[Laparoscopic surgery of Meckel's diverticulum]. / Chirurgie coelioscopique du diverticule de Meckel.

Meckel's diverticulum is an evolution of omphalomesentric channel one of the most frequent embryologic abnormality of digestive tract. It is observed in two circumstances: during a routine exploration or after a complication: intestinal obstruction, peritonitis, recurrent abdominal pain. Only open or laparoscopic explorations allow a diagnosis. Resection of the diverticulum is recommended in children because the complications are frequent and serious. The preferred therapeutic method is the bowel resection with immediate anastomosis.

Intraoperative localization of neuroblastoma in children with 123I- or 125I-radiolabeled metaiodobenzylguanidine.

BACKGROUND: This study describes a novel method of intraoperative localization of neuroblastoma with a gamma-detecting probe, to detect in situ tumor binding of radiolabeled 123I- or 125I-metaiodobenzylguanidine (MIBG) and improve the quality of tumor resection. METHODS: Fifty-eight children underwent 66 surgical procedures with intraoperative detection of radiolabeled MIBG. All patients with positive MIBG scintiscans at diagnosis were included in the study. A tumor/background ratio exceeding 2:1 at the time of operation was considered positive, indicating a significant uptake of MIBG, compatible with the presence of malignant cells. The surgeons were requested to evaluate the contribution of the method to the surgical procedure. Sensitivity and specificity of the method with either 123I-labeled MIBG or 125I-labeled MIBG, on the basis of correlations between probe findings and pathologic analysis of 288 resected specimens, were determined. RESULTS: Intraoperative detection was helpful in 65% of surgical procedures, allowing a better definition of tumor limits and extension to locoregional nodes or detection of small and nonpalpable tumors in sites with difficult surgical access, especially during operation for relapse. The detection was not contributory in 35% of the procedures (well-localized tumors, thoracic neuroblastoma for technical reasons, highly differentiated tumors as ganglioneuroma, and tumors with mainly necrosis or fibrosis). The sensitivity of 123I and 125I was the same (91% and 92%), but the specificity of 125I (85%) was significantly higher than that of 123I (55%) (p < 0.005). CONCLUSIONS: First, this study demonstrates the feasibility of intraoperative detection, with radiolabeled MIBG, of neuroblastoma in children. We advocate the use of 125I rather than 123I. Second, the method is useful to improve the quality of macroscopic resection in widespread neuroblastoma with nodal involvement, in sites with difficult access, and in operations for relapse.

Gastroesophageal reflux after repair of congenital diaphragmatic hernia.

Seventy-four survivors of congenital diaphragmatic hernia (CDH) repair were reviewed for gastroesophageal reflux (GER). Twenty-nine patients had a prenatal diagnosis of CDH, 31 had the diagnosis established during the first 60 minutes of life, and 14 had a late diagnosis. Fifty-seven of the 60 patients with a prenatal diagnosis or diagnosis at birth had their CDH repaired during the first 24 hours of life. Thirty-six of the 37 patients with clinical signs of GER and 10 patients without typical clinical signs had documented GER. The overall incidence of GER was 62% (46 of 74). The 46 comprised 22 of the 29 patients (75.8%) with a prenatal diagnosis of CDH, 21 of the 31 (67.7%) with a diagnosis at birth, and 3 of the 14 with a late diagnosis. Eleven patients had surgical treatment of GER. A significant correlation was found between GER and the preoperative thoracic position of the stomach (32 v 8, GER+ v GER-; P < .01) and GER and the prenatal diagnosis of CDH (22 v 7, GER+ v GER-; P < .01). Duration of artificial ventilation (68.97 +/- 15.33 days v 14.14 +/- 3.89 days, GER+ v GER-; P < .005) and duration of hospitalization (22.04 +/- 3.59 weeks v 3.9 +/- 0.88 weeks, GER+ v GER-; P < .0003) were significantly longer for the patients with pathological GER. To decrease the morbidity related to GER, we propose using diaphragmatic patches during hernia repair to lower the strain on the crus, and using parietal patches to lower intraabdominal pressure after reintroduction of the herniated viscera.

Coexisting left congenital diaphragmatic hernia and esophageal atresia with tracheoesophageal fistula: successful management in a premature neonate.

The combination of left congenital diaphragmatic hernia (CDH) with esophageal atresia (EA) and distal tracheoesophageal fistula (TEF) is extremely rare and is considered highly lethal. The authors describe a premature neonate with this association, who is alive at 6 1/2 years of age. Temporary banding of the gastroesophageal junction and gastrostomy was performed concurrently with hernia repair and prosthetic abdominoplasty to enlarge the abdominal cavity. A right thoracotomy for ligation of the fistula, using extracorporeal membrane oxygenation (ECMO), was performed 13 days later. Complete repair of the esophageal atresia was accomplished 7 weeks after birth. The methods that have been suggested in the literature are discussed. The institution of ECMO at birth could allow a primary complete surgical repair of EA and CDH. Nevertheless, surgical management with staged repair, as described herein, can be useful.

Use of expanders for protection of viscera during irradiation of pelvic tumors in children.

The authors describe a new technique for radioprotection of pelvic viscera by placement of expanders in the subperitoneal area before irradiation of pelvic tumors. They use round shape sub-cutaneous expanders, the volume corresponding to children's weight. Seven patients were treated with excellent results, and minor complications: 2 rectitis due to unsatisfactory displacement of rectum by the balloon. There were no complications related to the device itself. The prosthesis was easy to withdraw. This method seems a safe and effective technique in protecting viscera.

Gastroesophageal reflux in neonates with congenital abdominal wall defect.

Gastroesophageal reflux (GER), not yet described as a real complication, takes place very often in neonates with congenital abdominal wall defect. Our aim was to determine whether it is due to abdominal hyperpressure alone, or if another factor is involved in this occurrence. Thus we studied one group of 80 gastroschises and one of 67 omphaloceles, treated in our department between December 82 and December 92. Overall occurrence was found to be about 50% in both groups. The main feature is the particular severity of GER in neonates with wide omphalocele who required staged closure, leading to further surgical antireflux procedure. We suggest that this procedure could be performed earlier, at the time of closure, for these babies in whom moreover the anatomic approach is favorable.

Childhood actinomycosis: report of two cases.

The authors report two cases of actinomycosis in children: one thoracic and the other retroperitoneal. They emphasize the difficulties of diagnosis before the stage of parietal extension with cutaneous fistula and characteristic yellow granular discharge. These difficulties are due to: The rarity of visceral actinomycosis, particularly in children. The lesion has a similar appearance to that of a tumor; an extensive pre-operative work-up is mandatory (ultrasound, computed tomogram scan, repeated ultrasound-guided needle biopsy), although this work-up may not necessarily lead to the correct diagnosis. A surgical biopsy will often confirm the diagnosis, provided the diagnosis has been previously considered. The necessity of using very specific tests for correct identification of the organism. Therefore, in a case of pseudo-inflammatory pseudotumor, visceral actinomycosis must be considered in order to guide microbiological and pathological studies, although this diagnosis is rare. Once the diagnosis has been made, prolonged treatment with penicillin is effective and complete recovery is generally obtained.

Budd-Chiari syndrome following repair of a giant omphalocele.

We report a case of Budd-Chiari syndrome following repair of a giant omphalocele. Thrombosis of hepatic veins and of retrohepatic inferior vena cava may result from direct pressure on the hepatic venous outlet after visceral reduction and final abdominal wall closure.

Conservative intestinal surgery to avoid short-bowel syndrome in multiple intestinal atresias and necrotizing enterocolitis: 6 cases treated by multiple anastomoses and Santulli-type enterostomy.

Neonates with multiple sites of intestinal atresia (MIA) may be predisposed to short-gut syndrome. Anastomoses of the intervening segments may prevent this complication. 5 neonates with MIA, one of them with a gastroschisis, were operated on: a proximal enterostomy was constructed, a side-to-end anastomosis as described by Santulli and several end-to-end anastomoses between the intervening intestinal segments (n = 3 to 7) were performed. An additional infant, initially operated on for a necrotizing enterocolitis (NEC) was managed with the same surgical procedure. Without use of this technique, the remaining length of small intestine would have been 28, 27, 40, 58, 70 and 7 cm. This technique enabled an intestinal length of 49, 54, 96, 107, 92 and 93 cm respectively to be achieved. Ileocecal valve was present in all 5 cases with MIA, but resected in the case with NEC. The enterostomy was reversed 7 weeks later. The initial outcome (delay of enteral feeding, duration of parenteral nutrition) was good: the babies were weaned from parenteral nutrition (PN) after a mean time of 90 days (48 to 163 days). The prognosis (mean follow-up: 31 months, range 14 to 57) was good with regards to growth and development and length of time required before adaptation to normal enteral feedings and stools. This surgical method allows complete decompression of the proximal jejunum so that nutriment can pass into the distal bowel allowing it to enlarge. In cases of MIA, a long tapering proximal enteroplasty is a better procedure than resecting more than 5-10 cm of the proximal distended and hypertrophied bowel. We prefer to perform an enterostomy in association with multiple anastomoses between intervening intestinal segments. The enterostomy is preserved for long enough waiting period to enable the reversion of the histochemical and morphological changes that may have taken place in the bowel.

Iatrogenic pharyngoesophageal perforation in premature infants.

BACKGROUND: Premature infants are particularly at risk of iatrogenic pharyngoesophageal perforation. It is a rare occurrence but when it does occur it often mimics esophageal atresia. In the light of 10 patients treated in our service and those reported in the literature we have highlighted the diagnostic difficulties and discussed the appropriate management. PATIENTS: Between 1980 and 1995, we treated 10 premature neonates for pharyngoesophageal perforation. Six of these neonates weighed less than 1500 g. Esophageal atresia was the primary diagnosis in 4 cases. The pharyngoesophageal perforation was caused by repeated airway intubation in 3 cases and by overenthusiastic routine postpartum suctioning or nasogastric tube (NGT) insertion in 7 others. Severe respiratory distress occurred in 7 neonates. A plain chest x-ray revealed a large right pneumothorax in 3 cases and an aberrant NGT in 3 other cases. Four neonates had a contrast esophagography and 4 neonates underwent endoscopy. Five cases were treated surgically. In 3 of these, esophageal atresia was the presumptive diagnosis and the perforation was only diagnosed intraoperatively via a right thoracotomy. One neonate required suturing of the perforation and another had a gastrostomy. In all 5 cases a mediastinal drain was left in situ. The 5 remaining neonates were treated conservatively with broad spectrum antibiotics, total parenteral nutrition, a silastic NGT and pharyngeal aspiration. One of these neonates had previously had a laparotomy for a colonic perforation. There was a good outcome in 4 neonates, one of whom required instrumental dilatation for an esophageal stricture. Bronchopulmonary dysplasia developed in 3 cases and necrotizing enterocolitis in 1 other case. Two neonates died. CONCLUSION: An iatrogenic perforation is often difficult to diagnose and can easily be confused with esophageal atresia. Clinical findings, a plain chest x-ray, an esophagography and endoscopy are helpful. Surgery can be avoided in most instances. The outcome is not always favorable especially as premature neonates are at risk of severe concomitant pathology.

Management of ovarian cyst detected by prenatal ultrasounds.

As a result of refinements in Prenatal Ultrasonography (US), neonatal ovarian cysts are more frequently encountered than in the past. Between January 1981 and December 1990, 21 consecutive fetuses with ovarian cysts were followed up by ultrasonography. 23 ovarian cysts were diagnosed between 28 and 38 weeks gestation. 18 cysts were initially large cysts (more than 50 mm in diameter). In 9 cases, an anechoic cyst was observed and a US-guided needle aspiration of the cyst was performed (2 antenatally and 7 postnatally). Ultrasonographic patterns of complicated cyst were observed in 3 fetuses. After a postnatal ultrasound control, 11 infants were operated on: 8 surgical interventions were required for complicated cysts (torsion: 4, hemorrhage: 4), 3 cases irrespective of their sonographic appearance in our initial experience. In the remaining cases, spontaneous resolution was followed by repeated ultrasonographic examination. Prenatal ultrasonography today allows diagnosis of ovarian cysts and may suggest antenatal complications. To preserve as much ovarian tissue as possible, cysts greater than 50 mm in diameter should be candidates for percutaneous aspiration and complex cystic masses should be operated on.

[Laryngo-tracheo-esophageal cleft associated with missed atresia]. / Fente laryngo-trachéo-oesophagienne associée à une atrésie manquée.

Laryngo-tracheo-esophageal cleft (LTEC) is a rare malformation. Treatment is always surgical and still has uncertain results. One case of LTEC (type III), associated with a "missed atresia" of the esophagus is reported. The diagnosis of eso-tracheal, H-Type fistula was first suspected at birth before transfer of the baby to the neonatal surgery department where the diagnostic of long LTEC was established. Surgical repair was done through lateral cervicotomy and allowed complete cure of the eso-tracheal communication without tracheotomy. Barium swallowing, controlled on the eleventh post-operative day, showed a perfect result of the reconstruction and an underlying esophageal malformation, previously described as "missed atresia". The treatment of this second malformation was performed two months later by plain resection-anastomosis with excellent outcome at a one year follow up with no recurrent fistula nor GE reflux or laryngeal nerve palsy. To the best of our knowledge, this type of association has not been previously reported.

[Prenatal diagnosis of visceral malformations by ultrasonography]. / Le diagnostic anténatal des malformations viscérales par ultrasonographie.

The authors study a series of 64 cases of neo-natal visceral malformations which diagnosis had been done through maternal ultrasonography. The benefits of this technic depend on the affection or the malformation; they are presented here separately. These very early diagnosis in some rare cases allow an antenatal therapy; specially in urology, an earlier surgery than usual can be provided. A case of antenatal diagnosis of Cantrell Syndrome is described.

[The surgeon facing malignant non-Hodgkin's lymphoma of the abdomen in children]. / Le chirurgien face au lymphome abdominal malin non hodgkinien de l'enfant.

From February 1981 to December 1988, 30 children with Abdominal Malignant Non Hodgkin's Lymphoma (NHL) have been followed and treated in the Department of Pediatric Surgery of Saint Vincent de Paul's Hospital. The place of surgery in the Diagnosis, Evolution and Treatment of NHL is defined. In the diagnostic Stage, Surgery should be a fortuitous event, as in some cases of acute Intestinal Intussusception, or Appendicectomy, where lymphoma is an unexpected discovery. In all other cases, a cytologic study of ascites and/or pleural effusion that should be searched, can give a quick and reliable Diagnosis. Exceptionally, a complication of chemotherapy, as a peritonitis, with or without intestinal perforation, require an intervention. Most often in cases of already diagnosed and treated NHL, an abdominal residual mass have to be removed surgically and submitted to careful pathologic examination, to determine further treatment. If in some cases, initial Diagnosis is an unexpected discovery, the treatment of NHL is essentially medical. Surgery takes place in the Remission Evaluation after conventional chemotherapy.

[Risk of recurrent laryngeal nerve palsy in surgery of esophageal atresia]. / Le risque récurrentiel dans la chirurgie de l'atrésie de l'oesophage.

From the last 100 cases of esophageal atresia treated since october 1975, the authors emphasised the incidence of left or right recurrent laryngeal nerve palsy. This incidence is about 20%. Most often, an unilateral palsy is asymptomatic, but in a few cases many complications have been reported. Therefore it is necessary to insist on the surgical and anatomic factors which could increase the risk of a nervous injury and the technics to prevent it.

[Liver inflammatory lesions masquerading tumors (author's transl)]. / Les lésions inflammatoires du foie simulant une tumeur. A propos de trois observations d'abcès du foie simulant une tumeur.

The Authors report three unpublished cases of tumoral abscess of the liver in infants and children. Two different situations are considered:--clinical findings, laboratory tests and intraoperative examination can be more in favor of a tumor at times. Means of avoiding needless excisions are outlined.--two uncommon types of abscess are considered. One type has an areolar structure whereas the other is in fact inflammatory tumoral fibrosis. This abscess is a true tumor and must be treated accordingly. Pathological studies, etiology, bacteriology and clinical aspects of such abscess of the liver are reviewed.

[A rare form of congenital esophageal stenosis: abortive esophageal atresia (author's transl)]. / Une forme rare de sténose oesophagienne congénitale: l'atrésie manquée.

This communication describes two new cases of esophageal malformation situated at the usual level of atresias. In these two stenosis, the superior segment overlapped the inferior segment a certain length, and the inferior segment adhered closely to the trachea. When recognized, this malformation responds well to instrumental dilatation.

[Meconium peritonitis. The value of prenatal diagnosis]. / Péritonites méconiales. Intérêt du diagnostic prénatal.

Over an eight year period (1980-1987), fifteen cases of meconium peritonitis have been studied. As it has been reported, this pathology is still very rare. Ten pregnancies have been followed on by multiple échographies and the prenatal diagnosis of meconium peritonitis, suspected as early as 24 weeks of amenorrhea, has been established in ten cases. Among these, eight infants have been operated on before twelve hours of life, and for the ninth, surgical treatment was not advocated. The most frequent cause of the pathology is a perforation above a bowel obstruction. Two had cystic fibrosis. Of the 15 infants with meconium peritonitis, nine survived, and among these, one with cystic fibrosis and the one that has not been operated. Prenatal diagnosis in meconium peritonitis is of major interest in taking care early infants that will need an urgent surgical operation in most cases.

[Laparoschisis. Hypotrophy and intestinal lesions]. / Laparoschisis. Hypotrophie et lésions intestinales.

37 cases of gastroschisis were operated on at Saint-Vincent-de-Paul's Hospital from january 1983 to july 1987. They were more frequently premature by birth weights (70% below the 10 th percentile), than by period of gestation (40%). The comparison of their weights plotted on the centile charts with 28 neonates with omphaloceles and 25 neonates with upper intestinal atresia (esophageal atresia without tracheoesophageal fistula and complete duodenal and proximal jejunal atresia) shows that the 2 groups of laparoschisis and anomalies of the alimentary tract are quite similar. The authors suggest that the amniotic fluid may play a role in the fetal growth so that the alteration of the herniated bowel is responsible of the fetal growth retardation observed in gastroschisis.