Elisabeth Carricaburu

Laparoscopic distal pancreatectomy for Frantz’s tumor in a child

Solid pseudopapillary tumor of the pancreas is a rare pathologic entity. Although the role of laparoscopy in surgery of the pancreas is still controversial, laparoscopic distal pancreatectomy has been reported with good results in adults. We report a laparoscopic spleen-preserving distal pancreatectomy in a 9-year-old boy who presented with a low-grade malignant tumor. Needle biopsy was impossible. A laparoscopic spleenpreserving distal pancreatectomy was performed. We used four trocars, and the operative time was 240 min. Conversion to open surgery was not necessary. The boy’s postoperative recovery was uneventful, and he was discharged on the 6th day. CT-scan control at 6 months was normal. This case shows that even in advanced surgical cases, such as spleen-preserving distal pancreatectomy, laparoscopic procedures can be done safely, within a reasonable operative time, in children.

Laparoscopic Duhamel procedure. Management of 30 cases.

BACKGROUNDnBetween February 1995 and June 1998, 30 laparoscopic Duhamel pull-through procedures were performed in our department.nnnMETHODSnOur main aim was to prove the feasibility of the laparoscopic abdominal Duhamel procedure for different localizations of Hirschsprung disease. We used one camera port and three working ports. The sigmoid colon and posterior rectum were mobilized laparoscopically. A standard posterior colo-anal anastomosis was fashioned and a stapler was used for the anterior anastomosis. The top of the rectum was then closed by endo stapler under laparoscopic vision.nnnRESULTSnThirty patients underwent laparoscopic surgery for this procedure. Three laparoscopic procedures were converted because of technical difficulties. The operative time was 100-330 mn. Oral feeding was started at a mean postoperative time of 2.5 days. Mean postoperative hospitalization was 9 days. Early postoperative complications included 1 anastomotic leak, 1 retrorectal abscess, 2 urinary infections, and 1 evisceration (after conversion). No enterocolitis or enterocolitis-like symptoms were noted. All patients now have daily spontaneous bowel movements.nnnCONCLUSIONnThe laparoscopic Duhamel procedure can be performed safely, giving good results.

Retroperitoneal laparoscopic pyeloplasty in children: long-term outcome and critical analysis of 10-year experience in a teaching center.

BACKGROUNDnLaparoscopic pyeloplasty in children remains controversial and is not included in most pediatric urology centers because of technical difficulties and lack of long-term results.nnnOBJECTIVEnTo critically analyze our 10-yr experience with the retroperitoneal approach (RA), with a particular interest on the impact of the learning curve in a teaching center.nnnDESIGN, SETTING, AND PARTICIPANTSnPatients who underwent pyeloplasty between 1999 and 2010 at our institution were reviewed (n=390). The diagnosis of ureteropelvic junction obstruction was confirmed by ultrasound and technetium Tc 99m mercaptoacetyltriglycine-3 renal scan or magnetic resonance imaging; the same criteria were used to evaluate the outcome. The lateral RA was selected in children >1 yr of age without abnormal migration or fusion of the kidney (n=104).nnnSURGICAL PROCEDUREnDismembered pyeloplasty and anastomosis were performed using running monofilament 5-0 or 6-0 absorbable suture. All were drained by double-J stent except 20 cases drained by external transanastomotic stent.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnWe assessed intra- and postoperative morbidity and analyzed the teaching of technique and learning curve. Data are expressed as medians and interquartile range (25th, 75th percentiles) for quantitative variables.nnnRESULTS AND LIMITATIONSnMedian age was 6.2 yr (2.2-10.3). Thirty-three patients had crossing vessels. Median operative time was 185 min (160-235). Median hospital stay was 2 d (1-2). Redo pyeloplasty was needed in only two children (2%). Median follow-up was 2.1 yr (1.4-4.1). Operative time was <3 h after 35 cases. After 30 cases performed by the same surgeon, standardization of the technique was feasible, which helped in the teaching process because 50% of the final 30 cases were done by trainees.nnnCONCLUSIONSnRetroperitoneal dismembered laparoscopic pyeloplasty is a safe, reliable, and efficient procedure with an excellent outcome in selected children according to their indications and age, and the experience of the surgical team. Even if the transmission to trainees is successful, it is still a long learning process and remains a challenging task for a teaching center.

Is laparoscopic management suitable for solid pseudo-papillary tumors of the pancreas?

PurposeSolid pseudo-papillary tumors (SPT) are rare pancreatic neoplasms of low-malignant potential occurring mainly in young women. The purpose of this report is to describe our experience with laparoscopic management of these tumors with 4-year follow-up.MethodsThree children with SPT were admitted to two hospitals in Paris, France, between February 2000 and December 2006. Diagnosis or treatment was carried out using laparoscopic techniques (biopsy and resection in one case and biopsy only in two). Long-term follow-up data were collected.ResultsAll three patients presented recurrences within 3xa0years after resection, i.e., disseminated peritoneal recurrence in two patients and local recurrence in one. The two patients with peritoneal recurrences were treated by surgical resection and chemotherapy. The patient with local recurrence could not be treated due to contraindicating local factors. All three patients were alive at the time of this writing.ConclusionThis is the first report describing long-term follow-up after laparoscopic management of SPT. All three patients developed recurrences. These poor results contrast sharply with the low risk of local or disseminated recurrence after open laparotomy without chemotherapy that has been considered as the treatment of choice up to now. Recurrences after laparoscopic management may have been due to diffusion of tumor cells caused by gas insufflation especially during biopsy. Laparoscopic biopsy should not be performed in patients presenting SPT.

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).

Is intraabdominal pressure a good predictor of mortality in necrotizing enterocolitis

Sir: Intraabdominal pressure (IAP) is elevated in many pediatric patients with critical illnesses, injuries, or surgery. Several methods for measuring intravesical pressure (IVP) have been described [1, 2]. At the acute phase of necrotizing enterocolitis, both fluid resuscitation and medications lead to the development of a third abdominal compartment and, therefore, to IAP elevation, which worsens the bowel ischemia. We are prospectively evaluating IVP as a predictor of death in neonates with necrotizing enterocolitis, and we report our preliminary results. All neonates admitted to our pediatric ICU for severe necrotizing enterocolitis were enrolled prospectively from December 2004 to December 2005. Necrotizing enterocolitis was diagnosed when pneumatosis intestinalis was visible on the abdominal radiographs. A Foley catheter was placed to monitor the urine output. Surgery was performed when radiographs showed free intraperitoneal gas or the medical treatment induced no response. IVP was measured via a transurethral bladder catheter as first suggested by Kron et al. [3] and described recently by Davis et al. [4]. Intra-vesical pressure was used instead of gastric pressure because we felt that manipulating the nasogastric tube of patients who required continuous suction for an occlusive condition was problematic. Furthermore, nasogastric tube placement varies widely, especially in very premature babies. The tube is often obstructed by the gastric mucosa because of the low levels of Gomco suction used. IVP was measured every 3 h for 48 h (ten values per patient). Quantitative data were described as median (range) and qualitative data as number (percentage). Spearman’s correlation coefficient was computed to assess correlations between the ten IVP values and the ten mean pressure values, both summarized as the mean in each patient. The relationship between IVP and mortality was evaluated using the generalized estimating equation method. Statistical tests were performed using SAS 9.1 (Cary, NC). P values 0.10 were considered statistically significant. There were seven patients (Table 1) with a median gestational age of 32.9 weeks (range, 27–41) and a median birth weight of 1,689 g (range, 840–3,340). Surgery was needed in five patients. Another patient (no. 4) responded well to medical treatment. Patient 5 was too unstable for surgery. Three patients died (3/7, 43%). IVP was associated with mortality (odds ratio for a 1-mmHg increase, 1.22; 95% confidence interval, 0.96–1.55; P = 0.098). Individual mean IVP correlated with individual mean value of mean ventilatory pressure (rho = 0.68, P = 0.094). Mean IVP value did not correlate with FiO2 or mean fluid resuscitation volume. IVP measurement to assess IAP may help to predict mortality in premature babies with necrotizing enterocolitis. Furthermore, a study in

One-Year Outcome for Congenital Diaphragmatic Hernia: Results From the French National Register

Objective To evaluate the status of congenital diaphragmatic hernia (CDH) management in France and to assess predictors of adverse outcomes. Study design We reviewed the first‐year outcome of all cases of CDH reported to the French National Register in 2011. Results A total of 158 cases were included. Of these, 83% (131) were prenatally diagnosed, with a mortality rate of 39% (44 of 112) for live born infants with a known outcome at hospital discharge. Mortality increased to 47% (60 of 128) including those with termination of pregnancy and fetal loss. This contrasts with the 7% (2 of 27) mortality rate of the patients diagnosed postnatally (P = .002). Mortality worsened with 1 prenatal marker of CDH severity (OR 3.38 [1.30‐8.83] P = .013) and worsened further with 2 markers (OR 20.64 [5.29‐80.62] P < .001). Classic postnatal risk factors of mortality such as side of hernia (nonleft P = .001), prematurity (P < .001), low birth weight (P = .002), and size of the defect (P < .001) were confirmed. Of the 141 live births (114 prenatal and 27 postnatal diagnosis) with known outcomes, 93 (67%) survived to hospital discharge, 68 (60%) with a prenatal diagnosis and 25 (93%) with a postnatal diagnosis. The median time to hospital discharge was 34 days (IQR, 19.25‐62). Of these survivors, 71 (76%) were followed up for 1 year. Conclusions Despite advances in management of CDH, mortality was high and associated with prenatal risk factors. Postnatally, severe persistent pulmonary hypertension was difficult to predict and presented persistent challenges in management.

SFCP CO-55 - Suivi à un an de la hernie congénitale du diaphragme: résultats du registre national français

Prise en charge et resultats a 1 an du traitement de la hernie congenitale du diaphragme (HCD) en France. Analyse du registre national francais des HCD sur 157 cas de HCD enregistres en 2011. Parmi les 157 cas le diagnostic etait post-natal dans 27 cas et antenatal dans 130 cas. Le poids moyen de naissance etait 2900 +/- 709g, le terme moyen de naissance etait 36+/-5SA. La HCD etait gauche dans 73% et droite dans 17%. Le plug antenatal etait pose dans 13 cas. Le sejour median en reanimation etait de 24 jours (1-161), la mortalite etait de 36/139 (26%). 9 patients ont eu une ECMO. L’âge median au moment de la chirurgie etait de 3.6 jours (0–32). La chirurgie a ete realisee par laparotomie dans 74 cas, coelioscopie dans 1, thoracotomie dans 4 et thoracoscopie dans 7 cas. Le defect diaphragmatique etait ferme simplement dans 60 cas, un patch a ete utilise chez 28 patients (32%). Neuf valves antireflux et 6 gastrostomies ont etes realises au moment de la chirurgie premiere. Pendant la 1ere annee 9 autres gestes antireflux et 8 gastrostomies ont ete realises, 7 patients ont ete operes pour recidive, 5 pour occlusion sur bride. A 1 an le poids moyen etait de 8.8xa0kg (23 percentile), 8 ont une nutrition enterale, 5 ont les troubles de l’oralite, 6 ont des complications neurologiques

SFCP CO-45 - Néphrectomie partielle par rétropéritonéoscopie; peut-on reconsidérer sa mauvaise réputation ?

Objectif La nephrectomie partielle laparoscopique (NPL) reste controversee chez les jeunes enfants en raison de taux eleve des complications et de conversion. Methodes Etude retrospective mono centrique entre 1997–2013. La technique a ete progressivement standardisee:1) position laterale, approche retroperitoneale 2) insertion retrograde de catheter ureteral dans le pole restant, injection de bleu de methylene au cours de la section du parenchyme 3) le pole restant est garde attache au peritoine. L’evaluation est effectuee par echographie Doppler renale +/_ scintigraphie au DMSA. Resultats 58 NPL (43 superieurs) ont ete effectuees a un âge median de 15mois [1–156], duree operatoire 140min [75–270], duree d’hospitalisation 2 jrs, suivi 23mois [6–109]. Une seule conversion (1,7%) (4 mois, 6eme cas). Un seul enfant (1,7%) a eu une perte du pole inferieure restant, (7 ans, 4eme cas). Deux enfants ont eu urinome dont un necessitant un drainage. 25 enfants ont ete operes a un âge Conclusions NPL reste une intervention a risque. Une technique standardisee et maitrisee peut reduire le taux des complications et de conversion. Le principal facteur limitant est la courbe d’apprentissage du chirurgien par rapport a l’âge du patient.

Maladie de Hirschsprung : quel suivi pour quelles complications à court et moyen terme ?

Elle peut être liée à 4 causes : la bride postopératoire, l’éventration avec incarcération d’anse, le twist de l’intestin abaissé et la sténose de l’anastomose. En cas d’occlusion, il faudra palper le ventre et faire un toucher rectal afin d’éliminer une sténose. Si l’examen n’est pas concluant, il faut réaliser une opacification. Le twist est très difficile à diagnostiquer, c’est bien souvent l’exploration chirurgicale qui permettra de confirmer ou d’infirmer le diagnostic.