V. Rousseau

Emergency Management and Conservative Surgery of Ovarian Torsion in Children: A Report of 40 Cases

INTRODUCTION The authors describe and discuss the clinical and therapeutic features of 40 ovarian torsions (OT) in children with its urgent treatment that has advanced in recent years. MATERIALS AND METHODS A retrospective study of 40 cases of OT in 38 children under 16 years of age, excluding adnexal torsions in neonates. RESULTS Abdominal and/or pelvic pain was the presenting symptom ; 8 of these children had pain between 2 to 9 months prior to surgery and 27/40 (67.5%) had associated vomiting. Before the procedure, ultrasound (US) diagnosed 29 ovarian lesions, related to 14 mature teratomas (MTE) and 10 cystadenomas (CA), one association of MTE and CA in the same ovary, 2 functional cysts and 2 malignant neoplasms. 19/40 torsions could benefit from conservative management. Eleven torsions occurred, 10/11 of these ovaries had an increased volume, and 5/11 had US evidence of small subcortical cysts. Three detorsions with incomplete removal of CA were followed by enlargement of the tumor and re-torsion in 2 of them. Five children had bilateral ovarian pathology which led to unilateral ovariectomy, while the other benefited from conservative treatment. CONCLUSIONS In any girl presenting with abdominal pain, the diagnosis of an ovarian torsion must be considered. US is performed emergently, but only surgery, most often a laparoscopic procedure, assures diagnosis. The treatment of the torsion is an emergency and must be as conservative as possible in order to preserve the ovarian function. Bilateral torsions are not unusual.

Performance of prenatal diagnosis in esophageal atresia.

The aim of this study was to evaluate the performance of prenatal diagnosis of esophageal atresia (EA) and its associated abnormalities.

Serous and seromucinous infantile ovarian cystadenomas—A study of 42 cases

The rarity of infantile ovarian cystadenoma (CA) accounts for the very little knowledge about their behaviour. The aim of this retrospective study is to highlight the modes of presentation and to evaluate the treatments and the recurrence risks of these benign tumours. Relation to adult epithelial ovarian tumours is discussed. The medical records and imaging studies of 42 CA in 31 children less than 16 years of age operated at our institution between 1985 and 2003 were retrospectively evaluated. Mean age of first surgery was 11.5 years. 7/31 girls (22.6%) presented with a bilateral CA, four of them were synchronous. 8/42 (19%) CA were in torsion at surgery, conservative management was possible in four cases. 31/42 (74%) CA were treated conservatively. 4/42 CA recurred 1-3.5 years after complete cyst removal. All were endocervical type CA, there was no intestinal type. The 42 CA were serous in 18/42, mucinous in 23/42 and unqualified in one. Mucinous epithelial cells were often sparse and focal along the cyst wall. Four CA presented with micropapillae in post-pubertal girls. No borderline tumours were observed. Mucinous cystadenomas (MCA) are better described as seromucinous cystadenoma (SMCA) because of the mucinous cells localisation. CA occurs early in life, we surmise that they may need hormonal stimulation to develop micropapillae. Complete removal of these potentially low-grade malignant ovarian tumours precursors is advocated. Conservative surgery is recommended to preserve ovarian function.

Prenatal diagnosis of intra‐abdominal cystic lesions by fetal ultrasonography: diagnostic agreement between prenatal and postnatal diagnosis

The aim of this study was to assess the diagnostic agreement between the prenatal diagnosis of intra‐abdominal cystic lesions made by ultrasound examination and the postnatal diagnosis.

Malformations ano-rectales

Resume Les malformations ano-rectales (MAR) sont la consequence d’anomalies du developpement de la partie terminale du tube digestif interessant l’anus et/ou le rectum qui surviennent precocement entre la 6e et la 10e semaines de developpement embryonnaire. Elles realisent un spectre malformatif dont la severite est fonction du niveau d’interruption du conduit ano-rectal et des malformations caudales associees (sacrum et cone terminal de la moelle). Les MAR s’associent dans plus de la moitie des cas a d’autres malformations pouvant s’integrer dans des syndromes connus. Si le traitement chirurgical permettant de restaurer une anatomie aussi proche que possible de la normale est essentiel, la prise en charge postoperatoire est tout aussi fondamentale pour obtenir chez ces patients, dont les mecanismes defecatoires sont toujours alteres, sinon une continence, au moins une proprete socialement acceptable.

SFCP-030 – Chirurgie viscérale – Volvulus du grêle de diagnostic périnatal : deux entités, deux pronostics

Objectif Les volvulus du grele de diagnostic perinatal peuvent etre separes en deux entites anatomiques distinctes : les volvulus complets sur anomalie de la rotation mesenterique et les volvulus segmentaires. Nous avons revu 22 cas de volvulus de diagnostic perinatal et compare l’evolution en fonction du type anatomique. Materiel et methode Dix presentaient un volvulus segmentaire (VS) et 12 un volvulus complet sur anomalie de la rotation mesenterique (VC). Pour ces deux groupes, les conditions du diagnostic, le type de l’intervention chirurgicale et l’evolution post operatoire ont ete compares (test non parametrique de Wilcoxon). Resultats Le diagnostic a ete realise en antenatal dans un cas dans le groupe VC et dans 9 cas dans le groupe VS. Le terme moyen de naissance etait de 39 SA et de 36 SA respectivement. L’echographie realisee en post natal chez 9 patients du groupe VC retrouvait une image typique (whirlpool) alors qu’elle n’apportait aucun argument en faveur du volvulus chez les 5 enfants du groupe VS ayant eu cet examen. Les interventions ont ete realisees a une mediane de 6 jours dans le groupe VC (0 – 23 jours) et toujours dans les premieres 24 heures pour le groupe VS (p = 0,002). Dans les cas du VC il n’a pas ete retrouve de souffrance digestive majeure et aucune resection intestinale n’a ete realisee. Dans le groupe VS, on notait 4 cas de necroses segmentaires et 5 peritonites et tous ont eu une resection digestive (12,5 cm en moyenne) avec la realisation d’une ileostomie dans 3 cas. La mediane de reprise du transit a ete de 2 jours dans le groupe VC, sans nutrition parenterale, alors qu’elle etait de 7 jours (2 – 17 jours) dans le groupe VS (p Conclusion Malgre une resection intestinale limitee, le pronostic du VS apparait ici plus pejoratif que celui du VC. L’existence d’un obstacle digestif evoluant depuis la periode antenatale dans les VS pourrait induire une souffrance du systeme nerveux enterique qui n’est pas observe dans les VC de survenue neonatale, ou l’obstacle est de survenue recente. Cette notion doit etre prise en compte dans l’information qui est faite aux familles.

Early surgical management for giant omphalocele: Results and prognostic factors

OBJECTIVES Giant omphalocele often represents a major surgical challenge and is reported with high mortality and morbidity rates. The aim of this study was to assess the outcome of neonates with giant omphalocele managed with early operative surgical treatment, and subsequently to identify possible factors that could alter the prognosis. METHODS We reviewed the medical records of 29 consecutive newborns with prenatally diagnosed giant omphalocele. In these cases one of two procedures had been performed: either staged closure after silo, or immediate closure with a synthetic patch. The cases were separated into 2 groups: Isolated giant omphalocele (IO group) and giant omphalocele associated with malformation (NIO group). RESULTS Infants in the IO group had a lower size of the omphalocele (p<0,001), a shorter hospital stay (95 days [45-915] vs. 41.5 days [10-110] p= 0, 02), and a shorter median ventilation length (10 days [1-33] vs. 27, 5 [6-65] p = 0, 05). In the NIO group, 5 cases displayed a significantly more difficult course than the others. They were compared to the remaining cases for prenatal and anatomic features. Four factors associated with greater morbidity were identified: CONCLUSIONS: Isolated omphalocele, even containing the whole liver, has a very good prognosis with early surgical treatment. Without associated anomalies, 95% of giant omphaloceles can be discharged with a median of 41.5 days in hospital. However, associated anomalies (especially cardiopathies) may burden the prognosis and should be both carefully assessed during pregnancy and taken into account in parental information. TYPE OF STUDY Retrospective Study LEVEL OF EVIDENCE: Level I.

Diaphragmatic function in infants and children with congenital diaphragmatic hernia: a cross-sectional study

OBJECTIVES Few studies have evaluated long-term diaphragmatic function in congenital diaphragmatic hernia (CDH). The aim of our cross-sectional study was to assess diaphragmatic function in infants and young children with CDH after surgical repair. METHODS All the patients with CDH repair followed in our centre between February 2014 and January 2016 were enrolled. Patients with a postnatal diagnosis after 1 month of life were excluded. Breathing pattern and diaphragmatic function were assessed using esophageal and gastric (Pgas) pressure recording after surgery, or at 1 or 5 years of age. RESULTS Twenty-eight patients (24 left-sided CDH, 6 with diaphragmatic patch) were included. Twelve patients were assessed before hospital discharge (Y0), 6 around the age of 1 year (Y1) and 10 around the age of 5 years (Y5). Mean antenatal estimated pulmonary volume (VLA) was 42 ± 10% (n = 23). Diaphragmatic strength, assessed by transdiaphragmatic pressure during crying/sniff, was low at Y0 (47 ± 18 cmH2O, n = 12) and within normality at Y5 (81 ± 15 cmH2O, n = 7). Diaphragmatic dysfunction, assessed by Pgas during crying/sniff, was present at Y0 (-58 ± 22 cmH2O, n = 12) and Y1 (-53 ± 36 cmH2O, n = 5) and still present at Y5 (3 ± 9 cmH2O, n = 7) but to a lesser extent. The diaphragmatic tension time index (TTdi), which estimates diaphragmatic endurance, was high at Y0 (0.10 ± 0.04, n = 11) and within normality at Y5 (0.03 ± 0.01, n = 6). VLA correlated with neonatal TTdi (r = -0.961, P < 0.001). CONCLUSIONS Infants with CDH have diaphragmatic dysfunction in the neonatal period, which correlates with VLa and normalizes with age. Future longitudinal studies should assess the role of CDH side, size of diaphragmatic defect and patch repair.

Fetal MRI compared with ultrasound for the diagnosis of obstructive genital malformations

To compare the accuracy of magnetic resonance imaging (MRI) and ultrasound (US) to diagnose and characterize congenital obstructive genital abnormalities.

Segmental volvulus in the neonate: A particular clinical entity

BACKGROUND Complete intestinal volvulus is mainly related to congenital anomalies of the so-called intestinal malrotation, whereas segmental volvulus appears as a distinct entity, mostly observed during the perinatal period. Because these two situations are still lumped together, the aim of this study was to describe the particular condition of neonatal segmental volvulus. STUDY DESIGN We analyzed the circumstances of diagnosis and management of 17 consecutives neonates operated for segmental volvulus more than a 10-year period in a single institution. During the same period, 19 cases of neonatal complete midgut volvulus were operated. RESULTS Prenatal US exam anomalies were observed in 16/17 (94%) of segmental volvulus, significantly more frequently than in complete volvulus (p=0.003). Intestinal malposition was described peroperatively in all cases of complete volvulus, but also in 4/17 segmental volvulus (23%). Intestinal resection was performed in 88% of segmental volvulus when only one extensive intestinal necrosis was observed in complete volvulus. Parenteral nutrition was required in all patients with segmental volvulus with a median duration of 50days (range 5-251). CONCLUSION Segmental volvulus occurs mainly prenatally and leads to fetal ultrasound anomalies. This situation, despite a limited length of intestinal loss, is associated to significant postnatal morbidity. TYPE OF THE STUDY Treatment study. LEVEL OF EVIDENCE Level IV.