Earle L. Wrenn

Is there a role for laparoscopic appendectomy in pediatric surgery

Although laparoscopic procedures are currently in vogue in general surgery, the role of this approach in children has not been prospectively evaluated in the United States using the new instrumentation now available to us. To assess the value of laparoscopic appendectomy (LA) in childhood, we prospectively compared 14 LAs with 50 open appendectomies (OA) over 6 months in a single childrens hospital. Antibiotic usage was at the discretion of the surgeon regardless of the procedure performed and was not different between groups. LA was performed under the direction of a single laparoscopy-trained surgeon and patient selection was based on parental consent. A three-puncture LA technique was used; children from this group were allowed to return to full activities as soon as they were comfortable. There were no significant differences between groups for severity of disease, age, weight, hospital cost, or complications. The types of complications that developed were comparable in both groups. The percent of complicated appendicitis (gangrene or perforation) was 32% in the OA group and 36% in the LA group. Patients in the LA group spent significantly fewer days in the hospital and returned to unrestricted activities (school, athletics, etc) faster than patients in the OA group. LA is approximately

Silver Nitrate Irrigation to Control Bladder Hemorrhage in Children Receiving Cancer Therapy

1,000 more expensive than OA, the differences being easily explainable by the cost of the disposable supplies necessary for the procedure (laser fibers, trocars, etc), but because of the shorter hospital stay in the LA group the mean total cost for each group was comparable. These data suggest that although there appears to be no cost advantage, LA shortens the hospital stay and allows children to return to unrestricted activity sooner than OA.(ABSTRACT TRUNCATED AT 250 WORDS)

Combined therapy to prevent complete pelvic exenteration for rhabdomyosarcoma of the vagina or uterus.

Silver nitrate irrigations after cystoscopic evacuation of clots stopped intractable hemorrhage from the bladder in 8 of 9 children who had received cyclophosphamide and/or pelvic irradiation for various malignant diseases. This method of management produces fewer adverse side effects yet appears to be as effective as the more drastic measures of control, such as cystectomy or colocystoplasty.

Acute appendicitis in children with leukemia and other malignancies: Still a diagnostic dilemma

Three children with rhabdomyosarcoma (sarcoma botryoides) of the vagina or uterus were managed by modified radical resection combined with pre‐ and/or postoperative chemotherapy and high‐dose irradiation. This plan of therapy contrasts sharply with the conventional approach: i.e., pelvic exenteration consisting of cystectomy, hystovaginectomy, and oophorectomy, with urinary diversion by ureteroileostomy or ureterosigmoidostomy. Two patients had complete regressions of tumor following preoperative chemotherapy and irradiation. The third patient received no preoperative therapy, but was given postoperative radium implantation, irradiation, and chemotherapy. The surgical approach consisted of hystovaginectomy and oophorectomy without urinary diversion. These patients are free of tumor for 32, 44, and 54 months, respectively. There were no serious toxic reactions to the drugs, nor any significant postoperative urinary tract problems. The results reported here suggest that hystovaginectomy and oophorectomy coordinated with chemotherapy and irradiation is an acceptable alternative to pelvic exenteration in patients with sarcoma botryoides of the vagina or uterus.

Survival of children with neuroblastoma treated with combination chemotherapy

Of 6,099 children treated for malignancy, 16 (ages 3.5 to 18 years) developed acute appendicitis between 1962 and 1989. Fourteen had leukemia (ALL 10, AML 4). One each had rhabdomyosarcoma and Ewings sarcoma. Active malignancy at diagnosis was noted in 10, 4 of whom had severe neutropenia (absolute neutrophil count less than 500/mm3). Of all the leukemics (2,794/6,099), abdominal pain during induction was a frequent complaint. The incidence of appendicitis, however, was low (0.5%). Nine of the 16 patients presented classically, facilitating prompt diagnosis and treatment. Six diagnoses were delayed. Three of these patients presented atypically with vague, nonlocalized pain, abdominal distention, lack of abdominal guarding, fever, dehydration, diarrhea, and unusual symptoms such as upper gastrointestinal bleeding. In each of these 6 patients the appendix was ruptured. Delays led to complications and deaths. Three patients required perioperative transfusions to treat excessive bleeding and two patients with ruptured appendicitis developed wound abscesses. Two patients died; in one, ruptured appendix was diagnosed only at autopsy. The other patient died of uncontrolled sepsis. Typhlitis occurring during induction chemotherapy may present similarly and is the main differential diagnosis. Typhlitis will usually improve with medical treatment alone. Nausea and vomiting (13/16), right lower quadrant pain (13/16), guarding (14/16), tachycardia (12/16), fever (10/16), and rebound tenderness (10/16) were the most frequent signs and symptoms of appendicitis. Persistent localized abdominal pain and guarding, lack of improvement with medical treatment, clinical deterioration, and the development of a mass were our indications for laparotomy. Despite major improvements in therapy, there is still a 37.5% error rate in our ability to accurately diagnose appendicitis in pediatric cancer patients.

Effective chemotherapy of an abdominal liposarcoma

Survival of a group of children with neuroblastoma treated with vincristine and cyclophosphamide was compared retrospectively with that of a group which received only alkylating agents. The children receiving the combination had a longer median survival. The mortality rate was not reduced for those over 2 years of age but all 5 children under age 2, including 4 with systemic tumor, are living without evidence of disease for periods of 1 to 5 years.

Extralobar pulmonary sequestration and mediastinal bronchogenic cyst.

L I P O S A R ( 3 0 M A i s a n extremely u n c o m m o n t umor in children. K a u f f m a n and Stout 1 in 1959 found 15 wel l -documented cases in the l i te ra ture and a d d e d 13 cases which they had seen in consul ta t ion over a thir ty year period. I n 1960, Enter l ine and associates, 2 reviewed the experience with this tumor a t the Univers i ty of Pennsylvania Hospi ta l and the Presbyter ian HospitM (Phi ladelphia) dur ing the per iod f rom 1940 to 1957. Of a to ta l of 53 cases only 3 were inpat ients under 20 years of age. Ti le t r ea tment of choice for pat ients with resectable l iposarcomas is wide surgical excision.a, 2 W h e n this can be done, there is an excellent possibility of comple te eradicat ion of the mal ignancy. I f complete surgical excision is not possible, rad ia t ion therapy may offer pa l l ia t ion and occasionally will result i n longterm survival? The fol lowing is a repor t of a child with an abdomina l l iposarcoma who was t reated wi th chemotherapeut ic agents following unsuccessful surgical excision and radia t ion therapy. T h e appa ren t successful outcome in this pa r t i cu la r pa t i en t suggests tha t this ap-

Transmedullary amputation and resection of metastases in combined therapy of osteosarcoma

A child with coexisting mediastinal bronchogenic cyst and extralobar pulmonary sequestration is presented. Two distinct lesions were suggested by barium esophagram and confirmed by a chest computed tomography scan. The diagnostic and embryologic relationship of the two lesions is discussed.

Brain abscess: an unusual complication of multiple esophageal dilatations

The eradication of microfoci of metastatic osteosarcoma by adjuvant chemotherapy permits the surgeon to take a more conservative approach to amputation and to more aggressively resect metastases. In a series of 59 children with osteosarcoma of an extremity, transmedullary amputation carried no greater risk of stump recurrence than either disarticulation or amputation above the joint. We attribute this to careful selection of the level of amputation by use of preoperative bone scans, intraoperative frozen sections of bone stump and intensive postoperative adjuvant chemotherapy. Immediate application of a prosthetic limb has enhanced the physical and emotional rehabilitation of these patients. Resections of pulmonary metastases in 12 patients who were receiving adjuvant chemotherapy has resulted in a median tumor-free survival of 17 mo, with 3 patients still alive without disease for 13, 25, and 72 mo. A more aggressive approach to the resection of pulmonary metastases may substantially improve current rates of tumor-free survival.

Pig in pouch: A technique for the management of complete wound dehiscence after laparotomy for neonatal necrotizing enterocolitis

Lye ingestion in children continues to be a problem and may result in severe esophageal strictures. Esophageal dilatations to treat these strictures usually result in bacteremia. A case of 13-year-old boy who developed a brain abscess after multiple esophageal dilatations is presented and discussed and the literature on the subject is reviewed.