Jacques Moscovici

Abdominal cystic lymphangioma in children: Benign lesions that can have a proliferative course

Twenty-one pediatric cases of abdominal cystic lymphangioma (CL) treated in the past 20 years are reviewed. To date, this is the largest reported series. CL is a rare congenital malformation that presents either with chronic abdominal distension (and is detected by palpation of a cystic mass) or acutely with bowel obstruction or signs of peritonitis. It is more common among boys and most often occurs in children under 5 years of age. Abdominal ultrasonography is the procedure of choice for establishing the diagnosis. Acute cases with intracystic hemorrhage are more difficult to diagnose. Computed tomography and celioscopy may be useful. With these techniques, a correct diagnosis should be achieved in nearly every case. Enucleation (when feasible) or segmental intestinal resection (when the cyst is intimate to the bowel) is effective treatment. In a few cases the malformation is diffuse, and extensive bowel resection is necessary, with the risk of short bowel syndrome.

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.

The anconeus, an active lateral ligament of the elbow: new anatomical arguments

PurposeAs there are a few detailed anatomical studies of the active function of anconeus muscle in stabilizing the elbow, we aimed to look for anatomical features confirming its role as an active stabilizer of the humero-ulnar joint.MethodsThirty fresh unembalmed elbows from 15 cadavers were dissected. We examined the anatomy, insertions, relationships and orientation of the muscle fibres of the anconeus.ResultsThe anconeus lies in a separate compartment from the other forearm muscles, but in continuity with the extensor (triceps) compartment of the arm. In all the cases, at its proximal extremity we observed continuity of muscle and tendon with the vastus lateralis of the triceps brachii. The muscle fibres run downward and backward, parallel to the fibres of vastus lateralis of the triceps, when the elbow is in extension. Its deep aspect adheres closely to the lateral joint capsule of the humero-ulnar joint.ConclusionThe new anatomical characteristics of the anconeus revealed in this study make this muscle a digastric head of triceps brachii that coapts the ulna to the humerus and so reduces varus instability. The close relationships between triceps brachii and the anconeus on one hand and between the joint capsule and the anconeus on the other make the latter muscle an active lateral stabilizer of the elbow.

Anatomy of the bands of the hamstring tendon: How can we improve harvest quality?

BACKGROUND The hamstring tendons, gracilis and semitendinosus are widely used in ligament and reconstructive surgery. Their accessory bands or insertions are technical pitfalls during harvesting. METHODS Thirty fresh cadaver knees have been studied, in order to 1) determine the anatomy of the bands of the gracilis and semitendinosus tendons, and, 2) to identify risk factors for failure during harvesting. RESULTS Semitendinosus always had at least one band, sometimes two, strong, tendinous, and generally running to the fascia of gastrocnemius medialis to which they are attached, at an acute angle in a distal direction. Their presence is constant and they are only exceptionally found more than 100 mm from the tendons tibial insertion. Gracilis shows the greatest anatomical variability, and over one quarter have no bands (although there may be as many as three). Their location, destination and angle of attachment to the tendon vary greatly. These bands are mainly aponeurotic and less strong, but must be carefully and widely dissected. CONCLUSION Anatomical variability makes harvesting of pes anserinus tendons difficult. Three simple anatomical criteria have been highlighted that can be assessed by the surgeon during harvesting. The criteria are the insertion, the direction and the anatomical type of the bands.

Anatomic variations of the renal vessels: focus on the precaval right renal artery

The aim of this study was to determine the prevalence of precaval right renal artery and to investigate the distribution of renal arteries and veins. We discuss a theory of development of renal vascular variants. We retrospectively reviewed 120 arterial phase contrast material-enhanced spiral computerized tomography scans of the abdomen (1- to 2-mm section thickness) performed during a two-month period. Forty percent of the study group (48 patients) had one artery and one vein on each side, with typical course. There was a 9.17% prevalence of precaval right renal artery: 10 patients had a lower pole accessory artery in precaval position and one patient had the main and the accessory arteries that pass anterior to the inferior vena cava. In these cases, associated variations of renal vessels were higher than in the patients without precaval artery variant. There were multiple arteries in 28.3% of the right kidneys and in 26.7% of the left ones. Variants of the right renal vein consisted in multiple veins in 20% (24 cases). We detected no case of multiple left renal veins, but we described variations of its course (circum- or retroaortic vein) in 9.17% (11 cases). Twenty-six patients (21.7%) had associated variations of the renal pedicle. The current technical support allows for a minimally invasive study of vessels anatomy. In our study the prevalence of a precaval right renal artery appears to be higher than previously reported (9.17%). Knowledge on anatomical variations of right renal artery and associated renal vessels variations has major clinical implications.

L’obstruction urétérale distale secondaire : une complication rare du traitement endoscopique par Deflux ® du reflux vésico-urétéral de l’enfant

Surgically relevant obstruction after dextranomer/hyaluronic acid injection (Dx/Ha, Deflux(®)) for the treatment of vesicoureteral reflux (VUR) is rare with a 0.6% incidence. It occurs usually during the early postoperative period. We report here the case of a 9-year-old boy with a history of VUR who was previously treated with Deflux(®) and was referred more than 2 years later with acute flank pain (as he already did 2 weeks after surgery with a spontaneous relief under medical treatment). Initial radiological investigations showed hydronephrosis caused by distal ureteral obstruction which required open surgery removal of the Dx/Ha and Cohen procedure. This is the second case of delayed symptomatic obstruction due to Dx/Ha reported in the literature.

Modeling and determination of directionality of the kerf in epifluorescence sharp bone trauma analysis

Characteristics of sharp bone trauma can be extremely useful to determine the origin of cut marks and to provide information regarding the context of death. Using human ribs and clavicle bones, this study analyzes the characteristics of bone kerfs made by different bladed implements, thanks to epifluorescence macroscopy. This technique, which is a nondestructive tool that uses autofluorescence of bones, documents bone damage precisely with high resolution. Both qualitative and quantitative criteria are analyzed. Our results identify unique class characteristics on bone lesions, allowing modeling kerf depending on the weapon, regardless of the type of bone that is wounded. Moreover, we demonstrate for the first time microscopic criteria of directionality, using fluorescence excitation. Orientation of cracks, flakes, and lateral pushing back especially helps in determining the tip and the end of the lesion, leading to the position of the aggressor. Kerf wall characteristics and striation location are also very useful. Epifluorescence macroscopy could be a new tool of choice in anthropology through cut mark analysis in establishing how the blade was used and providing details about the blow.

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.

CL129 - Urétroplastie par greffon de muqueuse vésicale dans la chirurgie en deux temps des hypospadias proximaux : expérience toulousaine

L’uretroplastie par greffe de muqueuse vesicale a connu son essor dans les annees 1980 et a ete rapidement abandonnee en raison de ses complications. Nous presentons une serie retrospective de 48 cas d’hypospadias severes pris en charge par un seul operateur (1988-2008). Il s’agissait d’hypospadias natifs dans 77 % des cas. La longueur moyenne de muqueuse vesicale prelevee etait de 7,1 ± 1,8 cm. Le greffon etait tubulise et un tunnel sous-cutane realise au contact des corps caverneux. Le taux de complications, toutes mineures mais necessitant une reprise chirurgicale, s’elevait a 31 %. De 1988 a 1998, le taux de complications etait de 41 %, et passe a 21 % pour la periode 1999-2008, avec un meilleur resultat cosmetique. Ce taux est inferieur a celui des techniques de correction d’hypospadias proximaux en un temps (Koyanagi, Hayashi, Onlay et techniques combinees) et est comparable a celui d’autres techniques en deux temps (Bracka). Le point critique qu’est la realisation du neo-meat uretral a donne sa mauvaise reputation a ce greffon. L’enfouissement de la muqueuse vesicale au neo-meat et la realisation de l’anastomose distale en premier nous paraissent etre des elements essentiels qui concourent a la reussite de cette intervention, dans les mains d’un operateur entraine.