VIDEO-ASSISTED THORACOSCOPIC SURGERY (VATS) IN CHILDREN

O.Brankov, H.Shivachev, R.Drebov, M.Panov, N.Gavrilova Department of pediatric surgery University Hospital Pirogov Sofia, Bulgaria

Clinical material
PERIOD - may 2003 mart 2005 77 children Age - 10 m - 18 y 57 children with empyema 17 children with spontaneous pneumothorax 3 children with mediastinal masses

SPONTANEUS PNEUMOTHORAX (n = 17)

age 13 - 18 y 16 boys : 1 girl 9 children (52,9%) with 11 VATS procedures 8 children with percutaneous drainage pig-tail

SPONTANEUS PNEUMOTHORAX
Right sided pneumothorax - 1 pt Leftsided pn - 6 pt Bilateral pneumothorax - 2

Initial incident - 3 Recidives: one - 2 two - 3 three and more - 1

According to the classification of Vandershueren RGJRA (1990) gr (without any changes) - 0 gr (fibrous dystrophic changes) - 2 gr (multiple blebs) 0 V gr (single bullaes, blebs or adhesions ) - 7

Classification
Tamura M et al ( 2003)

- small single bleb - 1 - multiples large bulla - combination of dispersed bulla 6

Dystrophic changes are excluded

Surgical tactic

Diffuse dystrophic changes pursestring suture with Endo-stitch Polisorb 3/0, partial apical pleurectomy and fibringlue adhesion (Tissucol) Single or multiple blebs excision and suture with Endo-stitch Polisorb 3/0, pleural abrasion and fibrin glue adhesion

Suture of the blebs n = 7

Pleural abrasion n = 7

Apical pleurectomy n = 2

Fibrin glue insufflation

Results

Operative time:

Unilateral VATS - 35 - 55 min Bilateral VATS- 85 - 115 min

Average pleural drainage time - 3,2

days

(3 5)

Average hospital stay

5,4 days (5 - 7)

Results
Follow-up 5 - 22 months Without recurrence - 8 Recurrent pneumothorax after 8 months N=1
Thoracotomy, apical resection, partial pleurectomy

Thoracic empyema
Frequency in children - 0,4-6 1000 (Grewal H et al,1999) 2 - 5 % parapneumonic complications
40 50 % of all empyemas are consequence of complicated bacterial pneumonia (Oak S et al,2003)

The parapneumonic pleural complication is divided on three stages that are not sharply distinct but gradually one phase merges into another

Exudative stage ( 1 - 3 days) Exudate pH> 7,3, Gl > 60 mg/dl, LDH<1000 IU/l, negative culture Fibrino-purulent stage ( 4 - 14 days ) Purulent fluid with pH<7,1; Gl< 40mg/dl; LDH>1000U/l., positive culture of microorganisms Organizing stage ( after the 14 day ) Fibro-blasts grow into exudates, producing the peel and restricting lung movement (Light RW 1985)

Clinical material

57 children 17 with VATS and 40 with conventional thoracotomy age 10 months - 17 years

0 - 1 3,5% 1 - 7 59,6% 7 - 17 36,9%

32 boys : 25 girls

Term of admission after onset of disease - treatment approach

Up to 10 day (26 pts) transcutaneous pig-tail or tube thoracostmy 100 % From 10 to 20 day (20 pts) 60 % tube thoracostomy and 70 % VATS (primary 40 % ; secondary 30 %) After the 20 day (13 pts) 30 % primary VATS; 70 % thoracotomy)

Indication for VATS

All cases of II and III degree Multiloculated effusion Ineffective pleural drainage Separated empyema

Relative contraindication: fibrothorax, requiring open thoracotomy

DEBRIDEMENT, SANATIO 15 children

DECORTICATION- 2 children

pig- tail

tube drainage

VATS

Thoracotomy

19
33,3% Redo tube drainage Average drainage time Secondary thoracotomy Redo thoracotomy Average drainage time Average hospital stay

16
28,1%

17
29,8%

5
8,8%

3
7

5
10,9 5,4

5
(31,2%)

4
(23,5%)

1 (6,2%) 16 14,8 27

3,8 10,5

10,4 17,4

Biopsy of mediastinal masses

Operating time 35 min Duration of the drainage 24 h Hospital stay 3 days 100% confirmed diagnosis (Comparatively the percutaneous needle biopsy has only 28% diagnostic significance)

ADVANTAGES OF VATS

Less traumatic method Exact diagnosis Decreased postoperative complications Low duration of drainage Comfortable postoperative period Early rehabilitation Shorter hospital stay