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Video-thoracoscopic surgery for encircling and symptomatic aortic arch anomalies in children: a retrospective comparative study versus thoracotomy

Yohann Robert¹,², Pierre Yves Rabattu¹, Youssef Teklali¹, Chantal Durand³, Christian Piolat¹

¹University Clinic of Pediatric Surgery, Children-Couple Hospital, CHU Grenoble, Grenoble, France, ²Laboratory of Anatomy of French Alps, Joseph Fourier University, Grenoble, France, ³Clinic of Pediatric Radiology, CURIM, CHU Grenoble, Grenoble, France

 

Abstract 

Objectives: Symptomatic AAA require surgery usually by thoracotomy. The development of minimally invasive surgery allows for exclusive video-thoracoscopy (VTS). The objective was to determine the feasibility and the safety of VTS.
Methods: We performed a retrospective comparative analysis of morbi-mortality in 26 children with encircling and symptomatic AAA managed between 1992 and 2011. Surgical approach was VTS in 14 children, thoracotomy in 12 children. The secondary end points were operative duration, hospital length of stay, clinical evolution, and radiologic findings.
Results: No mortality was observed. The morbidity was 21.4% and 25% respectively (p=0.8286): 1 transitory chylothorax, 1 transitory recurrent nerve paresis, 1 Kommerell’s diverticulum hemorrhage that have required conversion in VTS group; 1 chylothorax that have required surgery, 1 pneumothorax, 1 transitory Claude Bernard Horner syndrome in thoracotomy group.
Mean operative duration was 132.9 and 137 minutes respectively (p=0.0895). Mean hospital length of stay was 5.5 and 23 days respectively (p=0.0136). Persistent minor symptoms rate was 35.7% and 16.7% respectively (p=0.2603), due to tracheomalacia in 6 patients and one minor dysphagia in a patient operated for esophageal atresia. All chest radiographs diagnosed AAA. Esophagogram, performed in 96.2% of patients, diagnosed 96% of the encircling AAA. Complementary cross-sectional and injected imaging was performed in 20 children (76.9%), including 13 MRI and 7 CT with good anatomical diagnosis in all cases.
Conclusions: The feasibility and the safety of VTS in encircling and symptomatic AAA are conditioned by knowing convert at the slightest doubt. Complementary cross-sectional and injected imaging can help to select surgical approach. A long-term evaluation is necessary to compare with sixty years of thoracotomy experience to answer the question of Kommerell’s diverticulum resection and reimplantation of left subclavian artery as a primary procedure. In the meantime, children who underwent surgery by VTS must benefit from a monitoring of Kommerell’s diverticulum.