Pediatric endoscopic subcutaneous mastectomy (pesma) with liposuction in adolescents with gynecomastia.

BACKGROUND: Surgical techniques for treatment of gynecomastia are increasingly less invasive. We described technical standardization of pediatric endoscopic subcutaneous mastectomy (PESMA) with liposuction. METHODS: All adolescents with primary gynecomastia, operated using PESMA with liposuction over the period June 2014-July 2021, were included. The video recording of procedures was analyzed to standardize the operative technique. After patient installation, 3 trocars were placed on the mid-axillary line. The technique included 5 steps: (1) subcutaneous injection of lipolysis solution and liposuction; (2) creation of working space using an inflated balloon; (3) gland dissection using 5-mm sealing device; (4) specimen extraction through the largest trocar orifice; and (5) placement of suction drainage tube. RESULTS: Twenty-four male adolescents, operated for Simon's grade 2B and 3 gynecomastia using PESMA with liposuction over the study period, were included. Mean patient age was 16 years (range 15-18). Gynecomastia was bilateral in 19/24 (79.2%) and unilateral in 5/24 (20.8%). One (4.1%) conversion to open was reported. The mean operative time was 87 min (range 98-160) for unilateral and 160 min (range 140-250) for bilateral procedure. The mean length of stay was 2.2 days (range 1-4). Patients wore a thoracic belt for 15 up to 30 days postoperatively. Post-operative complications occurred in 5/24 (20.8%): 2- or 3 mm second-degree burns in 4 (16.7%) and subcutaneous seroma in 1 (4.1%). All complications were Clavien 2 grade and did not require further treatment. Aesthetic outcomes were very good in 21/24 (87.5%). Three (12.5%) boys had persistent minimal breast asymmetry but did never perceive it negatively. CONCLUSION: PESMA combined with liposuction was feasible and safe for surgical treatment of gynecomastia in this selected cohort of patients. Although challenging, this procedure provided good aesthetic results, with no scars on the anterior thoracic wall. Standardization of the operative technique was a key point for successful outcome.

Mesothelioma in children and adolescents: the European Cooperative Study Group for Pediatric Rare Tumors (EXPeRT) contribution.

INTRODUCTION: Very little is known about the characteristics of mesothelial tumours in the paediatric population. In adults with malignant mesothelioma, the pemetrexed-based regimen with cytoreductive surgery (CRS) is a standard of care in limited tumours, but long-term survival is uncommon. MATERIAL AND METHODS: The European Cooperative Study Group on Pediatric Rare Tumors (EXPeRT) retrospectively reviewed children, adolescents and young adults (≤21 year) diagnosed with mesothelial tumours treated between 1987 and 2018. RESULTS: Thirty-three patients were identified, 15 male and 18 female patients. One patient's exposure to asbestos was documented. Primary tumour was mainly in the peritoneum (23 patients). Histology was multicystic mesothelioma of the peritoneum (MCM) (six patients) or malignant mesothelioma (MM) (27 patients). Among MM, the first-line treatment comprised preoperative chemotherapy (14 cases), surgery only (three cases), chemotherapy only (five cases), adjuvant chemotherapy (three cases) or palliative treatment (two cases). The response rate to cisplatin-pemetrexed was 50% (6/12 cases). CRS with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) was performed in 19 patients (upfront in three, after neoadjuvant therapy in 12, or after tumour progression in six patients, including three twice). After a median follow-up of 6.7 years (range, 0-20), five-year overall and event-free survivals were 82.3% (95% CI, confidential interval ((CI), 67.8-99.9) and 45.1% (95% CI, 28.4-71.7), respectively. All patients with MCM are alive after surgery (five patients) and CRS-HIPEC (one patient). CONCLUSIONS: Paediatric mesothelioma is exceptional and seems to be different from its adult counterpart with few asbestos exposures, more peritoneal primary, and a better outcome. The cisplatin-pemetrexed regimen showed promising efficacy. Relapses could be salvaged with active therapy including CRS-HIPEC.

Multicystic and diffuse malignant peritoneal mesothelioma in children.

BACKGROUND: Malignant and multicystic peritoneal mesotheliomas are extremely rare tumors in children, developing from mesothelial cells. No specific guidelines are available at this age. METHODS: We performed a retrospective analysis of all identified children (< 18-year-old) treated in France from 1987 to 2017 for a diffuse malignant peritoneal mesothelioma (DMPM) or a multicystic peritoneal mesothelioma (MCPM). RESULTS: Fourteen patients (5 males and nine females), aged 2.2 to 17.5 years, were included. The most frequent presenting symptoms were abdominal pain, ascitis, and alteration in the general condition. Eight patients had epithelioid mesothelioma, three had biphasic mesothelioma, and three had MCPM. Eight patients with DMPM diagnosis received cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). Among them, six patients had neoadjuvant systemic chemotherapy, one patient, post-operative chemotherapy, and one patient CRS and HIPEC only. Three patients received only systemic chemotherapy. All patients with MCPM had only surgery. After a median follow-up of seven years (2-15), six patients (6/11; one death) with DMPM and two patients (two/three) with MCPM had a local and distant recurrences. CONCLUSION: Peritoneal mesothelioma in children is a rare condition with difficult diagnosis and high risk of recurrence. Worldwide interdisciplinary collaboration and networking are mandatory to help diagnosis and provide harmonious treatment guidelines.

Is Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction in Infants Under 1 Year of Age a Good Option?

Purpose: Laparoscopic pyeloplasty in children younger than 1 year of age is still debatable due to its supposed technical difficulties and failure rate. We present our experience and outcome in infants. Materials and Methods: A retrospective study was conducted in 3 Departments of Pediatric Surgery. We reviewed the records of the children under 1 year of age operated on for ureteropelvic junction obstruction (UPJO), between 2007 and 2017. Anderson-Hynes laparoscopic transabdominal dismembered pyeloplasty was performed. Patients' demographics, results of preoperative and postoperative exams, perioperative details, complications, hospital stay, and long-term follow-up results were analyzed. Results: Sixty cases were operated on during this period (49 boys, 11 girls). Mean age at operation was 4.5 months (1-12 months). Mean operating time was 140 min (80-240 min). There was no conversion in this group. There were four early complications: 1 ileus, 1 hypertension immediately post-operatively requiring medical treatment, 1 omental herniation through a drain orifice, and 1 percutaneous transanastomotic stent migrated intra-abdominally. The two last children had to be reoperated. Mean hospital stay was of 2 days (1-10 days). Late complications: two patients (3.4%) presented a recurrence of UPJO, one had been re-operated 15 months later and for the patient with persistent hypertension, nephropexy was performed for malrotated kidney, 1 year after pyeloplasty. Long term follow-up with a mean of 2.8 years (1-10 years) showed that surgery improved mean pelvic dilatation from 31.8 mm (13-63 mm) preoperatively to 15.3 mm (4-40 mm) postoperatively (P < 0.0001). The renal function slightly improved, from a mean of 35.7% (5-55%) it passed to 40.5% (0-54%), p = 0.137. In three cases the operated kidney became finally non-functional and atrophic. Conclusions: Laparoscopic transperitoneal pyeloplasty is feasible and safe in children younger than 1 year of age. Nevertheless, it requires experience and good intra-abdominal suturing skills. Laparoscopic pyeloplasty has a success rate comparable with open treatment but with less morbidity and better cosmetic results.

Utility of radiation-free imaging for initial evaluation of pectus excavatum.

OBJECTIVES: The OrtenBodyOne scanner is a radiation-free, 3-dimensional imaging system recently developed for evaluation of the severity of pectus excavatum (PE). The goal of this study was to evaluate the utility of this new imaging system compared with that of computed tomography (CT) for the evaluation of the severity of PE. METHODS: Patients treated for PE from April 2015 to January 2017 with available CT and OrtenBodyOne data were included. Correlations between indexes calculated from CT and from OrtenBodyOne were determined by applying the non-parametric Spearman correlation procedure with a Bonferroni correction to adjust for multiple comparisons. RESULTS: Forty men (90.9%) and 4 women (9.1%), 20 with symmetrical (45.5%) and 24 with asymmetrical PE (54.5%), were included. The median age was 16.1 years (range 4.3-63.5 years). The following measures and indexes acquired using OrtenBodyOne and CT were significantly correlated: pectus depth (r = 0.84; P = 0.002), anthropometric index (r = 0.81; P = 0.002) and asymmetry index (r = 0.67; P = 0.002). The correlation between the CT Haller index and the external Haller index was only significant for symmetrical PE (r = 0.57; P = 0.008). CONCLUSIONS: The OrtenBodyOne imaging system can be used to evaluate the severity of symmetrical PE using the external Haller index. Asymmetry and anthropometric indexes are more reliable for the evaluation of asymmetrical PE. Measures can be repeated throughout treatment while avoiding unnecessary irradiation.

Treatment of Gynecomastia by Endoscopic Subcutaneous Mastectomy in Adolescents.

Background: Morbidity of traditional open surgery for the treatment of gynecomastia includes asymmetry, retraction of the nipple, and poor scarring. Other approaches were described to improve the results. Endoscopic subcutaneous mastectomy (ESCM) was reported in adult series, including a few adolescents. This technique was considered as safe with good aesthetic results. The aim of this study was to evaluate the results of ESCM in an adolescent series. Patient and Methods: We treated 19 adolescents with Simon's grade IIB and III gynecomastia between June 2014 and July 2018. They could choose open surgery through the nipple or endoscopic surgery by axillary approach. To perform ESCM, three trocars were placed on the midaxillary line to dissect the gland. The resection was performed leaving 1 cm thickness of gland behind the nipple. The gland was extracted after morcellation through the 10 mm trocar. A drainage tube was placed in the cavity. The patients wore a thoracic belt smoothly compressing the operative areas for 15 days. The result was considered as good when there was no remaining gland, good symmetry, and no nipple retraction or nipple lateral displacement. Results: During the study period, 12 adolescents were treated by ESCM and 7 preferred open surgery. Among the 12 ESCM patients, 7 had bilateral and 5 unilateral gynecomastia. A subcutaneous injection of serum was done in the last 6 patients to facilitate the creation of the work space. A 2- or 3-mm second-degree burn occurred in 4 cases, 2 on the nipple and 2 just above the nipple, with a 2 mm remaining scar above the nipple in 1 case. The postoperative course was uneventful in 11 adolescents. One subcutaneous seroma expanded at 15 days postoperative and resolved after 3 weeks of prolonged compression by thoracic belt. The adolescents had 11 good results and 1 persistent asymmetry; 2 other asymmetries had a spontaneous improvement after 1 or 2 years. Conclusion: ESCM is feasible and safe for the treatment of gynecomastia in adolescents. This technique is challenging but permits to reach good aesthetic results and avoids scars on the anterior wall of the thorax.

Laparoscopic vesico-ureteral reimplantation with Lich-Gregoir approach in children: medium term results of 159 renal units in 117 children.

PURPOSE: Vesico-ureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. Surgery is an important part of its management. Laparoscopic ureteric reimplantation using the Lich-Gregoir technique is an option for VUR. The aim of this study is to assess short- and medium-term outcomes of this approach. MATERIALS AND METHODS: This is a retrospective study including all children with VUR treated by laparoscopic extravesical ureteral reimplantation with the Lich-Gregoir technique in University Hospital of Saint-Etienne from August 2007 to May 2016. Surgery was performed after the age of 12 months in cases with repeated urinary tract infection (UTI) and a deterioration of renal function. All patients were followed-up post operatively. RESULTS: 117 children (92 girls, 25 boys) representing 159 renal units were included. The mean age at surgery was 47.1 months (±32.7 months). The mean follow-up was 59.3 months (±31 months). The resolution rate for VUR in terms of no febrile urinary UTIs was 98.3%. The mean operative time was 96 min (±37.7 min) for unilateral procedures and 128 min (±46.1 min) for bilateral procedures. The mean hospital stay was 25.3 h (±6.3 h). There was no difference between males and females regarding age, weight, renal function or follow-up duration. CONCLUSIONS: Laparoscopic reimplantation with Lich-Gregoir technique is an efficient, quick and safe technique for the management of VUR. The success rate is comparable to open techniques with the advantages of laparoscopic approach; this can potentially be performed as a Day Case procedure.

Endoscopic Excision of Forehead and Eyebrow Benign Tumors in Children.

OBJECTIVE: Direct excision of dermoid cysts of the eyebrow and forehead may lead to a prominent facial scar. Endoscopic techniques have greatly reduced the morbidity of excising benign orbitofacial masses. Access, visualization, and dissection of these masses are comparable to open approaches without the use of large or conspicuous incisions. This study evaluates the efficacy of the endoscopic approach in the treatment of dermoid cysts of the eyebrow and defines the place of this approach as an alternative to open surgery. MATERIALS AND METHODS: Between July 2008 and April 2015, a total of 23 pediatric patients (13 females and 10 males) with dermoid cysts of the brow underwent excision by endoscopy. The mean age was 11.9 months (2-32 months). The lesion was located on the lateral brow in 17 cases and on the hairless forehead in 6 cases. To assess osseous involvement, sonography and magnetic resonance imaging study were performed in 22 and 1 case, respectively. Medical photos documentation was done systematically. For those children having an excision of cyst by endoscopy, the operative time, hystopathological examination, specimen size, and hospital stay were evaluated. In addition, parents of these patients were contacted to determine satisfaction with the procedure. RESULTS: All procedures were successfully performed endoscopically. The mean operative time was 41 minutes (range 17-120 minutes). There was no intraoperative complication. The mean specimen size was 12 mm. In postoperative period, 1 patient presented edema on the forehead with uneventful course. All procedures were performed on the day-surgery. The hystopathological examinations were dermoid cysts in 21 cases, hemangioma in 1 case, and dermatofibroma in 1 case. The mean follow-up was 45.5 months (4-84 months). There was no residual mass or recurrence after long follow-up. Cosmetic results were excellent and all families were pleased with the outcome. CONCLUSIONS: Endoscopic excision of forehead masses and dermoid cysts of the eyebrow is safe and it has proven to be an effective and minimally invasive alternative to the conventional approach. The main advantage of this procedure is the minimization of scar visibility compared with open surgery.