Pediatric Thoracic Surgery

Pediatric thoracic surgery generally addresses diseases or injuries that affect the area between the neck and the abdomen. University of Arizona pediatric surgeons provide thoracic surgery for both congenital and acquired conditions, including:

• Chest wall anomalies including pectus carinatum and pectus excavatum
• Congenital lung disorders including congenital pulmonary airway malformations (CPAM), bronchogenic cysts, and congenital lobar emphysema (CLE).
• Esophageal atresia/tracheoesophageal fistula (EA/TEF):
• Mediastinal masses
• Pulmonary infection including pneumonias that have a parapneumonic effusion, empyema, or lung abscesses
• Recurrent pneumothorax

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Conditions we treat:

Chest wall anomalies: Chest wall anomalies range from mild to severe and happen when the rib cartilages develop abnormally. These congenital conditions may appear at birth, but they can also first appear later in childhood. In either case, they usually progress rapidly once puberty begins. Two of the most common chest wall deformities include:

• Pectus excavatum: Pectus excavatum, or concave chest, is when the sternum presses inward. In many cases, the condition is only cosmetic, but in more significant situations, the depression can reduce lung capacity and compress the cardiac area. Our providers treat this using either the minimally invasive Nuss Procedure, or in some complicated cases the Ravitch Procedure.
• Pectus carinatum: Pectus carinatum is a protrusion of the breastbone and ribs caused by costal cartilages growing outward and pushing the sternum forward. Pectus carinatum is typically treated first through external chest wall bracing. If bracing is not producing results, surgical repair may be considered.

Congenital lung disorders:

• Bronchogenic cysts: Bronchogenic cysts are not connected to the airway but are typically found in the middle of the airway tree. Typically filled with fluid or mucus, small cysts can be asymptomatic, while larger cysts can press on other chest cavity organs like the trachea, esophagus, or heart. Management of these cysts depend on their size; babies with small cysts may still be able to be delivered routinely.
• Congenital lobar emphysema (CLE): Congenital lobar emphysema leads to the hyperinflation of the lobes of the lungs. The hyperinflation is caused by an obstruction of the airway and can lead to breathing difficulties once the baby is born.
• Pulmonary sequestration: A pulmonary sequestration is a mass of nonfunctioning tissue that develops inside or outside of the lungs. In most cases, surgical removal, or resection, of the tissue is recommended. Pulmonary sequestrations develop their own vascular supply through an anomalous artery connected to the aorta. In rare cases, the anomalous artery diverts too much blood flow away from the rest of the body and can result in heart failure. Pulmonary sequestrations should be surgically removed to prevent complications as the baby continues to grow.
• Congenital pulmonary airway malformation (CPAM): Like pulmonary sequestrations, congenital pulmonary airway malformations are masses of abnormal, nonfunctioning fetal lung tissue. However, they are connected to the airway and can lead to recurring pneumonia, malignant transformation, and impaired normnal lung growth.

Lung lesions and tumors: In addition to congenital lung disorders and other cases of benign lung lesions and tumors, our pediatric surgeons can also provide surgical intervention to help in the treatment of lung cancers like pleuropulmonary blastoma and tracheobronchial tumors.

Esophageal atresia/tracheoesophageal fistula (EA/TEF): EA/TEF happens when the esophagus and the trachea do not develop normally. In most fetuses, the esophagus and windpipe begin development as one tube and then divide into two adjacent passages around four to eight weeks.

• Esophageal atresia is when the upper esophagus does not connect to the lower esophagus and stomach.
• Tracheoesophageal fistula is when the esophagus and the trachea connect abnormally, allowing fluids to get into the airway, which interferes with breathing.
• Almost 90 percent of babies who have esophageal atresia also have a tracheoesophageal fistula. Only a small number of babies have one or the other.

Mediastinal masses: Mediastinal masses are abnormal growths that form in the area of the chest between the lungs, containing the heart, aorta, trachea, esophagus and lymph nodes, among other structures. These masses are more likely to be symptomatic in children by causing obstructive respiratory symptoms. Mediastinal masses can be caused by cysts or tumors, and a biopsy may be needed to determine if the mass is benign or malignant. In some cases, the abnormal tissue may need to be removed either through a resection or, if appropriate, a video-assisted thoracoscopic surgical (VATS) approach.

Pulmonary infection: Pulmonary infections affect the lungs, like pneumonia, and are very common. Many cases of pulmonary infection can be treated fully using medication, but in some cases, surgical care may also be recommended.

Parapneumonic effusion: A parapneumonic effusion occurs when a lung infection spreads to the pleural space between then lungs and the surrounding membrane). This pleural effusion is the build-up of excess fluid with either high or low protein content in the pleura.

• Empyema: In contrast to an effusion, an empyema is the collection of pus in the pleural space. It is also often caused by an infection in the lungs that has spread, like pneumonia.
• Lung abscess: A lung abscess is a necrotizing lung infection characterized by a pus-filled cavity. It can be accompanied by an empyema if the abscess breaks out of the lung and into the pleural space.
• Treatments for effusions, empyema and lung abscesses depend on underlying conditions and severity of fluid accumulation. In some cases, a chest tube may be inserted to drain the fluid. When fluid won’t drain through a chest tube, one surgical intervention that may be considered is video-assisted thorascopic surgery (VATS), a minimally invasive technique that can be used to debride and remove thick fibrous material that may be blocking drainage.

Recurrent pneumothorax: A pneumothorax (aka a collapsed lung), occurs when air gets into the space between the lung and inside of the chest wall. The pressure of this air causes the lung to collapse either partially or completely. Cases of recurrent pneumothorax can be caused by an underlying medical conditions like cystic fibrosis or connective tissue disorders. Pulmonary blebs, small blister-like protrusions in the lungs filled with air, can also rupture and cause a pneumothorax. In some cases, recurrent pneumothorax may be treated with a wedge resection and pleurodesis.

Procedures and Services We Offer:

Biopsy: Biopsies are used to test cells for various pathologies. During a biopsy, a doctor will remove a collection of cells, which is then sent to a pathologist to test for damage or disease.

Lobectomy: A lobectomy is a procedure to remove a lobe of the lung, often used for people who have lung cancer. A lobectomy is usually performed using minimally invasive methods, but sometimes it is also done as an open surgery.

Nuss Procedure: The Nuss Procedure is a minimally invasive surgery for correcting pectus excavatum. During the procedure, the surgeon inserts a customized stainless steel bar that fits the contour of the patient's chest, and when positioned it pushes the sternum outward into the proper position. Over the next couple years, remodeling of that chest leads to correction of the defect over time. The bar is then removed after two to three years.

Pleurodesis: Pleurodesis is a medical procedure that uses various methods to cause the linings of the lung and chest wall to stick together. This is used to prevent fluid or air accumulation in the pleural cavity.

Ravitch Procedure: The Ravitch procedure is an open procedure that includes the following steps: An incision across the chest, mobilization of the pectoralis muscles, and then removal of the problematic cartilage to enable the sternum to be placed in a more appropriate position. In some cases, a small bar will be inserted to keep the sternum in the correct place. Following surgery and during the next two months, the child’s cartilage will regenerate and fix the sternum in its new position.

Resection: A resection is surgery to remove tissue or part or all of an organ.

• Wedge resection: A wedge resection is used to remove a small wedge-shaped portion of tissue, often from the lung.

Video-assisted thoracic surgery (VATS): Video-assisted thoracic surgery can be used to diagnose and treat a variety of conditions impacting the chest area. It is a form of minimally invasive surgery, so it utilizes a camera called a thoroscope, small incisions and special instruments to perform procedures. VATS can be used to perform lobectomies, wedge resections, biopsies, drainage and more.

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