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Ann Thorac Surg 2005;79:632-635
© 2005 The Society of Thoracic Surgeons
Unidad de Cirugia Cardiovascular de Guatemala (UNICAR), Guatemala Ciudad, Guatemala
Accepted for publication July 14, 2004.
* Address reprint requests to Dr Vida, Unidad de Cirugia Cardiovascular de Guatemala (UNICAR), 9 Avenida, 8-00, Zona 11, Guatemala Ciudad, Guatemala (E-mail: vladimirovida{at}interfree.it).
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Abstract |
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METHODS: Between August 1999 and December 2003, 513 patients with PDA were admitted to Unidad de Cirugia Cardiovascular de Guatemala, of whom 327 (64%) were considered surgical candidates. Of these, 218 (67%) were selected for surgical extrapleural (SEP) closure initially by weight (< 10 kg) and a ductal diameter at the pulmonary end of greater than 4 mm. Subsequently, we included also patients who weighed more than 10 kg. Median age at operation was 51 months (range 5 days to 38 years).
RESULTS: Median operating time was 32 minutes (range 23 to 52 minutes). All 218 patients had SEP closure and were extubated in the operating room. There were no hospital deaths. Two patients required a blood transfusion. Two additional patients bled postoperatively, requiring reoperation. A pneumothorax occurred in 3 patients that required a chest tube. The 6-month follow-up revealed residual ductal shunts in 2 patients that were closed percutaneously with a coil. The treatment of the remaining 295 patients included a surgical transpleural (STP) approach in 109 (37%) and transcatheter closure in 186 (63%), with a coil in 110 (37%) and an Amplatzer device in 76 (26%).
CONCLUSIONS: Minimally invasive closure of a PDA through a short, 3-cm to 5-cm skin and muscle-sparing posterior thoracotomy and an SEP approach provides a convenient and safe technique with a low incidence of complications and also a cost-saving option compared with other invasive techniques.
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Introduction |
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On August 26, 1938, Gross and Hubbard [3] accomplished the first successful surgical ligation of a PDA in a 7 year-old girl. In 1967 Honda and colleagues [4] proposed a surgical extrapleural (SEP) technique for PDA closure. An alternative approach to surgical treatment of this lesion was first introduced in 1971 by Portsman and colleagues [5], who used a catheter-delivered occlusive device for the percutaneous closure of a PDA. In 1993 Laborde and collaborators [6] reported the first video-assisted thoracoscopic closure of a PDA.
We report our experience in Guatemala between August 1999 and December 2003 with closure of PDAs through a minimally invasive muscle-sparing thoracotomy and an SEP approach. The principle aim was to explore a simple and safe surgical technique that had the additional potential for decreasing hospital stay and cost.
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Material and Methods |
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TopAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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The options available for PDA closure in our institution included either SEP or STP ligation or transcatheter occlusion (coil or an Amplatzer device). Selection criteria for surgical closure versus transcatheter occlusion of the PDA included the patient's weight and ductal diameter as summarized in Fig 1. Initially patients were selected for SEP closure by body weight (< 10 kg) and a ductal diameter at the pulmonary end of greater than 4 mm. Eventually the indications for a SEP approach were expanded to include patients weighing more than 10 kg (Fig 1). Subsequently, we transferred patients weighing more than 20 kg to a STP closure rather than the SEP approach because of more adherent parietal pleura in these patients and a consequently a higher incidence of pleural tears causing pneumothorax and bleeding requiring reoperation.
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In a right lateral decubitus position and through a limited subscapular skin- and muscle-splitting incision, the superficial thoracic fascia muscularis was incised. After incising the periosteum of the fifth rib, the parietal pleura were detached with blunt dissection from the thoracic wall. Once the aorta was exposed, the left hemiazygos vein was divided and the PDA was dissected from the surrounding tissues; the left recurrent laryngeal nerve was also identified. The ductus was encircled with two silk sutures and than doubly ligated, leaving sufficient space between the two ligatures to allow the placement of a 10-mm titanium clip to ensure triple occlusion of the ductus.
After adequate hemostasis was obtained, and excluding an accidental tear of the visceral pleura, the lung was expanded to prevent air entrapment within the extrapleural space and the chest was closed without the use of chest drainage. All patients were extubated in the operating room and were than transferred directly to the ward. Antibiotic prophylaxis consisted of a single dose of cefazolin (50 mg/kg) administrated in the operating room at induction. Pain relief was achieved in all with nonsteroid antiinflammatory medications (ketorolac, 1 mg/kg every 8 hours as needed).
The patients were routinely discharged home, commonly after 24 hours and after a clinical examination, chest roentgenogram, and an echocardiogram, which was also repeated 6 months after the operation.
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Results |
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Two patients bled during the operation (0.9%) and required a blood transfusion. Two other patients bled postoperatively, which necessitated surgical evacuation of an extrapleural hematoma. Three patients (1.4%) developed a pneumothorax and required a chest tube. All 7 patients with the described intraoperative or postoperative complications weighed more than 20 kg. The median postoperative stay was 1 day (1 to 4 days). There were no hospital deaths. In 2 patients late postoperative echocardiograms revealed residual shunts at the ductus level that were occluded successfully with coils. None of the patients had recurrent laryngeal nerve damage.
The procedures used in the remaining 295 patients referred to our institution for PDA closure who did not fulfill our selection criteria for the minimally invasive SEP technique, and the costs in US $ of the various techniques, are summarized in Table 1.
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Comment |
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The described minimally invasive SEP operation avoided some, albeit uncommon, late complications reported after a conventional STP technique such as scoliosis, a winged scapula, chest wall deformities, breast disfigurement, and rib fusion with secondary respiratory compromise [7–9].
Furthermore, the SEP approach offers excellent surgical exposure of the PDA irrespective of size and also allows direct visualization of the left recurrent laryngeal nerve and of the thoracic duct (in its extrapleural course), thus avoiding complications such as recurrent nerve injury or chylothorax. None of these complications occurred in this series.
The principal goal in the management of an uncomplicated PDA is to interrupt early the left-to-right shunt. This prevents chronic left ventricular volume overload and pulmonary hypertension and the consequent development of pulmonary vascular obstructive disease [2]. As reported by Zanardo and colleagues [10] and Brickenberg and colleagues [11], early PDA closure is advocated even in small PDAs without homodynamic significance (silent ductus) to avoid the risks of (uncommon) late bronco-pulmonary dysplasia [10] or infectious endocarditis [11]. Because of a very high incidence of dental neglect and poor basic sanitary conditions among the indigent children in Guatemala, the risk of developing infectious endocarditis is great.
Percutaneous catheter closure of PDAs had been favored since 1971 [6]. The initial absolute weight limitation of candidates for a transcatheter occlusion has by now been mostly overcome. Presently, children weighing as little as 4.5 kg are being treated by percutaneous techniques [15–17]. However, residual shunts through incompletely percutaneously occluded ducts have been reported to vary from 3% to 26% at 12 months follow-up. Persistent residual shunts seem to occur more often in larger-sized PDAs [12–14].
Migration or embolization of a dislodged occluding device is a complication that occasionally requires surgical removal [12–15]. Hemolysis may also occur from a periprosthetic residual shunt [15–16], and prophylaxis against infectious endocarditis is also recommended. Other complications of percutaneous techniques include femoral artery injuries, arteriovenous fistulas, partial left pulmonary artery obstruction caused by protruding coils into the vessel lumen, and vocal cord paralysis [17].
Because of intraoperative and postoperative complications such as pneumothorax (1.4%) and bleeding (0.9%) after the SEP technique in children weighing more than 20 kg, we decided to select instead the STP approach in this group of patients. We believe that these complications could be due to the more adherent parietal pleura to the thoracic wall in older children.
The 2 patients with a residual shunt at the ductus level after SEP closure had a large PDA (> 1 cm at the pulmonary end). In both, early in our experience, we occluded the ductus only with a double ligature, without placing a titanium clip to ensure triple occlusion. Now we recommended the use of a clip in all cases, However, in patients with a ductus larger than 1 cm, division of the PDA should be considered to make absolutely sure any residual shunt has been eliminated.
As reported by others [19–23], we are equally convinced that the modification of the original SEP technique for closure of a PDA, including a limited skin- and muscle-sparing incision and triple occlusion of the PDA, is a safe technique that offers a valid alternative, in selected patients, to other more recent minimally invasive techniques.
Video-assisted thoracoscopic surgery, according to numerous reports [5–18], offers excellent operative results for PDAs smaller than 1 cm in diameter. However, video-assisted thoracoscopic equipment is not yet available in our unit because of cost considerations.
This short SEP procedure with no need for intensive care and a hospitalization of only 24 hours allowed our unit a cost saving of US $292.00 compared with the traditional STP approach (Table 1). Comparing the SEP technique to percutaneous procedures, for example using a single coil, the cost saving amounted to US $180.00, whereas the use of an Amplatzer device increased the cost by US $2689.00.
Concerning the transcatheter occlusion of the PDA with coil, 69 patients (63%) required 1 coil and 30 patients (27%) required 2 coils, representing an additional cost with respect to the SEP surgery of US $389.00. Eight patients (7%) required 3 coils (US $482.00), 2 patients (2%) 4 coils (US $755.00), and 1 patient (1%) 5 coils (US $832.00). Clearly the Amplatzer device or the need for multiple coils does not prove cost-effective compared with surgical ligation either by a SEP or even a STP approach.
The minimally invasive skin and muscle splitting SEP technique proved safe, effective, more cosmetic, and significantly less expensive, and therefore continues to be favored in our third world Pediatric Cardiac Unit in Guatemala.
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Acknowledgments |
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V. L. Vida and A. R. Castaneda Reply Ann. Thorac. Surg., November 1, 2005; 80(5): 1976 - 1977. [Full Text] [PDF]
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