4. Discussion
In light of improvements in antenatal ultrasound diagnosis, an increased
number of fetuses are diagnosed with CCAM in utero. In this study, 23
patients were diagnosed with CCAM through prenatal sonography, with a
diagnosis rate of up to 96% (23/24). Most CCAMs are not associated with
severe respiratory symptoms after birth, but approximately 10% of lung
lesions, including CCAMs, will present with symptoms during the neonatal
period 8. Infection is the most common presenting
symptom, as indicated by the patients in this study. Other symptoms
include shortness of breath, respiratory distress, and mediastinal
deviation. The optimal timing for the resection of asymptomatic CCAM
remains controversial, but surgery is the accepted standard for all
symptomatic CCAMs 9,10, and thoracoscopic operations
are safe and feasible, even in neonates11,12. After
the infection subsided sufficiently, we performed surgical treatment of
symptomatic CCAM patients.
This study shows that both thoracoscopic and open resection for
symptomatic CCAM have achieved good clinical outcomes in the neonatal
period. When the two surgical methods are compared under the same
preoperative conditions, thoracoscopic resection results in a shorter
surgical incision and less operative blood loss, but the operation time
is longer. Therefore, thoracoscopic surgery achieved an esthetic effect
consistent with minimally invasive surgery. These clinical results are
similar to those described in the literature4,13,14.
In our experience, neonatal CCAM has a clear boundary with normal lung
tissue and no adhesions caused by repeated infections. The blood vessels
and bronchial tubes are relatively small and can be directly cut off by
an ultrasonically activated scalpel. These characteristics are conducive
to thoracoscopic resection. Thoracoscopic resection of CCAM has one
unfavorable factor: the operation space is small, making it difficult to
perform this operation during the neonatal period. Prior to this, we
performed thoracoscopic operations for congenital diaphragmatic hernia
and extralobar pulmonary sequestration to improve our skills. In
addition, when suturing is difficult, a 3-mm trocar can also be added to
assist. If blood oxygen maintenance is unstable during the operation, it
is necessary to temporarily stop the operation and stop the artificial
pneumothorax.
The extent of surgical resection in the management of CCAM also remains
controversial 15. Muller, CO et
al.16 state that adequate treatment of CCAM in
children requires lobectomy because of poor sensitivity and very poor
negative predictive value of preoperative CT for determining distal
adjacent lesions. Laberge JM et al.6 think that
Lobectomy is recommended in order to prevent postoperative air leaks,
residual disease, and perhaps reduce the risk of some later
malignancies. Fascetti-Leon, F. et al.17 state that
lung-sparing surgery for congenital lung malformations is a safe and
effective method of lung parenchymal preservation in pediatric patients.
If accurately planned in selected patients, lung-sparing surgery does
not carry a higher risk of residual disease and recurrence than
traditional lobectomy. Kim, HK et al.18 report that
the early and late outcomes were excellent even after parenchyma-saving
resection in patients with CCAM, and suggest that parenchyma-saving
resection can be safely performed in selected patients with a
well-confined CCAM lesion and thereby avoiding lobectomy.
In this study, twenty patients underwent a lung-preserving wedge
resection strategy for the treatment of CCAM of the lower lobe. Four
patients underwent lobectomy because the CCAM almost completely occupied
the upper or middle lobe. One early patient had the postoperative
complication of an air leaks, which was cured by continuous thoracic
drainage. We think that this complication was caused by poor wound
healing rather than a problem with the lung preservation strategy
because there was no recurrence in the postoperative follow-up. It may
also have been related to unskilled suturing under thoracoscopy at an
early stage of the procedure, but the complication rate was not
statistically significantly different from that of open resection (P=1).
In conclusion, based on the data and follow-up results of this study, we
believe that thoracoscopic resection is a safe and favorable approach
for treating symptomatic CCAM of the lung in neonates. Compared with
open resection, thoracoscopic surgery has minimal esthetic effects and
does not increase the risk of surgical or postoperative complications.
The lung-preserving resection strategy is feasible for neonatal CCAM
patients. However, the study results are limited because of the small
number of cases. In the next step, we will continue to perform long-term
follow-up and evaluate the respiratory function of these patients.