CLM represents a heterogeneous group of abnormalities. Several children exhibited complications associated with CLM, including fetal hydrops and lung hypoplasia, beginning from the prenatal period [3]. Although the number of cases that are suspected or diagnosed early has increased, many management questions remain unanswered. Especially in cases where children show no symptoms, there is no universally accepted surgical management [3]. While there is a general consensus that any symptomatic CLM should be treated, the best management of asymptomatic children remains controversial [6]. In this retrospective study, we analyzed children with CLM who underwent surgical resection at a tertiary care center in Thailand. Most of them had respiratory symptoms before surgery.

Our study found that children who had surgery while experiencing symptoms had a higher incidence of postoperative complications compared to those who did not have symptoms. This finding is consistent with previous research in the field [7,8,9]. Our research revealed that the most common complication encountered was ventilator-associated pneumonia. There are studies that suggest that prior infections can lead to the scarring of lung tissue, which can make surgeries more difficult. This could result in an increased number of complications post-surgery. Thus, our findings support the notion of undertaking an early resection before any symptoms begin to manifest.

The adoption of early surgical resection as a customary procedure may effectively mitigate the likelihood of severe respiratory complications and abbreviate hospital stays, thereby contributing to enhanced patient outcomes and decreased healthcare expenditures. This is consistent with previous research demonstrating that early resection in asymptomatic children results in improved postoperative recovery and fewer complications [10,11,12]. Adopting these findings into routine clinical protocols, coupled with the development of guidelines for the management of asymptomatic CLM, could provide clinicians with a clearer decision-making framework and optimize patient care.

Our study demonstrates that early surgical intervention in asymptomatic children with CLM potentially enhances lung growth and regeneration. Although the alveolarization process remains incompletely comprehended [13], the dominant theory holds that alveoli cease to proliferate by 2–3 years of age [14] and subsequently experience a growth in both volume and surface area. However, certain authors have proposed that alveolar formation could persist for an additional 7–8 years of age [15]. By performing surgical resections at a younger age, we can take advantage of this critical window for lung growth. Additionally, human hepatocyte growth factor (hHGF) has been identified as the most potent mitogen for alveolar type II cells. It plays a crucial role in the repair of the alveolar epithelium and compensatory lung growth. A study evaluating changes in serum hHGF levels in patients undergoing thoracic surgical procedures found that hHGF levels significantly increased following lung resection, indicating its role in lung regeneration [16]. These findings suggest that early resection in clinical practice could reduce immediate complications and foster optimal lung growth during this crucial developmental phase. This approach underscores the importance of developing robust clinical guidelines that advocate for early surgical intervention in asymptomatic children, ensuring that therapeutic decisions are grounded in both immediate and long-term benefits.

Our study did not reveal a significant difference in operative time, length of ventilation, and hospital stay between the two groups. These results contrast with the previous study [10]. In 2021, Elhattab et al. compared surgical outcomes via thoracoscopic surgery in 28 patients with a history of pulmonary infection and 62 patients with no such history. They reported that the operative time was significantly shorter in asymptomatic patients [8]. However, data regarding the frequency of infections or the duration from the onset of symptoms to surgery were not collected. Recurrent episodes of infection may lead to increased lung fibrosis, potentially affecting surgical outcomes [17].

Our study suggests that patients who display symptoms tend to have longer stays in the hospital as compared to those who are asymptomatic. Although the difference is not statistically significant, the median duration of hospitalization for symptomatic patients was 17 days, while for asymptomatic patients it was 11 days. The reason behind this could be a higher occurrence of postoperative complications among symptomatic patients. Consistent with the previous study in Belgium, they discovered postoperative complications and longer hospital stays were significantly higher in patients with preoperative clinical signs of CPAM [18].

Children with CLM who present asymptomatically and undergo early surgical resection in our study encounter a markedly reduced incidence of postoperative complications in comparison to those who exhibit symptoms. This observation lends support to the expanding corpus of evidence indicating that implementing early intervention measures before symptoms manifest could potentially result in improved surgical outcomes and decreased healthcare costs. In addition, to guide clinical decision-making, our findings highlight the significance of developing standardized protocols for the management of asymptomatic CLM. Considering the constraints of our retrospective study conducted at a single center, it is recommended that further prospective multicenter investigations be undertaken to validate these findings and examine the enduring clinical consequences, such as pulmonary function and quality of life, in older children and adolescents.

This retrospective study included only children who underwent surgical resection, excluding those who spontaneously regressed or remained under observation, which may introduce selection bias. Additionally, we did not determine the optimal age for surgery in asymptomatic patients or document the rationale behind such decisions, highlighting the need for prospective research. Our small sample size reduced statistical power, and as a single-institution study, the findings may not be widely applicable. Furthermore, we did not collect detailed data on intraoperative complications; however, no redo surgeries or recurrent symptoms were observed. Only short-term outcomes were evaluated, so long-term results remain unknown, underscoring the necessity of larger, multi-center studies with standardized follow-up protocols.