Address for Correspondence:
Dr VK Gopi, Department of Pediatric Surgery, Baby
Memorial Hospital, Kozhikkode, Kerala, India. Email:
gopivk99@gmail.com.
Abstract
Purpose: To report the feasibility and
effectiveness of thoracoscopic window
pericardiectomy for pyopericardium in children.
Material and methods: Nine month old
male infant presented with
abscess neck and continued to be
sick and further evaluation made the
diagnosis of pyopericardium and underwent
thoracoscopic window pericardiectomy.
Result: Thoracoscopic
window pericardiectomy was found to be effective
and follow up was done for a period of
six years.
Conclusion: In a very sick
infant, the concern is whether the baby will
withstand a major operative procedure
or not. Thoracoscopy has got a definite role
in such situations.
Keywords: Pyopericardium,
thoracoscopic window pericardiectomy.
Introduction
Pyopericardium is a life threatening, serious surgical
emergency in children. It is a rapidly progressive
disease leading to death, if not treated in early
stages [1]. Repeated pericardiocentesis, tube drainage,
instillation of streptokinase or urokinase,
subxiphoid window pericardiectomy
drainage and thoracotomy
window pericardiectomy drainage were
the treatment options for pyopericardium.
Another more feasible option is
thoracoscopy. Thoracoscopy has established itself
as an alternative to open
thoracotomy for the management
of many pleural and pulmonary
disorders in adults and children
[2-3]. But thoracoscopic surgery on pericardium is
rarely reported in infants. It gives excellent view of
pericardium. Pericardial resection can be done with ease.
Pericardial lavage can be done under
vision till the cavity is cleared of all the
purulent materials. Drainage tube can be properly placed under
vision. Since it is a minimally invasive procedure, body
response to trauma is minimal and recovery is
fast.
Material and methods
A nine month old male
infant was admitted for abscess neck. He had
polymorphonuclear leukocytosis and high ESR. Even after
drainage of abscess, infant continued to be sick
and lethargic. On further evaluation, x-ray of the chest
showed cardiomegaly and Echocardiogram was suggestive
of pyopericardium. Surgical management of pyopericardium
was done by Video Assisted Thoracoscopy. The follow up period
of the case is six years.
Procedure
After preoperative stabilization with IV fluids,
parenteral antibiotics and analgesics the infant was
taken up for thoracoscopic window pericardiectomy. With
patient under general anaesthesia, three port thoracoscopy was
done through left thoracic cavity. Patient was kept in
supine posture with folded towel beneath
chest on left side. Carbon dioxide insufflation was kept ready
but there was no requirement to use it because of sufficient
vision. Pericardial cavity was aspirated
with No 20 G intravenous cannula under
vision and aspirated around 50 ml of thick
yellowish pus. Then proceeded with incision of
pericardial sac and resection was done till phrenic
nerves were seen on both sides. Minor bleeding was controlled
with bipolar diathermy. The procedure was completed with
drainage of left pleural cavity using
No 16 suction catheter. Oral feeds were started after 4 hours.
Pus culture grew Staphylococcus aureus sensitive to Amikacin,
Cloxacillin and Vancomycin. He was treated with Amikacin and
Vancomycin. Drainage catheter was removed on
5th postoperative day. Catheter tip was sterile on
culture. Repeat X-ray chest and echocardiogram were normal. He
had uneventful recovery. He was on regular follow
up for the last 6 years and he is asymptomatic and
doing well.
Discussion
Accumulation of pus in pericardial cavity is the result of
severe sepsis by bacteria and fungi. In the post antibiotic
era, Staphylococcus aureus is the commonest organism
[4-5]. The mode of spread is either by
hematogenous or by direct spread from pulmonary
infection. Usual foci of infection are neumonia,
osteomyelitis,s eptic arthritis and pyomyositis.
In the present case even after effectively
treating the abscess, features of sepsis like fever clinical,
lethargy and toxic appearance were continuing and
further evaluation picked up cardiomegaly on
X-ray and pyopericardium on echocardiogram.
Pyopericardium if not treated in time, proceeds to
complications like cardiac tamponade, septicaemia and
constrictive pericarditis. Pyopericardium carries
considerable morbidity and even mortality. Timely diagnosis
assumes prime importance in pyopericardium. Unsettled
sepsis irrespective of effective management is an indicator
to pyopericardium.
Various treatment modalities are available, but window
pericardiectomy is the most effective. Recurrence
following pericardial resection varies between 3
to 18% [6]. Santos and Frater have suggested that increasing
the pericardial resection to the size of 4cm x 4 cm
leads to lower incidence of recurrence [7].
But size varies according to age and in our
case phrenic nerve to phrenic nerve extent
of pericardium was resected to avoid the chance of
constrictive pericarditis in the future. Median
sternotomy and left thoracotomy are
the surgical options in open operation. Minimally
invasive surgery is advanatageous in reducing tissue
response to trauma and for rapid recovery
especially in the very sick infants. Video Assisted
Thoracoscopic Surgery is found to be very
effective and advisable.
Conclusion
Thoracoscopic window pericardiectomy is an advisable
surgical procedure for pyopericardium in children. Post
operative pain is minimal and recovery is rapid when
compared to open operation. In very sick infants
who are unable to withstand a major operative procedure,
thoracoscopy is an effective and feasible alternative
Reduced hospital stay and impressive cosmesis are additional
attractions of Thoracoscopic partial
pericardiectomy.
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