|Year : 2005 | Volume
| Issue : 2 | Page : 117-119
M Raghvan, Manish Pathak, Gautam S Agarwal
Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi-110 029, India
Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi-110 029
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Raghvan M, Pathak M, Agarwal GS. Selected Summaries. J Indian Assoc Pediatr Surg 2005;10:117-9
Management of instrumental perforation of the esophagus occurring during treatment of corrosive stricture. Avanoglu A, Ergun O, Mutaf O. Department of Pediatric Surgery, Ege University, Faculty of Medicine, Izmir, Turkey. Journal of Pediatric Surgery, 1998;33: 1393-1395
Iatrogenic esophageal perforations due to instrumentation remain the commonest cause of esophageal perforation. This study was conducted from 1976 to 1996 and compared 54 patients with iatrogenic esophageal perforations (study group) of a total of 1249 patients treated for corrosive esophageal stricture. The treatment consisted of three weekly dilatation under general anaesthesia using rigid esophagoscopy which was started 3 weeks after the corrosive ingestion. Patients who developed features of esophageal perforation (evidenced by fever, tachycardia, respiratory distress, subcutaneous emphysema and plain X- ray showing widening of mediastinum, mediastinal emphysema, pneumothorax and pleural effusion0 were confirmed by barium study and included in the study.The treatment options for these included intercostal tube drainage, mediastinal drainage, gastrostomy, jejunostomy, total parenteral nutrition, primary repair, intraluminal stenting and esophageal replacement either in isolation or combinations. Pleural drainage alone was done in 19 patients, mediastinal drainage alone in 15 patients, both pleural and mediastinal drainage in 7 patients, feeding ostomies in 40 patients, primary repair in 2 patients, stenting in 9 patients and colonic replacement in 6 patients. 40 patients [77%] have survived and 12 [23%] patient died due to mediastinitis and sepsis. The study has concluded that early recognition by clinical suspicion and simple pleural drainage is life saving and heroic attempts to repair the esophagus or replace it in the acute phase in not safe. Intraluminal stenting is effective in tracheo esophageal fistula cases. The cause of death after esophageal perforation has been found to be due to sepsis and mediastinitis. The author also recommend 10 % barium for the contrast study since it has no false positive or false negative rate. The use of rigid instrument and barium is a controversial issue and the timing of esophageal replacement has not been emphasized in this article.
Topotecan and Irinotecan in the treatment of pediatric solid tumors. Yoshiaki Tsuchida Y and Shitara T, Gunma Children Medical Center, Gunma, Japan. Current Pediatric Review, 2005;1:55-61.
Newer chemotherapeutic agents are being sought in the management of pediatric solid tumors especially in recurrent and refractory tumors. A new topoisomerase I inhibitor, Camptothecin, derived from leaves of the Chinese tree Camptotheca acuminata has been found to be effective in the treatment of lung, ovarian and gastric carcinoma in adults. The Camptothecin derivatives, Toptecan and Irinotecan, were found to have a promising role in the treatment of childhood solid tumors such as rhabdomyosarcoma and neuroblastoma as evidenced from preclinical, phase I and phase II studies conducted by the Pediatric Oncology Group. These drugs act by inhibiting topoisomerase I enzyme, which is essential for DNA synthesis and they are S- phase specific. The recommended dosage, evaluated after various studies for Irinotecan is 50 mg/m2 body surface area per day for 5 days repeated every 4 weeks and for topotecan is 2 mg/m2 body surface area per day for 5 days repeated every 3 weeks. Improved response rate (56% over all) with no added toxicity were obtained when combined with other drugs namely cis-platinum, vincristine and doxorubicin to which the tumor was already refractory. The response was additive or synergistic and better in the recurrent cases. The dose limiting was myelosuppression and diarrhea. Neutropenia occurred after almost all courses but was remediable with Grastim (G-CSF) and hospitalization was required in only one third of cases. Outpatient administration of toptecan has been found to be safe. Well designed phase III randomized trial will be needed to establish these important agents in pediatric oncology.
Outcome Predictors for Infants With Cystic Lung Disease. Usui N, Kamata S, Sawai T, Kamiyama M, Okuyama H, Kubota A, Okada A. Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.Journal of Pediatric Surgery 2004;39:603-06
In this retrospective study, medical records of neonates who had undergone prenatal evaluation for cystic lung disease (CLD) at Osaka University Hospital and affiliated hospitals from 1989 to 2001 were reviewed. The aim was to identify characteristic features indicating congenital cystic adenomatoid malformation (CCAM) and evaluating the outcome predictors prenatally. Patients were divided into mild, moderate and severe groups depending upon the need for operation in the neonatal period and duration of requirement of postoperative mechanical ventilation. Ultrasonography (USG) findings in the fetus and their pulmonary lesions were evaluated. The normal lung to thorax transverse area ratio (L/T) was measured by USG. The diagnosis of CLD was made in 28 fetuses during the study period. The clinical diagnosis of CCAM was made in 17 patients. Of the other eleven with prenatal diagnosis of CLD, different pathologies were diagnosed in 7 patients by histological examination of the resected specimens; in 2 patients diagnosis was not confirmed while in another 2 patients, the lesions resolved spontaneously. CCAM was characterized by persistently high echogenicity, while other CLD showed either decrease in echogenicity towards term or echogenicity remained normal throughout pregnancy. Gestational age at delivery and Apgar score at 1 minute were lower in the severe group compared with other groups. Three factors were found to be important to determine severity. Polyhydraminos, hydrops and final L/T value less than 0.25. It was found that L/T increased in mild and moderate groups as pregnancy progressed, whereas no patient in the severe group had an increase in L/T ratio at the final measurement. Thus it was concluded that subgroup of fetuses with an increased probability of mortality or severe respiratory difficulty could be predicted from the combination of presence of polyhydramnios, fetal hydrops and a final L/T value of less than 0.25. Though this study has attempted to differentiate CCAM from other CLD but this may not be of any clinical significance as management of all CLD is the same; furthermore L/T was not found as important an prognostic indicator as initially thought to be in congenital diapragmatic hernia, so its prognostic importance in CLD needs further evaluation.
Hepatic hemangioendothelioma: Clinical experience and management strategy. Daller JA, Bueno J, Gutierrez J, Dvorchik I, Towbin RB, Dickman PS, Mazariegos G, Reyes J. Thomas E. Starzl Transplant Institute, University of Pittsburgh and Children's Hospital of Pittsburgh Transplantation Surgery, PA 15213, USA. Journal of Pediatric Surgery 1999;34:98-105, Discussion 105-06
This retrospective analysis of patients with hemangioendothelioma presenting to a tertiary liver transplantation center between 1989 and 1997 was designed to define management stategies based on clinical experience in treating infantile hepatic hemangioendothelioma. A total of fourteen children with the admitting diagnosis of hemangioendotelioma were identified. One girl was found to have metastatic angiosarcoma after orthotopic liver transplantation and was excluded from further analysis. Median age of presentation was 14 days, including two children with unusual presentation at 3.4 and 6.8 years. Hepatomegaly, abdominal mass, skin lesions and congestive heart failure (CHF) were the most common features found. Ultrasonography and computerized tomography were the most commonly used diagnostic modalities. Treatment options were divided into medical and interventional modalities. Medical management was based on high dose steroids and adjunctive alpha interferon. Digoxin and diuretics were given for symptomatic CHF. Interventional modalities included hepatic artery ligation, embolisation, resectional surgery and orthotopic liver transplantation. Patients who underwent resectional surgery with or without orthotopic liver transplantation had a lower 5 month mortality rate (p< 0.02) and a greater 2 year survival rate (p< 0.003) than did those who underwent hepatic artery ligation or embolisation. Early morbidity or mortality tended to be a consequence of the primary lesion, whereas late morbidity or mortality were reflective of the treatment modality used. Based on their experience the authors have proposed that asymptomatic solitary lesion can be observed whereas symptomatic solitary lesions should be managed medically at first, and if it does not respond then resection should be contemplated. In bilobar disease, asymptomatic patients should also be put on medical treatment. Manageable symptoms are attempted to be control by drugs first, then intervention in the form of embolisation or transplantation. Unmanageable symptoms will require arteriography followed by embolisation or transplantation is carried out. In this series, eight patients who received some form of medical therapy, eventually required invasive intervention because of treatment failure. Being a tertiary referral center, it is likely that their referral pattern did not include those patients who responded to medical therapy alone.
The treatment of high and intermediate anorectal malformation :one or three stage procedure. Guochong Lui, Jiyan Yuan, Jinmei Geng, Chunhua Wang and Tuanguang LI, Wuhan China (Journal of Pedaitric surgery, 2004, 39)
Since the early 1980's posterior sagital anorectoplasty (PSARP) as described by de Veries and Pena, has beome the popular procedure in many hospitals for patients with imperforate anus. The traditional PSARP is a 3 stage procedure over weeks or months .Obviously, 3 procedures burden the patients and their patients physiologically, psychologically and economically.
The aim of this study was to examine the safety. feasibility and long term outcome of complete 1-stage repair of high and intermediate ARM using PSARP in neonates. 113 patients with high type and ARM underwent follow up. Of the 113 cases, 48 cases underwent staged procedure (group1), the other 65 patients underwent 1 stage PSARP (group2). Anorectal function was measured by modified Wingspread scoring, including 'excellent', good, fair and poor. In barium enema studies, anorectal angulations was judged as clear, unclear and not present and leakage of barium was observed. For anorectal manometric studies, anal resting pressure , anal squeeze pressure and anorectal reflex was measured.
In group 1, the rate of excellent and good scores was 58.3% (28 of 43). In the barium enema 85.4% (41 of 48) was clear and 14.6 % (7 of 48) unclear or not present. The rate of barium leakage was 10.4% (5 of 48). In group 2, the rate of excellent and good was 53.8% (35 of 65). Anorectal angulations were clear in 83.1% of patients (54 of 65). Barium leakage happened in 7.69% of patients (5 of 65). Early operative complications occurred in 56.3% (27 of 48) of patients in group 1 and 29.2% (19 of 65) in group 2. The incidence of colostomy complications in group 1 was 39.6% (19 of 48). Soiling and constipation were the major complication after the PSARP operation. The respective rates of constipation in 2 groups were 47.9% (23 of 48) and 44.6% ( 29 of 65) and the respective rates of soiling were 47.9% (23 of 48) and 50.8% (33 of 65). There was no significant difference in the mean ARP between the 2 groups.
The 1 stage PSARP procedure in the neonate not only achieves the same long term outcome as the conventional PSARP procedure but also involves fewer short term complications. Complete 1 stage operation using the PSARP to treat high and intermediate type anorectal malformation is safe and feasible. It reduces the risk of anaesthesia and operation and is especially suits the developing countries economically.
Outcome and staging evaluation in Malignant germ cell tumors of the ovary in children and adolescents: An intergroup study. D. Billimire, C. Vinocus, F. Rescorla, B. Cliching, W. London. M. Schlatter, M. Dains, R.Giller, G. Lauer and T. Olson, On behalf of children's oncology group (COG) . Indianapolis, Indiana. Journal of Pediatric Surgery, Vol 39, No 3 (March, 2004)).
The purpose of this study was to perform an evaluation of outcome and role of surgical staging components in malignant germ cell tumors of the ovary in children and adolescents.
From 1990-1996, 2 intergroup trials on extra-cranial malignant GCT were undertaken by Pediatric Oncology Group (POG) and children's cancer study group (CCG). Stage I and II patients were treated with surgical resection and 4 cycles of standard dose cisplatin (100 mg/m2/d), etoposide 100 mg/m2/day x 5 days and bleomycin 15 mg/m2/d x 1 day for each cycle. Stage III-IV patients were treated with surgical resection and randomly assigned to chemotherapy with PEB or high dose cisplatin (200 mg/m2/cycle) with etoposide and bleomycin (HDPEB). Patients unresectable at diagnosis had second look operation after 4 cycles of chemotherapy if residual tumor was seen on imaging. IRB approval of the protocols was obtained at each participating institute. An analysis of outcome data, operative notes and pathology reports was done.
There were 131 patients with ovarian primary tumors. Mean age was 11.9 years (range 1.4- 20 yrs). Five year survival rate was stage ², 95.1%; stage II, 93.8%, stage II, 98.3%, stage IV 93.8%. In only 3 of 131 patients, were surgical guidelines followed completely. Surgical omissions resulting in protocol noncompliance resulted from failure to biopsy bilateral nodes (97%) no omentectomy (36%), no peritoneal cytology (21%), no contralateral ovary biopsy (59%). More aggressive procedure than recommended by guidelines included total hysterectomy and bilateral salphingo-oopherectomy in 6 patients and retro-peritoneal node dissection in 10 patients. Correlation of gross operative findings with pathology results was carried out for ascites, lymph nodes, implants, omentum and contralateral ovary.
Pediatric ovarian malignant GCT (stages I-IV) have excellent survival with conservative surgical resection and platinum based chemotherapy. Survival appears to have been unaffected by deviations from surgical guidelines. New guide lines are proposed based on correlation of gross findings, histology and outcome in these intergroup trials. The new guidelines include; collection of ascitic fluid or peritoneal washings on entry; examination of peritoneal surfaces with biopsy or excision of nodule, examination and palpation of omentum with removal, if any adherent or abnormal areas noted; examination and palpation of retroperitoneal nodes with sampling of any firm or enlarged nodes; inspection and palpation of contralateral ovary with biopsy of any abnormal areas, complete resection of tumor containing ovary with sparing of Fallopian tube More Detailss if not involved.