Congenital Pulmonary Airway Malformation in Children: Advantages of an Additional Trocar in the Lower Thorax for Pulmonary Lobectomy

Aim: To present the use of an additional trocar (AT) in the lower thorax during thoracoscopic pulmonary lobectomy (TPL) in children with congenital pulmonary airway malformation.Methods: For a lower lobe TPL (LL), an AT is inserted in the 10th intercostal space (IS) in the posterior axillary line after trocars for a 5-mm 30° scope, and the surgeon's left and right hands are inserted conventionally in the 6th, 4th, and 8th IS in the anterior axillary line, respectively. For an upper lobe TPL (UL), the AT is inserted in the 9th IS, and trocars are inserted in the 5th, 3rd, and 7th IS, respectively. By switching between trocars (6th↔8th for the scope, 4th↔6th for the left hand, and 8th↔10th for the right hand during LL and 5th↔7th, 3rd↔5th, and 7th↔9th during UL, respectively), vital anatomic landmarks (pulmonary veins, bronchi, and feeding arteries) can be viewed posteriorly. The value of AT was assessed from blood loss, operative time, duration of chest tube insertion, requirement for post-operative analgesia, and incidence of perioperative complications.Results: On comparing AT+ (n = 28) and AT– (n = 27), mean intraoperative blood loss (5.6 vs. 13.0 ml), operative time (3.9 vs. 5.1 h), and duration of chest tube insertion (2.2 vs. 3.4 days) were significantly decreased with AT (p < 0.05, respectively). Differences in post-operative analgesia were not significant. There were three complications requiring conversion to open/mini-thoracotomy: AT– (n = 2; bleeding), AT+: (n = 1; erroneous stapling).Conclusions: An AT and switching facilitated posterior dissection during TPL in children with congenital pulmonary airway malformation enhancing safety and efficiency.

European Pediatric Surgeons' Association Survey on the Management of Primary Spontaneous Pneumothorax in Children

Aim To evaluate the practice patterns of the European Pediatric Surgeons' Association (EUPSA) members regarding the management of primary spontaneous pneumothorax (PSP) in children. Methods An online survey was distributed to all members of EUPSA. Results In total, 131 members from 44 countries participated in the survey. Interventional approach (78%) is the most common choice of treatment in the first episode, and most commonly, chest tube insertion (71%) is performed. In the case of a respiratory stable patient, 60% of the responders insert chest tubes if the pneumothorax is more than 2 cm. While 49% of surgeons prefer surgical intervention in the second episode, 42% still prefer chest tube insertion. Main indications for surgical treatment were the presence of bullae more than 2 cm (77%), and recurrent pneumothorax (76%). Eighty-four percent of surgeons prefer thoracoscopy and perform excision of bullae with safe margins (91%). To prevent recurrences, 54% of surgeons perform surgical pleurodesis with pleural abrasion (55%) and partial pleurectomy (22%). The responders who perform thoracoscopy use more surgical pleurodesis and prefer shorter chest tube duration than the surgeons performing open surgery (p < 0.05). Conclusion Most of the responders prefer chest tube insertion in the management of first episode of PSP and perform surgical treatment in the second episode in case of underlying bullae more than 2 cm and recurrent pneumothorax. The surgeons performing thoracoscopy use more surgical pleurodesis and prefer shorter chest tube duration than the responders performing open surgery. The development of evidence-based guidelines may help standardize care and improve outcomes in children with PSP.

Persistent air leak (bronchopleural fistula) in neonates

Background: Pneumothorax is a known complication in neonates on ventilation but persistent air leak is infrequently seen in neonates and is troublesome to manage. Persistent air leak on chest tube insertion is suggestive of bronchopleural fistula, often resulting in significant mortality and morbidity. Various modalities of management like multiple chest tube insertions (thoracostomies), selective bronchial occlusion, pleurodesis using talc, tetracycline etc and urgent surgery to repair the leak have been mentioned. Islolated case reports for management of bronchopleural fistula in neonates are abound in literature but consensus and attention should be directed to improve awareness and access to clinical guidelines in management of bronchopleural fistula in neonates. Methods: Our aim was to evaluate the management and outcome of neonates with persistent air leak (bronchopleural fistula). Result: Eighteen neonates with bronchopleural fistula (BPF) were managed from 2012-2018. All neonates were managed by chest tube insertion, and slow suction (10-15cm of H2O). In those patients having persistent pneumothorax despite functioning tube with persistent air leak, second chest tube was inserted in 2nd intercostal space. Five of these patients even had cardiac arrest due to tension pneumothorax but were revived. One neonate required pleurodesis, two expired and remaining improved on multiple chest tube insertion and were discharged. None required selective bronchial intubation or surgery. Conclusion: Tension pneumothorax with persistent air leak on chest tube suggestive of Broncho-pleural fistula is a difficult and a rare problem in neonates. If not timely taken care of it can lead to cardiac arrest but despite cardiac arrest aggressive resuscitation and judicious use of multiple chest tube drainage and slow suction can help these little patients improve.

Clinical Microbiology Perspective of Empyema caused by Streptococcus constellatus in Malignancy Patient: A Case Report

Introduction: Streptococcus constellatus (SC) is commensal bacteria and belongs to Streptococcus anginosus group (SAG). However, SC causes infections especially in patient with underlying diseases. SC empyema is a clinical case that is described in very few studies, especially in Indonesia.Case: A 45-year-old man was admitted to emergency department in Dr. Soetomo General Hospital Surabaya with respiratory insufficiency on November 11th 2020 after 3 months of non-productive cough and a week of weakness. He was diagnosed with empyema on right hemithorax and received chest tube insertion. SC was isolated from pleural fluid sample after first day of culture on Bactec BD bottle. GeneXpert result of pleural fluid was negative for Mycobacterium tuberculosis (MTB). He completed 10 days of intravenous ampicillin-sulbactam and metronidazole. The CT scan reported solid mass of 4.7x7.4x7.8 cm in posterolateral segment of inferior lobe right lung, right pleural effusion, with adenocarcinoma as biopsy result.Discussion: SC is a normal commensal in respiratory tract, however with the presence of a certain factor such as immunocompromised, colonized SAG directly induces an infection after entering normal sterile sites in the body including pleural fluid.Conclusion: Although infection caused by SC is a rare case, it still should be considered in clinical diagnosis and treatment of related infections, particularly in patients with comorbidities. The prognosis was good with appropriate antibiotics and chest tube insertion.