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Neonatal Lung Lesions with Dr. Steven Rothenberg
With Dr. Steven Rothenberg · hosted by Dr. Ian Glenn & Dr. Todd Ponsky
Chapter 1 of 12 · Fundamentals
Introduction
Introduction and Guest Background
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Serial prenatal ultrasounds every couple of weeks are the best way to follow development of cystic lung lesions - noninvasive, quick, and adequate for monitoring.
Fetal MRI provides little benefit for lung lesions - doesn't change the plan or give much more definition than ultrasound.
6-40% of prenatally diagnosed lung lesions will regress with time, and in some cases appear to completely disappear.
Fetal intervention for lung lesions is extremely rare - CHOP does less than one open fetal surgery every couple of years for this indication.
Congenital lung lesions represent a spectrum - often see hybrid lesions on pathology combining features of CPAM and sequestration.
A chest X-ray or ultrasound after birth are not adequate to ensure there is absolutely no lung lesion present.
Multiple children with prenatal diagnosis and normal postnatal chest X-ray presented later (9 months to 6-7 years) with pneumonia and infected CPAM on further evaluation.
The incidence of malignancy in Rothenberg's series of congenital lung lesions is over 1%, which he considers significant.
Operating by 3 months of age avoids the problem of the baby getting an infection before surgery.
Surgery is technically easier in smaller infants - with current equipment and instrumentation, smaller vessels make the surgery easier and the anatomy is fresh.
Even in asymptomatic children, by around one year of age there are significantly enlarged lymph nodes in fissures and peribronchial spaces, and sometimes inflammation in the fissure, suggesting low-grade infections.
In Rothenberg's series, hospital stay, chest tube duration, recovery time, and operative time were all significantly less in patients under 5 kg compared to those under 10 kg.
Most children are discharged within 48 hours after lobectomy, and by one month post-op on chest X-ray, you cannot tell they had anything done due to compensatory lung growth.
Most asymptomatic children on room air will tolerate single lung ventilation without problem.
After lung collapse, babies initially desaturate for a few minutes (low 90s to high 80s) because they're still shunting blood to the collapsed lung; saturations come up once they stop shunting to that lung.
End-tidal CO2 in the mid-40s during thoracoscopic surgery is not a problem and doesn't cause significant acidosis or deleterious effects.
There is more room to work from the front of the chest towards the hilum than from the patient's back during thoracoscopic surgery.
The 3mm vessel sealer will seal vessels at least up to 5mm in diameter.
The technique for vessel control is to make two separate seals on the vessel at least 4-5mm apart, then cut partway between the seals - if you see lumen with no bleeding, it's safe to complete the division.
Using energy devices that seal and cut simultaneously on major vessels is a huge mistake and sets you up for trouble - every device can fail at some point.
Rothenberg had one case where he used a seal-and-cut device in another country, it didn't seal properly, there was bleeding, and they had to convert to open.
When completing an incomplete fissure, work layer by layer like finger fracturing during liver lobectomy, gradually exposing the pulmonary artery.
In a lower lobe, the pulmonary artery usually has a main trunk that bifurcates into four branches to the basal segments, plus a superior segmental branch that comes off higher and more posteriorly.
The bronchus sits right underneath the pulmonary artery - you can feel it and use it to help dissect behind the artery.
When dissecting behind the bronchus to reach it, the pulmonary vein is right behind - must stay hard on the backside of the bronchus and be aware the vein is there.
Critical rule: do not take the pulmonary vein trunk near the pericardium - if your device fails, it will retract into the pericardium and the child will bleed to death before you can do anything. Must have enough length for proximal control.
Right lower lobe is the exact opposite of left lower lobe - just switch hands and flip sides - but must be careful that middle lobe branches come off just above the lower lobe artery.
For upper lobectomy, retract the lung apex inferiorly to expose the pulmonary artery as it comes into the upper lobe near the apex, then work from top down around the front and up through the fissure.
The lingula is almost always taken with an upper lobectomy on the left; on the right, the middle lobe is usually preserved.
If you have a lung with large cysts and limited space, use the sealing device to pop the cysts and decompress them at the beginning of the procedure - do a lung reduction to get room to work.
Systemic vessels to sequestrations can number up to 6, and Rothenberg has seen vessels as large as 15mm in diameter.
Critical warning: do not use sealing technology and clips on the same vessel - the sealing changes the vessel nature, causing necrosis, and clips can lose secure footing and fall off, causing delayed bleeding.
Extra-lobar sequestrations can become infected and cause problems, which is why Rothenberg removes them all rather than watching or embolizing.
Embolization of sequestrations requires general anesthetic and significant arterial intervention - Rothenberg believes thoracoscopic removal has almost no morbidity with no chest tube and next-day discharge.
Rothenberg has performed approximately 20 segmentectomies in cases where disease appeared confined to superior segment of lower lobe or lingula on CT, with good follow-up and no recurrent disease, but cannot widely recommend yet.
Average length of stay for lobectomy in patients who come in the morning is about 2.5 days, and even shorter for patients under 5 kg.
Cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and indicates cases more prone to need fetal intervention.
20-40% of untreated congenital lung lesions will develop a significant infection at some point.