Contemporary Role of Computed Tomography in Managing Pediatric Primary Spontaneous Pneumothorax
Simon Rahal1, Abigail J Engwall-Gill1, Eric Etchill1
1Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Johns Hopkins Children's Center, Baltimore, Maryland.
Insights
Chest computed tomography (CT) is not always reliable for diagnosing bleb disease in pediatric primary spontaneous pneumothorax (PSP). Clinical findings should guide surgical decisions, not CT scan results alone.
Area of Science:
- Pediatric Surgery
- Thoracic Surgery
- Diagnostic Imaging
Background:
- The diagnostic accuracy of chest computed tomography (CT) for pediatric primary spontaneous pneumothorax (PSP) is debated.
- Identifying bleb disease preoperatively is crucial for surgical planning in PSP.
Purpose of the Study:
- To evaluate the utility and diagnostic accuracy of preoperative CT scans in identifying bleb disease in children with PSP.
- To assess the role of CT findings in guiding surgical decisions for pediatric PSP.
Main Methods:
- Retrospective review of pediatric patients (≤18 years) who underwent video-assisted thoracoscopic surgery (VATS) for PSP between 2009 and 2019.
- Analysis of preoperative CT scans for the presence of bleb disease and comparison with intraoperative findings.
Main Results:
- Of 39 patients, 34 had intraoperative blebs. Preoperative CT correctly identified blebs in 17 patients (61% sensitivity, 100% positive predictive value, 36% negative predictive value).
- CT missed blebs in 7 patients (29% false negatives). Contralateral disease was identified in 11 patients (39%) on CT, with 8 developing PSP or undergoing elective surgery.
- Six patients (21%) without contralateral CT findings developed PSP with intraoperative blebs.
Conclusions:
- Preoperative CT has limitations in accurately detecting bleb disease in pediatric PSP.
- Clinical assessment should be the primary factor in deciding on surgical intervention for pediatric PSP, rather than relying solely on CT findings.
Introduction:
The value of chest computed tomography (CT) in pediatric primary spontaneous pneumothorax (PSP) remains controversial. This study sought to evaluate the utility of CT scans in a contemporary cohort of children with PSP.
Materials And Methods:
An institutional review board approval was obtained for a retrospective review of all children (aged ≤18 y) who underwent video-assisted thoracoscopic surgery (VATS) for PSP between 2009 and 2019 at a university-affiliated pediatric hospital. Preoperative CT scans were evaluated for diagnostic accuracy of the CT of bleb disease.
Results:
Thirty nine patients underwent VATS procedures for PSP, 34 (87%) of the patients were noted to have blebs. Twenty eight (72%) patients received preoperative CT scans with a 5.5:1 male to female ratio. On CT, 17 (61%) were diagnosed with blebs and all had blebs intraoperatively. CT did not identify disease in 11 patients, but seven had blebs intraoperatively. The positive and negative predictive values of preoperative CT for detecting ipsilateral bleb disease were 100% and 36%, respectively, with a sensitivity of 71%. Eleven patients had a contralateral disease on CT (39%). Five received elective contralateral VATS and three developed spontaneous PSP, with intraoperative blebs in all eight patients. Three never developed contralateral PSP. Six (21%) patients with no contralateral disease on CT developed spontaneous PSP with intraoperative blebs.
Conclusions:
The decision to operate for PSP should be made based on clinical findings rather than on the presence or absence of blebs identified by CT.
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