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Neonatal Lung Lesions with Dr. Steven Rothenberg
With Dr. Steven Rothenberg · hosted by Dr. Ian Glenn & Dr. Todd Ponsky
Chapter 1 of 11 · Fundamentals
Introduction
Introduction and Guest Background
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Host summaries · secondary, not cited in answers
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Serial prenatal ultrasounds are the best way to watch the development of cystic lung lesions; they are noninvasive and can be done quickly every couple of weeks.
Fetal MRI provides little benefit for lung lesions; it does not change the plan or give much more definition than ultrasound.
Anywhere from 6 to 40% of prenatally detected lung lesions will regress with time, and in some cases appear to completely disappear.
CHOP performs open fetal surgery for lung lesions less than once every couple of years; it is extremely rare.
Fetal thoracentesis or thoracoamniotic shunt placement is done only if the fetus shows significant distress and evidence of hydrops, when mortality rate goes up significantly.
A cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and indicates cases more prone to need fetal intervention.
When removing lung lesions, it is not uncommon to see a hybrid lesion on pathology, suggesting these represent a spectrum rather than distinct entities.
Intralobar sequestration is within the parenchyma of the lung and shares a common pleura with that lobe, usually the lower lobe.
Extralobar sequestration generally has its own pleural lining and is either completely separate or 90% separate from the lobe.
Sequestrations are classified by having a systemic artery coming into them, generally right off the aorta, either from the thoracic aorta or through the diaphragm from the abdominal aorta.
CT scan at 4 to 6 weeks of age is performed to fully evaluate the lesion; waiting this period reduces atelectasis during the study and allows outpatient scanning, sometimes without general anesthetic.
Dr. Rothenberg has seen multiple children who had normal chest X-ray at birth but later presented at 9 months to 6-7 years with pneumonia and were found to have an infected CPAM.
A plain chest X-ray or ultrasound are not adequate to ensure there is absolutely no lung lesion present; CT scan is required.
Depending on the series, 20-40% of untreated lung lesions will develop a significant infection at some point.
The incidence of malignancy in Dr. Rothenberg's series of lung lesions is over 1%, which he does not consider insignificant.
Dr. Rothenberg prefers to operate by 3 months of age to avoid infection before surgery, because the surgery is technically easier with smaller vessels and fresh anatomy, and to allow compensatory lung growth.
Even in asymptomatic children, waiting until around one year of age often reveals significantly enlarged lymph nodes in the fissures and peribronchial spaces, and inflammation in the fissure, suggesting low-grade infections.
In Dr. Rothenberg's series, hospital stay, chest tube duration, recovery, and operative time were all shorter in patients under 5 kg compared to those under 10 kg.
Most children undergoing early lobectomy are discharged within 48 hours, and by one month post-op on chest X-ray, you cannot tell they had surgery; the remaining lung undergoes compensatory growth.
Blood is typed and crossed for all lobectomy cases; if bleeding occurs, it can be significant and blood should be available.
Most asymptomatic children on room air will tolerate single-lung ventilation without problem.
Single-lung ventilation is obtained by mainstem intubation of the contralateral bronchus (e.g., left mainstem for right lower lobe resection).
Bronchial blockers are difficult to place and add extra time to the procedure; mainstem intubation is preferred and can often be done blindly with positioning.
After lung collapse, all babies will initially desaturate (low 90s to high 80s) for a few minutes due to continued shunting to the collapsed lung; saturations come up once shunting stops.
Anesthesiologists should use lower peak ventilatory pressures to avoid overcoming the pneumothorax or mainstem intubation; if ventilation needs to increase, increase rate rather than pressure.
End-tidal CO2 in the mid-40s during thoracoscopic lobectomy is not a problem and does not cause significant acidosis or deleterious effects.
For lobectomies, the patient is positioned in pure lateral decubitus with the surgeon and assistant standing at the patient's front (toward the nipple), which provides more room from the front of the chest toward the hilum than standing at the back.
The camera port is placed over the major fissure in the mid-axillary line, anterior to the tip of the scapula (not posterior), to allow working from front to back without paradoxical instrument orientation.
A 4mm 30-degree scope (about 20cm length) provides a more wide-angle view comparable to a 5mm scope; short scopes allow the surgeon to get close to the patient without the assistant getting in the way.
Low-profile reusable 3mm ports with small heads are essential in the small space of an infant chest to prevent instruments from banging against each other.
The technique for vessel control is to make two separate seals on the vessel at least 4-5mm apart using a 3mm vessel sealer, then cut partway between the seals to check for bleeding before complete division.
Cutting only partway through a sealed vessel allows recovery if bleeding occurs; complete division without checking loses vascular control.
Using energy devices that seal and cut simultaneously (like Harmonic) is a mistake and sets the surgeon up for trouble; if the device fails, recovery is not possible.
Dr. Rothenberg had a case where using a seal-and-cut device in another country resulted in failure to seal, bleeding, and conversion to open surgery.
For left lower lobectomy, the first step is to take down the inferior pulmonary ligament to check for a systemic vessel and expose the inferior pulmonary vein.
When the fissure is incomplete, complete it layer by layer using vessel-sealing technology, working anteriorly to posteriorly until the pulmonary artery is exposed.
In a lower lobe, the main pulmonary artery trunk bifurcates into four branches to the basal segments, with a superior segmental branch coming off higher and more posteriorly.
The bronchus sits right underneath the pulmonary artery and can be felt to help dissect behind the artery.
For larger vessels with good trunk length, a 5mm stapler can be used on the main trunk instead of isolating four separate basal segment branches, provided proximal control with a clamp is maintained during stapler firing.
When dissecting behind the bronchus to reach the pulmonary vein, stay hard on the backside of the bronchus and be aware the pulmonary vein is immediately behind it.
Never take the pulmonary vein trunk near the pericardium; if the device fails, the vessel will retract into the pericardium and the child will bleed to death before anything can be done. Ensure enough length away from the pericardium for proximal control.
For right lower lobectomy, the technique is the same as left lower lobe but with hands switched; be careful that branches to the middle lobe come off just above the lower lobe artery and can be damaged if dissection migrates too far cephalad.
For left upper lobectomy, the camera port is placed in the 5th intercostal space and working ports may be moved up one space; the lung apex is retracted inferiorly to expose the pulmonary artery as it enters the upper lobe near the apex.
The lingula is almost always taken with an upper lobectomy on the left; on the right, the middle lobe is usually preserved but the technique for isolating the vein is the same.
For right middle lobe resection, complete the minor fissure first; the pulmonary artery enters at the posterior aspect and bifurcates into upper and lower branches.
If the lung has large cysts limiting space and manipulation, use the sealing device to pop the cysts and decompress them at the beginning of the procedure (a lung reduction technique).
Extralobar sequestrations can have up to 6 systemic vessels; Dr. Rothenberg's largest vessel was almost 15mm in diameter.
For sequestration vessels, apply clips proximally and distally with enough length to cut partway between them; alternatively, use vessel sealing with the same partial-cut technique, or use a 5mm stapler for very large vessels (e.g., 15mm).
Never use sealing technology and clips on the same vessel; as the vessel changes with sealing, the clip can lose secure footing and fall off, causing delayed bleeding.
Extralobar sequestrations become infected and can cause problems; embolization requires general anesthetic and significant arterial intervention, whereas thoracoscopic removal has almost no morbidity with no chest tube and next-day discharge.
Dr. Rothenberg has changed his practice to consider segmentectomy in select cases where CT scan shows disease confined to a single segment (easiest for superior segment of lower lobe or lingula) and anatomy is favorable; these patients are being followed but it is not yet widely recommended.
A chest tube is always left overnight after formal lobectomy; if no air leak or significant drainage in the morning, the tube is pulled, chest X-ray is checked in 2 hours, and the child is discharged that afternoon if the family lives in town.
Average length of stay for lobectomy in patients who come in the morning is about 2.5 days, and slightly shorter for patients under 5 kg.
When using the Covidien LigaSure without the 3mm sealer, do not use the cutting function; seal, remove the device, and use scissors to make a partial cut to verify the seal.