Thoracoscopic Right Lower Lobe Cystic Lesion Excision: Update Course 2014

We have time. It's a quick 3 minute video. I thought the audience, this is this child's thoracoscopic lobectomy. So this is a 3 month old, 5 kg baby. So there's a huge amount of space in here. I mean, space is not an issue. These are 3 millimeter instruments. This child ended up actually having an unseen sequestration associated with it. You can see the sequestration sitting down along the lower lobe right at the inferior pulmonary ligament. Um, this is, this kid had an incomplete fissure, and already what you'll see at 3 months as we open up the fissure and. We're using ceiling technology here to open it, but you can already see the enlarged lymph nodes. You can see that large lymph node right in the major fissure, and I will tell you I've seen a number of kids who are totally asymptomatic, 9 months to 1 year of age. You get in there and the lymph nodes are massive, and the inflammation in the fissure is massive, and it's not that you can't do the operation, it's just it makes it more difficult. In this kid, there's larger lymph nodes, but it's easy to dissect. Samir Pandia is anxiously waiting to see, are you going to take it. With a 5 millimeter stapler, you're going to take it with a clip. The bronchus. Well, in this particular case, I did not have the 5 millimeter stapler. That's what I've done. I've done since when I did this case. The stapler wasn't available yet, but this is a 3 millimeter sealer, and you can see how easy it is to dissect out all the vessels. There's no inflammation. This operation with the fellow. Assisting and doing about half of it took about 90 minutes and the vessels are small, so the sealer will take vessels, 3 millimeter sealer will take vessels safely up to 5 millimeters. So all these vessels fit within that, so we're able to just seal them and divide them easily. The dissection is easy and again I'll just tell you. Out of pure volume and experience, when you wait and do even these asymptomatic kids around a year of age, this dissection becomes much tougher because there's a, there's often a lot of inflammation in it. You will ask the parents and they say they never had had so much as a cold, let alone a chest infection or anything they needed to deal with. That's not every case, but it certainly happens. Uh, what we're doing here is just because we didn't have a 5 millimeter stapler, so this is the superior segmental bronchus to the, to the, um. Lower lobe, and we're taking that separately and then we take the basal trunks. Um, and in this case, again, at this age, you can safely use clips. It's just like using, uh, you know, if you go to the segmental, um, level and take them, uh, and then, um, Um, and I generally will take in a lower lobe, we'll take the bronchus first, and then that just leaves the, the vein exposed, um, and makes it, uh, quite easy to get at. Um, these are, you can see, if you're used to doing endoscopic surgery in babies, there's a huge amount of space, and, and it's, and movement is not a problem. It's all about the setup, and there's the vein being exposed. Um, and we'll just seal that and take it as well. Um, at the end of the case, we simply morsellate the specimen through the trochar site, so we take it out, uh, piecemeal. Um, it's hard to get any kind of bag in here, especially with a specimen that's big. That is one of the difficulties. So, I would say that when I trained. I did the same thing that you described, waiting a little longer. When I went to Steve's place, I thought it was going to be a Steve-ism, like, oh, you could do it at, you know, 3 months, and I thought that's just because Steve could do it at 3 months. But the truth is this does not at 3 months does not feel like a limited space operation. I think that at 3 months you get good lung collapse. It's, I never felt like I wish I had more space, but the vessels are small. It's a nice, easy dissection, so I actually am a believer now. And that it's easier to do it when they're smaller. And sure, I mean, I didn't have a lot of problems when I waited to 9 months. I just felt comfortable. But if it's easier, I'm not going to mind that. And you know, Dan Elley on, on the chat also said it's, uh, I'll quote him here, it is not even comparable. 3 months is way easier. So it sounds like there's, that's fine with me. If something's easier, I'll take it. So, so let me ask Benno or or Philip or anyone else on the virtual faculty, does anyone Have any, uh, do you guys do things differently, especially the guys, do you, are you more the, uh, the watch and wait or would you operate on these kids? We had extensive discussion in Europe also about this, and there are different approaches. In the Netherlands, the attitude is much more conservative than in Germany, for example, and we in my place, we operate 3 to 6 months of age, any kind of this lesion, any kind of cystic lesion because of potential malignancy later on. And we also think that the operation is most easily done when the patients are about 3 to 6 months of age, as Steve says. So there's not much difference to that. I knew I liked Benno for a reason. Philip, do you do anything different in Lucerne? No, we use the same devices and we have tried just to comment on the stapler. We have tried the stapler. It just didn't work properly. Oh, wait, wait, wait, you know, be very careful about this. You're not talking about the same stapler I am, so I know there are different devices, but just a comment to be cautious with any device or stapler. I agree, but it's a different stapler. What did the upper lobe look like when you got done? Was that normal? Yeah, it looked totally normal. What would happen if you saw in the lower part of the upper lobe? What would you do? So that's happened occasionally. If I could do a segmental resection at the same time, but I, I, I would do an anatomic segmental resection, and I think that's key. And we printed up a series, um, uh, that uh. We got, we printed up a series of segmental resections and we're following those in cases that on CT scan and at the time of surgery looked to be limited to just an anatomic segment, uh, but one child has shown evidence of recurrent disease, cystic disease, um, and, but that, but I am concerned and I've had a case where I went in. And I thought it was a lower lobe CPAP, and the child ended up having no fissure. I mean, it was just one giant lobe, and I had to do kind of a bi-segmental resection, and that child has had recurrent cystic disease, but I couldn't do anatomic resection. So I don't know that I can recommend that to everybody, but I think it is important to to keep in mind. I just want to, can we go back one slide? Mark, we go back the clickering. Yeah, no, no, goes forward there. So I just want, so, no, go back. There you go. So the surgery was uncomplicated. The chest tube was removed on post-op day 2. could have been removed on post-op day 1. The child went home on post-op day 3. But what's interesting here is that the path is that it showed lung tissue with cystic congenital pulmonary airway malformation, type 1 and type 2 changes, but with exuberant neoplastic mutagegenic proliferations and bronchial margin is negative, and this is a finding that I had actually not seen reported before. Um, I will tell you, in my, I've done about a little over 300 lobectomies for cystic lung disease. Some of those have been out of the country, so I don't have really good follow up. I've had two pulmonary blastomas and one adenoCA that, that I know of. But this is a new finding, and this is, um, maybe associated with the CRASS mutation, which is, um, also a marker in adult small cell, um, carcinoma. As well as colon cancer, um, and now this is at Columbia, and they're going back and review it and they found 4 others with this. So we get into the discussion about, um, you know, when and why to operate. So I believe the literature fairly clearly shows that 30-40% of these kids who have this kind of cystic lung disease will have a significant pulmonary infection at some point during their life. Um, and that's often how we used to diagnose these before it was prenatally diagnosed. Once these lesions become infected, they're much more difficult to do that. This, I think, and, you know, I think all these operations personally should be done thoracoscopically at this point. Getting to your point is, you know, there are many good centers who do that now, and if you can't do it, maybe you ought to send them to a center who can because I think avoiding the morbidity of a thoracoscopy, a thoracotomy. Um, especially when you do it young, young in life, the one thing we don't really have are good pulmonary function studies that show long term that we've actually, we need to do that to document that if you take a low bout, we all say if you take a low bout, it's an infant, that the rest of the lung will grow, they'll compensate. They really don't have any significant disability from that, but we should do the studies to, to show that. But if they become infected, they're much more difficult. Um, and then I think, uh, this risk of malignancy and now with this possibility of a new mutation being identified, so in my personal series incidence, it's almost 2%, certainly 1%, um, but it may be 2%. So I, I kind of open up the discussion about real quick, real quick discussion. I think that that actually I just like to ask you a little bit about that because I think If one of the indications for doing the lobectomy is risk of malignancy, which I agree with, then Um, the fact that you're morselating the tissue to pull it out raises some concerns. And are those things a contrary, are those sort of competing interests? Maybe should we not be morselating? Should we be putting them in a bag, right? So it's a good, it's a good point. So in the cases that we've done, the the, the hematologist, oncologist has said by doing that, we've not upgraded the tumor and that it doesn't change the treatment and nobody's getting chemotherapy or anything else, but we are watching those kids. But it is a reasonable point. You know, should we, now, it's hard to know because you never know. You don't know those kids. It would be difficult in, in a lot of these kids to get that specimen in a bag, um, especially if you're doing them early like we are. Um, that is, but it's a, it's a good point. Steve, what's the, uh, you said you saw 3 tumors in 300 cases. So that's much less than 1% incidence of cancer. It's 1%. It's 1, you know, 3 of, it's, it's 1% incidence. But if these mutations, you know, if this is, now I'm including these cases now, 4 cases that I know of that have this, may have this CRA mutation, and there needs to be more work done. But again, it's the morbidity of the procedure versus you take that plus a 40% chance of infection versus the morbidity of the procedure in the long term, um, issues associated with it. But I mean, that's where the debate comes in, right? That's where the tumor of the kids, the blas and the adeno all year of age. So let's, we can continue this conversation online. We're gonna, that's a great, uh, great job Steve. Thanks.