[Stenosis of the upper renal pelvis: rare complication of an incomplete ureteral duplicity. Embryological investigation]. / La sténose du pyélon supérieur : complication rare d'une bifidité urétérale. Enquête embryologique.

A stenosis of the upper pole of an incomplete renal duplication is presented. The prenatal diagnosis of a right renal ureteropyelic junction syndrome, isolated, with a normal amniotic liquid was confirmed at birth. Intravenous pyelogram 8 days after birth showed three right dilated calical groups with a dilated renal ureteropyelic junction, but an normal inferior calical group suspected a renal bifidity. Renal MagIII scintigraphy evaluated the anatomical and functional stenosis and indicated surgery. Postoperative followings were simple and results good 3 years after. From this rare case, embryogenesis is discussed.

Surgical treatment of malignant esophagotracheal fistulas.

Malignant esophagotracheal fistulas represent the fatal evolution of esophageal cancer. Since October 1974, 18 patients were seen who had confirmed esophagotracheal fistula, and in half of these patients, the fistula was the revealing symptom. Upper gastrointestinal studies (using hydrosoluble dye) and bronchoscopic examination confirmed the diagnosis, which was already strongly suspected in 16 of the patients due to the specific nature of the cough triggered by swallowing. The average age of the patients was 57 years, (range, 32 to 78 years). In 12 patients, the nutritional repercussions were moderate, and in only 6 patients, were the bronchopulmonary consequences serious. Therapeutically, we adopted a palliative surgical attitude since the physical and psychological condition of these patients was considered fatal the month after discovery of the fistula. In addition, the results of intubation were uncertain and transitory. Our surgical methods evolved in three stages: first, we performed bipolar exclusion of the esophagus coupled with gastrostomy (four patients), second, we performed retrosternal coloplasty (five patients), and third retrosternal gastroplasty with drainage of the inferior portion of the esophagus by Roux-Y jejunal anastomosis (six patients). The latter technique was inspired from that described by Kirschner in 1920. It is moderately aggressive and has the advantage of dealing with several objectives: exclusion of the fistula, reestablishment of normal alimentation, drainage of the inferior portion of the esophagus, and permitting postoperative radiotherapy. In our series, when only the patients who underwent coloplasty or gastroplasty were considered, 3 of 11 died, and the longest postoperative survival times were 16 and 23 months. Regarding gastroplasty alone, our results were in agreement with those in the literature. In the 19 patients who underwent gastroplasty, the operative mortality was 31.5 percent and the average length of survival was 9 months. Six patients survived from 8 to 26 months. Therefore, this "last resort" surgery seems legitimate in light of the fact that the results are sometimes superior to those of radical curative surgery for extirpative esophageal cancer.

Duhamel operation 40 years after: a multicentric study.

The authors present the results of an international retrospective study evaluating the present situation in using Duhamel's technique or its modifications in the treatment of Hirschsprung's disease on the basis a series of 2430 patients. After evaluation of all important criteria and discussion with data from the literature it is concluded that the techniques is simple, fast, less shocking, logical, reliable, respecting the rectal anatomy and physiology, ingenious in its principle, without serious complications. The rectum is preserved in place with all its vascular drainage and innervation. This technique can be performed by every sufficiently experienced surgeon.

Anatomical and sonographical studies on the development of fecal continence and sphincter development in human fetuses.

The aim of this study was to specify the sonographic, anatomical and morphological aspects of the fetal anal sphincter and to compare them with pathological and physiological findings. The sphincter was examined by serial sectioning and staining of embryo and fetal tissue and by real-time ultrasound. Its function was analysed using amniotic fluid digestive enzyme assays in cases of anorectal atresia and cystic fibrosis. Morphological findings indicate that the functional components of the anal sphincter do not differentiate before 30 weeks and therefore do not account for the observed anal continence at 22 weeks. Ultrasound measurements of the sphincter indicate three developmental phases: 1) slow growth from 14 to 19 weeks; 2) rapid growth from 19 to 30 weeks; 3) subsequently, no further increase, but contractions indicative of peristaltism. Amniotic fluid digestive enzyme assays indicate that anal sphincter maturation begins with perforation of the anal membrane at 12 weeks. Comparison of pathological cases (anorectal atresia and cystic fibrosis) suggests two possible explanations of fetal anal obstruction: increasing viscosity of digestive secretion or the presence of the three anal sphincter muscles, even if still immature. Our results clarify the evacuation and retention of meconium during fetal life and the role of the terminal part of the digestive tract, notably the anal sphincter. Prenatal diagnosis of anorectal atresia is therefore possible before 20 weeks of gestation by measurement of amniotic fluid digestive enzymes and ultrasonography, thus enabling better neonatal management.

Fetal development of the urethral sphincter.

A morphological study was carried out on 25 human embryos (3-60 mm CR) and 20 human fetuses (15-40 weeks). The anatomical analysis was completed by immunocytochemical studies of different markers of muscle differentiation (vimentin, desmin, titin and isoforms of the myosin heavy chains). A mesenchymal condensation forms around the urethra after the division of the cloaca (E.H. 12-15 mm CR). The m. pubo-rectalis appears in 20-30 mm CR embryos, following the opening of the anal membrane. Striated muscle fibers can be clearly differentiated at 15 weeks. At this time, the smooth muscle layer also becomes thicker at the level of the bladder neck and forms the inner part of the urethral musculature. The urethral sphincter is a functional unit composed of central smooth muscle fibers and peripheral striated muscle fibers. In the human fetus, this musculature mainly develops in the anterior wall of the urethra. We analysed the expression of smooth and skeletal markers as an original approach to the muscular development in this region.

Fracture of the femoral shaft in children: advantages of the descending medullary nailing.

In a 7-year period, 70 children aged 5-15 years (mean 9.2 years) were treated for a fracture of the femoral shaft (73 fractures: 71 closed and 2 open) by flexible medullary nailing, either ascending (12 cases) or descending (61 cases). Although the classic treatment is use of the ascending route described by the Nancy team, the subtrochanteric descending route was preferred for its simplicity. Noninvolvement of the knee by the insertion of the nail allows earlier autonomy in children. Results were satisfactory and no complications related to the method were observed. Biomechanical principles are also respected by such treatment.

A new method of ventilation with a mixture of helium and oxygen in the management of congenital diaphragmatic hernia. A preliminary study.

To prevent the severe prognosis of pulmonary hypoplasia in congenital diaphragmatic hernia, the authors developed a new method of ventilation, using a modulated mixture of helium and oxygen. Associated with a leptanalgesia (Chlorpromazine-Morphine), the authors observed with this method two good results. Efficiency of this technique has been confirmed by X-rays and successive pulmonary scintigraphies (Xenon 133).

[Fracture of the femoral shaft in children. Ascending or descending medullary nailing? A choice of principle or necessity?]. / Fracture de la diaphyse fémorale chez l'enfant. Embrochage centro-médullaire ascendant ou descendant? Un choix de principe ou de nécessité?

Over a period of 4 years, 40 children between the ages of 6 and 14 years (mean: 10 years) were treated for a fracture of the femoral shaft (39 closed fractures and 1 Cauchoix type I open fracture) by flexible medullary nailing, either ascending (5 cases) or descending (35 cases). Although it is classical to use the ascending route described by the Nancy team, the sub-trochanteric descending route was preferred for its simplicity; non-involvement of the knee by the insertion of the nail allows earlier autonomy in children. The results have been found to be satisfactory; no complications related to the method were observed. The biomechanical principles are also conserved.

[Strangulated ureterocele and prolapsed urethral mucosa in a little girl. Diagnostic difficulties]. / Urétérocèle étranglée et prolapsus de la muqueuse uréthrale chez la fillette. Difficulté du diagnostic.

The author reports a case of a 2 year-old girl, with prolapse of the urethra treated since birth, twice by electro-coagulations. The persistence of the symptoms required further urological examinations (Urography, Ultrasonography), which revealed an ureterocele, prolapsed into the urethra with total duplication of the urinary tract. The operation consisted of a nephro-ureterectomy of the upper tract, with resection and suture of the exteriorized part of the ureterocele in the urethra.

[Coralliform lithiasis in children. Apropos of 20 case reports]. / La lithiase coralliforme chez l'enfant. A propos de vingt observations.

The authors recall the characteristics of infantile staghorn calculus, in relation to twenty personal cases. The complaint is more frequently encountered in boys than in girls. A frequent etiology is proteus urinary infection. The morphology of the staghorn and the state of the parenchyma are determining factors in the treatment. A sinusoid morphology and thickness of the renal parenchyma are operative indications. The bivalving operation is exceptional. Results are generally satisfactory (80% of cases), and recurrences are rare.

[Embryological study of the mechanism of antenatal lower urinary tract obstruction]. / Obstruction anténatale du bas appareil urinaire: étude embryologique de son mécanisme.

Closure of the embryonic bladder based on the results of the study of 25 human embryos (Crown-Rump length: 5mm-60mm) and 8 Born's reconstructions, is presented. It is a complex but well regulated stage of organogenesis. Division of the cloaca depends on caudal regression, development of the genital tubercle and growth of the urorectal fold which joins the cloacal membrane. The didermal cloacal membrane (composed of the ecto and endodermal layers) opens on its caudal part. On the cranial part, there is a cloacal plug, composed of packed cells, which strengthens the inferior part of the genital tubercle. After progressive vacuolation, this plug is colonized by mesodermal tissue derived from the urorectal fold, which assumes the development of the anterior perineum. This stage depends on cranial growth of the genital tubercle. On a human embryo (31 mm Crown-Rump length, 52 days, 10 Weeks of amenorrhea), the bladder is closed, urachus obturated and urethra patent. The vesico-ureteral junction, and prostatic utricle are present and the colliculus seminalis is well developed. A temporary obstruction (caused by asynchronism between urachus closure and urethral opening) can induce antenatal vesicoureteral reflux which could regress after birth. However if urethral obstruction is definitive (posterior urethral valves or atresia), reflux persists. Antenatal sonographic bladder identification is possible after 10 weeks of amenorrhea with visualisation of the two umbilical arteries by color duplex ultrasound. If the urachus remains patent, it can be visualized inside the arterial umbilical triangle, on a transverse view.

[Replacement continent bladder in dogs by opening an antro-pyloric graft onto the abdominal wall (seven cases between 1980 and 1983)]. / Etude d'une vessie continente de remplacement chez le chien par ouverture à la paroi abdominale d'un greffon antro-pylorique (sept cas réalisés de 1980 à 1983).

To determine the usefulness of antral bladder controlled by the pyloric sphincter denervated for urological applications, bladder replacement was performed in 17 dogs using the antral segment with its own sphincter, initially with the pylorus supplied by the left gastro-epiploic artery, and later by the right gastro-epiploic artery. The smooth pyloric muscle was denervated to obtain permanent spasm and pulled through the striated anterior abdominal muscle. Both ureters were anastomosed by a Cohen's procedure. The best results were obtained with a gastric pouch supplied by the right gastro-epiploic artery; dissection and reimplantation of the ureters in the gastric wall are difficult. IVP and cystography indicated good function of the antral pouch, with no reflux. The antral bladder controlled by the denervated pyloric sphincter could be a possible alternative in the surgical management of neurogenic or exstrophic bladder.

[Dorso-ventral gradient of maturation for puborectalis muscle]. / Gradient dorso-ventral de maturation du muscle puborectalis.

Foetal maturation of the skeletal fibers in the anorectal sphincter and in the vesico-urethral sphincter follows a dorso-ventral gradient, in parallel with the development of their motor innervation. The anatomical situation of the m. puborectalis, which early development plays an important role in the establishment of the foetal anal continence, suggests that this muscle should also be submitted to this gradient. We have studied in parallel the development of both the ventral and the dorsal parts of the m. puborectalis in human foetuses aged between 19 and 40 weeks of pregnancy. The results indicate that the transversal thickness of the muscle increases progressively during pregnancy, with a dorsal part being always thicker than the ventral one. More interestingly, the increase in the diameter of the muscle fibers becomes significantly more important at the level of the dorsal part between 25 and 40 weeks of pregnancy. This last result confirms the existence of a dorso-ventral gradient of growth and maturation of the m. puborectalis, as part of the global mechanisms involved in the development of the striated musculature of the pelvic organs.

[Intrication of smooth and striated muscle during the development of the ano-rectal sphincter]. / Intrication de muscle lisse et de muscle strié au cours du développement du sphincter ano-rectal.

The development of the foetal anorectal continence is related to the appearance of the anatomical components of the sphincter. The present study has been carried out in order to analyse the development of the smooth and striated components of the anorectal sphincter, in a series of 7 embryo and foetuses aged from 10 to 40 weeks of pregnancy. Our results indicate that the external sphincter, the puborectalis muscle and the internal sphincter are present before 24 weeks, although they obviously play variable roles in the establishment of the foetal continence. The internal sphincter becomes quantitatively important after 14 weeks, and is likely to be responsible for the establishment of the initial continence. The growth of the striated components during the foetal period corresponds to the maturation of the innervation and of the voluntary mechanisms controlling continence. Intrication of smooth and striated muscle components in the external sphincter starts after the end of the embryonic period. All the anatomical components of the anorectal sphincter are present at birth.

[Appendicitis in children]. / L'appendicite de l'enfant.

In 1992, appendicitis is still common among children. Mortality due to a belated or erroneous diagnosis is far from being nil. The disease must always be present in the clinician's mind, and its diagnosis is purely clinical. No significant advance has been made on this subject, and clinical findings remain of paramount importance. Hospitalization for observation at the slightest doubt and emergency surgery when the diagnosis is probable are the best means of improving the management of appendicitis in children.

[Role of laparoscopic surgery in the treatment of abdominal pain in children]. / Miesto laparoskopickej chirurgie v liecbe bolestí brucha u detí.

Principal indications of the coelioscopy in pediatric surgery is the laparoscopic appendectomy. In compare with classic techniques it has several advantages but as well as some limitations. During decision about eventual laparoscopic intervention in children is important to take into the consideration personal and material facilities of the unit or hospital for pediatric coelioscopic interventions, their accessibility as well as longer operating time and higher price of the operation. It is amoral to use the laparoscopic appendectomy as a method of teaching surgeon and team to the technique. The authors consider the laparoscopic exploration of the peritoneal cavity with subsequent appendectomy to be a very suitable technique for examination and treatment of pre-pubertal and pubertal girls or young women with chronic or repeated abdominal pain of the uncertain origin, however, its indication in indubitable acute appendicitis of a boy is questionable.

[Congenital prenatal hemangioma: diagnosis and treatment]. / Hémangiome congénital à révélation anténatale.

An echogenic tumor (22 x 22 mm) isolated from the anterior part of the left leg at 27 WA of pregnancy suggested an angiomatous structure. This mass appeared to be well vascularized on Doppler examination. Three-dimensional imaging showed connections with adjacent tissues. The limbs were mobile. Delivery of a 3990-g-boy occurred normally. On the anterior part of the left leg, there was a plate-shaped mass with a pink hole at the superior part. Excision under general anesthesia was performed at the first month because of the risk of rupture and bleeding. The dissection was easy with the deep plane. Healing was complete 10 days after the surgical procedure and the aesthetic aspect was good 1 year later. Histological findings of the suspect mass emphasize the vascular aspect of the tumor. A hemangioma capillary with venous structures in the dermal hypodermic area was found.