Primary malignant pancreatic neoplasms in children and adolescents: A 20 year experience

Background

Malignant pancreatic neoplasms in children and adolescents are rare. The clinical presentation, pathologic characteristics, management, and outcomes at two institutions are discussed.

Methods

We retrospectively reviewed all pediatric patients (age < = 18 years) treated for malignant pancreatic neoplasms at two institutions between 1991 and 2011.

Results

Thirty-one patients were identified with median age of 14.7 years (4–18 years). The most common histology was solid pseudopapillary tumor (SPT) (n = 22, 71%) followed by neuroendocrine tumors (n = 4, 13%), pancreatoblastoma (n = 4, 13%), and one unclassified spindle cell neoplasm (3%). Most patients presented with abdominal pain (n = 22, 71%). Complications included pancreatic leak, pseudocyst formation, pancreatitis, pancreatic insufficiency, and small bowel obstruction. The overall 1- and 5-year survival was 96% (95% CI 74%–99%) and 78% (95% CI 43%–93%). Median follow-up among patients alive at the end of follow-up was 20 months (< 1 month–16.2 years). Patients with SPT had better overall survival compared to patients with neuroendocrine tumors or pancreatoblastomas (Log-rank; p = 0.0143).

Conclusion

The majority of pediatric and adolescent patients present with SPTs which are usually resectable and associated with an excellent prognosis. Other histologic subtypes more often present with distant metastases and portend a worse prognosis.     

A new surgical approach of temporary ovarian transposition for children undergoing brachytherapy: Technical assessment and dose evaluation

Purpose

We developed a new technique of temporary ovarian transposition (OT) for prepubertal girls undergoing brachytherapy. The aim of this study was to describe it, assess its feasibility and safety and calculate the dose delivered to the ovary in order to prove its efficacy.

Methods

Sixteen prepubertal patients underwent temporary OT for brachytherapy at our center from March 2001 to December 2012. OT was done either by laparotomy or by laparoscopy. In all patients, the ovaries were grasped with an atraumatic forceps and mobilized above the iliac crest level as high as possible without any dissection or division of the ovarian ligaments or of the fallopian tube. They were sutured to the anterior abdominal wall by a transfixing stitch of non-dissolvable suture knotted on the outside of the patient on a pledget.

Results

Median age at surgery was 3 years (range: 2–9 years). The integrity of the fallopian tube was respected and not a single ligament was dissected or divided. None of the patients had intraoperative or postoperative complications. The stitches were retrieved after completion of irradiation and the ovaries in all the patients fell back into the pelvis. The calculated median radiation dose to the ovary was 1.4 Gy (range: 0.4–2.4 Gy).

Conclusions

This surgical technique is simple and safe, either by laparotomy or by laparoscopy. It meets the radiation and physical constraints in prepubertal girls with vaginal or bladder RMS. However, longer follow-up is required to assess the ovarian function.     

Contemporary Management of Postchemotherapy Testis Cancer

Context

Some controversy still exists regarding the management of testis cancer following chemotherapy for disseminated disease.

Objective

To review the available literature concerning the management of postchemotherapy testis cancer.

Evidence acquisition

A Medline search was conducted to identify original and review articles, as well as guidelines addressing the management of testis cancer following first-line chemotherapy. Keywords included germ cell tumor, testis cancer, retroperitoneal lymph node dissection, and chemotherapy. The most relevant articles were critically reviewed with the consensus of all the collaborative authors, who have expertise in the management of germ cell tumors (GCTs).

Evidence synthesis

Approximately one-third of patients who undergo chemotherapy for metastatic GCTs have residual retroperitoneal disease. All patients with residual masses ≥1 cm after chemotherapy for nonseminomatous GCTs should undergo postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) because of the risk of mature teratoma in 40–45% of cases and of viable GCT in 10–15% of cases. Patients who obtain a complete serologic remission and radiographic residual <1 cm after chemotherapy have a 6–9% risk of relapse. Patients with a completely resected teratoma in only the PC-RPLND specimen have a >90% chance of cure, while patients with viable GCTs should be considered for additional therapy, depending on the percentage of viable tumor. In patients with disseminated seminoma, postchemotherapy masses <3 cm may be safely observed, while patients with masses >3 cm should be evaluated with positron emission tomography (PET)/computed tomography 2 mo after completion of chemotherapy, with very selective administration of PC-RPLND. Late relapse occurring >2 yr after chemotherapy is rare, and surgery remains the mainstay of therapy in cases of resectable masses independent of tumor markers. There is still controversy on whether high-dose chemotherapy confers a survival benefit compared with conventional-dose chemotherapy in the salvage setting. Surgery should always be considered for resectable masses following salvage therapies or in chemoresistant disease to maximize chance of cure.

Conclusions

Patients with advanced GCTs can achieve long-term disease-free survival when chemotherapy is combined with expert and judicious resection of residual disease. PC-RPLND is recommended for residual masses >1 cm identified on postchemotherapy imaging in nonseminomatous GCT and possibly for PET-positive residual disease ≥3 cm in treated seminomas.     

Inguinal hernia in premature boys: Should we systematically explore the contralateral side?

Objective

Bilateral surgery has been largely advocated in premature boys with unilateral inguinal hernia owing to the high incidence of contralateral patent processus vaginalis. Recently, the potential morbidity of herniotomy in low birth-weight babies and the progress in pediatric anesthesia questioned this attitude. This study aims to evaluate the incidence of contralateral metachronous hernia in a large series of premature boys and to compare the morbidity of preventive versus elective surgery.

Methods

This retrospective multicenter analysis of 964 premature boys presenting with unilateral inguinal hernia operated from 1998 to 2012 included 557 infants who benefited from a unilateral herniotomy and 407 from a bilateral herniotomy (median follow-up 12 months).

Results

Contralateral metachronous hernia after unilateral surgery occurred in 11% (n = 60) without significant difference according to the initial symptomatic side (9.5% on right vs 13% on left, p > 0.05). Postoperative morbidity on the contralateral side was higher after preventive surgery than elective surgery with metachronous hernia (2.45% versus 0.9%, p = 0.05) especially for secondary cryptorchidism (1% vs 0%, p = 0.03). Despite the risk of metachronous incarcerated hernia, elective surgery did not increase the rate of testicular hypotrophy on the opposite side (0.7%, vs 0.7%, p > 0.05).

Conclusion

Systematic bilateral herniotomy is unnecessary in almost 90% of patients and has a significant morbidity. Secondary surgery for metachronous hernia does not increase the risk of testicular lesion and even reduces the risk of secondary cryptorchidism. These results, along with the risk of hypofertility reported after bilateral surgery, may justify treating only the symptomatic side in premature boys.     

Predictors of ovarian malignancy in children: Overcoming clinical barriers of ovarian preservation

Background/Purpose

Ovarian preservation is desirable in girls with benign ovarian masses. We aimed to 1) identify clinical predictors of malignant ovarian masses, 2) investigate how often ovarian tissue is present to preserve in benign masses, and 3) identify factors associated with successful ovarian preservation.

Methods

Retrospective analysis (1997–2012) of girls age 1–18 years with an ovarian mass managed operatively. Data on presenting symptoms, imaging, biochemical markers, treatment, outcome, and pathology were extracted.

Results

We identified 150 patients. Large mass size, solid components, and elevated tumor markers (AFP, βHCG, and/or LDH) were significantly predictive of malignancy. All masses < 10 cm, predominantly cystic, and with negative tumor markers were benign. Masses with all three of these characteristics would decrease a 20% malignancy pretest probability to a posttest probability of 0.25%. Benign masses managed by oophorectomy contained normal ovarian tissue in 76% of the specimens. For benign masses, successful ovarian preservation was significantly associated with size < 10 cm, predominantly cystic, laparoscopy, and absence of torsion or calcifications.

Conclusion

Ovarian masses that are < 10 cm, primarily cystic, and have negative tumor markers are most likely benign. Viable ovarian tissue is frequently present in benign masses, so significant efforts should be made for ovarian preservation.     

Solid pseudopapillary neoplasm of the pancreas in children: A 15-year experience and the identification of a unique immunohistochemical marker

Purpose

To review our 15-year experience in the management of children with solid pseudopapillary neoplasm (SPPN) of the pancreas at a single pediatric institution, to delineate a unique immunohistochemical marker for SPPN, and to analyze cumulative data on this rare entity in the literature.

Methods

We did a retrospective analysis of the demographic data, clinical presentation, immunohistochemical characteristics, surgical approach, and long-term outcomes of all patients diagnosed with SPPN between 1997 and 2012.

Results

There were 6 patients in the series, 5 females and 1 male. Median age at presentation and at surgery was 15 years (11–18 years). Abdominal pain was the presenting symptom in 5 cases and jaundice in 1 case. Two patients had a pancreatic head tumor and underwent a pylorus-preserving pancreaticoduodenectomy. Two patients had the tumor in the pancreatic tail and underwent a distal pancreatectomy with splenectomy. Two patients had the tumor in the pancreatic body and underwent a distal pancreatectomy with splenectomy in one case and with preservation of the spleen in the other. All tumors were completely resected with pathologic margins free of disease. The median maximum diameter was 6.8 cm (3 to 15 cm). On immunohistochemistry the tumors exhibited different combinations of non-specific markers like chromogranin, vimentin and neuron-specific enolase, but all tumors showed the highly SPPN-specific paranuclear dot-like immunoreactivity pattern for CD99 in the solid as well as in the pseudopapillary areas. No patient had metastasis at presentation. Median follow-up was 6.5 years (6 months to 15 years). There were no recurrences, no long-term metastasis, and all patients are disease-free.

Conclusion

Our series supports the concept that complete resection is necessary to achieve the best possible long-term results. Additionally, we demonstrate that SPPN exhibits a very unique immunostaining pattern for CD99 that is present in all cases.     

Élargissement des plages horaires de visites dans une unité de réanimation : l’avis des proches

Objective

The present study was aimed at assessing the opinion of the patient's relatives concerning the visiting hours in the ICU.

Method

The visiting relatives were questioned about the information delivered in the Unit (assessed as 0 for minimal and 10 for maximal assessments, respectively) and the hypothesis to extend the Unit's visiting hours. The responses were given independently by the relatives.

Results

Eighty-seven out of 64 relatives responded (63% females). The delivered information was assessed by a median note = 10 (interquartile: [8–10]). The current visiting times (2 h per day during the week, 6 h in weekend) were assessed as sufficient by 48 closest (58%). Fifty-four (67%, CI95% = [56–77]) requested more liberal visiting times and 38 (46%, CI95% = [36–57]) requested 24 h visiting policy. Five relatives (6%, CI95% = [1–11]) would like to be present during patient's care. Most relatives do not wish to assist to patient's care to avoid interfering with caregiver's workload (81%), to respect the patient's intimacy (49%) and by fear of being impressed by the care (23%). Forty percent of the relatives would like to help feeding the patient.

Conclusion

Most of the relatives wish for more liberal visiting times without interfering with patient's care.     

Biological characteristics of pediatric renal cell carcinoma associated with Xp11.2 translocations/TFE3 gene fusions

Purpose

To investigate the clinical features of pediatric Xp11.2 translocation renal cell carcinoma (RCC).

Methods

A retrospective review of 22 cases over 35 years.

Results

Xp11.2 translocation RCCs were identified in 13 boys and 9 girls with a median age of 10.5 years (range: 2.5–16 years). RCC presented with hematuria in 17, abdominal mass in 1, abdominal masses with hematuria in 2, abdominal pain with hematuria in 1, and as an incidental finding in 1 patient. Ten patients were classified stage I, 10 were stage III, and two were stage IV. Of the 10 patients with stage I RCCs, 3 patients with tumor measuring less than 7 cm had nephron-sparing surgery (NSS) and 17 patients underwent simple nephrectomy. A 15-cm tumor was incompletely removed in one patient and another patient with a 25-cm × 18-cm × 15-cm tumor had gross residual. Of the 15 patients followed up between 6 months and 35 years, 13 were still living and 2 had died after surgery.

Conclusions

Xp11.2 translocation RCC is the predominant form of pediatric RCC, associated with advanced stage at presentation. Nephrectomy is the usual treatment for RCC but NSS is an option for patients with tumors measuring < 7 cm. Patients with N + M0 maintained a favorable prognosis following surgery alone.     

Management of Neonatal Ovarian Cysts and its Effect on Ovarian Preservation

Background/Purpose

Management of asymptomatic neonatal ovarian cysts varies. Some surgeons advocate initial observation, while others recommend immediate operation depending on cyst size and complexity. This study aims to compare outcomes of initial observation versus primary surgery, focusing on incidence of postnatal torsion and ovarian preservation.

Methods

A retrospective study (1997–2012) of neonates with an ovarian mass was performed. Data on cyst size, ultrasound characteristics, clinical course, complications, and pathology were extracted.

Results

Thirty-seven neonates with asymptomatic ovarian cysts were identified (N = 25 observed, N = 12 primary surgery). Overall, 12/25 (48%) observed had successful cyst regression, including 3/8 (38%) cysts ≥ 50 mm and 6/15 (40%) complex. 13/25 patients (52%) underwent surgery for failure of cyst regression (11/13) or concern for interval torsion (2/13). Postnatal torsion occurred in 1/25 observation patients (4%), or 1/8 (13%) with cysts ≥ 50 mm. Overall rate of ovarian preservation between groups was not statistically different [6/8 (75%) observed versus 8/9 (89%) primary surgery; P = 0.577]. Pathology found viable ovarian tissue in all oophorectomy specimens (N = 3).

Conclusions

Postnatal torsion is rare. A period of observation spares half of neonates from an operation, without decreasing ovarian salvage. Initial management should consist of observation, regardless of size or complex characteristics. If operative intervention is necessary, ovary preserving techniques should be utilized.     

Does the volume of ductal carcinoma in situ impact the positive margin rate in patients undergoing breast conservation for invasive breast cancer?

Background

We sought to investigate whether the volume of ductal carcinoma in situ (DCIS) impacts margin status in patients undergoing lumpectomy for invasive breast cancer.

Methods

We identified 358 patients with stages I–III invasive breast cancer and associated DCIS who were treated with breast-conserving therapy from 1999 to 2009. Data included patient and tumor characteristics, percentage of DCIS (<25%, 26%–50%, or >50%), and pathologic outcomes. Data were compared using chi-square and Fisher exact tests. A two-tailed P value of <0.05 was considered significant.

Results

The 358 patients had a mean age of 58 ± 13 y; 260 (72%) patients were >50 y. The volume of DCIS in lumpectomy specimens was <25% in 296 (83%) patients, 26%–50% in 29 (8%) patients, and >50% in 33 (9%) patients. Tumors with decreasing DCIS volume were more likely to be estrogen receptor positive (239 [82%] with <25% DCIS, 21 [72%] with 26%–50% DCIS, 22 [67%] with >50% DCIS; P = 0.026). DCIS volume was not significantly associated with patient age, tumor size, grade, and stage, nodal status, progesterone receptor status, or Her2 status (P > 0.05). Overall, 137 (38%) patients had one or more positive margins, including 97 of 296 (33%) with <25% DCIS volume, 17 of 29 (59%) with 26%–50% DCIS volume, and 23 of 33 (70%) with >50% DCIS volume (P < 0.0001).

Conclusions

The volume of DCIS associated with an invasive breast cancer in the final lumpectomy specimen is a strong predictor of positive surgical margins. Future analyses will focus on the ability of core pathology to provide this information for intraoperative surgical decision making.     

Impact of the severity of trauma on early retirement

Objective

To assess the association between Injury Severity Score (ISS) and subsequent risk of early retirement.

Design

Observational cohort study with follow-up based on prospectively collected data. Hospital-based data were linked to national register data on pension reception and vital status.

Setting

Level-one urban trauma centre.

Participants

Patients aged 18–64 years entering the trauma centre in Copenhagen during 1999–2007 who were alive after three days were followed until early retirement, death or emigration.

Main outcome measures

Primary outcome was early retirement, defined as receiving disability pension (unintentional) or voluntary early retirement pension (intentional) before the regular age of retirement (65 years). Relative risk of early retirement according to ISS (low, ISS 1–15 vs. high, ISS 16–75) was assessed using Cox proportional hazards regression, adjusted for age and gender.

Results

Of all 6687 patients admitted to the trauma centre, a total of 1722 trauma patients were included and followed for a median of 6.2 years (interquartile range (IQR) 3.7–9.1). Of these, 1305 (75.8%) were males, median age was 35.0 years (IQR 25.4–46.5), and median ISS was 16 (IQR 9–25). Three hundred and twenty-two patients retired during follow-up. Patients with high ISS, compared to patients with low ISS, had an increased risk of early retirement, adjusted hazard ratio 2.60 (95% confidence interval (CI) 2.05–3.30; p < 0.001). Relative increase in retirement risk was 1.04 (95% CI 1.03–1.05) per ISS point and 1.03 (95% CI 1.03–1.04) per year older. Gender was not found to be a significant risk factor (p = 0.69). Five-year absolute risks of early retirement were 9.9% (95% CI 7.8–12.0%) for the low ISS group and 24.6% (95% CI 21.6–27.5%) for the high ISS group.

Conclusions

The risk of early retirement is 2.6 times higher in severely injured patients (ISS 16–75) than the risk in low to moderately injured patients (ISS 1–15) and they have a high absolute 5-year risk as well. Early, targeted interventions to assist with return to work might be able to reduce this risk.     

Features Associated with Recurrence Beyond 5 Years After Nephrectomy and Nephron-Sparing Surgery for Renal Cell Carcinoma: Development and Internal Validation of a Risk Model (PRELANE score) to Predict Late Recurrence Based on a Large Multicenter Database (CORONA/SATURN Project)

Background

Approximately 10–20% of recurrences in patients treated with nephrectomy for renal cell carcinoma (RCC) develop beyond 5 yr after surgery (late recurrence).

Objective

To determine features associated with late recurrence.

Design, setting, and participants

A total of 5009 patients from a multicenter database comprising 13 107 RCC patients treated surgically had a minimum recurrence-free survival of 60 mo (median follow-up [FU]: 105 mo [range: 78–135]); at last FU, 4699 were disease free (median FU: 103 mo [range: 78–134]), and 310 patients (6.2%) experienced disease recurrence (median FU: 120 mo [range: 93–149]).

Interventions

Patients underwent radical nephrectomy or nephron-sparing surgery.

Outcome measurements and statistical analysis

Multivariable regression analyses identified features associated with late recurrence. Cox regression analyses evaluated the association of features with cancer-specific mortality (CSM).

Results and limitations

Lymphovascular invasion (LVI) (odds ratio [OR]: 3.07; p < 0.001), Fuhrman grade 3–4 (OR: 1.60; p = 0.001), and pT stage >pT1 (OR: 2.28; p < 0.001) were significantly associated with late recurrence. Based on accordant regression coefficients, these parameters were weighted with point values (LVI: 2 points; Fuhrman grade 3–4: 1 point, pT stage >1: 2 points), and a risk score was developed for the prediction of late recurrences. The calculated values (0 points: late recurrence risk 3.1%; 1–3 points: 8.4%; 4–5 points: 22.1%) resulted in a good-, intermediate- and poor-prognosis group (area under the curve value for the model: 70%; 95% confidence interval, 67–73). Multivariable Cox regression analysis showed LVI (HR: 2.75; p < 0.001), pT stage (HR: 1.24; p < 0.001), Fuhrman grade (HR: 2.40; p < 0.001), age (HR: 1.01; p < 0.001), and gender (HR: 0.71; p = 0.027) to influence CSM significantly. Limitations are based on the multicenter and retrospective study design.

Conclusions

LVI, Fuhrman grade 3/4, and a tumor stage >pT1 are independent predictors of late recurrence after at least 5 yr from surgery in patients with RCC. We developed a risk score that allows for prognostic stratification and individualized aftercare of patients with regard to counseling, follow-up scheduling, and clinical trial design.     

Treatment of undifferentiated embryonal sarcoma of the liver in children—single center experience

Background

Undifferentiated embryonal sarcoma of the liver (UESL) represents less than 5% of all malignant hepatic tumors in childhood. It is considered an aggressive neoplasm with an unfavorable prognosis. The aim of this paper is to present a single center experience in the treatment of children with UESL.

Materials and methods

Ten children with UESL were treated between 1981 and 2012. Age at diagnosis ranged from 4 months to 17 years (median age, 6 years and 9 months). Surgery after neoadjuvant chemotherapy (CHT) was performed in 7 patients, and in 3 patients primary surgery was done. Adjuvant chemotherapy was administered in all 10 patients (CYVADIC, CAV, CAV/ETIF/IF + ADM, CDDP/PLADO). Right hemihepatectomy was performed in 1 patient, extended right hemihepatectomy in 6, and partial resection of the right lobe (segments V-VI, segment V) in 2 patients. One patient with unresectable tumor affecting both lobes was listed for liver transplantation (LTx).

Results

Follow-up from diagnosis ranged from 50 to 222 months (mean 138 months). Among 9 patients treated with partial liver resection, distant metastases/local recurrence was not observed in any, and disease-free survival in this group is 100% (9 patients alive). The patient that underwent liver transplantation died of multiorgan failure 4 months postoperatively.However, this patient was misdiagnosed as having hepatoblastoma (HBL) and received PLADO chemotherapy. The overall survival rate is 90%.

Conclusion

Excellent results with long-term survival can be achieved in children with UESL with conventional therapy, including a combination of neoadjuvant and adjuvant chemotherapy and surgery, even in large extensively growing tumors.     

Biochemical Recurrence Following Robot-Assisted Radical Prostatectomy: Analysis of 1384 Patients with a Median 5-year Follow-up

Background

There is a paucity of data on long-term oncologic outcomes for patients undergoing robot-assisted radical prostatectomy (RARP) for prostate cancer (PCa).

Objective

To evaluate oncologic outcomes in patients undergoing RARP at a high-volume tertiary center, with a focus on 5-yr biochemical recurrence–free survival (BCRFS).

Design, setting, and participants

The study cohort consisted of 1384 consecutive patients with localized PCa who underwent RARP between September 2001 and May 2005 and had a median follow-up of 60.2 mo. No patient had secondary therapy until documented biochemical recurrence (BCR). BCR was defined as a serum prostate-specific antigen ≥0.2 ng/ml with a confirmatory value. BCRFS was estimated using the Kaplan-Meier method. Event–time distributions for the time to failure were compared using the log-rank test. Univariable and multivariable Cox proportional hazards regression models were used to determine variables predictive of BCR.

Intervention

All patients underwent RARP.

Measurements

BCRFS rates were measured.

Results and limitations

This cohort of patients had moderately aggressive PCa: 49.0% were D’Amico intermediate or high risk on biopsy; however, 60.9% had Gleason 7–10 disease, and 25.5% had ≥T3 disease on final pathology. There were 189 incidences of BCR (31 per 1,000 person years of follow-up) at a median follow-up of 60.2 mo (interquartile range [IQR]: 37.2–69.7). The actuarial BCRFS was 95.1%, 90.6%, 86.6%, and 81.0% at 1, 3, 5, and 7 yr, respectively. In the patients who recurred, median time to BCR was 20.4 mo; 65% of BCR incidences occurred within 3 yr and 86.2% within 5 yr. On multivariable analysis, the strongest predictors of BCR were pathologic Gleason grade 8–10 (hazard ratio [HR]: 5.37; 95% confidence interval [CI], 2.99–9.65; p < 0.0001) and pathologic stage T3b/T4 (HR: 2.71; 95% CI, 1.67–4.40; p < 0.0001).

Conclusions

In a contemporary cohort of patients with localized PCa, RARP confers effective 5-yr biochemical control.     

Review of risk factors for the development of contralateral breast cancer

Background

Women treated for breast cancer have an increased risk for developing metachronous contralateral breast cancer (CBC). Patient perception of this risk is often overestimated and has been found to contribute to the decision to undergo contralateral prophylactic mastectomy. An individual's risk is dependent on both patient and tumor characteristics. This review examines and summarizes the current literature on the factors that affect CBC risk.

Data Sources

English-language publications with the keyword “contralateral breast cancer” were identified through a MEDLINE literature search.

Conclusions

The global incidence of CBC is decreasing, a trend that is attributed to more effective adjuvant therapies. Patients with BRCA germ-line mutations demonstrate the highest risk for CBC. In the absence of known genetic mutations, patients with strong family histories who are diagnosed at young ages (<35 years) with estrogen receptor–negative index tumors appear to have a higher incidence of CBC.     

Major abdominal surgery for cancer: Does epidural analgesia have a long-term effect on recurrence-free and overall survival?

Background

Retrospective studies have suggested that regional analgesia combined with general anaesthesia could decrease cancer recurrence. The purpose of this study was to assess the influence of regional analgesia on recurrence-free (RFS) and overall survival in patients undergoing major intra-abdominal surgery for cancer.

Method

Patients previously included in a prospective randomized study comparing two postoperative techniques of analgesia were retrospectively studied. The EP group received general anaesthesia with bupivacaine thoracic epidural analgesia and the SC group received general anaesthesia with fentanyl followed by continuous subcutaneous morphine.

Results

One hundred and thirty-two patients were analyzed (63 and 69 in SC and EP group, respectively) with a 17-year-median follow-up. After 5 years, RFS was 43% [95% CI: 32%–55%] in EP group and 24% [95% CI: 15%–36%] in SC group, but the difference did not reach statistical significance for RFS nor for overall survival (P = 0.10 and 0.16 respectively). Using multivariable analysis over the whole follow-up period, the type of analgesia was not a statistically significant predictive factor for RFS (EP/SC, HR = 1.3 [95% CI: 0.8–2.0%]). The anaesthesia effect changed moderately over the follow-up and HR for overall survival (EP/SC) reached statistical significance after 5, 6 and 8 years.

Conclusion

Despite a trend in favour of the epidural, this retrospective review of patients included in a previous randomized study failed to demonstrate a statistically significant association between the perioperative analgesia and RFS after abdominal surgery for cancer. The duration of follow-up may have an impact on the analgesia effect on survival.     

Implementation of laparoscopic splenectomy in children and the incidence of portal vein thrombosis diagnosed by ultrasonography

Background

The aim of this study is to evaluate if symptomatic or asymptomatic PVT, as diagnosed with ultrasonography (US), occurs more often in children after the introduction and implementation of LS compared to open splenectomy.

Methods

A retrospective cohort of 76 splenectomized patients for benign hematological disease were analyzed, 24 after open splenectomy (OS) and 52 after LS.

Results

In six of the OS and 40 after LS a postoperative US was obtained. In two patients after LS, a PVT was seen on US. Both patients were symptomatic and also underwent a laparoscopic cholecystectomy. The length of stay in the hospital was significantly shorter for LS (median 4.5 days, range 2–12) compared to OS (median 7 days, range 5–12), (P = .00). Median operation time of OS was 65 min (range 35–130 min) and of LS 170 min (range 85–275 min) (P = .00). There was no difference in postoperative complications.

Conclusion

The risk of developing a PVT after laparoscopic splenectomy seems low, and thus LS is not contraindicated in patients with benign hematological disease. When combining LS and laparoscopic cholecystectomy, prophylactic heparin might be considered.     

Le Smur meilleur vecteur pour une analgésie des patients traumatisés à l’arrivée aux urgences

Objectives

To find out prehospital factors linked with low pain on arrival into a traumatic emergency unit.

Methods

A 4-month monocentric prospective study, including patients recruited at their arrival into a traumatic emergency unit. Pain (with a numerical rating scale [NRS]), anxiety, prehospital care including the type of transportation (Physician staffed ambulances Smur, emergency medical technicians or firemen ambulances), immobilization and analgesics used were evaluated. These data were collected on arrival at the hospital by the ED orientation nurse. Uni- and multivariate analysis were performed to identify low pain's predictive factors (e.g. with a NRS ≤ 3).

Results

Three hundred and four patients were recruited, mean age = 51 ± 25, sex ratio = 1.8, mean pain/10 = 5.8 ± 2.9, 64% with a moderate or severe pain on arrival (NRS > 3). For one third of patients, immobilizations hadn’t been performed during the prehospital phase. Medical management by Smur is a low pain predictive factor (OR = 5.8; CI 95% = 1.4–24.16), anxiety is a pejorative factor (OR = 0.53 CI 95% = 0.38–0.75).

Conclusion

Our study highlights the physician staffed ambulances’ effectiveness in prehospital trauma victim's management and raises the question of anxiolysis as an adjuvant for traumatic pain management.