F. Nouira

Conservative management of post-appendicectomy intra-abdominal abscesses.

PurposeAppendicitis is the most common abdominal inflammatory process in children which were sometimes followed by complications including intra-abdominal abscess. This later needs classically a surgical drainage. We evaluated the efficacy of antibiotic treatment and surgical drainage.MethodsHospital records of children treated in our unit for intra-abdominal post appendectomy abscesses over a 6 years period were reviewed retrospectively.ResultsThis study investigates a series of 14 children from 2 to 13 years of age with one or many abscesses after appendectomy, treated between 2002 and 2007. Seven underwent surgery and the others were treated with triple antibiotherapy. The two groups were comparable.For the 7 patients who receive medical treatment alone, it was considered efficient in 6 cases (85%) with clinical, biological and radiological recovery of the abscess. There was one failure (14%). The duration of hospitalization from the day of diagnosis of intra-abdominal abscess was approximately 10.28 days (range 7 to 14 days). In the other group, the efficacy of treatment was considered satisfactory in all cases. The duration of hospitalization was about 13 days (range: 9 to 20).ConclusionCompared to surgical drainage, antibiotic management of intra-abdominal abscesses was a no invasive treatment with shorter hospitalization.

Congenital diaphragmatic hernia in neonate: A retrospective study about 28 observations

OBJECTIVE Our purpose was to review our experience with congenital diaphragmatic hernia emphasizing diagnosis, management, and outcome. STUDY DESIGN We conducted a retrospective review of all cases of babies with congenital diaphragmatic hernia diagnosed and treated in our centre from 1998 to 2010. RESULTS There were 28 congenital diaphragmatic hernia cases, 13 girls and 15 boys with a mean weight birth of 3 kg. Three patients (10, 6% of cases) died within a few hours after admission. In the remaining cases, surgery was performed after a stabilization period of 2 days. The diaphragmatic defect was sitting in the posterolateral left in 23 cases and right in 2 cases. Its dimensions were on average 4,5 cm, tow cases of agenesis of the cupola were seen and required the placement of gortex prosthesis. The remaining cases are treated by direct closure of defect. Postoperative course was marked by an early death in context of respiratory distress in six cases and later with sepsis in tow cases. The outcome was favourable in 17 cases (60, 7%), despite the occurrence of sepsis in four cases and evisceration in two cases. CONCLUSIONS Congenital diaphragmatic hernia remains a serious disease with high mortality and morbidity despite advances in prenatal diagnosis and neonatal resuscitation.

Management of congenital bladder diverticulum in children: A report of seven cases

Background: The purpose of the study is to present the author′s experience with congenital bladder diverticula in seven pediatric patients at a developing world tertiary care center. Materials and Methods: Records of seven patients diagnosed and treated as congenital bladder diverticulum, from January 1998 to December 2009 were retrospectively reviewed for age, sex, clinical symptoms, investigative work-up, operative notes, and postoperative follow-up. Results: All patients were males. Age at presentation ranged from six months to six years (mean three years and six months). All were manifested postnatally by urinary tract infection in four cases, bladder retention in three cases and abdominal pain in two cases. Diagnosis was suggested by ultrasound and confirmed by voiding cystourethrography (VCUG) in all cases and urethrocystoscopy in three cases. Open surgical excision of diverticulum was done in all the patients associated with ureteral reimplantation in four patients with VCUG-documented high-grade vesicoureteral reflux (VUR). Average follow-up was four years; there is a resolution of symptoms and no diverticulum recurrence at the defined mean follow-up. Conclusion: Recurrent urinary tract infections and voiding dysfunction in pediatric population should always be evaluated for congenital bladder diverticulum. Investigations such as abdominal ultrasound, VCUG and nuclear renal scanning, form an important part of preoperative diagnostic work-up and postoperative follow up. Diverticulectomy with ureteral reimplantation in case of high-grade reflux, provides good results without recurrence.

Testicular tumours in prepubertal children: About eight cases.

Background: To analyze the spectrum of testicular tumors in prepubertal children and the therapeutic resultants in an unselected population. Materials and Methods: Our hospital database was analyzed for testicular tumors from January 1995 to December 2010 concerning clinical presentation, treatment and therapeutic results. Results: Eight patients were operated on because of testicular tumors. In six cases (75%) the tumor was benign: benign teratoma (four cases), epidermoid cyst (one case) and immature teratoma (one case). Two patients (25%) had a malignant tumour: yolk-sac tumour (two cases). All this children underwent surgery. Radical inguinal orchidectomy was performed in six cases and conservative surgery was performed in two cases. One patient has received adjuvant chemotherapy. Follow-up was uneventfully three years after primary surgery. Conclusion: In prepubertal children, most testicular tumours are benign. If tumour markers were negative testis-preserving surgery can be proposed, complete excision of the tumour should be ascertained. In the case of testicular teratoma, the possibility of contralateral tumour should be considered in the follow-up.

Surgical management of recto-sigmoid Hirschsprung's disease.

Abstract Introduction : Over the years, the surgical management of recto-sigmoid Hirschsprung’s disease (HD) has evolved radically and at present a single stage transanal pull-through can be done in suitable cases, which obviates the need for multiple surgeries. Aim : The aim of this paper was to evaluate the role of transanal pull-through in the management of recto-sigmoid HD in our institution. Material and Methods : A retrospective analysis (between January 2003 and December 2009) was carried out on all cases of Hirschsprung’s reporting to unity of pediatric surgery of Tunis Children’s Hospital that were managed by transanal pull-through as a definitive treatment. All selected patients including neonates had an aganglionic segment confined to the rectosigmoid area, confirmed by preoperative barium enema and postoperative histology. Twenty-six children (86%) had their operation done without construction of prior colostomy. Results : Transanal pull-through was performed in 31 children. Mean operating time was 150 minutes (range 64 to 300 minutes). No patients required laparotomy because all patients including neonates had an aganglionic segment confined to the rectosigmoid area. Blood loss ranged between 20 to 56 ml without blood replacement. Since all children were given an epidural caudal block, the requirement of analgesia in these cases was minimal. Postoperative complications included perianal excoriation in 7 out of 31 patients lasting from 3 weeks to 6 months. Complete anorectal continence was noted in 21 of 31 (67%) children in follow up of 3–5 years. Conclusions : Transanal endorectal pull-through procedure for the management of rectosigmoid HD is now a well-established and preferred approach. Parental satisfaction is immense due to the lack of scars on the abdomen. As regards the continence, a long-term follow-up is necessary to appreciate better the functional results of this surgery.

Renal Cell Carcinoma in Children: About Two Case Report

Introduction Renal cell carcinoma (RCC) is extremely rare in children. Several factors could influence prognosis, including stage, grade, histology, symptomatic presentation, and performance status. Among these, tumor stage is the most important predictor of disease prognosis for RCC. We report our experience with two cases of children with renal cell carcinoma in children. Cases Case 1: A 13-year-old girl presented macroscopic hematuria after a right lumbar trauma. The renal ultrasonography and CT urography showed a very limited rounding medio renal mass. Fine needle renal aspiration objectified RCC. Patient underwent transabdominal radical nephrectomy. Histopathology revealed RCC grade 2 of Furhrman T1b N0 M0. The postoperative course was uneventful. Case 2: A 9-year-old girl presented macroscopic hematuria. The renal ultrasonography showed a horseshoe left kidney with limited rounding mass. CT urography showed limited left renal mass of 31 × 25 mm. Fine needle renal aspiration objectified RCC. Patient underwent transabdominal radical nephrectomy with regional lymphadenectomy. Histopathology revealed RCC associated with translocation Xp11.2 grade 2 of Furhrman T1a N1M0. The postoperative course was uneventful. Conclusion RCC is rare in children but in children older than 5 years with renal masses it is very important to suspect diagnosis. Surgery is the best treatment and prognosis is favorable when the tumor is localized and completely eradicated.

Meckelâs Diverticulum Complications in Chirldren: Results of a 51 Cases Unicentric Series

Objective: The aim of this study is to investigate the diagnosis and the treatment options of complicated Meckel’s diverticulum and compare that with the literature. Material and Methods: This study retrospectively evaluated 51 patients who had been operated on for complicated Meckel’s diverticulitis in our department of Pediatric Surgery, between January 1999 and February 2016. Clinical symptoms, signs, radiologic data and therapeutic management were retrieved. Results: A total of 51 children with a diagnosis of complicated Meckel’s diverticulitis (MD) were retrospectively analysed. The reason for consultation was an occlusive syndrome in 28 patients (55%), rectal bleeding or melena in 18 patients (35%) and isolated abdominal pain in 5 patients (10%). Abdominal ultrasound was performed in 49 patients, it was normal in 37% and it has objectified an intussusception in 26.5% of cases. All patients were operated. The way was a McBurney incision 45%, a midline laparotomy 21.5% and laparoscopic 33.5% of cases. The intra-operative diagnoses of MD complications were diverticulum perforation in 13.5%, mechanical intestinal obstruction due to diverticulum in 6%, diverticulum invagination in 21.5%, diverticulitis in 31.5%, volvulus in 3%, one attached to the hernia sac in Littre’s hernia and 21.5% appeared macroscopically healthy in intraoperative. All patients had partial small bowel resection and end-to-end anastomosis. Histopathologic ectopic tissue revealed: 21 gastric mucosa (41%), 3 pancreatic tissues (6%), 12 jejunal tissues (23.5%) and no heterotopic focus in 5 patients (10%). Conclusion: Meckel’s diverticulitis does not have specific clinical and radiological findings. Surgical intervention is the only treatment and laparoscopy is increasingly used.

P234 - Les invaginations intestinales secondaires : à propos de 25 cas pédiatriques

Nous rapportons 25 cas colliges dans le service de chirurgie pediatrique « B » a l’Hopital d’enfants de Tunis sur une periode de 15 ans. L’âge de nos malades varie de 2 mois a 11 ans, dont 13 cas sont superieurs a 2 ans. Il existe une predominance masculine nette, 18 garcons et 7 filles. La symptomatologie classique associant : une douleur paroxystique, refus de tetee ou vomissements et rectorragie n’est retrouvee que dans 5 cas. Le seul element clinique constant est represente par la douleur. La palpation d’une masse abdominale a ete possible dans 6 cas. L’echographie a permis d’etablir le diagnostic d’invagination intestinale aigue dans 23 cas. Aucune desinvagination par lavement hydrostatique n’a etait realisee. Tous nos malades ont ete operes en urgence. La desinvagination peroperatoire n’a ete possible que dans 5 cas. Le type anatomopathologique de l’invagination etait : – ileo-ileale : 17 cas – ileo-caecale : 3 cas – ileo-ileo-colique : 5 cas La resection intestinale a ete pratiquee dans tous les cas devant l’existence de lesions causales (diverticule de Meckel : 16 cas, lymphome : 7 cas, polypes du greles : 2 cas) L’evolution a ete bonne pour tous les patients, en incluant les formes lymphomateuses qui ont bien repandu a la chimiotherapie.

CL169 - Douleurs de la fosse iliaque droite Chez l’enfant : Intérêt de la surveillance hospitalière et apport des examens Radiologiques Étude rétrospective à propos de 300 cas

But de l’etude Evaluation de l’apport des examens radiologiques et de l’interet de la surveillance hospitaliere dans les douleurs de la fosse iliaque droite (DFID) chez l’enfant. Patients et Methodes Etude retrospective de 300 malades hospitalises pour DFID pendant l’annee 2009. Resultats Les signes cliniques et biologiques sont dominees par les vomissements dans 74 % des cas et une CRP > a 10 mg/l dans 71 %. L’ASP realise dans tous les cas a montre un stercolithe dans 4 cas. On a divise les malades en deux groupes : - Premier groupe : Les malades operes d’emblee avant 6h: n = 178 - Deuxieme groupe : Les malades qui ont necessite une surveillance hospitaliere : n = 122. Dans le premier groupe il s’agissait d’une appendicite aigue dans 94 % ( n = 168). Parmi les 122 malades du deuxieme groupe, 36 malades (29 %) ont etaient operes dont 28 (22 %) avaient une appendicite aigue. Parmi les malades operes 24 malades avaient une echographie montrant des signes d’appendicite. Conclusion L’ASP est un examen radiologique inutile dans le diagnostic de l’appendicite. L’echographie, par contre, avec une sensibilite de 92 % et une specificite de 90 % constitue un examen performant surtout en cas de doute diagnostic, ainsi, couplee a la surveillance clinique a permis d’eviter dans 70 % des cas des interventions inutiles.

P233 - Les occlusions intestinales sur brides chez l’enfant : quand opérer ?

Analyser les etiologies des OIB chez l’enfant et essayer de definir les signes predictifs de souffrance intestinale. 42 enfants ont ete traites pour OIB sur une periode de dix ans. La pathologie appendiculaire etait la cause la plus frequente (69 %).19 patients ont beneficie du traitement conservateur avec une evolution favorable.L’exploration chirurgicale a ete realisee dans 23 cas. Dans 5 cas d’emblee et dans 18 cas apres echec du traitement conservateur. L’indication operatoire a ete retenue d’emblee devant la fievre, une defense abdominale generalisee, l’hyperleucocytose, CRP positive et la presence sur le scanner abdominal d’une distension intestinale avec un epaississement et absence de rehaussement parietal des anses greliques. Parmi ces patients 3 seulement ont necessite une resection d’anses necrosees. L’exploration chirurgicale a ete realisee apres traitement conservateur devant la persistance des douleurs abdominales, des NHA. La pathologie appendiculaire est l’etiologie la plus pourvoyeuse d’OIB chez l’enfant. L’alteration de l’etat general, les signes cliniques d’irritation peritoneale et la distension intestinale avec epaississement et defaut de rehaussement parietal des anses greliques au scanner abdominal temoignent d’une souffrance intestinale.