyst, uh, at the origin of the, uh, lobar bronchus or no cyst present. And uh. This is an example of that. Here you can see a, uh, bronchial, or bronchogenic cyst that's obstructing the upper lobe bronchus on the right side, and you can see the hyperplastic enlargement of the upper lobe. And unfortunately, uh, when you see this, the bronchus is, uh, destroyed enough that you can't just resect the cyst, but you need to actually do the lobectomy as well. Yes. This isn't too informative. I just wanted to show you what a cyst looks like. Um, I'm, there's an incomplete fissure here that I'm working in, but I couldn't do the usual approach to the upper lobe vessels through the fissure, so, uh, because of the distortion from the cyst. So, I ended up going up, uh, over the top like I used to with open lobectomies. But you can see where the cyst is located. It's sitting there right on top of the upper lobe bronchus between the pulmonary artery branches that go to the upper lobe. And the, uh, bronchus and obstructing the bronchus in that position. You can see the pulmonary arteries are actually slung over the cyst. On each side. This is when I was still Testing the seal and you can see it's pretty tight. Fit in there, um, because of its blunt ends. I didn't really like this, the NCal on this particular operation. The, the thing you need to be careful about with this particular energy source is that it's very operator dependent cause it's sealing as. Um-hum. The knife advances. And if you advance the knife, so you really have to have good technique, which I'm showing here, but if you advance the knife too fast, you'll divide the vessel before you seal it. Yeah, and they now have, they now, they didn't used to have it, but now they have a tone. Right. Frequency. That, uh, tells you when the, the vessel's sealed and it's safe to advance the, the blade. But, Yeah, it's not if you just get in there and squeeze, but it's not a good thing. The general point that I, that I, I want, and I'm sure that Steve will focus on in the second half is the whole idea of sealing and dividing as a second, as a separate step, and this looks to be very safe, but is a different approach to that. And again, I think it's, uh, this is a, a much better instrument for larger kids and larger. Right. Um, Dissection planes. I love it in the abdomen for doing, uh, you know, Coker maneuvers and things like that where you're going through a lot of mesentery or. Attachment. So I think that's all I have for, for various lung lesions. That was, that was great. And we have, let's, um, Alan, thanks for that. We have the, uh, Stefan, do we still have the, the panelists on the phone? OK, let's get, uh, let's get the panelists back on the phone and then we have many, many questions to go through and, um, I heard there was someone on the phone calling him, but I guess he left. Is that right, Jesse? We had a caller from India. Um, is that gone, Amanda? OK, so we'll just go with the text questions, and if you wanna call in, your questions will get prioritized. I can tell you we're not gonna get to all of these. Uh, we'll get to the ones that we can, um. Ramesh's question about the clip we're gonna get to, uh, later on in the second half about clips versus ligature versus suture, all the different techniques, um, we did touch upon it already. I don't know if there's any additional things you want to say, but we can probably focus on that in the second half of the show. The biggest thing I'll say about clips in terms of vessels, the reason I don't like to use clips on vessels is because during your dissection you can dislodge them, right? And so I think that to depend. And, and you could, and I've never. Dislodged the seal. So, uh, that's what I worry about clips. They're just, they stick out past the vessels. They're relatively big in a small space and I just worry about inadvertently knocking that clip off while I'm dissecting. Yeah, I use clips for my last maneuver. So, if I'm. Yeah. For the sequestration. Right. You know, it's the last thing you put on there, you can do that. Right. I usually reinforce it with a ligacele, or a ligature anyway, distal to the clip. Um, or, you know, when you're doing the pulmonary vein, you can clip it and then, Uh, Sealed this story. Uh, Jean-Martin, the, uh, is not seeing his webcam icon. I, it's in the top right corner on my screen, Jean-Martin, just above Jack's picture. Uh, uh, Stefan's gonna work with you. Um, and, and the comments that were made, uh, about the clips from a lot of people which a whole discussion ensued about using the weck clips or the liga clips, uh, which, which won't have the risk of, of falling off nearly as much, although there is the risk of perforating the vessel if you don't get all around it, um. There there was a question, I think in relation to your first talk, uh, from Fawn Lewis about can you please list the US referral centers which should be considered for advanced care of early unfavorable fetal lung lesions. It's chop the, no, no. Yeah, it's the best, but it's not. Um, no, certainly, uh, there are a number of, uh, places that are currently, uh, doing open fetal surgery. And those include UCSF, which has a long history, obviously, of fetal, uh, uh, intervention, uh, Cincinnati, although Tim Crummelholm recently went to Denver. Um, but they still have a program, uh, in fetal surgery. Uh, Houston, uh, has done a number of open procedures. Um, Texas Children's in Houston, um, so there are, there are a number of other possibilities. Great. Um, Doctor Gabbra uh as um. I guess it was a case you were talking about. How did you detect that it was a, uh, PPB if it was done thoracoscopically's a, that's a great question. Um, I think there's a misconception that you can't, uh, do good histologic diagnoses with thoracoscopic resections. Um, I've learned through my experience that in fact you get just about as good a histology as you do, uh, with open procedures. The pathologists complain a lot more, you know, there's always a lot of verbiage in the report about this is a macerated, uh, traumatized specimen, but then they come up with the diagnosis. And in fact, this case, uh, these cases were all sent to, um, another center with expertise in PPB. I've forgotten, I think it's in Saint Louis, um. Where they, uh, where they analyzed it as well and were able to definitively say it was PPB. So, uh, we have a, a question, a phone call question from India. Uh, Shari, are you there? Yes, I'm here. Welcome. Thank you for calling in. Uh, where are you in India? I'm an angler. Great, great. OK. Uh, go ahead with your question. Yeah, thanks for allowing me to ask the question. Uh, uh, I just wanted to know, uh, how, how long can you delay the treatment postnatally of a, a CCA? Would it affect the lung development later in life? That's a great question too. There's actually a recent study, I think published in uh JPS where they compared early versus slightly later, uh resection, and, and the interval was something like 18 months as opposed to 3 months. I don't remember the exact intervals, but they concluded, um. One that uh. There is an increased risk of complications occurring like infection prior to your resection. And 2, that it doesn't really make a difference in terms of outcome or long term. Uh, pulmonary function. I think there's another study as well looking at pulmonary function at slightly later resection times that showed fairly normal pulmonary function, Once the child had grown up a little bit, so I don't think it matters a great deal. I think theoretically recession in infancy has more potential for compensatory lung growth and alveolarization, but that phase of lung development continues until you're 4 to 6 years of age. And so I think. You know, probably it doesn't matter if you do it in the 1st 3 months from a lung growth perspective. Uh, Cherish, did that answer your question? Yes, uh, um, thank you for your answer. I have a patient, uh, whose, um, uh, mother was diagnosed antenatally with, uh, C cam with a CVR of 1.6 and was given steroids at the age of 30 weeks and, uh, fortunately was born with a normal baby but still has a C cam, uh, with the medicinal shift. So I was wondering when to take that out. Uh, it's about 2 months now. Well, I would take it out now. Yeah. Uh, but, um, you know, I, I think, particularly in the international sense, you have to look at your capabilities in your center. And if you have, uh, very good anesthesia and you're comfortable with doing an early lung resection, then it should be done sooner rather than later. There's no reason to wait. I would, I would probably in Allen in my center, most of these lesions are removed before 3 months of age. And, and, and honestly, it's technically easier, although you have to be comfortable working in a small space. The children recover quicker, and we'll talk about this. And so the hospitalization and everything else is less, and the, um, so, in general, that's, that's the timeframe. But part of it depends on what your center's able to do, the comfort of your anesthesiologist, um, doing single lung ventilation in a small infant, um, and also your technical, uh, capabilities. So, even though we say it's easier, It is a much smaller space and so you have to get comfortable. The setup becomes everything in these cases because if you set up wrong, if your trochars are in the wrong position, assuming you're doing it thoracoscopically, now if you're doing it open. It doesn't matter as much, but the setup is critical when you do these operations, especially in a small neonate, because if your trocars are in a bad position, it will be very, very difficult. All right, uh, Shari, thank you so much for your phone call and your question. We are enjoying it. Thank you very much. Thank you. Uh, we have another question, uh, from, uh, Vietnam. Professor Liam, are you there, Liam? Yes, welcome, Liam. Good to hear your voice again. Um, yes, do you have a question for Alan or Steve? Yeah, thank you very much for your lecture. I would like to know how high CO2 pressure because I watched the video, you seem to have very big room to perform operation. Thank you. Um, I, I usually use a pressure of 7 centimeters of water. Um, I may go up or down a little bit depending on the child and, uh, whether, uh, they're having any difficulty. But in general, uh, it's very well tolerated and it gives you adequate exposure. Right. I, I would agree. I start at a pressure of 4. Part of it depends on how good of a single lung ventilation you have and how much overflow ventilation. We'll talk about this a little bit, but if you, the majority of times, we just do a, a main stem innovation of the contralateral, um, bronchus. So, that you always have a little bit of overflow ventilation. But usually a pressure of 4 is adequate. Um, but sometimes you have to go up to 7 or 8 to get the lung collapsed, and then you can back off a little bit. But the kids actually tolerate that quite well. That mild tension pneumothorax is not usually a significant issue. All right. Uh, thank you, Liam, for the question. And I think, uh, we'll be hearing from Liam later on in the show. I know he's got a great experience. Um, we have a question from Emery. Uh, what is the lower limit for infant size in which you will perform a thoracoscopic resection? Steve, Steve probably has no limit. I don't know. The smallest of what I've done was uh 2400, approximately 22 2400 g. I don't, you know. It didn't seem to be that much different than doing a term baby. So, uh, I think you could probably go lower still. Um, Uh, but just have to try it and see. Yeah. I mean, uh, we're limited, honestly right now by our technology. Um, I think that once you get, for instance, uh, something like a PDA ligation, which you're still holding vessels, we're now routinely doing those thoracoscopically down to about 800 g. Um, certainly, and now suddenly, 1000 g, which a few years ago seemed extremely small, now seems like a huge space. The problem is we're limited by the technology and, and honestly, getting a clip, you have to get a 5 millimeter clip into that tiny chest, and so you have to get through the rib spaces. When you start doing a lobectomy in a kid under 2 kg or TF, and the smallest TF we've done has been 1300 g. But we don't rely necessarily on a clip. We just rely on small instruments. But when you start relying on technology to get in and seal vessels and things like that, the current, the current sealers that we have are 5 millimeter instruments that take up 2/3 of the chest, and so you can't get in there very effectively. And I think as your experience grows and hopefully as the technology gets better, we'll be able to go smaller and smaller. But I think under 2. Kilos for a lobectomy is difficult. Yeah, and I think there are physiologic and, and physical limitations. Right. So, when you're talking about CCAs, normally the only reason you would be resecting something in a premature infant is if it was a large mass that was impacting ventilation. And so, in that circumstance, you know, you're not going to be able to do it thoracoscopically. And you also have, Issues with, uh, the contralateral lung for single lung ventilation. So, you really need a healthy. Right. Stable baby to do a thoracoscopic lobectomy and you can't have a big mass in the chest, um, unless it's cystic when you, where you can, you know, break it down. But if you have a big solid mass in the chest, uh, it's not going to work. So, I mean, just a management issue. Most of these patients who come, delivered, uh, many of them, if we know it's small, we'll tell them they can deliver at home and they don't need to come to our center and deliver. There's some concern that the child might have some, um, Immediate postnatal issues, then we'll have them deliver in our high risk maternal center. But if the baby's stable and doing well and there aren't really issues, we'll often let mom and baby go home. Even they can live in a, you know, anywhere in the country. They'll go home for a month or two, have a chance to kind of grow and have some normal development and then come back for the resection, um, so that the, one, the operation's easier, and two, I think it's a little easier on the parents. So, the smallest you've done is 800 g, is that what you said? No. PDA, not a lobectomy. Lobectomy is a, is a, well, extra, we've done some where there, it's ended up being an extra lobar mass around 2 kg, but 2 kg is about as small as we've got. I mean, I saw Starla shaking her head, you know, you have to understand Steve, Steve likes going down the double black diamonds in his tele, what is your tele scheme. He, he likes those kind of challenges. Don't expect that we're gonna be doing, uh, you know, grammar machine. Yeah, we, we, yeah, again, we've tried to let most of these kids go home and grow for a time and. And do it. But, you know, if it was an extreme case. Uh, the patients I've had clinically that have been problematic have, uh, congenital pulmonary malformations that cross the lines into another lobe. So, they'll have a main lobe, a lower lobe, and then you have just a little involvement of the middle lobe without a fissure that's well formed. How do you manage that? I mean, you talked a lot about lobectomy. Are you doing segmentectomies? Are you doing double lobectomies? Well, well, I think what you're really referring to is abnormal, uh, lobulation and fissure formation. And, uh, true bilobar involvement is relatively rare. You see it, like the case I showed, but most of it is abnormalities of globulation or fissure formation. And so, uh, all you can do is try to, uh, you know, make a fissure. In an appropriate position where you preserve as much lung, um, parenchyma as you can. And we'll show some cases of that. And, and where you don't leave devascularized lung or, or lung without an airway. So, so that if there's some residual cystic lesion seen post resection, do you follow that? Do you go back and reresect? I, I go back and, Resect that. But I, I, it shouldn't really happen if you try to avoid, uh, or if you try to follow, you know, the anatomic boundaries that are there. It's pretty rare that I've had one case where I've had to go back and remove further sein. Um,