Experience with laparoscopic adrenalectomy in children

Surgical Approaches to Neuroblastoma: Review of the Operative Techniques

Neuroblastoma (NB) is the most commonly occurring soft-tissue malignancy of childhood. Surgery plays an important role in multidisciplinary treatment and its principal aim is a local control of the disease, respecting the integrity of the surrounding structures. There is no unanimous consensus on the best surgical technique, and the operative approach largely depends on the anatomical location and the extension of the mass. To have a complete overview of the different type of treatment, we made a review of the literature from the last twenty years of all the surgical approaches applied for NBs resection, accordingly to the anatomical site.

Adrenalectomy for non-neuroblastic pathology in children

BACKGROUND

Adrenalectomy for non-neuroblastic pathologies in children is rare with limited data on outcomes. We reviewed our experience of adrenalectomy in this unique population.

METHODS

Retrospective study of children (age ≤ 18) who underwent adrenalectomy with non-neuroblastic pathology from 1988 to 2018. Clinical and operative details of patients were abstracted. Outcomes included length of stay and 30-day postoperative morbidity.

RESULTS

Forty children underwent 50 adrenalectomies (12 right-sided, 18 left-sided, 10 bilateral). Six patients (15%) presented with an incidental adrenal mass while 4 (10%) had masses found on screening for genetic mutations or prior malignancy. The remaining 30 (75%) presented with symptoms of hormonal excess. Nineteen patients (48%) underwent genetic evaluation and 15 (38%) had genetic predispositions. Diagnoses included 9 patients (23%) with pheochromocytoma, 8 (20%) with adrenocortical adenoma, 8 (20%) with adrenocortical carcinoma, 7 (18%) with adrenal hyperplasia, 2 (5%) with metastasis, and 6 (14%) with additional benign pathologies. Of 50 adrenalectomies, twenty-five (50%) were laparoscopic. Median hospital length of stay was 3 days (range 0-11). Post-operative morbidity rate was 17% with the most severe complication being Clavien-Dindo grade II.

CONCLUSION

Adrenalectomy for non-neuroblastic pathology can be done with low morbidity. Its frequent association with genetic mutations and syndromes requires surgeons to have knowledge of appropriate pre-operative testing and post-operative surveillance.

Posterior retroperitoneoscopic adrenalectomy for pediatric adrenal tumors

BACKGROUND/AIMS

Posterior retroperitoneoscoic adrenalectomy has been reported as an option for adrenal tumor resection but is not commonly performed in children owing to the extreme semikneeling position advocated to flatten the lumbar lordosis in order to achieve adequate retroperitoneal space. As children have smaller lordosis angles, flattening of the lordosis and creation of optimal retroperitoneal space may be achieved with less hip flexion. We used pediatric lumbar lordosis measurements to develop a modified prone jackknife position and report our experiences with this setup for posterior retroperitoneoscopic adrenalectomy for adrenal tumors.

METHODS

Lordosis angles were measured on sagittal computed tomography (CT) and magnetic resonance imaging (MRI) studies of patients with adrenal tumors and compared to normal references. The data were used to develop our modified prone jackknife position. Selected patients with adrenal tumors underwent posterior retroperitoneoscopic adrenalectomy in this position. Patient demographics, diagnoses, operative times, complications, postop analgesia requirements, and length of hospitalization were analyzed.

RESULTS

CT and MRI studies were analyzed for 20 patients with adrenal tumors diagnosed in our institution from 2012 to 2017; median lordosis angle was 27.84° (range: 15.50°-36.48°) - less than reference lordosis angles of respective age groups, and flexion angles of common operating tables. Five patients underwent retroperitoneoscopic adrenalectomy between June 2016 and June 2018. Histological diagnoses were neuroblastoma, adrenal hyperplasia, pheochromocytoma, and adrenal angiomatoid fibrous histiocytoma. Median age was 4 years [range: 1-11]. Median operating time was 137 min [range 111-181 min]. No conversions to open surgery were required. One patient had intraoperative bleeding from the adrenal vein. Only 1 patient required postoperative opioids for analgesia. Median length of hospitalization after surgery was 2 days (range: 2-3 days).

CONCLUSIONS

Pediatric patients can achieve flattening of lumbar lordosis with less extreme positioning. Posterior retroperitoneoscopic adrenalectomy in a modified prone jackknife position is a feasible operation for pediatric patients with small adrenal masses.

TYPE OF STUDY

Clinical research paper.

LEVEL OF EVIDENCE

Level III.

Minimally Invasive Approaches to Pediatric Solid Tumors

Over the last decade, driven in part by the favorable adult experience and a crescendoing number of case series and retrospective reports in the pediatric surgical literature, minimally invasive surgical (MIS) approaches are increasingly used as adjunctive or definitive surgical treatments for an ever-expanding list of pediatric tumors. Although most current treatment protocols lack surgical guidelines regarding the use of MIS, this growing body of MIS literature provides a framework for the development of multicenter trial groups, prospective registries, and further centralization of subspecialist services. This article highlights the current available data on MIS approaches to a variety of pediatric malignancies.

Cystic adrenal lesions: focus on pediatric population (a review)

BACKGROUND AND AIM

The cysts may potentially affect any organ; adrenals cysts are rare. This is a review of the literature regarding adrenal cysts, focusing on children and young adults.

GENERAL DATA

Three major types have been described: pure cysts (endothelial, epithelial, and hemorrhagic or pseudocyst), parasitic (as hydatid) cysts and cystic part of a tumour (most frequent are neuroblastoma, ganglioneuroma, pheocromocytoma, and teratoma). The complications are: bleeding, local pressure effects; infection; rupture (including post-traumatic); arterial hypertension due to renal vessels compression. Adrenal hemorrhage represents a particular condition associating precipitating factors such as: coagulation defects as Factor IX or X deficiency, von Willebrand disease, thrombocytopenia; antiphospholipid syndrome; previous therapy with clopidogrel or corticosteroids; the rupture of a prior tumour. At birth, the most suggestive features are abdominal palpable mass, anemia, and persistent jaundice. Adrenal insufficiency may be found especially in premature delivery. The hemorrhage is mostly self-limiting. Antenatal ultrasound diagnosis of a cyst does not always predict the exact pathology result. The most important differential diagnosis of adrenal hemorrhage/hemorrhagic cyst is cystic neuroblastoma which is highly suggestive in the presence of distant metastases and abnormal catecholamine profile. The major clue to differentiate the two conditions is the fact that the tumor is stable or increases over time while the adrenal hemorrhage is expected to remit within one to two weeks.

CONCLUSION

Pediatric adrenal cysts vary from simple cysts with a benign behavior to neoplasia- related lesions displaying severe prognosis as seen in cystic neuroblastoma. A multidisciplinary team is required for their management which is conservative as close follow-up or it makes necessary different surgical procedures in cases with large masses or if a malignancy suspicion is presented. Recently, laparoscopic approach is regarded as a safe procedure by some authors but generally, open surgery is more frequent used compare to adults; in most cases the preservation of normal gland is advisable.

Contraindications and image-defined risk factors in laparoscopic resection of abdominal neuroblastoma

PURPOSE

Minimally invasive surgery (MIS) has become widely accepted as a technique for abdominal neuroblastoma resection. However, the indications for MIS are still controversial. The aim of this study was to evaluate image-defined risk factors (IDRFs), complications, and oncologic outcomes in patients with abdominal neuroblastomas treated with MIS.

METHODS

Between August 1998 and February 2016, MIS was planned for 20 children with abdominal neuroblastomas. Clinical data were retrospectively reviewed and compared between the IDRF-negative and IDRF-positive patients.

RESULTS

On the basis of the latest IDRF guidelines, five patients were classified as IDRF-positive and four of them had operative complications; namely, partial infarction of the ipsilateral kidney or open conversion. Concerning the two patients who needed open conversion, the primary reason for open conversion was difficulty in dissection of the tumor from the vena cava. Preoperative images of these cases showed either deformation or subtotal encasement of the vena cava. Relapse occurred in three high-risk patients and in none of the low/intermediate-risk patients. No complication occurred in the IDRF-negative cases.

CONCLUSIONS

IDRF-negative might be a good indication for MIS for abdominal neuroblastoma. However, deformation or subtotal encasement of the vena cava should be considered as IDRF-positive for MIS.

Transperitoneal laparoscopic adrenalectomy in children

Purpose:

The use of a minimally invasive approach for adrenalectomy is poorly defined in pediatric patients, although laparoscopic adrenalectomy is considered a standard procedure in adults. The aim of our study was to describe the safety and feasibility of minimally invasive adrenalectomy in children on the basis of surgical skills and results.

Materials and Methods:

This was a retrospective study of 4 pediatric laparoscopic adrenalectomies performed at our center between 2009 and 2012. All patients underwent transperitoneal lateral laparoscopic adrenalectomies (2 right and 2 left adrenalectomies).

Results:

Four laparoscopic adrenalectomies were performed. Indications for surgery were neuroblastoma in 2 patients, secernent adrenocortical tumor in 1 patient, and adrenocortical nodular hyperplasia in 1 patient. Patients had a mean age of 87 months (range, 17–156 months) at diagnosis, and the average lesion size was 3.23 cm (range, 0.7–6.4 cm). All laparoscopic adrenalectomies were successful, no conversions to open surgery were required, and no postoperative complications or deaths occurred. The average operating time was 105 minutes (range, 80–130 minutes), blood loss during surgery was minimal, and the mean postoperative hospital stay was 3.75 days (range, 3–5 days). None of the patients showed signs of recurring disease at 15-month follow-up.

Conclusions:

Laparoscopic adrenalectomy is a safe, feasible, and reproducible technique offering numerous advantages, including shortening of operating times and postoperative hospital stays, as well as reduction of blood loss and complications. It also provides good visibility and easy access to other organs.

The role of minimally invasive surgery in pediatric solid tumors

During recent years, minimally invasive surgery (MIS) has become the standard approach for various operations in infants and children. MIS in pediatric thoracic and abdominal tumors is a controversial approach in the surgical management of childhood cancer. Meanwhile, more and more oncological biopsies and resections are being performed laparoscopically or thoracoscopically. Despite its increasing role in pediatric tumor surgery, the different national and international multicenter trial groups have not yet implemented MIS within guidelines and recommendations in most of the current treatment protocols. An increasing number of retrospective reports describes a potential role of MIS in the management of different pediatric oncological entities. Over the time, there has been a diverse development of this approach with regard to the different neoplasms. Nevertheless, there is a lack of prospective randomized trails assessing MIS. This still represents a requirement for evidence-based medicine and judging the advantages and disadvantages of this approach. The purpose of this state-of-the-art article is to review the current literature to describe the application of MIS in pediatric solid tumors.

Minimally invasive surgery in the management of abdominal tumors in children

The application of minimally invasive surgical techniques to pediatric abdominal tumors is a controversial application towards the surgical management of childhood cancer. Although general pediatric surgeons practice minimally invasive surgery techniques in a vast array of abdominal cases, its role in pediatric oncology is still developing, with no consensus in North America about its use for pediatric solid abdominal tumors. The purposes of this article are to review the current literature about the use of minimally invasive surgery in pediatric abdominal oncology and to examine established indications, procedures and technologic advances.

Laparoscopic resection of adrenal neuroblastoma without image-defined risk factors: a prospective study on 21 consecutive pediatric patients

BACKGROUND

Over the last 20 years MIS has progressively gained popularity in children with cancer. We therefore aimed at evaluating the safety of Minimally Invasive Surgery (MIS) resection in a series of children affected by adrenal neuroblastoma (NB) presenting without Image-Defined Risk Factors (IDRFs).

METHODS

An Institutional protocol for MIS resection of adrenal NB in pediatric patients without IDRFs has been applied since 2008. Absence of IDRFs represented the main indication for MIS in NB, regardless of tumor size. All pediatric patients who underwent MIS for NB between January 2008 and May 2013 were included. Specific technical considerations, demographic data, and outcome have been recorded.

RESULTS

Twenty-one patients underwent MIS resection for IDRFs-negative adrenal NB. Nine of these patients experienced preoperative downgrading of IDRFs after chemotherapy. Radiological median diameter of the mass was 30 mm (range 10-83 mm). Median operative time was 90 min. Median hospital stay was 4 days. All patients were treated successfully, without serious intraoperative complications. One mild intraoperative hemorrhage occurred and was treated without the need for conversion to open surgery nor blood transfusion was required. No postoperative complications, including port-site or peritoneal metastases were experienced.

CONCLUSIONS

This study demonstrated the safety and effectiveness of MIS for the resection of adrenal NB without IDRFs in children. Pediatric surgeons dedicated to oncology should be aware of this alternative approach to open resection.

Clinical outcomes in children with adrenal neuroblastoma undergoing open versus laparoscopic adrenalectomy

BACKGROUND

Laparoscopic resection of adrenal neuroblastoma has become a common alternative to open surgery. Prior reports have largely focused on short-term operative complications. This study compares long-term oncologic outcomes in children undergoing laparoscopic or open adrenalectomy for neuroblastoma.

METHODS

Seventy-nine patients at a single center met inclusion criteria for having adrenal neuroblastoma and undergoing operative resection. Patients were assigned to high or low/intermediate (L/I) risk groups based upon Children's Oncology Group (COG) trial enrollment. Criteria for laparoscopic resection were absence of vascular encasement and size ≤ 5 cm in greatest dimension. Comparison between open versus laparoscopic groups was performed by Wilcoxon ranked-sum and Fisher's exact test. Multivariate Cox proportional hazard models analyzed the primary outcomes of mortality and recurrence.

RESULTS

In the L/I risk category (N=30) there was one non-neuroblastoma related death in the open cohort. Six of 7 patients in the High risk Group who underwent laparoscopic resection had favorable outcomes. Only higher tumor stage (Hazard Ratio 8.455, P=0.01) and earlier tumor recurrence were associated with increased mortality (Hazards Ratio 0.932, P=0.0002). Among patients who met selection criteria for laparoscopic surgery there was no difference in mortality or recurrence rates between High risk and L/I risk.

CONCLUSIONS

Laparoscopic resection of adrenal neuroblastoma is feasible and can be performed with equivalent recurrence and mortality rates in L/I risk patients and selected High risk patients. These data suggest that laparoscopic resection of adrenal neuroblastoma should be considered in patients who meet selection criteria, irrespective of risk group categorization.

Laparoscopic adrenalectomy in children

PURPOSE

Reporting on the laparoscopic technique for adrenal disease in children and adolescents has been limited. We review here our experience with laparoscopic adrenal surgery in children.

PATIENTS AND METHODS

19 laparoscopic unilateral adrenalectomies were performed in 10 girls and 7 boys (mean age 3.9 years) during 1998-2011. The clinical diagnosis before surgery was virilizing tumor (n = 8), pheochromocytoma (n = 3), nonfunctioning solid adrenal tumor (n = 3), mixed adrenocortical tumor (n = 2), cystic adrenal mass (n = 1). Unilateral adrenal lesions were 20-65 mm at the longest axis on computerized tomography (12 right side, 7 left side).

RESULTS

The final clinicopathological diagnosis was cortical adenoma (n = 9), pheochromocytoma (n = 3, bilateral in two), neuroblastoma (n = 1), ganglioneuroblastoma (n = 1), ganglioneuroma (n = 1), adrenocortical carcinoma (n = 1), benign adrenal tissue (n = 1). Average operative time was 138.5 min (range 95-270). Blood transfusion was required in one case (5%). No conversion to open surgery was required and no deaths or postoperative complications occurred. Average hospital stay was 3.5 days (range 2-15). Average postoperative follow-up was 81 months (range 2-144). Two contralateral metachronic pheochromocytomas associated with von Hippel-Lindau syndrome occurred, treated with partial laparoscopic adrenalectomy (one without postoperative need of cortisone replacement therapy).

CONCLUSIONS

Laparoscopic adrenalectomy is a feasible procedure that produces good results. It can be used safely to treat suspected benign and malignant adrenal masses in children with minimal morbidity and short hospital stay.

Adrenocortical tumors in children 18 years old and younger

Purpose

Pediatric adrenocortical tumors (ACTs) are rare. We reviewed findings in 8 children, 18 years of age or younger, diagnosed with ACT in our institution over the past 15 years.

Methods

We retrospectively reviewed 8 children with ACTs treated between 1996 and 2010.

Results

Three girls and 5 boys were treated for ACTs; their median age at presentation was 144 months (range, 28 months to 18 years). Seven patients showed signs of endocrine dysfunction, 4 with Cushing syndrome, 2 with virilization, and 1 with hyperaldosteronism. One patient, with symptoms of hematuria, underwent a computed tomography scan, which showed an adrenal mass. The median duration of symptoms prior to resection was 6 months (range, 1 to 24 months). Five patients had adenomas and 3 had carcinomas. All underwent complete resection of the tumor, with laparoscopic adrenalectomy performed on 3 patients with adenoma and 1 with carcinoma. The median tumor weight was 12.5 g (range, 1 to 130 g) and the median tumor volume was 18.3 cm³ (range, 2.2 to 299.2 cm³). At a median follow-up of 5.1 years (range, 4 months to 15 years), all 8 patients remain alive with no recurrence of disease.

Conclusion

The characteristics of pediatric ACTs vary considerably. Laboratory findings, clinical hormonal features, and tumor size could not distinguish adenomas from carcinomas before surgery. Complete tumor resection was successful, with no tumor recurrence. However, the small number of patients and short follow-up period limit assessments of prognosis.

Minimally invasive adrenalectomy in children

PURPOSE

Minimally invasive adrenalectomy (MIA) is the criterion standard for removal of small adrenal tumors in adults. The purpose of this review was to determine the place of MIA in children.

METHODS

The authors conducted a systematic review of the pediatric and adult literature about MIA, focusing on the technique and indications.

RESULTS

Minimally invasive adrenalectomy appears superior to open adrenalectomy for small tumors. The potential advantages of MIA are appealing for postoperative pain, risk of intestinal obstruction, and quality of scars. The most common approach is the transperitoneal lateral laparoscopy, which allows for a large working space. For small tumors or for bilateral adrenalectomy, the prone retroperitoneoscopy is a promising new technique. In children, the learning curve is an issue because the indications are rare. The most common indication is neuroblastoma without image-defined surgical risk factors. The incidence of local recurrence is low, but the follow-up is short in most cases.

CONCLUSIONS

Minimally invasive adrenalectomy is promising for removal of small adrenal tumors. Long-term follow-up is required to evaluate the efficacy of MIA in neuroblastomas. Benign diseases are excellent candidates for this minimally invasive technique.

Laparoscopic adrenal surgery in children: Lessons from a single centre experience

PURPOSE:

Although commonly performed in adults, laparoscopic adrenalectomy in children is performed only in centres with advanced laparoscopic expertise.

MATERIALS AND METHODS:

This is a retrospective analysis of laparoscopic adrenalectomies performed at a single centre between January 2003 and May 2010. After preoperative evaluation with biochemical assays and radiologic imaging, surgery was performed by using the lateral transabdominal approach in all patients.

RESULTS:

Ten laparoscopic adrenalectomies (including three bilateral) were performed in seven children, with a mean age of 9.6 years. The tumours ranged from 2 – 7 cms in size. The operative durations were 75 – 130 minutes (unilateral) and 250 – 270 minutes (bilateral). Operative blood loss was minimal. There were no open conversions, but terminal hand assistance was required in one large right pheochromocytoma. The postoperative hospital stay ranged from 3 – 10 days. The final pathological diagnoses included pheochromocytoma, hyperplasia and neuroblastoma. Follow-up at 24 – 87 months was uneventful.

CONCLUSION:

With adequate experience in laparoscopy, it is possible to perform adrenalectomy in selected children.

Surgical analysis of pediatric and adolescent sporadic pheochromocytoma: single center experience

INTRODUCTION

The aim of this study is to review our experience with sporadic pheochromocytoma in pediatrics and adolescents focusing upon surgical approach, incidence of malignancy, and recurrence rate.

MATERIALS AND METHODS

Between 1990 and 2007, 8 pediatric patients were diagnosed with sporadic pheochromocytoma. Demographic data, clinical and radiological findings, laboratory profile, preoperative preparation, surgical approach, operative findings, postoperative course as well as pathologic diagnosis of the removed specimen were reviewed.

RESULTS

Mean age of presentation was 13.1 ± 4.7 years. Five patients had right-sided masses, 1 harbored left-sided mass, and bilaterality was observed in 2 with mean size of 5.7 ± 1.3 cm. Computed tomography showed no evidence of local infiltration, regional lymphadenopathy or distant metastasis in all patients but two. Six masses were excised through thoraco-abdominal approach, 3 were removed laparoscopically, while percutaneous alcohol ablation was adopted for the last. We had one postoperative death (12.5%:1/8), and the remaining 7 patients were followed for a mean of 8.6 ± 3 years. Five patients never had recurrence. Bilateral recurrence developed in 2 patients, where they were safely excised in one patient and was a part of disseminated disease in the other. Malignant nature of the disease was proved in 2 patients and showed poor survival.

CONCLUSION

Under adequate anesthetic control, pediatric pheochromocytoma could be safely managed through both the open and laparoscopic approaches. Advanced radiological stage would suggest the malignant nature of the disease with dismal outcome. Long-term follow-up is warranted for possibility of delayed curable recurrence.

Bilateral simultaneous laparoscopic adrenalectomy for congenital adrenal hyperplasia: initial experience

OBJECTIVE

Congenital adrenal hyperplasia (CAH) is an uncommon syndrome which represents a therapeutic challenge. We analyzed the role of bilateral simultaneous laparoscopic adrenalectomy in the management of CAH.

MATERIAL AND METHODS

: Between October 2004 and September 2006, three female patients underwent bilateral simultaneous laparoscopic adrenalectomy for CAH. Data were retrospectively collected. Variables analyzed were persistence of CAH clinical signs, variations in 17 OH progesterone level and corticoid medication, operative time, median blood loss, postoperative pain, hospital stay, and body image perception after surgery.

RESULTS

Median age was 16.3 years. Complete regression of virilization signs, acne and hyperpigmentation was achieved in one case. The other two cases showed partial regression of signs. Levels of 17 OH progesterone reached normal parameters in all cases. Steroids doses were lowered and given only for replacement purposes. Mean operative time was 125, 65 and 60min for whole, right and left procedure, respectively. Median blood loss remained under 50ml in all cases and there were no complications. Median postoperative pain level was 5 according to visual analog pain scale. Median hospital stay was 4 days.

CONCLUSION

Bilateral simultaneous laparoscopic adrenalectomy shows all the advantages of minimally invasive surgery, and appears a viable alternative to medical management, which is not exempt from complications.

Laparoscopic right adrenalectomy for a large ganglioneuroma in a 12-year-old

INTRODUCTION

Laparoscopic adrenalectomy is well established as the standard technique for all indications of adrenalectomy except adrenal carcinoma; however, some also consider large adrenal masses a relative contraindication. We present a video of a laparoscopic excision of a large ganglioneuroma and right adrenalectomy in a 12-year-old female.

METHODS

Our patient was noted to have a right suprarenal mass on a computed tomography scan following complaints of back and abdominal pain. Upon surgical consultation, she underwent a magnetic resonance imaging, which showed a 7.9 x 4.4 x 5.6 cm heterogeneously enhancing suprarenal lesion that was either arising from or compressing the right adrenal gland. The patient's preoperative work-up included normal urinary metanephrines, alpha-fetoprotein, and beta-HCG. After discussion with the patient and family, the decision was made to proceed with laparoscopic excision of the mass.

RESULTS

The patient underwent successful laparoscopic excision of the suprarenal mass and right adrenalectomy and was discharged from the hospital on postoperative day 2. During the procedure, retraction was achieved by using a combination of 5-mm grasping instruments, Endokittner dissectors (Ethicon Endosurgery Cincinnati, OH), and a suction irrigator to provide traction and counter traction. A flexible 5-mm liver retractor (Mediflex; Velmed, Inc., Wexford, PA) was placed directly through the abdominal wall without a trocar in order to elevate the liver from the area of the right adrenal and retroperitoneum. This enabled us to "rotate" the lesion out from behind the vena cava and from along the vertebral bodies. The pathology revealed an 8.5 x 7.0 x 3.0 cm ganglioneuroma, with primarily neural and Schwann cell-type tissue with interspersed large, prominent ganglion cells, and a normal adrenal gland.

CONCLUSIONS

As demonstrated by our video, large adrenal masses in the pediatric population can be successfully excised laparoscopically with appropriate surgeon comfort and experience.

IPEG guidelines for the surgical treatment of adrenal masses in children

Laparoscopic adrenalectomy and adrenal biopsy are technically feasible in children. There are no absolute contraindications to the laparoscopic approach, but for neuroblastomas and other adrenal neoplasms, care must be taken to maintain the principles of cancer surgery. As opposed to adults, there are fewer benign indications for adrenalectomy, but in selected cases, laparoscopic resection of the adrenal is feasible. Both laparoscopic and retroperitoneoscopic approaches are recommended, with the choice being dictated by the experience of the surgeon. Recommendations throughout this guideline are based on class 3 evidence, with a single article demonstrating class 2 evidence, based on a retrospective comparison.

Case selection in minimally invasive surgical treatment of neuroblastoma

PURPOSE

The experience with minimally invasive surgery (MIS) in the treatment of neuroblastoma (NB) is anecdotal. The purpose of this study was to evaluate a retrospective cohort of NB patients who underwent MIS resection of their primary tumors.

METHODS

A retrospective study of NB patients who underwent MIS resection of their primary tumors over a 3-year period was undertaken. Study outcomes included complications, completeness of resection, and event-free and overall short-term survival.

RESULTS

Of a total of 21 children who underwent surgical resection for NB during the period of study, 8 (38%) underwent selected MIS resection. Six of the eight (75%) tumors were adrenal in origin and the remainder were located in the posterior mediastinum. Distribution by International Neuroblastoma Staging System (INSS) stage was: stage 1 (3), stage 2 (2), and stage 4 (3). One stage 4 tumor was N-myc amplified. All stage 4 patients experienced a >50% tumor volume cytoreduction in response to preoperative chemotherapy. All MIS resections were performed without need for blood transfusion, or conversion to open procedure, and there were no perioperative complications. All eight patients were alive and disease-free at a median 18-month follow-up.

CONCLUSIONS

With appropriate preoperative case selection based on anatomic features, MIS tumor resection in patients with NB can be performed safely and effectively.

Minimally invasive surgery

The field of Minimally Invasive Surgery or Minimally Access Surgery (MAS) as it is commonly known has grown remarkably over the past two decades. MAS has a steep learning curve and unexpected complications with MAS are not infrequent unless approached with great caution. However it leads to a shorter hospital stay, less analgesic use, rapid return to school and a better cosmetic outcome. MAS in children started in India a decade ago, and has a great impact on the way we manage pediatric surgical problems today. This article is a brief description of most of the procedures that are being done with the help of MAS. In addition to these, new techniques, procedures and innovations are always ongoing in this fast developing field. MAS is being practiced in limited centers in our country with expanding experience and indications. Its use in children as the first option for early appendicitis, intraabdominal testis, gall stone disease and a few other conditions is now proven beyond doubt. There are other indications and areas of application of MAS which are continuously evolving and needs institutional audit and validation at every step before moving to the next phase.

The laparoscopic approach of neuroblastoma

Neuroblastoma is one of the most common solid tumors, and the biopsy and excision of this tumor are often required as part of a planned multimodal treatment. In 1995, Holcomb and coworkers first reported endosurgical procedures for the diagnosis and treatment of pediatric malignancies; however, the usefulness of laparoscopic procedures for abdominal neuroblastoma is still unclear. Twenty-five laparoscopic biopsies for advanced abdominal neuroblastoma and nine laparoscopic excisions for localized abdominal neuroblastoma performed at Saitama Children's Medical Center were evaluated. The laparoscopic procedures significantly reduce the time to start postoperative feeding as well as the time to start postoperative chemotherapy and the duration of hospital stay. Also, the blood loss of laparoscopic excision of localized neuroblastoma was significantly little compared with that of open excision. Precise indications of laparoscopic procedure for the diagnosis and treatment of abdominal neuroblastoma provide better prognosis and quality of life for infants and children.

Laparoscopic resection of abdominal neuroblastoma

BACKGROUND

Since indications for laparoscopic adrenalectomy have progressively expanded to pediatric surgery, preliminary reports have studied the laparoscopic approach for abdominal neuroblastoma (NB). We aimed to report on the indications and the results of laparoscopic resection in a large series of abdominal NBs.

METHODS

A retrospective multicenter study included 45 children with abdominal NBs (28 localized, 11 stage 4, 6 stage 4s) and laparoscopic resection of their abdominal primary tumor. Primary site of the tumor was the adrenal gland in 41 cases and retroperitoneal space in 4. The median age at surgery was 12 months (1-122); median tumor size was 37 mm (12-70). Resection was performed through transperitoneal laparoscopy (n = 38) or retroperitoneoscopy (n = 7).

RESULTS

Complete macroscopic resection was achieved in 43 of 45 children (96%). The median duration of pneumoperitoneum was 70 min (30-160), and the length of hospital stay was 3 days (2-9). Four procedures (9%) were converted to open surgery, and tumor rupture occurred in three cases. Of the 28 children with localized disease, there was a 96% overall survival (OS) rate after a median follow-up of 28 months (4-94). There was one local relapse in this subgroup, with subsequent complete remission. For the entire 45-children cohort, four children died and three presented a recurrence resulting in OS, disease-free survival, and event-free survival rates of 84% +/- 8.1, 84% +/- 8.2, and 77% +/- 9.1 respectively.

CONCLUSION

Laparoscopic resection of abdominal primary allows effective local control of the disease in a wide range of clinical situations of neuroblastoma, with an acceptable morbidity.

Role of diagnostic and ablative minimally invasive surgery for pediatric malignancies

BACKGROUND

The use of minimally invasive surgery (MIS) in pediatric cancer is a matter of debate. The diagnostic and ablative roles of MIS were evaluated in a consecutive series of children with malignancies.

METHODS

A prospective study, including all patients, who underwent abdominal and thoracic surgery for confirmed or highly suspected pediatric cancer was performed from September, 2000, to December, 2005. An interdisciplinary panel approved the indication for minimally invasive or conventional surgery.

RESULTS

At a single institution, 301 operations were performed on 276 children with cancer. A minimally invasive approach was attempted in 90 of these patients (30%) and successfully employed in 69 (77%) of the operations. However, 21 operations (23%) were converted to an open approach. Regarding the abdominal operations attempted laparoscopically, 41 abdominal operations for biopsy or staging purposes were attempted laparoscopically (53%), but 6 were converted. In all, 139 abdominal resections were performed and 24 were attempted laparoscopically. Ten of these (42%) were converted. In 34 thoracic operations requiring biopsy, thoracoscopy was attempted in 14 (41%) and was successful in all but 1 (93%). Fifty-one thoracic tumors were resected and the thoracoscopic approach was attempted in 11 (22%) and successful in 7 (14%). Conversions from a minimally invasive operation to an open procedure occurred mainly due to limited visibility. Three bleeding complications occurred with 1 patient requiring a blood transfusion. In addition, 1 small bowel injury occurred with immediate laparoscopic closure. There were no port site recurrences after a median of 39 months.

CONCLUSIONS

MIS is a reliable diagnostic tool for pediatric abdominal and thoracic malignancy. The role of ablative MIS in pediatric cancer remains limited.

Adrenal surgery in the pediatric population

Adrenal tumors in children may be benign or malignant. In addition, both benign and malignant tumors may be hormonally active, leading to hypertension, metabolic crises, and endocrinopathies. These tumors may be found incidentally or secondary to signs and symptoms of the aforementioned disorders. Both a metabolic and a radiographic work-up are required before treatment of an adrenal tumor. The primary therapy for most adrenal lesions is surgical, though some are treated medically or require chemotherapy before excision. Laparoscopy has become the surgical approach of choice in both adult and pediatric patients with localized disease. Open surgical approaches remain necessary in patients with extensive locally invasive or metastatic disease.

Pediatric minimal-access surgery: update 2006

Pediatric patients continue to benefit from the advances made in minimal-access surgery. Improvements in techniques and tools have made minimal-access procedures increasingly available to children. Growing popularity of laparoscopy and thoracoscopy has resulted in greater numbers of patients available for outcomes analysis. Randomized, controlled studies have been difficult to perform because of parent, patient, and physician selection bias.

Malignant adrenal tumors

Adrenal tumors, apart from neuroblastoma, are relatively rare in infancy and childhood. Most adrenal lesions are benign, and both benign and malignant tumors may be hormonally active thus, making accurate preoperative diagnosis difficult. The two main malignant tumors are adrenocortical carcinoma and pheochromocytoma. In both tumors, it may be difficult to determine benign from malignant and the biologic behavior and degree of invasion may portend a more malignant course. Surgical excision is the primary therapy for both tumors, including excision of metastatic and recurrent tumor. An open procedure should be considered for invasive adrenocortical carcinoma and in pheochromocytomas in which preoperative imaging demonstrates metastatic nodal disease. A laparoscopic approach is preferred for lesions in which preoperative imaging demonstrates a localized lesion. Chemotherapy, although without proven efficacy, is utilized in some children with metastatic or unresectable disease.

Exposure to carbon dioxide and helium reduces in vitro proliferation of pediatric tumor cells

BACKGROUND

Minimally invasive techniques are increasingly applied to children with malignant tumors. We showed previously that CO(2) used for pneumoperitoneum modulates the function of macrophages and polymorphonuclear cells via direct effects and via acidification. Numerous in vitro and small animal model studies also confirmed an alteration of the behavior of several types of adult tumor cells by CO(2). The impact of CO(2) and other gases used for pneumoperitoneum on the behavior of various pediatric tumors has not yet been determined.

METHODS

Cell lines of neuroblastoma (IMR 32, SK-N-SH, Sy5y), lymphoma (Daudi), hepatoblastoma (Huh 6), hepatocellular carcinoma (Hep G2), and rhabdomyosarcoma (Te 671) were incubated for 2 h. Incubation was performed with 100% CO(2), 100% helium, and 5% CO(2) as control. Cell proliferation was determined by the MTT-assay [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] by actively growing cells to produce a blue formazan product. The MTT-assay was performed before, directly after incubation, and daily for 4 days. Vitality of the cells was determined by trypan blue. The extracellular pH during incubation was measured during gas exposition every 10 min using Bayer Rapid Lab 855.

RESULTS

CO(2) for 2 h significantly decreased the proliferation of neuroblastoma, lymphoma, hepatoblastoma, and hepatocellular carcinoma cells. This decrease persisted over 4 days in neuroblastoma, lymphoma, and hepatocellular carcinoma cells. The CO(2) had no impact on hepatoblastoma and rhabdomyosarcoma cells. Helium had a similar effect on neuroblastoma cells. After 4 days, a significant decrease of cell activity was found in two neuroblastoma cell lines and in hepatoblastoma cells. Helium had no effect on lymphoma and hepatocellular carcinoma cells. The extracellular pH was 6.2 during incubation with CO(2), and 7.6 during incubation with helium.

CONCLUSION

CO(2) and helium may affect the proliferation of some pediatric tumor cell lines in vitro. However, some of these effects and the impact on the extracellular pH are differential. The role of pH modulation, hypoxia and direct effects of gases remain to be investigated before a general recommendation on the use of minimally invasive techniques in pediatric oncology can be given.

Laparoscopic adrenalectomy and adrenal-preserving surgery

PURPOSE OF REVIEW

The aim of this paper is to define the current role of laparoscopy in the management of surgical adrenal diseases evaluating the surgical aspects, the indications and contraindications of laparoscopic adrenalectomy, focusing also on the most innovative tendencies in the laparoscopic adrenal-preserving surgery.

RECENT FINDINGS

Recent publications have described some interesting new indications that need to be confirmed by long-term follow up. The present review mainly focuses on defining the state of the art of current adrenal laparoscopic surgery.

SUMMARY

Laparoscopic adrenalectomy is becoming the 'platinum standard' for the treatment of the adrenal surgical diseases and it should be considered the treatment of choice for benign adrenal diseases. In cases of malignancy and conservative surgery, adrenalectomy appears to be very promising, although a longer follow up and further studies are still needed to accurately assess the role played by these procedures. Finally, who should do laparoscopic adrenalectomy? Every patient who requires the ablation of the adrenal should receive laparoscopic opportunity. And the surgeons? Only those with advanced laparoscopic skills and a good knowledge of adrenal anatomy and pathophysiology will obtain the same excellent results currently reported in the literature.