Thoracoscopic Lobectomy for Congenital Cystic Lung Disease in Infants

Background: Congenital cystic lung disease is a congenital disease with abnormal development of the trachea, pulmonary parenchyma and pulmonary vessels. Congenital cystic adenomatoid malformation and pulmonary sequestration are the two main types. With the development of endoscopic technology, congenital pulmonary dysplasia has been alleviated in an increasing number of infants through thoracoscopic surgery. However, the timing of the operation is controversial. Methods: Seventy-two infants with congenital cystic lung disease who underwent thoracoscopic lobectomy from March 2017 to April 2020 were selected as subjects. The data were summarized and analysed, including preoperative complications, operative situation, postoperative recovery, postoperative hospital stay time, etc. All children were followed regularly. Results: Seventy-two patients were aged 3 to 7 months, with an average age of 5.40±2.02 months: 44 were male, and 28 were female, with an average weight of 6.95±1.96 kg. Preoperative condition: 48 patients were observed and operated on when they were between 5 and 7 months old. Twenty-four patients were diagnosed with pneumonia, and thoracoscopic surgery was performed after anti-infective therapy. All children were diagnosed with congenital cystic pulmonary disease with a CT scan before the operation. Postoperative pathological diagnosis showed 50 cases of congenital cystic adenomatoid malformation, 16 cases of intralobar pulmonary sequestration, and 6 cases of both congenital cystic adenomatoid malformation and intralobar pulmonary sequestration. Anaesthesia was performed by articial pneumothorax or bronchial occlusion. The average operative time was 92.17±19.65 min, and the average length of postoperative ventilator assistance was 28.18±11.01 hours. Complications: 3 cases of pneumothorax after the operation and 5 cases of atelectasis, and the incidence of pneumonia was 33%. No bleeding, bronchial pleural stula or other serious complications were observed. All children were followed for 3 months to 2 years. The growth and development of all the children were not different from those of normal children. Conclusions: In study,

patients were observed and operated on when they were between 5 and 7 months old. Twenty-four patients were diagnosed with pneumonia, and thoracoscopic surgery was performed after anti-infective therapy. All children were diagnosed with congenital cystic pulmonary disease with a CT scan before the operation. Postoperative pathological diagnosis showed 50 cases of congenital cystic adenomatoid malformation, 16 cases of intralobar pulmonary sequestration, and 6 cases of both congenital cystic adenomatoid malformation and intralobar pulmonary sequestration. Anaesthesia was performed by arti cial pneumothorax or bronchial occlusion. The average operative time was 92.17±19.65 min, and the average length of postoperative ventilator assistance was 28.18±11.01 hours. Complications: 3 cases of pneumothorax after the operation and 5 cases of atelectasis, and the incidence of pneumonia was 33%.
No bleeding, bronchial pleural stula or other serious complications were observed. All children were followed for 3 months to 2 years. The growth and development of all the children were not different from those of normal children.
Conclusions: In this study, preoperative pneumonia accounted for 23.6% of children. Thoracoscopic lobectomy was effective and feasible for children with congenital cystic lung disease from 3 to 7 months  (Table 1).

Surgical Methods
Anaesthesia was achieved with endotracheal intubation, and bronchial embolization or piezotreatment was performed. Children were placed lying on the healthy side. One 5-mm trocar was positioned in the 8th intercostal space of the midaxillary line as the observation trocar, another 5-mm trocar was positioned in the 7th intercostal region of the posterior axillary line, and a 3-mm trocar was positioned in the 5th intercostal region of the anterior axillary line. The pneumothorax pressure was maintained at 4-8 mmHg with a ow of 1 L/min and was adjusted according to the degree of collapse of the lung. Pulmonary arteries, veins and bronchi were dissected one by one, the blood vessels were fully exposed, and the incomplete ssure was cut off with an ultrasonic scalpel. For BPS, lobectomy was performed after disconnection of the isolated pulmonary artery. After dissecting the pulmonary artery and pulmonary vein, the 8th intercostal incision was enlarged to 12 mm, the trachea of the dysplastic lobe was cut off with an endovascular gastrointestinal anastomosis stapler (ENDO-GIA), and the specimen was removed from the 8th intercostal cavity after being placed into a specimen bag. After lung recruitment and if no air leakage was detected, a closed thoracic drainage tube was indwelled, and the thoracic cavity was closed. Complications: Postoperative pneumothorax occurred in 3 cases and atelectasis in 5 cases, and the incidence of pulmonary infection wan 33%. No haemorrhage, tracheal pleural stula or other serious complications were observed, and all the children were discharged successfully. All the children were followed for 3 months to 2 years. During the follow-up, all the children recovered well. The re-examination of lung CT indicated a good recovery, and the growth, development and activity levels were no different from those of the normal children.

Discussion
Are CCAM and BPS treated surgically? At present, most people believe that CCLD in infants may lead to repeated pulmonary infection and respiratory distress and should be removed by surgery as soon as possible [5]. Clinically, it is generally believed that early or emergency surgery should be performed for those with early symptoms, and selective surgery should be performed for those with no complications.
Tsai et al. [6] performed surgical treatment on 105 infants, and the incidence of postoperative pneumothorax was 2.9%. In our case, 24 patients had recurrent pneumonia, and intraoperative pleural adhesion and hilar lymph node enlargement were found in those 24 patients, which caused certain di culties in dissecting the hilar blood vessels, and old purulent secretions could be seen in the resected lobes.
The timing of surgery for asymptomatic children is controversial. Aziz et al. [7] believe that CCAM may be self-regressive and that infant surgery is risky, so conservative observation should be performed. Eber [8] recommends that in CCLD, pneumonia should be treated early and that surgery should be performed before pneumonia develops. Calvert et al. [9] chose to operate at the age of 3-6 months, which could not only avoid risks such as those associated with surgical anaesthesia in the neonatal period but also avoid long-term complications. We believe that for CCAM and BPS diagnosed by foetal ultrasound, the size and changing nature of lesions monitored by prenatal ultrasound should be regularly reviewed, and postpartum diagnosis should be con rmed by X-ray and CT [10]. After birth, emergency surgery or selective surgery should be decided according to whether the baby has complications and the severity of symptoms. For asymptomatic infants, outpatient follow-up visits should be conducted for regular X-ray and CT re-examination until the age of 3-6 months.
Thoracoscopic lobectomy in children was rst reported by Rothenberg [11] in 2000 and has become extensive worldwide in recent years; recent reports have been in older children, and there are few reports of thoracoscopic lobectomy within the rst year of life. Due to an infant's narrow chest space, intercostal stenosis, di culty with one-lung ventilation and other factors, the operation di culty of infant thoracoscopic lobectomy is increased, which requires the performer to have better operational ability. In our study, 72 infants, with an average operating age of 5.04 months, were all operated on successfully by thoracoscopy.

Conclusions
1. Thoracoscopic lobectomy is effective and feasible for children 3 to 7 months of age with congenital cystic lung disease.
2. According to our data, preoperative pneumonia accounted for 23.6% of children.
3. For extensive pleural adhesion, another assisted incision is more effective and safer for infants.

Declarations
Ethics approval and consent to participate:The hospital ethics committee approval was granted of this article.