American Pediatric Surgical Association New Technology Committee review on video-assisted thoracoscopic surgery for childhood cancer

doi:10.1016/j.jpedsurg.2010.06.049

Journal of Pediatric Surgery

Volume 45, Issue 11, November 2010, Pages 2227-2233

https://doi.org/10.1016/j.jpedsurg.2010.06.049 Get rights and content

Abstract

Background/Purpose

Although the use of minimally invasive surgical (MIS) techniques for children with cancer is being practiced by some, its role remains unclearly defined. The purpose of this review was to describe the current literature on MIS for thoracic and mediastinal lesions in children.

Methods

We performed a literature search for English studies that evaluated MIS techniques for biopsy or resection in children with suspected or established cancer. Only studies with greater than 20 patients were included in the review.

Results

Ten studies were included for review. Each represented institutional retrospective reviews of experience. Seven were single-institution studies, and 3 were multi-institutional. There were no prospective nor randomized identified.

Conclusions

Based on primarily retrospective and observational data, the use of MIS for children with cancer who have pulmonary and mediastinal lesions seems to be effective and safe. Ideally, prospective studies are needed to evaluate this further.

Section snippets

Search strategy

A handful of studies have focused on children with cancer who have had MIS. In reviewing the literature, we chose to include only studies with greater than 20 patients and those focused either exclusively on video-assisted thoracoscopic surgery (VATS), or where the evidence could be properly extracted in those studies that combined laparoscopy and VATS. Ten studies met the inclusion criteria and are summarized in Table 1. All 10 studies were retrospective; 7 were single-institution studies and

VATS for lung biopsy only

In patients with pulmonary infiltrates, for the purpose of this study, success was defined as making an accurate diagnosis on lung biopsy. Smith et al [5] describe a cohort of 52 children with cancer who underwent 63 thoracoscopic procedures. Of the 63 procedures, 15 (24%) were for pulmonary infiltrates in children who were critically ill and immunosuppressed. The lung biopsy was used in 1 of 2 ways: diagnosing an unexpected cause of the infiltrates, thereby leading to new therapy, or

Discussion

The trend toward using MIS in the abdomen and chest has been because of the belief that it offers distinct advantages compared with thoracotomy. Although superior cosmesis is generally accepted, perceived advantages include prevention of functional disorders of the thorax and shoulder, less postoperative pain, fewer complications, more rapid recovery time, fewer adhesions, less sampling error, and quicker resumption of chemotherapy [3], [14], [29], [39], [40]. Ure and colleagues [29] discuss

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En el tratamiento multidisciplinar del paciente oncológico pediátrico se va a requerir de múltiples pruebas de imagen, tomas de biopsias y resecciones tanto para el diagnóstico como para la estadificación inicial y reestadificación posterior. La existencia de nódulos pulmonares en estos pacientes no siempre es sinónimo de metástasis, por lo que un correcto diagnóstico influirá en su tratamiento y supervivencia. La localización percutánea de los nódulos pulmonares es clave en dos aspectos: por un lado, permite al cirujano resecar la menor cantidad de tejido pulmonar posible, y por el otro garantiza la inclusión del nódulo en la pieza de resección, ya que sin nuestra ayuda esta labor puede ser imposible (nódulos de muy pequeño tamaño, separados de la superficie pleural y por tanto no visibles con el toracoscopio). Presentamos una revisión de la técnica de localización de nódulos pulmonares con arpón para resección toracoscópica con claves para mejorar la misma.
In the multidisciplinary treatment of pediatric oncologic patients, multiple imaging tests, biopsies, and resections are required for diagnosis, initial staging, and posterior restaging. In these patients, pulmonary nodules are not always metastases, so the correct diagnosis of these lesions affects their treatment and the patient's survival. Percutaneous localization of pulmonary nodules is key for two reasons: it enables the surgeon to resect the smallest amount of lung tissue possible and it guarantees that the nodule will be included in the resected specimen. Without percutaneous localization, it can be impossible to accomplish these two objectives in patients with very small nodules that are separated from the pleural surface and therefore impossible to see by thoracoscopy. This article reviews the technique for hook-wire localization of pulmonary nodules and the keys to ensuring the best results.
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Citation Excerpt :
The use of video-assisted thoracoscopy (VATS) for the resection of benign and malignant lesions of the chest has been more routinely implemented than laparoscopic approaches have been in the abdomen (Fig. 4). In 2010 the American Pediatric Surgical Association New Technology Committee approved the use of MIS in children with pulmonary and mediastinal neoplasms based on a review of 10 studies that evaluated MIS techniques for biopsy or resection of thoracic lesions.60 In a recent review of children undergoing laparoscopic or thoracoscopic resection for the diagnosis or treatment of a solid malignant tumor at Children’s Hospital Colorado over a 10-year period, 78 (74%) were thoracoscopic, although three-quarters of these were for biopsy and only 27% were for definitive resection.61
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Citation Excerpt :
No recurrence, secondary malignancy, or late effect of treatment was observed during an average follow-up period of 61.0±49.1 months for the VATS group and 87.3±69.7 months for the OT group. Although VATS is often the preferred method for surgical resection in adults, its safety and efficacy in children remains unclear because of a lack of clinical evidence [5]. Moreover, even though VATS is suitable for most lung diseases [6], its role in mediastinal tumor resection has been questioned because of technological limitations and the small working space.
Video-assisted thoracic surgery (VATS) has been increasingly used for the diagnosis and treatment of thoracic diseases. Pediatric mediastinal tumors are often difficult to resect because of their proximity to important organs. For this reason, VATS is not established as a standard surgical approach for such tumors. We compared the efficacy and safety of mediastinal tumor resection in children using open thoracotomy (OT) and VATS.
A total of 31 children underwent mediastinal tumor resection (21 by VATS and 10 by OT). These nonrandomized approaches were retrospectively compared for incidence of operative complications, morbidity, and mortality.
Tumor sizes and operation times were similar between groups. However, the VATS group required significantly fewer blood transfusions and shorter durations of thoracic drainage and hospital stays (p < 0.05). Complications greater than grade 2 on the Clavien–Dindo classification occurred in four patients treated by VATS and OT. No delayed effects were noted in the survivors of either group. A patient with clear cell sarcoma of the kidney who underwent OT relapsed and died.
Although complication rates were similar between the two approaches, VATS was suggested as less invasive because of fewer blood transfusions required, and shorter thoracic drainage and hospital stay durations.
Video-assisted surgery in children: Current progress and future perspectives
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L’objectif de ce travail était de réaliser une mise au point sur la place de la chirurgie vidéo-assistée en chirurgie viscérale pédiatrique et de discuter ses perspectives d’avenir. Les techniques de vidéochirurgie ont permis de minimiser l’impact esthétique et traumatique des interventions en chirurgie viscérale et sont en constant développement chez l’adulte comme chez l’enfant. Une formation plus précoce des chirurgiens à ces techniques, associée aux progrès anesthésiques et aux améliorations technologiques, a amélioré le savoir-faire, permettant de pratiquer des interventions plus complexes par cette voie d’abord. Si la plupart des interventions viscérales ont déjà été réalisées par voie cœlioscopique, la littérature peine à la définir comme un gold standard, notamment en raison des difficultés à démontrer des bénéfices esthétiques ou de diminution des douleurs. L’intérêt de la cœlioscopie pour la cholécystectomie est désormais admis en termes de suites opératoires sans augmentation des complications. Pour le traitement chirurgical du reflux gastro-œsophagien et pour la splénectomie, aucune étude pédiatrique ne conclut à la supériorité de la cœlioscopie mais des données chez l’adulte la suggèrent. L’abord par lomboscopie permet de réaliser des interventions urologiques en évitant de larges lombotomies. La cœlioscopie peut servir également d’outil diagnostique, comme pour les testicules non palpables, suivi d’un geste thérapeutique si nécessaire. L’appendicectomie par cette technique reste encore sujette à débat. Les études sont contradictoires et la chirurgie ouverte garde une place importante, mais la proportion de cœlioscopie dans cette indication semble augmenter. La cœlioscopie reste controversée pour la chirurgie oncologique pédiatrique.
This review presents the evidence of video-assisted surgery in the pediatric population and discusses future progress in this field. Videosurgery minimizes the cosmetic impact and the pain induced by open procedures and has been in constant development in adults and children. Earlier training of surgeons and residents combined with advances in anesthetics and technology have expanded the use of videosurgery for more complex interventions. Although most feasible surgical procedures have been performed by laparoscopy, the literature has not yet defined it as the gold standard for most interventions, especially because of the lack of evidence for many of them. However, laparoscopy for cholecystectomy is now the preferred approach with excellent postoperative outcomes and few complications. Although no evidence has been demonstrated in children, laparoscopy has been shown to be superior in adults for gastroesophageal reflux disease and splenectomy. Laparoscopic appendectomy remains controversial. Nevertheless, meta-analyses have concluded in moderate but significant advantages in terms of pain, cosmetic considerations, and recovery for the laparoscopic approach. Laparoscopy is now adopted for undescended testes and allows both localization and surgical treatment if necessary. For benign conditions, videosurgery can be an excellent tool for nephrectomy and adrenalectomy. However, laparoscopy remains controversial in pediatric surgical oncology.
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Review articleAmerican Pediatric Surgical Association New Technology Committee review on video-assisted thoracoscopic surgery for childhood cancer

Abstract

Background/Purpose

Methods

Results

Conclusions

Section snippets

Search strategy

VATS for lung biopsy only

Discussion

J Vasc Interv Radiol

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Am Coll Surg

Lancet

J Pediatr Surg

Thorac Surg Clin

Thorac Surg Clin

Ann Thorac Surg

J Pediatr Surg

Thorac Surg Clin

J Pediatr Surg

Minimally invasive surgery in children with cancer

Cancer

Present day concepts of thoracoscopy as a modality in pediatric cancer management

Int Surg

The application of minimal access procedures in infants, children, and young adults with pediatric malignancies

J Laparoendosc Adv Surg Tech A

Minimally invasive surgery and clinical decision-making for pediatric malignancy

Surg Endosc

Thoracoscopic surgery in childhood cancer

J Pediatr Hematol Oncol

Minimally invasive surgery for pediatric solid neoplasms

Am Surg

Minimally invasive surgery in pediatric cancer patients

Ann Surg Oncol

Review article
American Pediatric Surgical Association New Technology Committee review on video-assisted thoracoscopic surgery for childhood cancer