Daniel K. Robie

Complications of gastroesophageal antireflux surgery in neurologically impaired versus neurologically normal children

Antireflux surgery was performed in 234 children over a 5-year period; 153 were neurologically impaired (NI) and 81 were neurologically normal (NN). Initial presentation, demographic data, and type of antireflux operation were similar in the two groups. Eighty-six percent of the NI group versus 30% of the NN group had gastrostomy tubes placed. The incidence of late postoperative complications was 26% in the NI group and 12% in the NN group (P less than .01). During the late postoperative period, NI children underwent reoperation four times as frequently as NN children (19% v 5%, respectively; P less than .01). Wrap herniation accounted for 38% of complications and 59% of reoperations in the late postoperative period. Mortality due to aspiration occurred in 9% of the NI group versus 1% of the NN group. Combined failure rate (reoperation plus aspiration-induced deaths) was 28% in NI and 6% in NN (P less than .01). We conclude that neurological status is the major predictor of operative success and that wrap herniation due to crural disruption is the most common cause of operative failure.

Clinical features associated with metastasis and recurrence of differentiated thyroid cancer in children, adolescents and young adults

Differentiated thyroid cancer (DTC), including papillary (PTC) and follicular (FTC) variants, is unusual in children and accounts for only 10% of all cases. For that reason, knowledge of the clinical features which predict recurrence is limited. We reviewed 170 cases of childhood DTC to determine if specific clinical or pathological findings were associated with increased risk of recurrence.

Extensive surgery improves recurrence-free survival for children and young patients with class I papillary thyroid carcinoma.

BACKGROUND Children with papillary thyroid cancer (PTC) rarely die of their disease, but are at high risk for recurrence, particularly with multifocal tumors (which occur in 42% of children with PTC). It is not clear if more extensive surgery, with an increased risk of complications, lessens the risk for recurrence. The authors hypothesized that patients with disease presumed to be confined to the thyroid gland (class I PTC) could have multifocal disease, involving the contralateral lobe, of which the surgeon is unaware. Treatment with less than subtotal thyroidectomy might be associated with a higher risk of recurrence. METHODS The charts of 37 patients with Class I PTC diagnosed at < or =21 years of age between 1953 and 1996 were reviewed. The incidence of surgical complications and the risk of recurrence based on the extent of initial surgery ([1] lobectomy with or without isthmusectomy, [2] subtotal, or [3] total thyroidectomy) and adjunctive therapy with thyroid hormone or radioactive iodine (RAI) were examined. RESULTS Eight patients had recurrent PTC. Patients treated with lobectomy with or without isthmusectomy were more likely to have recurrence than patients treated with subtotal or total thyroidectomy (Odds ratio, 8.7; 95% CI 1.4 to 54). Although the incidence of complications was statistically similar among the 3 surgical groups, 3 patients, all treated with more extensive surgery, had permanent hypoparathyroidism. There were too few patients to determine whether treatment with thyroid hormone or RAI offered additional benefit. CONCLUSIONS In children with Class I PTC, more extensive surgery is associated with a lower risk of recurrence. This finding must be weighed against the risk of complications when determining the optimal treatment for individual patients.

The impact of initial surgical management on outcome in young patients with differentiated thyroid cancer.

BACKGROUND/PURPOSE It is generally believed that differentiated thyroid cancer (DTC) in young patients has an excellent prognosis. This calls into question the need for more extensive surgical ablation of the thyroid gland with attendant risks of surgical complications. The purpose of this report was to investigate both the incidence of surgical morbidity and the impact of surgery on locoregional recurrence of disease. METHODS The authors reviewed the clinical course of patients under 22 years of age treated for DTC within Department of Defense hospitals since 1950. Data were available for determination of surgical morbidity in 126 and for outcome in 105. RESULTS The incidence of postoperative hypocalcemia was 17% and of recurrent laryngeal nerve injury 3%. Factors predictive of morbidity were (1) more extensive thyroid surgery (P = .023), and (2) the presence of gross tumor invasion (P = .022). The incidence of neck recurrence was analyzed among a cohort of 90 patients. A total of 19 (21%) patients had a local recurrence. The median time to recurrence was 24 months. The factor predictive of recurrence was the presence of gross invasion (P = .0001). A strong trend toward locoregional recurrence was found among patients with metastatic disease to more than five cervical nodes (P < .08). The primary operations on the thyroid and regional nodes were not significant predictors of neck recurrence. Among these 19 patients there have been no deaths, but 25% had persistent disease at a mean follow-up of 12.6 years. CONCLUSIONS The incidence of surgical morbidity does increase with more extensive surgery. Outcome is predicted primarily by the initial extent of disease.

Modified nissen fundoplication: Improved results in high-risk children

A modified Nissen fundoplication was performed in 29 children (26 neurologically impaired and 3 neurologically normal). The modifications to the Nissen 360 degrees wrap were: (1) deliberate crural repair with pledgets; (2) recreation of the angle of His; and (3) anchoring wrap to the diaphragm. Presenting complaints were respiratory in 66%, nutritional in 28%, and for prophylaxis in 2 patients requiring gastrostomy tubes. Prospective follow-up was obtained in 26 of 29 patients for an average of 19 months. Early postoperative complications occurred in 3 patients, none due to recurrent reflux. Six late deaths occurred due to neurological deterioration, pulmonary disease, and medication overdose. Barium swallows were obtained in 20 of 22 available patients postoperatively and all wraps were intraabdominal. We conclude that the modified Nissen prevents wrap herniation and improves postoperative results in the high-risk neurologically impaired child.

Is surgical ligation of a patent ductus arteriosus the preferred initial approach for the neonate with extremely low birth weight

The optimal approach to a patent ductus arteriosus (PDA) in an extremely low birth weight (ELBW) neonate, whether initial surgical ligation or a trial of indomethacin, has not been established. The authors reviewed the records of 82 ELBW premature infants who had surgical ligation of a PDA during a 2-year period. Thirty-one received indomethacin before ligation. Bronchopulmonary dysplasia (BPD) occurred in 33% of the infants. Predictors of BPD were prolonged positive pressure ventilation, severe intraventricular hemorrhage (IVH) and lower birth weight (BW). Seventy-seven percent of the infants survived. Predictors of mortality were severe IVH, lower BW, and the occurrence of necrotizing enterocolitis (NEC). The indomethacin-treated infants had a lower incidence of NEC and IVH. Overall, 16% of the patients had perioperative morbidity, and 10% of the patients died. The study shows that a trial of indomethacin therapy is not associated with increased complications in ELBW infants with PDA.

Operative strategy for recurrent laryngeal cleft: A case report and review of the literature

A case is reported of recurrent laryngotracheoesophageal cleft following two attempted repairs. The anterior approach to the larynx and trachea provided excellent exposure for defining the extent of the recurrent cleft, and allowed precise anatomic repair. Neurovascular structures were easily avoided by this operative method. Of 170 clefts reported in the literature, 19 recurred necessitating reoperation. The anterior approach to the larynx and trachea is appropriate in recurrent clefts and may be preferable at the initial repair.

Early experience using telemedicine for neonatal surgical consultations

BACKGROUND/PURPOSE Telemedicine affords the opportunity to extend the presence of surgical evaluation to centers without an on-site pediatric surgeon. However, concern for cost, accuracy of diagnosis, and physician acceptance have limited its use. METHODS Using a low-cost, desktop computer-based system, this study was designed to test the effectiveness of telemedicine in neonatal surgical consultation. RESULTS Early experience with six video-teleconference (VTC) and six store-and-forward consultations are presented. Diagnosis was established accurately in all cases. With the three intestinal cases (jejunal atresia, duplication cyst, and r/o malrotation), diagnostic studies were guided by the images transmitted with the consult. Earlier care could be implemented in other cases. Technical problems were encountered primarily with the VTC modality, which also proved more consuming of physician time. CONCLUSIONS Telemedicine was used successfully in each case and proved accurate in diagnosis and guiding further evaluation. This is the first report of the use of telemedicine for surgical consultation in the intensive care nursery.

The Extent of Disease at Diagnosis Predicts Response to Initial Therapy for Papillary Thyroid Cancer. |[dagger]| 498

Surgery, radioactive iodine (RAI), and thyroid hormone suppression are routinely used to treat children with papillary thyroid cancer (PTC) but there is active debate regarding the extent of surgery, the optimal dose and the timing of RAI ablation. Children commonly present with cervical metastasis, but the mortality rate is low. This has led to speculation that current aggressive treatment is important in reducing mortality. We previously showed that children with metastatic PTC are at greater risk for later recurrence compared to patients without metastases at diagnosis. No pediatric study has yet determined how frequently initial therapy induces a prolonged remission or even cure for patients with metastatic thyroid cancer. In the current study, we determined success of initial treatment in patients with metastatic PTC at diagnosis. We identified 137 children diagnosed with PTC at ≤21yrs of age. Of these, 27 patients received similar initial treatment (subtotal or total thyroidectomy and RAI) and had a well documented response to this treatment. Patients with less extensive disease (Class 2, cervical lymph node metastasis, or Class 3, locally invasive disease) were more likely to be free of disease after initial treatment than patients with distant metastasis (Class 4, p=0.001, linear-by-linear association). These data show that initial therapy with extensive surgery and RAI ablation can induce remission in the majority of children with Class 2 or 3 PTC but not in patients with distant metastasis. Late recurrence appeared similar in all groups. Table

Aggressive Surgical Therapy Improves Disease Free Survival in Children with Class 1 Papillary Thyroid Cancer † 499

Aggressive Surgical Therapy Improves Disease Free Survival in Children with Class 1 Papillary Thyroid Cancer † 499