C. Francois-Fiquet

Should we question early feminizing genitoplasty for patients with congenital adrenal hyperplasia and XX karyotype

BACKGROUND There is a wide difference of opinion between the medical-surgical community and advocacy group regarding Disorders of Sexual Development (DSD) secondary to congenital adrenal hyperplasia (CAH) being ranked in the intersex category. This rupture is even more evident when the issue of genitoplasty is brought up. For physicians it is obvious and unequivocal that a person with CAH and an XX karyotype has a female gender identity, whereas associations tend to rank persons with CAH in the intersex category and advocate holding-off on surgical management. MATERIAL/METHODS A retrospective case study vs. control group, spanning over 40years, included 21 patients who were treated in 3 different centers. Each patient and their parents were contacted independently and interviewed regarding interpersonal relationships, psychological impact of genitoplasty, gender identity and opinion on optimal care management for this disorder. Three couples controls (parent-child) per CAH patients were used and matched according to age, sex assigned at birth and ethnic origin. RESULTS Sex assigned at birth seemed to concord with the gender identity perceived by the patients in 85.7% of cases. In fact, 89.7% of patients and 100% of parents felt that feminizing genitoplasty should be performed within the first year of life. There is however a significant difference compared to controls who felt that surgical management should occur later on in life. No difference was highlighted during childhood regarding parents-child relationships or social integration. However, during adolescence, the parents-child relationship tended to be significantly more painful for the CAH group. Integrating their parenting role was significantly harder for patients in the CAH-DSD group. In the population of CAH-DSD patients who had genitoplasty the level of sexual fulfillment was not lower to the one reported by the control group. CONCLUSION Female sex assignment seems legitimate according to this study and the development of gender identity in these patients matches the sex assigned at birth. Resolving early on the adequacy of the genital anatomy with the sex assigned is promoted by patients as well as their parents. Proper psychomotor development and sexual satisfaction underline the absence of complications related to the surgical technique and the relevance of early surgical management.

Article originalSite donneur de greffe de peau mince : quel pansement utiliser ?Split-thickness skin graft donor site: Which dressing use?

INTRODUCTION The management of split-thickness skin graft donor sites is targeted towards promoting the healing process, reducing pain. This has been an inconclusive topic. The aim of this study was to list and to discuss the French practices in term of split-thickness skin graft (STSG) donor site dressing. MATERIALS AND METHODS Multicentric national study by questionnaire (Google Drive(®)) for the attention of the plastic and/or pediatric surgeons. The type of dressing used on skin and sclap and the rhythm of dressing changes were analyzed. RESULTS The study included 26 surgical centers on 40 contacted. The alginate is mainly used (Algostéril(®)) (17/26). It is left in position until healing (13/17). Five other types of dressings have been reported: paraffin gauze (3/26), lipidocolloides (1/26), Mepitel(®) (1/26), Mepilex(®) (1/26), indifferent use of gauze or alginate dressings (4/26). Twenty-two out of 26 centers make no difference in dressing choice between skin and scalp. Medical practices did not differ between adult or pediatric departments. CONCLUSION Cost-effectiveness has become an important issue in wound management, requiring judicious use. The lack of consensus regarding split-thickness skin graft donor site dressing and our clinical practices force us to reconsider the best therapeutic option. This study coupled with the analysis of the literature highlights the difficulties of the practitioner in choosing the best dressing. The alginate seems to get the preference of our practices by its ease of use, its absence of change (reduces pain by limiting manipulations) and its moderate cost.

Retour d’expérience d’une nouvelle technique de préputioplastie comme alternative à la circoncision

Surgery is required for phimosis with a contracted fibrous ring or when the medical treatment with steroids has been unsuccessful. Surgical teams often opt for circumcision when a conservative technique can be used. This surgery could have some psychologic consequences, and when the circumcision in not according to religious convictions, it cannot be live well for the patient and his family. Furthermore, some surgery procedures for prepuce conservation seem to give some unaesthesics aspects with cutaneous excess. The objective of this study was to evaluate our new preputioplasty technique according to the initial diagnosis (phimosis with scarred foreskin or long and narrow foreskin), in situation where circumcision is required currently. Outcome evaluated was: easy and painless foreskin retraction, absence of postoperative phimosis as well as cosmetic aspects of the penis. In this study, 90 children benefited from this technique and subsequent follow-up. The mean age was 7.9 years for the 32 children in the sclerotic phimosis group and 6.8 years for the 58 children in the long and narrow foreskin group. We observed complete foreskin retraction without any recurrence in 100% of children with a phimosis resistant to medical treatment which consisted of progressive foreskin retraction and application of topical steroids, with a mean postoperative follow-up of 1.4 years. Results showed an excellent cosmetic aspect of the penis with absence of enlarged foreskin in all our subjects. This study underlines the relevance of this surgical technique.

SFCP CO-22 - Site donneur de greffe de peau mince: quel pansement utiliser?

Objectif Le site donneur d’une GPM doit profiter d’un pansement permettant une cicatrisation rapide et peu algique. Il n’existe pas de consensus a ce sujet. Objectif repertorier et discuter les pratiques francaises. Materiels et methodes Etude multicentrique par questionnaire(Google Drive®) a l’attention des chirurgiens plasticiens et infantiles. Le type de pansement choisi sur peau glabre ou cuir chevelu, ainsi que le rythme de changement ont ete analyses. Resultats 40 centres contactes, 25(24 CHU,1 centre prive) ont repondu a l’etude. (9 adultes,6 pediatriques,4mixtes adultes et enfants, 6centres de grands brules) Les alginates (Algosteril®) sont majoritairement utilises(17/25) et laisses en place jusqu’a cicatrisation(13/17). 5 autres protocoles decrits:Pansement gras (3/25), lipidocolloides(1/25), Mepitel®(2/25), utilisation indifferente de pansements gras ou d’alginate(4/25). Pas de difference entre peau glabre et le cuir chevelu(22/25). Pas de difference d’utilisation des pansements en terrain pediatrique ou adulte. Discussion L’absence de consensus et nos habitudes cliniques nous ont fait etudier nos pratiques. L’alginate semble avoir la preference de nos pratiques par sa facilite d’utilisation, son absence de changement (limitation de la douleur par absence de manipulation) et son faible cout.

Cleft palate associated with cervico-facial teratoma: Report of two cases and review of the literature

We report two original cases of association of cleft palate and lateral cervico-facial teratoma. We discuss the embryological explanation. The first child presented a cleft palate associated with two cervico-facial localisations of teratoma. The other had Pierre Robin sequence associated with lateropharyngeal teratoma with an extra sub maxillary localisation. Most reported cases were of midline teratomas, leading different authors to advance a mechanical origin to the cleft. Our cases are different: we could hardly find reported cases of associate lateral tumours and cleft palate, which would suggest two different embryologic mechanisms, or at least a combination of more complicated phenomenons.

CL039 - Étude rétrospective multicentrique du GECI sur 114 duplications digestives opérées par thoracoscopie ou laparoscopie

Objectifs Determiner les resultats a court et moyen terme des duplications digestives de tout site operees par laparoscopie ou thoracoscopie chez l’enfant. Materiel et Methodes Etude retrospective multicentrique: 114 enfants provenant de 18 centres. P Resultats La localisation etait a l’œsophage(14 %), a l’estomac(12 %), au duodenum(6 %), a l’intestin grele(62 %), et au colon(6 %). Il y a eu 102 laparoscopies et 12 thoracoscopies. Le taux de conversion etait de 42 % chez les patients avec diagnostic antenatal(DAN) contre 20 % sans DAN (S). Il y a eu 29 % de patients symptomatiques avec DAN contre 63 % chez les patients sans DAN (S). Le taux de conversion etait de 48 % en cas d’intervention urgente contre 26 % si non urgente (S). L’abord a ete combine (exteriorisation de la duplication par orifice de trocart) pour 26 % des patients. Les complications post operatoires(7 %) ne dependaient pas de d’une conversion, de l’âge de l’enfant ou de l’urgence. Conclusion Le traitement des duplications digestives par thoraco/ laparoscopie comporte peu de complications. Le DAN permet de prevenir l’apparition des symptomes mais la thoraco/laparoscopie est plus difficile chez ces enfants. L’abord combine est une alternative a l’abord intracorporel pour les duplications du grele.

CL121 - Douleurs abdominales aux urgences pédiatriques : utilisation du score de Bargy

L’appendicite reste parfois de diagnostic difficile et l’organisation des urgences ne permet pas toujours d’assurer sa prise en charge dans un delai optimal. Afin d’orienter au mieux les douleurs abdominales, nous avons etudie l’applicabilite du score de Bargy aux urgences pediatriques. Etude prospective (decembre 2008/avril 2009) Les items du score de Bargy ont ete saisis aux urgences (fiche informatisee), par les internes (pediatrie, chirurgie, medecine generale) ou les seniors urgentistes, devant toutes douleurs abdominales de l’enfant (4 a 13 ans). 290 enfants (52,8 % F, 47,2 % G) âge moyen 8,5 ans Le score n’etait complet que dans 17 % des cas : - etat general renseignee dans 44 % des cas - hyperleucocytose dans 38 % - signes radiologiques dans 36 % Le reste des items etait renseigne permettant le calcul minimal d’un score sur 5. On retrouvait des scores: 3-5 : 34,6 % > 5 : 5,1 % 49 enfants hospitalises (16,9 %), 39 en chirurgie pediatrique. 81,5 % (40/49) des enfants hospitalises avaient un score ≥ 3. 13 enfants ont ete operes : - 53,9 % (7/13) avait un score ≥ 5 - 46 % (6/13) avait une appendicite (50 % score > 5) - 38,5 % (5/13) une peritonite (80 % score > 5) Nous analyserons les resultats en discutant les aspects positifs de l’utilisation d’un tel score au niveau d’urgences pediatriques.

CL073 - La rate oscillante chez l’enfant : étude multicentrique

Le diagnostic de rate oscillante est difficile et tout retard peut etre responsable, en cas de torsion, d’une ischemie splenique. Un questionnaire portant sur l’epidemiologique, la semiologique, le diagnostic, la chirurgie, a ete envoye par e-mail aux chirurgiens pediatriques Francais. 14 (6 F et 8 G) cas entre 1984/2009 (1 j-15 ans). 86 % ont consulte en urgence. Il s’agissait du premier episode dans 57 % des cas. 93 % presentaient des douleurs abdominales. 54 % des vomissements. Aucun diagnostic n’a ete pose sur la seule clinique. Tous les patients ont eu un diagnostic preoperatoire grâce a l’imagerie. Le traitement a consiste a une chirurgie a ciel ouvert dans 64 % des cas. 43 % ont eu une splenectomie pour ischemie. 36 % ont eu une splenopexie. 14 % ont eu une gastropexie par laparoscopie, et 7 % ont eu un repositionnement de la rate et avivement. Les complications a long terme : 60 % d’ischemies spleniques post splenopexie. La precocite du diagnostic et l’intervention garantissent au mieux la survie splenique. Meme si le choix entre splenopexie et gastropexie reste discutable, la gastropexie nous semble avoir l’avantage d’eviter la manipulation splenique, et de restaurer l’anatomie. En l’absence d’antecedent de chirurgie abdominale, la laparoscopie nous parait devoir etre preferee.