1
|
Huerta CT, Beres AL, Englum BR, Gonzalez K, Levene T, Wakeman D, Yousef Y, Gulack BC, Chang HL, Christison-Lagay ER, Ham PB, Mansfield SA, Kulaylat AN, Lucas DJ, Rentea RM, Pennell CP, Sulkowski JP, Russell KW, Ricca RL, Kelley-Quon LI, Tashiro J, Rialon KL. Management and Outcomes of Pediatric Lymphatic Malformations: A Systematic Review From the APSA Outcomes and Evidence-Based Practice Committee. J Pediatr Surg 2024:S0022-3468(24)00349-X. [PMID: 38914511 DOI: 10.1016/j.jpedsurg.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/25/2024] [Accepted: 05/29/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Significant variation in management strategies for lymphatic malformations (LMs) in children persists. The goal of this systematic review is to summarize outcomes for medical therapy, sclerotherapy, and surgery, and to provide evidence-based recommendations regarding the treatment. METHODS Three questions regarding LM management were generated according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Publicly available databases were queried to identify articles published from January 1, 1990, to December 31, 2021. A consensus statement of recommendations was generated in response to each question. RESULTS The initial search identified 9326 abstracts, each reviewed by two authors. A total of 600 abstracts met selection criteria for full manuscript review with 202 subsequently utilized for extraction of data. Medical therapy, such as sirolimus, can be used as an adjunct with percutaneous treatments or surgery, or for extensive LM. Sclerotherapy can achieve partial or complete response in over 90% of patients and is most effective for macrocystic lesions. Depending on the size, extent, and location of the malformation, surgery can be considered. CONCLUSION Evidence supporting best practices for the safety and effectiveness of management for LMs is currently of moderate quality. Many patients benefit from multi-modal treatment determined by the extent and type of LM. A multidisciplinary approach is recommended to determine the optimal individualized treatment for each patient. LEVEL OF EVIDENCE: 4
Collapse
Affiliation(s)
| | - Alana L Beres
- Division of Pediatric General and Thoracic Surgery, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Brian R Englum
- Division of Pediatric Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Katherine Gonzalez
- Division of Pediatric Surgery, St. Luke's Children's Hospital, Boise, ID, USA
| | - Tamar Levene
- Division of Pediatric Surgery, Joe DiMaggio Children's Hospital, Hollywood, FL, USA
| | - Derek Wakeman
- Division of Pediatric Surgery, University of Rochester, Rochester, NY, USA
| | - Yasmine Yousef
- Division of Pediatric Surgery, Joe DiMaggio Children's Hospital, Hollywood, FL, USA
| | - Brian C Gulack
- Division of Pediatric Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Henry L Chang
- Department of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | | | - Phillip Benson Ham
- Division of Pediatric Surgery, John R. Oishei Children's Hospital, University at Buffalo, Buffalo, NY, USA
| | - Sara A Mansfield
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Afif N Kulaylat
- Division on Pediatric Surgery, Penn State Children's Hospital, Hershey, PA, USA
| | - Donald J Lucas
- Division of Pediatric Surgery, Naval Medical Center San Diego, CA, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Rebecca M Rentea
- Division of Pediatric Surgery, Children's Mercy- Kansas City, Kansas City, MO, USA; Department of Surgery, University of Missouri- Kansas City, Kansas City, MO, USA
| | | | - Jason P Sulkowski
- Division of Pediatric Surgery, Children's Hospital of Richmond, Richmond, VA, USA
| | - Katie W Russell
- Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, USA
| | - Robert L Ricca
- Division of Pediatric Surgery, University of South Carolina, Greenville, SC, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Jun Tashiro
- Division of Pediatric Surgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, NY, USA
| | - Kristy L Rialon
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
| |
Collapse
|
2
|
Hyvönen H, Aronniemi J, Salminen P, Kyrklund K. Operative Management of Intra-abdominal Lymphatic Malformations in Children: A Single Tertiary Center Experience. J Pediatr Surg 2024:S0022-3468(24)00313-0. [PMID: 38890018 DOI: 10.1016/j.jpedsurg.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 04/26/2024] [Accepted: 05/15/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Intra-abdominal lymphatic malformations (LMs) are relatively rare congenital anomalies and can be divided into intra- and retroperitoneal subgroups. This study aims to evaluate the outcomes after surgical resection of intraperitoneal LMs in children. METHODS The records of all patients ≤16 years of age with intraperitoneal LMs managed at our tertiary center between 2007-2022 were reviewed. Patients with retroperitoneal LMs were excluded. Our preferred approach is surgical exploration for large (>5 cm), symptomatic lesions if they are potentially resectable on imaging. RESULTS A total of 12 patients (10 males) were diagnosed with intraperitoneal LMs located in the small bowel mesentery or omentum at a median age of 6.6 (range, 0.6-14.4) years. Ten (83%) patients presented with acute symptoms, including abdominal pain (n = 8; 67%) and vomiting (n = 3; 25%). Two (17%) intraperitoneal LMs were found on imaging performed for other reasons. Surgical exploration was performed in 11/12 (92%) cases. Intestinal volvulus around a mesenteric macrocyst had occurred in 4 (36%) patients. Complete macroscopic resection was achieved in 10/11 (91%) patients. Most lesions were localized to a short intestinal segment. One mixed type LM with an extensive mesenteric involvement was biopsied as the lesion was deemed to be unresectable in preoperative imaging and the diagnosis was initially unclear. There was one recurrence (8%) during postoperative follow-up on imaging (median 3.6 (range, 1.5-6.9) years) but the patient has remained asymptomatic and not undergone interventions. 6/8 (75%) of screened intraperitoneal LMs were positive for a somatic PIK3CA mutation. CONCLUSIONS Most large, pedunculated macrocystic LMs in the small bowel mesentery or omental location were amenable to macroscopic resection. Intraperitoneal LMs tend to present with acute symptoms including a risk for intestinal volvulus based on anatomical location. Our results suggest low recurrence rates or need for further interventions over follow-up. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Hanna Hyvönen
- New Children's Hospital, Department of Pediatric Surgery, Helsinki University Hospital and University of Helsinki, P.O. Box 347 (Stenbäckinkatu 9), 00029 HUS, Helsinki, Finland.
| | - Johanna Aronniemi
- HUS Diagnostic Center, Department of Radiology, New Children's Hospital, Helsinki University Hospital and University of Helsinki, P.O. Box 347 (Stenbäckinkatu 9), 00029 HUS, Helsinki, Finland
| | - Päivi Salminen
- New Children's Hospital, Department of Pediatric Surgery, Helsinki University Hospital and University of Helsinki, P.O. Box 347 (Stenbäckinkatu 9), 00029 HUS, Helsinki, Finland; Rare Disease Centre, Department of Pediatric Surgery, Helsinki University Hospital and University of Helsinki, Finland; VASCERN VASCA European Reference Centre, P.O. Box 347 (Stenbäckinkatu 9), 00029 HUS, Helsinki, Finland
| | - Kristiina Kyrklund
- New Children's Hospital, Department of Pediatric Surgery, Helsinki University Hospital and University of Helsinki, P.O. Box 347 (Stenbäckinkatu 9), 00029 HUS, Helsinki, Finland; Rare Disease Centre, Department of Pediatric Surgery, Helsinki University Hospital and University of Helsinki, Finland; VASCERN VASCA European Reference Centre, P.O. Box 347 (Stenbäckinkatu 9), 00029 HUS, Helsinki, Finland
| |
Collapse
|
3
|
Yan J, Fu Y, Liu S, Bai Y, Chen Y. Mesenteric and omental lymphatic malformations in children: seven-year surgical experience from two centers in China. BMC Pediatr 2024; 24:360. [PMID: 38783260 PMCID: PMC11112925 DOI: 10.1186/s12887-024-04808-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 05/02/2024] [Indexed: 05/25/2024] Open
Abstract
PURPOSE To compare the clinical characteristics, surgical management and prognosis of mesenteric lymphatic malformations (ML) and omental lymphatic malformations (OL) in children. METHODS This retrospective study included 148 ML patients and 53 OL patients who underwent surgical treatment at two centers between January 2016 and December 2022. Details about the patients' clinical characteristics, cyst characteristics, preoperative complications, surgical methods, and prognosis were retrieved and compared. RESULTS No significant differences in sex ratio, prenatal diagnosis, or age of diagnosis were noted between ML and OL patients. Vomiting was more common in ML patients than in OL patients (46.6% vs. 22.6%, P = 0.002), but OL patients were more likely to be misdiagnosed (35.8% vs. 18.9%, P = 0.012). The size of the cysts in OL patients was significantly larger than that in ML patients (14.0 [4.0-30.0] vs. 10.0 [2.0-50.0] cm, P<0.001), and cysts with turbid fluid were more common in OL patients (38.0% vs. 20.6%, P<0.001). More OL patients than ML patients had preoperative hemorrhage or infection of cysts (41.5% vs. 31.8%, P<0.016). Cyst excision was performed in 137 (92.6%) ML patients and 51 (96.2%) OL patients, and the incidence of postoperative complications was lower (12.6% vs. 4.2%, P = 0.165) among OL patients. The main postoperative complications included adhesive ileus and recurrence of cysts. Additionally, more OL patients than ML patients were treated with laparoscopic surgery (69.8% vs. 39.2%, P<0.001). CONCLUSIONS There were differences in clinical characteristics, cyst characteristics and preoperative complications between ML and OL patients. Cyst excision was the most common surgical method that was used to treat both ML and OL patients, and laparoscopic surgery could be a feasible surgical approach for treating OL patients with a good prognosis. TRIAL REGISTRATION Retrospectively registered.
Collapse
Affiliation(s)
- Jiayu Yan
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Yao Fu
- School of Public Health, China Medical University, Shenyang, 110122, China
| | - Shuting Liu
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Yuzuo Bai
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Shenyang, 110004, China.
| | - Yajun Chen
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.
| |
Collapse
|
4
|
Mehl SC, Kinley A, Todd HF, Mir DI, Iacobas I, Pezeshkmehr A, Mahajan P, Rialon KL. Institutional Management of Abdominal Lymphatic Malformations: Evolution of Treatment Over a Decade. J Surg Res 2022; 280:296-303. [PMID: 36030605 DOI: 10.1016/j.jss.2022.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/15/2022] [Accepted: 07/27/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Abdominal lymphatic malformations (LM) have been historically managed with surgical resection; however, sclerotherapy and sirolimus have emerged as effective therapies. The purpose of our study is to evaluate our institutional change in management and outcomes for abdominal LM over the past decade. METHODS A retrospective cohort study was performed for all children with an abdominal LM managed at our multidisciplinary Vascular Anomalies Center from 2011 to 2020. Patient demographics, symptoms, treatment, treatment response, and complications were analyzed with descriptive statistics. RESULTS Twenty-nine patients with abdominal LM were identified with a median age at treatment of 6 y (interquartile range 3-14). A majority of lesions were identified as macrocystic (n = 18, 62%). The most common intervention was surgery alone (n = 14, 48%) followed by sirolimus alone (n = 4, 14%), and sclerotherapy + sirolimus (n = 4, 14%). Five patients were observed due to lack of symptoms at presentation. Prior to 2017, 91% (10/11) of LM were treated with surgery alone. Following 2017, only 31% (4/13) were treated with surgery alone. Sixty-seven percent (16/24) of treated patients had >95% reduction in LM maximum diameter. A majority of patients (23/24) who received treatment had improvement or resolution of symptoms at median 9-mo follow-up. Only three patients had post-treatment complications, including a drain site infection, small bowel obstruction, and an aspiration event. Complications only occurred after sclerotherapy sessions. CONCLUSIONS Over the study period, our institution has transitioned to initial management of symptomatic abdominal LM with sclerotherapy and/or sirolimus with almost all treated patients having excellent or satisfactory treatment response. Post-treatment complications were rare.
Collapse
Affiliation(s)
- Steven C Mehl
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas.
| | - Austin Kinley
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Hannah F Todd
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Danial I Mir
- Department of Radiology, Division of Interventional Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Ionela Iacobas
- Department of Pediatrics, Division of Hematology and Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Amir Pezeshkmehr
- Department of Radiology, Division of Interventional Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Priya Mahajan
- Department of Pediatrics, Division of Hematology and Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Kristy L Rialon
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
| |
Collapse
|
5
|
Al-Sofyani MS, Alharbi NN, Alotaibi MS, Alotaibi RM. Sclerotherapy of Giant Abdominal Lymphangiomas in a Six-Year-Old Boy: A Case Report and Literature Review. Cureus 2022; 14:e26914. [PMID: 35983403 PMCID: PMC9377283 DOI: 10.7759/cureus.26914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2022] [Indexed: 11/05/2022] Open
|
6
|
Lee JJ, Ignacio RC, Vicente DA, Bachmann AM, Choi PM. Tumor or Inflammatory Myofibroblastic Reaction in an Adolescent With an Abdominal Lymphatic Malformation? Cureus 2022; 14:e23702. [PMID: 35505749 PMCID: PMC9056083 DOI: 10.7759/cureus.23702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2022] [Indexed: 11/15/2022] Open
Abstract
We report the case of a 17-year-old male who presented with intractable nausea and vomiting. Cross-sectional imaging revealed a large retrogastric abdominal mass. Fine needle aspiration done via endoscopic ultrasound (EUS) was nondiagnostic. Exploratory laparotomy revealed a large inflammatory mass densely adherent to the stomach and retroperitoneum. Incisional biopsy frozen section revealed spindle cells, and subsequent resection of the mass with en-bloc subtotal gastrectomy with Roux-en-y gastrojejunostomy reconstruction was performed. Final pathology demonstrated a lymphatic malformation with reactive myofibroblastic proliferation. Inflammatory abdominal lymphatic malformations are especially rare and not well described in the literature. These masses may present diagnostic challenges until the specimen is sent for pathologic analysis.
Collapse
|