Thoracic

Aim of the Study

Pectus carinatum has traditionally been treated using surgical techniques but conservative orthotic management is increasingly popular. We reviewed our experience, 4 years after establishing a multidisciplinary clinic for managing pectus carinatum using a compressive orthotic device.

Methods

A retrospective analysis of clinic records was performed to determine outcomes. Patients were referred to the multidisciplinary clinic after review in the general outpatient clinic on two occasions by a surgeon with an interest in chest wall deformities.  Patients from out of region were assessed by two telephone consultations and photographs.  Patients had a final assessment for motivation and compliance with bracing on their first attendance at the bracing clinic prior to measurement. Patients were followed in the clinic until they and the clinic team were happy they had achieved full correction, they decided to give up with bracing or were lost to follow up.

Main Results

78 patients have been fitted with a brace.  23 have successfully completed treatment, 24 are currently in active treatment, but 31 did not complete treatment. Reasons for discontinuing treatment are detailed in the table. No patients were referred back to the clinic due to recurrence of their pectus carinatum after successful completion of treatment.

Reason for discontinuing treatment	Number of patients
Did not return after fitting	12
Brace uncomfortable	8
Brace distressing	1
Requested surgery	2
Lost to follow up	5
Happy with appearance	3

 

Conclusion

Bracing is an effective treatment for pectus carinatum provided adequate compliance is achieved.  Our patient population demonstrates a very high dropout rate despite careful assessment and education of patients and families prior to enrolment into the bracing programme. Further evaluation of these findings is required to identify factors to improve patient selection and compliance

Aim: Surgical repair of chest wall deformities, using the Nuss or modified-Ravitch technique can be associated with significant post-operative pain.  Thoracic epidurals have previously been the mainstay of perioperative analgesia in our centre, however these are invasive procedures and can be associated with significant complications. Continuous peripheral nerve blockage using local anaesthetics via wound infusion catheters (WICs) can be an effective alternative.  However, recent reports have suggested that surgical site infection (SSI) rates of up to 30% may be seen when used alongside chest wall surgery.

The aim of this retrospective study was to determine whether the change from epidural analgesia to WICs has been associated with any increase in SSIs following chest wall surgery.

 
Methods: All patients undergoing a modified-Ravitch procedure from April 2014 to October 2017 were identified. Demographic, operative, anaesthetic and complication data were collected. The primary outcome measures were documented SSI and removal of metal support bars.  Data are presented as median (interquartile range) unless specified otherwise. Fishers’ exact test was used for categorical data and Mann-U Whitney for non-parametric continuous data, significance was set at p=0.05.

Results: 24 modified-Ravitch procedures were performed for both pectus carinatum (11/24) and excavatum (13/24) deformities, at a median age of 15.8 (15.4-17) years.  Metal support-bars were placed in 13 patients (8 with WICs).   12 patients received epidural analgesia and 12 had WICs. Median follow-up was 5.8 (3.9-8.9) months. There was no significant difference in length of stay (p=0.6) or duration to switch to oral analgesia (p=0.3) between the two groups. Two SSIs were recorded in the study period, one superficial wound infection and empyema, both in the epidural group. No metal implants required removal for infection.

Conclusion: In our series, WICs are a safe and efficacious alternative to thoracic epidurals following chest wall surgery with or without metal implants.

Aim of the study:

The optimal age for correction of pectus excavatum with the Nuss procedure is debated. Recent publications suggest inferior results in prepubertal children although earlier correction was historically thought to be preferable. The majority of our corrections are done post puberty with good cosmetic results. Concerned that outcomes were poorer in prepubertal patients, we reviewed our 18-year experience.

Methods:

Retrospective cohort study of patients under 13 years old who underwent treatment for pectus excavatum by the Nuss procedure. The indication was cosmetic in all cases.  Patients records were scrutinized for Haller index, age (years), length of stay (days), complications, duration of bar placement (months), length of follow-up, cosmetic outcome (satisfactory or unsatisfactory) and need for further corrective surgery.

Main Results:

Ninety-two children underwent pectus repair during the period 1997-2015. Twenty-one (23%) patients were <13 years (14 male). Full information was available for 19. Median age at bar placement was 10years (7.8-12.5). Haller index was 4.2±0.8. One bar was placed in all patients. Length of stay post insertion was 7 days (5-15). Four patients (21%) experienced early complications: pneumothorax requiring chest drain (n=2; 10%), and pneumonia (n=1; 5%).  Median duration of bar in situ was 24 months (23-33). Three patients experienced late complications: chronic wound infection (n=1; 5%), local reaction to implant (n=1; 5%) and pain (n=1; 5%).

Overall the operating surgeons felt the cosmetic result, after bar removal, was satisfactory in only 36% of patients (n=7). Follow-up was 19 months (2-48).  Further corrective surgery was undertaken or being considered in 3 (16%) patients.

Conclusion:

Outcomes in prepubertal children undergoing pectus bar placement for repair of pectus excavatum in our centre have been disappointing. Encouraging children (and their parents) to wait until after puberty for corrective surgery may be in their best long-term interest.

Aim of the study: We compared the severity of the lesion and long term outcomes in patients who were treated with Nuss thoracoplasty with patients who had no treatment.

Methods: Hospital records of 140 patients referred for treatment of funnel chest from 2001 to 2016 were reviewed. Main indication for surgery was cosmetic appearance. Eighty-five (61%) patients underwent Nuss procedure and 55 (39%) received no treatment. Outcome was measured with Nuss, psychometric (SLC-90) and quality of life (SF-36) questionnaires and spirometry.

Results: In surgical patients male/female ratio was 75/10 and in non-treated patients 40/15 (p=0.02). Median age at surgery was 16 (IQR 15-17) years, patients with no treatment were evaluated at a median age of 14 (IQR 12-15) years. Median Haller index was 5.0 (IQR 4.0-6.5) in surgical patients and 3.2 (2.6-4.2) in non-treated patients (p<0.0001). At initial evaluation 33 (38%) surgical patients and 9 (16%) of non-treated were symptomatic (p=0.005). Spirometry values did not differ between surgical and non-treated patients. Median follow-up was 7.3 (IQR 3.6-11) years. Of surgical patients 40 (47%) and of non-treated 14 (26%) returned the questionnaire and of these 12 (30%) and 4 (29%) had spirometry. At follow-up questionnaire scores and the spirometry results did not differ statistically significantly between surgical and non-treated patients. Symptoms at initial evaluation were not related with scores at follow-up.  

Conclusion: Children who underwent surgical treatment for funnel chest had more severe lesions, were more often symptomatic and of male gender than patients who received no treatment. Outcomes in surgical and non-treated patients were similar.

TABLE 1. Nuss evaluation, psychometric SLC-90, quality of life SF-36 questionnaires and spirometry at follow-up

 

Aim
Tracheomalacia is caused by flaccidity of the tracheal wall leading to tracheal collapse, particularly on expiration. Often it requires no treatment but when severe can warrant surgical intervention. Aortopexy is one surgical option and has been described using a variety of approaches.

We aim to report outcomes of aortopexy performed via a suprasternal incision in a single centre, by a single surgeon. 

 

Methods
All patients undergoing aortopexy between February 2016 and January 2018 were prospectively included.  Patients were managed by a multi-disciplinary team (MDT) comprising ENT, paediatric and cardiac surgeons, paediatric intensivists, cardiologists and respiratory physicians. All underwent standardised work-up including dynamic flexible bronchoscopy (DFB) and contrast enhanced CT. Aortopexy was performed via a suprasternal skin crease incision.  Surgery was guided by intra-operative flexible bronchoscopy.

Data regarding pre-operative symptoms, degree of tracheomalacia and outcomes were recorded.

 

Main results
Eighteen patients were included, 14 boys, median age 5 months (range 1 month – 5 years). Underlying diagnoses and outcomes are as in the table.  Two aortopexy sutures were used in all cases, three patients required an additional tracheopexy suture. Median operating time was 1 hour 24 minutes (range 47 minutes – 2 hour 35 minutes). Median pre-operative tracheal collapse on DFB was 85% (range 80-95%), improving to 35% (35-80%) intra-operatively. Median post-operative length of stay was 5 days (range 1-118).  

Conclusions
Aortopexy via a suprasternal incision is a useful treatment modality for tracheomalacia with short operating times and rapid recovery.

Outcomes vary with the best results in the TOF and premature groups.  Careful patient selection and MDT work-up are essential to optimise outcomes.

Pre-operative diagnosis (n)	Outcome (n)
	Symptom free	Improved	No change
TOF (7)	3	3	1
Premature birth (4)	3	1	0
Syndromic (3)	0	0	3
Others (4)	1	2	1

Aim of the study:

Lung biopsy in children is an invasive technique associated with significant morbidity.  However, it offers histological evidence to aid diagnosis. The aim of this study is to determine the diagnostic accuracy of paediatric lung biopsies and to identify the preoperative factors that influence the efficacy of lung biopsy.

 

Methods:

A retrospective review of all diagnostic lung biopsies in children from January 2007 to December 2017 was performed. Therapeutic resections were excluded. Data were collected from clinical coding, patient records, histology reports and operation notes. The indications, techniques and diagnostic accuracy for each biopsy were collated.  

 

Main Results:                                                                                           

Thirty nine patients were available for this study. Median age at biopsy was 3.5 years (range= 7 days – 15 years). Male to Female ratio was 7:6. Open procedures were performed in 35 patients compared to 4 which were thoracoscopic (10%). Indications were suspicion for neoplasm (26%), infection (41%), interstitial lung disease (23%), abnormal infiltrative chest x-ray (10%). Lung biopsy was diagnostic in 25 (64%), inconclusive in 12 (31%) and normal parenchyma found in 2 (5%). Diagnostic accuracy (positive or negative for malignancy) was highest in the neoplastic group (90%) and lowest in the infiltrative x-ray group (50%). If preoperative investigations indicated a particular diagnosis, lung biopsy was confirmative in 77% of cases. However, if preoperative investigations were inconclusive and the biopsy was performed to aid diagnosis, the histology results in 63% of cases were inconclusive as well.

 

Conclusion:

In our cohort, lung biopsy mostly confirmed the preoperative diagnosis. However, in a significant number, the diagnosis was inconclusive. It is infrequent to diagnose a new condition on lung biopsy which was not suspected preoperatively. Careful patient selection is recommended to maximise diagnostic yield.

 

Background - Anterior mediastinal masses (AMM) pose diagnostic challenges of exaggerated cardiorespiratory risks during anaesthesia for biopsy. We reviewed our institutional practice to assess the safety of our approach. Methods - Retrospective review of patients with AMM at a single tertiary paediatric surgical oncology centre (January 2011 -December 2016). Data analysed on clinical presentation, mode of tissue diagnosis, anaesthetic techniques and complications. Results – Of the 44 patients (median age 11 years, 27 male) admitted with AMM, 22 had respiratory symptoms. Imaging confirmed tracheobronchial compression in 26 children. Histology included Hodgkin’s lymphoma (16), non-Hodgkin’s lymphoma (14), leukaemia (9), lipoblastoma (1), teratoma (1), PNET (1), rhabdomyosarcoma (1) and mediastinal metastasis from nasopharyngeal carcinoma (1). Twenty patients had a lymph node biopsy. Pleural fluid and peripheral blood film confirmed diagnosis in 4 and 7 patients respectively. Ten patients had image-guided core biopsy of mediastinal mass and 2 had mediastinoscopic biopsy of paratracheal lymph node. One patient with likely metastatic recurrence of a relapsed ethmoid carcinoma did not have tissue diagnosis. We assessed the 25 anaesthetics performed in our hospital. Spontaneous breathing was maintained in 18 patients (2 had pressure support or CPAP, 3 had supraglottic airway) and 7 controlled ventilation (6 with an endotracheal tube). Spontaneous breathing patients had ketamine (13), ketamine and midazolam (3), ketamine and propofol (1), propofol (1), inhalation anaesthetic (2) and local anaesthesia (1). There were no anaesthetic complications. There were 11 planned PICU admissions. Four patients needed admission to PICU for tumour lysis syndrome. Two patients needed a repeat node biopsy (1 post steroid and 1 inadequate sample). Conclusion- Safe tissue diagnosis of anterior mediastinal masses can be obtained by a personalised multidisciplinary approach. Use of alternative tissues, local anaesthesia and ketamine sedation helps reduce the need for general anaesthetic, muscle paralysis and controlled ventilation.

Aims

A growing body of literature suggests that the presence of a hernial sac (HS) in newborns with congenital diaphragmatic hernia (CDH) may improve prognosis. By examining a large cohort of CDH babies admitted to our centre we aimed to establish if the presence of HS is a robust independent predictor of improved survival.

Methods 

All CDH patients admitted to a single centre were recruited. Post neonatal presentation and Morgagni hernias were excluded. Demographics, defect type, laterality, survival and recurrence were recorded.

Results  

192 CDH cases were managed in a 20 year period during 1997 - 2017. Ten babies had Morgagni hernia and 29 remaining cases diagnosed beyond the neonatal period were excluded. Analysis was undertaken in 153 newborns with Bochdalek hernia. There were 53 females giving a statistically significant male to female preponderance with a ratio of 1.89 (p = 0.0002 , Binomial test). Twenty two (14%) newborns had a HS. Survival with a HS was 21/22 (95%) vs 108/131 (82%) without HS ; non significant (p = 0.20, Fisher's Exact Test). No difference(s) in HS incidence were identified by sex  (M:F 15% vs 13.2%, p = 0.81, Fisher's Exact Test). Subgroup analysis according to gender found the presence of HS showed a consistent trend towards improved overall survival in both sexes (100% vs 87% in females, 93% vs 80% in males ). 

Conclusion

Like early published studies recording a significant survival advantage with the presence of a HS we herein demonstrate a trend towards improved survival for CDH patients with a HS. These findings were also consistent between sexes. Future multicentre studies and registry(s) may provide additional data to fully answer this hypothesis. 

 

Aim of the Study

Multiple biomaterials, both novel and combinations of pre-existing materials are employed in patch repair of congenital diaphragmatic hernia (CDH).  This systematic review aims to evaluate current practice and outcomes of biomaterials used in patch repair of CDH.

Methods

All paediatric CDH cases were included in the literature review using PUBMED and MEDLINE up to January 2018. The specific search criteria used were: “congenital diaphragmatic hernia (CDH) patch repair”, “CDH prosthetic materials”, “CDH biomaterials” and “CDH recurrence”.  Only publications that explicitly reported patch repair, material used and recurrence data were included.

 

Main Results

Forty-three papers were analysed (n= 3013 patients) of which n=1423 (47.2%) were managed with 14 types of patch. Goretex^TM (GTX) (n=651) was most frequently employed followed by Surgisis^TM (n=140), Marlex/GTX (n=46), Tutoplast dura^TM (n=40), Dacron^TM(n=34), Dacron/GTX (n=32), Teflon^TM (n=24), Permacol^TM (n=24),  SIS/GTX (n=15), Marlex^TM (n=9), Alloderm^TM (n=8), Silastic^TM (n=3), Collagen Coated Vicryl Mesh- CCVM (n=2).

Biomaterials were further subgrouped:  Synthetic non-resorbable (SNOR) (n=721), Natural-resorbable (NR) (n=215), Combined natural and synthetic-resorbable (NSR) (n=2) and Combined natural and synthetic non-resorbable (NSNOR) (n=93).

Recurrences were lowest with Marlex/Goretex (2.2%) followed by Teflon^TM (4.2%), Dacron^TM (5.9%), Permacol^TM (16.7%), Tutoplast dura^TM (17.5%), Marlex^TM (22.2%), SIS/GTX (26.7%), GTX (18.6%), Silastic^TM (33.3%), Dacron/GTX (37.5%), SIS (37.1%), Alloderm^TM(50%), and CCVM and Dermamatrix^TM (both 100%).

When analysed by biomaterial groups recurrence was highest in NSR (100%), followed by NR (32.6%), NSNOR (18.3%) and SNOR the least (17.6%).

Conclusion

In this cohort, approximately half of CDH repairs utilised a patch. To date, 14 patch types/variations were used. GTX is the most popular, employed in almost half of the patients (45.7%); however GTX/Marlex is associated with least recurrences (2.2%).  SNOR was the material type least associated with recurrence while NSR experienced recurrence in every instance.