Letter to the Editor
Letter to the Editor
Evidence for Thoracoscopic Ligation of Patent Ductus Arteriosus Francesco Macchini1
Anna Morandi1
1 Department of Pediatric Surgery, Ospedale Maggiore Policlinico,
Fondazione IRCCS Ca’ Granda, Milano, Italy Eur J Pediatr Surg
We read with great interest the publication by Dingemann et al1 concerning the best available level of evidence for thoracoscopic procedures in pediatric surgery. Five surgical procedures have been investigated: congenital diaphragmatic hernia repair, esophageal atresia/tracheoesophageal fistula repair, lung resection, treatment of pneumothorax, and resection of neuroblastoma. The authors state that only retrospective comparative studies (RCS) are available, thus reaching level III of evidence according to the “Oxford Centre for Evidence-Based Medicine (CEBM).” They conclude that randomized controlled trials (RCTs) comparing video-assisted thoracoscopic surgery (VATS) and the corre-
Ernesto Leva1
Address for correspondence Anna Morandi, MD, Department of Pediatric Surgery, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca’ Granda, Via Commenda 10, Milano 20122, Italy (e-mail: [email protected]).
sponding open procedures are mandatory to obtain the highest possible evidence. We applied the authors’ criteria to a surgical procedure that, despite usually performed by cardiothoracic surgeons, we have recently adopted in our department, namely, the patent ductus arteriosus (PDA) thoracoscopic ligation. To the best of our knowledge (PubMed accessed on November 7, 2014), there are neither RCTs nor systematic review/meta-analysis available. We could find three RCSs. Only statistically significant data are reported in ►Table 1.2–4 Furthermore, our search revealed some relevant case series5–7 (level IV of CEBM) stating that the VATS technique for PDA closure is simple, effective, rapid, cost-effective, and more
Table 1 Details of RCS providing evidence for VATS versus open procedures in PDA ligation References
Study type
CEBM levels
Advantage of VATS versus open
Disadvantage of VATS versus open
2
RCS
3b
None
None
3
RCS
3b
Shorter operative time
None
Kennedy et al Vanamo et al
Faster recovery Shorter hospital stay Duration of pleural drainage Chen et al
4
RCS
3b
Shorter operative time
None
Lower postoperative temperature Better cost effectiveness Fewer acute complications Fewer residual shunt Fewer scoliosis Abbreviations: CEBM, Oxford Centre for Evidence-Based Medicine; PDA, patent ductus arteriosus; RCS, retrospective comparative studies; VATS, videoassisted thoracoscopic surgery.
received November 7, 2014 accepted November 12, 2014
© Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1544051. ISSN 0939-7248.
Downloaded by: University of Florida. Copyrighted material.
Valerio Gentilino1
convenient for the patient. It requires a shorter hospital stay and carries cosmetic benefits compared with the conventional thoracotomy.8 Moreover, some authors describe the application of VATS for PDA ligation in very low-birth-weight infants.9 In view of such considerations and after specific training, we recently adopted VATS for PDA ligation, and our preliminary results reflect other authors’ experiences. In the absence of level I and II evidences, it has been suggested to follow the trail to the next best external evidence and work from there.10 We therefore believe that adequately trained pediatric surgeons willing to perform thoracoscopic PDA ligation can safely move from open surgical technique to VATS.
Conflict of interest None.
3
4
5
6
7
8
References
9
1 Dingemann C, Ure B, Dingemann J. Thoracoscopic procedures in
pediatric surgery: what is the evidence? Eur J Pediatr Surg 2014; 24(1):14–19 2 Kennedy AP Jr, Snyder CL, Ashcraft KW, Manning PB. Comparison of muscle-sparing thoracotomy and thoracoscopic ligation for the
European Journal of Pediatric Surgery
10
treatment of patent ductus arteriosus. J Pediatr Surg 1998;33(2): 259–261 Vanamo K, Berg E, Kokki H, Tikanoja T. Video-assisted thoracoscopic versus open surgery for persistent ductus arteriosus. J Pediatr Surg 2006;41(7):1226–1229 Chen H, Weng G, Chen Z, et al. Comparison of posterolateral thoracotomy and video-assisted thoracoscopic clipping for the treatment of patent ductus arteriosus in neonates and infants. Pediatr Cardiol 2011;32(4):386–390 Liem NT, Tuan TM, Linh NV. A safe technique of thoracoscopic clipping of patent ductus arteriosus in children. J Laparoendosc Adv Surg Tech A 2012;22(4):422–424 Villa E, Folliguet T, Magnano D, Vanden Eynden F, Le Bret E, Laborde F. Video-assisted thoracoscopic clipping of patent ductus arteriosus: close to the gold standard and minimally invasive competitor of percutaneous techniques. J Cardiovasc Med (Hagerstown) 2006; 7(3):210–215 Rothenberg SS, Chang JHT, Toews WH, Washington RL. Thoracoscopic closure of patent ductus arteriosus: a less traumatic and more costeffective technique. J Pediatr Surg 1995;30(7):1057–1060 Nezafati MH, Soltani G, Mottaghi H, Horri M, Nezafati P. Videoassisted thoracoscopic patent ductus arteriosus closure in 2,000 patients. Asian Cardiovasc Thorac Ann 2011;19(6):393–398 Lukish JR. Video-assisted thoracoscopic ligation of a patent ductus arteriosus in a very low-birth-weight infant using a novel retractor. J Pediatr Surg 2009;44(5):1047–1050 Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 312(7023):71–72
Downloaded by: University of Florida. Copyrighted material.
Letter to the Editor
Letter to the Editor
Evidence for Thoracoscopic Ligation of Patent Ductus Arteriosus Francesco Macchini1
Anna Morandi1
1 Department of Pediatric Surgery, Ospedale Maggiore Policlinico,
Fondazione IRCCS Ca’ Granda, Milano, Italy Eur J Pediatr Surg
We read with great interest the publication by Dingemann et al1 concerning the best available level of evidence for thoracoscopic procedures in pediatric surgery. Five surgical procedures have been investigated: congenital diaphragmatic hernia repair, esophageal atresia/tracheoesophageal fistula repair, lung resection, treatment of pneumothorax, and resection of neuroblastoma. The authors state that only retrospective comparative studies (RCS) are available, thus reaching level III of evidence according to the “Oxford Centre for Evidence-Based Medicine (CEBM).” They conclude that randomized controlled trials (RCTs) comparing video-assisted thoracoscopic surgery (VATS) and the corre-
Ernesto Leva1
Address for correspondence Anna Morandi, MD, Department of Pediatric Surgery, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca’ Granda, Via Commenda 10, Milano 20122, Italy (e-mail: [email protected]).
sponding open procedures are mandatory to obtain the highest possible evidence. We applied the authors’ criteria to a surgical procedure that, despite usually performed by cardiothoracic surgeons, we have recently adopted in our department, namely, the patent ductus arteriosus (PDA) thoracoscopic ligation. To the best of our knowledge (PubMed accessed on November 7, 2014), there are neither RCTs nor systematic review/meta-analysis available. We could find three RCSs. Only statistically significant data are reported in ►Table 1.2–4 Furthermore, our search revealed some relevant case series5–7 (level IV of CEBM) stating that the VATS technique for PDA closure is simple, effective, rapid, cost-effective, and more
Table 1 Details of RCS providing evidence for VATS versus open procedures in PDA ligation References
Study type
CEBM levels
Advantage of VATS versus open
Disadvantage of VATS versus open
2
RCS
3b
None
None
3
RCS
3b
Shorter operative time
None
Kennedy et al Vanamo et al
Faster recovery Shorter hospital stay Duration of pleural drainage Chen et al
4
RCS
3b
Shorter operative time
None
Lower postoperative temperature Better cost effectiveness Fewer acute complications Fewer residual shunt Fewer scoliosis Abbreviations: CEBM, Oxford Centre for Evidence-Based Medicine; PDA, patent ductus arteriosus; RCS, retrospective comparative studies; VATS, videoassisted thoracoscopic surgery.
received November 7, 2014 accepted November 12, 2014
© Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1544051. ISSN 0939-7248.
Downloaded by: University of Florida. Copyrighted material.
Valerio Gentilino1
convenient for the patient. It requires a shorter hospital stay and carries cosmetic benefits compared with the conventional thoracotomy.8 Moreover, some authors describe the application of VATS for PDA ligation in very low-birth-weight infants.9 In view of such considerations and after specific training, we recently adopted VATS for PDA ligation, and our preliminary results reflect other authors’ experiences. In the absence of level I and II evidences, it has been suggested to follow the trail to the next best external evidence and work from there.10 We therefore believe that adequately trained pediatric surgeons willing to perform thoracoscopic PDA ligation can safely move from open surgical technique to VATS.
Conflict of interest None.
3
4
5
6
7
8
References
9
1 Dingemann C, Ure B, Dingemann J. Thoracoscopic procedures in
pediatric surgery: what is the evidence? Eur J Pediatr Surg 2014; 24(1):14–19 2 Kennedy AP Jr, Snyder CL, Ashcraft KW, Manning PB. Comparison of muscle-sparing thoracotomy and thoracoscopic ligation for the
European Journal of Pediatric Surgery
10
treatment of patent ductus arteriosus. J Pediatr Surg 1998;33(2): 259–261 Vanamo K, Berg E, Kokki H, Tikanoja T. Video-assisted thoracoscopic versus open surgery for persistent ductus arteriosus. J Pediatr Surg 2006;41(7):1226–1229 Chen H, Weng G, Chen Z, et al. Comparison of posterolateral thoracotomy and video-assisted thoracoscopic clipping for the treatment of patent ductus arteriosus in neonates and infants. Pediatr Cardiol 2011;32(4):386–390 Liem NT, Tuan TM, Linh NV. A safe technique of thoracoscopic clipping of patent ductus arteriosus in children. J Laparoendosc Adv Surg Tech A 2012;22(4):422–424 Villa E, Folliguet T, Magnano D, Vanden Eynden F, Le Bret E, Laborde F. Video-assisted thoracoscopic clipping of patent ductus arteriosus: close to the gold standard and minimally invasive competitor of percutaneous techniques. J Cardiovasc Med (Hagerstown) 2006; 7(3):210–215 Rothenberg SS, Chang JHT, Toews WH, Washington RL. Thoracoscopic closure of patent ductus arteriosus: a less traumatic and more costeffective technique. J Pediatr Surg 1995;30(7):1057–1060 Nezafati MH, Soltani G, Mottaghi H, Horri M, Nezafati P. Videoassisted thoracoscopic patent ductus arteriosus closure in 2,000 patients. Asian Cardiovasc Thorac Ann 2011;19(6):393–398 Lukish JR. Video-assisted thoracoscopic ligation of a patent ductus arteriosus in a very low-birth-weight infant using a novel retractor. J Pediatr Surg 2009;44(5):1047–1050 Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 312(7023):71–72
Downloaded by: University of Florida. Copyrighted material.
Letter to the Editor
