Prophylactic surgery in pediatric oncology and parenchymal-sparing surgery: two examples of preventive surgery in children and adolescents.

Preventive surgery is particularly relevant for children and adolescents: operating without waiting for clinical symptoms or complications to arise, in order to enable them to lead a normal life with a life expectancy identical to that of the general population. This preventive surgery is mainly considered in two major nosological fields: congenital malformations and tumors and cancers. It involves pre-symptomatic screening carried out in two distinct situations: prenatal screening and screening for predispositions to tumors and cancers. Recent decades have seen extraordinary developments in these screening methods: many congenital malformations are now detected in utero during the three mandatory prenatal ultrasounds in France (under the auspices of the CPDPN: multidisciplinary prenatal diagnosis centers), allowing teams to plan for the care of the child while it is still a fetus by preparing the parents at this prenatal stage for possible surgery, rapid advances in oncogenetics have led to a better understanding of syndromes that predispose individuals to tumors and cancers and a better assessment of the risk and average age of cancer development in order to establish recommendations for preventive surgery. Here are two notable examples: more than 80% of bronchopulmonary malformations are detected in utero, and the majority of these will be operated on preventively in the first few months of life, preventing children from developing serious complications (secondary infection, increase in volume, degeneration). In cases of Multiple Endocrine Neoplasia type 2A (MEN 2A), children at risk are tested in the first few months of life and, if they carry the genetic mutation in question, undergo preventive surgery at around the age of 3 (total thyroidectomy). These preventive surgeries performed on children (often infants under 2 years of age or even under 1 year of age) have greatly benefited from advances in many fields (pediatric imaging, pediatric anesthesiology, neonatal and pediatric resuscitation, surgical instrumentation, etc.) and particularly in the field of minimally invasive surgery. Since these preventive surgeries are by definition intended for asymptomatic children, it is obviously essential to be able to offer surgery with the lowest possible morbidity in order to make it more acceptable to parents. Minimally invasive techniques (laparoscopy, thoracoscopy, retroperitoneoscopy) have greatly improved scarring and postoperative outcomes, while the development of parenchymal-sparing surgery (increasingly performed using minimally invasive techniques) allows the healthy part of the organ (lung, liver, spleen, kidney, gonad), which is particularly important for a child who still has his entire growth ahead of him. In some situations, the surgical indications and techniques to be used are widely agreed upon and rarely disputed, while in other situations questions remain: can screening be improved? is the tumor risk really well assessed? is the proposed surgery appropriate, with the certainty of protecting the child from tumor risk? does preserving a “healthy” part of the organ not introduce additional complexity and a possible risk of incomplete excision? what will be the contribution and impact of the major advances expected in genetics in the coming years? This presentation aims to review the circumstances surrounding presymptomatic screening in children, the principles of preventive or prophylactic surgery, the role of parenchymal-sparing surgery, and the uncertainties that remain.