Difficult Cases of Lung Lesions: Pediatric Thoracic Surgery Part 1-Lung...
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What the experts said
The patient was an 11-year-old boy from a particular area of Chile with right pulmonary hydatid cyst occupying the entire right thorax.
Initial thoracoscopic approach was attempted but was impossible due to the size of the cyst.
After a month, eight bronchial fistulas were treated through mini-thoracotomy.
A second thoracoscopic procedure was performed to address the residual cavity, using experience from esophageal atresia cases to judge available space.
Only one port was used during the second thoracoscopic procedure because the tissue was highly inflamed and the surgeon did not want to damage too much parenchyma.
Intraoperative bleeding occurred during closure of the last fistula due to limited room and instrument depth, controlled by compression with the needle driver.
A small piece of Surgicel was placed in the fistula and closed with PDS suture.
Patient was discharged 5 days after surgery with no complications and no pneumothorax after chest drain removal.
At 3 months postoperative, the patient is doing well.
Yama believes the entire mucosa should be removed rather than suturing from the inside, and predicts recurrence with the suturing approach.
Yama would perform bronchoscopy to identify the involved segment, then thoracotomy (not thoracoscopy) in conjunction with intraoperative bronchoscopy for a patient with multiple prior operations.
Alan suggests the intracavitary approach might be useful for treating pneumatoceles, recalling a case where he inadvertently entered a large pneumatocele with the camera and identified a discrete bronchopleural fistula that could be addressed.
Hydatid cyst is very common in the southern part of Argentina and is a parasitosis not commonly seen in first-world countries.
Marcello's group was the first to perform hydatid cyst removal thoracoscopically from the beginning.
The key to hydatid cyst surgery is removing the white parasitic membrane inside the lung; there is usually a good plane between the lung and the cyst.
After membrane removal, bronchi from the lung will always show some bubbling, and these small holes should be carefully identified and sutured during the first surgery when tissues are not yet friable or bleeding.
Marcello believes Marco's patient had a very good result because once the parasitic membrane is removed in the first surgery, the patient is cured; the remaining issue is only closing the fistulas.
Marco attempted the first surgery thoracoscopically but all lung tissue was fixed to the thoracic wall, necessitating conversion to mini-thoracotomy for the standard procedure.
The situation with hydatid cyst bronchial fistulas is very similar to bronchial fistulas after staphylococcal pneumonia and empyema.
Liam always performs thoracoscopy to remove the membrane and allow lung expansion, which is very important for fistula healing.
Marco believes the intracavitary suturing technique works because the fistula size was small; he would not try this technique for a huge fistula.
Alan has performed one recurrent lobectomy and found it easier than expected.
Liam uses Hem-o-lok, but if the bronchus diameter is bigger than 5 mm, he performs interrupted suture closure and is pleased with that approach.
Marcello's group has used Hem-o-lok for at least 10 years for esophageal atresia and all lung lobectomies with no problems.
Hem-o-lok clips come in three sizes; the large size with a 10-mm plier can take very wide and large bronchi.
Marcello's group uses Hem-o-lok in patients over 7 years old for lobectomy, applying a proximal clip when the ligature alone is not enough for a large vessel, avoiding stapler use for a single vessel.
Marcello describes Hem-o-lok as 'a mechanical suture of the third world countries' because it is cheap and not as expensive as staplers, which are very expensive in resource-limited settings.
Alan has not experienced persistent air leaks lasting more than a few days maximum in infant lobectomies with incomplete fissures.
Alan worries about tissue sealant including the chest tube and has not used it in infant lobectomies because he has not needed it.
Yama uses Hem-o-lok clips and finds them more reliable compared to metal clips.