Predictive Factors for the Occurrence of Perioperative Complications in Pediatric Posterior Fossa Tumors

OBJECTIVE

Central nervous system tumors are the most common solid neoplasm in children, 60%-70% occurring in the posterior fossa. Surgery is the mainstay of treatment but surgery in the pediatric population is associated with a high risk of perioperative complications. We aimed at analyzing the perioperative complications after posterior fossa surgery in a pediatric population and identifying the associated risk factors.

METHODS

Retrospective study of all pediatric patients undergoing surgery for resection of a posterior fossa tumor between 1999 and 2019, at the University Hospital of Lausanne. Data were collected including age, clinical presentation, tumor localization, presence of preoperative hydrocephalus, timing of surgery, surgical approach, surgical team, extent of surgical resection, perisurgical complications, and histopathological diagnosis. Statistical analysis was performed to correlate the data with the risk of complications.

RESULTS

Sixty-seven patients were included. Perisurgical complications were identified in 39 patients (58.2%), of which 14 (35.9%) required corrective interventions. The perioperative mortality rate was zero. In the univariate analysis, surgery performed under emergency conditions, transvermian and telovelar approaches were statistically correlated with an increased rate of complications. Extent of resection, hydrocephalus, and Lansky index at presentation were not predictive of perioperative complications. Midline tumor, tumor volume >25 cm³, and surgery performed by a nonspecialized pediatric onconeurosurgeon were found to be independent risk factors in the multivariate analysis.

CONCLUSIONS

Surgery in the posterior fossa in the pediatric population harbors a high risk of complications. Identifying the variables contributing to these complications is important in order to improve surgical management of these patients.

Three-Dimensional Volumetric Assessment of Resected Gliomas Assisted by Horos Imaging Software: Video Case Series of Postoperative Tumor Analyses

Horos (LGPL 3.0; GNU Lesser General Public License, Version 3) is a free, open-source medical image viewer with a user-friendly interface and three-dimensional (3D) volumetric rendering capabilities. We present the use of Horos software as a postoperative tool for residual tumor volume analysis in children with high-grade gliomas (HGG). This is a case series of two pediatric patients with histologically confirmed high-grade gliomas who underwent tumor resection as definitive treatment from June 2011 to June 2019. Volumetric data and extent of resection were obtained via region of interest-based 3D analysis using Horos image-processing software. Horos software provides increased accuracy and confidence in determining the postoperative volume and is useful in assessing the impact of residual volume on outcomes in patients with high-grade gliomas. Horos software is a highly effective means of volumetric analysis for the postoperative analysis of residual volume after maximal safe resection of high-grade gliomas in pediatric patients.

NIMG-42. HOROS SOFTWARE FOR POSTOPERATIVE ANALYSIS OF PEDIATRIC HIGH-GRADE GLIOMAS

INTRODUCTION

Horos (LGPL 3.0) is a free, open source medical image viewer that has gained attention in the neurosurgical community because of the familiar OsiriX-based interface and its useful three-dimensional (3D) volumetric rendering capabilities. We present the use of Horos software as a postoperative tool for residual tumor volume analysis in children with high-grade gliomas.

METHODS

A retrospective study of 11 pediatric patients with histologically confirmed HGG underwent tumor resection (n=8) or biopsy (n=3) as definitive treatment from 6/2011 to 6/2019. Volumetric data and extent of resection were obtained via region of interest-based 3D analysis using Horos image-processing software. Age, initial tumor volume, extent of resection, and postoperative residual volume were assessed as predictors of overall survival or event free survival.

TECHNIQUE

Region of interest (ROI) segmentation was performed utilizing the “Closed Polygon Tool” to outline the tumor and the “Generate Missing ROIs” function to capture the entirety of the tumor within the MRI series. The “Computer Volume” function was used to render the 3D tumor volumes. The preoperative and postoperative tumor volumes were compared per patient to yield the percent extent of resection and residual volume.

RESULTS

The Horos software is a highly effective means of volumetric analysis for high-grade gliomas depicted in T1 and T2 MRI series. In our series, eight (73%) patients underwent tumor resection and three (27%) underwent biopsy. Patients who underwent resection were older than biopsy patients [12 (8-18) vs. 9 (8-21) years old]. Age, initial tumor volume, extent of resection, and postoperative residual volume were not significant predictors of overall survival or event free survival.

CONCLUSION

Horos software provides increased accuracy and confidence in determining post-operative volume and is useful in assessing the impact of residual volume on outcome after maximal safe resection in pediatric patients with high-grade gliomas.

Early Decompressive Craniectomy as Management for Severe Traumatic Brain Injury in the Pediatric Population: A Comprehensive Literature Review

BACKGROUND

Severe traumatic brain injuries (TBIs) are a principal cause of neurologic dysfunction and death in the pediatric population. After medical management, the second-tier treatment is decompressive craniectomy in cases of intractable intracranial pressure (ICP) elevation. This literature review offers evidence of early (within 24 hours) and ultraearly (6-12 hours) decompressive craniectomy as an effective form of management for severe TBI in the pediatric population.

METHODS

We conducted a literature review of articles published from 1996 to 2019 to elucidate neurologic outcomes after early decompressive craniectomy in pediatric patients who suffered a severe TBI. Time to decompressive craniectomy and neurologic outcomes were recorded and reported descriptively. Qualitative data describe clinically important correlations between pre- and postoperative ICP levels and improved postoperative neurologic outcomes.

RESULTS

Seventy-eight patients were included in this study. The median age of patients at diagnosis was 10 years of age (range, 1 months to 19 years). Median admission Glasgow Coma Scale score was 5 (range, 3-8). Time to decompressive craniectomy ranged from 1 to 24 hours. Median peak preoperative ICP was 40 (range, 3-90; n = 49). Median postoperative ICP was 20 (range, 0-80; n = 33). Median Glasgow Outcome Scale (GOS) score at discharge was 2 (range, 1-5; n = 11). Median GOS score at 3- and 6-month follow-up was 3 (range, 1-5; n = 11). Median GOS score at 7- to 23-month follow-up was 4 (range, 1-5; n = 29). Median GOS score at 24- to 83-month follow-up was 4 (range, 1-5; n = 31). Median modified Rankin Scale score at discharge was 3 (range, 2-4; n = 6). Median modified Rankin Scale score at 6- to 48-month follow-up was 2 (range, 0-3; n = 6). Median Rancho Los Amigos Scale (RLAS) score at discharge was 6 (range, 4-8; n = 5). Median RLAS score at 6-month follow-up was 10 (range, 8-10; n = 5).

CONCLUSIONS

Early (within 24 hours), with consideration of ultraearly (within 6-12 hours), decompressive craniectomy for severe TBI should be offered to pediatric patients in settings with refractory ICP elevation. Reduction of ICP allows for prompt disruption of pathophysiologic cascades and improved neurologic outcomes.

[Work-life balance : Thoughts of the Young Surgeon representatives of the German Surgical Society]

Work-life balance is a commonly used term that appears in different contexts and has a different meaning for many colleagues. Unfortunately, however, it is often used as a negative, simplified term to describe the assumed attitude of young surgeons towards work and a medical career, even though this is not universally applicable. As the representatives for Young Surgeons of the German Society of Surgery the aim of this article is to present our thoughts on the issue and associated problems and provide a differentiated outline for discussion.