Evidence for Thoracoscopic Ligation of Patent Ductus Arteriosus

We read with great interest the publication by Dingemann et al[1] 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 corresponding 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] [3] [4]

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
Kennedy et al[2]	RCS	3b	None	None
Vanamo et al[3]	RCS	3b	Shorter operative time	None
			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, video-assisted thoracoscopic surgery.

Furthermore, our search revealed some relevant case series[5] [6] [7] (level IV of CEBM) stating that the VATS technique for PDA closure is simple, effective, rapid, cost-effective, and more 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.

• References

• 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 Jr AP, Snyder CL, Ashcraft KW, Manning PB. Comparison of muscle-sparing thoracotomy and thoracoscopic ligation for the treatment of patent ductus arteriosus. J Pediatr Surg 1998; 33 (2) 259-261
• 3 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
• 4 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
• 5 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
• 6 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
• 7 Rothenberg SS, Chang JHT, Toews WH, Washington RL. Thoracoscopic closure of patent ductus arteriosus: a less traumatic and more cost-effective technique. J Pediatr Surg 1995; 30 (7) 1057-1060
• 8 Nezafati MH, Soltani G, Mottaghi H, Horri M, Nezafati P. Video-assisted thoracoscopic patent ductus arteriosus closure in 2,000 patients. Asian Cardiovasc Thorac Ann 2011; 19 (6) 393-398
• 9 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
• 10 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