BACKGROUND:The specific use of minimally invasive surgery (MIS) in pediatric cancer patients is limited. We evaluated the 5-year experience at a single institution with MIS in children with malignancies.METHODS:A retrospective review was undertaken of all MIS performed between November 1995 and October 2000.RESULTS:A total of 101 pediatric oncology patients underwent 113 MIS procedures-64 laparoscopic (57%) and 49 thoracoscopic (43%)-during this period. Laparoscopy was performed for diagnostic purposes in 27 cases (42%) and was successful in 25 (93%) cases. Laparoscopic tumor resection was performed in seven cases (11%). Thirty additional laparoscopic procedures (47%) were attempted for complications of the malignancy or its treatment. Four of these cases were converted to open laparotomies. Indications for thoracoscopy included the evaluation of a mediastinal mass (n = 7) or biopsy or resection of pulmonary lesions (metastatic, n = 31; infectious, n = 9). Fourteen cases (29%) had to be converted to open thoracotomy procedures, generally because of the inability to localize a lesion. The other 35 procedures were successful. The overall complication rate was 5%. No trocar site recurrences or infections were observed.CONCLUSIONS:We conclude that MIS in pediatric cancer patients is a safe and effective diagnostic modality. The role of MIS for primary tumor resection remains to be defined.

Purpose: The aim of this study was to evaluate the outcome of children undergoing treatment for malignancy and immunodeficiency syndromes in whom invasive pulmonary aspergillosis (IPA) developed. Methods: The authors reviewed the medical records of all patients treated at their institution from January 1990 to August 1999 for culture-proven pulmonary aspergillus infection. Results: Among the 43 patients studied, the median age at the time of diagnosis of IPA was 13.1 years. The most common primary diagnoses were acute myelogenous leukemia (n = 18) and acute lymphoblastic leukemia (n = 14); 27 patients (63%) had received a bone marrow transplant (BMT). Of the 18 patients who underwent surgical intervention for IPA, 14 (78%) had one operation, whereas the remaining 4 patients had 2. The 4 patients alive at the time this report was written had undergone surgical intervention 2, 10, 23, and 44 months previously respectively. Surgical resection of the involved lung parenchyma was significantly prognostic for survival (P < .001). Other factors that influenced outcome were the extent of pulmonary invasion, steroid use, and the timing of bone marrow transplantation (BMT) in regard to the diagnosis of IPA. Conclusions: The overall mortality rate of children treated for malignancies and immunodeficiency syndromes in who IPA develops remains high, and antifungal therapy alone may not be curative. Surgical resection may provide a small but possibly the only chance for survival. Therefore, we would advocate for resection of all involved tissue, even if it requires reoperation.

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 χ2 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 ≥15% is associated with an increased likelihood of failure and complications. J Pediatr Surg 36:165-168. Copyright © 2001 by W.B. Saunders Company.

Purpose: When gastroesophageal reflux (GER) is unresponsive to medical management, life-threatening complications may mandate surgical intervention in the very young. The aim of this study was to determine whether laparoscopic Nissen fundoplication in babies less than 3 months of age or 3.5 kg is safe and effective. Methods: The medical records from three institutions of all patients younger than 3 months of age or <3.5 kg undergoing fundoplication were reviewed. The short gastric vessels were routinely divided, and the crura were reapproximated. Short floppy 360° wraps were fashioned over a bougie (22F-30F) with two to four sutures incorporating the anterior esophagus. Laparoscopic Nissen fundoplication was performed in 104 infants fulfilling the size or weight criteria. Eighty two patient had concurrent gastrostomies. The mean age and weight were 68 days and 3.1 kg, respectively. Results: The mean operative time was 60 minutes, and the patients were at full feedings by a mean of 3 days. The mean patient follow-up is more than 150 days. One patient was converted to the open technique. There were 12 major complications (10.7%), which were related to laparoscopy (4), gastrostomy (4), patient selection (1), fundoplication (2), and pulmonary (1). One infant with a malpositioned gastrostomy tube still has occasional emesis; all others have no clinical evidence of GER. There was one death in an infant with trisomy 18 and a gastrostomy tube leak. Conclusions: Small infants requiring fundoplication may be safely managed with this minimally invasive technique. Most complications are attributable to technical errors and can be avoided; pulmonary complications and bowel obstruction are minimized.

Lymphoscintigraphy and sentinel lymph node biopsy techniques can be applied successfully to young children with melanoma to detect nodal disease. The authors describe their methods of lymphoscintigraphy and sentinel node biopsy and its application in 2 young children with malignant melanoma of the head and neck. J Pediatr Surg 35:965-966. Copyright © 2000 by W.B. Saunders Company.

To determine the efficacy, safety, and cost of managing perforated appendicitis with intravenous antibiotics followed by an interval appendectomy, the charts of 87 children with ruptured appendicitis were retrospectively reviewed. These patients were treated with intravenous fluid resuscitation and antibiotics (consisting of clindamycin and ceftazidime) and underwent appendectomy, either on that admission (n = 46) or as a delayed interval procedure (n = 41). Antibiotics in all cases were discontinued either at home or in the hospital after the child was a febrile for 48 hours with normal white and differential blood cell counts, and the two groups were compared. Seven patients (17%) "failed" the interval appendectomy protocol. All but one "failure" was due to the development or persistence for >72 hours of a bowel obstruction. The data are described below as percent or mean +/- 1 standard deviation. [table: see text] We conclude that antibiotics and interval appendectomy is a safe effective alternative for the management of perforated appendicitis. When successful, hospitalization, charges, and morbidity are less with this approach. A persistent bowel obstruction for 72 hours is an indication to proceed with appendectomy on admission.

Laparoscopic appendectomy is a common surgery in most pediatric surgical centers. Many studies, mostly retrospective reviews in adults, show the advantages of the laparoscopic approach to be less wound infections, shortened postoperative recovery, and faster return to normal activities. In addition, less analgesic medication is required postoperatively. Potential disadvantages of laparoscopic appendectomy include an increased operative time, elevated costs when disposable instruments are used, and possibly more infectious complications when performed for complicated appendicitis. There are no prospective, randomized trials comparing laparoscopic versus open appendectomy in children. Until these studies are completed, questions will persist regarding the benefits of laparoscopic appendectomy in children.

A modified technique of laparoscopic pyloromyotomy was used to treat infantile hypertrophic pyloric stenosis. Introducing a 5-mm periumbilical port for visualization, two stab wounds are made on either side laterally to directly insert 2.7-mm instruments for manipulation. From the left, the stomach is grasped – not the duodenum! From the right, an inexpensive disposable arthroscopy knife is used to incise the serosa and begin the myotomy, which is completed with a laparoscopic spreader until the muscle is separated sufficiently to relieve the obstruction. Twenty-nine children treated with laparoscopic pyloromyotomy were compared to 125 children treated with the conventional open Ramstedt pyloromyotomy. There were no statistically significant differences in the presentation or results between groups, suggesting that the laparoscopic technique is a safe and equal alternative.

Children with appendicitis often present with perforation. With the recent development of minimal access surgery and improved delivery of antibiotics, we postulated that hospitalization and postoperative morbidity for this problem could be reduced. We undertook this pilot study to determine the efficacy and safety of managing perforated appendicitis with intravenous antibiotics and performing an interval laparoscopic appendectomy at 6 weeks after presentation. Between June 1, 1995 and September 1, 1995, we admitted 29 patients with appendicitis. Of these, 13 (44%) were perforated. Ten patients with perforated appendicitis were treated by conventional operative appendectomy and antibiotics. Three patients with perforated appendicitis were started on intravenous antibiotics in the hospital and these were continued at home. These patients returned for an interval laparoscopic appendectomy at 6 weeks using all disposable instruments. Intravenous antibiotics were discontinued in both groups when, after being afebrile for 48 hours, the white blood cell and differential counts were normal. Lengths of total hospitalization, charges, and associated morbidity were compared in these two groups. All 3 patients in the laparoscopic group were admitted for 3 days, received home intravenous antibiotics for 7 days, and had a single day of outpatient surgery. The total charges, including those for the disposable instruments, were $12,600 ± 1223 (mean ± SD), and there was no morbidity in this group. Patients in the conventionally treated group had 8.2 ± 5.6 hospitalization days for surgery and antibiotics therapy. Four of these patients also went home on intravenous antibiotic for 10 ± 7.4 days. Their charges were $13052 ± 6419. Two of these patients had minor complications: 1 wound infection and 1 prolonged ileus due to interloop abscesses. Three patients in the conventionally treated group required second operative procedures to drain large intra-abdominal abscesses. This preliminary study shows that antibiotic therapy followed by interval laparoscopic appendectomy is a safe alternative. Total hospitalization is less with this approach and hospital charges can be decreased, especially if all reusable instruments are used for the laparoscopic procedure. A randomized trial comparing these two approaches is warranted.

Recently, we began using minimal access techniques to perform a primary pull-through without a preliminary stoma in children of all ages (range 1 month to 8 years old) with Hirschsprung's disease (HD). To evaluate our results, we reviewed the medical records of all children treated for HD (n = 32) over the past 3 years to compare the outcome of the laparoscopic-assisted pull-through (LAP, n = 14) to standard open pull-through (OPEN, n = 18). The mean ages at diagnosis and presenting symptoms were similar between the 2 groups. Constipation was the most common complaint (LAP, 9, OPEN, 10) followed by persistent emesis (LAP, 2, OPEN, 5), enterocolitis (LAP, 2, OPEN, 2), and failure to thrive (LAP, 1, OPEN, 1). The operative time for the pull-through was similar between the two groups, but the total operative time was longer in the OPEN group when the additional time required for colostomy was included (p < 0.05). Hospitalization after laparoscopic-assisted pull-through was shorter than after the Duhamel procedure (2.5 ± 3.5 days vs. 5.3 ± 1.9, LAP vs. OPEN, p < 0.01). Follow-up was similar between groups (6.7 ± 3.2 months vs. 12.2 ± 14.4, LAP vs. OPEN). Complications in the LAP group included diarrhea (1), and enterocolitis (2), and only 1 child required a secondary procedure (sphincterotomy). Morbidity in the OPEN group included bowel obstruction (3), constipation (3), prolapsed ostomy (2), enterocolitis (1), failure to thrive (1), and aganglionosis (1). Secondary operations required in the OPEN group included division of a "spur," surgical reduction of intussusception, operative extraction of a fecaloma, sphincterotomy, redo-colostomy and pull-through, revision of ileostomy, and adhesiolysis (2). The number of bowel movements was similar in both groups. Two children in the OPEN group take Imodium for loose stool and another child has soiling problems. Our preliminary results suggest that LAP is superior to OPEN. Advantages include no need for ostomy care, shorter total operative time and hospitalization, and fewer complications.

ABSTRACT Antireflux procedures are among the most common operations performed in children today, most of which are done in the neurologically impaired (IMP). While some advocate a minimal access su...

Laparoscopic lymph node dissection is routinely performed for diagnosing and staging malignancies in adults; however, reports of this technique used in children have been sparse. We reviewed our experience with laparoscopic lymph node sampling performed in children (mean age 15 years old) at a pediatric oncology center to help determine its efficacy. All patients (n = 8) were suspected of having intraabdominal or pelvic malignancy based on diagnostic imaging. The mean operative time was 158 min (range 55–300 min). The postoperative course was uniformly uneventful, and all patients (except one with histoplasmosis) were fed a regular diet on the day of surgery. There was no immediate or long-term complication in these children and there was no error in diagnosis. Laparoscopic lymph node sampling is minimally invasive and well tolerated. It provides adequate tissue for diagnosis and staging of malignancies in children. Unlike open procedures, adjuvant therapy can be started on the day of surgery. We recommend laparoscopic lymph node sampling as the diagnostic and staging procedure of choice in children with pelvic or intraabdominal lymphadenopathy.

Minimal-access surgery (MAS) is rapidly becoming the surgical approach of choice for a variety of surgical disorders in adults, but its use in children remains a relative novelty. Most pediatric surgeons continue to harbor justifiable concerns about the morbidity of this modality owing to the cumbersome nature of the instruments and the technical difficulty associated with two-dimensional views. The purpose of this study was to determine the complication rate and the lessons learned from the use of MAS in performing a variety of procedures in a large series of children. To determine complications, the authors reviewed the medical records of all children (n = 636; age range, 1 month to 19 years) who underwent laparoscopy (LAP) or thoracoscopy (THO) during a 5-year period (January 1, 1990 through December 31, 1994). The follow-up ranged from 1 week to 45 months. THO was performed in 62 children. Conversion to thoracotomy occurred in eight children (13%), because of inability to localize the lesion (3), unresectibility (2), inadequate tissue sample (1), unsafe access (1), hypoxemia (1), or inadvertent esophagotomy (1). Postoperatively, two ventilator-dependent children had tension pneumothorax after lung resection and required chest tubes. LAP was performed on 574 children, with conversion to laparotomy occurring in 15 (2.6%), because of technical reasons (10) or intraoperative complications (5). The complication rate of LAP was 2% (12 of 574). Early in the experience, intraoperative complications that led to laparotomy included hemorrhage during appendectomy (2), cholecystectomy (1), and splenectomy (1); and esophagotomy during a fundoplication (1). Other technical problems in the postoperative period were a malpositioned Nissen fundoplication and a gastric volvulus after gastrostomy and Nissen fundoplication owing to improper gastrostomy tube position. In addition, two children had a hernia at the umbilical trocar site that had been used for contralateral inguinal exploration, and cellulitis developed in three patients when a gastrostomy tube was brought out through a trocar site. Other complications not specific to MAS included pelvic abscess after appendectomy (5); small bowel obstruction after jejunostomy catheter placement (1) and combined cholecystectomy/appendectomy (1); enterocolitis (1) and severe hyponatremia (1) after pull-through for Hirschsprung's disease; and pneumonia after splenectomy (1). The overall complication rate of MAS was 4% (26 of 626), and there were no deaths. The initial use of MAS was associated with technical errors, which decreased with experience. Based on this study, the authors recommend (1) routine placement of a thoracostomy tube in children after THO if they require postoperative ventilator support; (2) using the open hernia sac to place a 70 degrees telescope for contralateral inguinal exploration; and (3) not using a trocar site for gastrostomy tube placement in immune-suppressed patients. With appropriate training and experience, MAS can be used safely in children, for a wide variety of diseases, with minimal morbidity and mortality.

Thoracoscopy has been proposed as the procedure of choice for the evaluation of focal, suspected malignant pulmonary lesions in children. One drawback with this approach, however, is the concern that intraparenchymal lesions may go undetected. We prospectively evaluated the ability of an endoscopic ultrasonic probe to detect intraparenchymal nodules. The handheld probe contains a piezoelectric ultrasound emitter and receiver that operates at 7.5 MHz. The axial resolution of the probe is 1.1 cm. Two different probe tips were used. One is a forward viewing tip and the other is angled at 45 degrees relative to the axis of the probe shaft. Both probes image 90 degrees sectors. Twelve thoracoscopies on nine patients were performed using the ultrasound probe. Of seven patients with confirmed metastatic disease, six had thoracoscopy converted to open thoracotomy to assure that no lesion had been missed. The probe was able to accurately assess surrounding bronchovascular structures and the presence and location of previously placed surgical clips. Although deep structures were readily visualized with the probe, lesions within 1.5 cm of the surface of the lung were poorly visualized. No complications occurred. This ultrasound system allows for the distinction of dense lesions from the surrounding pulmonary parenchyma except for those lying near the surface of the lung, which are usually easy to see directly. Furthermore, the images define the broncho vascular structures adjacent to the lesion. This device may enhance thoracoscopy by facilitating the detection of, and ability to resect, pulmonary intraparenchymal lesions.

Minimal access surgery (MAS) is becoming an accepted modality in the management of adult trauma, but its use in children is rarely reported. Recently, we began using minimal access surgery to evaluate injured children. The purpose of this report is to review our preliminary experience with the use of laparoscopy and thoracoscopy in blunt and penetrating pediatric trauma. Eight children aged 2-14 years old were evaluated using MAS. Two children with blunt injuries had persistent abdominal pain despite normal radiologic studies. Laparoscopy documented a disrupted gallbladder and a small bowel perforation. Laparoscopy was also used to evaluate five hemodynamically stable children with penetrating wounds to the abdominal wall with potential peritoneal penetration. Only one child was converted to a laparotomy. Four were found to have either tangential penetrating wounds or nonbleeding solid organ injuries and were spared an open exploration. Two children with penetrating trauma with potential mediastinal injury were assessed with thoracoscopy. MAS was also used as a therapeutic modality in two children who had diaphragmatic lacerations repaired with an endoscopic "hernia" stapler. MAS accurately identified all injuries. All children were subsequently discharged without complications. We conclude that MAS is a safe and effective way to evaluate and manage hemodynamically stable children with both penetrating and blunt traumatic injuries.

In 25 years, 18 patients with breast cancer were treated at St Jude Children's Research Hospital, 16 were female and 2 were male. The patients presented with primary malignancy (2), metastatic disease (13), or secondary malignancy (3). One of the females with primary breast malignancy had alveolar rhabdomyosarcoma. She was treated with wide excision and is currently receiving chemotherapy. The other patient presented with non-Hodgkin's lymphoma of the right breast. After biopsy, she was treated with chemotherapy. Of 13 patients with metastatic disease, the primary lesion was rhabdomyosarcoma in nine. One patient each had non-Hodgkin's lymphoma, Hodgkin's lymphoma, neuroblastoma, and signet-cell adenocarcinoma. All patients with metastatic disease to the breast died of the disease. Three females presented with invasive ductal carcinoma of the breast after treatment for Hodgkin's disease. Two underwent mastectomy and are alive without evidence of disease. One patient refused therapy and died of the second malignancy. We conclude that (1) breast malignancies had three distinctly different presentations in our patients, (2) the breasts of pediatric oncology patients should be carefully and routinely examined for metastatic disease, and (3) metastatic disease in the breast of a child is a manifestation of disseminated disease and is associated with an extremely poor prognosis.

The authors describe their technique for laparoscopic splenectomy in childhood. Five ports, including one 12-mm port for an endoscopic stapler, are placed. With the patient in the supine position, the short gastric vessels are divided between clips. The patients is then placed in the lateral decubitus position for mobilization of the splenic flexure of the colon, division of the posterolateral ligamentous attachments, and en masse transection of the splenic hilum using the EndoGIA stapler. The freed spleen is placed in a nylon reinforced Lap Sac, which is exteriorized at the neck. The spleen is morcellated and the sac removed. Concomitant cholecystectomy is performed in patients with hereditary spherocytosis who have cholelithiasis or sludge. The procedure has been performed without complications in six patients who had hematologic disorders. For another patient, the procedure was converted to an open splenectomy to achieve better hemostasis.

Now that endoscopic removal of tumors and other solid structures from the abdomen and chest is possible, it is important to know the suitability of this technique for the removal of solid pediatric malignancies where accurate histological assessment becomes important for prognosis and staging. The authors tested an automatic tissue morcellator on a variety of pediatric tissues to assess the interpretability of the material obtained. The morcellator consists of a rotary blade within a 1-cm sleeve. When suction is applied to the morcellator and the device is activated, the solid material is shaved or morcellated into bits of tissue that are aspirated and collected for analysis. To test the interpretability of morcellated tissue, the device was used on six Wilms' tumors, three hepatoblastomas, a lung resection, a splenectomy, and a bowel resection. The average size of the pieces of tissue was 1.33 × 0.58 × 0.43 cm. In every instance, the histology was as good as the evaluation of sections from the gross tumor. It was difficult to distinguish the edge of tissue procured by the morcellator from an edge cut by the pathologist's knife. Conclusions: (1) Morcellated pediatric tissues are available by experienced pediatric pathologists. (2) The adoption of this technique should not interfere with proper histological evaluation of solid pediatric tumors.