# Thoracoscopic Lung Resection — GCMD Library living collection Updated: n/a · 39 episodes · 298 cited statements ## Episodes ### Congenital lung lesions: evaluation and timing - [Postnatal Management of Lung Lesions Part III: Pediatric Thoracic Surgery...](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418) — video · 27:56 · [machine version](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418.md) - [Postnatal Management of Lung Lesions Part II: Pediatric Thoracic Surgery...](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419) — video · 25:07 · [machine version](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419.md) - [Postnatal Management of Lung Lesions Part I: Pediatric Thoracic Surgery Part...](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420) — video · 31:07 · [machine version](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420.md) - [Management of Asymptomatic Lung Lesions: Pediatric Thoracic Surgery Part...](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883) — video · 20:11 · [machine version](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883.md) - [Congenital Cystic Lung Lesions: Update Course 2014](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643) — video · 24:39 · [machine version](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643.md) - [Should We Resect Asymptomatic CPAM Flake vs Langer](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391) — video · 14:03 · [machine version](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391.md) - [Lobectomy for CPAM](https://qa.library.globalcastmd.com/video/11935) — article · [machine version](https://qa.library.globalcastmd.com/video/11935.md) ### Lobectomy, lobe by lobe - [Technique: Right Upper Lobectomy](https://qa.library.globalcastmd.com/watch/technique-right-upper-lobectomy-947) — video · [machine version](https://qa.library.globalcastmd.com/watch/technique-right-upper-lobectomy-947.md) - [IPEG Academy: Thoracoscopic Right Upper Lobectomy](https://qa.library.globalcastmd.com/watch/ipeg-academy-thoracoscopic-right-upper-lobectomy-8889) — video · [machine version](https://qa.library.globalcastmd.com/watch/ipeg-academy-thoracoscopic-right-upper-lobectomy-8889.md) - [Thoracoscopic Right Upper Lobectomy in a 3-Month-Old with Incomplete Fissures](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-upper-lobectomy-in-a-3-month-old-with-incomplete-fissures-11956) — video · 20:17 · [machine version](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-upper-lobectomy-in-a-3-month-old-with-incomplete-fissures-11956.md) - [RUL](https://qa.library.globalcastmd.com/watch/rul-11957) — video · [machine version](https://qa.library.globalcastmd.com/watch/rul-11957.md) - [Technique: Right Middle Lobectomy](https://qa.library.globalcastmd.com/watch/technique-right-middle-lobectomy-1007) — video · [machine version](https://qa.library.globalcastmd.com/watch/technique-right-middle-lobectomy-1007.md) - [IPEG Academy: Thoracoscopic Right Middle Lobectomy](https://qa.library.globalcastmd.com/watch/ipeg-academy-thoracoscopic-right-middle-lobectomy-8890) — video · [machine version](https://qa.library.globalcastmd.com/watch/ipeg-academy-thoracoscopic-right-middle-lobectomy-8890.md) - [Right Middle Lobe 7 min](https://qa.library.globalcastmd.com/watch/right-middle-lobe-7-min-11959) — video · [machine version](https://qa.library.globalcastmd.com/watch/right-middle-lobe-7-min-11959.md) - [Technique: Right Lower Lobectomy](https://qa.library.globalcastmd.com/watch/technique-right-lower-lobectomy-1008) — video · [machine version](https://qa.library.globalcastmd.com/watch/technique-right-lower-lobectomy-1008.md) - [Technique: Intralobar Right Lower Lobectomy](https://qa.library.globalcastmd.com/watch/technique-intralobar-right-lower-lobectomy-975) — video · [machine version](https://qa.library.globalcastmd.com/watch/technique-intralobar-right-lower-lobectomy-975.md) - [IPEG Academy: Thoracoscopic Right Lower Lobectomy](https://qa.library.globalcastmd.com/watch/ipeg-academy-thoracoscopic-right-lower-lobectomy-8891) — video · [machine version](https://qa.library.globalcastmd.com/watch/ipeg-academy-thoracoscopic-right-lower-lobectomy-8891.md) - [Thoracoscopic Right Lower Lobe Cystic Lesion Excision: Update Course 2014](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041) — video · 11:24 · [machine version](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041.md) - [JRS RLL short](https://qa.library.globalcastmd.com/watch/jrs-rll-short-11921) — video · [machine version](https://qa.library.globalcastmd.com/watch/jrs-rll-short-11921.md) - [RLL 2020 3 mo old](https://qa.library.globalcastmd.com/watch/rll-2020-3-mo-old-11953) — video · 16:38 · [machine version](https://qa.library.globalcastmd.com/watch/rll-2020-3-mo-old-11953.md) - [RLL extralobar JRS](https://qa.library.globalcastmd.com/watch/rll-extralobar-jrs-11954) — video · [machine version](https://qa.library.globalcastmd.com/watch/rll-extralobar-jrs-11954.md) - [RLL vein PAPS](https://qa.library.globalcastmd.com/watch/rll-vein-paps-11955) — video · [machine version](https://qa.library.globalcastmd.com/watch/rll-vein-paps-11955.md) - [Technique: Left Upper Lobectomy](https://qa.library.globalcastmd.com/watch/technique-left-upper-lobectomy-1005) — video · [machine version](https://qa.library.globalcastmd.com/watch/technique-left-upper-lobectomy-1005.md) - [Technique: Blinded Left Upper Lobectomy](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006) — video · 4:28 · [machine version](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006.md) - [LUL CLE IPEG v2](https://qa.library.globalcastmd.com/watch/lul-cle-ipeg-v2-11929) — video · [machine version](https://qa.library.globalcastmd.com/watch/lul-cle-ipeg-v2-11929.md) - [Thoracoscopic Left Lower Lobectomy Technique by Dr. Steven Rothenberg: How I...](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977) — video · 18:52 · [machine version](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977.md) - [Left Lower Lobectomy for Sequestration: Pediatric Thoracic Surgery Part...](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922) — video · 35:45 · [machine version](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922.md) - [IPEG Academy: Thoracoscopic Left Lower Lobectomy](https://qa.library.globalcastmd.com/watch/ipeg-academy-thoracoscopic-left-lower-lobectomy-9313) — video · [machine version](https://qa.library.globalcastmd.com/watch/ipeg-academy-thoracoscopic-left-lower-lobectomy-9313.md) - [LLL Bronchus](https://qa.library.globalcastmd.com/watch/lll-bronchus-11926) — video · 0:11 · [machine version](https://qa.library.globalcastmd.com/watch/lll-bronchus-11926.md) - [LLL for metastatic Osteosacoma](https://qa.library.globalcastmd.com/watch/lll-for-metastatic-osteosacoma-11927) — video · 6:17 · [machine version](https://qa.library.globalcastmd.com/watch/lll-for-metastatic-osteosacoma-11927.md) - [LLL intra lobar JRS](https://qa.library.globalcastmd.com/watch/lll-intra-lobar-jrs-11928) — video · 4:50 · [machine version](https://qa.library.globalcastmd.com/watch/lll-intra-lobar-jrs-11928.md) - [Left Lower Lobe](https://qa.library.globalcastmd.com/watch/left-lower-lobe-11932) — video · [machine version](https://qa.library.globalcastmd.com/watch/left-lower-lobe-11932.md) - [pulm artery LLL](https://qa.library.globalcastmd.com/watch/pulm-artery-lll-11995) — video · 0:09 · [machine version](https://qa.library.globalcastmd.com/watch/pulm-artery-lll-11995.md) - [lobectomy](https://qa.library.globalcastmd.com/watch/lobectomy-11986) — video · 0:59 · [machine version](https://qa.library.globalcastmd.com/watch/lobectomy-11986.md) - [PAPS stapler lobectomy 2016](https://qa.library.globalcastmd.com/video/11949) — article · [machine version](https://qa.library.globalcastmd.com/video/11949.md) ### Lung biopsy - [Lung bx 17 yo](https://qa.library.globalcastmd.com/watch/lung-bx-17-yo-11936) — video · [machine version](https://qa.library.globalcastmd.com/watch/lung-bx-17-yo-11936.md) - [Lung bx 5mm stapler](https://qa.library.globalcastmd.com/watch/lung-bx-5mm-stapler-11937) — video · [machine version](https://qa.library.globalcastmd.com/watch/lung-bx-5mm-stapler-11937.md) - [lung biopsy stapler](https://qa.library.globalcastmd.com/watch/lung-biopsy-stapler-11988) — video · [machine version](https://qa.library.globalcastmd.com/watch/lung-biopsy-stapler-11988.md) ## Chapters - [0:00](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=0) Malignancy risk in cystic lung lesions: CCAM versus PPB (Ep 4) - [3:44](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=224) Management of extralobar sequestrations (Ep 4) - [6:05](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=365) Limitations of surveillance for pulmonary lesions (Ep 4) - [7:08](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=428) Operative risk versus observation risk (Ep 4) - [11:20](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=680) Natural history debate: infection incidence (Ep 4) - [16:40](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1000) Shared decision-making and institutional experience (Ep 4) - [0:00](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=0) Prenatal Assessment and Delivery Planning for Lung Lesions (Ep 3) - [7:04](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=424) Indications for Resection and Thoracoscopic Technique (Ep 3) - [10:42](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=642) Case Presentations: Asymptomatic CPAM and Middle Lobe Challenges (Ep 3) - [15:04](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=904) Bilobar CPAM and Diagnostic Uncertainty (Ep 3) - [19:17](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1157) Hybrid Lesions and Vascular Management (Ep 3) - [23:31](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1411) Extralobar BPS: Indications and Technique (Ep 3) - [25:50](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1550) Complex BPS Variants and Esophageal Bronchus (Ep 3) - [0:00](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=0) Case presentation and prenatal imaging debate (Ep 5) - [2:52](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=172) Delivery planning and postnatal management of asymptomatic infant (Ep 5) - [5:46](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=346) Timing of surgery: 3 months vs. later (Ep 5) - [10:00](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=600) Surgical technique and video demonstration (Ep 5) - [19:52](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=1192) Pathology findings and indications for resection (Ep 5) - [0:00](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=0) Anatomic Variations in Bronchopulmonary Sequestrations and Venous Drainage Patterns (Ep 2) - [3:26](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=206) Surgical Management of Infra-diaphragmatic Sequestration with Esophageal Obstruction (Ep 2) - [7:20](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=440) Bronchogenic Cysts and Bronchial Atresia: Pathophysiology and Surgical Approach (Ep 2) - [10:54](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=654) Vessel Management Techniques and Pleuropulmonary Blastoma Diagnosis (Ep 2) - [14:58](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=898) Timing of Postnatal Resection and Impact on Lung Development (Ep 2) - [16:49](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=1009) Technical Aspects: CO2 Insufflation Pressures and Single-Lung Ventilation (Ep 2) - [20:04](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=1204) Size Limitations for Thoracoscopic Resection in Premature and Small Infants (Ep 2) - [23:12](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=1392) Management of Bilobar Involvement and Incomplete Fissures (Ep 2) - [0:00](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=0) Canadian perspective on asymptomatic lesion management and PPB risk (Ep 1) - [3:53](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=233) Debate on extralobar sequestration management (Ep 1) - [5:22](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=322) Surveillance limitations and counseling challenges (Ep 1) - [7:13](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=433) Operative risk versus observation risk (Ep 1) - [11:03](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=663) Infection risk data and natural history debate (Ep 1) - [17:40](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1060) Informed consent and outcome data gaps (Ep 1) - [20:17](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1217) Rapid-fire clinical questions (Ep 1) - [0:01](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=1) Patient presentation and port placement (Ep 24) - [0:43](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=43) Pulmonary artery and vein management (Ep 24) - [2:04](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=124) Major fissure dissection and lingular vessels (Ep 24) - [3:07](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=187) Bronchial division and specimen extraction (Ep 24) - [4:13](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=253) Postoperative course and outcomes (Ep 24) - [0:00](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=0) Case presentation and operative technique for thoracoscopic lobectomy in a 3-month-old (Ep 18) - [3:15](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=195) Timing of surgery: early operation (3–6 months) versus waiting (Ep 18) ## Statements Every statement is attributed, typed, and timestamped; the link is the citation. - Most experts now believe CCAMs do not become pleuropulmonary blastoma (PPB); rather, PPB is a de novo tumor that is cystic and cannot be differentiated from CCAM on imaging. — Jean Martin (clinical) [Ep 4 · 0:31](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=31) - There are cases of prenatally diagnosed cystic lung lesions that turned out to be PPB after resection. — Jean Martin (clinical) [Ep 4 · 0:51](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=51) - A Toronto series estimates that approximately 4% of cystic lesions that appear to be CCAM will actually turn out to be pleuropulmonary blastoma. — Jean Martin (epidemiological) [Ep 4 · 1:24](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=84) - There is approximately 1% risk of bronchioloalveolar carcinoma arising from CCAM, typically in teenage years or early adulthood. — Jean Martin (epidemiological) [Ep 4 · 1:34](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=94) - If thoracoscopic resection is performed, the specimen should be placed in a bag before extraction to avoid tumor spillage in case the lesion is PPB, as there is a risk of recurrence. — Jean Martin (clinical) [Ep 4 · 2:11](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=131) - Non-communicating extralobar sequestrations have a very low infection rate; hematogenous infection is possible but rare, similar to any other body tissue. — Jean Martin (clinical) [Ep 4 · 2:39](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=159) - Malignant transformation of extralobar sequestration is extremely rare, with perhaps one or two cases of squamous cell carcinoma described in world literature. — Jean Martin (epidemiological) [Ep 4 · 3:00](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=180) - Infection and cancer are not good arguments to resect a non-communicating extralobar sequestration. — Jean Martin (opinion) [Ep 4 · 3:11](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=191) - The incidence of infection and malignancy in extralobar sequestrations is very low, but has occurred. — Steve (clinical) [Ep 4 · 3:44](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=224) - Current imaging is not perfect and cannot always definitively diagnose extralobar sequestration or rule out hybrid lesions. — Steve (clinical) [Ep 4 · 3:51](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=231) - The morbidity of resecting extralobar sequestrations is very low, which favors resection over observation. — Steve (opinion) [Ep 4 · 4:03](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=243) - There is no role for embolization of extralobar sequestrations; it is much easier to resect them using minimally invasive techniques than to subject an infant or child to embolization. — Steve (opinion) [Ep 4 · 4:49](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=289) - The differential diagnosis for infradiaphragmatic lesions prenatally includes adrenal hemorrhage and neuroblastoma (including cystic neuroblastoma). — Alan (clinical) [Ep 4 · 5:18](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=318) - Small infradiaphragmatic lesions can be followed by ultrasound; if they stay the same size or get smaller, they do not require resection. — Alan (clinical) [Ep 4 · 5:24](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=324) - Adrenal hemorrhage will evolve over time and become recognizable on imaging. — Alan (clinical) [Ep 4 · 5:37](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=337) - A Children's Oncology Group (COG) study showed it is safe to observe adrenal masses suspicious for neuroblastoma, though they must be watched. — Jean Martin (clinical) [Ep 4 · 5:52](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=352) - There is no good way to follow pulmonary lesions; CT scan is the best method but induces a certain incidence of malignancy itself. — Alan (clinical) [Ep 4 · 6:17](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=377) - CT scan cannot differentiate CCAM from pleuropulmonary blastoma, so surveillance imaging will not allow earlier detection of malignancy until stage 2 or 3 disease occurs. — Alan (clinical) [Ep 4 · 6:32](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=392) - It is almost universal that families cannot be counseled with the word 'cancer' and then choose to watch the lesion. (opinion) [Ep 4 · 6:56](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=416) - When deciding whether to operate, the risks of not operating must be weighed against the risks of operating. — Jack (opinion) [Ep 4 · 7:10](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=430) - There has been very little discussion about the risks of performing lobectomy during the panel. — Jack (opinion) [Ep 4 · 7:23](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=443) - The risks of pulmonary lobectomy are low, especially in experienced hands, but there are still children who die from pulmonary lobectomy, particularly when done thoracoscopically. — Jack (clinical) [Ep 4 · 7:29](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=449) - Thoracoscopic lobectomy should not be performed unless the surgeon is experienced; in experienced hands, thoracoscopic lobectomy should have no more morbidity than open lobectomy. — Steve (opinion) [Ep 4 · 8:08](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=488) - Thoracoscopic lobectomy should only be performed by surgeons with advanced thoracic and minimally invasive skills; in such hands, mortality should be zero. — Steve (opinion) [Ep 4 · 8:26](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=506) - If you do enough of any operation, you will have significant complications, whether open or thoracoscopic. — Jack (opinion) [Ep 4 · 8:40](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=520) - If massive bleeding occurs during thoracoscopic lobectomy, the chance of salvaging the situation is probably better if the case is already open rather than thoracoscopic. — Jack (opinion) [Ep 4 · 9:04](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=544) - Pleuropulmonary blastoma (PPB) can be indistinguishable radiologically from CCAM, but the incidence of CCAM/CPAM is markedly higher than the incidence of PPB; PPBs remain extremely rare. — Jack (epidemiological) [Ep 4 · 9:47](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=587) - Peter Kim's paper used the Stalker classification in which one histological category has been termed PPB, but the natural history of that histological finding is unknown. — Jack (clinical) [Ep 4 · 10:06](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=606) - At a high-volume center, de novo PPB is seen extremely rarely, approximately once every 3-4 years, while approximately 20-25 new cases of CCAM are seen annually. — Jack (epidemiological) [Ep 4 · 10:28](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=628) - The incidence of cancer in CCAM remains extremely low and must be balanced against the risk of the operation. — Jack (opinion) [Ep 4 · 10:44](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=644) - The estimated lifelong risk of infection for observed CCAM is approximately 20-30%, based on institutional data showing 10% infection rate with a mean follow-up of 4 years, tripled to estimate lifetime risk. — Jack (epidemiological) [Ep 4 · 10:54](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=654) - The only prospective study that followed asymptomatic CCAM patients long-term was small and showed 18 of 21 asymptomatic patients developed symptomatology during follow-up (average 2 years, up to 13 years). — Alan (epidemiological) [Ep 4 · 11:29](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=689) - Before prenatal diagnosis became common, it was not common for patients to present during teenage years or in adult thoracic surgery units with symptomatic infected CCAMs, though it happened from time to time. — Jack (epidemiological) [Ep 4 · 12:40](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=760) - In the early career of one surgeon in San Francisco, infected CCAMs were not a rare event and were seen on several occasions in the first few years. — Alan (epidemiological) [Ep 4 · 13:22](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=802) - Small asymptomatic extralobar sequestrations are a relatively known finding at autopsy, but asymptomatic CCAMs are essentially nonexistent in autopsy series. — Jean Martin (epidemiological) [Ep 4 · 15:44](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=944) - The majority of CCAMs become symptomatic; CCAM is not a normal variant. — Jean Martin (opinion) [Ep 4 · 16:04](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=964) - At one institution, all prenatally diagnosed lesions are followed with postnatal CT, and those not operated on are followed with chest X-ray and repeat CT. — Jack (clinical) [Ep 4 · 16:26](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=986) - One surgeon does not advocate non-operative management of all CCAMs; families are counseled about risks including cancer and infection, and many choose resection after hearing these risks. — Jack (opinion) [Ep 4 · 16:40](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1000) - A balanced approach should be given to families, allowing them to decide, rather than taking an approach where every single CCAM needs an operation. — Jack (opinion) [Ep 4 · 17:20](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1040) - In a poll, 25% of respondents do not advocate routine resection of asymptomatic CCAMs. — Jack (epidemiological) [Ep 4 · 17:58](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1078) - There is a hidden mortality in pediatric surgery because people do not report bad results; the only way to know about them is through lawsuits. (opinion) [Ep 4 · 18:25](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1105) - Future participation in the American College of Surgeons NSQIP-Pediatric will provide unbiased, large-scale data on thoracoscopic versus open surgery complications and mortality rates. (opinion) [Ep 4 · 18:48](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1128) - Currently there is insufficient data to make fully informed consent regarding CCAM management. (opinion) [Ep 4 · 18:58](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1138) - Thoracoscopic lobectomy should not be taken lightly; it requires a major investment in time and learning to become proficient. — Alan (opinion) [Ep 4 · 19:17](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1157) - Centers that routinely perform thoracoscopic lobectomy and see high volumes of CCAMs can treat them with extremely low morbidity and no mortality. — Alan (opinion) [Ep 4 · 19:29](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1169) - Infants generally do very well after thoracoscopic lobectomy, typically staying in the hospital for two days before going home. — Alan (clinical) [Ep 4 · 19:46](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1186) - In a review of the last 100 thoracoscopic lobectomies (not including sequestrations), there were only two transfusions and two prolonged air leaks as complications. — Alan (epidemiological) [Ep 4 · 19:49](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1189) - At 32 weeks gestation, ultrasound is performed to prognosticate whether the fetus will be asymptomatic or symptomatic at birth based on mediastinal shift. (clinical) [Ep 3 · 0:05](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=5) - If there is no mediastinal shift and a relatively small lesion at 32 weeks, the child is considered likely to be asymptomatic at birth and can deliver close to home with elective resection after CT scan. (clinical) [Ep 3 · 0:18](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=18) - If mediastinal shift is present at 32 weeks without major cardiac or lung compression, delivery should occur at a surgical center with postnatal resection during the first few days of life. (clinical) [Ep 3 · 0:40](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=40) - Major mediastinal shift with lung or cardiac compression requires delivery at a tertiary center with EXIT procedure or ECMO availability. (clinical) [Ep 3 · 1:00](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=60) - All CPAMs, intralobar BPS, and hybrid lesions should be resected routinely. (opinion) [Ep 3 · 1:20](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=80) - Extralobar BPS in some cases do not need resection and can be observed. (opinion) [Ep 3 · 1:33](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=93) - CPAMs are prone to infection and routinely have mucoid stasis; many show inflammatory evidence at 2-3 months of age when resected. (clinical) [Ep 3 · 2:05](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=125) - CPAMs have established malignant potential, with reported cases of pleuropulmonary blastoma, bronchoalveolar carcinoma, and rhabdomyosarcoma. (clinical) [Ep 3 · 2:27](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=147) - Pleuropulmonary blastoma cannot be differentiated radiologically from CPAM and is highly malignant and lethal if allowed to progress beyond stage 1. (clinical) [Ep 3 · 2:31](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=151) - The speaker personally resected three CPAMs that turned out to be stage 1 pleuropulmonary blastomas, which could not be differentiated from relatively small asymptomatic CPAMs. (clinical) [Ep 3 · 2:51](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=171) - There is anatomical and histological overlap between congenital lung lesion types; they exist on a continuum rather than as discrete categories. (clinical) [Ep 3 · 3:15](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=195) - A sequestration lesion with small cysts cannot be assumed to lack CPAM histology based on imaging alone. (clinical) [Ep 3 · 3:30](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=210) - Intralobar BPS can have communications via the pores of Kohn leading to infection risk and potential for high-flow physiology. (clinical) [Ep 3 · 3:40](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=220) - Waiting until 4-5 months of age for resection can result in significant inflammation within fissures that changes the complexion of the dissection. (clinical) [Ep 3 · 4:15](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=255) - Earlier resection is surgically easier and less traumatic for the infant than later resection. (opinion) [Ep 3 · 6:36](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=396) - Thoracoscopic resection has a difficult learning curve but is superior to open thoracotomy with shorter hospital stay, less pain, no thoracotomy morbidity, and better cosmesis. (opinion) [Ep 3 · 7:04](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=424) - Segmental bronchial stenoses have a very confluent appearance, almost like emphysematous pulmonary parenchyma, and may not require routine resection, though this is controversial. (opinion) [Ep 3 · 7:46](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=466) - If any cysts are visible in a segmental bronchial stenosis, that usually indicates CPAM histology. (clinical) [Ep 3 · 7:58](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=478) - Imaging studies are not good enough to definitively differentiate bronchial atresia from CPAM; lesions thought to be bronchial atresia can have CPAM elements and vice versa. (clinical) [Ep 3 · 8:12](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=492) - CPAMs often have abnormal fissures and globulated appearance related to developmental effects, so normal anatomy cannot be depended upon during lobectomy. (clinical) [Ep 3 · 10:28](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=628) - Some prenatally large CPAMs regress predominantly by birth but can air-trap and enlarge in the first weeks of life, requiring resection when symptoms develop. (clinical) [Ep 3 · 11:09](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=669) - Feeding vessels in sequestrations can arise from essentially any systemic source, not just the thoracic or abdominal aorta. (clinical) [Ep 3 · 15:55](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=955) - Some sequestrations have abnormal pleural investments or pleural caps that must be dissected during resection. (clinical) [Ep 3 · 16:11](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=971) - The speaker had a pulmonary artery hemorrhage when a ligature seal broke down during lobectomy, leading to conversion to open thoracotomy. (clinical) [Ep 3 · 17:26](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1046) - After the hemorrhage experience, the speaker tied every pulmonary artery and ligatured distally until the newer Force Triad energy source became available. (clinical) [Ep 3 · 17:52](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1072) - Tying all vessels intracorporeally takes about twice as long as using energy devices but is a safe alternative. (clinical) [Ep 3 · 18:12](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1092) - Many sequestrations are edematous due to restricted venous and lymphatic outflow, often with associated pleural effusions. (clinical) [Ep 3 · 19:17](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1157) - Edematous extralobar BPS typically have small vascular pedicles and are very easy to resect. (clinical) [Ep 3 · 19:30](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1170) - Intralobar sequestrations can drain almost directly into a pulmonary vein, creating a very high-output potential shunt that can lead to cardiac failure by 3-4 years of age. (clinical) [Ep 3 · 20:32](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1232) - Feeding vessels in sequestrations are often abnormal, tortuous, and have abnormal integrity similar to PDAs; they can cut through if tied too tightly or clipped too firmly. (clinical) [Ep 3 · 21:14](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1274) - When taking the inferior pulmonary ligament during lobectomy, careful inspection is needed because blood flow through small systemic vessels can be phenomenal. (clinical) [Ep 3 · 22:21](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1341) - If a systemic feeding vessel is missed and the pulmonary vein is taken first, tremendous congestion of the lobe will occur. (clinical) [Ep 3 · 22:32](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1352) - In high-output sequestrations, the pulmonary vein dilates dramatically and can become huge. (clinical) [Ep 3 · 22:56](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1376) - Extralobar BPS have separate pleural investment, no bronchial connection, systemic arterial supply from almost any source, and systemic or pulmonary venous drainage. (clinical) [Ep 3 · 23:09](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1389) - Extralobar BPS can have CPAM histology, usually indicated by a visible cyst on imaging. (clinical) [Ep 3 · 23:31](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1411) - Extralobar BPS have mucostasis but no airway communication, so there is no infection risk from that route. (clinical) [Ep 3 · 23:37](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1417) - Extralobar BPS can get infected, likely via hematogenous route, and present as pneumonias; infected lesions are much more difficult to resect. (clinical) [Ep 3 · 24:24](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1464) - A purely extralobar sequestration that is prenatally diagnosed is a relatively straightforward case and a great place to start when learning thoracoscopic resection. (opinion) [Ep 3 · 24:41](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1481) - Extralobar BPS could potentially be done as outpatient procedures with two ports and no chest tube. (opinion) [Ep 3 · 24:59](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1499) - The speaker previously thought intralobar and extralobar BPS could be differentiated by pulmonary versus systemic venous drainage, but has encountered extralobar BPS with pulmonary venous drainage. (clinical) [Ep 3 · 28:10](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1690) - Some sequestrations are essentially pure AV fistulas—a small piece of lung tissue with large blood vessels going in and out. (clinical) [Ep 3 · 28:31](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1711) - Arterialization of vasculature occurs in sequestrations, with even pulmonary veins becoming thickened like arteries due to high flow. (clinical) [Ep 3 · 21:19](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1279) - There are often multiple feeding vessels to sequestrations; what looks like one vessel on CT scan may be three or four vessels, or they may branch very early. (clinical) [Ep 3 · 21:57](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1317) - When a sequestration is against the esophagus and difficult to separate, an esophageal bronchus should be suspected. (clinical) [Ep 3 · 30:53](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1853) - Esophageal bronchi can be small and may be missed if the surgeon is not aware they may be present. (clinical) [Ep 3 · 31:00](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1860) - Sequestrations with esophageal bronchi are cesspools full of mucoid material. (clinical) [Ep 3 · 30:38](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-i-pediatric-thoracic-surgery-part-420?t=1838) - Fetal MRI for congenital cystic lung lesions does not change management in most cases unless the fetus shows signs of hydrops or the center uses prenatal steroids. — Steven Rothenberg (opinion) [Ep 5 · 1:02](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=62) - Prenatal steroids are indicated for microcystic lesions with CVR (congenital pulmonary airway malformation volume ratio) >1.6, based on UCSF findings that steroids can reduce lesion size or prevent growth relative to fetal growth. — Abdullah (guideline) [Ep 5 · 5:57](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=357) - Prenatal steroids do not work on macrocystic lesions, only microcystic lesions. — Abdullah (clinical) [Ep 5 · 6:30](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=390) - Operative time and complication rate are lower when congenital cystic lung lesions are resected earlier (3 months) compared to later (9+ months), supported by published data. — Steven Rothenberg (clinical) [Ep 5 · 10:41](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=641) - Asymptomatic infants with congenital cystic lung lesions develop subclinical inflammation and infection between 3 and 9 months of age, manifesting as enlarged lymph nodes and fissure inflammation that complicate surgery. — Steven Rothenberg (clinical) [Ep 5 · 10:51](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=651) - At 3 months of age, thoracoscopic lobectomy in a 5kg infant provides adequate working space with 3mm instruments; space is not a limiting factor. — Steven Rothenberg (clinical) [Ep 5 · 16:01](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=961) - A 3mm vessel sealer can safely seal and divide vessels up to 5mm in diameter during pediatric thoracoscopic surgery. — Steven Rothenberg (clinical) [Ep 5 · 14:40](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=880) - Even in asymptomatic infants who have never had a cold or chest infection, significant inflammation can develop in congenital cystic lung lesions by 1 year of age, making surgery more difficult. — Steven Rothenberg (clinical) [Ep 5 · 15:02](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=902) - 30-40% of children with congenital cystic lung disease will have a significant pulmonary infection at some point during their life. — Steven Rothenberg (epidemiological) [Ep 5 · 21:17](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=1277) - Once congenital cystic lung lesions become infected, they are much more difficult to resect surgically. — Steven Rothenberg (clinical) [Ep 5 · 21:32](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=1292) - In a personal series of over 300 lobectomies for cystic lung disease, the malignancy rate was 1-2%, including 2 pulmonary blastomas and 1 adenocarcinoma. — Steven Rothenberg (epidemiological) [Ep 5 · 20:36](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=1236) - All three malignancies (2 blastomas, 1 adenocarcinoma) in the surgeon's series occurred in children under 1 year of age. — Steven Rothenberg (epidemiological) [Ep 5 · 24:27](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=1467) - Neoplastic mucinogenic proliferations in CPAM may be associated with KRAS mutation, which is also a marker in adult small cell carcinoma and colon cancer. — Steven Rothenberg (clinical) [Ep 5 · 20:50](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=1250) - Columbia pathology review identified 4 additional cases of CPAM with neoplastic mucinogenic proliferations, a finding not previously reported in the literature. — Steven Rothenberg (clinical) [Ep 5 · 21:02](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=1262) - Morsellating tumor-containing lung tissue during specimen extraction does not upstage the tumor or change treatment according to hematology-oncology consultation, though patients require surveillance. — Steven Rothenberg (clinical) [Ep 5 · 23:06](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=1386) - All thoracoscopic lobectomies for congenital cystic lung lesions should be performed thoracoscopically at centers with expertise; if a center cannot perform the procedure thoracoscopically, referral should be considered to avoid thoracotomy morbidity. — Steven Rothenberg (opinion) [Ep 5 · 21:35](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=1295) - Long-term pulmonary function studies are needed to document that infants who undergo lobectomy compensate with growth of remaining lung tissue and do not have significant disability. — Steven Rothenberg (opinion) [Ep 5 · 21:51](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=1311) - In Germany, the standard practice is to operate on any cystic lung lesion at 3-6 months of age because of potential malignancy risk later in life. — Benno (guideline) [Ep 5 · 17:46](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=1066) - The Netherlands takes a more conservative approach to congenital cystic lung lesions compared to Germany. — Benno (guideline) [Ep 5 · 17:40](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=1060) - CT scan can identify multifocal disease in congenital cystic lung lesions, which may change surgical management (e.g., disease in all three lobes of one lung). — Todd Ponsky (clinical) [Ep 5 · 9:24](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=564) - Approximately 3 patients in several hundred cases had bilateral congenital cystic lung disease, requiring altered management. — Steven Rothenberg (epidemiological) [Ep 5 · 9:44](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=584) - Anatomic segmental resection is key when performing limited resection for congenital cystic lung lesions; non-anatomic resection carries risk of recurrent cystic disease. — Steven Rothenberg (clinical) [Ep 5 · 18:55](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=1135) - One child who underwent segmental resection for CPAM has shown evidence of recurrent cystic disease on follow-up. — Steven Rothenberg (clinical) [Ep 5 · 19:08](https://qa.library.globalcastmd.com/watch/congenital-cystic-lung-lesions-update-course-2014-643?t=1148) - Infra-diaphragmatic and sub-diaphragmatic sequestrations are frequently misdiagnosed as intrathoracic lesions — Steve (clinical) [Ep 2 · 0:22](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=22) - A new class of sequestrations exists within the leaves of the diaphragm muscle, requiring diaphragm opening for resection — Steve (clinical) [Ep 2 · 0:39](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=39) - Sequestrations at the esophageal hiatus can cause esophageal obstructive symptomatology — Alan (clinical) [Ep 2 · 0:51](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=51) - The majority of infra-diaphragmatic sequestrations approached abdominally extend up through the esophageal hiatus, even when not apparent on CT — Steve (clinical) [Ep 2 · 4:45](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=285) - Intra-diaphragmatic sequestrations (between diaphragm leaves) are frequently associated with the esophageal hiatus — Alan (clinical) [Ep 2 · 6:21](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=381) - Bronchogenic cysts can be associated with bronchial obstruction and cause hyperplastic growth of the distal lobe — Alan (clinical) [Ep 2 · 7:24](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=444) - In cases of fetal bronchial atresia causing hydrops not responsive to steroids, fetal lobe resection may be required — Alan (clinical) [Ep 2 · 7:37](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=457) - When bronchogenic cysts obstruct lobar bronchi, the bronchus is typically destroyed enough that lobectomy is required rather than cyst resection alone — Alan (clinical) [Ep 2 · 8:32](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=512) - Energy-based vessel sealers are operator-dependent because they seal as the knife advances; advancing too fast will divide the vessel before sealing — Steve (clinical) [Ep 2 · 9:49](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=589) - Modern energy sealers now have a tone frequency that indicates when the vessel is sealed and safe to advance the blade — Alan (clinical) [Ep 2 · 10:07](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=607) - The risk with clips on vessels is inadvertent dislodgement during dissection because they protrude past the vessel and are relatively large in small spaces — Steve (clinical) [Ep 2 · 11:50](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=710) - Clips are safer when used as the last maneuver, such as on sequestration feeding vessels, and can be reinforced with distal ligature — Alan (clinical) [Ep 2 · 12:17](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=737) - Thoracoscopic resection specimens provide adequate histology for diagnosis, comparable to open procedures, despite pathologist complaints about specimen quality — Alan (clinical) [Ep 2 · 14:15](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=855) - Compensatory lung growth and alveolarization continues until age 4-6 years, so resection timing within the first few years likely does not significantly impact lung development — Alan (clinical) [Ep 2 · 16:22](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=982) - CO2 insufflation pressure of 7 cm H2O is typically used for pediatric thoracoscopy and is well tolerated — Alan (clinical) [Ep 2 · 19:12](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=1152) - Starting CO2 pressure at 4 cm H2O is adequate if single-lung ventilation is good; pressure may need to increase to 7-8 cm H2O for lung collapse then can be reduced — Steve (clinical) [Ep 2 · 19:27](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=1167) - Main-stem intubation of the contralateral bronchus provides adequate single-lung ventilation with some overflow ventilation that is well tolerated — Steve (clinical) [Ep 2 · 19:35](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=1175) - The smallest thoracoscopic lobectomy performed was approximately 2400g, which was not significantly different technically from a term infant — Alan (clinical) [Ep 2 · 20:25](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=1225) - PDA ligations are now routinely performed thoracoscopically down to 800g, and 1000g now seems like a large space compared to a few years ago — Steve (clinical) [Ep 2 · 20:49](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=1249) - Current technology limits thoracoscopic lobectomy in small infants because 5mm clips and sealers occupy two-thirds of the chest space, making effective work difficult — Steve (clinical) [Ep 2 · 21:20](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=1280) - Thoracoscopic lobectomy under 2kg is difficult with current technology — Steve (clinical) [Ep 2 · 21:50](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=1310) - Premature infants requiring CCAM resection typically have large masses impacting ventilation, which cannot be done thoracoscopically and have contralateral lung issues preventing single-lung ventilation — Alan (clinical) [Ep 2 · 21:57](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=1317) - A healthy, stable baby with a healthy contralateral lung is required for thoracoscopic lobectomy — Alan (clinical) [Ep 2 · 22:12](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=1332) - Infants with small, stable CCAM lesions can be sent home for 1-2 months to grow before returning for elective resection, making the operation easier and less stressful for parents — Steve (clinical) [Ep 2 · 22:44](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=1364) - Most CCAM lesions are removed before 3 months of age; the operation is technically easier in small infants despite the smaller working space, and children recover more quickly with shorter hospitalization — Steve (clinical) [Ep 2 · 17:38](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=1058) - Trocar setup is critical in neonatal thoracoscopy; incorrect trocar positioning will make the operation very difficult, especially in small neonates — Steve (clinical) [Ep 2 · 18:15](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=1095) - True bilobar CPAM involvement is relatively rare; most cases involve abnormal lobulation or fissure formation rather than actual involvement of two lobes — Alan (clinical) [Ep 2 · 24:07](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=1447) - When fissures are abnormal, the approach is to create a fissure in an appropriate position that preserves maximal lung parenchyma while avoiding leaving devascularized lung or lung without an airway — Alan (clinical) [Ep 2 · 24:25](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=1465) - Following anatomic boundaries properly makes residual cystic lesions requiring re-resection rare; speaker has had only one case requiring return for further resection — Alan (clinical) [Ep 2 · 24:50](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=1490) - There are several cases of prenatally diagnosed lesions that turned out to be PPB after birth. — Jean-Martin (clinical) [Ep 1 · 0:59](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=59) - If you do thoracoscopic resection, put the specimen in a bag before extraction, because if it turns out to be PPB and you mush it up, there is a risk of recurrence. — Jean-Martin (clinical) [Ep 1 · 2:20](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=140) - Extralobar sequestrations with no communication and no air on CT scan do not have a high infection rate; hematogenous infection is possible but rare. — Jean-Martin (clinical) [Ep 1 · 2:48](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=168) - Malignant transformation of extralobar sequestration is extremely rare, with maybe one or two cases of squamous cell carcinoma in world literature. — Jean-Martin (epidemiological) [Ep 1 · 3:09](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=189) - Infection and cancer are not good arguments to resect a non-communicating extralobar sequestration. — Jean-Martin (opinion) [Ep 1 · 3:20](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=200) - The incidence of infection and malignancy in extralobar sequestration is very low, but it has occurred. — Steve (clinical) [Ep 1 · 3:53](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=233) - Imaging is not perfect and we cannot always be absolutely sure of the diagnosis or whether it is a hybrid lesion. — Steve (clinical) [Ep 1 · 4:00](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=240) - The morbidity of resecting extralobar sequestration is so low that removal is favored. — Steve (opinion) [Ep 1 · 4:28](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=268) - There is no role for embolization of extralobar sequestrations; it is much easier to resect them using minimally invasive techniques. — Steve (opinion) [Ep 1 · 4:58](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=298) - The differential diagnosis for infradiaphragmatic lesions prenatally is adrenal hemorrhage or neuroblastoma (cystic neuroblastoma). — Alan (clinical) [Ep 1 · 5:26](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=326) - Small infradiaphragmatic lesions can be followed by ultrasound; if they stay the same or get smaller, they do not require resection. — Alan (clinical) [Ep 1 · 5:33](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=333) - There is no good way to follow pulmonary lesions; CT scan is the best method but induces a certain incidence of malignancy. — Alan (clinical) [Ep 1 · 6:26](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=386) - You cannot differentiate CCAM from PPB on CT scan until you have a stage two or three occurrence. — Alan (clinical) [Ep 1 · 6:40](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=400) - You cannot counsel a family, say the word cancer, and have them watch; that is almost universally unacceptable. — Alan (opinion) [Ep 1 · 7:04](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=424) - When deciding to operate or not, we must weigh the risks of not doing the operation versus the risks of doing the operation. — Jack (clinical) [Ep 1 · 7:19](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=439) - There are children who die from pulmonary lobectomy, particularly done thoracoscopically. — Jack (clinical) [Ep 1 · 7:38](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=458) - Jack knows of two cases of death from thoracoscopic lobectomy that he was asked to review. — Jack (clinical) [Ep 1 · 7:58](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=478) - Thoracoscopic lobectomy should not be done unless the surgeon is experienced; in experienced hands it should have no more morbidity than open. — Steve (opinion) [Ep 1 · 8:16](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=496) - The mortality for thoracoscopic lobectomy in experienced hands should be zero. — Steve (opinion) [Ep 1 · 8:41](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=521) - If you do enough of any operation, you will have significant complications, whether open or thoracoscopic. — Jack (clinical) [Ep 1 · 8:48](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=528) - If you have massive bleeding when already open, your chance of salvaging the situation is probably better than if you have that bleeding in a thoracoscopic case. — Jack (opinion) [Ep 1 · 9:12](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=552) - PPB can be indistinguishable radiologically from CCAM, but the incidence of PPB remains extremely rare. — Jack (clinical) [Ep 1 · 9:55](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=595) - In a high-volume center (Toronto), de novo PPB is seen extremely rarely, like once every 3 or 4 years, while 20-25 new CCAM cases are seen every year. — Jack (epidemiological) [Ep 1 · 10:36](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=636) - The estimate of lifelong risk of infection for CCAM is somewhere around 20 or 30%. — Jack (epidemiological) [Ep 1 · 11:03](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=663) - Most infections in CCAM can be treated and lobectomy can be done afterwards. — Jack (clinical) [Ep 1 · 11:15](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=675) - Jack's data showed 10% infection rate with a mean follow-up of 4 years, which was tripled to estimate 30% lifetime risk. — Jack (epidemiological) [Ep 1 · 12:17](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=737) - Before prenatal diagnosis, it was not common for people to present in teenage years or adulthood with symptomatic infected CCAMs, though it happened from time to time. — Jack (clinical) [Ep 1 · 12:49](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=769) - If 25 new prenatally diagnosed asymptomatic CCAM cases are seen per year in Toronto and none were operated on, we should be seeing 25 infected cases per year if the infection rate were 100%. — Jack (clinical) [Ep 1 · 14:03](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=843) - The majority of CCAMs do become symptomatic; it is not a normal variant. — Jean-Martin (opinion) [Ep 1 · 16:12](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=972) - Toronto follows all prenatally diagnosed lesions with CT postnatally, and those not operated on are followed with chest X-ray and another CT. — Jack (clinical) [Ep 1 · 16:35](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=995) - Jack is not advocating non-operative management of all CCAMs; he counsels families about risks including cancer, and many choose surgery. — Jack (opinion) [Ep 1 · 16:49](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1009) - Jack advocates a balanced approach to families, allowing them to decide, rather than operating on every single lesion. — Jack (opinion) [Ep 1 · 17:29](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1049) - There is a hidden mortality in pediatric surgery because people do not report bad results; the only way to know is through lawsuits or future unbiased registry data like NSQIP. — Alan (clinical) [Ep 1 · 18:34](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1114) - We do not have the data to make truly informed consent, so we must give families the whole picture and let them decide. — Alan (opinion) [Ep 1 · 19:06](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1146) - Centers that do thoracoscopic lobectomy routinely and see high volumes of CCAMs can treat them with extremely low morbidity and no mortality. — Alan (opinion) [Ep 1 · 19:26](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1166) - In a review of the last 100 thoracoscopic lobectomies (not sequestrations), there were 2 transfusions and 2 latent pneumothoraces as the only complications. — Alan (clinical) [Ep 1 · 19:58](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1198) - For infected CCAM with abscess, 6 weeks of IV antibiotics is reasonable, but duration depends on symptoms (fever, ongoing symptoms). — Starla (clinical) [Ep 1 · 20:46](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1246) - Large abscesses in CCAM can be drained percutaneously and treated with antibiotics for a couple of weeks, then re-evaluated for residual mass. — Alan (clinical) [Ep 1 · 21:10](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1270) - It is very hard to clear infection from a macrocystic CCAM. — Alan (clinical) [Ep 1 · 21:21](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1281) - MRI is not used as primary study because children require more anesthesia for MRI than for CT. — Starla (clinical) [Ep 1 · 21:53](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1313) - MRI has been tried for follow-up of non-operated patients, but it does not give as clear a picture as CT. — Jack (clinical) [Ep 1 · 22:09](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1329) - Bronchial blocker is not needed in infants for single-lung ventilation and is potentially harmful (risk of bronchial stenosis). — Alan (clinical) [Ep 1 · 22:39](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1359) - The incidence of extralobar sequestration in diaphragmatic hernia is probably 15%; they are often small and can be ignored. — Alan (epidemiological) [Ep 1 · 23:30](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1410) - Bilateral lung lesions are managed sequentially, not at the same time. — Alan (clinical) [Ep 1 · 23:56](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1436) - Prophylactic antibiotics are given as one preoperative dose only; patients are not sent home on antibiotics if waiting a month for surgery. — Steve (clinical) [Ep 1 · 24:52](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1492) - Macrocystic lesions can always be reduced thoracoscopically by chipping away at them with a ligature. — Alan (clinical) [Ep 1 · 25:17](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1517) - Most CCAM specimens can be removed through a 5 millimeter incision, though hybrid lesions with big arteries are tougher. — Alan (clinical) [Ep 1 · 25:44](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1544) - You never lose anything by putting a scope in; you can evaluate thoracoscopically and convert to open if the fissure is obliterated or anatomy is difficult. — Steve (opinion) [Ep 1 · 27:32](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1652) - The patient is a 3-month-old, 5 kg infant undergoing thoracoscopic right lower lobectomy for a cystic lesion with an unseen sequestration. — Steven Rothenberg (clinical) [Ep 18 · 0:06](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=6) - Three-millimeter instruments are used for the procedure, and space is not an issue in a 3-month-old infant. — Steven Rothenberg (clinical) [Ep 18 · 0:11](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=11) - At 3 months of age, enlarged lymph nodes are already visible in the major fissure. — Steven Rothenberg (clinical) [Ep 18 · 0:36](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=36) - In asymptomatic children aged 9 months to 1 year, lymph nodes are often massive and inflammation in the fissure is extensive, making the operation more difficult. — Steven Rothenberg (clinical) [Ep 18 · 0:40](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=40) - A 3 mm sealer can safely take vessels up to 5 mm in diameter. — Steven Rothenberg (clinical) [Ep 18 · 1:26](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=86) - The operation with a fellow assisting took approximately 90 minutes. — Steven Rothenberg (clinical) [Ep 18 · 1:21](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=81) - When asymptomatic children are operated on around 1 year of age, dissection becomes much tougher due to inflammation, even in children who have never had a cold or chest infection. — Steven Rothenberg (clinical) [Ep 18 · 1:44](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=104) - At 3 months of age, clips can be safely used at the segmental level. — Steven Rothenberg (clinical) [Ep 18 · 2:21](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=141) - The specimen is morcellated through the trocar site and removed piecemeal because it is difficult to use a bag with a large specimen in a small infant. — Steven Rothenberg (clinical) [Ep 18 · 3:02](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=182) - At 3 months, thoracoscopic lobectomy does not feel like a limited-space operation; lung collapse is good and the dissection is easy. (opinion) [Ep 18 · 3:30](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=210) - In Europe, attitudes toward timing of surgery vary; the Netherlands is more conservative, while in Germany (and the speaker's institution) operations are performed at 3–6 months of age for any cystic lesion due to potential malignancy. — Benno (clinical) [Ep 18 · 4:26](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=266) - If cystic disease is seen in the lower part of the upper lobe, an anatomic segmental resection should be performed. — Steven Rothenberg (opinion) [Ep 18 · 5:39](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=339) - One child who had a segmental resection that appeared limited to an anatomic segment on CT and at surgery has shown evidence of recurrent cystic disease. — Steven Rothenberg (clinical) [Ep 18 · 5:48](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=348) - One child with no fissure (one giant lobe) required a bi-segmental resection and subsequently developed recurrent cystic disease because an anatomic resection could not be performed. — Steven Rothenberg (clinical) [Ep 18 · 6:15](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=375) - The chest tube was removed on postoperative day 2 and could have been removed on postoperative day 1; the child went home on postoperative day 3. — Steven Rothenberg (clinical) [Ep 18 · 6:54](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=414) - Pathology showed lung tissue with CPAM type 1 and type 2 changes with exuberant neoplastic mucinous proliferations; bronchial margin was negative. This is a finding not previously reported by the speaker. — Steven Rothenberg (clinical) [Ep 18 · 7:02](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=422) - In a personal series of over 300 lobectomies for cystic lung disease, the speaker has identified two pulmonary blastomas and one adenocarcinoma. — Steven Rothenberg (epidemiological) [Ep 18 · 7:22](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=442) - The neoplastic mucinous proliferations may be associated with KRAS mutation, which is also a marker in adult small cell carcinoma and colon cancer. — Steven Rothenberg (clinical) [Ep 18 · 7:36](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=456) - At Columbia, pathologists reviewing cases have found four others with exuberant neoplastic mucinous proliferations. — Steven Rothenberg (epidemiological) [Ep 18 · 7:47](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=467) - Once cystic lesions become infected, they are much more difficult to resect. — Steven Rothenberg (clinical) [Ep 18 · 8:17](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=497) - All lobectomies for cystic lung disease should be done thoracoscopically, and if a center cannot perform them thoracoscopically, patients should be referred to a center that can. — Steven Rothenberg (opinion) [Ep 18 · 8:21](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=501) - Good long-term pulmonary function studies are needed to document that if a lobe is removed in infancy, the rest of the lung will grow and compensate without significant disability. — Steven Rothenberg (opinion) [Ep 18 · 8:37](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=517) - In the speaker's personal series, the incidence of malignancy is almost 2%, certainly 1%, but may be 2%. — Steven Rothenberg (epidemiological) [Ep 18 · 9:02](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=542) - It is difficult to place a large specimen in a bag in young infants undergoing early lobectomy. — Steven Rothenberg (clinical) [Ep 18 · 10:07](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=607) - Three tumors in 300 cases represents a 1% incidence of cancer. — Steven Rothenberg (epidemiological) [Ep 18 · 10:30](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=630) - The three malignancies (blastomas and adenocarcinoma) were all diagnosed at 1 year of age. — Steven Rothenberg (clinical) [Ep 18 · 11:11](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=671) - CT scan is the best method to follow pulmonary lesions but induces a certain incidence of malignancy. (clinical) [Ep 6 · 0:12](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=12) - CPAM cannot be differentiated from pleuropulmonary blastoma (PPB) on imaging until stage 2 or 3 disease occurs. (clinical) [Ep 6 · 0:22](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=22) - Surveillance cannot prevent malignancy or allow earlier detection than would otherwise occur. (opinion) [Ep 6 · 0:40](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=40) - Families cannot be counseled to watch a lesion once the word cancer is mentioned. (opinion) [Ep 6 · 0:51](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=51) - Children have died from pulmonary lobectomy, particularly done thoracoscopically. — Jack (clinical) [Ep 6 · 1:25](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=85) - Jack (spk_3) has reviewed two cases of mortality from thoracoscopic lobectomy, not at his own institution. — Jack (clinical) [Ep 6 · 1:45](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=105) - In experienced hands, thoracoscopic lobectomy should have no more morbidity than open lobectomy. — Steve (opinion) [Ep 6 · 2:03](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=123) - Thoracoscopic lobectomy should only be performed by surgeons with advanced thoracic and minimally invasive skills, and mortality should be zero. — Steve (opinion) [Ep 6 · 2:21](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=141) - If massive bleeding occurs during thoracoscopic lobectomy, the chance of salvage is probably lower than if the case is already open. — Jack (opinion) [Ep 6 · 3:04](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=184) - Pleuropulmonary blastoma (PPB) can be indistinguishable radiologically from CPAM. — Jack (clinical) [Ep 6 · 3:42](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=222) - The incidence of CPAM is markedly higher than the incidence of PPB; PPBs remain extremely rare. — Jack (epidemiological) [Ep 6 · 3:55](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=235) - In a high-volume center, de novo PPB is seen extremely rarely, approximately once every 3 to 4 years, while 20 to 25 new cases of CPAM are seen annually. — Jack (epidemiological) [Ep 6 · 4:23](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=263) - The incidence of cancer in CPAM is extremely low and must be balanced against the risk of lobectomy. — Jack (opinion) [Ep 6 · 4:39](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=279) - The estimated lifelong risk of infection for untreated CPAM is approximately 20 to 30%, based on institutional data showing 10% infection at a mean follow-up of 4 years. — Jack (epidemiological) [Ep 6 · 4:50](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=290) - Most infections in CPAM can be treated, and lobectomy can be performed afterwards rather than prophylactically. — Jack (opinion) [Ep 6 · 5:02](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=302) - Before prenatal diagnosis, it was not common for teenagers or adults to present with symptomatic infected CPAMs, despite the lesions being common prenatally. — Jack (epidemiological) [Ep 6 · 6:36](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=396) - In early career in San Francisco, infected CPAMs were not a rare event. (clinical) [Ep 6 · 7:20](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=440) - If 25 new prenatally diagnosed asymptomatic CPAMs are seen per year in the Toronto area and none are operated on, one would expect to see 25 infected cases per year if the infection rate is 100%. — Jack (opinion) [Ep 6 · 7:50](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=470) - The majority of CPAMs become symptomatic; CPAM is not a normal variant. — Jean Martin (opinion) [Ep 6 · 10:00](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=600) - Jack's institution follows all prenatally diagnosed cystic lung lesions with postnatal CT, and those not operated on are followed with chest X-ray and repeat CT. — Jack (clinical) [Ep 6 · 10:21](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=621) - Jack does not advocate non-operative management of all CPAMs; he counsels families about risks including cancer and infection, and many choose surgery after hearing the risks. — Jack (opinion) [Ep 6 · 10:36](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=636) - A balanced approach should be given to families, allowing them to decide, rather than a dogmatic approach that every CPAM needs operation. — Jack (opinion) [Ep 6 · 11:15](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=675) - In an audience poll, 23-25% of respondents do not advocate routine resection of asymptomatic CPAM. — Jack (epidemiological) [Ep 6 · 11:53](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=713) - There is a hidden mortality in pediatric surgery because people do not report bad results; the only way to know about them is through lawsuits. (opinion) [Ep 6 · 12:20](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=740) - In 10 years, participation in the American College of Surgeons Pediatric NSQIP will provide unbiased large-scale data on thoracoscopic and open surgery complications and mortality. (opinion) [Ep 6 · 12:43](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=763) - Currently, there is insufficient data to make fully informed consent regarding CPAM management. (opinion) [Ep 6 · 12:53](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=773) - Thoracoscopic lobectomy requires a major investment in time and learning to become proficient. (opinion) [Ep 6 · 13:13](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=793) - Centers that routinely perform thoracoscopic lobectomy and see high volumes of CPAMs can treat them with extremely low morbidity and no mortality. (opinion) [Ep 6 · 13:22](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=802) - Infants undergoing thoracoscopic lobectomy are generally in the hospital for 2 days. (clinical) [Ep 6 · 13:44](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=824) - In a review of the last 100 thoracoscopic lobectomies (not sequestrations), there were 2 transfusions and 2 prolonged air leaks as the only complications. (clinical) [Ep 6 · 13:44](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=824) - The procedure uses 3mm sealer and 5mm stapler instruments for thoracoscopic left lower lobectomy in an infant with CPAM. — Steven Rothenberg (clinical) [Ep 27 · 0:23](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=23) - The surgeon and assistant stand at the patient's front with the patient in full lateral decubitus position, with monitors behind the patient for inline viewing during delicate portions. — Steven Rothenberg (clinical) [Ep 27 · 0:40](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=40) - Right mainstem intubation is used to obtain left lung collapse. — Steven Rothenberg (clinical) [Ep 27 · 1:00](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=60) - The camera port is placed anterior to the tip of the scapula in approximately the 5th intercostal space in the posterior axillary line. — Steven Rothenberg (clinical) [Ep 27 · 1:10](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=70) - Operating ports are placed in the anterior axillary line, with the right hand port just above the diaphragm, initially 3mm and later upsized to 5mm for the stapler. — Steven Rothenberg (clinical) [Ep 27 · 1:25](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=85) - In lower lobectomies, surgeons should always look for a systemic artery even if not identified on CT scan, as hybrid sequestration-CPAM lesions are not unusual and large vessels are occasionally missed. — Steven Rothenberg (clinical) [Ep 27 · 2:00](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=120) - The seal-and-tear technique (grasping tissue, sealing, then tearing gently upward) eliminates the need for sharp dissection when mobilizing the inferior pulmonary ligament. — Steven Rothenberg (clinical) [Ep 27 · 2:25](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=145) - It is important to identify the branch going to the lingula so it can be preserved during lower lobectomy. — Steven Rothenberg (clinical) [Ep 27 · 4:00](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=240) - In cases where the fissure is incomplete, lung parenchyma is gone through a layer at a time to expose the pulmonary artery. — Steven Rothenberg (clinical) [Ep 27 · 4:40](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=280) - The superior segmental artery of the left lower lobe usually comes off separately from the basal trunk and is best isolated alone. — Steven Rothenberg (clinical) [Ep 27 · 5:30](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=330) - When sealing thicker tissue, two separate seals should be made and the cut made between them rather than cutting in the center of a single seal. — Steven Rothenberg (clinical) [Ep 27 · 7:00](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=420) - The double-seal technique (proximal and distal seals 3-4mm apart, only partially dividing initially) ensures that if the seal is incomplete or there is bleeding, the surgeon still has control of the vessel before the ends separate and retract. — Steven Rothenberg (clinical) [Ep 27 · 7:40](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=460) - Even in asymptomatic CPAM patients, enlarged inflamed lymph nodes are often seen due to chronic inflammation secondary to the CPAM. — Steven Rothenberg (clinical) [Ep 27 · 11:00](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=660) - In a patient one year of age with CPAM, it is not unusual to have the fissure obliterated by inflammation and enlarged lymph nodes even though the patient has been completely asymptomatic. — Steven Rothenberg (clinical) [Ep 27 · 11:25](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=685) - The bronchus to the lower lobe lies just below the main arterial trunk to the basal segments and can be used as a tactile landmark during vessel dissection. — Steven Rothenberg (clinical) [Ep 27 · 12:20](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=740) - Taking the superior segmental artery first before the main trunk gives more length on the main trunk for safe ligation, sealing, and division. — Steven Rothenberg (clinical) [Ep 27 · 13:20](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=800) - The 5mm stapler is used for the main arterial trunk after upsizing the right hand trocar from 3mm to 5mm. — Steven Rothenberg (clinical) [Ep 27 · 14:00](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=840) - After placing the stapler, the surgeon should compress and wait for a count of 10 seconds to allow the staples to completely form. — Steven Rothenberg (clinical) [Ep 27 · 14:20](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=860) - In thoracoscopic lobectomy, it is often easier to take the bronchus first (rather than the traditional open surgery sequence of artery-vein-bronchus), which leaves the pulmonary vein well exposed. — Steven Rothenberg (clinical) [Ep 27 · 15:20](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=920) - It is important to remember that the vein lies just behind the bronchus during dissection to ensure no branches of the vein are injured. — Steven Rothenberg (clinical) [Ep 27 · 15:45](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=945) - In children over 2-3 months of age, separating the superior segmental bronchus from the basal segmental bronchi is preferable because of bronchial size, to ensure adequate division and seal using the stapler. — Steven Rothenberg (clinical) [Ep 27 · 16:00](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=960) - Compressing the bronchus before stapling aids in the formation of the staples. — Steven Rothenberg (clinical) [Ep 27 · 16:40](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=1000) - The 5mm stapler works well in children under 10kg; in larger children the bronchi may be too large for the 5mm stapler and must be evaluated case by case. — Steven Rothenberg (clinical) [Ep 27 · 17:00](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=1020) - Taking the superior branch of the inferior pulmonary vein first gains more length on the main trunk, allowing safe use of the stapler. — Steven Rothenberg (clinical) [Ep 27 · 17:50](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=1070) - The sealer works extremely well on lung tissue and has been used to complete incomplete fissures and perform segmental resections with no problems with bleeding or air leak. — Steven Rothenberg (clinical) [Ep 27 · 18:15](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=1095) - When going through a great deal of tissue with the sealer, it is important to clean the jaws and remove char that may build up. — Steven Rothenberg (clinical) [Ep 27 · 18:30](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=1110) - When stapling the main venous trunk, the staple line must be well away from the base of the vein and well away from the pericardium (at least 2cm), and the surgeon should grasp the trunk proximal to the stapler in case of leak or problem. — Steven Rothenberg (clinical) [Ep 27 · 18:40](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=1120) - This minimally edited procedure took 45 minutes in real time. — Steven Rothenberg (clinical) [Ep 27 · 17:30](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=1050) - The patient had a chest tube in just overnight, it was removed on the first postoperative day, and she was discharged later that evening. — Steven Rothenberg (clinical) [Ep 27 · 17:35](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=1055) - The pathology came back consistent with type 2 CPAM. — Steven Rothenberg (clinical) [Ep 27 · 17:45](https://qa.library.globalcastmd.com/watch/thoracoscopic-left-lower-lobectomy-technique-by-dr-steven-rothenberg-how-i-977?t=1065) - Patient is a 6-month-old with prenatal diagnosis of suspected cystic lung lesion, had CT scan in January at 2 weeks of life showing what appeared to be a solid-cystic lower lobe lesion, child has been asymptomatic — Steve (clinical) [Ep 28 · 1:19](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=79) - Intraoperative finding revealed the lesion to be an extralobar sequestration rather than the expected cystic lung lesion — Steve (clinical) [Ep 28 · 1:19](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=79) - Initial port placement is in the fifth intercostal space, approximately two-thirds of the distance between the tip of the scapula and the nipple, positioned directly over the fissure — Steve (clinical) [Ep 28 · 3:08](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=188) - CO₂ insufflation is used at a pressure of 8 with 2L flow through a single 5mm port, without achieving true lung isolation (clinical) [Ep 28 · 2:18](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=138) - Second 5mm port is placed in the anterior axillary line in as low an interspace as possible to provide room for manipulation and ligature placement — Steve (clinical) [Ep 28 · 3:08](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=188) - Using ports rather than simple stab wounds is preferred when using CO₂ insufflation because instruments will eventually leak around stab wounds with manipulation — Steve (opinion) [Ep 28 · 5:14](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=314) - Edematous sequestrations characteristically have a very narrow, small, tight pedicle — Steve (clinical) [Ep 28 · 9:05](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=545) - The edema in sequestrations is thought to result from the small pedicle size and abnormal lymphatic development through the pedicle — Steve (clinical) [Ep 28 · 9:05](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=545) - Careful dissection of the pedicle rather than mass ligation is preferred to identify what structures are present — Steve (opinion) [Ep 28 · 10:40](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=640) - The LigaSure LS1000 device is used for vessel sealing; while it takes longer than other methods (adding minutes to case time), it offers significant safety advantages — Steve (opinion) [Ep 28 · 12:25](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=745) - A 5mm trocar with 3mm reducer allows use of 3mm instruments while maintaining CO₂ seal; instruments should be lubricated with mineral oil to prevent sticking in the reducer — Steve (clinical) [Ep 28 · 14:49](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=889) - Pleural effusion associated with sequestrations results from either lymphatic or venous drainage issues, most likely lymphatic, with visible dilated lymphatic channels on the surface that weep fluid (clinical) [Ep 28 · 14:49](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=889) - The vascular pedicle in this case contained two separate vessels (artery and vein), each approximately 2mm in diameter (clinical) [Ep 28 · 21:34](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=1294) - Once a good seal is visualized on a vessel after LigaSure application, the seal has never been observed to break open in the surgeon's experience (clinical) [Ep 28 · 26:15](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=1575) - When extracting specimens through trocar sites, it is critical to avoid grasping normal lung and bringing it out through the trocar site (clinical) [Ep 28 · 26:49](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=1609) - In a case of segmentectomy requiring reoperation for recurrence, adhesions were remarkably clean and not difficult to dissect — Steve (clinical) [Ep 28 · 28:09](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=1689) - When completing a fissure during segmentectomy, fibrin glue is not routinely used unless there is a significant air leak observed — Steve (clinical) [Ep 28 · 28:54](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=1734) - For 3mm port sites, if fascia is visible it should be closed; if not visible, skin can be closed with monocryl and dermabond — Steve (clinical) [Ep 28 · 33:30](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=2010) - Chest tube is not necessary after sequestration resection; the chest can be evacuated through the trocar at the end of the procedure — Steve (opinion) [Ep 28 · 34:00](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=2040) ## Host summaries Recaps by a host of what the experts said — not the host's own clinical position. - Management decisions for CCAM should be made selectively based on resources, family preferences, patient factors, and location, rather than a dogmatic approach of operating on everyone. — The host summarizing the discussion [Ep 4 · 17:32](https://qa.library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1052) - A recent JPS study comparing early (approximately 3 months) versus later (approximately 18 months) CCAM resection found increased risk of complications like infection with delayed resection but no difference in long-term pulmonary function outcomes — Alan summarizing the discussion [Ep 2 · 15:33](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-ii-pediatric-thoracic-surgery-419?t=933) - Most people believe now that CCAMs do not become PPB, but PPB is a de novo tumor that is cystic and cannot be differentiated on imaging. — Jean-Martin summarizing the discussion [Ep 1 · 0:40](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=40) - One series out of Toronto estimates that cystic lesions that look like CCAM, about 4% of them will actually turn out to be PPB. — Jean-Martin summarizing the discussion [Ep 1 · 1:33](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=93) - There is about a 1% risk of bronchioalveolar carcinoma in the teenage years or early adulthood. — Jean-Martin summarizing the discussion [Ep 1 · 1:43](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=103) - The COG study showed that it was safe to observe adrenal masses (in the context of neuroblastoma concern). — Jean-Martin summarizing the discussion [Ep 1 · 6:00](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=360) - The paper by Peter Kim used the Stalker classification in which one classification has been termed PPB, but the natural history of that histological finding is unknown. — Jack summarizing the discussion [Ep 1 · 10:14](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=614) - The only prospective study that followed patients long-term showed 18 of 21 asymptomatic patients developed symptomatology during an interval averaging 2 years up to 13 years. — Alan summarizing the discussion [Ep 1 · 11:38](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=698) - Autopsy series show that small asymptomatic extralobar sequestration is a relatively known finding, but asymptomatic CCAM on autopsy is nonexistent. — Jean-Martin summarizing the discussion [Ep 1 · 15:43](https://qa.library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=943) - The patient was a 4 month old, 5 kg infant with a prenatally diagnosed CAM (congenital adenomatoid malformation). — The host summarizing a resource [Ep 24 · 0:01](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=1) - An anterior approach was used with 3 ports: a 4 mm port in the posterior axillary line for the telescope, and two 3 mm ports in the anterior axillary line. — The host summarizing a resource [Ep 24 · 0:08](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=8) - The lower port was later changed to a 5 mm port for access of the endoscopic clip applier. — The host summarizing a resource [Ep 24 · 0:16](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=16) - A new 3 millimeter sealer dissector was used for the case. — The host summarizing a resource [Ep 24 · 0:28](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=28) - The sealer was used to compress cysts in the left upper lobe to allow for easier access to the pulmonary vessels. — The host summarizing a resource [Ep 24 · 0:32](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=32) - The main trunk of the artery to the upper lobe was dissected out and sealed proximally and distally, then divided between the seals. — The host summarizing a resource [Ep 24 · 0:58](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=58) - This sealing technique allows for a safe, effective and reproducible method for sealing pulmonary vessels without risk of bleeding. — The host summarizing a resource [Ep 24 · 1:10](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=70) - Each of the main branches of the superior pulmonary vein were individually isolated, dissected out, and then sealed proximally and distally with division of the vessel between the seals. — The host summarizing a resource [Ep 24 · 1:36](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=96) - The major fissure was incomplete anteriorly. — The host summarizing a resource [Ep 24 · 2:11](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=131) - The sealer was used to help define the plane of the incomplete major fissure, and the lung between the upper and lower lobes was sealed and then divided. — The host summarizing a resource [Ep 24 · 2:11](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=131) - Almost a finger fracture technique was used to divide the lung parenchyma and expose the artery as the dissection continued posteriorly towards the main pulmonary arteries. — The host summarizing a resource [Ep 24 · 2:24](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=144) - The superior and inferior branches of the lingular artery were individually isolated, sealed, and divided using the 3 millimeter sealer. — The host summarizing a resource [Ep 24 · 2:54](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=174) - The bronchus to the lingula was sealed with a 5 millimeter clip applier, both proximally and distally, and divided between these clips. — The host summarizing a resource [Ep 24 · 3:12](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=192) - 5 millimeter clips have proven to be an effective way to seal the bronchus in infants under 10 kg. — The host summarizing a resource [Ep 24 · 3:25](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=205) - Each bronchial branch (apical posterior and anterior) was individually sealed with a 5 millimeter clip and then divided proximal to this. — The host summarizing a resource [Ep 24 · 3:45](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=225) - The upper lobe was brought out through the lower trochar site in a piecemeal fashion. — The host summarizing a resource [Ep 24 · 4:05](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=245) - The child had a chest tube in for 24 hours and was discharged on the 2nd postoperative day. — The host summarizing a resource [Ep 24 · 4:13](https://qa.library.globalcastmd.com/watch/technique-blinded-left-upper-lobectomy-1006?t=253) - The literature shows that 30–40% of children with cystic lung disease will have a significant pulmonary infection at some point during their life. — Steven Rothenberg summarizing the discussion [Ep 18 · 8:03](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=483) - Hematologist-oncologists have stated that morcellating the specimen does not upgrade the tumor, does not change treatment, and no patient has received chemotherapy, but these children are being watched. — Steven Rothenberg summarizing the discussion [Ep 18 · 9:51](https://qa.library.globalcastmd.com/watch/thoracoscopic-right-lower-lobe-cystic-lesion-excision-update-course-2014-1041?t=591) - Peter Kim published a paper on histological evaluation of pulmonary lesions using the Stocker classification, in which one classification has been termed PPB, but the natural history of that histological finding is unknown. — Jack summarizing the discussion [Ep 6 · 4:01](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=241) - A prospective study (Wong, Pediatric Surgery International) followed 21 asymptomatic patients (8 prenatally diagnosed, rest serendipitous) and found 18 of 21 developed infections or symptoms requiring resection, with mean follow-up of 2 years and range up to 13 years. — The host summarizing the discussion [Ep 6 · 5:25](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=325) - Small asymptomatic extralobar sequestrations are a relatively known finding at autopsy, but asymptomatic CPAMs are nonexistent in autopsy series. — Jean Martin summarizing the discussion [Ep 6 · 9:30](https://qa.library.globalcastmd.com/watch/should-we-resect-asymptomatic-cpam-flake-vs-langer-1391?t=570) - Covidien is not actively promoting the LigaSure device except to pediatric surgeons who continue to use it — The host summarizing the discussion [Ep 28 · 12:25](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=745) - Fibrin glue can clog chest tubes, which is a consideration when deciding whether to use it — The host summarizing the discussion [Ep 28 · 29:19](https://qa.library.globalcastmd.com/watch/left-lower-lobectomy-for-sequestration-pediatric-thoracic-surgery-part-922?t=1759) --- Educational content from recorded physician discussions — not medical advice. Cite the canonical URL or the ?t= deep link. Policy: https://qa.library.globalcastmd.com/ai