Panel Discussion: Pediatric Thoracic Surgery Part 1-Lung Lesions 2012

I was sitting, I was sitting here thinking I, I've heard you give so, so many thoracic talks, but this is the first time I've ever heard you give everything, and, um, I wish, I mean this will be archived and people will be able to go back and watch this, but, um, watching each lobe at a time is, is an amazing value because you see it, it just, it all puts it together and makes sense. I don't know if you guys got the same thing out of that, but at least I did. Alan's not nodding his head. He thought he didn't like it. It was too long. It was great, um, so, uh, we are, I would like to invite exactly, I'd like to invite the faculty now, the, the panelists to come on. Um, we're a few minutes early, and the reason is, is I'd like you here while we do the difficult case presentations. Uh, I'd like to get as many opinions on these cases, um, as possible. So I know we have, uh, Liam, I see you there. Hello, Professor Liam. Welcome from Vietnam, from Hanoi, and, um, we also, uh, there I see Marcello. Hey Marcelo, it's good to see you without, uh, actually this is the first time without, uh, 50 or 100 people behind you. Uh, uh, is that Carolina? She, she is, uh, she is from Chile. Oh, from Chile. OK. Yeah. OK. And, and you went from Chile to Argentina? Yes, yes, she, she comes to visit us because, uh, she wants to see some, uh, minimally invasive surgery, and because she's from Chile, she's the only one with me. All my, all my other people are in the Argentine, uh, meeting, and I'm, they left me here alone. Hey Marcello, shut off your computer speakers. We have an echo here, um, but, uh, or somehow we're hearing an echo from your office. Is that better now, guys? Would that be better? Yes, that's better, right guys? Jesse, is that better? OK, we'll, we'll find out in a minute. I think it's better, Marcello, um, and then, uh, we have Liam, and then we also have, uh, Giovanna. Are you on the, uh, phone as well? Yes, I have a phone. Hello and welcome from Italy. Thank you for joining us today. You can turn on your webcam if you see the button above Marcello's head. You can push the start my webcam button. And then we'll see you pop up there as well. And what time is it there? In Italy. Oh, it's 8:00. 0, well then, good evening. Thank you for joining us to you. And then uh Jean Martin, you're still there too, I think you're welcome to join us as well. I know you're, uh, I don't know if you're prepared to come on cam, but you're welcome to. And then, um, Yama, I hear that you're here too. Are you there, Yama? Yes, I'm here. Professor Yamataka from Tokyo, Japan, go ahead and turn your camera on. Oh yeah, if possible, if everyone can use an actual phone handset, then we'll get less echo and better sound. So Marcello and Giovanna, if you have a phone that you can talk into, it will probably get better sound. And so Yama, yes, could you hear me? Yeah, we can hear you OK actually. Is that good? I think it's good. Um, OK. And then Yamo, go ahead and turn your camera on. If not, we can put a picture of you on the screen logo, but uh it's not allowing me to, to do it. Who's that talking? I already put my Speaker mute. I hear someone talking. I don't know who's that. Oh, is that Yama? Hey Yama, What time is it there in Tokyo? Uh, 3 a.m. You're a good man, and Liam, it's the Liam, it's the same time zone. No. What time is it in Vietnam, Liam? Uh, 1 a.m. Well, let me tell you, you guys look fantastic for 1 to 3 a.m. You don't want to see me at that time. Uh, thank you so much to both of you for joining us here. So, um, This is the hardest part because we're going to get into some heated battle. We're getting into some serious discussion, and Mark McCollum, who I'd like to introduce, Mark McCollum is one of my partners here at Akron Children's Hospital, a great colleague and great surgeon. He is going to be doing a live case with Dr. Rothenberg. Mark, thanks for joining us today as well. Thank you, Todd, for having me. Uh, so now that we have everyone here, we got to make sure we relieve the tensions, and the only way to do that, the only way we know how to do that is with a nice ice cold beer. So we have, uh, Doctor Perry here, one of my partners who's going to bring us. I'm sorry you guys can't have beer, and actually for Steven, for Mark, we got you non-alcoholic beer because you're headed into the OR. This is good. This is good. I've been relegated to this. That's a nice local IPA. Perfect. We got the. Sorry guys, we need to enjoy the discussion. I think we need to cancel the case, but for, uh, for, for Liam and Yama, you all need either coffee or tea, uh, considering it's in the middle of the night. IPA. That's it. What do you got your tea there, Yama? It's actually the continually hopped IPA. I can't hear him. Is his audio on? But it's good. We can't hear you, Yama, for some reason. I'm having coffee. Don't worry. Pick up your phone, Yama. Can you pick up your phone? No, I'm having coffee. Coffee. OK, no beer. All right, no beer. So, uh, let's, no beer. All right, so let's start off with, um, the first case. Do we have, uh, Doctor Valenzuela, are you on the phone? We have Marco Valenzuela. We're gonna see if we can get him back on the phone. I know he was on a minute ago. If we can, maybe what we'll do is if we don't have him right now, wait 1, you know, 10 more seconds, if we don't have him. OK, when he comes back on, we'll do his case. In the meantime, why don't we do, Stefan, can you pull up, um, actually change of plans. We're gonna look at Steve's question here since the slide is there. Let's address that question, then we'll go into Doctor McCallum's, uh, case presentation, and then we'll go into Doctor Valenzuela. So Steve, go ahead and, and pose the question to the, uh, panelists here. So anyway, this is, uh, this is a. Two month old, prenatally diagnosed, uh, Uh, CPAP, uh, post, postnatal CT scan showed this lesion that, that you see there. And again, it, there was a lot of debate about whether it was, uh, an upper lobe or a lower lobe, um, lesion. And it took the reconstructions to convince me it was a lower lobe lesion. I was quite convinced initially it was upper lobe cause I was convinced, uh, this, this, Right here was the major fissure and we was just being compressed by the cystic lesion. Um, but then when we got in, um. Uh, thoracoscopically, what we could see was we could see this cystic area right here, this large cyst, um, separate from the upper lobe. Uh, and then this congenital cleft right here. And you'll just have to take the word, my word for it that the rest of the CT scan, the basal segments of the lower lobe basically look normal. So, is it reasonable to do, to just resect the superior segment of this lower lobe? Who do you want to call on? Uh, Giovanna, what do you think? I think that I will try to do a partial reduction. I mean. Go ahead, go ahead, Giovanna. Could you hear me? Yeah, we could. We could. Go ahead. Keep going. OK, uh, my, my opinion is to look inside and, uh, to, to perform a passive resection. I mean to perform a an upper segmentectomy of uh. Of the of the lower lobe. OK. Performing exactly the same technique that Steve showed before, I don't want to do a lobectomy. I tried to do a partial reduction, I think. OK. OK. Anyone have any other comments? I, I, I would say that I don't see the advantage of doing a partial resection in an infant. The downside is that you may leave disease behind, even though this is an isolated cyst. It's also more likely to have complications, although. No one's done enough of them thoracoscopically to know, but certainly the risk of air leaks, etc. is higher. And ultimately the pulmonary function will be the same because taking a lobectomy from an infant. Gives you normal pulmonary functions when you're older. So I don't really see the advantages to justify the more difficult procedure. If this patient were older, uh, then I think a segmentectomy would make perfect sense. If there were multilobar disease, it would make sense. But it's been reasonably well documented that the risk of leaving CA disease behind by segmentectomy is relatively high. Yeah, go ahead, Yama. Uh, for segmentectomy on the left side, I think a lingectomy or easier than other segmentectomy, especially, I think that is segment 6. Segmentectomy of segment 6 and segment 10 is, I think, I feel very difficult performing thoracoscopically. If I do a segmentectomy, uh, I'm not doing a thoracoscopically open technique. If I do, if I have to do a segmentectomy, but if I I have to do thoracoscopically, thoracoscopically, I will do, uh, you know, left lower lobectomy in this case, as Alan said. OK. All right. Any kind of Liam. What would you do? Referral lobectomy. Oh. And I, but then. We can hear you. Go ahead. Yeah, I prefer, uh, lobectomy in this case. OK. So. What'd you do? We did a segmentectomy. We completed the fissure, and you'll all get to see that video sometime in the next year. Uh, we completed the fissure, found the, uh, artery and bronchus as they came off here. Had a clear demarcation plane right here and, uh, came across it. Child had no air leak post op. Chest tube was taken out on the second post-op day and went home on post-op day three. Now, I do feel that this child needs to be monitored with a CT scan to do it. And I don't know, I would agree with you, uh, uh, and, and the case only took about 90 minutes, uh, and that was a fellow doing it. But, um, it, uh, to do this particular segment, I don't think is that difficult. And there is part of me that feels that, you know, if you can preserve lung, that that, And, and if I knew it was disease free, that that's, it would be hard to claim that was the wrong thing to do. But, um, I do think for a superior segment, I think the, the morbidity is extremely low, um, for that particular segment. But I think if you do 100 cases, OK. Again, the likelihood that you're going to miss disease is significantly higher, and the likelihood that you're going to have complications of one type or another is higher. Uh, and, and I can't, I can't argue that. I can't, I mean, I. I guess part of it is what I feel is, you know, based on how the anatomy presented itself and how the case went, I felt very comfortable that we were below, you know, at least grossly below the disease, and I also felt that I've done enough segments now that I feel like the risk of air leak and other issues are, are minimal, but I think that can't be argued, and I would like to know. You know, and I think it's a question yet to be answered, but in this particular case, it seemed, um, it seemed a worthwhile endeavor. Um, let's go. Valenzuela's on the phone. OK. Oh, almost. Well, let's go to, he's on now. Uh, Marco, can you hear me? Doctor Valenzuela, are you there? Now, now, what I wouldn't do is I wouldn't take a stapler and just wedge across this blindly. So, I just want, I didn't show it, but this was an anatomic dissection. OK. Complete anatomic dissection, so. Yes, oh, Marcello, sorry, go ahead. Um, last year we had a patient that, um, we thought it was just a, an inferior lobe, uh, C cam. When we got in, we actually, uh, saw that it, it, the compromise was in, in the two lobes, and, so we decided to perform an inferior lobectomy and then, uh, we performed a segmentectomy. Um, of the upper lobe, and, uh, we've been following that patient, although the segmentectomy was not perfectly anatomically, uh, performed, uh, we felt, uh, very comfortable with it and the patient is doing great. That's our experience. Actually, we, we would do that in patients that have a compromise of more than one lobe. OK. Um Thanks Marcello. Let's, let's go to uh Doctor Valenzuela. Are you there? Marco Valenzuela. All right, let, OK, all right. The answer I had was he should be, but he's not. So, um, let's, let's, uh, let's go ahead to Doctor McCollum's case and hopefully he'll come in at the end. OK. Um, can we pull up Doctor McCollum's case, uh, and then let me. Give an introduction before his introduction about this particular topic. Um, I, I, um, asked Doctor McCallum to present this, um, because here in in our group this is, uh, very controversial topic of a very simple, very common problem which is pneumothorax, and I was curious how the rest of the world manages this very simple common problem because in our own group. We have quite a bit of disagreement on on the best way to manage this and so we're gonna do this in about 5 or 10 minutes. We're gonna go over some of the common scenarios in in pneumothorax. So Doctor McCollum, yeah, thanks again. Can we bring up, uh, Stefan, can we bring up his slides, please? Thanks. Todd, Todd, thanks again for having me and, uh, uh, congratulations on your first Global cast MD web symposium from Akron Children's. We're excited to have you. It's great and uh Doctor Blake, Doctor Rothenberg as well, we're excited to have you here as Doctor Ponsky mentioned, uh, we wanted to talk about this is less than a, a complicated or difficult case and after looking at, uh, these last several presentations, the complexity of the cases as well as, uh, the technical expertise. Um, uh, this is more of a, a point of discussion and, uh, as, as Todd pointed out, um, trying to get an idea of, of, of various, um, modes of management. There is some disagreement in our own group and the literature, I don't think supports, uh, anything clearly. Uh, so, let's discuss a little bit primary spontaneous pneumothorax. So, uh, we'll start with a brief case presentation. If you would roll that slide over for me, please. Uh, no, uh, so, OK, so, I'll, oh, yeah, I'll do it for you. Hold on here. Yeah, I don't have a. Got it. Oh, you went too. I did. Did I? Someone did. Oh yeah, yeah, yeah. OK, sorry, I'll take care of it, Stephan. I got it. You've spoiled everything. This will be brief, but 14 year old young man, uh, presents, uh, not uncommonly with acute onset left sided chest pain and shortness of breath. Uh, the young man has no significant past medical history, and his vital signs are, uh, stable, um, with, uh, um, heart rate of 92, respiratory rate of 24. He's in the emergency department on 2 L nasal cannula with 02 sats of 94%, and on, uh, physical examination, he has, uh, moderately diminished breath sounds on the, uh, left chest. So an X-ray, I'm not sure how well that projects, but I'll, I'll put some arrows just to outline, um, uh, probably a 20% plus minus pneumothorax on the left side. Uh, so we, we thought we would start the discussion. I'm having a hard time rolling that slide. I can do it. I got it. OK, uh, there you go. With just a polling question on how this would be managed across the board, with choices being number one, observation, admission with repeat chest X-ray within 24 hours, uh, tube thoracostomy in the ED, uh, tube thoracostomy under anesthesia in the operating room, or VATs with tube thoracostomy as a primary procedure, uh, and then we threw other out there to see. OK, so, so while this poll is, uh, revving up, uh, it looks like we lost Liam's camera, but, uh, let me go to, um, Marcello. How would you handle this, Marcello? We would, uh, here in Argentina, uh, we would, uh, just, uh, uh, uh, do option two. We would just put a tube in the emergency room and wait. OK, uh, uh, Giovanna. Uh, in our country we use with us, uh, so limited thermothorax to wait 24 hours and then, so option one, option one, Alan, Steve, I would do option one. Option one, which is observation, Steve, observation with repeat X-rays 24 hours later, OK, but he has chest pain. He came to the ER, so. Yeah, yeah, he, he would, it would be some version of option two. Does it matter what time of the night it was? That would give him more chest pain. With that pigtail catheter, probably. Pigtail catheter, does it matter what time of the day this is? Oh, I wouldn't put it in. Uh, Yama, what happens in Tokyo? Yeah, observation option one. OK. All right, very good. So it looks like from the audience, it looks like 40, 50, it's pretty split between option one and 2, 54, so it's pretty split there, Mark. Interestingly, it's pretty interesting, right? Uh, interestingly though. I don't see what I, I look how, look what people wrote about option 3. So only 1% of those polled would, would actually do a VATS right now on this patient, an immediate VATS, uh, which is, I think, a point that I want to get to because that is actually what I always sought in general surgery was when these patients came in, we took them to the operating room for a VAT. So I, it's a, it's a great, where did you train on the moon. Uh, so, uh, let's, let's go to, uh, the, actually, hey, Todd, one other question. Let's ask the, let's ask the group here, uh, uh, patients that undergo chest tube placement, let's assume now that the child doesn't improve his pneumothorax or is persistently symptomatic. And he's gonna need a chest tube of some sort. What percentage of those patients get a chest tube under local anesthesia or go to the operating, excuse me, yeah, local, or go to the operating room under general? Let's get a chest tube. Let's ask the, um, because that's driven a lot of our, our patient management here is, um, in the older chil, well, in the intermediate age children, um, we typically take them to the operating room to place a chest tube. Uh, which then makes progressive management with VATs more appropriate. All right. What is the, so, let's ask, uh, Marcello. I'm, I'm sorry. I'm sorry. I was talking, I'm sorry. You know what? You got to pay attention. To have a discussion here, but I was trying to get a beer. Wait, in Argentina it's wine though, right? So, all right, so Marcello, the question was, the question was, because what was your answer? I don't remember, you said you were put in a chest tube in in the ER. So the question is, of those who put a chest tube in, do you do it with anesthesia in the operating room? Do you do it with local at the bedside? If it's, uh, most of these kids are big, uh, kids like 18 years old, so we would do it with local anesthesia, uh, just there. OK. Local anesthesia, and that's true. I mean, most of them are adolescents, right? Yes, yeah, so that's a good point. Uh, uh, Liam. Liam, Liam, the question is, I, I think in this case, I may have two options. The first one is I would like to perform a CT scan to know better the nature of the cause of, uh, of, uh, pneumothora. Otherwise, I will perform thoracoscopy to find the nature, the cause of pneumothorax, and based on CT scan, or based on thoracoscopy finding, I will decide what I will do. OK. So, we're going to get to that. I want to talk more about CT scans later in your. You bet. Right? That's the next point we're going. So, we're going to get to that, Liam, in a second. You're bringing up the next point. Um, I guess, but the question that, that Mark, because let me just tell you, let me preface it. The argument, why don't you make the argument on, on, or the why, why don't you ask, answer why you're asking that question about anesthesia versus local? Well, because the majority of our children, um, elect to undergo general anesthesia and, uh, maybe we're spoiled regionally or nationally, uh, but most of the kiddos that we see don't want to undergo with their family at the bedside, uh, a local introduction of a, of a chest tube, so they default to the operating room, which is where we do almost everything at our children's hospital. Once we've exposed the child to general anesthesia and have made a 1 centimeter incision in the chest, uh, it's made a very good sense to me to put a scope in to define exactly what the problem is because these kids that, that, uh, either get chest tube placement or observation, 50% of those kids are gonna recur and need additional intervention. And if we've already exposed them to anesthesia, then I'm gonna stick a scope in, try to define a problem, uh, and if, if I do find blebs, then I'll address the blebs at the time. But the point you're making is that if you are a center that believes that you're putting a chest tube in under anesthesia, why not stick a scope in first and see if there's a bleb? That's the argument you're making, which I think is a valid argument if you're doing a job, but you're making an assumption that if they have blebs, they will recur. And that's not necessarily proven. It's not proven, but certainly if you, if you were to take all comers that undergo simple chest tube placement for a symptomatic pneumothorax, of those that have bleb disease, upwards of 50% will recur. Right. But I don't know of a study, maybe you do, that has taken the entire population. Separated out those that have blebs versus those that don't with spontaneous pneumothorax and determines the risk of recurrence for the two groups. No, most of the data is more retrospective looking at, looking at intervention and then. So overall, they have a risk of recurrence of around 50%, right? Correct. Second recurrence of about 75 labs are not, and you can always treat them when they have a recurrence. So I'm not, I'm, I'm not criticizing your approach. I'm just saying, uh, I don't know that it's, it's based on objective evidence that if they have blebs, they're more likely to recur and you need to treat them in their first occurrence. So what study do you want to see? I want to see a study that separates out patients that on their first event, have blebs versus no blebs and look at the risk of recurrence of a second event. Which would be either done by having a CAT scan on everybody thoracoscopy. So, OK, well, and I believe in getting a CAT scan on everybody. Well, this goes to a point you do or do not. I do. OK. Yeah, we're gonna get. So then, yeah, flip to the next slide because that's the question is when is time, timing for the, uh, the CT because a lot of people wanted to observe these patients, but you're not going to get a very effective CAT scan of the chest with a partially collapsed lung, right. Uh, may I say one thing, Marcello? Yeah, yeah, go ahead. OK, um, when I say a place of a chest tube, I, what I mean with the local anesthesia is that, uh, most of the times we would just place on that patient, uh, like a double pigtail, very, very thin, and attached to a hemlich valve. Yeah. Not, not, not a, a, a big piece of chest. To just uh something uh percutaneous, right, I understand the position of it if you have to take it to the OR, if you're there, why not to scope it, and I understand the discussion. Just wanted to say that, yeah, yeah, yeah, but, uh, a question for you, and I, well, I don't want to jump ahead, but to answer you, we're gonna get to that point is I think that almost all of these do have bleb disease and so even if I don't see a bleb. I treat, I treat, but we're gonna, well, we're, that's actually you're, you're getting to my point, OK, which is, which is that you wait until they have a second recurrence recurrence, and then you treat all of them, whether they have blebs or they don't, correct. And I do the same, but we're gonna go ahead cause we're, so here's the next poll question is role and, uh, timing of CT scan of the chest in these, in these children. OK. So, Mark, go ahead and pick on someone. Who do you wanna ask? Do you wanna ask, uh, Giovanna, who's sleepiest? Who, who, where, where is it 0300 in the morning? So I think, well, let's go, let's go to, I mean, so we already know Liam's answer to that, right? Uh, Liam says he, he gets a CT scan on everyone when they come in. Is that right, Liam? The patient is stable. If the patient is stable, and I prefer a CT scan first. OK. If, if he's still having pain, uh, Liam, do you, do you re-expand the chest before you get the CT scan? In other words, put a chest tube or a pigtail catheter in. So ask him again. Can you hear me? Yeah, Giovanna, go ahead. Oh, so I think that, uh, my attitude is to observe the patient for 24 hours, and if the pneumothola will improve, I prefer to perform a CT scan. So you have to decide to do, to put the chest drain or to perform a. So, uh, this is my attitude. So I think that CT scan is important for you to first surgical option, uh. Can I answer, uh, uh, and then I want to go to Alan. I just don't understand. I'm curious cause I'm going to prep this. I don't understand how a CT scan would ever help me. So, I'm just curious because I go by clinical, like if they recur again, I go back in and I resect the apex, whatever I see. So, I'm curious how you want to see, I agree. It doesn't change your management, but it may give you insight into how much disease the person has. So, they may have contralateral blood disease as well. They may have superior segment of the lower lobe blood disease and upper lobe. They can have a variety of Interesting. Things that you can see on CT scan. How often have you seen the lower lobe, uh, labs? You have seen them? Yes. Yeah. Uh, well, I, CT scan, Often the way I use it is to help the patient or their parents make an informed decision. Like I had a kid who came in spontaneous pneumothorax. We watched it, didn't do it, didn't get, you know, it didn't completely resolve, and she was going away on a, you know, outward bound kind of thing where she was going to be up in the hills for 6 weeks away from medical care. We got a CT scan and it showed she had bilateral blebs. So, you know, you make an, make an informed decision. In her particular case, the risk of being out in the wilderness and getting a tension pneumothorax is higher than if she was in the city. You know, doing it. But I think, um, in general, I'm not sure it, it makes a, a huge role in the, in the change of management. Um there's a question about how sensitive is the CT scan for blebs. It's pretty good, actually, from what I've seen. I don't know. Once you get the lung reexpanded, yeah. Right. You got a comment you wanna make, I, I think there's a recent study out from Saint Peter in, uh, in Kansas City that looks at just that how, how, uh, how accurate is a CT scan of defining blood disease, and he found it was very, very poor, uh, whenever he looked at that in comparison with subsequent thoracoscopy. So I think we're missing, like you said, almost all these kids, I think, are gonna have blood disease whether we define it early or not, or, or whether just because they have blood disease they recur. Maybe they don't, but I think the majority of them do have some degree of blood disease. But that's my point. Blood disease doesn't necessarily mean recurrence. No, but if I were given a choice, if I had an active kiddo like Doctor Rothenberg pointed out, who's gonna be on, so would you treat blood disease before a second recurrence based on the presence of bloods? Yes. Yes, uh, well, I would discuss it with the family, but, but the, the idea I think of, of a, of a, a child at a football game or on a trip or at school, this is a big issue for these kids, acute onset pain, it changes their schedule. They rush to the emergency room. You treat them on the admitted 24 hours. You're gonna be doing, uh, potentially a number of unnecessary phlebectomies and. Um, Pleurectomies, right? The scope is going in. We have to define whether they have the labs. Right, and if you treat every kid that has blebs, and you say that most of them will have blebs, then you're doing a 50% rate of unnecessary. If you do 100% of kids that, you know, present to you, your, your points you're doing a lot of unnecessary the flip side of that is you're saving 50% of kids from an untimely recurrence, uh, of a potential that they usually don't recur when they're off on, on top of a mountain somewhere on an outward bound trip. They usually with Doctor Roth they usually recur when they're at home. Have you ever seen someone come in in extremists? I haven't. No, I don't think I have. Pain. They usually come on pigtails, yeah, but not, uh, from an outside extremist extremists. And by the way, guys, out in, uh, everywhere else, chime in, be, uh, interrupt us, be rude. We don't, don't wait for me to call on you. I'm trying to be rude. Yeah, I mean, sometimes you got to just yell to shut us up, so we're just going to keep talking unless you say something. Uh, OK, OK. All right, I'm getting told to, to hurry along. So let's, let's go on, um, Mark, uh, so we'll go to the next slide here. And we'll just hurry this up. OK. Let's make the assumption then that the patient does have blood disease based on a CT scan. Uh, the approach with VATs for unilateral blood disease, uh, As far as panel goes, uh, is anybody doing single port surgery? Uh, far and away the majority, uh, are doing multi-port, but there are some articles written about single port and its efficacy. Yeah, I, I've done one case and reported it and I've never done it since I did my own report. OK, we, we, we, we've done a couple of cases, uh, not with single port but reducing the number of ports by placing a magnet, uh. So we grab the blade with a magnet and just uh move it all over the place and just uh in this way we, we would just say to put uh another 5 millimeter port so we can perform. Um, one of these resections just with 15 millimeter port for the camera and then a 12 millimeter port for the scope for the stapler and and and just that. Marcello, you're so predictable. I knew you were going to say you're going to use magnets somehow. Uh, all right, um, any comments about this before we go to the next slide from anybody? OK, let's go to the next one here, Mark, which is. This here. Yes, as Doctor Flake pointed out earlier, one of the reasons I think CT scan is useful, uh, is, is diagnosing blebs on the contralateral side. And so that brings up the question, if you do have a patient with bilateral bleb disease, uh, and, uh, for argument's sake we'll say second recurrence or first recurrence, second episode, um, how are you going to address that? Um, one stage or two stage procedure and then timing, uh, of the second procedure. I mean, I, I do symptomatic side only. I don't know what you do. Uh, I would do both sides. If they, if I saw blood disease on both sides and I'm doing an operation. Same time. Same time. I would, I would Discuss it with the family, but I would do both sides. Yama on the symptomatic side. OK, Liam. Uh, we're not hearing you, Liam. Go ahead. Uh, I, I will do bilateral patch. OK, bilateral, which seems like we're having a split here. Giovanna? I do bilateral because I did in the past the symptomatic side only and I had a recurrence on the contralateral side during the immediate post-operative period, so I prefer to do bilateral now but I am looking to the importance of the lesion at the CT scan before. OK, so this, I mean this just, this makes the argument for getting a CAT scan if you're gonna do that because without a CAT scan you would never know that there was contralateral plebs, Marcello. I would, um, just treat the symptomatic one. We just have a patient like this right now at the hospital. If, if the patient is symptomatic, it's just the, that side. If it's just a CT scan, uh, observation and he's asymptomatic, we send him home with the, with the lips. Unless he has a pneumothorax, then we will treat it bilateral. OK. It looks like, uh, 70% of the audience, uh, would do the symptomatic side only. Someone had a comment? Yes. Thought I heard someone say something, OK. Um. Mark, do you have another, let's see what the last, I think this is additional workup. We probably don't need to touch on that much more, but I, I would, I would be curious as well, uh, technique. More and more people are using chemical pleurodesis instead of the mechanical pleurodesis and finding better results, shorter OR times, as well as decreased recurrence rates, and still there's a pretty high recurrence rate even after VATs with blebectomy and mechanical and or chemical pleurodesis. So, um, are people reinforcing staple lines? Are we using talk? Are we using, uh, um. A mechanical abrasion. Can I start with this one and then we'll go? I, so I learned from initially I used to use the little bovi pad thing which I don't think, I think it's fun, but I don't think it does anything. Steve, you taught me, I don't know if you still do this, where you actually really do a pleurectomy. You actually apical pleurectomy, apical pleorectomy, which. I loved and did for the last 5 years where I just would score it and pull it down caused a lot of pain. I don't know if you found that. Maybe it's my technique, but it seemed like when I would do that they would be hurting more than if I used talc. And when Scott Bollinger, my partner when I was at Rainbow, taught me this uh aerosolized talc. Do we have that here? Yeah, we've started to use and you just put the chest tube in, squirt it down the chest tube. It snows inside the chest, and you're done. It takes a second. I'm curious what, you still do that or? Oh, I don't, I don't like talc. OK. Cause I think you're doing a, a random massive, Chemical pleurodesis and you don't know if anybody's ever going to be, need to be in their chest again. But then what's the purpose of your apical pleur? Because it's only the apex. The apex of the lung. Oh, interesting. And I think. Putting talc in a kid is a bad idea. OK. Yeah, I save talc if I have a recurrence with the other approach. Right. But, which is, um, I actually use a hydrostatic pleurectomy. So, you can basically, this is a very cool technique. OK. So, you make a little, uh, incision in the pleura. OK. Um, and you put a suction irrigator into the opening. Yeah. And you, you seal the pleura around your suction irrigator. Yeah. And you irrigate. And it basically dissects the entire pleura. How does that help? And then you can grab it and, and you rotate. You just roll it up and you can basically dissect the whole pleura, OK, you know, even, even more than an apical pleurectomy. You get like a hemi. Thorax, pleura. Why is that better than talc? Uh, I don't know that it, uh, I think talc's probably better, but I think I agree with Steve, you know, you do talc in there and if you ever need a thoracotomy for anything, you're really solidly adhesed. Don't you think it would be with what you're doing too? Uh, uh, I don't know, not as much, I would hope. OK. And it wouldn't be the entire pleural space, you know, it's more the upper component of the lung. OK. Steve, when you do the apical pleurectomy, how far down? How many rib spaces down do you go? Oh, it's just a few. I mean, if it's just a, if I really see apical blebs, I'm only going down to like the third inner space. What if you get in and see no blebs at all? Your scope's in there and then no blebs at all. That's a tough problem. I always take the apex. So, yeah, I seal the apex with a ligature. Um-hum. Oh, really? And then I do an apical pleectomy. Yeah. Wait, so you just come across the apex with a ligature? I don't, I don't cut anything out. I just seal it. He, he can't resist ligature. Yeah, oh, is the patient ready to go? Is the patient? Sounds like the patient's ready to go. So finish up your beer. We might, uh, in 5 minutes we're gonna excuse those two, but then we're gonna hear, uh, Doctor Valenzuela. Actually, uh, we're good to go, right? I'm good. That was a great discussion. Thank you. We're gonna go on to Doctor Valenzuela. Can you hear me? Can you say hello? Say, can you hear me? Can you say something? We're not hearing you. All right. Hello. OK, we hear you. Perfect. Can you hear me OK? Yes, I can hear you very well, and Marco, you're coming to us from Santiago, no? Yes, perfect. OK, well, welcome and thank you for, thank you for your case and you very much. Thank you, uh, Stefan, can you pull up, uh, Doctor Valenzuela's, uh, difficult case? We have two, right, Marco? Well, I, I'm not sure if you finally received the two cases, but let's see. I think we did, so I think we were missing. We got the videos too, so we're going to pull up your case. I think which one do you want to do first, the Bronco player fistula. Perfect. We'll do that first. I, yeah, I would put that one first, OK. Sorry, but do, do, do you have the, uh, the slides? Yeah, can we go up the slides? Good, uh, yeah, the, the, the first slides, well. Go ahead. This is a, yeah, so this is a very interesting case that we had a few months ago here in my, in, in my hospital, in the Roberto del Rio Hospital in Santiago, uh, in a, in a patient with, uh, can you go, uh, please to the next slide? Yes, yes. Now we did Marco, we just gave you, uh, the, the ability to advance the slides if you click those arrows. Oh, good, thanks. Uh, so 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 well, and after months. Of, uh, that's deceased. OK. You can see a few margins 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 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 it, 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 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, this is like an orange, more or less inside. Hold on one second. Sorry, we're OK, yeah, now we see it better. So we explored this and we found. 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. Uh, 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, uh, 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. 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, uh, 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 the thickness of the of the lung tissue. You, you Can you go, uh, farther 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? 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 Yama, 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 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 pneumatoceless 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, 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 idiatic 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 did a first try archoscopically, but unfortunately all the lung tissue was very, um, you know, thicked 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 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 gonna go to the next case because we only have about 5, actually, yeah, Marco, we're gonna have to edit this case. So Liam, go ahead and give your comments. Uh, yes, the situation is very similar with the, the bronchial fistula after staphylococcal infection, I mean, pneumonia due to staphylococcus, and, of course, from emyma. So in our practice, we only perform a thoracoscopy to remove membrane to allow the The lung is bent, and I think that is very important, uh, otherwise difficult to, to, to heal with 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 do 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 have a question, Steve left, but 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 it 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 2nd 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 that. It's uh 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 bronchiies, because you have three sizes. There's a large size with a plier. That unfortunately it is 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 just apply a proximal clip just in case when the ligature, 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 hema lock 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. Stapers are very expensive for us, right, right. Any other comments? I have a question. Yes. 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.