Does preoperative calcium and 1, 25 OH vitamin D supplementation impact postoperative hypocalcemia and length of stay following pediatric thyroidectomy?

OBJECTIVE

To investigate whether perioperative calcium and 1,25 OH vitamin D supplementation (PCDS) influences the rates of postoperative hypocalcemia and length of stay (LOS) following pediatric thyroidectomy.

STUDY DESIGN

Retrospective Cohort Review.

SETTING

Tertiary children's hospital.

METHODS

94 patients who underwent completion or total thyroidectomy with or without concomitant neck dissection from 2010 to 2020 at a single institution were included. Patients with pre-existing hypocalcemia or preoperative vitamin D insufficiency were excluded. Rates of postoperative hypocalcemia and LOS were compared for patients receiving PCDS to those receiving no supplementation.

RESULTS

Thirty percent of patients with PCDS had documented postoperative hypocalcemia compared to 64% of patients without PCDS (p = 0.01). Patients with PCDS had a median LOS of 30 h compared to 36 h (p = 0.002). Multivariable analyses confirmed that patients with PCDS had lower odds of postoperative hypocalcemia (OR: 0.32, CI: 0.11, 0.89) and shorter LOS by 17 h (SE: 8, p = 0.04) after adjustment for confounders.

CONCLUSION

PCDS is associated with significantly lower risk of hypocalcemia and shorter LOS. Standardizing preoperative care for pediatric patients undergoing thyroidectomy may decrease variability and improve outcomes following surgery.

Intradural Pituitary Hemitransposition: Technical Note and Case Series Illustration

BACKGROUND AND OBJECTIVES

Lesions located in the retrosellar region, interpeduncular cistern, and petroclival region are among the most difficult to access in neurosurgery. Transcranial approaches are useful; however, the large distance between the surgeon and the lesion as well as the presence of major neurovascular structures surrounding the lesion may limit surgical exposure. A midline transsphenoidal route avoids transgression of the neurovascular plane and provides direct access to the interpeduncular cistern. To safely access the interpeduncular fossa, it requires mobilization of the pituitary gland. The pituitary hemitransposition technique permits mobilization of the gland, while preserving its venous drainage and arterial supply to the gland on one of its sides, preserving gland function. The authors aim to describe the intradural pituitary hemitransposition technique and to demonstrate its safe application for resection of skull base tumors in the retrosellar space.

METHODS

The authors describe the surgical technique and illustrate its application in 5 cases of different types of skull base tumors, including a video demonstrating all the steps to perform this approach. In addition, the authors discuss the advantages and limitations of this technique compared with other approaches to the retrosellar space.

RESULTS

The intradural pituitary hemitransposition technique was used to safely resect a chondrosarcoma, chordoma, craniopharyngioma, teratoma, and meningioma involving the parasellar and retrosellar spaces, while minimizing endocrine morbidity. We had one patient with mild, albeit permanent hyperprolactinemia and hypothyroidism after surgery. No other patients had permanent dysfunction related to surgery.

CONCLUSION

The endonasal endoscopic intradural pituitary hemitransposition approach is an effective technique for resection of lesions located within the retrosellar and petroclival regions, allowing adequate exposure while potentially optimizing the preservation of the pituitary function.

The development of a pediatric skull base team: how, where and why?

PURPOSE OF REVIEW

The purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.

RECENT FINDINGS

Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.

SUMMARY

The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.

Pediatric Endoscopic Endonasal Skull Base Surgery: A Retrospective Review Over 11 Years

OBJECTIVE

To show the safety and efficacy of the endoscopic endonasal approach (EEA) for skull base surgery in pediatric patients through descriptive analysis of cases over an 11-year period.

METHODS

The study comprised 94 patients undergoing EEA for skull base surgery, between January 2007 and June 2018, at 2 tertiary pediatric hospitals. Descriptive statistics are presented regarding the presentation, intraoperative details, and complications.

RESULTS

Over the study period, 130 surgeries were performed in 94 patients: 94 primary surgeries and 36 reoperations. The mean patient age was 13.8 years and 48.9% of patients were female. Presenting signs/symptoms included endocrinopathies (56.4%), vision abnormalities (37.2%), and cranial nerve deficits (20.2%). EEA alone was used in 95.7% of primary surgeries and 91.7% of reoperations. Diseases treated included craniopharyngioma (18.1%), pituitary adenoma (17.0%), Rathke cleft cyst (13.8%), chordoma (9.6%), osteosarcoma (5.3%), juvenile nasopharyngeal angiofibroma (4.3%), skull base fracture (4.3%), and encephalocele (3.2%). A lumbar drain was used in 20.2% of primary surgeries and 25% of reoperations. A nasoseptal flap was used in 36.2% of primary surgeries and 25% of reoperations. Postoperative complications included cerebrospinal fluid leak (12.8%), sinusitis (7.4%), bacterial meningitis (3.2%), and carotid artery injury in 1 reoperation.

CONCLUSIONS

EEA for anterior cranial base disease is safe and efficacious in pediatric patients and can be used to treat many of the rare and heterogenous diseases that arise in this anatomic location. Management strategies and rates of sinonasal and intracranial complications including cerebrospinal fluid leak rate are similar to those reported in adult cohorts.

Perceptions of telemedicine at a pediatric otolaryngology-head and neck surgery program

Objective

With few studies investigating the effectiveness of telemedicine (TM) in pediatric otolaryngology (ear, nose, and throat; ENT), its role in clinical practice is unclear. The objective of this study was to investigate provider perspectives regarding utility of TM in pediatric ENT practice.

Methods

A survey gauging the relative merits of TM visits for common pediatric ENT chief complaints and postoperative visits was distributed to all pediatric ENT providers at a tertiary care, free-standing children’s hospital. Respondents were asked to assess the effectiveness of TM visits compared with in-person visits for completing the following tasks: history collection, physical examination, medical decision-making, and patient counseling.

Results

Providers rated TM visits as less useful than in-person visits for completing the most predefined tasks but did identify advantages in history taking via TM for the majority of complaints. Compared with providers with ≥10 years of experience, those with <10 years of experience found TM to be more effective than the in-person appointment for making clinical decisions for patients presenting with recurrent/chronic pharyngitis, neck masses, and stridor/noisy breathing. Opinions regarding the utility of TM for postoperative visits were mixed, with adenoidectomy, tonsillectomy and superficial procedures being most frequently deemed appropriate for TM.

Conclusions

The introduction of TM to pediatric ENT faces limitations in detailed examination of areas not accessible without specialized instrumentation. Due to its strength in history taking, results suggest an asynchronous, ‘store and forward’ encounter followed by an in-person physical examination to confirm the diagnosis and treatment plan could be beneficial.

PMON324 Crooke Cell Corticotroph Adenoma: A rare but Real Possibility in Children

Background

Cushing disease (CD) is uncommon in the pediatric population and is usually caused by benign pituitary corticotroph microadenomas. In some adults with CD, Crooke cell adenoma (CCA), a more aggressive histologic variant of corticotroph adenomas, has been described. CCA has rarely been reported in children as the etiology of CD and its course is not well described.

Objectives

To report a pediatric case of CCA, the youngest to our knowledge

Case

An 11-year-old African American female presented to the endocrinology clinic with concerns for diabetes, excessive weight gain and linear growth arrest. Workup for possible etiology showed: midnight salivary cortisol 0.924 (normal < 0.112 µg/dL), ACTH 119(6-48 pg/mL), morning cortisol 8.5 (normal < 1.8 µg/dL) post 1 mg dexamethasone mg/dL, consistent with the diagnosis of CD. Magnetic resonance imaging (MRI) showed a 4 mm pituitary microadenoma in the left anterior side of the adenohypophysis for which she underwent endoscopic endonasal transsphenoidal resection. Histopathologic examination revealed pituitary adenomatous tissue consisting of a uniform population of basophilic cells with granular cytoplasm, arranged in trabeculae and small nests with bundles encircling the nuclei, findings pathognomonic of CCA. Given persistence of hypercortisolemia, another transsphenoidal gross total resection of residual adenomatous tissue was performed 4 months later. This led to resolution of CD as evidenced by weight loss and linear growth. Twelve months following the second surgery, the patient experienced rapid weight gain and a decelerated linear growth accompanied by pubertal arrest. Another pituitary MRI showed a recurrent left sided adenoma (8×8×7 mm). Biochemical investigation this time again showed elevated midnight salivary cortisol and 24- hour urine free cortisol (UFC). In addition, AM cortisol was unsuppressed following 1 mg overnight dexamethasone administration. In response, repeat transsphenoidal gross total resection was performed, however residual microscopic disease in the cavernous sinus wall was highly suspected intraoperatively. A spine MRI did not show disseminated disease. Despite this, hypercortisolemia persisted both clinically and biochemically. The patient subsequently underwent proton beam radiation therapy in combination with adjuvant adrenolytic therapy with mitotane. The patient responded to these interventions with normalization of 24-hour UFC, resumption of linear growth, and pubertal progression. The treatment course was complicated by the development of isolated TSH deficiency requiring thyroid hormone replacement.

Conclusion

CCA is an aggressive entity described in the adult literature as a cause of CD. The current report adds to the limited pediatric cases of this disease. CCA can be equally aggressive in children and refractory to surgical treatment. Here, we show that it may respond to proton beam radiation and adrenolytic therapy. Pediatric endocrinologists should be aware of the rare occurrence of CCA in children and tailor treatment accordingly using a multi-disciplinary approach.

Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Management of infected nasal dermoid cysts and sinuses

This study investigates outcomes of surgical management of pediatric patients with nasal dermoids with prior infection. A retrospective review at Nationwide Children’s Hospital, a large free-standing pediatric hospital in the Midwestern USA, was performed. Patients were identified by the Current Procedural Terminology codes 30124 (simple excision of dermoid cyst) and 30125 (complex excision of nasal dermoid cyst) from 2011 to 2016. Demographic, imaging data, surgical findings, microbiological data and recurrence rates were collected for these patients. Descriptive statistical investigation was performed. In total, 14 patients were identified, 4 of the 14 patients (28.5%) had recurrent infection and required additional surgery. Three of seven patients required incision and drainage prior to definitive excision. One of seven patients in the infected group had recurrence. Prior infection does not increase the recurrence rate and almost half of the patients required I&D prior to definitive management.

Diagnostic Accuracy of Midline Pediatric Neck Masses

Objective

To assess clinical evaluation, ultrasound, and previously published predictive score at preoperatively diagnosing midline neck masses and demographic or clinical associations that aid in differentiation of thyroglossal duct and dermoid cysts.

Study Design

Retrospective chart review.

Setting

Tertiary care children’s hospital.

Subjects

Patients <18 years undergoing primary midline neck mass surgery with histopathologic diagnosis of thyroglossal duct or dermoid cyst who had preoperative ultrasound performed were included.

Methods

An electronic medical record query generated 142 patients whose histopathologic diagnosis was thyroglossal duct cysts (TGDCs) or dermoid cysts (DCs). Charts were reviewed for demographic and clinical features. A radiologist blindly reviewed patients’ ultrasounds for SIST (septae + irregular walls + solid components = thyroglossal) score components. Each patient received 3 preoperative diagnoses: clinical, ultrasound, and SIST. Statistical analyses were conducted to determine association of demographic, clinical, or radiographic variables with diagnoses. Specificity, sensitivity, and predictive values were evaluated for each candidate diagnosis.

Results

There were 83 TGDCs and 59 DCs. Tenderness, infection history, depth relative to strap muscles, and SIST components were more common among TGDCs. Sensitivity and positive and negative predictive values surpassed 63% for each diagnostic modality. SIST score outperformed other diagnostic modalities with sensitivity, positive predictive value, and negative predictive value of 84%, 91%, and 81%, respectively. Clinical and ultrasound assessments were largely inconclusive for dermoid cysts, but SIST correctly identified 89% of DCs.

Conclusion

SIST score was the most accurate predictor of pediatric midline neck masses. Clinical and radiographic findings may help guide preoperative diagnosis, although further evaluation is required to develop more efficacious diagnostic tools.

Pediatric Cervical Lymphadenitis

Enlargement of the lymph nodes in the head and neck region is a common presenting symptom in the pediatric population as the upper aerodigestive tract is a common source of inoculation of many infectious agents. While infectious processes—both viral and bacterial and both acute and chronic—are the most likely etiology of enlargement of cervical lymph nodes, other potential causes including inflammatory conditions and malignancy should be considered in the evaluation of cervical adenopathy. In this article, the anatomy and physiology as well as pathophysiology of the head and neck lymphatic system will be reviewed as this relates to clinical presentation of cervical lymphadenitis. Also, the myriad causes for cervical adenopathy will be discussed with a comprehensive review of the epidemiology of infectious etiologies. An evidence-based framework for the diagnostic workup and therapeutic interventions available to appropriately manage infectious cervical lymphadenitis will be reviewed, and the complications that can result from failure to adequately diagnose and treat cervical lymphadenitis will be discussed.

Stationäre und ambulante Thromboembolieprophylaxe in der Chirurgie und der perioperativen Medizin

Präambel: Alle aufgeführten medizinischen Fachgesellschaften haben sich zusammengefunden, um die früheren verschiedenen Empfehlungen zur Thromboembolieprophylaxe zu aktualisieren und in einer gemeinsamen »Leitlinie zur stationären und ambulanten Thromboembolieprophylaxe in der perioperativen Medizin« zusammenzufassen. Dazu wurden in einem ersten Schritt durch eine Konsensuskonferenz mit nominalem Gruppenprozess die früheren Empfehlungen (Fassung vom Juni 2000) überarbeitet (S2-Leitlinie). Dies erschien notwendig, um neue Therapieprinzipien und neu zugelassene Medikamente zu berücksichtigen. Als nächster Schritt erfolgt die Weiterentwicklung der vorliegenden Leitlinie nach der Vorgaben der 3. Stufe der Leitlinienentwicklung der AWMF (S3-Leitlinie).

3D Volumetric Conformal Analysis of Vestibular Schwannomas

Objective: Compare 3D conformal volumetric analysis (3DCVA) versus traditional linear measurements on serial MRI imaging of vestibular schwannomas (VS) for determination and assessment of accurate tumor volume and growth rates.

Method: Retrospectively identified VS patients followed with serial 0.7-3.0 Tesla MRI were included. Maximal linear dimensions were obtained from gadolinium-contrasted T1 sequences from 3 serial MRI scans per RECIST guidelines. Volumetric analysis was performed with semiautomated 3DCVA. Annual tumor growth rate and percentage change were compared for linear and volumetric measurements.

Results: The average time span during which the serial MRI scans were obtained was 2.86 years in this initial retrospective analysis of 11 patients. The linear growth measurements averaged 0.5 mm/y, corresponding to a 6.4% average change per year. With 3DCVA the average tumor growth rate was 5mm3/y, corresponding to 3.7 mm/y growth in each dimension. There was an average increase in tumor volume of 29% per year with 3DCVA, compared with 6.4% with linear measurements. The difference in percentage change per year between methods was significant when compared with paired 2-tailed t-test ( P = .036).

Conclusion: VS assume complex configurations. In this initial retrospective study, linear measurements may underestimate true tumor growth compared to 3D conformal volumetric analysis. 3DCVA may provide a more robust tool in assessing tumor volume, growth rate, and volume change for a more accurate reflection of tumor progression compared to linear measurements.

Distal Revascularization and Interval Ligation (DRIL) Procedure for the Treatment of Ischemic Steal Syndrome after Arm Arteriovenous Fistula

The objective of this study was to investigate the efficacy of the distal-revascularization-interval ligation (DRIL) technique in alleviating symptoms of ischemic steal syndrome and in preserving hemodialysis access. A retrospective chart review was conducted of all patients receiving the DRIL procedure in a 3-year period. There were 38 DRIL bypass grafts identified in 35 patients, with 36 DRILs with follow-up adequate for analysis. Comparison of preoperative and postoperative digital pulse volume recording (PVR) data was made using the t-test. The majority of patients presented with multiple ischemic symptoms, most commonly coolness, pain, and paresthesias. Six patients presented with frank digital necrosis. The mean interval to DRIL was 4.9 months following fistula construction (range 0.1-24). In 66.7% of patients for whom complete follow-up data were available (24/36), all ischemic symptoms were alleviated by DRIL. Of the remaining 12 patients, 11 experienced partial symptom relief. One patient required digital amputation following DRIL. A comparison of pre- and post-DRIL PVRs illustrated a significant increase in these values following DRIL (P < 0.05). DRIL effectively eliminates ischemic symptoms in the majority of patients and produces a significant increase in flow to the ischemic limb. The data support the usage of DRIL as the procedure of choice in the correction of ischemic steal following arm arteriovenous fistula.

Onset of protection from experimental infection with type 2 bovine viral diarrhea virus following vaccination with a modified-live vaccine

The onset of protection after the administration of a modified-live bovine viral diarrhea virus (BVDV) vaccine was determined. Protection was determined following experimental infection with a virulent type-2 BVDV (strain 1373) in cattle vaccinated 3, 5, or 7 days before BVDV infection. Protection, as measured by reduced virus shedding, lack of leukopenia, reduction in viremia, and reduced mortality, was present as early as 3 days after vaccination with a single dose of modified-live BVDV vaccine. Complete protection was obtained in cattle vaccinated 5 or 7 days before BVDV experimental infection.

Partial excision of infected fistula results in increased patency at the cost of increased risk of recurrent infection

Reliable vascular access is often an issue of ongoing frustration for those requiring dialysis. Synthetic arteriovenous fistulae (SAVF) have been widely used to provide vascular access; however, the risk of infection at the SAVF site is significant, especially because the SAVF is potentially exposed to pathogens on a regular basis due to the cannulation required for dialysis. Between 11 and 35% of all SAVF become infected and require surgical removal. The purpose of this investigation was to: (1) compare the risk of recurrent infection with complete versus partial excision of the infected SAVF (ISAVF) and (2) explore the risks and benefits of attempting to preserve patency of noninfected portions of ISAVF. In a retrospective review to determine the risk of recurrent infection after removal of ISAVF, charts of 77 patients undergoing surgery for the removal of an ISAVF from the arm were identified with 84 instances of excision of an ISAVF. Of the 84 ISAVF, 26 (31 %) were treated with complete excision (CE), 30 (35.7%) grafts were partially excised with blood flow restoration through a new interposed PTFE segment (PERF), and 28 (33.3%) grafts were partially excised with no flow restoration (PENF), leaving portions that were not grossly infected. Fourteen of 30 (46.7%) PERF grafts, 4/28 (14.3%) PENF, and 0/26 CE grafts developed further infection at the excision site. These differences were significant when comparing PERF to CE (p < 0.001) and PERF to PENF (p < 0.025), but no significance was found when comparing CE to PENF. Patency was significantly greater for the PERF group at 1 and 2 years than for both CE (p < 0.001) and PENF (p < 0.001). In conclusion, the data suggest that restoring blood flow to the remainder of a partially excised ISAVF significantly increases patency without necessitating catherer placement and a new hemoaccess site, but at the cost of significantly increased risk of recurrent infection.

European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG)

Germ cell tumour is the most frequent malignant tumour type in young men with a 100% rise in the incidence every 20 years. Despite this, the high sensitivity of germ cell tumours to platinum-based chemotherapy, together with radiation and surgical measures, leads to the high cure rate of > or = 99% in early stages and 90%, 75-80% and 50% in advanced disease with 'good', 'intermediate' and 'poor' prognostic criteria (IGCCCG classification), respectively. The high cure rate in patients with limited metastatic disease allows the reduction of overall treatment load, and therefore less acute and long-term toxicity, e.g. organ sparing surgery for specific cases, reduced dose and treatment volume of irradiation or substitution of node dissection by surveillance or adjuvant chemotherapy according to the presence or absence of vascular invasion. Thus, different treatment options according to prognostic factors including histology, stage and patient factors and possibilities of the treating centre as well may be used to define the treatment strategy which is definitively chosen for an individual patient. However, this strategy of reduction of treatment load as well as the treatment itself require very high expertise of the treating physician with careful management and follow-up and thorough cooperation by the patient as well to maintain the high rate for cure. Treatment decisions must be based on the available evidence which has been the basis for this consensus guideline delivering a clear proposal for diagnostic and treatment measures in each stage of gonadal and extragonadal germ cell tumour and individual clinical situations. Since this guideline is based on the highest evidence level available today, a deviation from these proposals should be a rare and justified exception.

[Gemcitabine/cisplatin vs. MVAC. 5 year survival outcome of the phase III study of chemotherapy of advanced urothelial carcinoma in Germany]

Of 405 patients with stage IV transitional cell carcinoma from an international multicenter phase III trial, 70 were randomized in Germany to receive either gemcitabine/cisplatin or standard MVAC systemic chemotherapy for locally advanced or metastatic urothelial cancer. Overall survival as the primary endpoint of the study was similar in both arms (median survival GC 15.4 months vs MVAC 16.1 months), as were tumor-specific survival and time to progressive disease. In the intent-to-treat analysis, the 5-year overall survival rate was 10% for patients randomized to GC and 18% randomized to MVAC. Tumor overall response rates (GC 54%, MVAC 53%) were similar. The toxic death rate was 0% in the GC arm and 3% (one patient) in the MVAC arm. Significantly more GC than MVAC patients experienced grade 3/4 anemia (GC 52%, MVAC 20%) with significantly more red blood cell transfusions in the GC arm.Significantly more GC than MVAC patients had grade 3/4 thrombocytopenia (GC 54%, MVAC 17%) without grade 3/4 hemorrhage or hematuria in either arm. More MVAC patients experienced grade 3/4 neutropenia (GC 56%, MVAC 61%, p=1.000), neutropenic or leukopenic fever (GC 0%, MVAC 10%, p=0.237), mucositis (GC 0%, MVAC 7%, p=0.495), and alopecia (GC 6%, MVAC 36%, p=0.004). GC represents a reasonable alternative for the palliative treatment of patients with locally advanced and metastatic transitional cell carcinoma. Sustained long-term survival was only found for patients with locally advanced cancer, lymphatic metastases, or solitary distant metastasis but not for visceral metastatic disease.

Sonographic biometry in obstructive uropathy of children: preoperative diagnosis and postoperative monitoring

Renal sonography was performed in 92 children with obstructive uropathy or vesicoureteral reflux preoperatively and at follow-up. Renal volume and the anteroposterior diameter of the renal pelvis proved to be the most reliable morphometric criteria for objective sonographic staging and follow-up of urinary tract obstruction. If transient obstruction occurred after uncomplicated antireflux ureterovesico-plasties (n = 41), it lasted at most 4 weeks. Kidneys with transient postoperative ureterovesical junction obstruction (n = 21) reverted to normal sonographic pattern within 4 weeks following ureteral reimplantation. In cases of ureteropelvic junction obstruction (n = 30), it took up to 6 months for the majority of kidneys to present almost normal sonographic findings. Sonographic biometry and the knowledge about the uncomplicated postoperative course render postsurgical monitoring easier and more reliable.