RESUMO
BACKGROUND: The choice of how to repair inguinal hernias in adolescents has historically been a matter of experience and differed between pediatric surgeons who traditionally performed a high ligation of the sac and general surgeons who typically perform a repair using mesh. This up-to-date review thoroughly examines the subject and discusses the suitability of both types of repairs in this unique age group. METHODS: A 20-year Pub Med search was performed for the following terms: adolescent hernia repair including reports of mesh hernia repair in adolescents and postoperative complications including chronic inguinal pain and recurrences. RESULTS: The evidence in the literature suggests that while there appears to be no difference between the two types of repairs with regards to recurrence and complications, changes in the pelvic floor physiology in adolescents suggest that a selective, individualized approach can be recommended depending on the size and nature of the presenting pathology. CONCLUSIONS: A selective approach to the inguinal hernia in adolescent patients based on the size of the defect appears justified.
Assuntos
Dor Crônica , Hérnia Inguinal , Laparoscopia , Adolescente , Criança , Dor Crônica/cirurgia , Virilha/cirurgia , Hérnia Inguinal/complicações , Hérnia Inguinal/cirurgia , Herniorrafia/efeitos adversos , Humanos , Laparoscopia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Recidiva , Telas Cirúrgicas/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: The benefits of surgery for gastroesophageal reflux disease (GERD) in infants and children have been questioned in the recent literature. The goal of this review was to determine the best current practice for the diagnosis and management of this disease. METHODS: The literature was reviewed for all recent English language publications on the management of GERD in 8- to 10-year-old patients. RESULTS: In infants and children, GERD has multiple etiologies, and an understanding of these is important for determining which patients are the best surgical candidates. Proton pump inhibitors (PPIs) have become the mainstay of current treatment for primary GERD. Although laparoscopic surgery appears to be better than open surgery, there remains some morbidity and complications that careful patient selection can minimize. CONCLUSION: Surgery for GERD should be performed only after failure of medical management or for specific problems that mandate it.
Assuntos
Fundoplicatura/métodos , Refluxo Gastroesofágico/cirurgia , Laparoscopia/métodos , Adolescente , Fatores Etários , Criança , Pré-Escolar , Seguimentos , Fundoplicatura/efeitos adversos , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/tratamento farmacológico , Refluxo Gastroesofágico/epidemiologia , Antagonistas dos Receptores H2 da Histamina/uso terapêutico , Humanos , Incidência , Lactente , Recém-Nascido , Recém-Nascido Prematuro , Laparoscopia/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Complicações Pós-Operatórias/epidemiologia , Inibidores da Bomba de Prótons , Medição de Risco , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
BACKGROUND: Laparoscopic herniorrhaphy in pediatrics is rarely performed. We evaluated our 2-year experience of minimally invasive inguinal herniorrhaphy in children. METHODS: All procedures were performed under general anesthesia using <2-mm instruments and scopes and a surgical awl to accomplish high ligation of the hernia sac under direct vision. RESULTS: A total of 90 consecutive children (76 males and 14 females) older than the age of 6 months underwent a minimally invasive herniorrhaphy (60 unilateral and 30 bilateral; total of 120 hernias repaired). Seventeen children underwent herniorrhaphy in conjunction with another procedure. All children who underwent herniorrhaphy alone were discharged immediately and allowed unrestricted activity. Only four patients requested a narcotic analgesic. There was one recurrence early in the series (0.83%), prompting a change in technique. CONCLUSIONS: Minimally invasive inguinal herniorrhaphy in children is a safe alternative for the experienced pediatric laparoscopist. There is a similar recurrence rate as that of the traditional open approach with a superior cosmetic result.
Assuntos
Hérnia Inguinal/cirurgia , Laparoscopia/métodos , Adolescente , Analgésicos/uso terapêutico , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Laparoscopia/estatística & dados numéricos , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos , Dor Pós-Operatória/tratamento farmacológico , Recidiva , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND/PURPOSE: In 1996, the Surgical Sections of the Children's Cancer Group (CCG) and the Pediatric Oncology Group (POG) received National Cancer Institute funding to conduct a prospective, randomized, controlled, surgeon-directed study to evaluate the role of minimally invasive surgery (MIS) in children with cancer. Because of lack of patient accrual, the study was closed in 1998. The purpose of this study is to evaluate and describe those factors that impacted on study failure to ensure future successful clinical trials. METHODS: One hundred forty surgeons representing the surgical membership of CCG and POG as well as 111 institutions within CCG and POG were asked to complete a questionnaire about the failed clinical trial. The questionnaire focused on study objectives, organization, and institutional review board (IRB) submission. It also examined the surgeon's ability to perform the minimal access operation, the influence of the pediatric oncologist, and the existence of preconceived biases by surgeons, oncologists, and families. Statistical analysis was performed as appropriate. RESULTS: Eighty-six of 140 (62%) surgeons responded to the questionnaire. Only 23% of the potential protocols were submitted for IRB approval. Of responding surgeons, 39% were not actively performing MIS when the study opened. A surgeon's support of the study was directly related to when the surgeon received the protocols (P <.001) and whether the participating surgeon was actively participating in MIS (P <.016). The oncologist's knowledge and support of the study affected IRB submission and approval (P <.02) and was influenced by whether MIS was practiced at the institution (P <.05). The majority of responding surgeons believed the experimental question was relevant (P <.05). However, responding surgeons believed that a preconceived bias existed within both their local surgical and oncology communities favoring a particular surgical approach (P <.001), but this bias did not extend to the families (P >.05). CONCLUSION: The study failed because of lack of accrual for a variety of reasons: failure to submit to the institution's IRB, lack of surgical expertise with MIS procedures, and preconceived surgeon bias toward either an endoscopic or traditional open approach.
Assuntos
Estudos Multicêntricos como Assunto/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/normas , Estudos Multicêntricos como Assunto/classificação , Estudos Multicêntricos como Assunto/normas , Neoplasias/cirurgia , Pediatria/métodos , Pediatria/organização & administração , Pediatria/normas , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto/normas , Projetos de Pesquisa/normas , Projetos de Pesquisa/estatística & dados numéricos , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Laparoscopic common bile duct exploration is commonplace in adults; however, this procedure is not often performed in children. The goal of this study was to evaluate the results of laparoscopic common bile duct exploration in children. METHODS: Of 50 patients undergoing laparoscopic cholecystectomy, six patients (12%) had obstructing lesions of the common bile duct (CBD). Five children underwent laparoscopic common bile duct exploration, and one child had a preoperative endoscopic sphincterotomy and stone removal. RESULTS: The mean age at laparoscopic CBD exploration was 11.6 years (range, 5-16). The obstructing lesion was visualized by intraoperative cholangiography in all five patients. The mean operative time for laparoscopic cholecystectomy along with CBD exploration was 215 min (range, 160-282). The transcystic laparoscopic CBD exploration was performed using a 7-Fr, multichannel rigid, or 10-Fr flexible fiberoptic cystoscope. The stones were either pushed into the duodenum with the scope or extracted through the cystic duct using a 3-Fr Segura basket. In one patient, a candidial ball disintegrated during an attempt to remove it with the basket. A repeat cholangiogram at the end of each procedure showed an anatomically normal CBD with free flow of contrast into the duodenum. All patients enjoyed a quick recovery. They were started on a regular diet on the same day of surgery and discharged on the 1st or 2nd postoperative day. One patient with sickle cell disease developed a pulmonary infarction and required 5 additional days of hospitalization. One patient developed recurrent choledocholithiasis 6 months after laparoscopic exploration and was treated successfully with endoscopic sphincterotomy and stone extraction. CONCLUSIONS: Laparoscopic CBD exploration can be performed safely at the time of the cholecystectomy in children. Endoscopic sphincterotomy before cholecystectomy is not necessary. We recommend laparoscopic CBD exploration for obstructing lesions of the CBD. Endoscopic sphincterotomy should be reserved for recurrent lesions of the CBD after laparoscopic cholecystectomy.
Assuntos
Colecistectomia/métodos , Colestase/cirurgia , Ducto Colédoco/cirurgia , Laparoscopia/métodos , Adolescente , Criança , Pré-Escolar , Colangiografia , Tecnologia de Fibra Óptica , Humanos , Monitorização Intraoperatória , Recidiva , Resultado do TratamentoRESUMO
PURPOSE: Use of retroperitoneal lymph node dissection (RPLND) in paratesticular rhabdomyosarcoma (PTRMS) is controversial and has changed over the past 2 decades. The Intergroup Rhabdomyosarcoma Study Group (IRSG) required ipsilateral RPLND (IRPLND) for all patients with PTRMS treated on IRS-III (1984-91), but changed to clinical evaluation of RPLNs using computerized tomography (CT) in IRS-IV (1991 through 1997). In IRS-IV, only those patients with identified lymph node involvement on CT required surgical evaluation of the RPLNs. Nodal radiation therapy was administered only to patients with RPLNs recognized as positive; such patients received more intensive chemotherapy as well. Thus, they compared the incidence of recognized RPLN involvement using these 2 different approaches. They then analyzed patient outcome to determine whether this change in management affected outcome. METHODS: Eligible patients with group I or II PTRMS who were treated on IRS III (n = 100) or IRS IV (n = 134) were analyzed. Failure-free survival (FFS) and survival (S) rates were estimated using the Kaplan-Meier method and compared using the log-rank test. RESULTS: There was a significant change in the distribution of patients with group I versus II tumors from IRS-III to IRS-IV (group I, 68% in IRS-III versus 82% in IRS-IV). This was the result of decreased node recognition when CT was used to stage RPLNs in IRS-IV and was most notable for adolescents (>10 years of age). Overall, 3-year FFS was 92% for patients treated on IRS-III and 86% for those treated on IRS-IV (P =.10), whereas survival estimates were 96% and 92%, respectively (P =.30). Adolescents were at higher risk of RPLN relapse than were children (<10 years of age) and their FFS and survival were worse, regardless of IRS protocol. Furthermore, adolescents with recognized group II tumors experienced better 3-year FFS than those with group I tumors on IRS-IV (100% versus 68%, P =.06), most likely as a result of receiving radiotherapy and intensified chemotherapy. CONCLUSIONS: Use of only CT scan evaluation of RPLN in IRS-IV led to a decrease in identification of RPLN involvement in boys who present with localized PTRMS, and a higher rate of regional relapse as compared with IRS-III. Adolescents had much higher likelihood of RPLN disease, and they fared significantly worse than did younger children on both studies. Furthermore, adolescent boys with group I tumors experienced worse FFS than those with Group II tumors on IRS-IV, probably because some patients with group II tumors were not identified by CT imaging and thus received less effective therapy. These data suggest that adolescents should have ipsilateral RPLN dissection as part of their routine staging, and those with positive lymph nodes require intensified chemotherapy as well as nodal irradiation.
Assuntos
Excisão de Linfonodo , Estadiamento de Neoplasias , Espaço Retroperitoneal/cirurgia , Rabdomiossarcoma/tratamento farmacológico , Rabdomiossarcoma/cirurgia , Adolescente , Quimioterapia Adjuvante , Criança , Pré-Escolar , Humanos , Masculino , Taxa de Sobrevida/tendências , Neoplasias Testiculares , Resultado do TratamentoRESUMO
BACKGROUND: A 4-week-old male infant (4.9 kg) with persistent hyperinsulinemic hypoglycemia of infancy (PHHI) underwent a laparoscopic pancreatectomy to evaluate its feasibility. Preoperative medications included diazoxide and glucagon to maintain adequate blood glucose levels. METHODS: Laparoscopic pancreatectomy was performed using a 5-mm cannula at the umbilicus, external fixation, transcutaneous suture-assisted gastric retraction to expose the lesser sac, and three additional 3.5-mm cannula sites. The pancreas was resected from the splenic hilum to the mesenteric vessels. The splenic vein was dissected from the under surface of the pancreas using electrocautery, and the spleen was easily preserved. Surgery time was 75 min, and minimal blood loss occurred. RESULTS: The child required no narcotic medication and tolerated a regular diet immediately after surgery. Serum glucose levels did decrease postoperatively, and the child required diazoxide, dextrose infusion, glucagon, and octreotide. On postoperative day 7, the child underwent an open near-total pancreatectomy, after which he remained asymptomatic. Essentially no scarring was found in the lesser sac, and the remaining pancreatic remnant was resected without difficulty. CONCLUSIONS: Laparoscopic pancreatectomy can be performed safely, even in a newborn patient, without prolonged operative time or unnecessary risk. The technique using external fixation and transcutaneous suture-assisted gastric retraction provides excellent exposure to the pancreas and lesser sac. In patients with PHHI, in whom reoperative additional pancreatectomy is very likely, this technique is the ideal initial surgical approach.
Assuntos
Hiperinsulinismo/cirurgia , Hipoglicemia/cirurgia , Laparoscopia/métodos , Pancreatectomia/métodos , Humanos , Hiperinsulinismo/complicações , Recém-Nascido , MasculinoRESUMO
PURPOSE: The study goal was to improve outcome in children with rhabdomyosarcoma by comparing risk-based regimens of surgery, radiotherapy (RT) and chemotherapy. PATIENTS AND METHODS: Eight hundred eighty-three previously untreated eligible patients with nonmetastatic rhabdomyosarcoma entered the Intergroup Rhabdomyosarcoma Study-IV (IRS-IV) (1991 to 1997) after surgery and were randomized treatment by primary tumor site, group (1 to 3), and stage (I to III). Failure-free survival (FFS) rates and survival were the end points used in comparisons between randomized groups and between patient subgroups treated on IRS-III and IRS-IV. Most patients were randomized to receive vincristine and dactinomycin (VA) and cyclophosphamide (VAC, n = 235), or VA and ifosfamide (VAI, n = 222), or vincristine, ifosfamide, and etoposide (VIE, n = 236). Patients with group 3 tumors were randomized to receive conventional RT (C-RT) versus hyperfractionated RT (HF-RT). RESULTS: Overall 3-year FFS and survival were 77% and 86%, respectively. Three-year FFS rates with VAC, VAI, and VIE were 75%, 77%, and 77%, respectively (P =.42). No significant difference in outcome was noted with HF-RT versus C-RT (P =.85 and P =.90, respectively). Overall, patients with embryonal tumors benefited from intensive three-drug chemotherapy in IRS-IV (3-year FFS, 83%). The improvement was seen for patients with stage I or stage II/III, group 1/2 disease, many of whom received VA chemotherapy on IRS-III. Patients with stage 2/3, group 3 disease had similar outcomes on IRS-III and IRS-IV. Three-year FFS for the nonrandomized patient subsets was 75% with renal abnormalities; 81% for paratesticular, group 1 cases; and 91% for group 1/2 orbit or eyelid tumors. Patients with paratesticular primaries had poorer outcomes if they were more than 10 years old (3-year FFS, 63% v 90%). Myelosuppression occurred in most patients, but toxic deaths occurred in less than 1%. CONCLUSION: VAC and VAI or VIE with surgery (with or without RT), are equally effective for patients with local or regional rhabdomyosarcoma and are more effective for embryonal tumors than therapies used previously. Younger patients with group 1 paratesticular embryonal tumors and all patients with group 1/2 orbit or eyelid tumors can usually be cured with VA chemotherapy along with postoperative RT for group 2 disease.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Radioterapia/métodos , Rabdomiossarcoma/terapia , Adolescente , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Criança , Pré-Escolar , Terapia Combinada/métodos , Intervalo Livre de Doença , Fracionamento da Dose de Radiação , Neoplasias Palpebrais/mortalidade , Neoplasias Palpebrais/patologia , Neoplasias Palpebrais/terapia , Feminino , Humanos , Lactente , Masculino , Neoplasias Orbitárias/mortalidade , Neoplasias Orbitárias/patologia , Neoplasias Orbitárias/terapia , Prognóstico , Estudos Retrospectivos , Rabdomiossarcoma/mortalidade , Rabdomiossarcoma/patologia , Taxa de Sobrevida , Neoplasias Testiculares/mortalidade , Neoplasias Testiculares/patologia , Neoplasias Testiculares/terapiaRESUMO
BACKGROUND/PURPOSE: The routine use of interval appendectomy for the treatment of perforated appendicitis, with or without abscess, remains controversial. The purpose of this study is to confirm the efficacy of this approach and to identify factors associated with failures and complications. METHODS: All patients (n = 101) with their clinical diagnosis of perforated appendicitis confirmed with imaging were treated prospectively with fluids and intravenous antibiotics (clindamycin, ceftazidime) and were discharged home on oral fluids and analgesics regardless of fever. Intravenous antibiotics were continued at home until the patients were afebrile for 48 hours, and their white blood cell and differential counts were normal. Patients were readmitted at 8 to 12 weeks for an interval appendectomy. Failure to improve by 72 hours of antibiotic therapy mandated an early appendectomy. P values were determined by chi(2) analysis and Student's t test. RESULTS: The 79 patients (78%) successfully treated with interval appendectomy had an overall 6.3% complication rate, and total hospitalization averaged 5.2 days. The treatment in 21 of 22 patients (22%) requiring early appendectomy failed because of a clinical picture suggesting small bowel obstruction. The patients with the failed procedures had a complication rate of 50% and were hospitalized an average of 12.8 days. The overall complication rate for the 101 patients was 15.8%, and the overall total hospitalization was 6.9 days. Patients requiring early appendectomy had a more frequent finding resembling a small bowel obstruction on their initial x-ray (50% v 13%, P = .004) and a higher percent band count on their initial differential blood cell count (22.6% v 7.6%, P<0.0001) than did those successfully treated with interval appendectomy. An initial band count <15% was predictive of an uncomplicated course (84% positive predictive value). CONCLUSIONS: Interval appendectomy without complications is successful in the majority of patients with perforated appendicitis. An elevated initial band count > or =15% is associated with an increased likelihood of failure and complications.
Assuntos
Apendicectomia/métodos , Apendicite/cirurgia , Perfuração Intestinal/cirurgia , Contagem de Leucócitos , Adolescente , Antibacterianos/uso terapêutico , Apendicite/sangue , Apendicite/complicações , Distribuição de Qui-Quadrado , Criança , Pré-Escolar , Feminino , Hidratação , Humanos , Lactente , Perfuração Intestinal/sangue , Perfuração Intestinal/etiologia , Tempo de Internação/estatística & dados numéricos , Masculino , Complicações Pós-Operatórias , Valor Preditivo dos Testes , Estudos Prospectivos , Falha de TratamentoRESUMO
PURPOSE: This study was designed to estimate the partial and complete response rates (CR and PR) of two novel drug pairs (vincristine and melphalan vs. ifosfamide and etoposide) and to improve overall survival of previously untreated patients with metastatic rhabdomyosarcoma. PATIENTS AND METHODS: One hundred twenty-eight patients were randomly assigned to phase II window therapy consisting of vincristine and melphalan (VM-containing regimen) or ifosfamide and etoposide (IE-containing regimen). Brief window therapy (12 wks) was immediately followed-up by vincristine, dactinomycin, and cyclophosphamide (VAC), chemotherapy, surgery, and irradiation, with continuation of either VM or IE in patients with initial response. Major endpoints were initial CR and PR rates after the phase II window phase of therapy, failure-free survival (FFS), and survival. RESULTS: Patients who received the VM-containing regimen experienced significantly more anemia, neutropenia, thrombocytopenia, and had more cyclophosphamide dose reductions. The initial PR and CR rates were not significantly different for patients treated with either regimen (VM, 74%; IE, 79%; P = 0.428). However, FFS and overall survival (OS) at 3 years were significantly better with the IE-containing regimen (FFS: 33% vs. 19%; P = 0.043; OS: 55% vs. 27%; P = 0.012). CONCLUSIONS: Although the VM-containing regimen produced a high response rate, inclusion of melphalan appeared to limit the cyclophosphamide dose that could be administered, and ultimately, this regimen was associated with a significantly worse outcome than was the IE-containing regimen. Also, the IE-containing regimen was associated with a gratifyingly high survival rate at 3 years (55%), which is significantly higher than has been observed on any previous Intergroup Rhabdomyosarcoma Study Group regimen for similar patients. We believe that this promising outcome indicates that this drug pair merits further randomized testing in metastatic rhabdomyosarcoma.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Rabdomiossarcoma/tratamento farmacológico , Neoplasias de Tecidos Moles/tratamento farmacológico , Adolescente , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Doenças da Medula Óssea/induzido quimicamente , Bronquiolite Obliterante/induzido quimicamente , Quimioterapia Adjuvante , Criança , Pré-Escolar , Terapia Combinada , Ciclofosfamida/administração & dosagem , Ciclofosfamida/efeitos adversos , Dactinomicina/administração & dosagem , Dactinomicina/efeitos adversos , Intervalo Livre de Doença , Etoposídeo/administração & dosagem , Etoposídeo/efeitos adversos , Feminino , Seguimentos , Humanos , Ifosfamida/administração & dosagem , Ifosfamida/efeitos adversos , Lactente , Nefropatias/induzido quimicamente , Tábuas de Vida , Masculino , Melfalan/administração & dosagem , Melfalan/efeitos adversos , Metástase Neoplásica , Radioterapia Adjuvante , Indução de Remissão , Rabdomiossarcoma/mortalidade , Rabdomiossarcoma/patologia , Rabdomiossarcoma/radioterapia , Rabdomiossarcoma/cirurgia , Sepse/etiologia , Neoplasias de Tecidos Moles/mortalidade , Neoplasias de Tecidos Moles/patologia , Neoplasias de Tecidos Moles/radioterapia , Neoplasias de Tecidos Moles/cirurgia , Análise de Sobrevida , Resultado do Tratamento , Vincristina/administração & dosagem , Vincristina/efeitos adversosRESUMO
With advances in medical technology, including intensive care, new medications, alterations in the composition of parenteral nutrition, and the institution of minimally invasive surgery, our understanding of the spectrum of diseases of the gallbladder resulting in stone formation or inflammation, and the management of these disorders has changed over the past few decades. The discussion herein focuses on our thinking about the current diagnosis and treatment for these disorders.
Assuntos
Colecistite/diagnóstico , Colecistite/terapia , Colelitíase/diagnóstico , Colelitíase/terapia , Criança , Colecistectomia Laparoscópica , Colecistite/etiologia , Colelitíase/etiologia , HumanosRESUMO
The technique for thoracoscopic in children is described. The average operating time is under 2 hours, and the procedure appears to be safe and effective.
Assuntos
Miastenia Gravis/cirurgia , Toracoscopia/métodos , Timectomia/métodos , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Masculino , Miastenia Gravis/diagnóstico , Sensibilidade e Especificidade , Resultado do TratamentoRESUMO
BACKGROUND/PURPOSE: Rhabdomyosarcoma (RMS) of the biliary tract is rare, and, in addition to multiagent chemotherapy with or without radiotherapy (RT), some investigators recommend aggressive surgery. To assess the role of surgery, records of all 25 eligible patients with biliary RMS enrolled in IRSG studies I through IV from 1972 to 1998 were reviewed. METHODS: Treatment included surgery with or without vincristine, dactinomycin, cyclophosphamide, doxorubicin, cisplatin, etoposide, ifosfamide, and with or without RT. Data evaluated included clinical presentation, treatment, complications, and outcome. RESULTS: Diagnostic imaging identified the primary tumor but failed to identify regional metastases. Despite aggressive surgery, gross total resection at diagnosis was possible in only 6 cases, 2 of which had negative surgical margins. Although only 6 (29%) patients without distant metastases underwent gross total resection, estimated 5-year survival rate was 78% (95% CI 58%, 97%). Infectious complications were common and frequently associated with external biliary drains. Five (20%) died within the first 2 months, 3 of sepsis. CONCLUSIONS: Surgery is critical for establishing an accurate diagnosis and determining the extent of regional disease. Gross total resection is rarely possible despite aggressive surgery, and outcome is good despite residual disease after surgery. External biliary drains increase the risk of postoperative infectious complications.
Assuntos
Neoplasias do Sistema Biliar/cirurgia , Procedimentos Cirúrgicos do Sistema Biliar , Rabdomiossarcoma/cirurgia , Neoplasias do Sistema Biliar/mortalidade , Neoplasias do Sistema Biliar/terapia , Criança , Pré-Escolar , Terapia Combinada , Feminino , Humanos , Lactente , Masculino , Reoperação , Estudos Retrospectivos , Rabdomiossarcoma/mortalidade , Rabdomiossarcoma/terapia , Resultado do TratamentoRESUMO
BACKGROUND: During the fourth Intergroup Rhabdomyosarcoma (RMS) Study (IRS IV, 1991-97), a preoperative staging system was evaluated prospectively for the first time. The authors evaluated this staging system and the role of surgery in extremity RMS in contemporary multimodal therapy. METHODS: A total of 139 patients (71 girls; median age, 6 years) were entered in IRS IV with extremity-site RMS. Stage was assigned by the IRSG Preoperative Staging System. Postsurgical group was determined by tumor status after initial surgical intervention. Multivariate analysis was performed using all pretreatment factors that were significant by univariate analysis, including clinical Group (i.e., I through IV), tumor invasiveness (T1,T2), nodal status (N0,N1), and tumor size (< or > or =5 cm). Failure-free survival rates (FFS) and survival rates were estimated using the Kaplan and Meier method. RESULTS: Preoperative staging and clinical group distribution were as follows: Stage 2, n = 34; Stage 3, n = 73; Stage 4, n = 32; Group I, n = 31; Group II, n = 21; Group III, n = 54; Group IV, n = 33. Three-year FFS was 55%, and the overall survival rate was 70%. Eighty-seven patients had either unresectable, gross residual disease (Group III) or metastases (Group IV). FFS was significantly worse for these patients with advanced disease, compared with that for patients with complete resection or with only microscopic residual tumor (i.e., Group I or II; Group I, 3-year FFS, 91%; Group II, 72%; Group III, 50%; Group IV, 23%; P<.001). Lymph nodes were evaluated surgically in 76 patients with positive results in 38. Clinically, 13 additional patients had nodal disease. Both stage and group were highly predictive of outcome and were highly correlated. By multivariate analysis, none of the other variables were predictors of FFS. CONCLUSIONS: This review confirms the utility of pretreatment staging for stratification of patients with extremity RMS with widely different risks of relapse, thereby paving the way for development of risk-based therapy. Group (operative staging) remains the most important predictor of FFS, emphasizing the importance of complete gross resection at initial surgical intervention, when feasible without loss of limb function. The high incidence of nodal disease in the patients who had lymph node biopsy confirms the need for surgical evaluation of lymph nodes to ensure accurate staging in children with extremity rhabdomyosarcoma.
Assuntos
Extremidades , Rabdomiossarcoma/patologia , Rabdomiossarcoma/cirurgia , Criança , Terapia Combinada , Feminino , Humanos , Masculino , Análise Multivariada , Invasividade Neoplásica , Estadiamento de Neoplasias , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Rabdomiossarcoma/mortalidade , Resultado do TratamentoRESUMO
The purpose of this report is to evaluate the cost-effectiveness of a single-stage laparoscopic pull-through for Hirschsprung's disease compared to the traditional two-stage Duhamel procedure. In this series of 33 children, the length of hospitalization (2.5 +/- 3.5 vs 10.6 +/- 3.9, p < 0.01), cost (19,088 +/- 13,075 vs 34,110 +/- 19,443, p < 0.05), and complications were all significantly less with the laparoscopic assisted pull-through compared to the more traditional open approach.
Assuntos
Doença de Hirschsprung/cirurgia , Laparoscopia/economia , Criança , Análise Custo-Benefício , Custos e Análise de Custo , Tomada de Decisões , Feminino , Doença de Hirschsprung/economia , Humanos , Lactente , Recém-Nascido , Tempo de Internação , MasculinoRESUMO
BACKGROUND/PURPOSE: During its 25 years of experience, the Intergroup Rhabdomyosarcoma Study Group (IRSG) has completed four sequential prospective clinical trials to improve survival and decrease morbidity rates in childhood rhabdomyosarcoma (RMS). Surgical management of vaginal RMS has changed dramatically. METHODS: The records of 72 patients with localized vaginal RMS were reviewed to assess surgical therapy, chemotherapy, and radiotherapy and their relation to outcome. RESULTS: Each successive IRSG trial resulted in decreased need for surgical resection (IRS-I, 100%; IRS-II, 70%; IRS-III, 30%; IRS-IV, 13%) and excellent disease-free survival using increasingly effective multiagent chemotherapy. CONCLUSIONS: Primary chemotherapy after initial biopsy provides excellent tumor control. Local resection may be appropriate, but removal of organs (ie, complete vaginectomy/hysterectomy) has no role except in persistent or recurrent disease. Mature, residual rhabdomyoblasts may be evidence of a chemotherapy response, and further surveillance and biopsy without surgical resection is adequate treatment.
Assuntos
Rabdomiossarcoma/cirurgia , Neoplasias Vaginais/cirurgia , Algoritmos , Antineoplásicos/uso terapêutico , Criança , Feminino , Humanos , Estudos Retrospectivos , Rabdomiossarcoma/tratamento farmacológico , Resultado do Tratamento , Neoplasias Vaginais/tratamento farmacológicoRESUMO
UNLABELLED: BACKGROUND, METHODS, AND PURPOSE: The authors examined demographic and clinical features, therapy, and outcome of patients with advanced (group III or IV) rhabdomyosarcoma (RMS) of the retroperitoneum and nongenitourinary pelvis treated in the Intergroup Rhabdomyosarcoma Study Group (IRSG) III (1984 to 1991, n = 41) or IV pilot (1987 to 1991, n = 53) studies to assess the role of initial debulking surgery. RESULTS: Ninety-four patients with retroperitoneal primary tumors and gross locoregional residual tumor (group III, n = 53) or metastatic disease (group IV tumors, n = 41) were treated with combination chemotherapy (ie, vincristine, dactinomycin, and cyclophosphamide with or without other agents plus radiation therapy, RT) after biopsy only or subtotal resection. These retroperitoneal tumors usually were invasive (T2, 76%). Most patients were younger than 10 years of age (n = 69, 73%), the male to female ratio was 1.4, and tumors usually were embryonal (n = 64, 68%). Overall 4-year failure-free survival (FFS) was 50%; survival was 60%. Survival rate was better for girls (4-year survival rate, 75% v49% for boys; P = .05) and was not significantly different for patients treated in IRS-III (66%) or IRS-IV pilot (52%). However, it was better for patients with embryonal versus alveolar or undifferentiated tumors (4-year survival rate, 70% v 42%; P = .002). In adolescents, RMS is different from that seen in children less than 10 years old; most cases are alveolar or undifferentiated (16 of 29, 55%). Surgery for most (21 of 24) patients with alveolar tumors comprised biopsy only. By contrast, of 64 patients with embryonal tumors, 39 (61%) underwent biopsy only, whereas 25 (39%) had debulking surgery. Patients whose tumors were debulked fared better than those whose tumors underwent biopsy only (4-year FFS rate, 72% v48%; P = 0.03). Patients with group IV embryonal tumors fared unexpectedly better than those with group IV alveolar or undifferentiated tumors (70% versus 42% 4-year survival rate, P < .05), and patients less than 10 years of age with group IV embryonal tumors had 4-year survival rate of 77%, indicating the importance of the biology of these tumors. CONCLUSIONS: Multimodal therapy, including multiagent chemotherapy plus RT, appears to improve survival rate in patients with advanced embryonal RMS arising in the retroperitoneum. These data suggest that debulking tumors of embryonal histology improves outcome further. This approach will be assessed in IRSG V.
Assuntos
Neoplasias Retroperitoneais/mortalidade , Neoplasias Retroperitoneais/cirurgia , Rabdomiossarcoma Embrionário/mortalidade , Rabdomiossarcoma Embrionário/cirurgia , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Rabdomiossarcoma Alveolar/mortalidade , Rabdomiossarcoma Alveolar/cirurgia , Resultado do TratamentoRESUMO
Lung resections in children are performed for a variety of reasons including congenital malformations, infections, bronchiectasis, and tumors. There are no long-term reports on pneumonectomy alone in children, but those on lung resection as a group state that children tolerate these operations well, with mild sequelae if any, and that the majority of them in adulthood can perform non-physically demanding jobs adequately. The authors' findings concur with the reports that younger patients can endure pulmonary resections with minimal functional limitations.