Difficult Cases of Lung Lesions: Pediatric Thoracic Surgery Part 1-Lung...

This patient is an 11 year old boy. Who came from the, a particular area from the country here in Chile, OK? And, well, he had a right pulmonary idatidosis. OK, And, uh, I'll show you the, the, the image in, in a few minutes because, uh, this cyst, um. Uh, was, uh, you know, occupying all, all the, uh, right thorax, so we went through as a first, uh, you know, approach to treat it, uh, thoracoscopically. We did a, we did the first try actually, uh, thoracoscopically, but it was, uh, impossible because of the, of the size of the, of the cyst, and after a month, that surgery, uh, you know, went, went well, and after months. Of, uh, that's deceased. OK. You can see a few imagings from the CT study. And well, this is the last X-ray before, uh, you know, discharge the patient from the hospital, but Um The, the, the main problem was that after a month with the, with the fistula, we, we, we treated at least 8 bronchial fistulas, um, uh, you know, through the mini thoracotomy, and we decided to go on with uh to this cavity. Aragoscopically thinking that well, we, my team and I, we were trying some cases of esophagaltrisia so we thought that we should have enough space over there. So, uh, I would like to show you the video now. Todd, yeah, can we pull up the, uh. The video we're getting at, Marco. OK, unfortunately, the video is not quite well like, uh, you know, the other video that that's OK in this meeting, but That is the Equipment that we have in my hospital. It's not working. It's not working. I Can you see the video? There is, yeah, I see it. Hello. Yeah, I see it. I see the fistula. OK, so Now we, we are in the cavity. OK, uh, this is like uh an orange, more or less inside. Uh, hold on one second. Sorry, we're OK, yeah, now we see it better. So, uh, we explored this and uh we found uh. Uh, 4, well, 22, fistula with the, with the, um, uh, with the main, uh, uh, sizes, I mean, uh, um, fistula to, to, to go and, and suture, and you, you can see. A well, first shooter of one of them. I decided to put just one port because of the because of the tissue was so inflammated, so. I didn't want to go to the uh too much uh parenchyma. OK, it was a little bit difficult, uh, at the end of the surgery because of the, of the last fistula that you will see in a minute because, uh, well, uh, technically we, we, uh, I didn't have too much room and and breast to, to, uh, to put it uh um. With, with, with a, with confidence and you will see. And because of this. Uh inflammation in this cavity that I had a bleeding at that time. That fortunately, I could, uh, control and finish the, the, the surgery, but I put a small piece of, uh, surgicel in that, uh, fistula. And I closed it with the PDS. And well, fortunately for me and my team and for my patients, it's work. You will see this in a couple of seconds. Marco, do I understand that you only did this to the one hole or you did this to both? Well, 222 ports, camera and, and, and 1 port for the right, but you sutured both, you sutured both of the fistula. There were 2 fistulas, right? Or just, yeah, you sutured both of them. Yes, OK. So we are taking that, uh, you know, a little bit of water. Where is the other one? And this was the one that I had the problem. You will see that actually, I think I I had a mistake with, with, uh, you know, going too deep with my instrument in that part of the world, so, uh, you will see. It was a very scary moment during the surgery. But I thought, well, there is. I thought it was, it must be very, you know, superficial in the cavity, so I did a little bit of compression and then I could finally put my stitch compression with your needle driver. You just pushed with your needle driver, yes, yes, with the needle driver, yes, OK. In that moment, I, you know, I missed my, my left hand, obviously, but that's what I explained to you that. I decided to go on with just one port because of, uh, the thickness of the, uh, of the lung tissue. You, you Can you go, uh, further with the video? Oh, we are OK in, in time. I don't know. Well, uh, yeah, let's go. This is, we'll go double speed here. There's 4 times the speed. Good. OK, good. Because I would like to show you the Well, the idea that we have a With my team, uh, you know, putting, uh, and, and, and a piece of, uh, surgery cell, uh, in, in, in the, in the fistula. Oh this is the first one already yeah yeah yeah we have to go pretty far ahead here uh Stefan, go, yeah, that's probably and then go 4 times after the bleeding. Good, good, good. Keep going 4 times. I don't know in the audience if uh somebody, oh Marco, that's where the video ends. I'm sorry, that's where the video ends. Oh really? Yes. Oh. Well, there's a 2nd video, but I think that's for the other case you received, yeah, that's OK. You received the, uh, the very short one because the, the problem that we had, uh, so what happened? So what did you do? Well, the patient went well, and I discharged him 7 days after the surgery, you know, after, uh, to take, uh, no complications, no pneumothorax. I removed the thoracic drain. I, it was 5 years, I'm sorry, 5 days after surgery, and patient, well, um, I've been following him at least. 2 times now and he's doing well. So what is he, 1 year out now, 6 months? I'm sorry, how far out? How long ago did you do the operation? Oh, OK, uh, uh, it was 3 months ago, more or less. OK, Yama, Yama, have you had, what do you think about this technique? Yeah, I feel we have to remove the entire, you know, mucosa. I mean, uh, rather than suturing from the inside. You think it's going to recur? You think it's going to recur? Yeah, I think. OK, so what would you do? And before I go, I see Marcella wants to make a comment, but what would you do, Yama? How would you have managed this patient? I think probably I will do bronchoscope. And which segment was involved? Then uh we do thoracotomy. In conjunction with the bronchoscope at the time of the uh tho thoracoscopic uh excision. Interesting. So, OK, uh, you have a comment, Alan. Thoracoscopic, you said, yeah, you said this patient had many recurrences, right? Had adhesion of the lung to the chest wall. Marco 00, Marco, we lost your phone. If you could call back again, um, so he's chatting. Marco, you can answer us by chat. We're, it's OK. So, uh, while, while Marco's answering that, so Yara, you would do a, we didn't understand, was it thoracoscopy or thoracotomy? I think because he he already had, you know, multiple operations. I think in this case I tried to not thoracoscopically, thoracotomy in conjunction with intraoperative bron bronchoscopy, OK. I, I actually think, uh, this approach might be good for some other things. I, I once remember treating a, a large pneumatocele and I inadvertently entered the cyst with my camera, um, and looking around, I could see a very discreet, you know, bronchopleural fistula feeding this pneumatocele. So, I wonder if you couldn't treat pneumatoces which don't have a mucosal lining. Or anything else by this approach, I think it's very interesting. So, uh, Liam and, uh, Marcello both raised their hand. Marcello, go ahead. My guess is you have some innovative way to treat this. No, it's just, uh, I'm sure that Liam has a lot of experience because hidiatic cyst is very common in, in the southern part of Argentina. So, and it's a parasitosis that maybe you, you don't have so many in the first world. But we have a lot of these patients, and, um, first of all, I, I want to make sure that you taped that uh Yamataka said the word thoracotta. We have it on tape, Yama. We have it on tape, OK, OK, because I consider him like an extreme laparoscopist. Yeah, Yama, you hear what we're saying here? We're, we're talking to, we're, we're, we, yeah, Marcello just said we make sure that we, we got you on recording that you said the word thoracotomy because we can. So if uh. That, that may have serious consequences. OK. The, the next thing I wanted to say is that, um, I wanted to ask Marco, uh, the first, as I think he said, the first time they operated this patient open, like, uh, with that word that I don't want to say, did they open, did they, did it open? The first surgery for the idiotic cyst was, I think he did say thoracotomy, and that's a great question. Marco can answer by text. I think he's he's answering right now about whether or not he did the first operation open. Um, are you on the phone, Marco? He's waiting. He's coming in in a minute, but, uh, OK, just I wanted to say this. Since a long time ago we've, our group was, I think, the first ones to perform these cysts thoracoscopically just from the beginning, and the important thing of these cysts is just to take the membrane of the parasite that is inside of the lung. And fortunately enough, most of the times that's not so, so difficult because there's a good plane between the lung and the cyst. So once you remove this white membrane, then you always will see some bubbling from some bronchi from the lung. And so it's good to do it just in the first surgery whereas the tissues are not so friable, not so bleeding as what Marcos showed us today. So what we do is take the membrane away and then look very carefully for all these little holes that bubble and then suture them just in the first time we do the surgery. I think that that would be my approach. And then on the other hand, I think that what he did was excellent and I would do exactly the same thing. And actually I think his patient had a very good result because as long as in the first surgery they took the membrane of the parasite away from the patient, the patient is cured. Now it's only just a matter of closing those fistula. I want to have Marco respond and I want to hear Liam's comments. Marco, yes, hi Marcelo, how are you? Hi, how are you doing? Yeah, very well. The, actually, in the, in the, I, I did the first try tchoscopically, but unfortunately all the lung tissue was very, um, you know, fixed to the abdominal, I mean to the thoracic wall, so I couldn't. So that's why I went through the minimal thoracotomy, and I, and I performed the regular surgery because everybody, you know, do it. And in the 2nd time, well, I tried this, uh, two, fistulas, um, uh, with this technique after, you know, uh, closing at least 8 in the first surgery. All right, quickly, Liam, and then we're going to go to the next case, because we only have about 5, actually, yeah, Marco, we're going to have to end it this case. So, Liam, go ahead and give your comments. Uh, yes, the situation is very similar with the, the bronchial, uh, fistula after staphylococcal, uh, infection, I mean, pneumonia due to staphylococ, and, uh, of course, uh, uh, palm, uh, emyma. So in our, uh, practice, we always perform the thoracoscopy to remove, uh, membrane the path to, to allow the, the lung expand. And I think that is very important, uh, otherwise difficult to, to, to heal the fistula. Yeah. OK. Marco, do you have a comment about that? I'm sorry, do you have any, uh, comments to Professor Liam? Yeah, I think, uh, actually there is another, uh, doctor, you know, uh, asking me and said that I think this, uh, technique works because, uh, the size of the fistula is, uh, I think that's the main issue. I probably, I, I, I, I didn't, I, I will not try this uh in, in a, in a huge fistula. Um, OK, so I'm, we're gonna end this case now, Marco, uh, uh, uh, you showed me about having a, uh, you know, I see you can teach me more than just about have a good time in Uruguay, uh, that, uh, you can actually, I can learn about how to manage, uh, fistulas. So thank you, and, uh, and, and, and everyone else here. We are gonna be going in a few minutes to the OR, and I would like to have you all stay on the phone, but Liam and, uh, Yama. It's uh in the middle of the night for you so if you have to go, uh, that's no problem. Thank you for, for spending so much time with us in the middle of the night um what's that Jesse? Oh yeah, yeah, um, if there's anyone, we still have like about 5 minutes left. If anyone has any last comments about anything that Rothenberg said in his talks, uh, Giovanna, Marcello, Liam, Yama, if, if anyone here wants to make any comments about anything that, that, uh, Rothenberg discussed, let me know and we can talk. I, I have a question, yeah, Steve, Steve left, but, uh, we'll ask him. What's that. I have one question, Steve. Steve mentioned one case who had a segmentectomy. But the patient had recurrence and then he did another thoracoscopic treatment. What was the finding? OK. Was it, was the operation was easy or lots of adhesions? OK, so I've done one recurrence and it was actually easier than I thought. Yama, we're gonna have Steve on the phone from the operating room in a minute, and I will ask him that question when we have him on the phone, um, but, uh, I appreciate that question. Any other questions, uh, or comments about anything that we've discussed today? Yeah, Todd, I would like to ask uh to the audience and particularly Dr. Rotenberg, if you will use or have used Emmalog for Uh, yeah, the hemalock, that was my, my second case actually, but unfortunately we don't have right, uh, by the way, Marco, we're gonna post your case in the archive so people can go watch the case and make comments about it in the archive that will be up in about 6 weeks. So, um, we appreciate you sending that case and and we hopefully on this, uh, thoracic part two we might be able to have a chance to get to that, um. But the, the answer I will ask about the Hemalock. We talk about that a lot. Um, I know that uh there's now a, uh, a disposable even hemalock clip. I think that he, he uses the metal clips and he is not opposed to using the Hemalock. I don't know why he doesn't use it routinely. I don't know if you've ever used it. I haven't. It's a great clip, Mark, uh, Marcello. I know you love it. The wet clip, yeah, big two thumbs up there. I know. Uh, Liam, Giovanna, uh, or Yama, do you use the hemalock clip instead of the metal clip? Yeah, I, I love it. I use the, uh, metallic clip as you show it in the video. OK, metallic, Liam. I use Humalog and but if its diameter is bigger, broncos is bigger than 5 now I perform I suture. I glow with some interrupted suture and I am pleased with that suture. Yama, you said you use the Hemalock, right? is more reliable compared to metal click. OK, uh, Marcello. We've, we've been using the Humalog for at least the last 10 years for each esophageal atrichia and had no problem. Then for all lung lobectomies, and we, what we do, we, we use them for the bronchi, even huge bronchis, because you have three sizes. There's a large size with a plier. That unfortunately it's 10 millimeters diameter, but you can take very wide and very large bronchi. So and we've been using it a lot and we never had a problem with them, even in patients with more than 7 years old when we have to perform a lobectomy, and we published that we we we just apply a proximal clip just in case when the liga, when you feel that the ligature is not enough for a for a large vessel. And we don't want to use a stapler just for one vessel. We just place one proximal hemalock clip, and then we apply the ligature, and that's very safe. And then, so we use them a lot. We are really fans. I say it's like a mechanical suture of the of the third world countries because it's cheap and it's not so expensive even for us that we, we, it's so difficult for us to get like a like a stapler. Staplerers are very expensive for us, right, right. Any other comments? Any other question? Excuse me. Can I. Yeah, go ahead, Giovanna. Oh, I have a question about tissue sealing. Do you use some sort of glue? I mean, not in older children, where you can use tape, but in the smaller one, do you think it could be useful? You mean to, uh, for which purpose, Giovanna, for reinforcing a staple line or for the leak leakage. I mean some tissue sealing or some glue on the tissues that you dissect when you have not clear. Ah, so after you, you identify the fissure, you do the resection, reinforce the the the parenchyma with glue. Uh, I've never done that. Do you think it could be useful or not? Yeah, it might be. I think it could be, but really, you know, persistent air leak hasn't been a problem. Um, at least in the infant lobectomies with incomplete fissures, I've had no, no persistent air leaks that have lasted more than a few days maximum. And I worry about the tissue seal stuff, including the chest tube and, you know, all of that. So, I haven't used it. Uh, there, there may be some usefulness for it, but in infant lobectomies, I haven't needed it. Jesse, can you call up to the operating room and see if they're close.