video-assisted thoracoscopic surgery (vats) in children
TRANSCRIPT
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VIDEO-ASSISTED
THORACOSCOPICSURGERY
(VATS)IN CHILDRENO.Brankov, H.Shivachev, R.Drebov,M.Panov, N.Gavrilova
Department of pediatric surgery
University Hospital Pirogov Sofia, Bulgaria
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Clinical material
PERIOD - may 2003 mart 2005
77 children
Age - 10 m - 18 y 57 children with empyema
17 children with spontaneous
pneumothorax 3 children with mediastinal masses
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SPONTANEUS
PNEUMOTHORAX (n = 17)
age 13 - 18 y
16 boys : 1 girl 9 children (52,9%) with 11 VATS
procedures
8 children with percutaneous drainage pig-tail
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Right sided pneumothorax- 1 pt
Leftsided pn - 6 pt
Bilateral pneumothorax - 2
Initial incident - 3
Recidives:
one - 2 two - 3
three and more - 1
SPONTANEUS PNEUMOTHORAX
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According to the classification ofVandershueren RGJRA (1990)
gr(without any changes) - 0
gr (fibrous dystrophic changes) - 2
gr (multiple blebs) 0
V gr (single bullaes, blebs oradhesions ) - 7
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Classification
Tamura M et al ( 2003)
- small single bleb - 1
- multiples large bulla - combination of dispersed bulla 6
Dystrophic changes are excluded
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Surgical tactic
Diffuse dystrophic changes
purse-string suture with Endo-stitch Polisorb3/0, partial apical pleurectomy and fibrin-
glue adhesion (Tissucol) Single or multiple blebs excision and
suture with Endo-stitch Polisorb 3/0,
pleural abrasion and fibrin glue adhesion
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Suture of the blebs n = 7
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Pleural abrasion n = 7
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Apical pleurectomy n = 2
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Fibrin glue insufflation
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Results
Operative time:
Unilateral VATS - 35 - 55 min
Bilateral VATS- 85 - 115 min
Average pleural drainage time - 3,2 days
(3 5)
Average hospital stay 5,4 days(5 - 7)
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Results
Follow-up 5 - 22 months
Without recurrence - 8
Recurrent pneumothorax after 8 months
N = 1Thoracotomy, apical resection, partial
pleurectomy
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Thoracic empyema
Frequency in children - 0,4-6 1000
(Grewal H et al,1999)
2 - 5 % parapneumonic complications
40 50 % of all empyemas are
consequence of complicated bacterialpneumonia
(Oak S et al,2003)
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The parapneumonic pleural complication isdivided on three stages that are not sharplydistinct but gradually one phase merges intoanother
Exudative stage ( 1 - 3 days) Exudate pH> 7,3, Gl > 60mg/dl, LDH
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57 children
17 with VATS and 40 with conventional
thoracotomy age 10 months - 17 years
0 - 1 3,5%
1 - 7
59,6% 7 - 17 36,9%
32 boys : 25 girls
Clinical material
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Term of admission after onset ofdisease - treatment approach
Up to 10 day (26 pts) transcutaneouspig-tail or tube thoracostmy 100 %
From 10 to 20 day (20 pts) 60 % tubethoracostomy and 70 % VATS (primary40 % ; secondary 30 %)
After the 20 day (13 pts) 30 % primaryVATS; 70 % thoracotomy)
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Indication for VATS
All cases of II and IIIdegree
Multiloculated
effusion Ineffective pleural
drainage
Separated empyema
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Relative contraindication: fibrothorax, requiringopen thoracotomy
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DEBRIDEMENT, SANATIO 15 children
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DECORTICATION- 2 children
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pig- tail
1933,3%
tube drainage
1628,1%
VATS
1729,8%
Thoracotomy
58,8%
Redo tube drainage 3 5
Average drainagetime
7 10,9 5,4
Secondarythoracotomy
5(31,2%)
4(23,5%)
Redo thoracotomy 1 (6,2%)Average drainage
time 16 3,8 10,4Average hospital
stay14,8 27 10,5 17,4
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Biopsy of mediastinal masses
Operating time 35 min
Duration of the drainage 24 h
Hospital stay 3 days
100% confirmed diagnosis
(Comparatively thepercutaneous needle biopsy hasonly 28% diagnosticsignificance)
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ADVANTAGES OF VATS
Less traumatic method
Exact diagnosis
Decreased postoperative complications Low duration of drainage
Comfortable postoperative period
Early rehabilitation Shorter hospital stay