Frederique Lemasson

Ovarian torsion. Management and ovarian prognosis: a report of 45 cases

BACKGROUND/PURPOSE Ovarian torsion in childhood and adolescence is a rare entity. Traditionally, treatment is oophorectomy. The aim of this study was to evaluate ovarian outcome and to propose a decision-making protocol for suspected ovarian torsion. METHODS Between January 1986 and December 2007, 45 ovarian torsion cases in 40 girls were operated on. In all the cases, when the ovary was preserved, patients were clinically and ultrasonographically followed up for several months. RESULTS Median age was 11 years. Median delay between the first symptoms and surgical procedure was 3 days. There was a statistical difference (P = .0003) between the mean of the largest diameter of twisted normal ovary and the mean of the largest diameter of twisted diseased ovary. Underlying pathology was benign in 22 cases and low-grade malignancy in 2 (one grade II immature teratoma and one steroid cell tumor). Conservative management was performed in 26 cases. At follow-up, 17 ovaries were follicular, 7 being black-bluish during surgery. CONCLUSIONS Conservative approach after detorsion of black-bluish ovaries is safe and effective in children. Although very unlikely, the fear of missing malignancy must incite to proceed with caution and can lead, when the size of the twisted ovary is greater than 75 mm, to prefer laparotomy to laparoscopy.

Ovarian germ cell tumors in children. Management, survival and ovarian prognosis. A report of 75 cases.

BACKGROUND/PURPOSE The aims of this study were to evaluate survival and ovarian prognosis in patients treated for ovarian germ cell tumor (OGCT) and to propose a decision-making protocol. METHODS Charts of girls operated on for OGCT from 1976 up to 2009 were reviewed retrospectively. Tumor characteristics were assessed by tumor markers, imaging, and pathology. RESULTS Charts were available in 71 children presenting 75 OGCT. Tumors were benign in 58 cases and malignant in 17 cases. The average of the largest diameter of benign OGCT was significantly lower than that of malignant OGCT (76.5 +/- 49 mm versus 169 +/- 54 mm, P < .0001). Ovarian-sparing tumorectomy was carried out in 27 benign OGCT; 23 (85%) preserved ovaries were follicular. Malignant OGCTs were managed according to the protocols of the French Society for Pediatric Oncology. Bilateral oophorectomy had to be performed in 2 children. One patient presented a recurrence and 1 died. CONCLUSIONS In our series, both benign and malignant OGCTs have a good prognosis. A 75-mm cutoff size is proposed as an important criterion to preoperatively differentiate between benign and malignant tumors. In benign OGCT, ovarian-sparing tumorectomy leads to preserve ovaries in approximately 85% of cases, and in malignant OGCT, high survival rate has been obtained.

Conservative management of blunt pancreatic trauma in children: a single center experience.

INTRODUCTION Blunt trauma of the pancreas represents a significant part of abdomen trauma in children with an incidence estimated at around 10%. If the conservative management is widely accepted concerning the stages I and II, it remains controversial concerning stages III and IV. The aim of our study was to perform a descriptive analysis of the nonoperative management, with a focus on the occurrence of pseudocysts. MATERIALS AND METHODS The charts of the patients treated in our center for pancreatic trauma from 1990 to 2010 have been reviewed. It was defined by an initial lipase greater than three times the norm and an abnormal computed tomography scan. RESULTS A total of 36 patients were included, with 26 boys (72%) and 10 girls (28%) with an average age of 8.7 years. The trauma was isolated in 13 cases (36.1%) and in 23 cases, there were other associated lesions (mainly liver [n = 9] and spleen [n = 5]). Pancreatic injuries were graded as follows: I (n = 21), II (n = 2), III (n = 7), and IV (n = 6). Pseudocysts occurred in 11 patients (30.5%) mainly in grades III (n = 3) and IV (n = 7), with an average delay of 17 days. Initial management of pseudocysts was conservative in six patients (54.6%), whereas five patients required mini-invasive procedures. CONCLUSION Nonoperative management remains a safe way to treat pancreatic injuries despite an average 30% rate of pseudocyst (PC) appearance. It allows a reduction in the number of children who required procedures to less than half of the patients where PC occurred. Furthermore, these procedures were exclusively mini-invasive.

Torsion du cordon spermatique chez l’enfant : impact du mode de consultation sur le délai de prise en charge et le taux d’orchidectomie

INTRODUCTION Acute scrotal pain is a true surgical emergency as patients presenting with acute scrotal pain may suffer from spermatic cord torsion and gonadal loss. We assessed whether the type of consultation (first consultation in our center or secondary transfer from a peripheral hospital or primary care practice), distance from home to hospital, and duration of pain had an impact on the orchiectomy rate. PATIENTS AND METHODS We retrospectively reviewed the medical records of all patients under 15years of age suffering from acute scrotal pain who had surgical exploration between January 2007 and January 2010 in our center. Patient demographics, transfer status, time to consultation in our center, time to surgery, operative findings and clinical outcome were reviewed. RESULTS Of the 76 patients with acute scrotal pain in whom surgical exploration was performed, 59 had acute spermatic cord torsion, 16 had torsion of the testicular appendage, and 1 had orchitis. In patients with acute spermatic cord torsion, the median age was 13 years (range: 0.18-14.97). In patients with acute spermatic cord torsion, 32 came straight to our center (direct admission group, 54.2%), and 27 (45.8%) came after a prior consultation out of side the center (transfer group). The median journey was 19km (range: 2.5-113) in the direct admission group and 44km (range: 2.5-393) in the transfer group (P=0.0072). The median time between pain onset and consultation at our center was 4.3h (range: 0.5-48) in the direct admission group, and 11h (range: 2-48) in the transfer group (P=0.6139). The median time between admission at our center and surgery was 2.5h, with no difference between the 2 groups (P=0.8789). The orchiectomy rate was 25% in the direct admission group and 14.8% in the transfer group (P=0.5177). In children who underwent orchiectomy, the duration of pain was consistently over 6h. The duration of pain was greater in patients with orchiectomy (12h [range: 1-72]) than in patients without orchiectomy (12h [range: 6-48]; P=0.0001). CONCLUSION In this study, the orchiectomy rate depended on the duration of pain but not on transfer status. Acute scrotal pain must lead to surgical exploration as soon as possible, requiring close collaboration between peripheral hospitals, primary care physicians, and referral centers.

Unusual duplicate bladder exstrophy in a female newborn: a case report

The authors report a rare variant of exstrophy-epispadias complex, a duplicate bladder with normal bladder communicating with an exstrophic bladder by a fistula, in a girl with no genital malformation except for a duplicated clitoris. This variant could be a hybrid form of duplicate bladder exstrophy and superior vesical fistula. It seems easier to repair and has a better prognosis than classic bladder exstrophy.

SFCP-P09 – Chirurgie plastique – Mise au point sur la prise en charge chirurgicale des nævi pigmentaires de l’enfant

Objectifs La pathologie naevique de l’enfant est un motif de consultation frequent. Il est parfois difficile de poser les indications operatoires. Celles-ci reposent sur le risque de degenerescence et sur des problemes esthetiques. Le but de ce travail est de proposer un protocole de prise en charge des naevi pigmentaires. Methodes Il s’agit d’une etude retrospective d’avril 1986 a octobre 2007 portant sur 711 enfants (821 naevi) operes a l’Hopital des Enfants de Toulouse. A partir du dossier clinique et des comptes-rendus anatomopathologiques, nous avons etudie les donnees demographiques, les indications operatoires, les types histologiques, les complications et la survenue de degenerescence. Ont ete exclus les naevi non pigmentaires (naevi sebaces et verruqueux) et un cas de Xeroderma pigmentosum. Resultats 711 enfants ont ete operes, 352 filles et 359 garcons âges en moyenne de 7,5 ans (± 4,5) au moment de la chirurgie. Les 821 naevi se repartissaient comme suit : tronc et abdomen 35,1 %, membre pelvien 27,3 %, tete et cou 24,6 %, membre thoracique 10 %, organes genitaux externes 3 %. L’indication operatoire a ete posee sur les criteres suivants : antecedents familiaux de melanome, taille du naevus, localisation a prejudice esthetique, modifications recentes d’aspect. L’exerese en un seul temps a ete possible dans 82,6 % des cas. Dans 93,1 % des cas il s’agissait d’un naevus commun acquis ou congenital ; dans 5,4 %, d’une tumeur de Spitz ; dans 1,4 %, de formes particulieres telles que le naevus bleu ou le naevus de Sutton. Un cas de melanome est survenu dans l’evolution d’un naevus congenital geant. Le taux de complications s’elevait a 13 % : cicatrices hypertrophiques et cheloides, infections, desunions et elargissements cicatriciels. Le recul post-operatoire moyen est de 6,1 ans (± 4,4). Conclusion A l’heure actuelle, il n’y a pas d’argument qui justifie une exerese precoce de tous les naevi chez l’enfant. Le risque de degenerescence reste tres faible. L’exerese doit donc etre reservee aux naevi de grandes dimensions (afin de profiter de l’elasticite de la peau de l’enfant jeune), aux tumeurs de Spitz, aux naevi cliniquement atypiques et aux formes avec prejudice esthetique. Quant aux autres, ils doivent beneficier des consignes de surveillance et de prevention habituelles.