RESUMO
OBJECTIVE: The purpose of this study was to describe management and outcomes from a contemporary cohort of children with Wilms tumor complicated by inferior vena caval thrombus. BACKGROUND: The largest series of these patients was published almost 2 decades ago. Since then, neoadjuvant chemotherapy has been commonly used to manage these patients, and outcomes have not been reported. METHODS: Retrospective review of 19 North American centers between 2009 and 2019. Patient and disease characteristics, management, and outcomes were investigated and analyzed. RESULTS: Of 124 patients, 81% had favorable histology (FH), and 52% were stage IV. IVC thrombus level was infrahepatic in 53 (43%), intrahepatic in 32 (26%), suprahepatic in 14 (11%), and cardiac in 24 (19%). Neoadjuvant chemotherapy using a 3-drug regimen was administered in 82% and postresection radiation in 90%. Thrombus level regression was 45% overall, with suprahepatic level showing the best response (62%). Cardiopulmonary bypass (CPB) was potentially avoided in 67%. The perioperative complication rate was significantly lower after neoadjuvant chemotherapy [(25%) vs upfront surgery (55%); P =0.005]. CPB was not associated with higher complications [CPB (50%) vs no CPB (27%); P =0.08]. Two-year event-free survival was 93% and overall survival was 96%, higher in FH cases (FH 98% vs unfavorable histology/anaplastic 82%; P =0.73). Neither incomplete resection nor viable thrombus cells affected event-free survival or overall survival. CONCLUSIONS: Multimodal therapy resulted in excellent outcomes, even with advanced-stage disease and cardiac extension. Neoadjuvant chemotherapy decreased the need for CPB to facilitate resection. Complete thrombectomy may not always be necessary.
Assuntos
Neoplasias Renais , Oncologia Cirúrgica , Trombose Venosa , Tumor de Wilms , Humanos , Criança , Neoplasias Renais/cirurgia , Veia Cava Inferior/cirurgia , Tumor de Wilms/cirurgia , Tumor de Wilms/tratamento farmacológico , Trombose Venosa/patologia , Trombectomia/métodos , Estudos Retrospectivos , Nefrectomia/métodosRESUMO
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.
Assuntos
Linfadenopatia , Pescoço , Ultrassonografia , Humanos , Criança , Linfadenopatia/diagnóstico , Linfadenopatia/etiologia , Linfadenopatia/diagnóstico por imagem , Estudos Retrospectivos , Masculino , Feminino , Pré-Escolar , Adolescente , Lactente , Biópsia , Linfonodos/patologia , Linfonodos/diagnóstico por imagemRESUMO
Germ cell tumors (GCT) are a complex, heterogeneous collection of tumors that may present in either gonadal or extragonadal sites. They consist of a variety of benign and malignant histologies that can occur at several locations throughout the body. An important component of treatment is surgical resection, and while the key components of resection are site specific, the universal goals of GCT resection include the complete resection of tumor without violating the tumor capsule, while preserving function of surrounding organs, minimizing morbidity, and assessing for regional spread.
RESUMO
PURPOSE: Our objectives were to compare overall survival (OS) and pulmonary relapse between patients with metastatic Ewing sarcoma (EWS) at diagnosis who achieve rapid complete response (RCR) and those with residual pulmonary nodules after induction chemotherapy (non-RCR). PATIENTS AND METHODS: This retrospective cohort study included children under 20 years with metastatic EWS treated from 2007 to 2020 at 19 institutions in the Pediatric Surgical Oncology Research Collaborative. Chi-square tests were conducted for differences among groups. Kaplan-Meier curves were generated for OS and pulmonary relapse. RESULTS: Among 148 patients with metastatic EWS at diagnosis, 61 (41.2%) achieved RCR. Five-year OS was 71.2% for patients who achieved RCR, and 50.2% for those without RCR (p = .04), and in multivariable regression among patients with isolated pulmonary metastases, RCR (hazards ratio [HR] 0.42; 95% confidence interval [CI]: 0.17-0.99) and whole lung irradiation (WLI) (HR 0.35; 95% CI: 0.16-0.77) were associated with improved survival. Pulmonary relapse occurred in 57 (37%) patients, including 18 (29%) in the RCR and 36 (41%) in the non-RCR groups (p = .14). Five-year pulmonary relapse rates did not significantly differ based on RCR (33.0%) versus non-RCR (47.0%, p = .13), or WLI (38.8%) versus no WLI (46.0%, p = .32). DISCUSSION: Patients with EWS who had isolated pulmonary metastases at diagnosis had improved OS if they achieved RCR and received WLI, despite having no significant differences in rates of pulmonary relapse.
Assuntos
Neoplasias Ósseas , Neoplasias Pulmonares , Sarcoma de Ewing , Humanos , Sarcoma de Ewing/mortalidade , Sarcoma de Ewing/terapia , Sarcoma de Ewing/patologia , Feminino , Masculino , Criança , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/terapia , Neoplasias Pulmonares/secundário , Estudos Retrospectivos , Adolescente , Neoplasias Ósseas/mortalidade , Neoplasias Ósseas/terapia , Neoplasias Ósseas/secundário , Neoplasias Ósseas/patologia , Pré-Escolar , Taxa de Sobrevida , Prognóstico , Seguimentos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Adulto Jovem , Indução de Remissão , Lactente , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/terapia , Quimioterapia de InduçãoRESUMO
BACKGROUND: Undifferentiated embryonal sarcoma of the liver (UESL) is a rare tumor for which there are few evidence-based guidelines. The aim of this study was to define current management strategies and outcomes for these patients using a multi-institutional dataset curated by the Pediatric Surgical Oncology Research Collaborative. METHODS: Data were collected retrospectively for patients with UESL treated across 17 children's hospitals in North America from 1989 to 2019. Factors analyzed included patient and tumor characteristics, PRETEXT group, operative details, and neoadjuvant/adjuvant regimens. Event-free and overall survival (EFS, OS) were the primary and secondary outcomes, respectively. RESULTS: Seventy-eight patients were identified with a median age of 9.9 years [interquartile range [IQR): 7-12]. Twenty-seven patients underwent resection at diagnosis, and 47 patients underwent delayed resection, including eight liver transplants. Neoadjuvant chemotherapy led to a median change in maximum tumor diameter of 1.6 cm [IQR: 0.0-4.4] and greater than 90% tumor necrosis in 79% of the patients undergoing delayed resection. R0 resections were accomplished in 63 patients (81%). Univariate analysis found that metastatic disease impacted OS, and completeness of resection impacted both EFS and OS, while multivariate analysis revealed that R0 resection was associated with decreased expected hazards of experiencing an event [hazard ratio (HR): 0.14, 95% confidence interval (CI): 0.04-0.6]. At a median follow-up of 4 years [IQR: 2-8], the EFS was 70.0% [95% CI: 60%-82%] and OS was 83% [95% CI: 75%-93%]. CONCLUSION: Complete resection is associated with improved survival for patients with UESL. Neoadjuvant chemotherapy causes minimal radiographic response, but significant tumor necrosis.
RESUMO
INTRODUCTION: This study evaluated North American pediatric surgeons' opinions and knowledge of business and economics in medicine and their perceptions of trends in their healthcare delivery environment. METHODS: We conducted an elective online survey of 1119 American Pediatric Surgical Association members. Over 8 mo, we iteratively developed the survey focused on four areas: opinion, knowledge, current practice environment, and trends in practice environment over the past 5 y. RESULTS: We received 227 (20.3%) complete surveys from pediatric surgeons. One hundred ninety four (85.5%) perceive healthcare as a business and most (85.9%) believe healthcare decisions may affect patients' out-of-pocket expenses. More than half (51.1%) of surgeons believe it has become more challenging to perform emergent cases and most believe staff quality has decreased for elective (56.4%) and emergent (63.0%) cases over the past 5 y. CONCLUSIONS: Pediatric surgeons recognize that medicine is a business and have concerns regarding the decreasing quality of operating room staff and the increasing difficulty providing surgical care over the last 5 y.
Assuntos
Especialidades Cirúrgicas , Cirurgiões , Criança , Humanos , Estados Unidos , Inquéritos e Questionários , Gastos em Saúde , ComércioRESUMO
BACKGROUND: Numerous studies have demonstrated a variety of social inequalities within pediatric and young adult patients with solid tumors. This systematic review examines and consolidates the existing literature regarding disparities in pediatric and young adult solid tumor oncology. PROCEDURE: A MeSH search was performed on the following databases: MEDLINE, PubMed, OvidSP Cochrane, Central, Embase, Cinhal, and Scopus. The systematic review was performed using Rayyan QCRI. RESULTS: Total 387 articles were found on the initial search, and 34 articles were included in final review. Twenty-seven studies addressed racial and ethnic disparities; 23 addressed socioeconomic disparities. Patients with Hispanic ethnicity, Black race, and lower socioeconomic status were more likely to present at later stages, have differences in treatments and higher mortality rates. CONCLUSION: This qualitative systematic review identified both racial and socioeconomic disparities in pediatric cancer patients across a variety of solid tumor types. Patients with Hispanic ethnicity, Black race, and lower socioeconomic status are associated with disparities in stage at presentation, treatment, and outcome. Characterization of existing disparities provides the evidence necessary to support changes at a systemic level.
Assuntos
Etnicidade , Neoplasias , Criança , Humanos , Adolescente , Adulto Jovem , Classe Social , Fatores Socioeconômicos , Grupos RaciaisRESUMO
Wilms tumor (WT) is the most common renal malignancy in children. Children with favorable histology WT achieve survival rates of over 90%. Twelve percent of patients present with metastatic disease, most commonly to the lungs. The presence of a pleural effusion at the time of diagnosis of WT may be noted on staging imaging; however, minimal data exist regarding the significance and prognostic importance of this finding. The objectives of our study are to identify the incidence of pleural effusions in patients with WT, and to determine the potential impact on oncologic outcomes. A multi-institutional retrospective review was performed from January 2009 to December 2019, including children with WT and a pleural effusion on diagnostic imaging treated at Pediatric Surgical Oncology Research Collaborative (PSORC) participating institutions. Of 1259 children with a new WT diagnosis, 94 (7.5%) had a pleural effusion. Patients with a pleural effusion were older than those without (median 4.3 vs 3.5 years; P = .004), and advanced stages were more common (local stage III 85.9% vs 51.9%; P < .0001). Only 14 patients underwent a thoracentesis for fluid evaluation; 3 had cytopathologic evidence of malignant cells. Event-free and overall survival of all children with WT and pleural effusions was 86.2% and 91.5%, respectively. The rate and significance of malignant cells present in pleural fluid is unknown due to low incidence of cytopathologic analysis in our cohort; therefore, the presence of an effusion does not appear to necessitate a change in therapy. Excellent survival can be expected with current stage-specific treatment regimens.
Assuntos
Neoplasias Renais , Derrame Pleural Maligno , Derrame Pleural , Oncologia Cirúrgica , Tumor de Wilms , Criança , Humanos , Incidência , Neoplasias Renais/epidemiologia , Neoplasias Renais/cirurgia , Derrame Pleural/epidemiologia , Derrame Pleural/etiologia , Derrame Pleural Maligno/epidemiologia , Derrame Pleural Maligno/etiologia , Derrame Pleural Maligno/cirurgia , Estudos Retrospectivos , Tumor de Wilms/epidemiologia , Tumor de Wilms/cirurgiaRESUMO
Inflammatory myofibroblastic tumor (IMT) is a mesenchymal neoplasm of intermediate malignancy. We describe the largest cohort of IMT patients to date, aiming to further characterize this rare, poorly understood tumor. This is a multi-institutional review of IMT patients ≤39 years, from 2000 to 2018, at 18 hospitals in the Pediatric Surgical Oncology Research Collaborative. One hundred and eighty-two patients were identified with median age of 11 years. Thirty-three percent of tumors were thoracic in origin. Presenting signs/symptoms included pain (29%), respiratory symptoms (25%) and constitutional symptoms (20%). Median tumor size was 3.9 cm. Anaplastic lymphoma kinase (ALK) overexpression was identified in 53% of patients. Seven percent of patients had distant disease at diagnosis. Ninety-one percent of patients underwent resection: 14% received neoadjuvant treatment and 22% adjuvant treatment. Twelve percent of patients received an ALK inhibitor. Sixty-six percent of surgical patients had complete resection, with 20% positive microscopic margins and 14% gross residual disease. Approximately 40% had en bloc resection of involved organs. Median follow-up time was 36 months. Overall 5-year survival was 95% and 5-year event-free survival was 80%. Predictors of recurrence included respiratory symptoms, tumor size and distant disease. Gross or microscopic margins were not associated with recurrence, suggesting that aggressive attempts at resection may not be warranted.
Assuntos
Oncologia Cirúrgica , Criança , Humanos , Recidiva Local de Neoplasia , Inibidores de Proteínas Quinases , Receptores Proteína Tirosina QuinasesRESUMO
BACKGROUND: Hepatocellular carcinoma (HCC) is a rare cancer in children, with various histologic subtypes and a paucity of data to guide clinical management and predict prognosis. METHODS: A multi-institutional review of children with hepatocellular neoplasms was performed, including demographic, staging, treatment, and outcomes data. Patients were categorized as having conventional HCC (cHCC) with or without underlying liver disease, fibrolamellar carcinoma (FLC), and hepatoblastoma with HCC features (HB-HCC). Univariate and multivariate analyses identified predictors of mortality and relapse. RESULTS: In total, 262 children were identified; and an institutional histologic review revealed 110 cHCCs (42%; 69 normal background liver, 34 inflammatory/cirrhotic, 7 unknown), 119 FLCs (45%), and 33 HB-HCCs (12%). The authors observed notable differences in presentation and behavior among tumor subtypes, including increased lymph node involvement in FLC and higher stage in cHCC. Factors associated with mortality included cHCC (hazard ratio [HR], 1.63; P = .038), elevated α-fetoprotein (HR, 3.1; P = .014), multifocality (HR, 2.4; P < .001), and PRETEXT (pretreatment extent of disease) stage IV (HR, 5.76; P < .001). Multivariate analysis identified increased mortality in cHCC versus FLC (HR, 2.2; P = .004) and in unresectable tumors (HR, 3.4; P < .001). Disease-free status at any point predicted survival. CONCLUSIONS: This multi-institutional, detailed data set allowed a comprehensive analysis of outcomes for children with these rare hepatocellular neoplasms. The current data demonstrated that pediatric HCC subtypes are not equivalent entities because FLC and cHCC have distinct anatomic patterns and outcomes in concert with their known molecular differences. This data set will be further used to elucidate the impact of histology on specific treatment responses, with the goal of designing risk-stratified algorithms for children with HCC. LAY SUMMARY: This is the largest reported granular data set on children with hepatocellular carcinoma. The study evaluates different subtypes of hepatocellular carcinoma and identifies key differences between subtypes. This information is pivotal in improving understanding of these rare cancers and may be used to improve clinical management and subsequent outcome in children with these rare malignancies.
Assuntos
Carcinoma Hepatocelular , Neoplasias Hepáticas , Oncologia Cirúrgica , Carcinoma Hepatocelular/patologia , Criança , Humanos , Neoplasias Hepáticas/patologia , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Estudos RetrospectivosRESUMO
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.
Assuntos
Doenças dos Anexos , Doenças dos Anexos/diagnóstico por imagem , Doenças dos Anexos/cirurgia , Adolescente , Criança , Feminino , Humanos , Náusea/complicações , Torção Ovariana , Estudos Retrospectivos , Anormalidade Torcional/diagnóstico por imagem , Anormalidade Torcional/cirurgia , Vômito/complicaçõesRESUMO
Intestinal atresia is a form of congenital bowel obstruction that requires operative repair in the early neonatal period. Duodenal atresia and jejunoileal (JI) atresia are appropriately seen as distinct entities. Both can be suspected with fetal imaging, which can assist with prenatal counseling of families. Duodenal atresia is more commonly associated with comorbidities, whereas JI atresia is more often an isolated finding. Surgical repair is essential and is typically well tolerated. Although it may take time to achieve intestinal function postoperatively, these infants are usually able to tolerate full feeds after resolution of the ileus. Excellent short- and long-term outcomes for isolated duodenal atresia and JI atresia are expected.
Assuntos
Obstrução Duodenal , Atresia Intestinal , Obstrução Duodenal/complicações , Feminino , Humanos , Lactente , Recém-Nascido , Atresia Intestinal/complicações , Atresia Intestinal/diagnóstico , Atresia Intestinal/cirurgia , Intestino Delgado/anormalidades , Gravidez , Diagnóstico Pré-NatalRESUMO
Complete surgical resection of pulmonary metastatic disease in patients with osteosarcoma is crucial to long-term survival. Open thoracotomy allows palpation of nodules not identified on imaging but the impact on survival is unknown. The objective of this study was to compare overall survival (OS) and pulmonary disease-free survival (DFS) in children who underwent thoracotomy vs thoracoscopic surgery for pulmonary metastasectomy. A multi-institutional collaborative group retrospectively reviewed 202 pediatric patients with osteosarcoma who underwent pulmonary metastasectomy by thoracotomy (n = 154) or thoracoscopy (n = 48). Results were analyzed by Kaplan-Meier survival estimates and multivariate Cox proportional hazard regression models. With median follow-up of 45 months, 135 (67.5%) patients had a pulmonary relapse and 95 (47%) patients were deceased. Kaplan-Meier analysis showed no significant difference in 5-year pulmonary DFS (25% vs 38%; P = .18) or OS (49% vs 42%, P = .37) between the surgical approaches of thoracotomy and thoracoscopy. In Cox regression analysis controlling for other factors impacting outcome, there was a significantly increased risk of mortality (HR 2.11; P = .027; 95% CI 1.09-4.09) but not pulmonary recurrence (HR 0.96; P = .90; 95% CI 0.52-1.79) with a thoracoscopic approach. However, in the subset analysis limited to patients with oligometastatic disease, thoracoscopy had no increased risk of mortality (HR 1.16; P = .62; 0.64-2.11). In conclusion, patients with metastatic osteosarcoma and limited pulmonary disease burden demonstrate comparable outcomes after thoracotomy and thoracoscopy for metastasectomy. While significant selection bias in these surgical cohorts limits the generalizability of the conclusions, clinical equipoise for a randomized clinical trial in patients with oligometastatic disease is supported.
Assuntos
Neoplasias Ósseas/cirurgia , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/secundário , Metastasectomia/métodos , Osteossarcoma/cirurgia , Toracoscopia/métodos , Toracotomia/métodos , Neoplasias Ósseas/patologia , Criança , Intervalo Livre de Doença , Feminino , Humanos , Colaboração Intersetorial , Masculino , Osteossarcoma/patologia , Estudos Retrospectivos , Oncologia CirúrgicaRESUMO
Hypertrophic pyloric stenosis is a common condition seen in the first 1 to 3 months after birth. Patients typically present with nonbilious projectile emesis after feeds that may result in hypokalemic, hypochloremic metabolic alkalosis. Although inability to tolerate feeds is frequently seen with self-limited conditions such as reflux, a low threshold to obtain an ultrasonographic image is important to prevent a delay in diagnosis. Although operative intervention is the treatment, it is imperative that patients are hydrated and serum electrolyte concentrations normalized before the induction of anesthesia. Laparoscopic pyloromyotomy is safe and effective. Postoperative emesis is normal, and reassurance to parents is appropriate. There is no significant long-term physiologic impairment from pyloric stenosis after successful surgical intervention.
Assuntos
Alcalose , Estenose Pilórica Hipertrófica , Humanos , Lactente , Estenose Pilórica Hipertrófica/diagnóstico , Estenose Pilórica Hipertrófica/cirurgia , Vômito/etiologiaRESUMO
BACKGROUND: The impact of social, racial, and economic inequities on health and surgical outcomes for children is poorly described. METHODS: A systematic review using search terms related to disparities in care of pediatric appendicitis identified 20 titles and narrowed to 11 full texts. Nine retrospective studies were analyzed, representing 350,408 cases treated across the United States from 1983 to 2010. Outcomes included length of stay (LOS), appendiceal perforation rate (AP), laparoscopic versus open approach, and rate of misdiagnosis. RESULTS: The most frequently reported outcomes were LOS (six of nine studies) and AP (six of nine studies). AP was higher for young children (48% for <6 versus 25% for >10), those in rural settings (42% versus 26% in urban settings), and patients receiving care at children's hospitals (35% versus 22% at nonchildren's hospitals). Longer LOS was associated with young age in three studies (2-5 d for age <10 y versus 1-3 d for age >11 y), race in four studies (1.5-3 d for African American children versus 1-2 d for other races), and lower family income in two studies (2-4 d versus 1-3 d for highest income). Inequitable use of laparoscopy, time to surgery, and rates of misdiagnosis were also reported to be associated with age and race. CONCLUSIONS: Although limited, the existing literature suggests that social, racial, and economic inequalities impact management and outcomes in pediatric appendicitis. More studies are needed to better describe and mitigate disparities in the surgical care of children.
Assuntos
Apendicectomia/estatística & dados numéricos , Apendicite/cirurgia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Perfuração Intestinal/epidemiologia , Laparoscopia/estatística & dados numéricos , Negro ou Afro-Americano/estatística & dados numéricos , Fatores Etários , Apendicite/complicações , Apendicite/diagnóstico , Criança , Erros de Diagnóstico/estatística & dados numéricos , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Perfuração Intestinal/etiologia , Tempo de Internação/estatística & dados numéricos , População Rural/estatística & dados numéricos , Fatores Socioeconômicos , Tempo para o Tratamento/estatística & dados numéricosRESUMO
Neonates often have congenital lumps or sinuses. It is expected that pediatricians will distinguish those with important physiologic implications from those without. Accurate understanding of these lesions is important for the practitioner to avoid unnecessary tests and anxiety and to ensure that seemingly benign lesions with important implications are addressed in a timely manner. This review aims to clarify the consequences of some lesions that can easily be misinterpreted, offering guidance in the initial management of patients with congenital lumps or sinuses. We address several lesions that can easily be misconstrued, including wattles, preauricular lesions, sacral sinuses, second branchial cleft anomalies, torticollis, and dermoid cysts.
Assuntos
Região Branquial/anormalidades , Cisto Dermoide/diagnóstico , Doenças do Recém-Nascido/diagnóstico , Sacro/patologia , Anormalidades da Pele/diagnóstico , Torcicolo/congênito , Humanos , Recém-Nascido , Torcicolo/diagnósticoRESUMO
INTRODUCTION: Nonmedical opioid use is a major public health problem. There is little standardization in opioid-prescribing practices for pediatric ambulatory surgery, which can result in patients being prescribed large quantities of opioids. We have evaluated the variability in postoperative pain medication given to pediatric patients following routine ambulatory pediatric surgical procedures. METHODS: Following IRB approval, pediatric patients undergoing umbilical hernia repair, inguinal hernia repair, hydrocelectomy, and orchiopexy from 2/1/2017 to 2/1/2018 at our tertiary care children's hospital were retrospectively reviewed. Data collected include operation, surgeon, resident or fellow involvement, utilization of preoperative analgesia, opioid prescription on discharge, and patient follow-up. RESULTS: Of 329 patients identified, opioids were prescribed on discharge to 37.4% of patients (66.3% of umbilical hernia repairs, 20.6% of laparoscopic inguinal hernia repairs, and 33.3% of open inguinal hernia repairs [including hydrocelectomies and orchiopexies]). For each procedure, there was large intrasurgeon and intersurgeon variability in the number of opioid doses prescribed. Opioid prescription ranged from 0 to 33 doses for umbilical hernia repairs, 0 to 24 doses for laparoscopic inguinal repairs, and 0 to 20 doses prescribed for open inguinal repairs, hydrocelectomies, and orchiopexies. Pediatric surgical fellows were less likely to discharge a patient with an opioid prescription than surgical resident prescribers (P < 0.01). In addition, surgical residents were more likely to prescribe more than twelve doses of opioids than pediatric surgical fellows (P < 0.01). Increasing patient age was associated with an increased likelihood of opioid prescription (P < 0.01). There were two phone calls and two clinic visits for pain control issues with equal numbers for those with and without opioid prescriptions. CONCLUSIONS: There is significant variation in opioid-prescribing practices after pediatric surgical procedures; increased awareness may help minimize this variability and reduce overprescribing. Training level has an impact on the frequency and quantity of opioids prescribed.
Assuntos
Analgésicos Opioides/uso terapêutico , Ambulatório Hospitalar/estatística & dados numéricos , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Criança , Pré-Escolar , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Herniorrafia/efeitos adversos , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Lactente , Masculino , Epidemia de Opioides/etiologia , Epidemia de Opioides/prevenção & controle , Orquidopexia/efeitos adversos , Dor Pós-Operatória/etiologia , Estudos Retrospectivos , Centros de Atenção Terciária/estatística & dados numéricos , Hidrocele Testicular/cirurgia , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Thymectomy in pediatric patients is an effective treatment for myasthenia gravis (MG), thymic neoplasms, and other rarer pathologies. It is an uncommon procedure in children and studies have focused on small, single-institution cohorts. We sought to better characterize its use by utilizing a national database. METHODS: The Kids' Inpatient Database was used to identify hospital discharge records of patients ≤ 20 years old who underwent thymectomy. A retrospective cross-sectional analysis for 2003, 2006, 2009, and 2012 was performed. Trends in patient characteristics, diagnosis, surgical approach, and short-term outcomes were analyzed. Risk factors were identified using univariate and multivariate analyses. RESULTS: There were 600 thymectomies identified. MG was the most common indication. Thoracoscopy is being used increasingly for all diagnoses except malignancy. The overall morbidity rate was 14.0%, with respiratory complications representing the largest group. No in-hospital deaths were identified. Private insurance was associated with shorter hospital stays and lower costs. Hispanic race was associated with more complications, longer stays, and higher costs. Thoracoscopic thymectomies had shorter stays than open procedures. CONCLUSION: Thymectomy in the pediatric population is being performed safely, with low morbidity and no identified mortalities. Thoracoscopy results in reduced length of stay and is being used increasingly. Of note, socioeconomic and racial factors impact outcomes.
Assuntos
Miastenia Gravis/cirurgia , Cirurgia Torácica Vídeoassistida/métodos , Timectomia/métodos , Timoma/cirurgia , Neoplasias do Timo/cirurgia , Adolescente , Criança , Estudos Transversais , Feminino , Humanos , Tempo de Internação/tendências , Masculino , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Necrotizing enterocolitis (NEC) is a frequently encountered condition in the premature neonate, which can have devastating effects. The signs and symptoms of NEC are variable and can be confused with those of sepsis. An abdominal radiograph is often obtained for diagnosis, and findings that indicate NEC include pneumatosis and portal venous gas. The treatment of NEC includes gastrointestinal rest, gastric decompression, broad-spectrum intravenous antibiotics, and systemic support. A finding of pneumoperitoneum signifies intestinal perforation, which requires surgical intervention. Long-term sequelae of NEC include short-gut syndrome, intestinal stricture, and neurodevelopmental delays. The presentation of intestinal stricture can be puzzling. It can appear at presentation as a bowel obstruction or, conversely, as increased stool output or diarrhea. The clinician should have a high level of suspicion for intestinal stricture in a patient with a history of NEC.