Olivier Reinberg

Tracheobronchial ruptures from blunt thoracic trauma in children

BACKGROUND/PURPOSE Tracheobronchial ruptures in blunt thoracic trauma in children are rare. The aim of this study was to suggest the means of an early diagnosis and a conservative management as often as possible. METHODS Sixteen cases of tracheobronchial ruptures by blunt thoracic trauma were observed over 26 years in 9 regional pediatric centers. RESULTS There were 12 boys and 4 girls, from ages 1 hour to 17 years. Nine children presented with associated lesions. Fibroscopy established the following diagnosis: 8 tracheal wounds and 8 bronchial wounds. Six children were operated on within 18 hours (on average) after installation of a thoracic drainage. Two lobectomies, 3 ideal tracheal sutures, and 1 bronchial suture were performed. Seven children were treated exclusively by thoracic drainage. Two of them were intubated through the lesion, leading to a transitory endoprothesis accompanied or not by an external thoracic drainage. One infant recovered spontaneously. There were no deaths in this series. Two recurrent postoperative nerve injuries were noted, one of which was a transitory spontaneously resolutive scar bud and one a granuloma treated by laser. Three times, a stenosis occurred after a conservative management. Two were operated on. CONCLUSIONS Tracheobronchial ruptures in children are rare. An early fibroscopy holds an important place in the approach of this pathology. Treatment is variable, based on thoracic lesions, their tolerance by the child, and associated lesions. Surgery is not the only therapy because conservative treatment by simple thoracic drainage or lesion intubation has proved effective.

Multicentric assessment of the safety of neonatal videosurgery

BackgroundComplex procedures for managing congenital abnormalities are reported to be feasible. However, neonatal videosurgery involves very specific physiologic constraints. This study evaluated the safety and complication rate of videosurgery during the first month of life and sought to determine both the risk factors of perioperative complications and the most recent trends in practice.MethodsFrom 1993 to 2005, 218 neonates (mean age, 16 days; weight, 3,386 g) from seven European university hospitals were enrolled in a retrospective study. The surgical indications for laparoscopy (n = 204) and thoracoscopy (n = 14) were congenital abnormalities or exploratory procedures.ResultsOf the 16 surgical incidents that occurred (7.5%), mainly before 2001, 11 were minor (parietal hematoma, eventration). Three neonates had repeat surgery for incomplete treatment of pyloric stenosis. In two cases, the incidents were more threatening (duodenal wound, diaphragmatic artery injury), but without further consequences. No mortality is reported. The 26 anesthetic incidents (12%) that occurred during insufflation included desaturation (<80% despite 100% oxygen ventilation) (n = 8), transient hypotension requiring vascular expansion (n = 7), hypercapnia (>45 mmHg) (n = 5), hypothermia (<34.9°C) (n = 4), and metabolic acidosis (n = 2). The insufflation had to be stopped in 7% of the cases (transiently in 9 cases, definitively in 6 cases). The significant risk factors for an incident (p < 0.05) were young age of the patient, low body temperature, thoracic insufflation, high pressure and flow of insufflation, and length of surgery.ConclusionDespite advances in miniaturizing of instruments and growth in surgeons’ experience, the morbidity of neonatal videosurgery is not negligible. A profile of the patient at risk for an insufflation-related incident emerged from this study and may help in the selection of neonates who will benefit most from these techniques in conditions of maximal safety.

Esophageal leiomyoma in children: Two case reports and review of the literature

Leiomyoma of the esophagus is not uncommon in the adult population but is rarely seen in children; only 20 cases have been reported in the pediatric population. In this paper we describe two cases of esophageal leiomyoma in female patients aged 6 and 13 years and review previous reports. Several differences were noted between the pediatric and adult population. The mean age in children is 14 years (range, 4 to 20 years). Leiomyoma appears 1.71 times more often in females than in males. Localized lesions are found in only 9%, whereas the diffuse form predominates in 91%. The entire esophagus may be involved 35% of the time, and encroachment on the cardia or upper stomach occurs in 70%. Leiomyomas associated with familial syndromes (familial leiomyoma and Alports syndrome) occur in 22% of the cases. Major symptoms include dysphagia (86%), dyspnea (36%), vomiting (27%), retrosternal pain (27%), and coughing (22%). The initial diagnosis following contrast studies is most often achalasia. The diagnosis of leiomyoma is made only with subsequent endoscopy. Enucleation was performed in only 11% of the cases; surgical resection (including part of the stomach) was necessary in 78% with a 21% postoperative mortality. Esophageal leiomyoma should be considered in the differential diagnosis of mediastinal masses and esophageal obstruction. Accurate preoperative diagnosis is desirable in order to plan proper surgical treatment.

Femur fracture in preschool children: experience with flexible intramedullary nailing in 72 children.

Spica cast immobilization is the preferred treatment for closed femur fracture in preschool children. Flexible intramedullary nailing (FIN) is an alternative treatment but has never been specifically evaluated in this age group. A retrospective analysis of 72 children (mean age, 4.1 years; age range, 1.5-5.9 years) with 73 femur fractures treated by means of FIN was performed. The mean length of stay in hospital was 9.1 days (range, 1-46); weight bearing was started at a mean of 16.4 days (range, 1-60 days) after surgery. Follow-up was available in 62 children (mean, 36.7 months; range, 4-124 months). Complications included early distal nail exteriorization in 9 children (12.3%) during the first 10 years of the study. More than 1 cm of femur overgrowth was noted in 6 children (8.2%). Preschool children with femur fracture treated by means of FIN benefited from short hospital stay, early mobilization and weight bearing. Technique-related complications could be avoided. Long-term follow-up is mandatory in these children.

Major perineal trauma in children

Between 1976 and 1987, 22 children aged 3 to 17 years (mean age, 9.5 years) were admitted to our institution with major perineal trauma. There were 14 urethral ruptures and 9 rectal lesions. The lesions were multiple and combined: vaginal and urethral or vaginal and rectal injuries were found in 10 females, while only 1 of 12 males had both urethral and rectal lesions. In most instances, perineal physical signs did not reflect the severity of the lesion. Among the patients with urethral lesions, there was no sex or age predominance; complete rupture occurred in four females and eight males. The insertion of a urethral catheter was of no diagnostic help. Retrograde urethrogram demonstrated a lesion in seven of eight cases. The intravenous pyelogram (IVP) showed evidence of extravasation in two of the eight cases, and in four instances there were indirect rupture signs. A suprapubic cystostomy was performed in 12 of the 14 urethral injuries. A primary repair with urethral stenting was carried out twice without bladder drainage. Immediate repair was performed in eight cases and delayed in five others. Within this last group, two patients were cured without sequelae by stenting without suture, while the three others who underwent only cystostomy necessitated multiple reconstructive operations with poor results. It is of interest that the four treatment failures occurred in the youngest patients (4 to 7 years of age). The rectal lesions were related to impalement in seven of nine patients. Rectoscopy allowed localization of perforations but did not permit identification of sphincter injuries when the mucosa was intact. Primary repair was possible in all cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Prenatal diagnosis of congenital lung malformations

Prenatal diagnosis of congenital lung anomalies has increased in recent years as imaging methods have benefitted from technical improvements. The purpose of this pictorial essay is to illustrate typical imaging findings of a wide spectrum of congenital lung anomalies on prenatal US and MRI. Moreover, we propose an algorithm based on imaging findings to facilitate the differential diagnosis, and suggest a follow-up algorithm during pregnancy and in the immediate postnatal period.

Comparison of foetal US and MRI in the characterisation of congenital lung anomalies

OBJECTIVES To compare the accuracy of prenatal ultrasonography (US) to magnetic resonance imaging (MRI) in the characterisation of congenital lung anomalies, and to assess their agreement with final diagnosis. To evaluate the influence of additional MRI information on therapeutic management. METHODS 26 prenatal congenital lung anomalies detected consecutively between 2006 and 2012 were retrospectively evaluated. Lesions were initially observed at prenatal US and further investigated with MRI. Prenatal US and MRI imaging findings, and suggested diagnosis were compared with the final diagnosis, obtained from autopsies (4), pathological evaluation following surgical resection (15) and postnatal imaging studies (7). RESULTS Postnatal diagnoses included 7 congenital pulmonary airway malformations, 8 complex lesions, 7 overinflations, 1 sequestration, 1 bronchogenic cyst, 1 blastoma and 1 bilateral lymphangioma. Suggested prenatal US and MRI diagnosis was correct in 34.6% and 46.2% of patients, respectively, mainly isolated lung lesions with typical imaging findings. Nonspecific imaging findings at US and MRI studies were observed in 38.4% of cases. In 42% of the operated anomalies, pathological dissection revealed the presence of complex anomalies. MRI changed the US diagnosis, but not the further management in 9.7% of the lesions. CONCLUSIONS Prenatal US and MRI showed a high accuracy in the diagnosis of isolated congenital lung lesions with typical imaging findings. However, overall characterisation rates were low, because of both a high percentage of complex lesions and of lesions with nonspecific imaging findings. MRI was better than US in characterising complex lesions, but its additional information did not influence therapy decisions.

24-hour, weekly, and annual patterns in traumatic and non-traumatic surgical pediatric emergencies

24 h patterns with high frequency components in the incidence of pediatric trauma were validated and quantified in one of our earlier studies. Herein, we further explored the temporal—high frequency, 24 h, weekly (7 d), hemi‐weekly (3.5 d), and annual – patterns in traumatic (1990–1997; n=15,110 events) and non‐traumatic pediatric surgical emergencies (PSE) (1992–2001; n=5,593 events) as well as automobile accidents (AA) (1990–1997; n=67,712) in the County of Vaud, Switzerland. The latter served as a reference system of human adult activity and risk. Two‐way ANOVA, χ2, correlation, and cosinor analyses were used as statistical tools. A 24 h pattern, reproducible from year to year, was validated in traumatic and non‐traumatic PSE and AA. The 24 h patterns were not correlated and differed from one another in terms of their acrophase (peak time) and amplitude. A gender‐related difference was found only in the non‐traumatic time series for weekly (7 d) and hemi‐weekly (3.5 d) patterns. The latter were detected in boys but not girls. No statistically significant difference was found in the acrophase and amplitude between boys and girls in the temporal patterns of other periods. An annual pattern was validated in automobile accidents (acrophase: 4th of September ±37 d (SD)) and pediatric trauma (acrophase: 14th of June ±10 d), but not in non‐traumatic PSE. These results suggest that environmental modulations differ between the incidence of traumatic and non‐traumatic PSE. Presumably, the two phenomena involve different aspects of the temporal organization and/or different levels of susceptibility of a set of biological rhythms to environmental factors.

Gastric outlet obstruction by Brunner's gland hyperplasia in an 8-year-old child

Several cases of Brunners gland hyperplasia causing hemorrhage, obstruction, or intussusception have been published in the adult literature. Similar cases in the pediatric population are very rare and have only been described twice, always associated with chronic renal failure. We report the third and youngest case of gastric outlet obstruction because of Brunners gland hyperplasia focusing on histopathologic condition and treatment based on a review of the literature.

ACCIDENTS IN CHILDREN DO NOT HAPPEN AT RANDOM: PREDICTABLE TIME-OF-DAY INCIDENCE OF CHILDHOOD TRAUMA

In a prospective study, 15,110 childhood traumas were recorded by the Pediatric Surgery Service (CHUV, Lausanne) between January 1, 1990 and December 31, 1997. The exact clock hour when the injury occurred and other germane data were obtained. Time series thus obtained were analyzed by several statistical (ANOVA, cosinor, χ2, Table Curve, etc.) methods. High statistically significant circadian patterns were detected with a trough at night—almost no traumas/hour (t/h), and a peak in the afternoon (∼16:00h)—9.3±0.4 (SD) t/h. Such 24h variation was validated for the whole sample for the entire 8yr study span as well as the data of each year. Neither gender- nor age-related differences in the 24h pattern were detected between children under 5 yr of age, who have not yet attended school and children from 5 to 16 yr of age, who attend school. Small but statistically significant differences in the 24h patterns were observed when categorized by the type of activity associated with the trauma and the place of trauma occurrence. The great stability of the 24h pattern in childhood trauma over the 8yr study span suggests an endogenous origin in addition to the role presumably played by environmental factors. Periods of 12 and 8 h were also detected in the time series. The afternoon peak time of childhood traumas differs from that of adults, which is located ∼04:00h in rotating shift workers and automobile drivers and 06:00–08:00h in adult day-workers. The validation of a circadian pattern in childhood traumas with an afternoon peak should be taken into account in the design of childrens preventative injury programs.