Isabelle Lacreuse

Wandering spleen in children: multicenter retrospective study

Wandering spleen in children is a rare condition. The diagnosis is difficult, and any delay can cause splenic ischemia. An epidemiologic, semiological, and surgical diagnosis questionnaire on incidence of wandering spleen in children was sent to several French surgical teams. We report the results of this multicenter retrospective study. Fourteen cases (6 girls, 8 boys) were reported between 1984 and 2009; the age range varies between 1-day-old and 15 years; 86% were seen in the emergency department. Ninety-three percent had diffuse abdominal pain. For 57% of the cases, it was their first symptomatic episode of this type. No diagnosis was established based on the clinical results alone. All patients had presurgical imaging diagnosis. Open surgery was performed on 64% cases. Forty-three had splenectomy for splenic ischemia. Thirty-six percent had splenopexy, 14% had laparoscopic gastropexy, and 7% had spleen repositioning and regeneration. Complications were noted in 60% of the cases resulting in postsplenopexy splenic ischemia. Early diagnosis and surgery are the best guarantee for spleen preservation. Even if the choice of one technique, splenopexy or gastropexy, can be argued, gastropexy has the advantage of avoiding splenic manipulation and restoring proper physiologic anatomy. When there is no history of abdominal surgery, laparoscopy surgery seems the best procedure.

Pectus excavatum repair according to Nuss: is it safe to place a retrosternal bar by a transpleural approach, under thoracoscopic vision?

We present a new case of cardiac perforation during retrosternal dissection beginning a Nuss procedure for pectus excavatum repair in an 18-year-old boy. The true incidence of life-threatening complications, such as heart injuries during Nuss bar placement for pectus excavatum repair, as well as cardiac lacerations during removal of the bar, remains unknown. Many papers suggest measures to prevent these complications: approaching the retrosternal space through an additional subxiphoid short incision, lifting the sternum during bar placement, or placing the bar extrapleuraly. Nuss procedure is gaining more and more popularity due to its apparent simplicity; however, its operational complications should be well known and discussed to be avoided later on.

Postoperative bowel obstruction after laparoscopic and open appendectomy in children: a 15-year experience

PURPOSE The purpose of the study was to determine and evaluate the incidence of postoperative bowel obstruction (PBO) after laparoscopic and open appendectomy in children. MATERIAL AND METHODS The medical files of children who have undergone an appendectomy, either via the laparoscopic or open approach, at our department from 1992 until 2007 were reviewed. Collected data included age at appendectomy, initial surgical approach, time interval to PBO, and type of definitive treatment. The incidences of PBO after laparoscopic and open appendectomy were compared with the chi(2) analysis. RESULTS From the 1684 children who were found, 1371 had nonperforated appendicitis and 313 had perforated appendicitis. Laparoscopic appendectomy was performed in 954 patients of the nonperforated group and in 221 of the perforated group. Open appendectomy was performed in 417 and 92 patients of the 2 groups, respectively. Overall, the incidence of PBO development was 2.2%. In the laparoscopic appendectomy population, a significantly low incidence of 1.19% of PBO development was detected, compared with the 4.51% of the open appendectomy group (P < .0001). CONCLUSION Laparoscopic appendectomy diminishes the potential of PBO development. The overall incidence of PBO is not related to the severity of the disease but only to the initial operative approach.

Cecostomy button for antegrade enemas: survey of 29 patients

OBJECTIVE This study evaluated the Trap-door button use (Cook Medical, Bloomington, IL) for antegrade enemas in children. METHODS Since 2002, patients with fecal incontinence or encopresis and constipation underwent percutaneous cecostomy under laparoscopy using a button. Technical details are described. Age at surgery, operative time, hospital stay, diagnosis, indications for cecostomy, and duration of follow-up were recorded. A survey was proposed via a questionnaire that was sent to the patients. Patients wearing the button for less than 1 month were excluded from this evaluation. The survey concerned volume and frequency of enemas, difficulties encountered, benefits and disadvantages of this method, and assessment of the antegrade enemas in continence. RESULTS Twenty-nine patients, 18 males and 11 females, aged 3 to 21 years (mean, 8.5 years) underwent laparoscopic Trap-door button placement. The indications for all the patients were intractable fecal incontinence in 24 cases and constipation with encopresis in 5 cases. Incontinence was because of myelomeningocele (n = 10), anorectal malformations (n = 11), caudal regression syndrome (n = 1), 22q11 syndrome (n= 1), and Hirschsprung disease with encephalopathy with convulsions (n = 1). Constipation with encopresis was because of sacrococcygeal teratoma (n = 1), cerebral palsy (n = 1), and acquired megarectum with psychiatric and social disorders (n = 3). A total of 26 cecostomy button placements and 3 sigmoidostomy button placements were successful with no intraoperative complication. The mean operative time was 25 minutes (10-40 minutes), and the hospital stay was 2.5 days (1-4 days). Twenty-two parents or patients answered the questionnaire. At the time of this survey, 2 patients had improved their fecal continence and had had the button removed. A mean of 4 weekly enemas was enough to improve fecal continence troubles (range, 1 daily to 1 for 2 weeks). The volume for enemas was 250 to 1000 mL (mean, 700 mL). The time required for the irrigation of the bowel by gravity took from 5 to 60 minutes (mean, 25 minutes) for 20 patients. Before surgery, 14 patients needed a diaper, day and night, and 6 needed sanitary protection. Soiling was a very significant inconvenience for all the patients. After surgery, only 5 patients needed a diaper (cerebral palsy, 22q11, cloacal malformation, myelomeningocele, bladder exstrophy) because of moderate results or urinary incontinence and continued soiling. Patients were asked to give an assessment (null = 0, bad = 1, fair = 2, good = 3, very good = 4). None of the patients felt there had been no changes or a bad result. There were 5 patients who felt they had an average result, 5 a good result, and 12 a very good result. The mean grade was 3.44 (17.2/20). A total of 3 patients had hypertrophic granulation tissue formation around the cecostomy button, and 12 had tiny leakage. CONCLUSION Percutaneous placement of a cecostomy button under laparoscopic control is an easy and major complication-free procedure. The use of the Trap-door device by the patients or with the help of the parents for antegrade enemas is effective and satisfactory. It improves the quality of life and is reversible.

Congenital diaphragmatic hernia: an evaluation of risk factors for failure of thoracoscopic primary repair in neonates

PURPOSE Publications aiming to prove the feasibility and safety of thoracoscopic CDH-repair in neonates grow in numbers. Some teams use selection criteria, but none have proven statistical evidence. The aim of this study is to detect risk factors for failure of thoracoscopic primary closure of CDH in neonates. METHODS In 8 centers performing minimal access surgery (MAS), complete prenatal, postnatal, and operative data were evaluated for a retrospective study concerning patients with thoracoscopic congenital diaphragmatic hernia (CDH) repair. Most of the selection criteria and risk factors mentioned in the literature were analyzed. Two groups were defined: Group A - neonates who tolerated thoracoscopic primary repair, and Group B - neonates who required conversion or presented with major complications after thoracoscopic repair. Univariate and multivariate logistic regressions were used to compare these two groups. RESULTS From 2006 to 2010, thoracoscopy was performed in 40 neonates: Group A consisting of 28 neonates, and Group B 9 patients. Three patients were excluded because of insufficient data or major associated malformations. Significant statistical differences were found in Group B for postnatal PaCO2 >60 mmHg, need of iNO during postnatal stabilization, intrathoracic position of the stomach, pulmonary hypertension signs on the postnatal cardiac ultrasound, and preoperative OI >3.0. On multivariate analysis, only an OI >3.0 was significantly associated with conversion or major post-operative complication of thoracoscopic primary repair. CONCLUSION CDH can be safely repaired in the neonatal period by thoracoscopy. The limiting factor for thoracoscopic CDH repair is PPHN. The best preoperative indicator for PPHN is OI. Prospective studies are nonetheless necessary to prove the effectiveness of using these risk factors as selection criteria to help design surgical management protocols for neonates presenting CDH.

Postoperative intestinal obstruction after laparoscopic versus open surgery in the pediatric population: A 15-year review.

PURPOSE The aim of the study was to determine the possible advantages of a laparoscopic approach versus open surgery in infants and children with regard to the development of postoperative intestinal obstruction (PIO). MATERIAL AND METHODS A retrospective study was performed. The medical records of all infants and children who underwent an abdominal operation in our department between 1992 and 2007 were included. Data included initial diagnosis, age at initial operation, initial surgical approach, time to PIO, and type of definitive treatment. RESULTS From 1992 to 2007, a total of 3 600 abdominal operations were performed in our institution. As not all types of operations can be performed using a laparoscopic approach, in order to obtain a more exact result we compared only operations of the same type performed either by laparoscopy or laparotomy in this period. A total of 2 243 comparable abdominal operations were performed, of which 1 558 (69.46%) were performed using a laparoscopic approach and 685 (30.54%) were performed by laparotomy. Postoperative intestinal obstruction (PIO) was diagnosed in 36 cases. In 14 of these patients (38.88%), the initial operation was performed via a laparoscopic approach, while the remaining 22 (61.12%) were initially operated using laparotomy. Overall, 0.89% of the patients initially managed by laparoscopy and 3.21% of the patients initially treated by laparotomy were treated for postoperative intestinal obstruction (p<0.0001). CONCLUSION Abdominal surgery via a laparoscopic approach reduces the likelihood of PIO development. The risk for re-operation after development of PIO in infants and children is significantly higher in patients initially treated by laparotomy than for patients treated by laparoscopy.

Modified Spitz procedure using a Collis gastroplasty for the repair of long-gap esophageal atresia.

OBJECTIVE We report here on our experience with a modified Spitz procedure using a Collis gastroplasty for the repair of long-gap esophageal atresia (EA). PATIENTS AND METHODS The authors reviewed 5 cases of children with long-gap (5-6 vertebral bodies) EA. The repair was carried out after 3 months of permanent monitoring, enteral nutrition through a gastrostomy tube and permanent aspiration of the proximal esophagus. The Collis gastroplasty was performed to create a gastric tube along the gastric lesser curvature using an Endo-GIA linear stapler. The gastric tube can be easily mobilized into the thorax after ligation of the left gastric vessels and anastomosed to the proximal esophageal segment. RESULTS There were no intraoperative complications. The median postoperative hospital stay was 39 days (range: 30-60) with a median follow-up of 20 months (range: 16-29). During the early follow-up period, a digestive occlusion occurred in one patient, and several months later, she suffered from hiatal herniation. Other postoperative complications included anastomotic stricture (n = 2) treated by dilatations, gastroesophageal reflux (GER) (n = 3), and weight delay (n = 3) requiring additional enteral nutrition in 2 cases. No mortality was seen in our series. CONCLUSIONS We propose a modified Spitz procedure using a Collis gastroplasty in the primary repair of long-gap EA as an alternative option to esophageal replacement or elongation techniques. The complications noted in our series are common complications of EA surgical repair, such as GER, anastomotic stricture and ponderal stagnation.

Observational, medical or surgical management of vesicoureteric reflux.

The clinical management of vesicoureteric reflux includes observational, medical and surgical procedures. The choice of management is often a joint decision made between the paediatric nephrologist and urologist. The use of prophylactic antibiotics has become increasingly debated. In recent years, the surgical treatment of reflux (including endoscopic intervention or ureteral reimplantation) has mainly been limited to cases of high‐grade reflux. There are several important risk factors that influence the final outcome which need to be identified and treated. The aim of reflux management is no longer to treat imperatively, but rather to avoid renal damage. It is perhaps time to revise the classic saying ‘diagnosed reflux – treated reflux’ with a new objective ‘diagnosed reflux – evaluated reflux’.

Buschke-Löwenstein Anal Tumour in Children: Two Case Reports

gh te d m at er ia l. surgery if this liver tumor is suspected at presentation. Spontaneous or traumatic rupture is an important complication affecting the prognosis and may even be fatal [8,14]. The present case was treated successfully despite rupture of the tumor into the peritoneal cavity. UESL is a rare and malignant tumor of childhood. Abdominal distension and pain may lead to admission to hospital which may be initially considered to be a consequence of trauma. Diverse findings on US and CT and a normal AFP level in a child between 5 and 10 years of age should suggest the possibility of UESL. The exact origin of the UESL may be overlooked during surgery because of the small area of connection with the liver and complete coverage of the tumor by the omentum. The origin of the tumor should be searched for carefully, both during surgery and macroscopic examination. A favorable outcome can be expected in cases who underwent complete surgical excision and received chemotherapy.

Hypercalcemia in a child with juvenile granulosa cell tumor of ovary: Report of an unusual paraneoplastic syndrome and review of the literature.

Highlights ► Hypercalcemia is an extremely rare paraneoplastic syndrome in children. ► Small cell carcinoma is the commonest ovarian tumor associated with hypercalcemia. ► Small cell carcinoma must be ruled out because of poor prognosis. ► We report the only third case of JGCT associated with paraneoplastic hypercalcemia.