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INTRODUCTION: Cervical lymphadenopathy in children is typically self-limited; however, the management of persistent lymphadenopathy remains unclear. This study aimed to evaluate the management and outcomes of patients with persistent cervical lymphadenopathy. METHODS: Single-institution, retrospective review of children <18 years undergoing ultrasound (US) for cervical lymphadenopathy from 2013 to 2021 was performed. Patients were stratified into initial biopsy, delayed biopsy, or no biopsy groups. Clinical characteristics and workup were compared, and multivariate analyses were performed to assess predictors of delayed biopsy. RESULTS: 568 patients were identified, with 493 patients having no biopsy, 41 patients undergoing initial biopsy, and 34 patients undergoing delayed biopsy. Presenting symptoms differed: no biopsy patients were younger, were more likely to present to the emergency department, and had clinical findings often associated with acute illness. Patients with USs revealing abnormal vascularity or atypical architecture were more likely to be biopsied. History of malignancy, symptoms >1 week but <3 months, and atypical or change in architecture on US was associated with delayed biopsy. Patients with long-term follow-up (LTF) were followed for a median of 99.0 days. Malignancies were identified in 12 patients (2.1%). All malignancies were diagnosed within 14 days of presentation, and no malignancies were identified in LTF. CONCLUSIONS: Patients with persistent low suspicion lymphadenopathy are often followed for long durations; however, in this cohort, no malignancies were diagnosed during LTF. We propose an algorithm of forgoing a biopsy and employing primary care surveillance and education, which may be appropriate for these patients in the proper setting.
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Linfadenopatía , Cuello , Ultrasonografía , Humanos , Niño , Linfadenopatía/diagnóstico , Linfadenopatía/etiología , Linfadenopatía/diagnóstico por imagen , Estudios Retrospectivos , Masculino , Femenino , Preescolar , Adolescente , Lactante , Biopsia , Ganglios Linfáticos/patología , Ganglios Linfáticos/diagnóstico por imagenRESUMEN
BACKGROUND: To examine the use of abdominal ultrasound (AUS) as a diagnostic adjunct in the diagnosis of necrotizing enterocolitis (NEC) in cases where abdominal radiography (AXR) is equivocal in order to reduce unnecessary antibiotic use in neonates. METHODS: Retrospective study (2017-2019) of infants undergoing NEC evaluation with equivocal AXR findings (n = 54). Paired AXR and AUS were reviewed with respect to presence or absence of pneumatosis. Concordance of AUS findings with decision to treat for NEC was evaluated. RESULTS: Among 54 infants where AXR was equivocal, AUS demonstrated presence of pneumatosis in 22 patients (41%), absence of pneumatosis in 31 patients (57%), and was equivocal in 1 patient. All patients with pneumatosis on AUS were treated for NEC. Of 31 patients without pneumatosis on AUS, 25 patients (78%) were not treated for NEC. Patients without pneumatosis on AUS received a significantly shorter mean duration of antibiotics compared to those with pneumatosis (3.3 days (+/- 4.8 days) vs 12.4 days (+/- 4.7 days)); p < 0.001). Of those patients not treated, none required treatment within 1 week following negative AUS. CONCLUSION: AUS is a valuable tool for evaluating the presence or absence of pneumatosis in the setting of equivocal AXR. Absence of pneumatosis on AUS informs clinical decision making and reduces unnecessary treatment and antibiotic usage.
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Enterocolitis Necrotizante , Enfermedades del Recién Nacido , Lactante , Recién Nacido , Humanos , Enterocolitis Necrotizante/diagnóstico , Estudios Retrospectivos , Radiografía Abdominal/métodos , Enfermedades del Recién Nacido/diagnóstico , Ultrasonografía/métodosRESUMEN
OBJECTIVE: To assess the clinical implications of cryoanalgesia for pain management in children undergoing minimally invasive repair of pectus excavatum (MIRPE). BACKGROUND: MIRPE entails significant pain management challenges, often requiring high postoperative opioid use. Cryoanalgesia, which blocks pain signals by temporarily ablating intercostal nerves, has been recently utilized as an analgesic adjunct. We hypothesized that the use of cryoanalgesia during MIRPE would decrease postoperative opioid use and length of stay (LOS). MATERIALS AND METHODS: A multicenter retrospective cohort study of 20 US children's hospitals was conducted of children (age below 18 years) undergoing MIRPE from January 1, 2014, to August 1, 2019. Differences in total postoperative, inpatient, oral morphine equivalents per kilogram, and 30-day LOS between patients who received cryoanalgesia versus those who did not were assessed using bivariate and multivariable analysis. P value <0.05 is considered significant. RESULTS: Of 898 patients, 136 (15%) received cryoanalgesia. Groups were similar by age, sex, body mass index, comorbidities, and Haller index. Receipt of cryoanalgesia was associated with lower oral morphine equivalents per kilogram (risk ratio=0.43, 95% confidence interval: 0.33-0.57) and a shorter LOS (risk ratio=0.66, 95% confidence interval: 0.50-0.87). Complications were similar between groups (29.8% vs 22.1, P =0.07), including a similar rate of emergency department visit, readmission, and/or reoperation. CONCLUSIONS: Use of cryoanalgesia during MIRPE appears to be effective in lowering postoperative opioid requirements and LOS without increasing complication rates. With the exception of preoperative gabapentin, other adjuncts appear to increase and/or be ineffective at reducing opioid utilization. Cryoanalgesia should be considered for patients undergoing this surgery.
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Tórax en Embudo , Trastornos Relacionados con Opioides , Niño , Humanos , Adolescente , Analgésicos Opioides/uso terapéutico , Estudios Retrospectivos , Tórax en Embudo/cirugía , Dolor Postoperatorio/prevención & control , Dolor Postoperatorio/tratamiento farmacológico , Morfina , Procedimientos Quirúrgicos Mínimamente InvasivosRESUMEN
INTRODUCTION: Clinical and radiographic findings often lead to diagnostic laparoscopy for presumed adnexal torsion (AT). To better understand the preoperative factors leading to AT, we evaluated the clinical course of patients with ultrasound findings concerning for AT to assess intraoperative AT rates and predictive factors for AT. METHODS: An institutional review board-approved retrospective review in two hospital centers over a period of 5 y was performed for females (4-18 y) with ultrasound (US) findings concerning for AT (n = 225). Preoperative clinical, radiographic, and intraoperative findings were assessed for patients with intraoperative AT versus for those without. RESULTS: The median age of patients was 14 y. Of those who went to the operating room (OR) (n = 113), AT was found in 57%. There was no difference between patients taken to the OR with or without AT regarding demographics or presentation. The presence of nausea/vomiting, tenderness, leukocytosis, lack of blood flow, or a mass/cyst >5 cm were found to be more likely in patients with AT than in those without. An ovarian volume ratio >15 was noted to be predictive of AT. Six patients initially discharged from the emergency department returned and went to the OR, two of which had AT, both with ovarian salvage. CONCLUSIONS: Limited data are available when counseling patients with presumed AT. We found the larger mean ovarian volume and an ovarian volume ratio >15 were predictive of AT. Despite this, 43% of patients taken to the OR did not have AT. This relatively high rate of not finding AT intraoperatively may be justified given the sequelae of missing AT.
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Enfermedades de los Anexos , Enfermedades de los Anexos/diagnóstico por imagen , Enfermedades de los Anexos/cirugía , Adolescente , Niño , Femenino , Humanos , Náusea/complicaciones , Torsión Ovárica , Estudios Retrospectivos , Anomalía Torsional/diagnóstico por imagen , Anomalía Torsional/cirugía , Vómitos/complicacionesRESUMEN
Complications after pancreatoduodenectomy are common, and range widely in timing of presentation, relation to pancreatobiliary pathology, and necessity of operative intervention. We present a case of a 74-year-old male with history of pancreatoduodenectomy for pancreatic adenocarcinoma who presented 11 months after index operation with cecal volvulus and required emergent right hemicolectomy. Prior history of pancreatoduodenectomy with mobilization of the right colon likely predisposed him to development of this surgical emergency. Patients have altered gastrointestinal anatomy after pancreatoduodenectomy and special care is necessary to protect the afferent biliopancreatic limb during intraoperative exploration, and particularly if right colectomy is necessary.
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BACKGROUND: Subtotal colectomy with end ileostomy (STC-I) has been well established in the adult literature as an initial surgical treatment for refractory inflammatory bowel disease (IBD)-related colitis. However, in the pediatric population, the efficacy of this approach has been less well characterized, likely because of concerns regarding the advisability of leaving a diseased rectum in situ. Our aim was to examine the outcomes after STC-I for refractory IBD at our pediatric tertiary care center. METHODS: An institutional review board-approved retrospective review of patients aged 5-21 y who underwent operative treatment with initial STC-I for medically refractory IBD from January 2010 to August 2018. Only complications related to the STC-I were considered; complications subsequent to reconstruction are excluded from analysis. Early complications were defined as occurring within 60 d of STC-I. We performed descriptive statistics using the Fisher exact test and the Student t-test, as appropriate. RESULTS: Over the study period, 37 patients (aged 12.3 ± 4.2 y) underwent STC-I, with 73.0% performed laparoscopically. Patients were predominately male (51.4%) and Caucasian (48.6%). Thirty-one (83.8%) colectomies were performed for ulcerative colitis, two (5.4%) for Crohn disease, and four (10.8%) for indeterminate colitis. Nutritional status improved postcolectomy. Albumin levels of 3.3 ± 0.8 preoperatively increased to 4.3 ± 0.47 postoperatively (P < 0.001). Colonic bleeding was stopped by STC-I with increases in the hematocrit from 30.5 ± 6.8 preoperative to 38.9 ± 4.1 postoperatively (P < 0.001). Average time to discontinuation of IBD-related medications was 4 wk (n = 27). Forty-eight percent required outpatient rectal treatment for proctitis. Patients did well long term, with 67.5% reestablishing intestinal continuity at our institution. Average postoperative length of stay was shorter in the laparoscopic group compared with those undergoing open operations (5.1 ± 2.2 versus 6.9 ± 1.6 d, P = 0.03). Readmission rate at 30 d was 21.1%. Patients experiencing unplanned readmission or unplanned operations were similar between groups (30% versus 33.3%, P = 0.85 and 30% versus 18.5%, P = 0.45, respectively). Overall, 14 (37.8%) patients experienced a complication with many patients experiencing multiple complications. Early complications occurred in nine (24.3%) patients. Late complications also occurred in 24.3% of patients. There were four (10.8%) patients with five admissions for bowel obstruction, two of whom required operative intervention (5.4%). CONCLUSIONS: Use of STC-I as an initial procedure in the treatment of refractory IBD-related colitis in children is a safe and reasonable surgical approach that allows weaning from immunosuppressing mediations and stops colonic bleeding. Implementing a laparoscopic approach to subtotal colectomy provides further benefit by reducing postoperative length of stay.
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Colectomía/estadística & datos numéricos , Colitis Ulcerosa/cirugía , Ileostomía/estadística & datos numéricos , Adolescente , Niño , Preescolar , Femenino , Humanos , Masculino , New York/epidemiología , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Adulto JovenRESUMEN
BACKGROUND: Osteosarcoma is a highly metastatic primary bone tumor that predominantly affects adolescents and young adults. A mainstay of treatment in osteosarcoma is removal of the primary tumor. However, surgical excision itself has been implicated in promoting tumor growth and metastasis, an effect known as surgery-accelerated metastasis. The underlying mechanisms contributing to surgery-accelerated metastasis remain poorly understood, but pro-tumorigenic alterations in macrophage function have been implicated. METHODS: The K7M2-BALB/c syngeneic murine model of osteosarcoma was used to study the effect of surgery on metastasis, macrophage phenotype, and overall survival. Pharmacological prevention of surgery-accelerated metastasis was examined utilizing gefitinib, a receptor interacting protein kinase 2 inhibitor previously shown to promote anti-tumor macrophage phenotype. RESULTS: Surgical excision of the primary tumor resulted in increases in lung metastatic surface nodules, overall metastatic burden and number of micrometastatic foci. This post-surgical metastatic enhancement was associated with a shift in macrophage phenotype within the lung to a more pro-tumor state. Treatment with gefitinib prevented tumor-supportive alterations in macrophage phenotype and resulted in reduced metastasis. Removal of the primary tumor coupled with gefitinib treatment resulted in enhanced median and overall survival. CONCLUSIONS: Surgery-accelerated metastasis is mediated in part through tumor supportive alterations in macrophage phenotype. Targeted pharmacologic therapies that prevent pro-tumor changes in macrophage phenotype could be utilized perioperatively to mitigate surgery-accelerated metastasis and improve the therapeutic benefits of surgery.
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Neoplasias Óseas , Neoplasias Pulmonares , Osteosarcoma , Animales , Línea Celular Tumoral , Modelos Animales de Enfermedad , Gefitinib , Neoplasias Pulmonares/tratamiento farmacológico , Ratones , Metástasis de la Neoplasia , Osteosarcoma/tratamiento farmacológicoRESUMEN
Most patients with osteosarcoma have subclinical pulmonary micrometastases at diagnosis. Mounting evidence suggests that macrophages facilitate metastasis. As the EGFR has been implicated in carcinoma-macrophage cross-talk, in this study, we asked whether gefitinib, an EGFR inhibitor, reduces osteosarcoma invasion and metastatic outgrowth using the K7M2-Balb/c syngeneic murine model. Macrophages enhanced osteosarcoma invasion in vitro, which was suppressed by gefitinib. Oral gefitinib inhibited tumor extravasation in the lung and reduced the size of metastatic foci, resulting in reduced metastatic burden. Gefitinib also altered pulmonary macrophage phenotype, increasing MHCII and decreasing CD206 expression compared with controls. Surprisingly, these effects are mediated through inhibition of macrophage receptor interacting protein kinase 2 (RIPK2), rather than EGFR. Supporting this, lapatinib, a highly specific EGFR inhibitor that does not inhibit RIPK2, had no effect on macrophage-promoted invasion, and RIPK2-/- macrophages failed to promote invasion. The selective RIPK2 inhibitor WEHI-345 blocked tumor cell invasion in vitro and reduced metastatic burden in vivo In conclusion, our results indicate that gefitinib blocks macrophage-promoted invasion and metastatic extravasation by reprogramming macrophages through inhibition of RIPK2.
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Neoplasias Óseas/tratamiento farmacológico , Gefitinib/farmacología , Regulación Neoplásica de la Expresión Génica/efectos de los fármacos , Macrófagos/metabolismo , Osteosarcoma/tratamiento farmacológico , Proteína Serina-Treonina Quinasa 2 de Interacción con Receptor/antagonistas & inhibidores , Animales , Antineoplásicos/farmacología , Apoptosis , Neoplasias Óseas/metabolismo , Neoplasias Óseas/secundario , Proliferación Celular , Femenino , Humanos , Macrófagos/efectos de los fármacos , Masculino , Ratones , Ratones Endogámicos BALB C , Ratones Noqueados , Ratones Desnudos , Invasividad Neoplásica , Osteosarcoma/metabolismo , Osteosarcoma/patología , Proteína Serina-Treonina Quinasa 2 de Interacción con Receptor/fisiología , Células Tumorales Cultivadas , Ensayos Antitumor por Modelo de XenoinjertoRESUMEN
Pediatric robotic-assisted surgery is quickly gaining traction in pediatric surgical disciplines but presents unique challenges as compared to adult robotic surgery. Small abdominal and thoracic cavities limit working space and operative indications differ from the adult population. This article describes the development of pediatric robotic-assisted surgery, discusses technical limitations and benefits, and reviews training considerations particular to robotic surgery. Applications and published outcomes of common procedures in urology, general and thoracic surgery, otolaryngology, and pediatric surgical oncology are described. Finally, costs and the anticipated future direction of pediatric robotic-assisted surgery are discussed.
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Pediatría/métodos , Procedimientos Quirúrgicos Robotizados/métodos , Tamaño Corporal , HumanosRESUMEN
Introduction: Multistaged surgical management of inflammatory bowel disease (IBD), culminating in ileal pouch-anal anastomosis (IPAA), can provide cure for refractory IBD symptoms while maintaining fecal continence. Surgical approaches to IPAA historically included a three-stage approach done by subtotal colectomy (STC) followed by IPAA with diversion. Recently, a variant two-stage approach without diversion at IPAA has become increasingly utilized, yet evidence of the efficacy of this approach is limited. Methods: Retrospective review of patients aged 5-21 years who underwent initial STC, followed by a total proctocolectomy with IPAA +/- diversion for medically refractory IBD from January 2010 to August 2018 (n = 25). Results: Majority of IPAA procedures were done laparoscopically (88.5%). Thirteen patients (52%) underwent two-stage variant IPAA. There were no differences in readmission rates (66.7% versus 53.8%, P = .5) or reoperation rates (50% versus 30.8%, P = .3) between groups. Forty percent of patients experienced a complication after IPAA. Complication rates were similar between two-stage and three-stage IPAA groups (38.5% versus 50%, P = .33). Complications within the two-stage group included anastomotic leak, pouchitis, wound infection, anastomotic stricture, and incarcerated hernia. Complications within the three-stage group included bloody ostomy output, dehydration, anastomotic stricture, small bowel obstruction, and pouch volvulus. Conclusions: Treatment of refractory IBD in children remains challenging, but STC followed by IPAA is an approach that provides symptom relief and preserves continence. Complication rates remained unchanged regardless of whether IPAA was conducted with or without diversion, demonstrating that the two-stage variant approach is a safe and feasible treatment that may reduce subsequent anesthesia exposure and trips to the operating room.
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Colitis Ulcerosa/cirugía , Proctocolectomía Restauradora/métodos , Adolescente , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Laparoscopía , Masculino , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Laparoscopic gastrostomy tube (GT) placement is a common procedure and frequent cause of morbidity. Some surgeons perform a Seldinger technique (ST), while others perform a modified open technique (MOT). We hypothesized that the modified open technique would result in more complications. METHODS: A prospective study of primary GT placed 12/2016-06/2018, ensuring at least 6 months follow up. We assessed any episode of granulation tissue, troublesome leaking, tube dislodgment, and infection requiring antibiotic or drainage. RESULTS: 92â¯GT were placed, with 56 were placed as modified open (60.9%). 34 children (37.0%) developed granulation tissue, 18 children (19.6%) experienced tube dislodgment, and 6 children (6.5%) developed a site infection, with no difference depending on technique (Pâ¯=â¯0.56, 0.29, and 0.76, respectively). Following ST, 2 children developed leakage (5.6%), whereas 15 children (26.8%) had leakage following the MOT (Pâ¯=â¯0.01). CONCLUSION: MOT resulted in significantly more leaks. Other complications were similar between groups. Surgeons choosing MOT should be mindful of the size of gastrotomy at time of surgery, as this may result in increased complications.
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Gastrostomía/efectos adversos , Gastrostomía/métodos , Intubación Gastrointestinal/efectos adversos , Intubación Gastrointestinal/métodos , Laparoscopía/efectos adversos , Complicaciones Posoperatorias/epidemiología , Niño , Preescolar , Estudios de Cohortes , Nutrición Enteral/efectos adversos , Femenino , Humanos , Lactante , MasculinoRESUMEN
PURPOSE: The incidence of Marfan syndrome in the general population is 0.3%. Two-thirds of patients with Marfan syndrome have concurrent pectus deformity. However, incidence of Marfan syndrome and cardiac abnormalities in patients presenting with an isolated pectus deformity remains unknown. We sought to establish the degree of association between pectus deformities and these abnormalities, and whether referral of these patients for cardiac and genetic workup is warranted. METHODS: Our pediatric surgery group refers patients with pectus deformities for genetic and cardiac evaluation. We examined 415 records from 2009 to 2016, and identified 241 patients with a chief complaint of a pectus deformity. Patient characteristics, echocardiogram results, Haller indices, and genetic results were analyzed. RESULTS: The frequency of Marfan syndrome in our study was 5.3%. The incidence of Marfan was highest among patients with combined type pectus deformity (20%). Cardiac anomalies showed an overall incidence of 35%. Of those diagnosed with Marfan, 84% had cardiac abnormalities. CONCLUSION: More than 5% of patients presenting with a chief complaint of pectus deformity will have a diagnosis of Marfan syndrome, compared to 0.3% in the general population. Approximately a third of this population will have cardiac abnormalities. Referral of patients with pectus deformities for evaluation for Marfan syndrome and cardiac abnormalities is appropriate. LEVEL OF EVIDENCE: Level IV.
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Tórax en Embudo , Cardiopatías Congénitas , Síndrome de Marfan , Pectus Carinatum , Femenino , Tórax en Embudo/complicaciones , Tórax en Embudo/epidemiología , Cardiopatías Congénitas/complicaciones , Cardiopatías Congénitas/epidemiología , Humanos , Incidencia , Masculino , Síndrome de Marfan/complicaciones , Síndrome de Marfan/epidemiología , Pectus Carinatum/complicaciones , Pectus Carinatum/epidemiología , Estudios RetrospectivosAsunto(s)
Analgesia , Apendicitis , Laparoscopía , Apendicectomía , Niño , Humanos , Manejo del DolorRESUMEN
PURPOSE OF REVIEW: Pilonidal disease, and the treatment associated with it, can cause significant morbidity and substantial burden to patients' quality of life. Despite the plethora of surgical techniques that have been developed to treat pilonidal disease, discrepancies in technique, recurrence rates, complications, time to return to work/school and patients' aesthetic satisfaction between treatment options have led to controversy over the best approach to this common acquired disease of young adults. RECENT FINDINGS: The management of pilonidal disease must strike a balance between recurrence and surgical morbidity. The commonly performed wide excision without closure has prolonged recovery, while flap closures speed recovery time and improve aesthetics at the expense of increased wound complications. Less invasive surgical techniques have recently evolved and are straightforward, with minimal morbidity and satisfactory results. SUMMARY: As with any surgical intervention, the ideal treatment for pilonidal disease would be simple and cost-effective, cause minimal pain, have a limited hospital stay, low recurrence rate and require minimal time off from school or work. Less invasive procedures for pilonidal disease may be favourable as an initial approach for these patients reserving complex surgical treatment for refractory disease.
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Seno Pilonidal/cirugía , Adolescente , Enfermedad Crónica , Endoscopía , Humanos , Satisfacción del Paciente , Seno Pilonidal/diagnóstico , Seno Pilonidal/terapia , Complicaciones Posoperatorias/prevención & control , Procedimientos de Cirugía Plástica/métodos , Recurrencia , Colgajos Quirúrgicos , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Although metastasis is the major cause of mortality in patients with osteosarcoma, little is known about how micrometastases progress to gross metastatic disease. Clinically relevant animal models are necessary to facilitate development of new therapies to target indolent pulmonary metastases. Intratibial injection of human and murine osteosarcoma cell lines have been described as orthotopic models that develop spontaneous pulmonary metastasis over time. However, there is variability in reported injection techniques and metastatic efficiency. QUESTIONS/PURPOSES: We aimed to characterize a widely used murine model of metastatic osteosarcoma, determine whether it is appropriate to study spontaneous pulmonary metastasis by establishing a reliable volume for intratibial injection, determine the incidence of primary tumor and metastatic formation, determine the kinetics of pulmonary metastatic seeding and outgrowth, and the contribution of the primary tumor to subsequent development of metastasis. METHODS: The metastatic mouse osteosarcoma cell line K7M2 was injected into the tibia of mice. The maximum volume that could be injected without leakage was determined using Evan's blue dye (n = 8 mice). Primary tumor formation and metastatic efficiency were determined by measuring the incidence of primary tumor and metastatic formation 4 weeks after intratibial injection (n = 30). The kinetics of metastatic development were determined by performing serial euthanasia at 1, 2, 3, and 4 weeks after injection (n = 24; five to six mice per group). Number of metastatic foci/histologic lung section and metastatic burden/lung section (average surface area of metastatic lesions divided by the total surface area of the lung) was calculated in a blinded fashion. To test the contribution of the primary tumor to subsequent metastases, amputations were performed 30 minutes, 4 hours, or 24 hours after injection (n = 21; five to six mice per group). Mice were euthanized after 4 weeks and metastatic burden calculated as described previously, comparing mice that had undergone amputation with control, nonamputated mice. Differences between groups were calculated using Kruskal-Wallis and one-way analysis of variance. RESULTS: The maximum volume of cell suspension that could be injected without leakage was 10 µL. Intratibial injection of tumor cells led to intramedullary tumor formation in 93% of mice by 4 weeks and resulted in detectable pulmonary metastases in 100% of these mice as early as 1 week post-injection. Metastatic burden increased over time (0.88% ± 0.58, week 1; 6.6% ± 5.3, week 2; 16.1% ± 12.5, week 3; and 40.3% ± 14.83, week 4) with a mean difference from week 1 to week 4 of -39.38 (p < 0.001; 95% confidence interval [CI], -57.39 to -21.37), showing pulmonary metastatic growth over time. In contrast, the mean number of metastatic foci did not increase from week 1 to week 4 (36.4 ± 33.6 versus 49.3 ± 26.3, p = 0.18). Amputation of the injected limb at 30 minutes, 4 hours, and 24 hours after injection did not affect pulmonary metastatic burden at 4 weeks, with amputation as early as 30 minutes post-injection resulting in a metastatic burden equivalent to tumor-bearing controls (48.9% ± 6.1% versus 40.9% ± 15.3%, mean difference 7.96, p = 0.819; 95% CI, -33.9 to 18.0). CONCLUSIONS: There is immediate seeding of the metastatic site after intratibial injection of the K7M2 osteosarcoma cell line, independent of a primary tumor. This is therefore not a model of spontaneous metastasis. CLINICAL RELEVANCE: This model should not be used to study the early components of the metastatic cascade, but rather used as an experimental model of metastasis. Improved understanding of this commonly used model will allow for proper interpretation of existing data and inform the design of future studies exploring the biology of metastasis in osteosarcoma.
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Neoplasias Óseas/patología , Modelos Animales de Enfermedad , Neoplasias Pulmonares/patología , Siembra Neoplásica , Osteosarcoma/patología , Animales , Línea Celular Tumoral , Inyecciones , Neoplasias Pulmonares/secundario , Ratones , Tibia/patologíaRESUMEN
INTRODUCTION: Despite its minimally invasive approach, laparoscopic surgery can cause considerable pain. Regional analgesic techniques such as the rectus sheath block (RSB) offer improved pain management following elective umbilical hernia repair in the pediatric population. This effect has not been examined in laparoscopic single-incision surgery in children. We sought to compare the efficacy of bilateral ultrasound-guided RSB versus local anesthetic infiltration (LAI) in providing postoperative pain relief in pediatric single-incision transumbilical laparoscopic assisted appendectomy (TULA) with same-day discharge. METHODS: We retrospectively reviewed 275 children, ages 4 to 17 years old, who underwent TULA for uncomplicated appendicitis in a single institution from August 2014 to July 2015. We compared those that received preincision bilateral RSB (n=136) with those who received LAI (n=139). The primary outcome was narcotic administration. Secondary outcomes included initial and mean scores, time from anesthesia induction to release, operative time, time to rescue dose of analgesic in the PACU and time to PACU discharge. RESULTS: Total narcotic administration was significantly reduced in patients that underwent preincision RSB compared to those that received conventional LAI, with a mean of 0.112 mg/kg of morphine versus 0.290 mg/kg morphine (p<0.0001). Patients undergoing RSB reported lower initial (0.38 vs. 2.38; p<0.0001) and mean pain scores (1.26 vs. 1.77; p<0.015). Time to rescue analgesia was prolonged in patients undergoing RSB compared to LAI (58.93min vs. 41.56min; p=0.047). CONCLUSION: Preincision RSB for TULA in uncomplicated appendicitis in children is associated with decreased opioid consumption and lower pain scores compared with LAI. As the addition of this procedure only added 6.67min to time under anesthesia, we feel that it is a viable option for postoperative pain control in pediatric single-incision laparoscopic surgery. RETROSPECTIVE COMPARATIVE STUDY: LEVEL III EVIDENCE.