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NEUROBLASTOMA
CONSIDERATIONS FOR MIS
CHRISTINA KIM MD, FAAP
PEDIATRIC UROLOGY ASSOCIATES
LAPAROSCOPIC ADRENALECTOMY
• 1992
•
Gagner et al: First transperitoneal adrenalectomy
• Adult experience
•
Faster recovery, lower EBL, Less pain, better cosmesis
•
Gold standard for benign lesions and select malignant lesions
• Pediatric Role?
Catellani et al. JSLS. 2014 Jul-Sep;18(3).
RETROPERITONEAL APPROACH
• Pros
•
Directly on top of adrenal vein
•
Avoids also colonic mobilization
•
Minimizes the risk of injury to hollow viscera
•
Minimal risk of adhesion formation
• Cons
•
reversed orientation of the kidney and hilum
•
significantly smaller working space
Yankovic et al. J Pediatr Urol. 2014 Apr;10(2):400.e1-2
Literature Outcome Data for Laparoscopic Adrenalectomy in Children
Study
# Patients
de Barros et al
7
Lopes et al
17
St Peter et al
140
Sukumar et al
7
Eassa et al
2
Nerli et al
18
Lopez et al
5
Laje et al
Skarsgard et al 20
Saad et al
Kadamba et al
10
De Lagausie et al 9
Miller et al
17
Castilho et al
13
Catellani et al
4
Technique
T
T
NS
T
R
T
R
8
T
6
T
T
T
T
T
# Bilateral
0
0
5
3
0
0
1
T
0
T
1
0
0
1
0
OR Time(min)
138.6
138.5
130.2*
111/263
255
95
154†
0
101
0
141/330
85
120
107/180
105
Conversion(%)
14.3
0
9.9
0
0
0
0
99
5
149.2
20
11.1
7.7
15.4
0
Transfusion (%) Complications(%)Hospital Stay
14.3
5
2.8
0
0
0
—
0
0
0
0
0
0
7.7
0
0
0
0.7
14.3
0
0
—
0
0
—
0
11.1
—
0
0
2.9
3.5
NS
5,3
1.5
2.1
—
0
1.5
—
5.5
4.5
1.5
5.5
3.75
1.5
5.7
POSITIONING RIGHT ADRENALECTOMY
Reverse Trendelenberg
Semilateral decubitus
Flex to get space between anterior superior iliac
crest and costal margin
Start between medial edge of adrenal and IVC
Go Caudal to Cephalad direction and access take
off of Right adrenal vein from Vena Cava
POSITIONING LEFT ADRENALECTOMY
Get separation between anterior plane of kidney
and lateral/dorsal to spleen and tail of pancreas
Release splenocolic and spleen’s suspensory
ligaments
Follow splenic vein to Left renal vein, Left Adrenal
vein and Left adrenal artery
Ligate adrenal vessels with tissue sealer or clips
Remove specimen in endocatch bag
INTERNATIONAL PEDIATRIC ENDOSURGERY GROUP
GUIDELINES
• < 6 cm
• No vascular encasement
• No adjacent organ involvement
• No absolute contraindication
• Can do post chemotherapy
ADRENAL NEUROBLASTOMA
• Single center
• 79 patients
• Based on COG trial enrollment
•
High 49
•
Intermediate/Low risk 30
• Lap candidates
•
NO vascular involvement
•
Tumor <5 cm
Kelleher et al. J Pediatr Surg. 2013 Aug;48(8):1727-3
ADRENAL NEUROBLASTOMA
• 7 High risk had laparoscopy
•
6 had favorable outcomes
• Increased mortality
•
Higher tumor stage
•
Earlier recurrence
IMAGE DEFINED RISK FACTORS
RISK FACTORS FOR MIS WITH NEUROBLASTOMA
• Using image factors
• Image Defined Risk Factors (IDRFs)
• 5 of 20 patients had positive IDRF
•
4 of 5 had complications
•
No complications in those with Negative IDRF
• Deformation or Subtotal Encasement of Vena Cava
•
Consider Positive IDRF
Tanaka et al. Pediatr Surg Int. 2016
Sep;32(9):845-50.
MIS AND NEUROBLASTOMA SITES
• 39 patients
• IDRF positive 19 IDRF Negative 20
• Locations: peravertebral (18); perivascular (5); adrenal (13); pleural (2) pelvic (1)
• Mean follow up 25 months
• Overall survival 98%
• No complications for abdominal and adrenal
Irtan et al. Pediatr Blood Cancer. 2015
Feb;62(2):257-261
WILMS TUMOR AND MIS
• 24 patients
• High experience of surgeons
• Inadequate Lymph node sampling
• Mean follow up 47 months
•
Overall survival
•
Event free survival
•
1 local relapse
Warmann et al. J Pediatr Surg. 2014 Nov;49(11):1544-8.
COCHRANE DATABASE
• 2015, 2012, 2010
• Reviewed CENTRAL, Pubmed, Ovid
• MIS in solid tumors (thoracic and abdominal)
• NO Randomised controlled trials (RCTs) or controlled clinical trials (CCTs)
•
542 reviews
• All reports were case reports, cohort studies, retrospective reviews
Van Delan EC et al. Cochrane Database Syst Rev. 2015 Jan 5
de Lijster et al. Cochrane Database Syst Rev. 2012 Jan 18
De Lijster et al. Cochrane Database Syst Rev. 2010 Mar 17
QUESTIONS
• [email protected]
• 860-409-0413