Although several studies have been conducted on the role of surgery in localized neuroblastoma, the impact of surgical timing and extent of primary tumor resection on outcome in high-risk patients ...remains controversial.
Patients from the German neuroblastoma trial NB97 with localized neuroblastoma INSS stage 1-3 age > 18 months were included for retrospective analysis. Imaging reports were reviewed by two independent physicians for Image Defined Risk Factors (IDRF). Operation notes and corresponding imaging reports were analyzed for surgical radicality. The extent of tumor resection was classified as complete resection (95-100%), gross total resection (90-95%), incomplete resection (50-90%), and biopsy (<50%) and correlated with local control rate and outcome. Patients were stratified according to the International Neuroblastoma Risk Group (INRG) staging system. Survival curves were estimated according to the method of Kaplan and Meier and compared by the log-rank test.
A total of 179 patients were included in this study. 77 patients underwent more than one primary tumor operation. After best surgery, 68.7% of patients achieved complete resection of the primary tumor, 16.8% gross total resection, 14.0% incomplete surgery, and 0.5% biopsy only. The cumulative complication rate was 20.3% and the surgery associated mortality rate was 1.1%. Image defined risk factors (IDRF) predicted the extent of resection. Patients with complete resection had a better local-progression-free survival (LPFS), event-free survival (EFS) and OS (overall survival) than the other groups. Subgroup analyses showed better EFS, LPFS and OS for patients with complete resection in INRG high-risk patients. Multivariable analyses revealed resection (complete vs. other), and MYCN (non-amplified vs. amplified) as independent prognostic factors for EFS, LPFS and OS.
In patients with localized neuroblastoma age 18 months or older, especially in INRG high-risk patients harboring MYCN amplification, extended surgery of the primary tumor site improved local control rate and survival with an acceptable risk of complications.
The aim was to assess the results of primary anastomosis (PA) compared to enterostomy (ES) in infants with spontaneous intestinal perforation (SIP) and a weight below 1000 g. Between 2014 and 2016, ...enterostomy was routinely carried out on extremely low birth weight (ELBW) patients with SIP. From 2016 until 2019, all patients underwent anastomosis without stoma formation. We compared outcome and complications in both groups. Forty-two patients with a median gestational age of 24.3 weeks and a birth weight of 640 g with SIP were included. Thirty patients underwent PA; ES was performed in 12 patients. Overall in-hospital mortality was 11.9% (PA: 13.3%, ES: 8.3%). Reoperations due to complications became necessary in 10/30 patients with PA and 4/12 patients with ES. Length of stay was 110.5 days in the PA group and 124 days in the ES group. Median weight at discharge was higher in the PA group (PA: 2258 g, ES: 1880 g,
p
= .036).
Conclusion
: Primary anastomosis is a feasible treatment option for SIP in infants < 1000 g and may have a positive impact on weight gain and length of hospitalization. However, further studies on selection criteria for PA are necessary.
What is Known:
• Enterostomy (ES) and primary anastomosis (PA) are feasible treatment options in preterm infants with spontaneous intestinal perforation (SIP).
• Stomal complications or failure to thrive due to poor food utilization can pose significant problems.
What is New:
• Primary anastomosis in case of SIP is equal to enterostomy in terms of mortality and revision rate; however, length of stay and weight gain can be presumably positively influenced.
• Primary anastomosis is a valid treatment option even for patients weighing less than 1000 g.
Anorectal malformations (ARM) are common congenital anomalies seen throughout the world. Comparison of outcome data has been hindered because of confusion related to classification and asssessment ...systems.
The goals of the Krinkenbeck Conference on ARM was to develop standards for an International Classification of ARM based on a modification of fistula type and adding rare and regional variants, and design a system for comparable follow up studies.
Lesions were classified into major clinical groups based on the fistula location (perineal, recto-urethral, recto-vesical, vestibular), cloacal lesions, those with no fistula and anal stenosis. Rare and regional variants included pouch colon, rectal atresia or stenosis, rectovaginal fistula, H-fistula and others. Groups would be analyzed according to the type of procedure performed stratified for confounding associated conditions such as sacral anomalies and tethered cord. A standard method for postoperative assessment of continence was determined.
A new International diagnostic classification system, operative groupings and a method of postoperative assessment of continence was developed by consensus of a large contingent of participants experienced in the management of patients with ARM. These methods should allow for a common standardization of diagnosis and comparing postoperative results.
The presented study shows a new and innovative method to determine nasal asymmetries in a simple way in patients with cleft lip and palate (CLP) in order to plan corrective surgery.
86 non-syndromic ...patients with cleft lip and palate were divided into 2 groups: a) patients with unilateral cleft lip and palate b) patients with bilateral cleft lip and palate.
follow-up of hospital records of 86 patients aged 2–18 years.
Based on standardised photos of the nose from 3 different directions, the nose symmetry was assessed. A new digital measurement system was used, which is integrated into proven clinical programmes. These were compared with a control group. In addition, a mirror fog test and a standardised questionnaire were used.
The overall results showed a good symmetry of the nose postoperatively, as well as a high satisfaction of the patients and their parents. Profile and angle measurements showed a better result.
The presented measurement system and especially the Cleft Lip Component Symmetry Index (CLCSI) allows an individual and very effective assessment of the symmetry of the nose as well as a control of the growth in patients with CLP. The method is easy to apply in daily practice, even for untrained practitioners.
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Serious games enable the simulation of daily working practices and constitute a potential tool for teaching both declarative and procedural knowledge. The availability of educational serious games ...offering a high-fidelity, three-dimensional environment in combination with profound medical background is limited, and most published studies have assessed student satisfaction rather than learning outcome as a function of game use.
This study aimed to test the effect of a serious game simulating an emergency department ("EMERGE") on students' declarative and procedural knowledge, as well as their satisfaction with the serious game.
This nonrandomized trial was performed at the Department of General, Visceral and Cancer Surgery at University Hospital Cologne, Germany. A total of 140 medical students in the clinical part of their training (5th to 12th semester) self-selected to participate in this experimental study. Declarative knowledge (measured with 20 multiple choice questions) and procedural knowledge (measured with written questions derived from an Objective Structured Clinical Examination station) were assessed before and after working with EMERGE. Students' impression of the effectiveness and applicability of EMERGE were measured on a 6-point Likert scale.
A pretest-posttest comparison yielded a significant increase in declarative knowledge. The percentage of correct answers to multiple choice questions increased from before (mean 60.4, SD 16.6) to after (mean 76.0, SD 11.6) playing EMERGE (P<.001). The effect on declarative knowledge was larger in students in lower semesters than in students in higher semesters (P<.001). Additionally, students' overall impression of EMERGE was positive.
Students self-selecting to use a serious game in addition to formal teaching gain declarative and procedural knowledge.
The aim was to determine if peritoneal drainage (PD) is a suitable treatment for pneumoperitoneum in extremely low birth weight (ELBW) infants. A retrospective chart review of 42 ELBW infants with ...pneumoperitoneum at the University Hospital of Cologne between November 2014 and April 2017 was performed. Forty-two infants with a median birth weight of 645 g (interquartile range (IQR) 550, 806) and a median gestational age of 24.3 weeks (IQR 23.2, 25.6) were treated for pneumoperitoneum. Twenty-six (62%) received PD, and in ten (38%), the drain could be removed without further intervention. Infants in the PD group were of significantly lower birth weight (622g vs. 750 g), age (4.5 vs. 10.0 days), and weight at diagnosis (538 vs. 778 g). The mortality in the PD group was 15% at 90 days of life, but no patient deceased in the primary laparotomy group.
Conclusion
: We suggest PD with close evaluation of drainage and clinical course as an alternative treatment for pneumoperitoneum in ELBW infants allowing bridging the vulnerable first days of life until these infants are in a more stable condition. Despite not reaching statistical significance in our series, PD showed the trend towards higher mortality.
What is known:
•
Pneumoperitoneum is traditionally treated with laparotomy, but placement of peritoneal drainage (PD) is a valuable treatment option.
•
Previous randomized controlled trials have shown no significant differences in mortality for PD versus laparotomy.
What is new:
•
In our cohort, 38% of the infants with PD could be saved from secondary laparotomy, but in the PD group there was a trend towards higher mortality.
•
PD allows bridging the vulnerable first days of life until ELBW infants are in a more stable condition for possible laparotomy
In order to better and more objectively assess and compare the aesthetics of the lip, we offer an inovative, digital measurement method.
Patients were divided into 2 groups:
a) patients with ...unilateral CLP and
b) patients with bilateral CLP.
Based on standardised photos from 3 different directions, lip symmetry and aesthetics were assessed. A new digital measurement system was used, which was integrated into a proven clinical programme. Different symmetry indices were compared with a non-cleft control group. In addition, the function was investigated and a standardised questionnaire was used.
In total, 92 patients with operated CLP could be recruitetd and showed significant residual asymmetry compared to the control group with 49 patients. The results were more symmetrical in group b) than in group a). In contrast, scar width and scar aesthetics as well as orofacial function were better in group a). The preoperative cleft width showed a positive correlation with the postoperative scar width and scar aesthetics. Socioeconomic factors were not related to surgical outcome. Satisfaction of affected children and parents correlated with objectively assessed scar aesthetics and function. There was no correlation between satisfaction and symmetry or cleft width or scar width.
The presented measurement system can be used excellently and effectively in clinical routine, especially for the inexperienced examiner, for fast and yet detailed, objective recording of findings. The measurement results can be analyzed comparatively and interpreted predictively for diagnostics, planning and therapy.
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The impact of abdominal topography and surgical technique on resectability and local relapse pattern of relapsed abdominal high-risk neuroblastoma (R-HR-NB) is not clearly defined.
A sample of ...thirty-nine patients with R-HR-NB enrolled in the German neuroblastoma trials between 2001 and 2010 was analyzed retrospectively using surgical and imaging reports. We evaluated resectability and local relapse pattern within 6 standardized abdominal regions, impact of extent of the first resective surgery on overall survival (OS), and of number of operations and a higher cumulative surgical assessment score (C-SAS) on OS after the first event.
In the left upper abdomen, rates for tumor persistence and relapse were 45.9% and 13.5% and in the left lower abdomen 27.7% and 8.3%, respectively. OS in months did not differ between complete and incomplete first resections (median (interquartile range): 35 (45.6) vs. 40 (65.4), P=.649). Better OS after the first event was associated with repeated as compared to single surgery (47.7 (64.7) vs. 4.3 (12.5), P=.000), and with higher as compared to lower C-SAS (47.7 (64.3) vs. 7.6 (14.7), P=.002).
OS after relapse/progression was not dependent on the extent of first resection. The number of operations was associated with better outcome after event.
Treatment study.
LEVEL III Retrospective comparative study.
Esophageal atresia (EA) is often accompanied by tracheobronchial malformations leading to stridor, recurrent bronchitis, and occasionally to life-threatening obstructive apnea after surgical repair. ...The aim of this study was to identify the presence of tracheomalacia in patients with EA and tracheoesophageal fistula (TEF) pre- and postoperatively and to find endoscopic correlates leading to clinical airway symptoms.
In a cohort of 362 patients with EA-TEF who underwent 595 tracheoscopies at the Children's Hospital of Cologne between January 1983 and December 2002, impaired tracheal lumen, localization of TEF, tracheal pulsations, and corresponding clinical symptoms were retrospectively analyzed.
The incidence of tracheomalacia was higher in patients with EA and TEF (Gross B-D) compared with patients with EA alone (Gross A) and average tracheal collapse does not significantly change before and after surgical repair of the esophagus in all types. Patients with cyanosis while eating and obstructive apnea presented with an average tracheal collapse of 89%. The presence of respiratory symptoms such as cough, stridor, or bronchitis was not associated with a higher grade of tracheal collapse compared with patients without any airway symptoms (average tracheal collapse of 37% in symptomatic patients vs. 33% in nonsymptomatic patients).
Tracheomalacia tends to be present independently of surgical procedure. Tracheomalacia should be measured by tracheoscopy (in % of tracheal collapse). Patients with a tracheal collapse of >80%, a ventral pulsation, and obstructive apnea or cyanosis in combination, are at risk for life-threatening situations and further surgical treatment should be considered.
Arterial Hypertension in a 10-Year-Old Girl Meeser, Alina; Beck, Bodo B; Dübbers, Martin ...
American journal of kidney diseases,
03/2021, Volume:
77, Issue:
3
Journal Article
PDF
