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General Perspective and Overview

The relative risks and complications increase proportionately according to the site, size, and type and complexity of the problem being addressed within the chest and in relation to the age of the patient and other comorbidities. This is principally related to the surgical accessibility, ability to resect, risk of lung injury and respiratory compromise, functional reserve, technical ease, and the ability to achieve correction of the problem.

The main serious complications are bleeding and infection, which can be minimized by the adequate exposure, mobilization, technical care, and avoiding lung injury and hematoma formation. Infection is the main sequel of tissue injury, respiratory obstruction, and hematoma formation and may arise from preexisting infection or be newly acquired. This can lead to pleural infection, lung consolidation, abdominal sepsis, abscess formation, and systemic sepsis. Multisystem failure and death remain serious potential complications from surgery and systemic infection.

Positioning on the operating table has been associated with increased risk of deep venous thrombosis and nerve palsies, especially in prolonged procedures. Limb ischemia, compartment syndrome, and ulnar and common peroneal nerve palsy are recognized potential complications, which should be checked for, as the patient’s position may change during surgery.

Mortality associated with most major surgical procedures is usually low and principally associated with infection or thromboembolism. Procedures involving the major vessels, vena cava, or larger arteries carry higher risks associated with possible serious bleeding and infection, including increased risk of mortality. Rare failure of stapling devices can cause catastrophic bleeding. In children, mortality may more relate to comorbidities, for example, from underlying congenital problems.

This chapter therefore attempts to draw together in one place the estimated overall frequencies of the complications associated with pediatric tumor procedures, based on information obtained from the literature and experience. Not all patients are at risk of the full range of listed complications. It must be individualized for each patient and their disease process but represents a guide and summary of the attendant risks, complications, and consequences.

With these factors and facts in mind, the information given in this chapter must be appropriately and discernibly interpreted and used.

Important Note

It should be emphasized that the risks and frequencies that are given here represent derived figures. These figures are best estimates of relative frequencies across most institutions, not merely the highest-performing ones, and as such are often representative of a number of studies, which include different patients with differing comorbidities and different surgeons. In addition, the risks of complications in lower- or higher-risk patients may lie outside these estimated ranges, and individual clinical judgment is required as to the expected risks communicated to the patient and staff or for other purposes. The range of risks is also derived from experience and the literature; while risks outside this range may exist, certain risks may be reduced or absent due to variations of procedures or surgical approaches. It is recognized that different patients, practitioners, institutions, regions, and countries may vary in their requirements and recommendations.

For complications related to other associated/additional surgery that may arise during pediatric tumor surgery, see the relevant volume and chapter.

Surgery for Neuroblastoma

Description

Neuroblastoma is one of the more common solid tumors in childhood. It arises during fetal or early postnatal life from sympathetic cells derived from the neural crest and can be found in the adrenal medulla, sympathetic ganglia, or within preaortic ganglia. It is a highly malignant progressive tumor and the outlook for most children with advanced disease remains dismal. However, spontaneous regression and tumor maturation may occur into a benign ganglioneuroma. The incidence of neuroblastoma is about 1 in 10,000 with more than half presenting <4 years of age and 95 % having presented by the age of 10. Most arise in the abdomen, with the adrenal being the most common site (50 %), with tumors arising in the mediastinum in about 10 % and pelvis in 6 %. Metastases occur frequently to bone, liver, and lung. The management is based on the restratification that takes into account not only the stage but also clinical and biological variables. Low-stage tumors with favorable biological profiles are managed by surgical excision alone, with aggressive chemotherapy used for those with a poor biological profile. The management of high-risk disease is usually not amenable to resection. These children undergo biopsy followed by aggressive high-dose chemotherapy, with responders undergoing surgical resection of residual primary tumor with subsequent radiation to the primary and metastatic tumor sites. The incision(s), extent of resection, and complications are largely determined by the location and extent of disease.

Anatomical Points

Preoperative planning using CT and MRI scans is essential in determining the anatomical extent of the tumor and the involvement and displacement of adjacent organs. Relatively large transverse incisions are required depending on tumor size and required access. The sigmoid and descending colons are reflected and spleen, pancreas, and the stomach mobilized to enable full access to the tumor. Initially, all major relevant vessels involved in the tumor should be completely displayed. Neuroblastoma does not usually invade the tunica media of major blood vessels and a plane of dissection may be developed between the tunica adventitia and tunic media.

Table 4.1 Surgery for neuroblastoma estimated frequency of complications, risks, and consequences
Full size table

Perspective

See Table 4.1. The extent of disease dictates the extent of surgery and associated type and risk of complications. The dissection required to remove neuroblastoma is extremely tedious and time consuming with complications related specifically to the site of tumor and the respective vessels/organs involved. Extensive surgery is associated with a higher rate of complications and notably major complications. Injuries to major vessels, including the aorta, vena cava, and renal and mesenteric vessels, can result in major vascular complications with a significant operative mortality. Severe bleeding and injury to adjacent structures cause the most common immediate devastating problems that lead to immediate and further major complications such as infection, peritonitis, and abscess formation. Renal loss due to involvement with tumor, arterial damage, or renal vein thrombosis is a common complication. It is common to identify substantial lymphatic leakage during the course of surgery, and chylous ascites in the immediate postoperative period is frequently seen. This usually resolves within a week, but may persist causing severe distension. The insertion of peritoneovenous shunt may be required when the large collection persists and becomes symptomatic. Postoperative diarrhea is common in the initial postoperative period probably due to the dissection of the celiac and superior mesenteric arteries with damage to the inhibitory sympathetic nerve supply. This usually settles but may persist, producing problems in the long-term survivors. Injury to the pancreas can result in pancreatic leakage with collections, pancreatitis, infections, and external fistulae. Small bowel obstruction due to adhesions is relatively infrequent but may occur after extensive operative dissection and associated radiotherapy. Management may require major surgery. Pelvic neuroblastoma is associated with a significant incidence of neurological problems including sciatic nerve palsy, urinary and fecal incontinence, neuropathic bladder, and leg weakness. Death occurs in a significant number due to the major associated vascular injuries, splenic damage, and associated metabolic problems.

Major Complications/Consequences

Early death is usually related to catastrophic bleeding or early postoperative infection leading to abscess formation, systemic sepsis, and multisystem organ failure. Late mortality is due to tumor recurrence. Renal loss is common in children with compromised renal function following chemotherapy. Bowel injury is often associated with ischemia and can be debilitating, especially in a child who has had radiotherapy. Significant lymphatic leakage from thoracic duct injury resulting in lymphatic or chylous ascites can be debilitating. Pancreatic leakage, persistent collections, and fistulas while rare can require surgical intervention. Small bowel obstruction can be a recurrent major issue requiring repeated surgery, carrying considerable risk. Despite risk of numerous complications, complete excision of neuroblastoma may confer a survival advantage and outweigh the conservative approach. As with most complex surgery, these risks need to be evaluated carefully for the individual and balanced accordingly.

Consent and Risk Reduction

Main Points to Explain

  • GA risk

  • Pain/discomfort

  • Bleeding/hematoma*

  • Infection (local/systemic)*

  • Urinary obstruction*

  • Urine leakage*

  • Urine collection*

  • Risk of other abdominal organ injury*

  • Possible stoma formation*

  • Possible blood transfusion

  • Possible tumor recurrence*

  • Possible further surgery*

  • Risks without surgery*

*Dependent on pathology, comorbidities, and surgery performed