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Lemoine CP, Madadi-Sanjani O, Petersen C, Chardot C, de Ville de Goyet J, Superina R. Pediatric Liver and Transplant Surgery: Results of an International Survey and Expert Consensus Recommendations. J Clin Med 2023; 12:jcm12093229. [PMID: 37176667 PMCID: PMC10179485 DOI: 10.3390/jcm12093229] [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: 03/01/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Pediatric liver surgery is a complex and challenging procedure and can be associated with major complications, including mortality. Best practices are not established. The aims of this study were to evaluate surgeons' individual and institutional practices in pediatric liver surgery and make recommendations applicable to the management of children who require liver surgery. METHODS A web-based survey was developed, focusing on the surgical management of children with liver conditions. It was distributed to 34 pediatric surgery faculty members of the Biliary Atresia and Related Disorders (BARD) consortium and 28 centers of the European Reference Network-Rare Liver. Using the Delphi method, a series of questions was then created to develop ideas about potential future developments in pediatric liver surgery. RESULTS The overall survey response rate was 70.6% (24/34), while the response rate for the Delphi questionnaire was 26.5% (9/34). In centers performing pediatric liver surgery, most pediatric subspecialties were present, although pediatric oncology was the least present (79.2%). Nearly all participants surveyed agreed that basic and advanced imaging modalities (including ERCP) should be available in those centers. Most pediatric liver surgeries were performed by pediatric surgeons (69.6%). A majority of participants agreed that centers treating pediatric liver tumors should include a pediatric transplant program (86%) able to perform technical variant grafts and living donor liver transplantation. Fifty-six percent of responders believe pediatric liver transplantation should be performed by specialized pediatric surgeons. CONCLUSION Pediatric liver surgery should be performed by specialized pediatric surgeons and should be centralized in regional centers of excellence where all pediatric subspecialists are present. Pediatric hepatobiliary and transplant training needs to be better promoted amongst pediatric surgery fellows to increase this subspecialized workforce.
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Affiliation(s)
- Caroline P Lemoine
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Omid Madadi-Sanjani
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Claus Petersen
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Christophe Chardot
- Service de Chirurgie Pédiatrique Viscérale, Hôpital Necker-Enfants Malades, Université de Paris, 75015 Paris, France
| | - Jean de Ville de Goyet
- Department for the Treatment and Study of Pediatric Abdominal Diseases and Abdominal Transplantation, ISMETT, 90127 Palermo, Italy
| | - Riccardo Superina
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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Fuchs J, Ruping F, Murtha-Lemekhova A, Kessler M, Günther P, Mehrabi A, Hoffmann K. Comparison of transection techniques in pediatric major hepatectomy: a matched pair analysis. HPB (Oxford) 2023; 25:593-601. [PMID: 36882355 DOI: 10.1016/j.hpb.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/30/2023] [Accepted: 02/13/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Evidence on safety and efficacy of different liver transection techniques in pediatric major hepatectomy is completely lacking, as no study has been conducted so far. The use of stapler hepatectomy has never before been reported in children. METHODS Three liver transection techniques were compared: (1) ultrasonic dissector (CUSA), (2) tissue sealing device (LigaSure™), and (3) stapler hepatectomy. All pediatric hepatectomies performed at a referral center in a 12-year study period were analyzed, patients were pair-matched in a 1:1:1-fashion. Intraoperative weight-adjusted blood loss, operation time, use of inflow occlusion, liver injury (peak-transaminase levels), postoperative complications (CCI), and long-term outcome were compared. RESULTS Of 57 pediatric liver resections, 15 patients were matched as triples based on age, weight, tumor stage, and extent of resection. Intraoperative blood loss was not significantly different between the groups (p = 0.765). Stapler hepatectomy was associated with significantly shorter operation time (p = 0.028). Neither postoperative death nor bile leakage occurred, and no reoperation due to hemorrhage was needed in any patient. CONCLUSION This is the first comparison of transection techniques in pediatric liver resection and the first report on stapler hepatectomy in children. All three techniques can be safely applied and may harbor individual advantages in pediatric hepatectomy each.
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Affiliation(s)
- Juri Fuchs
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Germany.
| | - Fabian Ruping
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Division of Pediatric Surgery, Germany
| | | | - Markus Kessler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Division of Pediatric Surgery, Germany
| | - Patrick Günther
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Division of Pediatric Surgery, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Katrin Hoffmann
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Germany
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Whitlock RS, Portuondo JI, Commander SJ, Ha TA, Zhu H, Goss JA, Kukreja KU, Leung DH, Terrada DL, Masand PM, Nguyen HN, Nuchtern JG, Wesson DE, Heczey AA, Vasudevan SA. Integration of a dedicated management protocol in the care of pediatric liver cancer: From specialized providers to complication reduction. J Pediatr Surg 2022; 57:1544-1553. [PMID: 34366130 DOI: 10.1016/j.jpedsurg.2021.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/15/2021] [Accepted: 07/20/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Up to a third of children undergoing partial hepatectomy for primary hepatic malignancies experience at least one perioperative complication, with a presumed deleterious effect on both short- and long-term outcomes. We implemented a multidisciplinary treatment protocol in the management of these patients in order to improve complication rates following partial hepatectomy. METHODS A retrospective chart review was completed for all patients < 18 years of age who underwent liver resection at our institution between 2002 and 2019 for primary hepatic cancer. Demographic, intraoperative, postoperative, pathologic, and outcome data were analyzed for perioperative complications using the CLASSIC and Clavien-Dindo (CD) scales, event-free survival (EFS) and overall survival (OS). RESULTS A total of 73 patients were included in the analysis with 33 prior-to and 40 after dedicated provider protocol implementation. Perioperative complication rates decreased from 52% to 20% (p = 0.005) with major complications going from 18% to 10% (p = 0.31). On multivariable logistic regression, protocol implementation was associated with a reduction in any (OR 0.29 [95% CI 0.09 - 0.89]) but not major complications. On multivariate cox models, post protocol implementation was associated with improved event free survival (EFS) (HR 0.19 (0.036 - 0.195). Among patients with a diagnosis of hepatoblastoma (n = 62), the occurrence of a major perioperative complication was associated with a worse EFS (HR=5.45, p = 0.03) on multivariate analysis, however this did not translate into an impact on overall survival. CONCLUSIONS Our results demonstrate that, for children with primary liver malignancies, a dedication of patients to high-volume surgeons can improve rates of complications of liver resections and may improve the oncological outcome of hepatoblastoma.
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Affiliation(s)
- Richard S Whitlock
- Division of Pediatric Surgery, Texas Children's Surgical Oncology Program, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, United States
| | - Jorge I Portuondo
- Division of Pediatric Surgery, Texas Children's Surgical Oncology Program, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, United States
| | - Sarah J Commander
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Tu-Anh Ha
- Division of Pediatric Surgery, Texas Children's Surgical Oncology Program, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, United States
| | - Huirong Zhu
- Outcomes and Impact Service, Texas Children's Hospital, Houston, TX, United States
| | - John A Goss
- Division of Abdominal Transplantation, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, United States
| | - Kamlesh U Kukreja
- Division of Interventional Radiology, Singleton Department of Pediatric Radiology, Texas Children's Liver Tumor Program, Baylor College of Medicine, Houston, TX, United States; Singleton Department of Pediatric Radiology, Texas Children's Liver Tumor Program, Baylor College of Medicine, Houston, TX, United States
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Liver Tumor Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Dolores Lopez Terrada
- Departmant of Pathology, Texas Children's Liver Tumor Program, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, United States
| | - Prakash M Masand
- Singleton Department of Pediatric Radiology, Texas Children's Liver Tumor Program, Baylor College of Medicine, Houston, TX, United States
| | - HaiThuy N Nguyen
- Singleton Department of Pediatric Radiology, Texas Children's Liver Tumor Program, Baylor College of Medicine, Houston, TX, United States
| | - Jed G Nuchtern
- Division of Pediatric Surgery, Texas Children's Surgical Oncology Program, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, United States
| | - David E Wesson
- Division of Pediatric Surgery, Texas Children's Surgical Oncology Program, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, United States
| | - Andras A Heczey
- Texas Children's Cancer and Hematology Center, Texas Children's Liver Tumor Program, Department of Pediatrics, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, United States
| | - Sanjeev A Vasudevan
- Division of Pediatric Surgery, Texas Children's Surgical Oncology Program, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, United States.
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Liu J, Xiu W, Duan G, Dong Q. Application of 3D Simulation Software in Chemotherapy and Hepatoblastoma Surgery in Children. Front Surg 2022; 9:908381. [PMID: 35722529 PMCID: PMC9200229 DOI: 10.3389/fsurg.2022.908381] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose This study aims to explore the clinical value of a computer-assisted surgery system (Hisense CAS) in hepatoblastoma (HB) surgery in children after neoadjuvant chemotherapy. Patients and Methods The clinical medical records of children with HB treated after neoadjuvant chemotherapy at the Affiliated Hospital of Qingdao University from January 2016 to January 2019 were analyzed retrospectively. Results A total of 21 children were enrolled in this study, including 13 boys and 8 girls. All cases successfully underwent three-dimensional (3D) reconstruction of the liver and tumor using Hisense CAS, simulated hepatectomy, and hepatectomy according to the preoperative operation plan. There were twelve cases of right hemihepatectomy, four cases of right trefoil hepatectomy, one case of left lobe hepatectomy, and three cases of middle lobe hepatectomy, and one case of V and VI segment hepatectomy. All children recovered well after the operation. The follow-up ranged from 5 months to 3 years. One child died of systemic metastasis 8 months after the operation. One child received one course of chemotherapy after the operation. Due to the serious reaction to the chemotherapy, the family refused further treatment and follow-up. The remaining 19 children had no complications or recurrence. Conclusion Hisense CAS can clearly and intuitively display the position and shape of the HB before and after chemotherapy and its relationship with the intrahepatic pipeline system and accurately evaluate the changes in tumor volume and the distance between important blood vessels, which is conducive to the operator selecting the best operation opportunity, timely formulating the best operation plan and implementing individualized and accurate liver tumor resection.
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Affiliation(s)
- Jie Liu
- Department of Pediatric Surgery, Yijishan Hospital of Wannan Medical College, Wannan Medical College, Wuhu, China
- Department of Pediatric Surgery, Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Wenli Xiu
- Department of Pediatric Surgery, Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Guangqi Duan
- Department of Pediatric Surgery, Yijishan Hospital of Wannan Medical College, Wannan Medical College, Wuhu, China
- Correspondence: Qian Dong Guangqi Duan
| | - Qian Dong
- Department of Pediatric Surgery, Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
- Correspondence: Qian Dong Guangqi Duan
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Fuchs J, Murtha-Lemekhova A, Kessler M, Günther P, Hoffmann K. The role of liver resection in metastatic nephroblastoma: a systematic review and Meta-regression analysis. BMC Cancer 2022; 22:76. [PMID: 35038991 PMCID: PMC8764777 DOI: 10.1186/s12885-022-09182-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 01/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The impact of hepatic resection for liver metastases (LM) on the survival of pediatric patients with Wilms' tumor (WT) is unclear. So far, there is a lack of studies investigating the best suited treatment for patients with WTLM, and the role of liver resection has rarely been investigated. Thus, the development of evidence-based guidelines concerning indications of liver resection for WTLM remains difficult. AIM To investigate the role of surgery in the therapy of WTLM. All available data on liver resections and subgroup outcomes of patients with WTLM are analyzed. Main research question is whether liver resection improves survival rates of patients with WTLM compared to non-surgical treatment. METHODS A systematic literature search of MEDLINE, Web of Science, and Central provided the basis for this PRISMA-compliant systematic review. For the main analysis (I), all studies reporting on surgical treatment of pediatric WTLM were included. To provide a representative overview of the general outcome of WTLM patients, in analysis II all studies with cohorts of at least five WTLM patients, regardless of the kind of treatment, were reviewed and analyzed. A Multiple meta-regression model was applied to investigate the impact liver resection on overall survival. RESULTS 14 studies with reports of liver resection for WTLM were found (Analysis I). They included a total of 212 patients with WTLM, of which 93 underwent a liver resection. Most studies had a high risk of bias, and the quality was heterogenous. For the analysis II, eight studies with subgroups of at least five WTLM patients were found. The weighted mean overall survival (OS) of WTLM patients across the studies was 55% (SD 29). A higher rate of liver resection was a significant predictor of better OS in a multiple meta-regression model with 4 covariates (I2 29.43, coefficient 0.819, p = 0.038). CONCLUSIONS This is the first systematic review on WTLM. Given a lack of suited studies that specifically investigated WTLM, ecological bias was high in our analyses. Generating evidence is complicated in rare pediatric conditions and this study must be viewed in this context. Meta-regression analyses suggest that liver resection may improve survival of patients with WTLM compared to non-surgical treatment. Especially patients with persisting disease after neoadjuvant chemotherapy but also patients with metachronous LM seem to benefit from resection. Complete resection of LM is vital to achieve higher OS. Studies that prospectively investigate the impact of surgery on survival compared to non-surgical treatment for WTLM are highly needed to further close the current evidence gap. STUDY REGISTRATION PROSPERO 2021 CRD42021249763 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=249763 .
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Affiliation(s)
- Juri Fuchs
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Anastasia Murtha-Lemekhova
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Kessler
- Department of General, Visceral and Transplantation Surgery, Division of Pediatric Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Patrick Günther
- Department of General, Visceral and Transplantation Surgery, Division of Pediatric Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Katrin Hoffmann
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany.
- Division of Liver surgery, Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
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Fuchs J, Hoffmann K, Murtha-Lemekhova A, Kessler M, Günther P, Frongia G, Probst P, Mehrabi A. Establishing a Standardized Measure of Quality in Pediatric Liver Surgery: Definition and Validation of Textbook Outcome With Associated Predictors. Front Surg 2021; 8:708351. [PMID: 34368218 PMCID: PMC8333609 DOI: 10.3389/fsurg.2021.708351] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/25/2021] [Indexed: 01/10/2023] Open
Abstract
Purpose: To establish comparable reporting of surgical results in pediatric liver surgery, the recently introduced composite outcome measures Textbook Outcome (TO) and Comprehensive Complication Index (CCI) are applied and validated in a pediatric surgery context for the first time. In a representative cohort of pediatric patients undergoing liver resection, predictive factors for TO and CCI are investigated, and outcomes are compared to available literature on surgical outcomes of pediatric liver resection. Methods: All liver resections for patients under 21 years of age performed at the Department of General, Visceral, Transplantation and Pediatric Surgery of the University of Heidelberg between 2009 and 2020 were included in the analysis. Criteria for TO were defined prior to the analysis. Univariate and Multivariate regression was applied to identify factors associated with TO and CCI. Results: Fifty-three pediatric patients underwent liver resections during the observation period. No 30- or 90-day mortality occurred. Twenty-three patients (43.4%) had a TO. CCI and TO showed highly significant correlation (b = −30.33, 95% CI [−37.44; −23.22], p < 0.001). Multivariate analyses revealed significant association between intraoperative blood loss (adjusted for circulating blood volume) and CCI (b = 0.70, 95%CI [0.22; 1.32], p = 0.008) and failure to achieve TO (OR = 0.85, 95%CI [0.69; 0.97], p = 0.048). Conclusion: TO and CCI are suited outcome measures in pediatric surgical studies and offer objective comparability of results. Their application in clinical studies will be a major step forward to establish evidence-based therapies in pediatric surgery. Systematic utilization of TO and CCI can aid in generating comparable studies on surgical techniques and outcomes in pediatric liver resection.
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Affiliation(s)
- Juri Fuchs
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Katrin Hoffmann
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Anastasia Murtha-Lemekhova
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus Kessler
- Division of Pediatric Surgery, Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Patrick Günther
- Division of Pediatric Surgery, Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Giovanni Frongia
- Department of General, Visceral, Thorax, Pediatric and Endocrine Surgery, Johannes Wesling Hospital Minden, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Postsurgical Management of Dilated Biliary Tract in Children: Ultrasound-Guided Percutaneous Transhepatic Cholangial Drainage and Subsequent Percutaneous Ultrasound Cholangiography. AJR Am J Roentgenol 2020; 214:1377-1383. [PMID: 32160054 DOI: 10.2214/ajr.19.22225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE. The purpose of this study was to evaluate the feasibility of ultrasound (US)-guided percutaneous transhepatic cholangial drainage (PTCD) and consequent percutaneous US cholangiography in managing the dilated biliary tracts of children who have undergone hepatobiliary surgery. SUBJECTS AND METHODS. Sixteen children (11 boys, five girls; age range, 3-144 months) who underwent hepatobiliary surgery from December 2016 to October 2018 and had US evidence of biliary dilatation were included. All patients had undergone US-guided PTCD because of elevated postoperative serum bilirubin levels or bile duct infection. Immediately after the PTCD procedure, diluted sulphur hexafluoride microbubbles dispersion was injected through the PTCD tube to evaluate the anastomosis and the intrahepatic bile duct tree. Laboratory results, including those of serum bilirubin measurement, liver function tests, and routine blood tests, were evaluated before and after PTCD. Nine of 16 patients also underwent percutaneous transhepatic cholangiography (PTC). The percutaneous US cholangiography findings were evaluated and compared with the PTC findings. RESULTS. Liver enzyme levels decreased after PTCD with a statistically significant difference from the values before PTCD. Percutaneous US cholangiography showed that the anastomosis in 6 of the 16 patients (37.5%) was patent and depicted the morphologic featuresof intrahepatic bile duct tree in five of these patients. In the other 10 patients, the anastomosis was completely obstructed, and percutaneous US cholangiography depicted the morphologic features of intrahepatic bile duct tree in eight patients. In the nine patients who underwent PTC, the percutaneous US cholangiographic findings were the same as the PTC findings. CONCLUSION. US-guided PTCD is helpful in relieving jaundice and inflammation in children who have undergone hepatobiliary surgery and have biliary dilatation. Findings at consequent percutaneous US cholangiography are comparable to those of PTC in depicting the anastomosis in these patients.
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Application of the Clavien-Dindo classification to a pediatric surgical network. J Pediatr Surg 2020; 55:312-315. [PMID: 31727385 DOI: 10.1016/j.jpedsurg.2019.10.032] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/26/2019] [Indexed: 01/10/2023]
Abstract
INTRODUCTION A comprehensive validated system to evaluate surgical complications is required in our specialty to facilitate comparison and audit. The Clavien-Dindo (CD) classification of post-surgical complications was originally described in an adult general surgical setting in 1992 and has become widely used. We aimed to apply this to a pediatric surgical setting. METHODS Data were collected on emergency and elective surgical activity together with complications in a prospective audit over a recent 4-month period in three geographical conjoined regional pediatric surgical units (including two major trauma centres). Briefly the CD classification codes complications according to degree of harm and magnitude of intervention required [I - V (death) with III and IV sub-divided according to whether general anesthesia was needed]. Length of stay and mode of admission were recorded. Data are given as median (range). Non-parametric comparison was used, and a p value of <0.05 was regarded as significant. RESULTS During the period JULY - OCT 2018 (inclusive), there were 1822 admissions (elective, n = 1186: emergency, n = 636) and 1556 operations (elective, n = 1189, and of these 393 were urological). There were 69 patient complications: CDI (n = 7), CD-II (n = 19), CD-IIIa (n = 4), CD-IIIb (n = 28), CD-IV (n = 4), CD-V (n = 7). Deaths were principally in neonates and due to NEC (n = 6) at 2.5 (1-140) days post-operatively. There was a single post-traumatic death in an adolescent. LOS was 9 (0-217) days in CD I-IV. The incidence of any complication was 4.4%, of serious complication (defined as ≥CD III) 2.6% (A = 2.1%, B = 2.0%, and C = 3.2%: p = 0.16), and of death 0.45%. The most frequent complications were wound infection (n = 12) and post-appendicectomy collections/abscess (n = 10). CONCLUSIONS This appears to be the 1st report of the C-D classification in a general pediatric surgery network and can be considered a benchmark. The risk of death or serious harm is very low in such a practice. TYPE OF STUDY Prospective Cohort Study. LEVEL OF EVIDENCE IIb.
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Du M, Wang J, Tang Y, Jiang J, Chen G, Huang Y, Shen Z, Dong R, Zheng S. Evaluation of Perioperative Complications in the Management of Biliary Atresia. Front Pediatr 2020; 8:460. [PMID: 33014917 PMCID: PMC7493688 DOI: 10.3389/fped.2020.00460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/30/2020] [Indexed: 11/13/2022] Open
Abstract
Purpose: To analyze the influence of perioperative complications in the management of biliary atresia (BA). Methods: A retrospective study was performed using a total of 422 BA patients who underwent Kasai portoenterostomy (KPE) in a single institution between February 2016 and May 2017. Data on patients' clinical characteristics, laboratory examinations, perioperative complications, and outcomes were collected. Unpaired two-tailed t-test and χ2 test were employed for the comparison between BA patients with and without perioperative complications. Cox regression analysis was used to screen the risk factors for 2-years NLS in BA, and their influence on the 2-years NLS was analyzed using Kaplan-Meier survival analysis as well as the log-rank test. Results: The incidence of perioperative complications, 6-months jaundice clearance (JC) and 2-years native liver survival (NLS) rate were 60.4, 59.5, and 56.6%, respectively. Patients with perioperative complications had lower serum albumin (ALB) level, but higher aspartate aminotransferase-to-platelet ratio index (APRI) and international normalized ratio (INR) levels when compared with those without perioperative complications (ALB, P < 0.05; APRI, P < 0.01; INR, P < 0.05). Moreover, perioperative complications were correlated with glucocorticoid administration (P = 0.002). Univariate Cox regression analysis showed no relationship between perioperative complications and 2-years NLS (P > 0.05). However, multivariate Cox regression analysis indicated 6-months JC was an independent protective factor for 2-years NLS [P < 0.0001, hazard ratio (HR) = 0.074, 95% confidence interval = 0.05-0.11], and concordance index of this prediction model including age, weight, APRI, glucocorticoid, and 6-months JC was 0.811. Conclusion: Although perioperative complication is common during and after KPE, it had no influence on the prognosis of BA. However, assessment of the serum level of total bilirubin after KPE may serve as an important predictor for the outcome in BA.
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Affiliation(s)
- Min Du
- Department of Pediatric Surgery, Children's Hospital of Fudan University, and Shanghai Key Laboratory of Birth Defect, Shanghai, China
| | - Junfeng Wang
- Department of Pediatric Surgery, Children's Hospital of Fudan University, and Shanghai Key Laboratory of Birth Defect, Shanghai, China
| | - Yue Tang
- Department of Pediatric Surgery, Children's Hospital of Fudan University, and Shanghai Key Laboratory of Birth Defect, Shanghai, China
| | - Jingying Jiang
- Department of Pediatric Surgery, Children's Hospital of Fudan University, and Shanghai Key Laboratory of Birth Defect, Shanghai, China
| | - Gong Chen
- Department of Pediatric Surgery, Children's Hospital of Fudan University, and Shanghai Key Laboratory of Birth Defect, Shanghai, China
| | - Yanlei Huang
- Department of Pediatric Surgery, Children's Hospital of Fudan University, and Shanghai Key Laboratory of Birth Defect, Shanghai, China
| | - Zhen Shen
- Department of Pediatric Surgery, Children's Hospital of Fudan University, and Shanghai Key Laboratory of Birth Defect, Shanghai, China
| | - Rui Dong
- Department of Pediatric Surgery, Children's Hospital of Fudan University, and Shanghai Key Laboratory of Birth Defect, Shanghai, China
| | - Shan Zheng
- Department of Pediatric Surgery, Children's Hospital of Fudan University, and Shanghai Key Laboratory of Birth Defect, Shanghai, China
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Ernst L, Grabhorn E, Brinkert F, Reinshagen K, Königs I, Trah J. Infantile Hepatic Hemangioma: Avoiding Unnecessary Invasive Procedures. Pediatr Gastroenterol Hepatol Nutr 2020; 23:72-78. [PMID: 31988877 PMCID: PMC6966222 DOI: 10.5223/pghn.2020.23.1.72] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 09/30/2019] [Indexed: 11/14/2022] Open
Abstract
Infantile hepatic hemangioma, the most common vascular tumor of the liver in infancy, can occur with acute postnatal liver and congestive heart failure. Nevertheless, its course is often benign, and many children can be diagnosed and treated without surgical intervention. The distinction from malignant diseases is not always easy and it not clear whether invasive procedures for diagnosis and therapy should be performed. Here we report our experiences in our Center for Pediatric Liver Disease and postulate that large studies are needed to avoid unnecessary invasive procedures for these patients in the future.
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Affiliation(s)
- Lukas Ernst
- Department of Pediatrics, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Enke Grabhorn
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florian Brinkert
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Konrad Reinshagen
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ingo Königs
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julian Trah
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Abstract
In contrast to gallstones, which are increasingly diagnosed in children and adolescents, congenital or perinatally acquired malformations of the biliary tree are rare entities. The surgical treatment of these diseases frequently represents a technical challenge. For children with biliary atresia Kasai portoenterostomy is a therapeutic option in the first weeks of life. Most affected children, however, require a liver transplantation before they enter adulthood. Segmental dilatations of the bile duct carry the risk of ascending infections and malignant transformation. This requires early resection of the biliary tree and reconstruction with a bilioenteric anastomosis. While laparoscopic cholecystectomy has become the standard approach also for children, the value of minimally invasive procedures for more complex surgical procedures of the biliary tract has not yet been defined.
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Affiliation(s)
- M Dübbers
- Schwerpunkt Kinderchirurgie, Klinik für Allgemein‑, Viszeral- und Tumorchirurgie, Uniklinik Köln, Kerpener Straße 62, 50937, Köln, Deutschland.
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12
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Culbreath KD, Garcia AV, Leeds IL, Ladd MR, Crawford T, Boss E, Rhee DS. Evaluation of Anemia and Nutritional Status on Children Undergoing Resection of Primary Liver Tumors. J Surg Res 2018; 232:547-552. [PMID: 30463771 DOI: 10.1016/j.jss.2018.06.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/22/2018] [Accepted: 06/19/2018] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Complete tumor resection of primary malignant liver tumors offers the best chance of survival. However, many of these children may experience anemia and failure to thrive. This study analyzes the association of preoperative anemia and nutritional support with outcomes in children undergoing major resection of primary malignant liver tumors. METHODS Using the National Surgical Quality Improvement Program Pediatric database from 2012 to 2015, children undergoing major liver resections for primary malignant hepatic tumors were selected. Patient demographics, comorbidities, and 30-d outcomes were compared with respect to the presence of preoperative anemia and the need for nutritional support. Outcomes included 30-d postoperative complications, perioperative blood transfusions, and hospital readmissions. Propensity score matching was performed to control for significant confounders. RESULTS One hundred ten children were included, 76 (69.1%) with preoperative anemia, and 36 (32.7%) receiving nutritional support. Anemia was associated with preoperative chemotherapy (P = 0.02) and steroids (P = 0.03). Nutritional support was associated with cardiac (P = 0.01), respiratory (P < 0.01), neurologic (P < 0.01), and hematologic comorbidities (P = 0.02). There were 20 (18.2%) postoperative complications and 6 (5.5%) hospital readmissions. After propensity score matching, there was no difference in complications between anemic and nonanemic patients (P = 0.13). Preoperative nutritional support was associated with an increased rate of complications (P < 0.01). Neither anemia (P = 1.00) nor nutritional support (P = 0.49) were associated with readmissions. CONCLUSIONS The need for nutritional support is common in children undergoing resection of primary malignant hepatic tumors. Anemia was not significantly associated with postoperative complications. In this study, nutritional support was associated with an increased risk of postoperative complications. The need for nutritional support may warrant special attention to the patient's overall conditioning during operative planning.
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Affiliation(s)
- Katherine D Culbreath
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Alejandro V Garcia
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ira L Leeds
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mitchell R Ladd
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd Crawford
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emily Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel S Rhee
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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13
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Bjørnland K, Hinna M, Aksnes G, Stensrud KJ, Ertresvåg K, Bjørnstad-Østensen A, Sanengen T, Line PD, Aagenæs I, Aabakken L, Emblem R, Almaas R. Outcome for biliary atresia patients treated at a low-volume centre. Scand J Gastroenterol 2018; 53:471-474. [PMID: 29546790 DOI: 10.1080/00365521.2018.1439097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The importance of case load for treatment of extrahepatic biliary atresia (BA) is debated. The aim of this study was to register results of BA treatment in a small volume centre. METHODS Retrospective chart review study of patients with BA treated from 2000 to 2017. The institutional review board approved the study. RESULTS Forty-five babies were identified of which 42 (93%) are alive. Forty-one patients had a Kasai portoenterostomy (PE), two had a hepaticojejunostomy and two had a primary liver transplantation. The age at PE/hepaticojejunostomy was median 63 (4-145 days). Seven surgeons performed the operations, and the median duration of the diagnostic work-up was 8 (3-24) days. Clearance of jaundice was achieved in 23/43 (53%) babies, and 3- and 5-year native liver survival was 47% and 40%, respectively. Clearance of jaundice post-PE/hepaticojejunostomy was a strong predictor of native liver survival (adjusted OR: 0.027; 95%; p = .009). Plasma level of conjugated bilirubin at time of referral was also a significant predictor of native liver survival (adjusted OR: 1.053; p = .017). CONCLUSION A small volume centre may achieve satisfactory results for BA patients. The study has, however, identified factors that may further improve results; earlier referral, optimizing diagnostic work-up and establishing one dedicated surgical team.
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Affiliation(s)
- Kristin Bjørnland
- a Department of Gastro and Paediatric Surgery , Oslo University Hospital , Oslo , Norway.,b University of Oslo , Oslo , Norway
| | | | - Gunnar Aksnes
- a Department of Gastro and Paediatric Surgery , Oslo University Hospital , Oslo , Norway
| | - Kjetil Juul Stensrud
- a Department of Gastro and Paediatric Surgery , Oslo University Hospital , Oslo , Norway
| | - Kjetil Ertresvåg
- a Department of Gastro and Paediatric Surgery , Oslo University Hospital , Oslo , Norway
| | - Anniken Bjørnstad-Østensen
- a Department of Gastro and Paediatric Surgery , Oslo University Hospital , Oslo , Norway.,c Department of Paediatrics , Oslo University Hospital , Oslo , Norway
| | - Truls Sanengen
- c Department of Paediatrics , Oslo University Hospital , Oslo , Norway
| | - Pål-Dag Line
- b University of Oslo , Oslo , Norway.,d Department of Transplantation Medicine , Oslo University Hospital , Oslo , Norway
| | - Ingegerd Aagenæs
- e Department of Radiology , Oslo University Hospital , Oslo , Norway
| | - Lars Aabakken
- b University of Oslo , Oslo , Norway.,f Department of Medicine , Oslo University Hospital , Oslo , Norway
| | - Ragnhild Emblem
- a Department of Gastro and Paediatric Surgery , Oslo University Hospital , Oslo , Norway.,b University of Oslo , Oslo , Norway
| | - Runar Almaas
- c Department of Paediatrics , Oslo University Hospital , Oslo , Norway.,g Department of Pediatric Research , Oslo University Hospital , Oslo , Norway
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