A. Bonnard

Calretinin immunohistochemistry: a simple and efficient tool to diagnose Hirschsprung disease

Diagnosis of Hirschsprung disease (HD) is quite entirely based on the histopathological analysis of suction rectal biopsies. This hematoxylin and eosin approach has some limitations, despite the help of acetylcholinesterase staining. The aim of this study was to assess the diagnostic value of calretinin immunochemistry as a simple and reliable method in the diagnosis of HD. A total of 131 initial rectal biopsies carried out for suspicion of HD in children were retrieved, and calretinin immunohistochemistry was carried out on paraffin-embedded biopsies. Diagnosis of HD was made when no staining was observed. The results were statistically analyzed in comparison with our standard method (histology and acetylcholinesterase staining). 130 biopsies were accurately diagnosed on the basis of the positivity or negativity of calretinin staining. The senior pathologists diagnosed all cases of HD with no false positives. Furthermore, 12 additional cases initially considered as doubtful for HD using the standard method, were accurately diagnosed using calretinin immunohistochemistry. The false negative was a case of HD with a calretinin-positive biopsy. We also demonstrate the ease of calretinin interpretation compared with acetylcholinesterase for the junior pathologist. Calretinin immunohistochemistry overcomes most of the difficulties encountered using the combination of histology and acetylcholinesterase staining, and detects almost all cases of HD with confidence, with no false positives. Thus, we demonstrate that calretinin is superior to acetylcholinesterase to complete histology and could advantageously substitute for acetylcholinesterase.

Expression of TLR-2, TLR-4, NOD2 and pNF-κB in a Neonatal Rat Model of Necrotizing Enterocolitis

Background The etiology of necrotizing enterocolitis (NEC) results from a combination of several risk factors that act synergistically and occurs in the same circumstances as those which lead to innate immunity activation. Pattern recognition molecules could be an important player in the initiation of an exaggerated inflammatory response leading to intestinal injury in NEC. Methodology/Principal Findings We specifically evaluated intestinal epithelial cell (IEC) expression of Toll-like receptor 2 (TLR-2), TLR-4, NOD2 and phosphorylated NF-κB (pNF-κB) after mucosal injury in a rat model of NEC induced by prematurity, systemic hypoxia, and a rich protein formula. In the control group (group 1), neonatal rats were full-term and breast-fed; in the experimental groups, rat pups were preterm at day 21 of gestation and rat-milk fed (group 2) or hand-gavaged with a protein rich formula after a hypoxia–reoxygenation procedure (group 3). Morphological mucosal changes in the small bowel were scored on hematoxylin- and eosin-stained sections. Immunohistochemistry was performed on frozen tissue sections using anti TLR-2 and active pNF-κB p65 antibodies. Real-time RT-PCR was performed to assess mRNA expression of NOD2, TLR-2 and TLR-4. Proliferation and apoptosis were studied in paraffin sections using anti Ki-67 and caspase-3 antibodies, respectively. The combination of immaturity, protein rich formula and a hypoxia–reoxygenation procedure induces pathological mucosal damage consistent with NEC. There was an overexpression of TLR-2, and pNF-κB in IECs that was correlated with the severity of mucosal damage, together with an increase of apoptotic IECs and markedly impaired proliferation. In addition, these immunological alterations appeared before severe mucosal damage. TLR-2 mRNA were also increased in NEC together with TLR-4 mRNA using real-time RT-PCR whereas NOD2 expression was unchanged. Conclusions/Significance These results show that this rat model of NEC induced mucosal injury, leading to a highly responsive IEC phenotype and suggesting that alterations in the innate immune system participates in the pathogenesis of NEC and are enhanced by prematurity.

Retroperitoneal laparoscopic nephrectomy in children: At last the gold standard?

PURPOSEnWe analyzed our experience with retroperitoneal laparoscopic nephrectomy giving special attention to the learning curve, morbidity, and feasibility in a teaching institution.nnnMATERIAL AND METHODSnBetween 1996 and 2004, we performed 104 laparoscopic nephrectomies in 88 children. Only four were performed via the transperitoneal approach, the others being via the retroperitoneal approach; the files of the latter were analyzed. Mean age was 5 years (20 days-15 years). Main indications were pretransplant nephrectomy for arterial hypertension, nephrotic syndrome or uremic hemolytic syndrome (51%), non-functioning kidney secondary to obstruction, reflux or ectopic ureter (38%), and multicystic dysplastic kidney (11%). Bilateral nephrectomy was performed in 13 children.nnnRESULTSnThe lateral retroperitoneal approach was feasible in all cases even for those who had previous renal surgery. Conversion was not needed in any patient. No significant blood loss was observed. Mean operative time was 97 min (range 44-240) for unilateral nephrectomy; 46 nephrectomies were done in less than 90 min. In bilateral cases the mean operative time was 260 min (range 160-390). The operative time was less than 4 h in seven bilateral cases. Postoperative course was uneventful. Hospital stay was 1.9 days (range 1-3) for urological indications and 5 days (range 3-7) for patients with terminal renal disease. The procedure was initially performed by one surgeon, but was then expanded to other surgeons of the team, and safely taught to residents and fellows.nnnCONCLUSIONSnThe procedure is safe, the learning curve is reasonable, teaching is feasible, operating time becomes with experience closer to open surgery without morbidity, and cosmetic results are excellent. This procedure may be considered as the gold standard for nephrectomy in children.

Necrotizing Enterocolitis (NEC) and the Risk of Intestinal Stricture: The Value of C-Reactive Protein

Necrotizing enterocolitis (NEC) is a severe complication frequently seen during the neonatal period associated with high mortality rate and severe and prolonged morbidity including Post-NEC intestinal stricture. The aim of this study is to define the incidence and risk factors of these post-NEC strictures, in order to better orient their medicosurgical care. Sixty cases of NEC were retrospectively reviewed from a single tertiary center with identical treatment protocols throughout the period under study, including systematic X-ray contrast study. This study reports a high rate of post-NEC intestinal stricture (nu200a=u200a27/48; 57% of survivors), either in cases treated surgically (91%) and after the medical treatment of NEC (47%). A colonic localization of the strictures was more frequent in medically-treated patients than in those with NEC treated surgically (87% vs. 50%). The length of the strictures was significantly shorter in case of NEC treated medically. No deaths were attributable to the presence of post-NEC stricture. The mean hospitalization time in NICU and the median age at discontinuation of parenteral nutrition were longer in the group with stricture, but this difference was not significant. The median age at discharge was significantly higher in the group with stricture (pu200a=u200a0.02). The occurrence of post-NEC stricture was significantly associated with the presence of parietal signs of inflammation and thrombopenia (<100 000 platelets/mm3). The mean maximum CRP concentration during acute phase was significantly higher in infants who developed stricture (p<0.001), as was the mean duration of the elevation of CRP levels (p<0.001). The negative predictive value of CRP levels continually <10 mg/dL for the appearance of stricture was 100% in our study. In conclusion, this retrospective and monocentric study demonstrates the correlation between the intensity of the inflammatory syndrome and the risk of secondary intestinal stricture, when systematic contrast study is performed following NEC.

Perforation pharyngoœsophagienne traumatique du nouveau-né

Resume Les enfants prematures et de petit poids de naissance sont particulierement exposes aux perforations pharyngoœsophagiennes traumatiques. Ces perforations restent de diagnostic difficile, la symptomatologie evoquant souvent une atresie de lœsophage. Observations. — Douze nouveau-nes ont ete traites pour perforation pharyngoœsophagienne entre 1980 et 1995. Dix enfants etaient prematures, leur poids de naissance etant inferieur a I 500 g pour sept d’entre eux. La cause de ta perforation etait une intubation tracheale dans quatre cas et une aspiration pharyngee avec butee de la sonde lors du test de permeabilite œsophagienne pour les huit autres cas. Sur la radiographie de thorax, un pneumothorax droit etait present dans trois cas, un trajet rectiligne de la sonde dans deux cas. Une opacification par la sonde œsophagienne laissee en place a ete effectuee quatre fois; une endoscopie a ete effectuee trois fois. Le diagnostic initial etait celui d’une atresie de l’œsophage dans cinq cas. Six enfants ont eu un traitement conservateur: sonde gastrique mise en place, aspiration pharyngee, antibiotherapie et alimentation parenterale. Une gastrostomie a ete effectuee une fois. Dans cinq cas une thoracotomie a ete effectuee, quatre fois avec le diagnostic initial d’atresie de l’œsophage. Un drainage du mediastin a ete mis en place dans chaque cas, et une suture œsophagienne effectuee dans un cas. L’evolution a ete favorable six fois, sans sequelle dans cinq cas, au prix d’une stenose œsophagienne traitee par dilatation instrumentale dans un cas. L’evolution a ete emaillee de complications pulmonaires quatre fois, et de sequelles neurologiques dans un cas. Deux enfants sont decedes, un de sepsis, l’autre d’une enterocolite ulceronecrosante. Conclusion. — L’analyse critique de cette serie souligne les difficultes diagnostiques, en particulier avec l’atresic de l’œsophage, et l’importance d’accorder une attention toute particuliere au contexte clinique, a la radiographie thoracique et a l’opacification avec un cliche de profil. Le traitement non operatoire est le plus souvent efficace. L’evolution n’est cependant pas toujours favorable, dependant surtout du terrain (prematurite, etat respiratoire initial).

Gastrografin for uncomplicated adhesive small bowel obstruction in children

PurposeThe risk of bowel injury during surgery for small bowel obstruction (SBO) has generated interest in conservative treatment modalities. Few data are available on conservative Gastrografin treatment for SBO in children.MethodsWe prospectively included patients with uncomplicated adhesive SBO managed at a pediatric center between March 2009 and September 2010. Patients who were unimproved after 48xa0h of conservative treatment received 50–100xa0ml of Gastrografin. If Gastrografin was seen in the cecum on the abdominal radiograph 4–6xa0h later, feeding was initiated and the patient was discharged on the same day. Each patient was matched to 2 controls on the number of previous SBO episodes. The primary outcome was length of hospital stay (>3xa0days), and the secondary outcome was time from admission to first feed (>2xa0days). Both were compared in the two groups using conditional logistic regression.ResultsThe 8 patients admitted for SBO were matched to 16 controls. Gastrografin administration was associated with significantly lower risks of staying in the hospital longer than 3xa0days (Pxa0<xa00.10) and waiting more than 2xa0days before the first feed.ConclusionThis preliminary study suggests that Gastrografin may be useful for managing adhesive SBO in children.

Safety and efficacy of one-stage total laparoscopic treatment of common bile duct stones in children.

AbstractBackground The purpose of this study is to confirm the effectiveness of total laparoscopic treatment of common bile duct (CBD) stones in children.MethodsAll children who were treated in our department for cholelithiasis were reviewed from 1996 to 2013. Data collection focused on children with CBD stones, including age, sex, symptoms at diagnosis, hepatic and pancreatic blood tests results, US scan results, etiology, detailed surgical technique, operative time, length of hospital stay, complications, and stone-free status or not, at last follow-up.Results551 children were treated for cholelithiasis and had undergone laparoscopic cholecystectomy. Among those, 36 children (6.5xa0%) presented with CBD stones with a mean age at symptom onset of 10.4xa0years (min–max: 4xa0months–18xa0years). A majority of the patients presented with hemolytic disease (61xa0%). In 55xa0% of the cases, cholangiography alone or simple serum saline flush of the biliary tree was sufficient to obtain a stone-free CBD. Additional maneuvers with Dormia basket or Fogarty catheter led to 72xa0% of success rate. In 9 cases (25xa0%) of failure of the procedure, 6 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES), 1 patient was re-operated at day1 for hemorrhage, and 2 patients were followed by US scan with spontaneous evacuation of CBD stones. Mean follow-up was of 2xa0years (min–max: 1xa0month–5xa0years). All patients were stone free at last clinical and radiological evaluation.nConclusionA one-stage total laparoscopic treatment of common bile duct stones in children is a safe, feasible, reproducible, and efficient procedure in 72xa0% of the cases. This rate could be upgraded by a combination of laparoscopic and endoscopic technique during the same anesthesia and preserving Oddi sphincter function. These minimal invasive techniques still need to be developed in children.n

Acute chest syndrome after laparoscopic splenectomy in children with sickle cell disease: operative time dependent?

BackgroundLaparoscopic splenectomy remains a technically demanding procedure. On patients with sickle cell disease (SCD), a post operative acute chest syndrome (ACS) can occur. The aim of the study was to look for predictive factors of post operative ACS.Patients and methodIt’s a retrospective study on patients with SCD, who underwent a laparoscopic splenectomy in Robert Debré hospital, Paris, France, between March 2008 and December 2013. Diagnosis of ACS was done if the patient developed hypoxemia associated with fever above 38.5xa0°C and an infiltrate on chest x ray during the post operative course. Pre-, post- and operative factors were studied. Descriptive statistics were compared using the Mann–Whitney test or the exact Fisher test. A p inferior to 0.05 was considered as significant.Results52 patients with SCD underwent a laparoscopic splenectomy. Twelve patients presented a post operative ACS (23xa0%) (mean age at surgery 4xa0years old) while forty did not (mean age 5.25xa0years old). Neither previous episode of ACS nor any factors reflecting SCD severity were significant. The shorter the operative time was, the greater the risk of developing an ACS (pxa0<xa00.05).ConclusionACS is an important complication following laparoscopic splenectomy in patients with SCD. The immediate post operative management, in the absence of predictive factors for ACS, should be carefully followed in a high dependency unit at least for 48xa0h for all patients.

SFCP CO-09 - Variation de marquage par la calrétinine dans les formes courtes de Maladie de Hirschsprung : un facteur pronostic ?

Introduction Evaluer la valeur pronostic fonctionnelle d’une variation du marquage a la calretinine apres ATA selon Swenson pour MH recto sigmoidienne. Materiels et Methodes Etude retrospective de 2008 a 2012 de tous les patients operes d’un ATA selon Swenson pour MH recto sigmoidienne. L’analyse du marquage par la calretinine distinguait 2 groupes : un groupe (P-) avec une absence totale de marquage et un groupe variant (P+) avec une positivite de la sous-muqueuse. Les 2 groupes etaient compares sur les suites post operatoires a court terme. Resultats 33 patients etaient inclus. Le recul moyen etait de 4,1 ans (1–6 ans). Le groupe variant P+ incluait 17 patients (51.5%). Les deux groupes etaient comparables en terme d’âge gestationnel ou poids a la naissance, de comorbidites, de presentation clinique initiale ou de type de chirurgie. Il n’etait pas retrouve de difference statistiquement significative en terme de pronostic fonctionnel digestif entre ces 2 groupes Conclusion Un variant anatomopathologique de marquage a la calretinine etait identifie dans 51.5% des formes recto sigmoidiennes de MH mais ne semble pas etre un facteur pronostic. Ceci est une etape supplementaire dans la recherche de correlation clinico-pathologique dans la MH.

SFCP CO-60 - Apport de la thoracoscopie dans la chirurgie aortique de l’enfant

But de l’etude Comparer la chirurgie de l’aorte sous thoracoscopie a ceux de la thoracotomie a court terme. Patients et methode Etude retrospective de 1995 a 2013 des patients operes pour canal arteriel (CA) et double arc aortique (DAA). Etait compare les patients operes sous thoracoscopie, par un meme operateur, a une serie historique de patients operes par thoracotomie (les patients appareilles pour le poids et l’âge au moment de la chirurgie). Etait note : poids et âge a la chirurgie, temps operatoire, traitement antalgique post-operatoire, ventilation post operatoire, paralysie recurrentielle, chylothorax et duree d’hospitalisation. Resultats Sous thoracoscopie 12 CA (moyenne, 29 jours et 1758xa0g) et 9 DAA (7,8 mois et 6534xa0g) etaient inclus. Il n’etait pas retrouve de difference significative entre les 2 groupes pour les principales donnees. La seule difference significative retrouvee en faveur du groupe opere sous thoracoscopie concernait le traitement antalgique post operatoire. Conclusion Les resultats a court terme de la chirurgie de l’aorte type CA et DAA sous thoracoscopie sont comparables a la chirurgie sous thoracotomie en terme de morbidite post operatoire, avec un avantage en terme d’analgesie post-operatoire en faveur de la thoracoscopie.