L. Carfagna

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.

Pathologie urgente des organes génitaux externes chez le nourrisson

Resume C’est un motif de consultation frequent en cabinet mais aussi dans les services d’urgence. L’urgence, en dehors de la hernie etranglee et de la torsion du cordon spermatique, n’est que tres relative. Toutefois, comme frequemment chez l’enfant, cette pathologie s’accompagne de beaucoup d’angoisse chez les familles.

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.

Congenital anterior urethrocutaneous fistula associated with a stenosis of the bulbar urethra in the context of high anorectal malformation without fistula

SUMMARY Congenital anterior urethrocutaneous fistulas are infrequent. We report a case of a congenital anterior urethrocutaneous fistula associated with a stenosis of the bulbar urethra in the context of a high anorectal malformation. We describe the surgical technique for the reconstruction of the urethra.

Anatomical study of the inferior vesical artery: is it specific to the male sex?

PurposeThe aim of our study was to clarify the origin of the inferior vesical artery and determine its existence in women.MethodsThis descriptive study is based on 25 dissections (6 male and 19 female cadavers). We dissected the internal iliac artery and its branches from the iliac bifurcation, bilaterally and comparatively. Each arterial branch supplying the bladder was identified and dissected as far as the bladder.ResultsIn total, 50 topographies of the bladder vascularization were visualised. The inferior vesical artery was observed in 92% of the male subjects and in 47.4% of the female subjects. In the male cadavers, it arose from the internal iliac artery in 72.7% of cases and from the umbilical artery in 27.3% of cases. In the female cadavers, it arose from a common trunk with the umbilical artery and the uterine artery in 33.3% of cases and directly from the umbilical artery in 33.3% with one terminal branch supplying the upper part of the vagina. In two female subjects, the inferior vesical artery arose from the first segment of the uterine artery (22.2%), and in one subject from the obturator artery (11.1%).ConclusionsThe inferior vesical artery is not specific to the male sex. The contradictions found in the literature of this artery are due to the variations observed in pelvic vascularization and to the close connections between vaginal and bladder vascularisation in women. However, surgeons should consider these variations, to prevent bladder devascularization by non-selective ligation.

Non-operative Management for Uncomplicated Appendicitis: An Option to Consider

Abstract Aim The main goal of our study was to assess a 7 days long course of antibiotics for acute uncomplicated appendicitis. Materials and Methods From March 2014 to November 2015, all patients diagnosed with acute appendicitis have been considered to be treated by only antibiotics. Inclusion criteria included clinical (tenderness), biological (C‐reactive protein [CRP] < 50), and radiological features (diameter > 6 mm). All patients were treated with intravenous amoxicillin and clavulanic acid (100 mg/kg/day) for 2 days (six doses). At the end of the treatment, clinical and paraclinical examinations included blood samples at day 7 and ultrasound (US) scan at 3 months. Results A total of 166 patients were treated and followed up prospectively during the study period. Mean age at diagnosis was 10.8 ± 0.6 years. All children, but four were discharged with a clinical improvement after 48 hours and six intravenous antibiotics injection according to our protocol. Four children required surgery during the initial hospitalization period. Initial ultrasound scan showed a mean diameter of 7.85 ± 1.6 mm, with inflamed fat in 124 patients (74.7%). At Day 7, the diameter was 5.2 ± 1.6 mm (p < 0.0001). During a median follow‐up of 18.8 months (3.5‐18), 22 patients (13.25%) had to be managed for a novel episode of acute appendicitis after a median period of 138 days (13‐270). None had to be managed for a complicated appendicitis. Conclusion Non‐operative treatment (NOT) is a safe alternative for the management of uncomplicated acute appendicitis in children. Further study should be conducted to determine relapse risk factors.

CL070 - Traumatismes hépatiques sévères de l’enfant : quelle présentation, quelle prise en charge ?

Objectif Analyser la presentation, la prise en charge et l’evolution des traumatismes hepatiques fermes de haut grade. Materiel et Methode Les donnees retrospectives unicentriques de 11 patients admis de janvier 1999 a decembre 2009 pour traumatisme hepatique ferme de grade III a V selon Schweitzer sont reprises. Resultats L’âge moyen etait de 8,8 ans. Le mecanisme etait un accident de la voie publique ( n = 5), un accident de sport ( n = 4), ou une defenestration ( n = 2). Le traumatisme relevait d’un stade III dans 3 cas, IV dans 5 cas, V dans 3 cas. Une laparotomie d’hemostase a ete realisee chez 6 patients pour packing et/ou suture vasculaire. On deplore 3 deces post-operatoires precoces sur decompensation hemorragique. Dans 5 cas une complication biliaire a necessite un drainage peritoneal et une derivation par cholecystostomie. Les complications vasculaires associaient 2 pseudo-anevrysmes arteriels, traites par embolisation selective, une thrombose sus-hepatico-cave, traitee par anti coagulation, une thrombose portale gauche segmentaire respectee. La duree d’hospitalisation moyenne des patients etait de 56 jours (17- 104). Conclusion Les rares traumatismes fermes severes de l’enfant demeurent une urgence vitale dont la prise en charge doit repondre aux multiples complications evolutives.

P364 - Urétroplastie suspendue par greffon libre de muqueuse vésicale dans la prise en charge de sténoses congénitales de l’urètre bulbaire et membraneux chez l’enfant : à propos de deux cas

Nous decrivons, dans le cadre de malformations urogenitales complexes chez deux nouveau-nes de sexe masculin, la reparation uretrale par une technique dont nous n’avons pas retrouve de description prealable dans la litterature. Observations Le 1er enfant presentait, dans un contexte de malformation anorectale haute, une large fistule uretrale penienne moyenne, en amont d’un uretre balanique permeable et d’un meat apical. Il existait une stenose de l’uretre membraneux en amont de la fistule. Le second presentait une duplication de l’uretre avec un meat apical et un meat hypospade balano-preputial. Il existait une stenose a la confluence bulbaire des 2 uretres. Dans les 2 cas, la prise en charge a consiste en la realisation neonatale d’une vesicostomie incontinente, puis d’une reconstruction employant une uretroplastie suspendue par greffon libre de muqueuse vesicale, a 1 et 2 ans respectivement. Chez le 1er enfant, la fistule penienne moyenne a ete fermee a 3 ans. Resultats Les suites ont ete simples, le jet urinaire est correct, il n’y a pas de dysurie, l’aspect cosmetique de la verge est satisfaisant. Conclusion L’uretroplastie suspendue par greffon libre de muqueuse vesicale est une bonne technique de reparation de stenoses de l’uretre anterieur et posterieur chez l’enfant.