Long-term outcomes after operative versus conservative management of congenital thoracic malformations: a propensity-matched cohort study

PURPOSE: Management of asymptomatic congenital thoracic malformations (CTMs) remains controversial. Early resection may prevent infection or malignancy and promote compensatory lung growth, but its long-term impact is unclear. This study compared long-term cardiorespiratory and psychosocial outcomes after operative versus conservative management of CTMs and evaluated open versus thoracoscopic surgery. METHODS: Children with congenital pulmonary airway malformation, pulmonary sequestration, or congenital lobar emphysema treated at a tertiary center between 2000 and 2023 were identified retrospectively. Operative patients underwent open or thoracoscopic resection, while conservatively managed children were followed radiologically. Prospective follow-up included the 6-minute run, pulmonary function testing, and psychosocial assessment. Propensity score matching adjusted for gestational age, birth weight, lesion extent, prenatal intervention, and associated congenital diaphragmatic hernia. RESULTS: Among 194 children (median follow-up 8.7 years), 162 underwent surgery and 32 were observed. Surgical patients showed smaller prenatal relative lung volume (51% vs. 79%, p = 0.02) and higher neonatal acuity (ICU admission 78% vs. 54%, p < 0.01). After matching, postnatal length of stay remained longer after surgery (15 vs. 6 days, p = 0.03). Thoracoscopy was associated with shorter postoperative stay, fewer complications and no mortality. Long-term fitness and quality of life were comparable between groups (p > 0.5). CONCLUSION: Surgical management of CTMs does not impair long-term exercise capacity or psychosocial outcomes. Minimally invasive resection appears safe and may be offered as a preventive option in asymptomatic patients.