Abstract
Abstract
The use of video-assisted techniques (VATs) in the paediatric field has become increasingly more frequent, based on reports of prompter recovery following VATs in respect to standard techniques. Specific advantages have been documented, in particular for pediatric patients undergoing chemioradiotherapic treatment. We retrospectively reviewed data of severely compromised patients who underwent VAT for lung wedge resections and biopsies carried out in our center over a 7-year period. As far as the area of therapeutic tumor resection is concerned, the present data are consistent with the view that thoracoscopy is both an effective and safe tool in diagnostic procedures.
Introduction
Materials and Methods
Eighteen patients (9 male, 9 female), who underwent VAT from January 2001 to December 2008 in our department for lung biopsies and wedge resections, were retrospectively reviewed. Demographics, indications, preoperative anesthesiologic risk, past or current chemotherapy, ability to obtain adequate tissue sample for histologic diagnosis, length of hospital stay, operative complications, and duration of follow-up were examined. For each patient, preoperative imaging included a plain chest X-ray and a thoracic computed tomography (CT) scan.
Patients underwent intravenous (i.v.) general anesthesia and were positioned in the lateral decubitus position. A nasogastric tube and a bladder catheter were inserted. To aid the lung collapse, selective bronchial intubation or, in the case of newborns and infants, a carbon-dioxide (CO2) pneumothorax with low pressure (3–4 mm Hg) and low flow (1 L/min) was used. Thoracoscopy was carried out by using the “three-trocar technique.” A 12-mm trocar was used only in older children in order to allow the insertion of the endoscopic linear stapler. The ports were positioned according to the lesion site. Local anesthesia with lidocaine (2%) was performed before cutaneous incisions. For both biopsies and wedge resections, an endoloop was employed in smaller children, whereas an automatic stapler (Multifire Gia®; Tyco Healthcare, Norwalk, CT) was employed in older children. At the end of each procedure, an Argylle-type drain (Ch 14–16) was placed through a trocar wound. Depending on size, specimens were placed inside an endobag or glove finger to minimize the risk of tumor-cell dissemination before extraction. Prior to the telescope removal, the thoracic cavity was reexamined to confirm hemostasis.
Results
Patients' mean age at operation was 9.6 years (range, 1–17). Patients were divided in two groups: oncologic patients (group A) and patients with ILD (group B).
Group A (n = 13)
Indications for thoracoscopy in this group were both diagnostic and therapeutic: biopsy of newly discovered lesions (n = 2); biopsy/exeresis of residual nodules or detections of new nodules during follow-up studies (n = 6); and exeresis of fungal lung lesions in patient candidates for bone marrow transplant (n = 5) (Table 1). Six of 13 procedures were bilateral. Overall conversion rate was 3 of 13, due to incomplete radicality. No postoperative complications occurred. In 1 of 5 cases with suspect lung fungal nodules and in 1 of 4 patients with metastases, histology did not confirm the clinical diagnosis.
RC, complete remission; AWD, alive with disease; DOD, death of disease.
At follow-up (median, 2.2 years), 5 patients were alive and free from disease, 2 were still affected by extrapulmonary fungal infection and waiting for bone marrow transplant, 3 were alive with progressive disease, and 1 died for progression of disease. Two patients were lost at follow-up. Clinical decision regarding prolongation of antifungal therapy, changes of chemotherapy regimen, and need for radiation therapy were based on histology. In this group, no death was due to misdiagnosis of tissue obtained by VATs.
Group B (n = 5)
Indications for thoracoscopy in this group was ILD of unknown origin. At the time of surgery, every ILD patient reported a various degree of respiratory failure and immunodepression, associated with a high-dose steroid treatment. Previous procedures, such as broncoscopy, transbronchial biopsy, bronchial washouts, and cultures could not provide a precise diagnosis. Lung biopsies during VATs were performed on selected areas based on CTs scan imaging and intraoperative inspection. All procedures were completed successfully without conversions. No postoperative complication occurred. Histologic diagnosis was obtained in all cases, and immunosuppressive therapy was modulated accordingly. At follow-up (median, 2.9 years), all patients in this group were alive with a specific treatment. Duration of the procedure was 30–180 minutes (median, 105) (Table 2). The thoracic drain was generally removed 36 hours after surgery. Length of hospital stay was variable, because surgery was often performed during hospitalization for medical management of their primary disease. When admitted for surgery only, the patients' hospital stay was, on average, 2 days long.
ILD, interstitial lung disease.
Discussion
Thoracoscopy represents a fundamental diagnostic tool for patients with both ILD and cancer. In particular, for oncologic patients, VATs have proved to be useful in obtaining diagnostic specimens and/or determining resecability, providing thus more information on tumor extension than traditional methods. 5 Thoracoscopic second-look procedures can give additional information in the case of tumors treated with neoadjuvant regimen and can help to determine tumor response to chemotherapy or histologic changes.6,7 VATs allow one to carry out large excisional biopsies with close-to-nil complications. Compared to tru-cut biopsies, VAT specimens are always taken under conditions in which the affected site may be monitored through direct visual inspection. Sampling accuracy can be enhanced by using needle-localization methods. 8
In the present study, thoracoscopic biopsies turned out to be safe and effective without major complications and with a low conversion rate (16.6%). VATs are reported reliable even for severely compromised patients with severe immunosuppression or acute respiratory failure. In our series of ILD and oncologic cases, with any degree of respiratory failure or immunosuppression VAT was well tolerated. 4 Thoracoscopy has a role of increasing importance also as a therapeutic tool for lung wedge resections. VATs are performed in selected oncologic patients with lung metastases and fungal nodules. Complete surgical resection of pulmonary metastases, after response to induction therapy, may increase survival in some patients, even in cases with multiple and recurrent metastatic disease. 9 Pulmonary fungal nodules, as well as all documented infection sites, have to be eradicated before bone marrow transplantation to avoid septic complications. Moreover, VATs can greatly reduce the number of thoracotomies, thereby limiting the morbidity associated with this procedure. In children, bilateral thoracotomy is possible without an increased complication rate, but thoracoscopy is surely better tolerated.10,11 To reduce tumor spread, the use of an endobag or a glove finger for tumor extraction is indicated. 2
The major drawback of VAT is the lack of palpation of micrometastases detected by preoperative CT scan. Conversion to an open procedure, to allow palpation of the lung, was, indeed, performed in 3 cases in our series. Standard rules for cancer surgery must be respected when performing VATs. Selection of patients should consider immunosuppression and pulmonary function, bilateral pulmonary involvement, need of a prompt restarting of systemic therapy, control achieved on primary tumor, degree of response to chemotherapy, and histology and biology of the tumor. 9 For example, lung metastases of osteogenic sarcoma should not be treated by VATs, as port-site metastasis have been reported 12 and tiny metastasis detected with a CT scan require a thoracotomy to be palpated. 13 All these elements were considered in our series. The main advantage was the possibility to treat bilateral lesions at the same time in severely compromised patients, which would have not tolerated a bilateral thoracotomy/sternotomy or a delayed treatment.
Conclusions
VATs performed for lung biopsies and wedge resections can be safely and effectively performed in pediatric age for diagnostic purpouses. Larger series and longer follow-up are still required to extend indication of VATs for therapeutic procedures.
Footnotes
Disclosure Statement
No competing financial interests exist.