‏Israeli Pediatric Surgery Association and Society of

Pediatric Hematology Oncology ‏Summer Meeting 22.06.2017

Bet Oranit, 40 kaplans street Petah Tikva בית אורנית, רח' קפלן 40 , פתח תקוה 9.30-9.40 Preliminary experience with surgical resection of all stages of neuroblastoma. – ediatric Ben Barak A, Golan H, Waldman D, Arkovitz MS. ,Department of pediatric oncology and pediatric surgery האיגוד הישראלי לכירורגית ילדים Surgery The Israel Association of Pediatric Surgery Rambam Health Care Center, Haifa Department of Pediatric Oncology and Surgery, Tel Hashomer Medical Center, Ramat Gan האיגוד הישראלי להמטולוגיה ואונקולוגית ילדים The Israel Society of Pediatric Hematology Oncology

Colorectal Carcinoma in Children and 9.40-9.55 ד"ר שפרה אש - יו"ר ד”ר יחיאל שויד - יו”ר Adolescents: Two Case Reports and Review of ד"ר גואן יעקובוביץ - מזכירה פרופ’ איגור סוחוטניק- מזכיר the Epidemiology, Biologic Features, Treatment ד"ר חגי ת מיסקין - גזברית ד”ר דרגן קרברושיץ- גזבר Strategies and Outcome ד"ר דרור לוין - חבר ד"ר צבי שטיינר- חבר ד"ר אירנה זיידמן - חברה ,A. Shapira, A. Sarahni, M. Oz, A. Benny, R.Steinberg פרופ' שושנה וילק-רבל - חברה A.Vachyan, A.Ariche, M. Ben Arush, S. Postovsky Department of Pediatric Hematology and Oncology, The Ruth ‏Israeli Pediatric Surgery Association and Rappaport Children's Hospital, Rambam Medical Center, Haifal Gastrointestinal Cancer Service, Division of Oncology, Rambam Society of Pediatric Hematology Oncology Medical Center, Haifa Dept Pediatric Surgery, The Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa Department of Hepatobiliary Surgery, Chaim Sheba Medical ‏Summer Meeting Center, Tel-Hashomer, Tel Aviv 22.06.2017 9.55-10.05 Minimal access surgery as primary approach Bet Oranit, 40 kaplans street Petah Tikva for selected tumors in pediatric population Dragan Kravarusic and Enrique Freud 08.15-08.50 Registration Pediatric Surgery Department – Soroka University Medical Center, Ben Gurion University, Beer Sheva , Israel 08.50-09.00 Opening Remarks: Sweed Yechiel, MD Pediatric Surgery Department – Schneider Children’s Medical Center of Israel, University of Tel Aviv, Israel Ash Shifra, MD ‏Session 1: 10.05-10.15 Intraoperative imaging for localization of surgical targets Chairmen: Miriam Ben-Arush, Nadav Slijper E. Seguier, A. Baazov, I. Samuk, E. Avinadav, A. Almog, A. 9.00-9.30 A surgical approach to neuroblastoma resection Nika, O. Cohen, E. Delugy,. S. Grosovski, N. Freud Edward Kiely Department of Pediatric and Adolescent Surgery, Department of Radiology. Schneider Children’s Medical Center of Israel, Petach Tikva, Honorary Consultant Surgeon Great Ormond Street Hospital for affiliated to Sackler School of Medicine, Tel Aviv University, Tel Aviv Children, London Pediatric Hematology Oncology Department, Rambam Health "התמודדות צוותים סיעודיים עם גילוי וטיפול ב"מחלה 10.15-10.25 Care Center, Haifa אבט'צ שיפרין, רעיה מדר, פבל ולקין, ענת גונן Pediatric Hematology Oncology Department, Tel Aviv Sourasky Medical Center, Tel Aviv מחלקת כירורגית ילדים המרכז הרפואי האוניברסיטאי סורוקה, ,Pediatric Hematoloy Unit, Shaare Zedek Medical Center מחלקה המטואונקולוגית המרכז הרפואי האוניברסיטאי סורוקה Jerusalem Department of Pediatric Hematology-Oncology, Schneider 10.25-10.35 Robot assisted laparoscopic surgery in children Children's Medical Center of Israel, Petach Tikva – what have we learned until now? Nadav Slijper, Arcady Vachyan, Igor Shaikis, Ran 11.50-12.20 Surgical options in the management of Steinberg necrotising enterocolitis Department of Pediatric and Adolescent Surgery, Meyer's Edward Kiely Children’s Hospital, Rambam Medical Center, Haifa Honorary Consultant Surgeon Great Ormond Street Hospital for Children, London

10.35-11.00 Coffee Break 12.20-12.30 Emergencies in the treatment of wandering spleen O. Cohen, A. Baazov, I. Samuk, M. Schwarz, R. Steinberg, D. Kravarusic, E. Freud ‏Session 2: Departments of Pediatric and Adolescent Surgery, and Pediatric Radiology. Schneider Children’s Medical Center of Israel, Chairmen: : Shifra Ash , Igor Sukhotnik Petach Tikva 4920235 and Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel 12.30-12.40 Vaginal tumors in children Shifra Ash, Shira Amar, Isaac Yaniv 11.00-11.25 Surgery and Siamese Twins The Rina Zaizov Hematology-Oncology Division, Schneider Children’s Medical Center of Israel Sackler Faculty of Medicine, Edward Kiely Tel Aviv University, Israel Honorary Consultant Surgeon Great Ormond Street Hospital for Children, London 12.40-12.50 Efficacy and safety of nonoperative treatment for uncomplicated acute appendicitis: Three years, 11.25-11.40 Surgery and Siamese Twins - keep it simple 334 children experience ד"ר ר. שטיינברג, ד"ר א. ווציאן, ד"ר חורי G. Buklan, M. Gutermacher, S. Arnon, Z. Steiner Dept. of Pediatric Surgery, Meir Medical Center, Affiliated to the המחלקה לכירורגיית ילדים ונוער והמכון הקרדיולוגי Sackler Faculty of Medicine, Tel-Aviv University רות - בית חולים לילדים, רמב"ם – הקריה הרפואית לבריאות האדם, חיפה 12.50-13.00 Innovations in Wound Closure for Challenging 11.40-11.50 Pleuropulmonary blastoma (PPB)- Lung cysts Abdominal Wounds in Trauma are not always CCAM. Hayari L, Fedorenko A, Shir-On E, Topaz M T. Ben-Ami, M. Ben-Arush, R. Dvir, H. Miskin, S. Ash Pediatric Surgery , Ziv Medical Center Zefat, Israel Pediatric Hematology Oncology department, Hadassa Ein Faculty of Medicine in the Galilee, Bar Ilan University Kerem University Hospital, Jerusalem, Plastic Surgery, Hillel Yaffe Medical Ctr 13.00-13.10 Pediatric GIST – Gastrointestinal Stromal Tumor ‏Prof. Edward Kiely Dan Harlev Pediatric Hematology - oncoligist Department of Pediatrics Meir Medical Center

13.10-14.00 LUNCH ‏Mr Edward Kiely is a general paediatric surgeon at Great Ormond Street and has worked there since 1983. ‏His areas of interest are neonatal, minimally invasive and oncology surgery. Mr. 14.00-15.30 Professional meeting - The Kiely trained in Cork, Ireland, and went onto postgraduate training in London, Birmingham and Johannesburg. He has written over twenty five chapters in Israeli Association of paediatric surgical text books and published almost two hundred articles in peer review journals. Pediatric Surgery ‏Mr Kiely also featured on the BBC documentary series “Great Ormond Street” in the episode “A chance at life” during which he removed a 3kg tumour from a 10 year old girl’s abdomen. He has also been invited to operate abroad in approximately twenty countries and is renowned for his work on separation of 15.30 Closing Remarks conjoined twins. A surgical approach to neuroblastoma resection Preliminary experience with surgical resection of all stages of neuroblastoma. Edward Kiely Honorary Consultant Surgeon 1 2 2 3 Great Ormond Street Hospital for Children, London Ben Barak A , Golan H , Waldman D and Arkovitz MS *.

1 Department of pediatric oncology and pediatric surgery3 Rambam Health Care Center, Haifa, Israel The contribution of surgical resection in neuroblastoma remains controversial. 2 There is no consensus in regard to the importance of complete resection especially Department of pediatric oncology and surgery3, Tel Hashomer Medical Center, Ramat Gan when dealing with high risk disease. A recent SIOP study suggests that the surgeon has a part to play and that surgical pessimism is unjustified. Background: Neuroblastoma is the most common non-central nervous system (CNS) solid tumor in childhood. The surgical treatment of high risk neuroblastoma This presentation deals with the surgical approach to resection and the outcome presents a challenge and the benefits of aggressive surgical resection has been after 373 attempted neuroblastoma resections. called into question. Objective: Here we examined our preliminary experience with surgical resection The surgical mortality was 0.5% and failed resection occurred in <10%. of all stages of neuroblastoma. Complete resection was associated with greatly improved survival in Stage 3 Methods: We report a retrospective chart review of our preliminary surgical disease but not in Stage 4 disease in this single surgeon series. experience in 25 patients with neuroblastoma operated on by a single surgeon at two institutions over a three year period. Demographic data including stage of The usual approach to therapeutic uncertainty is a randomised controlled trial, tumor and risk stratification were recorded. Primary outcome was total gross but such a trial is unlikely with this disease. resection. Patients were followed for 3 years after surgery. Results: 80% of the patients, including high risk neuroblastoma, had total gross resection of their tumor with minimal operative morbidity and no mortality. 88% had greater than 90% resection of their tumor. Overall 3 year survival was 84% (21/25). Conclusions: Resection of neuroblastoma, even large, high risk, bilateral tumors was possible when performed by surgical services with a high volume of experience. ‏Colorectal Carcinoma in Children and Adolescents: ‏Discussion: Colorectal cancer in children adolescents is a rare entity associated with unfavorable clinical and biologic features. Given the poor prognosis in Two Case Reports and Review of the Epidemiology, children, there is need for collaborative efforts in order to design new treatment Biologic Features, Treatment Strategies and Outcome strategies for this population.

‏Adi Shapira, MD1, Amira Sarahni, MD1, Oz Mordechai, MD1, Alexander Benny, MD2, Ran Steinberg, MD3, Arkadi Vachyan, MD3, Arie Ariche, MD4, Myriam Ben Arush, MD1, Sergey Postovsky, MD1

1‏ Department of Pediatric Hematology and Oncology, The Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel 2‏ Gastrointestinal Cancer Service, Division of Oncology, Rambam Medical Center, Haifa, Israel 3‏ Department of Pediatric Surgery, The Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel 4‏ Department of Hepatobiliary Surgery, Chaim Sheba Medical Center, Tel-Hashomer, Israel

‏Introduction: Although colorectal carcinoma (CRC) is one of the most common malignancies in adults, it is a rare diagnosis in the pediatric setting with an incidence of about 1 per million persons below 20 years of age. In children, adolescents and young adults, CRC exhibits a greater frequency of mucinous histology, high microsatellite instability (MSI- H) and a higher incidence of mutations in mismatch repair (MMR) genes. Children are more likely to have metastatic disease at diagnosis. Current treatment strategies are based on adult data and guidelines regarding management in children are lacking due to the rarity of the disease and lack of prospective treatment trials. Outcome remains extremely poor for patients with metastatic disease with an overall survival of 10% or less for stage IV disease. ‏Case description: Two adolescents with metastatic colorectal carcinoma were treated at the Ruth Rappaport Children's hospital over the last two years. The first patient was diagnosed with stage 4 colorectal carcinoma at 14 yearsof age. Her tumor was of mucinous histology, RAS mutation positive with low probability of MSI-H. She responded well to therapy but progressed shortly after completion of treatment. She failed second and third line treatment strategies and subsequently died of progressive liver metastases. The second patient is a 17-year-old male with stage 4 colorectal cancer with widespread metastatic disease at diagnosis involving liver, spleen and lymph nodes. He was determined to have complete metastatic response to chemotherapy. He recently underwent partial hepatectomy, splenectomy and right hemicolectomy. This patient was found to have an extremely high number of mutations on next generation sequencing of his tumor sample and therefore may benefit from immunotherapy. Minimal access surgery as primary approach for selected Intraoperative imaging for localization of surgical targets tumors in pediatric population

1 2 Dr. Emmanuelle Seguier¹, Dr. Artur Baazov¹, Dr. Inbal Samuk¹, Dr. Efrat Dragan Kravarusic and Enrique Freud Avinadav¹, Dr. Anastasia Almog¹, Dr. Adriana Nika¹, Dr. Osher Cohen¹, Dr. 1 Pediatric Surgery Department – Soroka University Medical Center, Elena Delugy¹, Dr. Sylvia Grosovski², Pr. Naftali Freud¹ Ben Gurion University, Beer Sheva , Israel 2 Pediatric Surgery Department – Schneider Children’s Medical Center of Israel, ¹Department of Pediatric and Adolescent Surgery. Schneider Children’s Medical University of Tel Aviv, Israel Center of Israel, Petach Tikva , affiliated to Sackler School of Medicine, Tel Aviv University, Tel Aviv ²Department of Radiology. Schneider Children’s Medical Center of Israel, Petach Tikva , affiliated to Sackler School of Medicine, Tel Aviv University, Tel Aviv Background : Minimal access surgery for "pediatric" tumors is still controversial and literature is mostly focused in the "open" procedures. We are presenting our experience with children's who underwent MAS resection for selected The use of intraoperative ultrasound is a useful technique widely used in the tumors. Special attention was paid to the adequacy and safety with assessment adult population and in many instances changes the course of management. of recovery, morbidity, cosmesis and recurrence. We describe a series of 6 patients where intraoperative ultrasound assisted in Methods: Retrospective review of 24 consecutive patients who underwent localization of the lesions, decrease operative time and minimize the abdominal complete tumor excision by MAS approach over the last 6 years. Most of the wall incision. These 4 girls and 2 boys were aged from 3 days to 4.11 years tumors were found incidentally with different imaging modalities. at the time of surgery. They presented with an intraluminal duplication cyst Results: Nine patients underwent thoracoscopic and fifteen laparoscopic (2), polypoid lesion of the transverse colon (2), appendiceal foreign body (1), resection. The median age was 4.5 years, median weight 13.5 kg . Tumor size umbilical granuloma without intra-abdominal extension (1). ranged from 3 to 8 cm maximum diameter. One conversion was done for intra There is clear benefit of intraoperative ultrasound in regards to real-time imaging, operative bleeding and second for bowel resection / anastomosis . The mean avoidance of radiation, rapid determination and localization of the pathology hospital stay was 2 days - related mostly to IV analgesia . Final diagnoses and possibility of adjusting surgical course. Pediatric surgeons are well advised included: ganglioneuroma (n = 6), neuroblastoma (n = 1), pheochromocytoma to adopt this modality into their practice. (n = 1), adrenal adenoma (n = 2) castelman disease ( n= 2), lymphoma (n = 2) , thymoma ( n=1) , GIST ( n=1) and dermoid tumor (n = 8). No recurrence was detected in relatively short mean follow-up of 2.3 y. Conclusions: MAS for tumor resection can be performed safely in carefully selected patients with excellent outcomes in terms of minimal discomfort, rapid recovery, and excellent cosmesis. Studies with larger volume of patients and longer follow up are required to adequately assess recurrence rate. – Robot assisted laparoscopic surgery in children התמודדות צוותים סיעודיים עם גילוי וטיפול ב"מחלה" what have we learned until now? אבט'צ שיפרין1, רעיה מדר1, פבל ולקין2, ענת גונן3 Nadav Slijper, Arcady Vachyan, Igor Shaikis, Ran Steinberg 1 מחלקת כירורגית ילדים המרכז הרפואי האוניברסיטאי סורוקה 2 מחלקה המטואונקולוגית המרכז הרפואי האוניברסיטאי סורוקה 3 מנהלת סיעוד חטיבת ילדים המרכז הרפואי האוניברסיטאי סורוקה ‏ Department of Pediatric and Adolescent Surgery, Meyer's Children’s Hospital, Rambam Medical Center, Haifa עבודה זו מציגה את האתגרים הסיעודיים במחלקה הכירורגית והאונקולוגית במהלך האבחון Robot assisted operations are held over the world for over a decade and have והטיפול בילדה ומשפחה קבלת אבחנה של: .RT OVARIAN MALIGNANT MIXED GERM CELL TUMOR become accepted as mainstream approach in various surgical specialties, mainly .urology and gynecology. Pediatric surgery is trailing behind in this field המקרה המוצג מתאר שיתוף פעולה מולטי דיסציפלינרי בין המחלקות השונות בבית החולים We describe our experience with this technique over the last three years, as ובין אנשי המקצוע השונים, על מנת להשלים טיפול כוללני במטופלת מורכבת, תוך תמיכה well as review recent literature and discuss where we stand today, what are the במשפחתה. .benefits and what are the drawbacks of this approach and what lies a head בינואר 2017 הגיע למיון ילדים ילדה בת 12 שנים, ברקע בריאה. פנתה למלר"ד ילדים עקב תלונה של כאבי בטן, תחושת נפיחות, בחילה והקאה בודדת. במדידת חום אורלית, חום c380. סימפטומים אלה לוו עצירות מזה כ4- ימים. בבדיקה פיזיקלית נמוש גוש גדול ונוקשה בבטן מרכזית תחתונה בקוטר של 10 ס"מ לפחות. בבדיקת דם נמצא B-HCG חיובי. נמצא A-FP. בעקבות ממצא זה הופנתה למיון נשים ונבדקה על ידי גניקולוג הילדה טרם קיבלה ווסת, שוללת הריון ומגע מיני. בבדיקת הדמיה נצפה גוש בטני גדול. הילדה אושפזה במחלקת ילדים להמשך בירור שכלל בדיקות דימות נוספות הכוללות: CT בטן הציג תהליך תופס מקום 16*16 ס"מ, הטרוגני, המערב שחלה ימנית. MRI בטן הדגים תוצאה דומה. עקב תלונות על כאבי ראש בוצע MRI ראש - שנמצא תקין. PET-CT - ללא עדות לגרורות. בעקבות הממצאים עלה חשד לגידול מסוג GERM CELL . לאחר דיון בשיתוף צוות רב מקצועי הכלל צוותים כירורגים ואונקולוגיים, הוחלט על ביצוע כריתת הגידול. המטופלת הועברה למחלקה כירורגית ילדים, בוצעה הכנה לניתוח, במהלך הניתוח בוצעה כריתה מלאה של גידול אגני בטני המערב שחלה ימנית. על פי בדיקה פתולוגית: .RT OVARIAN MALIGNANT MIXED GERM CELL TUMOR לאחר הניתוח שהתה כיממה בטיפול נמרץ ילדים, לאחר מכן הועברה לכירורגית ילדים. מהלך האשפוז ללא סיבוכים. הילדה הודרכה להמשך טיפול במחלקה האונקולוגית ושוחררה לביתה. בקבלתה למחלקה האונקולוגית נערכו מספר שיחות בנוכחות מנהל המחלקה, הצוות הסיעודי דובר שפת האם ועובדות סוציאליות, התגלו קשיים רבים בתובנה של המטפלת העיקרית )האם( בנוגע לאופי המחלה, הטיפול הכימותרפי המקובל )פרוטוקול BEP(. לאחר שכנוע האם לגבי חשיבות הטיפול, הילדה קיבלה כימי על פי פרוטוקול BEP, הושלמו 4 סבבים קבלת הטיפול הושלמו 4 סבבים טיפול. מהלך האשפוז ללא סיבוכים. מתוכננת למעקב תגובה לטיפול ב PET/CT כמקובל.

Surgery and Siamese Twins Surgery and Siamese Twins - keep it simple ד"ר ר. שטיינברג, ד"ר א. ווציאן, ד"ר חורי. המחלקה לכירורגיית ילדים ונוער והמכון הקרדיולוגי. Edward Kiely רות - בית חולים לילדים, רמב"ם – הקריה הרפואית לבריאות האדם, חיפה. Honorary Consultant Surgeon תאומים סיאמיים מתוארים בספרות הרפואית והפופולרית כבר לפני יותר מ 1000 שנים. Great Ormond Street Hospital for Children מדובר באחת התופעות המוזרות שהטבע יצר ושאנו נאלצים להתמודד איתם בפאן הרפואי, London ניתוחי. להוציא מדינות כגון הודו ודרום אפריקה בהם קיימת שכיחות יותר גדולה של תאומיים .The qualities which are considered desirable in a “good surgeon” are debatable סיאמיים, התופעה עצמה נדירה למדי, וסיכוייו של מנתח ילדים להיתקל בא במהלך חייו Patients, parents, referring physicians or surgeons will have widely differing המקצועיים הינה קטנה מאוד. .views on what they might consider essential אנחנו נביא לפניכם סקירת ספרות, תיאור מקרה, ועל סמך ניסיון מצטבר של מספר מקרים גם המלצות שיכולות לעזור בעתיד למי שיידרש לטפל בתופעה נדירה זאת. No surgeon works in isolation and all are dependent on anaesthetists and theatre staff. Few will wish to manage associated medical diseases by themselves. Despite prevailing opinion, surgeons always work in teams and often lead the team.

The author’s opinion on what makes a competent surgeon is discussed.

Separating Siamese twins is a formidable surgical undertaking and often tests the surgeons’ personal and professional qualities. The experience with 38 sets of conjoined twins is described.

‏Pleuropulmonary blastoma (PPB)- Lung cysts are not always Surgical options in the management of necrotising enterocolitis CCAM. Edward Kiely ‏Tal Ben-Ami1, Miriam Ben-Arush2, Rina Dvir3, Hagit Miskin4, Shifra Ash5 1‏ Pediatric Hematology Oncology department, Hadassa Ein Kerem University Hospital, Honorary Consultant Surgeon Jerusalem,. Great Ormond Street Hospital for Children London 2‏ Pediatric Hematology Oncology Department, Rambam Health Care Center, Haifa.

3‏ Pediatric Hematology Oncology Department, Tel Aviv Sourasky Medical Center, There are many surgical options in the management of NEC in newborns. What Tel Aviv is done is often dependent on surgical preference and institutional practice and there are few high quality published studies to guide decision making. Population 4‏ Pediatric Hematoloy Unit, Shaare Zedek Medical Center, Jerusalem studies in the UK suggest that the survival of premature babies continues to 5‏ Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center improve but NEC-related mortality has risen. of Israel, Petach Tikva As the affected babies are of greatly differing maturity, birth weight and physiological derangement, the approach should be tailored for the individual ‏Background: Pleuropulmonary blastoma (PPB) is a very rare and highly infant. aggressive neoplasm arising in the lungs presenting in early childhood, with This presentation reviews the management of 302 infants presenting to the author most cases diagnosed in children less than 6 years of age. Most cases of PPB with NEC. The preferred surgical option was resection and primary anastomosis have evidence for DICER1 germ line mutation. PPB can be classified into 3 types where possible. Two thirds underwent surgery and 82 of these had resection and based on clinical and pathological characteristics. Type I PPB- cystic type, type one or more primary anastomoses. The leak rate was 5% and none of these died II PPB cystic/solid, and type III PPB is a completely solid tumor with elements as a result. of high grade sarcoma. Treatment includes surgery only, or combination of The overall mortality was 14% and was unrelated to birth weight. surgery and chemotherapy based on PPB histological type. Surgical excision of On the basis of these results, resection and anastomosis is a valid surgical option type I PPB can prevent the transition to the malignant aggressive type III PPB. in NEC and reduces hospital stay and time on TPN. ‏Methods: Data regarding the clinical presentation, diagnosis, treatment and outcome of all PPB cases in Israel was collected as part of the Israeli Forum for Rare Tumors in Children (IF-RTC). ‏Results: Since 2000, 6 cases of PPB were diagnosed in Israel. Two patients were diagnosed with type I PPB, 2 patients with type II, and two with type III. All but one patient had local disease at presentation. Of four tested cases, all were positive for DICER1 mutation. All patients underwent surgical resection of their tumor, four children received chemotherapy. One patient was treated with combination of chemotherapy and radiotherapy after disease relapse. Two children died after disease progression despite aggressive therapy. ‏Conclusion: Diagnosis of PPB could be challenging especially in pure cystic lesions. Early diagnosis and surgical removal of type I ppb lesions can prevent the progression to the aggressive and often fatal type III disease. ‏Emergencies in the treatment of wandering spleen Vaginal tumors in children

1 1 1 Shifra Ash, Shira Amar, Isaac Yaniv ‏Osher Cohen MD , Arthur Baazov MD , Inbal Samuk MD , Michael 2 1 1 Schwarz MD , Ran Steinberg MD , Dragan Kravarusic MD , Enrique 1 The Rina Zaizov Hematology-Oncology Division, Schneider Children’s Medical Center Freud MD of Israel Sackler Faculty of Medicine, Tel Aviv University, Israel

‏Departments of Pediatric and Adolescent Surgery (1), and Pediatric Radiology (2). Vaginal Bleeding in infants is rare. The etiology is variable and includes: Schneider Children’s Medical Center of Israel, Petach Tikva 4920235 and Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel in-utero endometrial stimulation by transplacental estrogens, trauma, tumors, precocious puberty, foreign body and warts. Malignant tumors of the vagina ‏Wandering spleen (WS) is a rare entity which may present as an emergency clinical in infants include Rhabdomyosarcoma (sarcoma botryoides), Germ cell tumor, condition most commonly after torsion of the splenic vessels. Nevertheless even Clear cell adenocarcinoma secondary to DES exposure and Paraganglioma. The after surgical treatment it has potential for complications which may necessitate clinical presentation of these tumors can be bleeding or blood-tinged discharge, emergency treatment. The difficulties in making the diagnosis can delay the a protruding vaginal mass, abdominal pain or chronic genital ulcer. Imaging appropriate surgical treatment.All the patients with WS treated as an emergency studies of the primary disease include ultrasound as the initial screening tool between 1996 to 2016 at the Department of Pediatric and Adolescent Surgery used to detect pelvic masses. CT and MR are used to assess local invasion and of The Schneider Children`s Medical Center of Israel were retrospectively distant metastases including evaluation for retroperitoneal lymphadenopathy, reviewed. Also review of the relevant literature was done. liver, lung, and bone metastases. ‏Among a total of 10 patients treated for wandering spleen, 5 of them underwent We will discuss the diagnosis and treatment of vaginal tumors and present a rare 7 emergency surgeries. One of those patients was operated immediately on case of Germ Cell Tumor in an Infant. his first arrival to medical care. Surgical treatment for the other 4 patients was delayed either due to misdiagnosis or for repetitive imaging once the diagnosis was already done. At the time of the emergency surgery the spleen was ischemic in all patients and 3 of them ended up with splenectomy while in 2 patients the spleen was preserved. 4 of the 7 emergency surgeries were done as the first surgery and 3 where done to deal with complications. ‏Conclusions: WS should ideally be treated as an elective or semi elective procedure in order to reduce the unfavorable results involving emergency surgery. Delays in operating patients with WS could be partially minimized by high index of suspicion for that diagnosis on one hand and by yielding unnecessary and time consuming imaging modalities on the other hand. ‏Efficacy and safety of nonoperative treatment for Innovations in Wound Closure for Challenging Abdominal uncomplicated acute appendicitis: Three years, Wounds in Trauma 334 children experience Hayari L 1 2 Fedorenko A,1 Shir-On E,2 Topaz M 3 ‏G. Buklan, M. Gutermacher, S. Arnon, Z. Steiner 1 Pediatric Surgery , Ziv Medical Center Zefat, Israel 2 Faculty of Medicine in the Galilee, Bar Ilan University ‏Dept. of Pediatric Surgery, Meir Medical Center, Affiliated to the Sackler Faculty 3 of Medicine, Tel-Aviv University Plastic Surgery, Hillel Yaffe Medical Ctr

‏Purpose: To evaluate whether antibiotics without surgery is sufficient and safe treatment for children with clinically and ultrasonographically uncomplicated Introduction acute appendicitis (AA). Abdominal closure remains a challenge following trauma and damage control surgery, especially when injury involves a large abdominal wall defect. Open ‏Method: Children with clinical, laboratory and radiological findings suspicious abdomen may be further complicated by concomitant internal organ injuries, for AA were evaluated prospectively. “frozen abdomen”, fistulation, retraction of the fascial layers and infection. Early ‏Patients with short history and local peritoneal signs, with appendicular diameter closure of the open abdomen is of extreme importance. > 6, < 10 mm and without appendicolith, were treated 3-4 days with IV Rocefine The TopClosure® Tension-Relief System (TopClosure®) is an innovative 50mg/Kg/D and Flagyl 30mg/Kg/D followed by oral Augmentin 40mg/Kg/D for method that enables the employment of both mechanisms of stress-relaxation 5-7 days without surgery. and mechanical creep for skin stretching. Its use has enabled the primary closure of medium to large soft tissue defects. ‏Results: From 1 January 2014 through 31 December 2016, 719 children Materials and Methods were diagnosed with AA, 334 of them (46%) were early uncomplicated acute A 7-year-old girl with multiple penetrating trauma of the abdomen following the appendicitis (clinically and ultrasonographically). Ages ranged from 3 to 16 shelling of her home, presented 12 hours after injury in septic shock. The patient years (mean 10.5) and 203 (61%) were boys. All were treated with antibiotics suffered from liver injuries, a perforated transverse colon with 8x16 cm oblique only without surgery. They were followed for 5-40 Months after discharge. abdominal wall defect and an open distal humerus fracture. She underwent Fifty eight children were admitted again with AA. Thirty of them (9%) were damage control laparotomy, suturing of the perforated colon and temporary successfully treated with IV antibiotics for the second time. The other 28 (8.4%) closure of the abdomen using a Bagota bag,. 12 hours later the patient underwent were operated. Their histologic examination revealed 8 normal appendixes, 18 a second look operation applying negative pressure wound therapy for temporary inflamed, and 2 with some necrotic changes. There were no cases of perforation. abdominal closure. Five days later the TopClosure® was applied to close the Two hundred and fifty nine children were followed for 1 year or more. Fifty lower part of the wound, incorporating the regulated negative pressure-assisted of them were admitted for recurrent AA. Twenty seven (19.4%) were treated wound therapy (RNPT) system to the upper wound area. Three days later this successfully without surgery, only 23 (9%) needed appendectomy. method was repeated for complete primary closure of the abdominal wall. Four days later the patient was returned to the operating theatre for closure of a leak ‏Conclusions: Our series suggests that non operative treatment for early AA is of the previously injured colon. A wedge colon resection and a loop ileostomy effective (91%) and safe even after more than 1 year follow up. on the left mid abdomen were performed with immediate definitive primary closure of the abdominal wall with the TopClosure®. Post-operative course was uneventful. The TopClosure® was removed in stages within 3-4 weeks and Ileostomy closure was performed a week later. Discussion The TopClosure® optimally utilizes the viscoelastic properties of the skin achieving full closure of the abdominal wall, fascia and skin, eliminating the need for the conventional long vacuum treatment, the use of synthetic or biological Pediatric GIST – Gastrointestinal Stromal Tumor fascia, skin graft and a delayed reconstructive surgery. Risk of infection and the common occurrence of a ventral hernia as a complication associated with an open abdomen may be avoided. A 2-stage closure procedure was employed in order Dan Harlev to reduce the risk of abdominal compartment syndrome. Even an immediate Pediatric Hematology - oncoligist secondary closure was feasible following an intestinal leakage. Pediatric Department of Pediatrics Meir Medical Center Conclusion This case illustrates the use of simple innovative wound closure technology for Pediatric GIST is rare. Prevalence estimates are not available, but several series early primary closure of an open abdomen, mitigating complications associated estimate that they account for only 1-2% of all sarcomas seen at large institutions. with challenging abdominal injuries with large abdominal wall defects The disease is more common in girls than in boys, and there seem to be differences the clinical course between younger and older patients. Most cases occur in the stomach, and the lesions involve multiple tumor nodules (multifocal disease). One of the main biological differences between pediatric and adult GIST is that pediatric patients lack activating mutations in the oncogenes that drive tumor formation in adults. The natural history of this disease also appears to be more indolent in children than in adults.