Thoracoscopic surgery for symptomatic congenital lung malformations in neonates: A retrospective study of 36 cases

Thoracoscopic surgery for symptomatic congenital lung malformations in neonates: A retrospective study of 36 cases | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Thoracoscopic surgery for symptomatic congenital lung malformations in neonates: A retrospective study of 36 cases Huiyu Xu, Mingbing Zhou, Weibing Liao, Jiequan Li, Jiezhong Xie, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6467699/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Jul, 2025 Read the published version in BMC Pulmonary Medicine → Version 1 posted 12 You are reading this latest preprint version Abstract Objective: To summarize and analyse the efficacy of minimally invasive thoracoscopic surgery for neonatal symptomatic congenital lung malformations (CLMs). Methods: The clinical data of 36 newborns (aged <=28 days) with symptomatic CLMs who underwent thoracoscopic surgery at Foshan Women and Children’s Hospital from April 2017 to May 2023 were retrospectively analysed. Results: Among the 36 patients, 33 had neonatal pneumonia before the operation, 8 had tachypnea with or without respiratory distress at birth, 3 had weak breathing and cyanosis requiring assisted ventilation and 1 had mediastinal displacement due to large lung lesions. Lobectomy was performed in 6 CPAM patients and 7 patients with extralobar sequestration, and lung-sparing resection was performed in 13 CPAM patients and 10 patients with intralobar sequestration. The median surgical incision length was 1.4 cm (1.3–6.0 cm), the median operative blood loss was 2 ml (1–20 ml), and the median operative time was 132 min (33–220 min). Conclusion: Thoracoscopic surgery for symptomatic CLMs can achieve good clinical results in neonates, and lung-sparing resection may be feasible. Neonate Congenital lung malformations Thoracoscopic Figures Figure 1 Introduction Congenital lung malformations (CLMs) refer to various types of lung structural defects caused by abnormal lung bud branches and alveolar development during embryonic development. It mainly includes congenital pulmonary airway malformation (CPAM), bronchopulmonary sequestration (BPS), congenital lobar emphysema (CLE) and other subtypes[ 1 ]. The incidence rate reported in the literature ranges from 1/10,000 to 1/35,000 live births. With the advancements in prenatal diagnostic technology and imaging technology, the clinical diagnosis rate has shown a significant upwards trend in recent years[ 2 , 3 ]. The clinical manifestations of CLMs vary greatly. Some children have asymptomatic lesions accidentally found via chest radiography, whereas some children have symptoms such as acute respiratory distress, shortness of breath and mediastinal compression at birth, which require emergency surgery[ 4 , 5 ]. At present, whether asymptomatic CLMs require surgery in the neonatal period is still controversial, but surgery for symptomatic CLMs is a more widely accepted standard and is performed in the neonatal period[ 6 , 7 ]. For symptomatic neonatal CLM patients, medical support is provided first, and surgical treatment is performed after evaluation when clinical symptoms disappear. CLMs can be treated by thoracotomy or thoracoscopic surgery. Thoracoscopic surgery is less invasive, has minimal effects on appearance, and is quick to recover from[ 8 ]. However, there are few reports on the treatment of CLMs by thoracoscopic surgery in neonates. In this paper, we retrospectively study 36 CLM patients that underwent thoracoscopic surgery to summarize our experience and evaluate the efficacy of this treatment. Methods The data of 36 newborns (aged < = 28 days) with symptomatic CLMs who underwent thoracoscopic surgery at the Affiliated Foshan Women and Children’s Hospital, Guangdong Medical University, from April 2017 to May 2023 was analysed in this retrospective study. The pathological findings for all patients were CLMs. The medical records were reviewed, and preoperative, intraoperative and postoperative clinical indicators were statistically analysed. Preoperative variables included sex, gestational age at birth, birth weight, head circumference, CLM location, lesion size, age at surgery and respiratory symptoms. The intraoperative variables included surgical incision length, operative blood loss and operation time. Postoperative variables included duration of postoperative ventilator support, duration of postoperative chest tube indwelling, duration of postoperative hospital stay and postoperative complications. This clinical study was approved by the Medical Ethics Committee of the Affiliated Foshan Women and Children Hospital, Guangdong Medical University (FSFY-MEC-2024-129). Neonates with symptomatic CLMs should receive medical treatment first, and surgery should be scheduled after clinical symptoms resolve, such as for patients in which pneumonia resolves and those without respiratory distress or shortness of breath without the need for oxygen inhalation. A chest CT examination was performed in all the patients, and 3D CT 3D colour visual reconstruction was performed to better determine the extent of the lesion and provide better assistance for surgery (Fig. 1 ). Before the operation, the surgical team discusses in detail the extent of the lesion on the basis of the chest CT and the surgical treatment plan and decides whether to perform lobectomy or lung-sparing surgery. The surgical position and direction of the surgical approach (head side or diaphragmatic side) are then determined (Fig. 1 ). Preoperatively, a central venous catheter and a urinary catheter are routinely placed. The anaesthesia methods used are general anaesthesia, endotracheal intubation, and non-one-lung ventilation. The patient is placed in a semiprone position with the affected side elevated to facilitate exposure of the lesion. Thoracoscopic surgery generally uses a three-port method (2 × 5 mm, 1 × 3 mm), and a 5 mm Olympus integrated thoracoscopy system is typically used. Nontraumatic forceps are used as instruments to reduce lung tissue damage and bleeding. The three-port method for the head‒side approach involves the following steps: A 5 mm thoracoscopy port is placed below the inferior angle of the scapula. The second 5 mm operating port is placed at the 5th intercostal space along the posterior axillary line, and the third 3 mm operating port is placed at the 5th intercostal space along the parascapular line. Three-port method for the diaphragmatic-side approach: A 5 mm thoracoscopy port was placed at the 8th intercostal space along the scapular line. The second 5 mm operating port is placed at the 8th intercostal space along the posterior axillary line, and the third 3 mm operating port is placed at the 8th intercostal space along the parascapular line. All the trocars are first covered with a small piece of rubber band and then sutured and fixed to prevent them from being pulled out. The carbon dioxide pressure is 3–5 mmHg. During lung-sparing surgery, an ultrasonic scalpel is routinely used for lesion resection, and the lung surface is sutured with a 4–0 absorbable suture. In lobectomy, hemilock clips are used to clamp the main vessels, and the main bronchus is ligated with silk thread. The sample is divided into small pieces and removed through the operating port. A closed thoracic drainage tube is routinely placed. Postoperatively, antibiotics are used routinely to prevent infection, and a ventilator is used to provide respiratory support. When the patient's condition is stable, the ventilator and the thoracic drainage tube are removed. Results Clinical data and patient characteristics Among the 36 patients, 17 were male and 19 were female. Prenatal ultrasound diagnosis was made for 34 patients. The most common respiratory symptoms in postnatal CLMs patients were pneumonia, tachypnea with or without respiratory distress and cyanosis. Among the 36 patients in this group, 33 had neonatal pneumonia before surgery. Eight patients had tachypnea with or without respiratory distress at birth, 3 patients had weak breathing and cyanosis requiring assisted ventilation, and 1 patient experienced a mediastinal deviation due to extensive lung lesions. The lesions were located on the left side in 24 patients and on the right side in 12 patients; the lesions were located in the upper lobe in 4 patients; and the lesions were located in the lower lobe in 32 patients. Surgical methods: Six patients with CPAM underwent lobectomy due to lesion involvement of the entire lobe, 7 patients with extralobar sequestration underwent resection of the affected lobe, and 13 patients with CPAM and 10 patients with intralobar sequestration underwent lung-sparing surgery. The final pathological results revealed 19 cases of CPAM, 10 cases of intralobar sequestration and 7 cases of extralobar sequestration; 1 patient developed bronchopleural fistula after surgery, and 1 patient developed chylothorax after surgery, both of which healed spontaneously after conservative treatment. The surgery of 1 patient was converted to thoracotomy because of the inability to maintain blood oxygen during the operation, and the surgery of 1 patient was converted to thoracotomy because of intraoperative bleeding. There were no deaths (Table 1 ). Table 1 Patient population and characteristics of the 36 patients Sex (male/female) 17:19 Prenatal ultrasound diagnosis 34 Respiratory symptoms Neonatal pneumonia 33 Tachypnea with or without respiratory distress 8 Weak breathing and cyanosis requiring assisted ventilation 3 Mediastinal deviation 1 Laterality (left-sided/right-sided) 24:12 CLM location Upper 4, lower 32 Resection method Lobectomy 6 patients with CPAM, 7 patients with ELS Lung-sparing resection 13 patients with CPAM, 10 patients with ILS Pathology 19 patients with CPAM, 10 patients with ILS, 7 patients with ELS Postoperative complications 1 case of air leak, 1 case of chylothorax CLMs, congenital lung malformations; CPAM, congenital pulmonary airway malformation; ILS, intralobar sequestration; ELS, extralobar sequestration Results for the clinically relevant variables of thoracoscopic surgery In this group of cases, the relevant preoperative variables were as follows: median gestational age, 39.3 weeks (range: 34.1–41.1 weeks); median birth weight, 3145 g (1830–4270 g); median head circumference, 33 cm (30–37 cm); median lesion size, 24.00 cm³ (3.40–300.00 cm³); and age at surgery, 8 days (4–21 days). The relevant intraoperative variables included the following: median surgical incision length, 1.4 cm (1.3 to 6.0 cm); median operative blood loss, 2 ml (1 to 20 ml); and median operative time, 132 minutes (33 to 220 minutes). The postoperative variables included the following: median duration of postoperative ventilator support, 3 days (1–7 days); median duration of postoperative chest tube indwelling, 7.5 days (0–22 days) (with no chest tube placed in patients undergoing extralobar sequestration); and median duration of postoperative hospital stay, 11.5 days (4–25 days) (Table 2 ). Table 2 Related variables Related variables Median (range) (N = 36) Preoperative: Gestational age at birth (w) 39.3 (34.1–41.1) Birth weight (g) 3145 (1830–4270) Head circumference (cm) 33 (30–37) Lesion size (cm 3 ) 24 (3.4–300) Age at surgery (d) 8 (4–21) Intraoperative : Surgical incision length (cm) 1.4 (1.3-6.0) Operative blood loss (ml) 2 (1–20) Operative time (min) 132 (33–220) Postoperative : Duration of postoperative ventilator support (d) 3 (1–7) Duration of postoperative chest tube indwelling (d) 7.5 (0–22) Duration of postoperative hospital stay (d) 11.5 (4–25) w, weeks; g, grams; cm, centimetres; d, days; ml, millilitres; min, minutes We followed the patients either in the clinic or by telephone for a median of 36 months (6–94 months), and none of the patients had shortness of breath, dyspnoea on exertion, recurrent pneumonia, or neurological retardation during follow-up. We performed postoperative CT or X-ray examinations, and there were no cases of postoperative recurrence. Discussion Congenital lung malformations (CLMs) account for 5–18% of all congenital malformations[ 9 ]. The classification of CLMs is complex. These include congenital pulmonary airway malformation (CPAM), pulmonary sequestration(PS), congenital lobar emphysema (CLE) and other subtypes [ 1 , 10 ]. In recent years, with the development of foetal ultrasound and foetal magnetic resonance imaging technology, the understanding of foetal lung diseases has gradually increased, and the incidence of CLMs has increased in recent years [ 3 , 11 ]. The overall survival rate of patients with CLMs has significantly increased from 60% to more than 95% owing to advances in prenatal diagnosis and clinical treatment, which have reduced the risk of circulatory failure and death caused by pulmonary hypoplasia[ 12 ]. Patients with main diseases, CPAM and PS, were studied by our group. Most CLM patients have no obvious respiratory symptoms after birth, and some patients are only incidentally diagnosed during chest X-ray examination, but approximately 10% of them have respiratory symptoms in the neonatal period[ 13 ]. CLM patients with severe lesions have critical clinical symptoms immediately after birth. For example, acute respiratory distress, shortness of breath, asphyxia, and congenital pneumonia require tracheal intubation for rescue, mainly because the compression of the mediastinal mass by CLMs affects the breathing and circulation of the child. In this group of cases, the most common symptoms were neonatal pneumonia, tachypnea, respiratory distress and mediastinal shift, which are consistent with reports in the literature[ 4 , 14 ]. At present, the optimal timing of surgery for asymptomatic CLMs is still controversial, but surgery for symptomatic CLMs is currently recognized as the standard[ 5 , 15 ]. The surgical methods for treating CLMs can be divided into traditional thoracotomy and thoracoscopic surgery. Traditional thoracotomy for the treatment of severe trauma, bleeding, and long recovery times can cause thoracic deformity, incisional hernia, severe scar hyperplasia and other complications. With the development of thoracoscopic technology, thoracoscopic treatment of CLMs has advanced rapidly, and thoracoscopic surgery is a safe and feasible method for the treatment of CLMs that causes minimal trauma, has minimal aesthetic effects and leads to rapid postoperative recovery, even in the neonatal period[ 5 – 7 ]. Our approach was to first provide medical support to symptomatic neonatal CLM patients. After the symptoms subsided sufficiently, we performed surgical treatment. Specifically, we surgically treated patients who exhibited pneumonia resolution and elimination of respiratory distress or shortness of breath without relying on supplemental oxygen[ 16 ]. For patients with asymptomatic CLMs, we opted for regular observation and follow-up. This study shows that the use of minimally invasive thoracoscopic techniques in the treatment of symptomatic CLMs in neonates has achieved good clinical results, and thoracoscopic surgery has achieved suitable results with minimal trauma and no thoracic deformity. These clinical results are similar to the results described in the literature [ 7 , 17 , 18 ]. In our experience, the advantages of thoracoscopic surgery for CLMs in the neonatal period are that CLMs have a clear demarcation with normal lung tissue, no adhesion caused by repeated infections, and that the vessels and small bronchi are relatively small and can be directly cut off with ultrasonic scalpels, features that facilitate successful completion of the operation. Thoracoscopic CLM resection in the neonatal period also has several disadvantages: a small operation space, brittle tissue, easy bleeding, and relatively high requirements for the surgeon. Our experience is that pulmonary sequestration is relatively easier to treat than CPAM and can be used as the first condition to evaluate neonatal thoracoscopy techniques in. After the technique is improved, CPAM can be treated. In addition, lateral CPAM is relatively easier to treat than medial CPAM. First, simple CPAM cases can be selected, and thoracoscopy can be performed, which is helpful for reducing surgical complications. In addition, a 3-mm clamp can be added to assist in performing the exposure when suturing is difficult. If the intraoperative blood oxygen level is temporarily unstable, the operation and artificial pneumothorax can be temporarily stopped, and surgical treatment can be continued after blood oxygen level is restored [ 16 ]. In addition to extralobar pulmonary sequestration, surgical resection for the treatment of CLMs is also controversial. The main methods of surgical treatment for CLMs include lobectomy, segmentectomy and lesion resection. At present, the standard treatment method is lobectomy[ 19 – 21 ]. Muller CO et al. noted that adequate treatment of CPAM in children requires lobectomy because preoperative CT has very low sensitivity for identifying distal adjacent lesions and very low negative predictive value[ 20 ]. Laberge JM et al. reported that to prevent postoperative air leakage and residual disease and possibly reduce the risk of some advanced malignancies, lobectomy is recommended for the treatment of CLMs[ 22 ]. The other treatment option is lung-sparing resection (LSR), which includes segmentectomy and pulmonary lesion resection. Segmentectomy entails the accurate removal of the segmental tissue involved in the lesion through anatomical separation of the segmental blood vessels and bronchial tissue structure while the normal lung tissue of the other segments in the lung lobe is retained. However, this operation is difficult to perform during the neonatal period because of the slender blood vessels and bronchi in neonates. Lung lesion resection removes only the lung tissue involved in the lesion along the boundary between the lesion and normal lung tissue, which is a common surgical method for the treatment of CLMs in the neonatal period[ 21 , 23 , 24 ]. Fascetti Leon F et al. reported that lung preservation surgery for CLMs is a safe and effective method for preserving the lung parenchyma in paediatric patients. If accurate planning is performed in selected patients, lung-sparing surgery does not carry a greater risk of residual disease and recurrence than conventional lobectomy does[ 21 ]. Kim HK et al. reported excellent early and late prognoses even after lung-sparing resection in CLM patients and indicated that it can be performed safely in selected patients with very narrow CLM lesions, thereby avoiding lobectomy[ 25 ]. In our group of patients, 23 patients underwent lung-sparing resection to treat lower lobe CLMs, which preserved healthy lungs and achieved good clinical results. In addition to the seven patients that underwent extralobar sequestration, six patients underwent lobectomy because their lesions almost or completely occupied the lobes, limiting the use of a LSR strategy. To reduce postoperative complications such as bronchopleural leakage and pneumothorax, we closed the lung wound with 4–0 absorbable sutures in addition to ligating the larger bronchi. Moreover, on the basis of experience and reports in the literature, we extended the duration of chest tube use accordingly[ 17 ], but we chose not to place thoracoscopic drainage tubes in patients with ELS. In the present study, one patient developed early postoperative air leakage complications, which were cured by continuous thoracic drainage. We considered that this complication was caused by poor wound healing rather than a problem with the lung preservation strategy because there was no recurrence during postoperative follow-up. However, this may also be related to unskilled suturing in the early stage of the thoracoscopy surgery. In summary, on the basis of the data and follow-up results of this study, we believe that thoracoscopic surgery for symptomatic CLMs achieves good clinical results without increasing the risk of surgical or postoperative complications, even when performed in the neonatal period. A lung preservation resection strategy may be suitable for neonatal CLMs. However, the results of this study are limited by the small sample size. In the next step, we will continue to conduct long-term follow-up to evaluate the respiratory function, growth and development of these patients. Abbreviations CLMs: congenital lung malformations, CPAM: congenital pulmonary airway malformation; PS: pulmonary sequestration. ILS, intralobar sequestration; ELS, extralobar sequestration; LSR: lung-sparing resection Declarations Ethics approval and consent to participate Ethical approval was obtained from the Medical Ethics Committee of The Affiliated Foshan Women and Children Hospital, Guangdong Medical University, Guangdong, China (FSFY-MEC-2024-129). All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Ceclaration and its later amendments or comparable ethical standards. Informed consent was obtained from the parents of the enrolled patients before thoracoscopic surgery. Consent for publication Not applicable. Competing interests The authors declare that no conflict of interest exists. Funding This study was funded by the Guangdong Medical Research Fund project (No. A2022437) and Science and Technology Planning Project of Guangzhou (No. 202206080002) Author Contribution JZ was responsible for the conception and design of the study. MZ, JL and WL were responsible for the acquisition of data. HX and JX were responsible for the analysis and interpretation of data. JZ and MZ were responsible for drafting the article and critically revising it for important intellectual content. All authors read, revised and approved the final manuscript. Data Availability Data is provided within the manuscript and in the manuscript it is - The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Langston C: New concepts in the pathology of congenital lung malformations . 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Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 03 Jul, 2025 Read the published version in BMC Pulmonary Medicine → Version 1 posted Editorial decision: Revision requested 26 May, 2025 Reviewers agreed at journal 16 May, 2025 Reviews received at journal 14 May, 2025 Reviewers agreed at journal 14 May, 2025 Reviews received at journal 24 Apr, 2025 Reviewers agreed at journal 24 Apr, 2025 Reviewers agreed at journal 22 Apr, 2025 Reviewers invited by journal 22 Apr, 2025 Editor assigned by journal 22 Apr, 2025 Editor invited by journal 22 Apr, 2025 Submission checks completed at journal 21 Apr, 2025 First submitted to journal 21 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6467699","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":447619815,"identity":"d89e6003-fe65-43b6-9692-39e1295006c2","order_by":0,"name":"Huiyu Xu","email":"","orcid":"","institution":"Guangdong Medical University","correspondingAuthor":false,"prefix":"","firstName":"Huiyu","middleName":"","lastName":"Xu","suffix":""},{"id":447619816,"identity":"465ccf81-6f53-4b26-890a-cedbfb67733e","order_by":1,"name":"Mingbing Zhou","email":"","orcid":"","institution":"Guangdong Medical University","correspondingAuthor":false,"prefix":"","firstName":"Mingbing","middleName":"","lastName":"Zhou","suffix":""},{"id":447619817,"identity":"2857e381-b479-467e-bc34-963a86fa5189","order_by":2,"name":"Weibing Liao","email":"","orcid":"","institution":"Guangdong Medical University","correspondingAuthor":false,"prefix":"","firstName":"Weibing","middleName":"","lastName":"Liao","suffix":""},{"id":447619818,"identity":"0cda1ab4-9999-4fbc-91cb-7cd9fe468475","order_by":3,"name":"Jiequan Li","email":"","orcid":"","institution":"Guangdong Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jiequan","middleName":"","lastName":"Li","suffix":""},{"id":447619819,"identity":"f964b2cd-99ad-4f72-bd75-818c950013e4","order_by":4,"name":"Jiezhong Xie","email":"","orcid":"","institution":"Guangdong Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jiezhong","middleName":"","lastName":"Xie","suffix":""},{"id":447619820,"identity":"09279bb5-88e4-4ab6-ad11-633fcc89dea2","order_by":5,"name":"Jintao Zheng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAElEQVRIiWNgGAWjYDACCTDJxgOmPtiASMbGA8RpYQOqnZEG1tJAjBaQLgYGZp40CBuvFvnZzccefmHgkzGXb3742CbBJnFt+2GgLTU20bi0MM45lm4sA3SYZRubsXFOQpqx2ZlEoJZjabkNOLQwS+SYSUv+Y+MxOMZgJp3747Cc2QGgFsaGwzi1sEnkf5OWYABpYf8mbZFwmMfs/EP8WngkctgkP4C18JhJMyQAbblBwBYJiTSgSrCWnGLDHpBfbgBtScDjF/kZyc8kfzAcszc4fHzjgx/AENt2Pv3hgw81Nji1gIOAh+EYmlACHuUgwPiDoYaAklEwCkbBKBjRAABCOlZygZtSVQAAAABJRU5ErkJggg==","orcid":"","institution":"Guangdong Medical University","correspondingAuthor":true,"prefix":"","firstName":"Jintao","middleName":"","lastName":"Zheng","suffix":""}],"badges":[],"createdAt":"2025-04-17 03:53:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6467699/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6467699/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12890-025-03789-5","type":"published","date":"2025-07-03T15:58:47+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82121877,"identity":"60dc8055-8b2b-4368-a770-1c3357432ac0","added_by":"auto","created_at":"2025-05-07 03:25:11","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":71381,"visible":true,"origin":"","legend":"\u003cp\u003ea shows the cephalic approach position, b shows the phrenic approach position, c shows the CT transverse view, d shows the CT coronal view, e shows the CT 3D reconstruction image, and the mass is in red.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6467699/v1/4e0338583220eeade647ecd1.jpg"},{"id":86179560,"identity":"1b8130b6-fa16-4feb-88c7-e65d3de18b5a","added_by":"auto","created_at":"2025-07-07 16:17:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1708935,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6467699/v1/949263f8-ba31-444a-95ce-a292d5fd457b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Thoracoscopic surgery for symptomatic congenital lung malformations in neonates: A retrospective study of 36 cases","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCongenital lung malformations (CLMs) refer to various types of lung structural defects caused by abnormal lung bud branches and alveolar development during embryonic development. It mainly includes congenital pulmonary airway malformation (CPAM), bronchopulmonary sequestration (BPS), congenital lobar emphysema (CLE) and other subtypes[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The incidence rate reported in the literature ranges from 1/10,000 to 1/35,000 live births. With the advancements in prenatal diagnostic technology and imaging technology, the clinical diagnosis rate has shown a significant upwards trend in recent years[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The clinical manifestations of CLMs vary greatly. Some children have asymptomatic lesions accidentally found via chest radiography, whereas some children have symptoms such as acute respiratory distress, shortness of breath and mediastinal compression at birth, which require emergency surgery[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. At present, whether asymptomatic CLMs require surgery in the neonatal period is still controversial, but surgery for symptomatic CLMs is a more widely accepted standard and is performed in the neonatal period[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. For symptomatic neonatal CLM patients, medical support is provided first, and surgical treatment is performed after evaluation when clinical symptoms disappear. CLMs can be treated by thoracotomy or thoracoscopic surgery. Thoracoscopic surgery is less invasive, has minimal effects on appearance, and is quick to recover from[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, there are few reports on the treatment of CLMs by thoracoscopic surgery in neonates. In this paper, we retrospectively study 36 CLM patients that underwent thoracoscopic surgery to summarize our experience and evaluate the efficacy of this treatment.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe data of 36 newborns (aged\u0026thinsp;\u0026lt;\u0026thinsp;=\u0026thinsp;28 days) with symptomatic CLMs who underwent thoracoscopic surgery at the Affiliated Foshan Women and Children\u0026rsquo;s Hospital, Guangdong Medical University, from April 2017 to May 2023 was analysed in this retrospective study. The pathological findings for all patients were CLMs. The medical records were reviewed, and preoperative, intraoperative and postoperative clinical indicators were statistically analysed. Preoperative variables included sex, gestational age at birth, birth weight, head circumference, CLM location, lesion size, age at surgery and respiratory symptoms. The intraoperative variables included surgical incision length, operative blood loss and operation time. Postoperative variables included duration of postoperative ventilator support, duration of postoperative chest tube indwelling, duration of postoperative hospital stay and postoperative complications. This clinical study was approved by the Medical Ethics Committee of the Affiliated Foshan Women and Children Hospital, Guangdong Medical University (FSFY-MEC-2024-129).\u003c/p\u003e \u003cp\u003eNeonates with symptomatic CLMs should receive medical treatment first, and surgery should be scheduled after clinical symptoms resolve, such as for patients in which pneumonia resolves and those without respiratory distress or shortness of breath without the need for oxygen inhalation. A chest CT examination was performed in all the patients, and 3D CT 3D colour visual reconstruction was performed to better determine the extent of the lesion and provide better assistance for surgery (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBefore the operation, the surgical team discusses in detail the extent of the lesion on the basis of the chest CT and the surgical treatment plan and decides whether to perform lobectomy or lung-sparing surgery. The surgical position and direction of the surgical approach (head side or diaphragmatic side) are then determined (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Preoperatively, a central venous catheter and a urinary catheter are routinely placed. The anaesthesia methods used are general anaesthesia, endotracheal intubation, and non-one-lung ventilation. The patient is placed in a semiprone position with the affected side elevated to facilitate exposure of the lesion. Thoracoscopic surgery generally uses a three-port method (2 \u0026times; 5 mm, 1 \u0026times; 3 mm), and a 5 mm Olympus integrated thoracoscopy system is typically used. Nontraumatic forceps are used as instruments to reduce lung tissue damage and bleeding. The three-port method for the head‒side approach involves the following steps: A 5 mm thoracoscopy port is placed below the inferior angle of the scapula. The second 5 mm operating port is placed at the 5th intercostal space along the posterior axillary line, and the third 3 mm operating port is placed at the 5th intercostal space along the parascapular line. Three-port method for the diaphragmatic-side approach: A 5 mm thoracoscopy port was placed at the 8th intercostal space along the scapular line. The second 5 mm operating port is placed at the 8th intercostal space along the posterior axillary line, and the third 3 mm operating port is placed at the 8th intercostal space along the parascapular line. All the trocars are first covered with a small piece of rubber band and then sutured and fixed to prevent them from being pulled out. The carbon dioxide pressure is 3\u0026ndash;5 mmHg. During lung-sparing surgery, an ultrasonic scalpel is routinely used for lesion resection, and the lung surface is sutured with a 4\u0026ndash;0 absorbable suture. In lobectomy, hemilock clips are used to clamp the main vessels, and the main bronchus is ligated with silk thread. The sample is divided into small pieces and removed through the operating port. A closed thoracic drainage tube is routinely placed. Postoperatively, antibiotics are used routinely to prevent infection, and a ventilator is used to provide respiratory support. When the patient's condition is stable, the ventilator and the thoracic drainage tube are removed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eClinical data and patient characteristics\u003c/h2\u003e \u003cp\u003eAmong the 36 patients, 17 were male and 19 were female. Prenatal ultrasound diagnosis was made for 34 patients. The most common respiratory symptoms in postnatal CLMs patients were pneumonia, tachypnea with or without respiratory distress and cyanosis. Among the 36 patients in this group, 33 had neonatal pneumonia before surgery. Eight patients had tachypnea with or without respiratory distress at birth, 3 patients had weak breathing and cyanosis requiring assisted ventilation, and 1 patient experienced a mediastinal deviation due to extensive lung lesions. The lesions were located on the left side in 24 patients and on the right side in 12 patients; the lesions were located in the upper lobe in 4 patients; and the lesions were located in the lower lobe in 32 patients. Surgical methods: Six patients with CPAM underwent lobectomy due to lesion involvement of the entire lobe, 7 patients with extralobar sequestration underwent resection of the affected lobe, and 13 patients with CPAM and 10 patients with intralobar sequestration underwent lung-sparing surgery. The final pathological results revealed 19 cases of CPAM, 10 cases of intralobar sequestration and 7 cases of extralobar sequestration; 1 patient developed bronchopleural fistula after surgery, and 1 patient developed chylothorax after surgery, both of which healed spontaneously after conservative treatment. The surgery of 1 patient was converted to thoracotomy because of the inability to maintain blood oxygen during the operation, and the surgery of 1 patient was converted to thoracotomy because of intraoperative bleeding. There were no deaths (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient population and characteristics of the 36 patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (male/female)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17:19\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrenatal ultrasound diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRespiratory symptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeonatal pneumonia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTachypnea with or without respiratory distress\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeak breathing and cyanosis requiring assisted ventilation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMediastinal deviation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLaterality (left-sided/right-sided)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24:12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCLM location\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUpper 4, lower 32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResection method\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLobectomy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 patients with CPAM, 7 patients with ELS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLung-sparing resection\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 patients with CPAM, 10 patients with ILS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePathology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 patients with CPAM, 10 patients with ILS, 7 patients with ELS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperative complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 case of air leak, 1 case of chylothorax\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCLMs, congenital lung malformations; CPAM, congenital pulmonary airway malformation; ILS, intralobar sequestration; ELS, extralobar sequestration\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eResults for the clinically relevant variables of thoracoscopic surgery\u003c/h3\u003e\n\u003cp\u003eIn this group of cases, the relevant preoperative variables were as follows: median gestational age, 39.3 weeks (range: 34.1\u0026ndash;41.1 weeks); median birth weight, 3145 g (1830\u0026ndash;4270 g); median head circumference, 33 cm (30\u0026ndash;37 cm); median lesion size, 24.00 cm\u0026sup3; (3.40\u0026ndash;300.00 cm\u0026sup3;); and age at surgery, 8 days (4\u0026ndash;21 days). The relevant intraoperative variables included the following: median surgical incision length, 1.4 cm (1.3 to 6.0 cm); median operative blood loss, 2 ml (1 to 20 ml); and median operative time, 132 minutes (33 to 220 minutes). The postoperative variables included the following: median duration of postoperative ventilator support, 3 days (1\u0026ndash;7 days); median duration of postoperative chest tube indwelling, 7.5 days (0\u0026ndash;22 days) (with no chest tube placed in patients undergoing extralobar sequestration); and median duration of postoperative hospital stay, 11.5 days (4\u0026ndash;25 days) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRelated variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelated variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (range) (N\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative:\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational age at birth (w)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.3 (34.1\u0026ndash;41.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBirth weight (g)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3145 (1830\u0026ndash;4270)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead circumference (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (30\u0026ndash;37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLesion size (cm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (3.4\u0026ndash;300)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at surgery (d)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (4\u0026ndash;21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntraoperative\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical incision length (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.4 (1.3-6.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative blood loss (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e132 (33\u0026ndash;220)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperative\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of postoperative ventilator support (d)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of postoperative chest tube indwelling (d)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.5 (0\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of postoperative hospital stay (d)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.5 (4\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ew, weeks; g, grams; cm, centimetres; d, days; ml, millilitres; min, minutes\u003c/p\u003e \u003cp\u003eWe followed the patients either in the clinic or by telephone for a median of 36 months (6\u0026ndash;94 months), and none of the patients had shortness of breath, dyspnoea on exertion, recurrent pneumonia, or neurological retardation during follow-up. We performed postoperative CT or X-ray examinations, and there were no cases of postoperative recurrence.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCongenital lung malformations (CLMs) account for 5\u0026ndash;18% of all congenital malformations[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The classification of CLMs is complex. These include congenital pulmonary airway malformation (CPAM), pulmonary sequestration(PS), congenital lobar emphysema (CLE) and other subtypes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In recent years, with the development of foetal ultrasound and foetal magnetic resonance imaging technology, the understanding of foetal lung diseases has gradually increased, and the incidence of CLMs has increased in recent years [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The overall survival rate of patients with CLMs has significantly increased from 60% to more than 95% owing to advances in prenatal diagnosis and clinical treatment, which have reduced the risk of circulatory failure and death caused by pulmonary hypoplasia[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Patients with main diseases, CPAM and PS, were studied by our group.\u003c/p\u003e \u003cp\u003eMost CLM patients have no obvious respiratory symptoms after birth, and some patients are only incidentally diagnosed during chest X-ray examination, but approximately 10% of them have respiratory symptoms in the neonatal period[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. CLM patients with severe lesions have critical clinical symptoms immediately after birth. For example, acute respiratory distress, shortness of breath, asphyxia, and congenital pneumonia require tracheal intubation for rescue, mainly because the compression of the mediastinal mass by CLMs affects the breathing and circulation of the child. In this group of cases, the most common symptoms were neonatal pneumonia, tachypnea, respiratory distress and mediastinal shift, which are consistent with reports in the literature[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt present, the optimal timing of surgery for asymptomatic CLMs is still controversial, but surgery for symptomatic CLMs is currently recognized as the standard[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The surgical methods for treating CLMs can be divided into traditional thoracotomy and thoracoscopic surgery. Traditional thoracotomy for the treatment of severe trauma, bleeding, and long recovery times can cause thoracic deformity, incisional hernia, severe scar hyperplasia and other complications. With the development of thoracoscopic technology, thoracoscopic treatment of CLMs has advanced rapidly, and thoracoscopic surgery is a safe and feasible method for the treatment of CLMs that causes minimal trauma, has minimal aesthetic effects and leads to rapid postoperative recovery, even in the neonatal period[\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Our approach was to first provide medical support to symptomatic neonatal CLM patients. After the symptoms subsided sufficiently, we performed surgical treatment. Specifically, we surgically treated patients who exhibited pneumonia resolution and elimination of respiratory distress or shortness of breath without relying on supplemental oxygen[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. For patients with asymptomatic CLMs, we opted for regular observation and follow-up.\u003c/p\u003e \u003cp\u003eThis study shows that the use of minimally invasive thoracoscopic techniques in the treatment of symptomatic CLMs in neonates has achieved good clinical results, and thoracoscopic surgery has achieved suitable results with minimal trauma and no thoracic deformity. These clinical results are similar to the results described in the literature [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In our experience, the advantages of thoracoscopic surgery for CLMs in the neonatal period are that CLMs have a clear demarcation with normal lung tissue, no adhesion caused by repeated infections, and that the vessels and small bronchi are relatively small and can be directly cut off with ultrasonic scalpels, features that facilitate successful completion of the operation. Thoracoscopic CLM resection in the neonatal period also has several disadvantages: a small operation space, brittle tissue, easy bleeding, and relatively high requirements for the surgeon. Our experience is that pulmonary sequestration is relatively easier to treat than CPAM and can be used as the first condition to evaluate neonatal thoracoscopy techniques in. After the technique is improved, CPAM can be treated. In addition, lateral CPAM is relatively easier to treat than medial CPAM. First, simple CPAM cases can be selected, and thoracoscopy can be performed, which is helpful for reducing surgical complications. In addition, a 3-mm clamp can be added to assist in performing the exposure when suturing is difficult. If the intraoperative blood oxygen level is temporarily unstable, the operation and artificial pneumothorax can be temporarily stopped, and surgical treatment can be continued after blood oxygen level is restored [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to extralobar pulmonary sequestration, surgical resection for the treatment of CLMs is also controversial. The main methods of surgical treatment for CLMs include lobectomy, segmentectomy and lesion resection. At present, the standard treatment method is lobectomy[\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Muller CO et al. noted that adequate treatment of CPAM in children requires lobectomy because preoperative CT has very low sensitivity for identifying distal adjacent lesions and very low negative predictive value[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Laberge JM et al. reported that to prevent postoperative air leakage and residual disease and possibly reduce the risk of some advanced malignancies, lobectomy is recommended for the treatment of CLMs[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The other treatment option is lung-sparing resection (LSR), which includes segmentectomy and pulmonary lesion resection. Segmentectomy entails the accurate removal of the segmental tissue involved in the lesion through anatomical separation of the segmental blood vessels and bronchial tissue structure while the normal lung tissue of the other segments in the lung lobe is retained. However, this operation is difficult to perform during the neonatal period because of the slender blood vessels and bronchi in neonates. Lung lesion resection removes only the lung tissue involved in the lesion along the boundary between the lesion and normal lung tissue, which is a common surgical method for the treatment of CLMs in the neonatal period[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Fascetti Leon F et al. reported that lung preservation surgery for CLMs is a safe and effective method for preserving the lung parenchyma in paediatric patients. If accurate planning is performed in selected patients, lung-sparing surgery does not carry a greater risk of residual disease and recurrence than conventional lobectomy does[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Kim HK et al. reported excellent early and late prognoses even after lung-sparing resection in CLM patients and indicated that it can be performed safely in selected patients with very narrow CLM lesions, thereby avoiding lobectomy[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our group of patients, 23 patients underwent lung-sparing resection to treat lower lobe CLMs, which preserved healthy lungs and achieved good clinical results. In addition to the seven patients that underwent extralobar sequestration, six patients underwent lobectomy because their lesions almost or completely occupied the lobes, limiting the use of a LSR strategy. To reduce postoperative complications such as bronchopleural leakage and pneumothorax, we closed the lung wound with 4\u0026ndash;0 absorbable sutures in addition to ligating the larger bronchi. Moreover, on the basis of experience and reports in the literature, we extended the duration of chest tube use accordingly[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], but we chose not to place thoracoscopic drainage tubes in patients with ELS. In the present study, one patient developed early postoperative air leakage complications, which were cured by continuous thoracic drainage. We considered that this complication was caused by poor wound healing rather than a problem with the lung preservation strategy because there was no recurrence during postoperative follow-up. However, this may also be related to unskilled suturing in the early stage of the thoracoscopy surgery.\u003c/p\u003e \u003cp\u003eIn summary, on the basis of the data and follow-up results of this study, we believe that thoracoscopic surgery for symptomatic CLMs achieves good clinical results without increasing the risk of surgical or postoperative complications, even when performed in the neonatal period. A lung preservation resection strategy may be suitable for neonatal CLMs. However, the results of this study are limited by the small sample size. In the next step, we will continue to conduct long-term follow-up to evaluate the respiratory function, growth and development of these patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCLMs: congenital lung malformations, CPAM: congenital pulmonary airway malformation; PS: pulmonary sequestration. ILS, intralobar sequestration; ELS, extralobar sequestration; LSR: lung-sparing resection\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e Ethical approval was obtained from the Medical Ethics Committee of The Affiliated Foshan Women and Children Hospital, Guangdong Medical University, Guangdong, China (FSFY-MEC-2024-129). All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Ceclaration and its later amendments or comparable ethical standards. Informed consent was obtained from the parents of the enrolled patients before thoracoscopic surgery.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare that no conflict of interest exists.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study was funded by the Guangdong Medical Research Fund project (No. A2022437) and Science and Technology Planning Project of Guangzhou (No. 202206080002)\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJZ was responsible for the conception and design of the study. MZ, JL and WL were responsible for the acquisition of data. HX and JX were responsible for the analysis and interpretation of data. JZ and MZ were responsible for drafting the article and critically revising it for important intellectual content. All authors read, revised and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003e Data is provided within the manuscript and in the manuscript it is - The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLangston C: \u003cstrong\u003eNew concepts in the pathology of congenital lung malformations\u003c/strong\u003e. \u003cem\u003eSemin Pediatr Surg \u003c/em\u003e2003, \u003cstrong\u003e12\u003c/strong\u003e(1):17-37.\u003c/li\u003e\n\u003cli\u003eGornall AS, Budd JL, Draper ES, Konje JC, Kurinczuk JJ: \u003cstrong\u003eCongenital cystic adenomatoid malformation: accuracy of prenatal diagnosis, prevalence and outcome in a general population\u003c/strong\u003e. \u003cem\u003ePrenat Diagn \u003c/em\u003e2003, 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\u003cstrong\u003e88\u003c/strong\u003e(2):143-148.\u003c/li\u003e\n\u003cli\u003eDuron V, Zenilman A, Griggs C, DeFazio J, Price JC, Fan W, Vivero M, Castrillon J, Schmaedick M, Iqbal E\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eAsymptomatic Congenital Lung Malformations: Timing of Resection Does Not Affect Adverse Surgical Outcomes\u003c/strong\u003e. \u003cem\u003eFront Pediatr \u003c/em\u003e2020, \u003cstrong\u003e8\u003c/strong\u003e:35.\u003c/li\u003e\n\u003cli\u003eZheng J, Tang H, Xu H, Li J, Mao X, Liu G: \u003cstrong\u003eThoracoscopic versus open resection for symptomatic congenital pulmonary airway malformations in neonates: a decade-long retrospective study\u003c/strong\u003e. \u003cem\u003eBMC Pulm Med \u003c/em\u003e2021, \u003cstrong\u003e21\u003c/strong\u003e(1):82.\u003c/li\u003e\n\u003cli\u003eVu LT, Farmer DL, Nobuhara KK, Miniati D, Lee H: \u003cstrong\u003eThoracoscopic versus open resection for congenital cystic adenomatoid malformations of the lung\u003c/strong\u003e. \u003cem\u003eJ Pediatr Surg \u003c/em\u003e2008, \u003cstrong\u003e43\u003c/strong\u003e(1):35-39.\u003c/li\u003e\n\u003cli\u003eAdams S, Jobson M, Sangnawakij P, Heetun A, Thaventhiran A, Johal N, Bohning D, Stanton MP: \u003cstrong\u003eDoes thoracoscopy have advantages over open surgery for asymptomatic congenital lung malformations? An analysis of 1626 resections\u003c/strong\u003e. \u003cem\u003eJ Pediatr Surg \u003c/em\u003e2017, \u003cstrong\u003e52\u003c/strong\u003e(2):247-251.\u003c/li\u003e\n\u003cli\u003eMorini F, Zani A, Conforti A, van Heurn E, Eaton S, Puri P, Rintala R, Lukac M, Kuebler JF, Friedmacher F\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eCurrent Management of Congenital Pulmonary Airway Malformations: A \u0026quot;European Pediatric Surgeons\u0026apos; Association\u0026quot; Survey\u003c/strong\u003e. \u003cem\u003eEur J Pediatr Surg \u003c/em\u003e2018, \u003cstrong\u003e28\u003c/strong\u003e(1):1-5.\u003c/li\u003e\n\u003cli\u003eMuller CO, Berrebi D, Kheniche A, Bonnard A: \u003cstrong\u003eIs radical lobectomy required in congenital cystic adenomatoid malformation?\u003c/strong\u003e \u003cem\u003eJ Pediatr Surg \u003c/em\u003e2012, \u003cstrong\u003e47\u003c/strong\u003e(4):642-645.\u003c/li\u003e\n\u003cli\u003eFascetti-Leon F, Gobbi D, Pavia SV, Aquino A, Ruggeri G, Gregori G, Lima M: \u003cstrong\u003eSparing-lung surgery for the treatment of congenital lung malformations\u003c/strong\u003e. \u003cem\u003eJ Pediatr Surg \u003c/em\u003e2013, \u003cstrong\u003e48\u003c/strong\u003e(7):1476-1480.\u003c/li\u003e\n\u003cli\u003eLaberge JM, Puligandla P, Flageole H: \u003cstrong\u003eAsymptomatic congenital lung malformations\u003c/strong\u003e. \u003cem\u003eSemin Pediatr Surg \u003c/em\u003e2005, \u003cstrong\u003e14\u003c/strong\u003e(1):16-33.\u003c/li\u003e\n\u003cli\u003eRothenberg SS: \u003cstrong\u003eFirst decade\u0026apos;s experience with thoracoscopic lobectomy in infants and children\u003c/strong\u003e. \u003cem\u003eJ Pediatr Surg \u003c/em\u003e2008, \u003cstrong\u003e43\u003c/strong\u003e(1):40-44; discussion 45.\u003c/li\u003e\n\u003cli\u003eJohnson SM, Grace N, Edwards MJ, Woo R, Puapong D: \u003cstrong\u003eThoracoscopic segmentectomy for treatment of congenital lung malformations\u003c/strong\u003e. \u003cem\u003eJ Pediatr Surg \u003c/em\u003e2011, \u003cstrong\u003e46\u003c/strong\u003e(12):2265-2269.\u003c/li\u003e\n\u003cli\u003eKim HK, Choi YS, Kim K, Shim YM, Ku GW, Ahn KM, Lee SI, Kim J: \u003cstrong\u003eTreatment of congenital cystic adenomatoid malformation: should lobectomy always be performed?\u003c/strong\u003e\u003cem\u003eAnn Thorac Surg \u003c/em\u003e2008, \u003cstrong\u003e86\u003c/strong\u003e(1):249-253.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Neonate, Congenital lung malformations, Thoracoscopic","lastPublishedDoi":"10.21203/rs.3.rs-6467699/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6467699/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective: To summarize and analyse the efficacy of minimally invasive thoracoscopic surgery for neonatal symptomatic congenital lung malformations (CLMs).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethods: The clinical data of 36 newborns (aged \u0026lt;=28 days) with symptomatic CLMs who underwent thoracoscopic surgery at Foshan Women and Children’s Hospital from April 2017 to May 2023 were retrospectively analysed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults: Among the 36 patients, 33 had neonatal pneumonia before the operation, 8 had tachypnea with or without respiratory distress at birth, 3 had weak breathing and cyanosis requiring assisted ventilation and 1 had mediastinal displacement due to large lung lesions. Lobectomy was performed in 6 CPAM patients and 7 patients with extralobar sequestration, and lung-sparing resection was performed in 13 CPAM patients and 10 patients with intralobar sequestration. The median surgical incision length was 1.4 cm (1.3–6.0 cm), the median operative blood loss was 2 ml (1–20 ml), and the median operative time was 132 min (33–220 min).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConclusion: Thoracoscopic surgery for symptomatic CLMs can achieve good clinical results in neonates, and lung-sparing resection may be feasible.\u003c/p\u003e","manuscriptTitle":"Thoracoscopic surgery for symptomatic congenital lung malformations in neonates: A retrospective study of 36 cases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 03:25:06","doi":"10.21203/rs.3.rs-6467699/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-26T11:36:14+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"220686003520608541835476191230065761054","date":"2025-05-16T10:26:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-14T12:54:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57934531992079019878064157255432357258","date":"2025-05-14T12:30:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-24T17:27:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"169419711864530537937606585198244012039","date":"2025-04-24T11:19:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150499942096344707348067596375394991156","date":"2025-04-22T07:38:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-22T07:20:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-22T07:18:47+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-22T07:07:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-21T12:22:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pulmonary Medicine","date":"2025-04-21T12:21:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cb41666f-39a9-413a-ab40-633a586ceefe","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-07T16:08:44+00:00","versionOfRecord":{"articleIdentity":"rs-6467699","link":"https://doi.org/10.1186/s12890-025-03789-5","journal":{"identity":"bmc-pulmonary-medicine","isVorOnly":false,"title":"BMC Pulmonary Medicine"},"publishedOn":"2025-07-03 15:58:47","publishedOnDateReadable":"July 3rd, 2025"},"versionCreatedAt":"2025-05-07 03:25:06","video":"","vorDoi":"10.1186/s12890-025-03789-5","vorDoiUrl":"https://doi.org/10.1186/s12890-025-03789-5","workflowStages":[]},"version":"v1","identity":"rs-6467699","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6467699","identity":"rs-6467699","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}