Thoracic sequels after thoracotomies in children with congenital cardiac disease

Abstract

a relatively common surgical approach for closed procedures in infants and children with congenital cardiac malformations. This approach results in division of the latissimus dorsi and serratus anterior muscles. Division of these muscles can result in significant postoperative pain, diminished pulmonary function, and marked impairment of motion.The thoracotomy incision may also result in longterm physical impairment and deformity. Scoliosis has been reported to develop with an incidence of 22% several years after left posterolateral thoracotomy for correction of aortic coarctation in infancy and childhood. 1 The long-term musculoskeletal consequences of thoracotomy for surgical treatment of congenital cardiac disease, however, have seldom been evaluated. [2][3][4][5][6] With this in mind, we sought to determine whether a posterolateral thoracotomy performed in children with congenital cardiac disease influences the postoperative anatomy and function of the musculoskeletal system. Materials and methodsWe evaluated 49 children, 28 boys and 21 girls, undergoing surgery through a posterolateral thoracotomy in the forth-intercostal space for treatment of congenital cardiac disease at Hacettepe University Hospital. An additional median sternotomy was needed in 9 (18%) of the patients.By means of a general clinical examination and radiological studies, we evaluated thoracic symmetry, Cardiol Young 2003; 13: 264-267 Abstract The standard surgical approach for closed heart procedures in small infants and children is to use a posterolateral thoracotomy incision, which results in the division of the latissimus dorsi and serratus anterior muscles. The aim of our study was to determine the frequency and type of musculoskeletal deformities in children undergoing surgery with this approach for congenital cardiac disease.We included 49 children, 28 boys and 21 girls, in the study. Their mean age was 10.2 Ϯ 4.8 years, the mean age at the time of surgery was 3.8 Ϯ 4.0 years, and they were evaluated at an average of 6 years after the thoracotomy. Of the patients, 94% had various musculoskeletal deformities. Scoliosis was observed in 15 patients (31%) but only in two patients did the curves exceed 25 degrees. Of these patients, three-fifths had aortic coarctation. Elevation of the shoulder was seen in 61%, winged scapula in 77%; while 14% had asymmetry of the thoracic wall due to the atrophy of the serratus anterior muscle. Deformity of the thoracic cage was observed in 18%; and 63% had asymmetry of the nipples.Thus, we found that musculoskeletal deformities are frequent after thoracotomies in children with congenital cardiac disease. Patients who have undergone such procedures for cardiac or noncardiac surgery should be followed until their skeletal maturation is complete. Techniques sparing the serratus anterior and latissimus dorsi muscles should be preferred. These adverse effects of thoracotomy may be another reason for using interventional procedures in these cases.

Video-assisted thoracoscopic lobectomy in infants☆

“…Some authors favor a non-operative attitude considering the risks and eventual complications of a thoracotomy [7], with lung resection, and the possibility of spontaneous resolution in some cases [3,4]. Postnatal imaging studies have shown that regression is rare in the cystic type lesions [5].…”

“…Pulmonary lobectomy via a posterolateral thoracotomy incision has been the standard surgical procedure. The associated morbidity of this approach in small infants has even questioned the need of resection itself [7]. In the recent years, thoracoscopy (VATS) has become an increasingly important tool in pediatric surgery and, as technology improves, more technically demanding procedures can be performed in small children [6,[8][9][10][11]].…”

Muscle sparing thoracotomy in pediatric age: a comparative study with standard posterolateral thoracotomy

“…This incidence would be higher, if the follow-up time could be longer. Patients who have undergone such procedures for cardiac or noncardiac surgery should be followed until their skeletal maturation is complete [9]. A computerized tomography based study demonstrated that severe unilateral atrophy of latissimus dorsi muscle ipsilateral to the operative side was due to denervation injury [10].…”

Thoracoscopy in the management of congenital lung diseases in infancy

“…The principal advantage of thoracoscopy over thoracotomy [4] is reduced postoperative pain, shorter chest tube duration, shorter hospital stay, and better cosmetic results. The main benefit is the reduction of long-term morbidity [13] including scoliosis, shoulder weakness, and chest wall deformity.…”

“…The main advantage is reduced long-term morbidity [4,13], namely, a lower incidence of scoliosis, shoulder weakness, and chest wall deformity.…”