[Outcome of severe closed kidney injuries in children]. / Devenir des traumatismes fermés sévères du rein de l'enfant.

AIMS: To analyze the results of treatment of major renal injuries according imaging data in order to determine their function after follow-up. PATIENTS AND METHODS: This is a retrospective study of 22 cases of fracture of the kidney (grade V) in two pediatric surgical services that were reviewed over a period of 16 years. After initial conservative treatment in 19 patients (86.5%), a scan and/or Uro-MRI were realized in all patients in monitoring evolving. Three children with vascular injury were treated by interventional radiology. The morphology and functional evolution of the injured kidney were determined. RESULTS: A DMSA scan investigation was performed in 21 patients (95.5%) associated with Uro-MRI in two cases; one patient was only explored with Uro-MRI. A complete restitution of the renal parenchyma was confirmed in 10 children (45.5%), we noted an atrophy of the upper pole in 30%, a lower pole atrophy in 4.5%, two complete renal atrophy in 9%. An urinoma was present in six patients (27%) that required drainage in five cases and declined during the surveillance in one case. Normal function of the injured kidney was noticed in half of grade V (11 of 22 patients) with a mean follow-up of 19 months. None of our patients did present hypertension. CONCLUSION: Non-operative conservative treatment in severe renal trauma was efficient, morphological and functional sequelae were present in 50% on scintigraphy and/or Uro-MRI.

[Flexible ureteroscopic lithotripsy in a 22-months-old child]. / Urétéro-renoscopie souple chez un nourrisson de 22 mois.

With the endourological development, the management of urinary tract calculi in children has significantly improved. The miniaturization of endoscopic equipment has allowed the use of flexible ureteroscopic with holmium YAG laser lithotripsy in children. We highlighted the case of a 22-month-old child, with an antecedent of megaureter, who had calculi in the right kidney lower pole. In collaboration with the urologist specialising in adult care, using an adapted technical tray, we underwent a laser intracorporeal lithotripsy using a 8 Charriere (Ch) ureteroscope and an holmium laser. No ureteral dilatation was required. A complete fragmentation of this infectious calculus was performed. This experience with a flexible ureteroscopy confirms that this technique is practicable, efficient and safe for stone treatment in children.

[Urinothorax: rare complication of neonatal sectioned posterior urethral valve]. / Urothorax: complication rare d'une valve de l'urètre postérieur sectionnée en période néonatale.

We report a newborn aged 19 days, carrying a posterior urethral valve antenatal screening in which developed 7 days after the entire section of the valve, a compressive urinothorax in connection with a perirenal urinoma. Pleural and bladder drainage has a surrender of effusions and a healing of the renal parenchyma. The thoracic urine effusion is a very rare complication of a posterior urethral valve with perirenal urinoma. This probably results from a rupture of a fornix dysplastic by hypertension of the urinary tract. The authors emphasize the unusual discovery of this disease by breathing problems and his delayed character after resection of the obstruction in the neonatal period.

[Diffuse xanthogranulomatous pyelonephritis in infant]. / Pyélonéphrite xanthogranulomateuse diffuse du nourrisson.

We report a case of a renal mass in a 4-month boy, which occured during the assessment of a pelvi-calyceal dilatation diagnosed at 23 weeks of gestational age. There was no history of urinary infection, fever or weight loss. Physical examination revealed a mass of the left flank with significant flank tenderness. Laboratory test showed a biological inflammatory syndrome and urine culture was negative. Investigations including ultrasound and computed tomography scan were suggestive of diffuse xanthogranulomatous pyelonephritis with a non-functioning left kidney. Left total nephrectomy was performed through a lumbar incision with an extraperitoneal approach. The kidney was enlarged with a dilated pelvis containing pus upstream of a proximal ureteral atretic segment. Pathological examination of the kidney confirmed the diagnosis of diffuse xanthogranulomatous pyelonephritis. The boy remains well at 1 year follow-up. Xanthogranulomatous pyelonephritis is very rare in infants. It is an uncommon severe progressive renal infection resulting in destruction of renal parenchyma, histologically replaced by xanthomatous cells and granulomatous reaction. Pathogenesis of xanthogranulomatous pyelonephritis remains unclear. But it is well known that urinary tract obstruction and renal lithiasis are determining factors. It can occur in variant clinical forms but its symptoms remain non-specific. Curative treatment consists in nephrectomy and definitive diagnosis is made on histological examination of the kidney. This diagnosis should be discussed when a renal mass occurs in a context of malformative uropathy and xanthogranulomatous pyelonephritis have to be included in the differential diagnosis of renal mass in infants and children.

[Ultrasonography of acute scrotum in children]. / La bourse aiguë de l'enfant : corrélations radiocliniques.

Paediatric surgeons and urologists are often asked to evaluate boys with acute scrotal pain and inflammation. Although, there is much aetiology for this syndrome: testicular torsion, appendicular testicular torsion, epididymo-orchitis, hernia, hydrocele, trauma, Henoch-Schonlein purpura, idiopathic scrotal edema. However, testicular torsion should be at the top of the list because of the medico legal aspects. It is the one diagnosis that must be made accurately and rapidly, if there is any hope for testicular salvage. Color Doppler ultrasound scan can reliably identify those children, who required exploration and spare medical causes. The purpose of this article is to update/review the appropriate evaluation and management of the acute scrotum and to guide the clinician in distinguishing testicular torsion from the other conditions that commonly mimic this surgical emergency.

[Abdominoscrotal hydrocele with leg edema in a 4-month-old boy]. / Hydrocèle abdomino-scrotale compliquée d'un lymphoedème de jambe chez un nourrisson.

We present a case of a 4-month-old boy with a right abdominoscrotal hydrocele associated to a compression of the femoral triangle, causing an unilateral leg edema. Abdominoscrotal ultrasound revealed a fluid collection with abdominal and scrotal components, communicating through the deep inguinal ring. Sagittal views of magnetic resonance imaging (MRI) showed a dumbbell-shaped hydrocele and the angio-MRI venous sequences confirmed the compression of the right iliac vessels. Curative treatment was surgical through an inguinal approach and consisted in high ligation of the processus vaginalis and hydrocelectomy. Abdominoscrotal hydrocele is an uncommon pathology, which rarely occurs in pediatric population. This diagnosis should be discussed when a cystic abdominal mass is associated to an ipsilateral scrotal hydrocele. The abdominal component of the hydrocele can result in compression of adjacent structures (iliac vessels, ureter). Surgical treatment is recommended. Epididymal and testicular abnormalities are frequently described, as in our observation, and the effects on the future fertility are unknown.

[Endoscopic management of severe pancreatic and biliary diseases in children]. / Prise en charge endoscopique des affections biliopancréatiques compliquées chez l'enfant.

Endoscopic treatment of pancreatic pseudocysts and choledocal lithiasis is a first-line treatment in adults. Nevertheless, due to technical difficulties such a management is not always feasible in children. This series reports our results in the management of pancreatic and biliary diseases in children. Seven children, two months to 12 years old, underwent endoscopic management of pancreatic and biliary diseases. Two of them had choledocal lithiasis with jaundice or acute pancreatitis, two had pancreatic pseudocyst due to abdominal traumatism, two had chronic pancreatitis with a communicating pseudocyst in one case, and one had a biliary leakage after traumatism. All the endoscopic treatments were performed under general anesthesia. In six cases, the duodenoscope was a regular one with a large operating channel (Olympus TJF 160; Japan) employed for children aged 33 months to 12 years. In the case of the two months child, a "rendez-vous" technique was performed with a percutaneous approach of the common bile duct followed by an endoscopic sphincteroclasy using an axial endoscope allowing the extraction of a choledocal stone. In two cases, post-traumatic pancreatic pseudocysts (eight and 12 year-old children) were managed with the transgastric insertion of two double pig-tail stents. In two cases, children with chronic pancreatitis (38 months and 12 years old) were managed with pancreatic sphincterotomy. Biliary leakage in an 11-year-old child was managed with biliary sphincterotomy and stenting. All the children became symptom-free without any procedural complications with an 11 months median follow-up. Endoscopic treatment of pancreatic and biliary diseases is possible in children like in adults with the same procedures and results.

Duodenal duplications. Clinical characteristics, embryological hypotheses, histological findings, treatment.

BACKGROUND: The aim of this study was to analyse different clinical aspects and embryologic hypotheses of duodenal duplications. METHODS: Duodenal duplications occurring since 1995 were recorded. The age of the children at the time of diagnosis, the sex, location of the duplication, type of mucosa, clinical signs, associated lesions, and the type of surgical intervention were defined. RESULTS: We identified 5 patients (3 girls and 2 boys) who presented with histological or intraoperative findings of duodenal duplication. Their ages ranged from 4 days to 9 years, with the exception of two prenatal diagnoses. Three children were symptomatic: high intestinal obstruction (1 case), digestive bleeding (2 cases). In 1 case we found a palpable abdominal mass and 1 case was completely asymptomatic (prenatal detection). The abnormality was located on the duodenal concavity, originating from the third part in 2 cases and from the second part in 3 cases. All cases were non communicating types, 4 of which were cystic duplications and 1 was a tube-like variety. The epithelial lining was duodenal mucosa in all patients, but gastric heterotopies were identified in 2 cases. We performed two complete resections and 3 intraduodenal derivations. The outcome was uneventful in 5 cases with an average follow-up of 2 years. CONCLUSION: Duodenal duplications are rare malformations with several anatomical varieties. The preferred treatment for duodenal duplications is complete removal when the location allows it without endangering nearby anatomical structures.

Postural therapy for renal stones in children: A Rolling Stones procedure.

INTRODUCTION: Despite many advances, the management of renal stones - especially lower caliceal stones (LCS) - remains a challenge. The gravity-dependent location of the lower calices hinders the spontaneous clearance of fragments, which can be a nidus for future growth and symptomatic recurrence. Currently, there is no standard adjunctive therapy to facilitate fragment passage. OBJECTIVES: To report the safety and effectiveness of mechanical percussion diuresis and inversion (PDI) therapy for eliminating renal stones in children. PATIENTS AND METHODS: Since November 2013, children with residual fragments (after shock wave lithotripsy or flexible ureteroscopy) or native symptomatic renal stones were prospectively included in a protocol of four PDI sessions. After giving written consent, the children drank 10 ml/kg of water 30 min before therapy. They then laid in a prone Trendelenburg position on a couch angled at 45° and received continuous 10-min mechanical percussion applied over the affected flank by a physiotherapist (Figure summary). Tolerance stone burden reduction and stone clearance were documented with ultrasound 4 weeks after the last session. RESULTS: Seventeen participants, with a median age of 10.8 years (range 18 months to 18 years), received 82 PDI sessions performed over 22 months. The median stone diameter was 5 mm (range 3-9). All children tolerated the PDI therapy well. Over a median follow-up of 11 months (range 3-18), no significant adverse effects were noted. The overall stone-free rate was 65%. Four of the six patients with residual fragment passed their fragments. The patients who did not become stone free by PDI experienced a decrease in fragment size of 57% (range 34-71). The observance rate was 100%. DISCUSSION: Many studies have demonstrated that the gravity-dependent position of the lower calyces appears to be an important factor limiting the clearance of LCS. Positioning patients with a degree of inversion in order to put the collecting system beyond the horizontal plane affected the LCS through gravitational force. Complications were rare. PDI appeared to save costs and have similar success rates as shock wave lithotripsy for native small renal stones in children. CONCLUSION: PDI is safe and effective for facilitating gravity-dependent drainage of renal stones and provides an opportunity to treat children in a quick, non-invasive, economic, painless, non-radiative and diverting fashion. This therapy is a valuable alternative in the pattern of stone management. In case of persistent fragments, it is recommend that the number of sessions be increased to six.

Effects of vitamin E supplementation on F(2)-isoprostane and thromboxane biosynthesis in healthy cigarette smokers.

BACKGROUND: Increased formation of 8-iso-prostaglandin (PG) F(2alpha) and thromboxane (TX) A(2), potent agonists of platelet and vascular thromboxane (TH)/PGH(2) receptors, has been detected in cigarette smokers. We performed a randomized, double-blind, placebo-controlled study of the effects of vitamin E (300, 600, and 1200 mg/d, each dose for 3 consecutive weeks) on 8-iso-PGF(2alpha) and TXA(2) biosynthesis in 46 moderate cigarette smokers. METHODS AND RESULTS: Urinary immunoreactive 8-iso-PGF(2alpha) and 11-dehydro-TXB(2), plasma vitamin E, and serum TXB(2) were measured by previously validated techniques. Baseline urinary 8-iso-PGF(2alpha) and 11-dehydro-TXB(2) excretion averaged 241+/-78 and 430+/-293 pg/mg creatinine, respectively. Urinary 8-iso-PGF(2alpha) was significantly correlated with 11-dehydro-TXB(2) (r=0.360, n=138, P<0.0001). Baseline plasma vitamin E levels averaged 20.6+/-4.9 micromol/L and were inversely correlated with urinary 11-dehydro-TXB(2) (r=-0.304, P=0.039) but not with 8-iso-PGF(2alpha) (r=-0.227, P=0.129). Vitamin E supplementation caused a dose-dependent increase in its plasma levels that reached a plateau at 600 mg (42.3+/-11.2 micromol/L, P<0. 001). This was not associated with any statistically significant change in urinary 8-iso-PGF(2alpha) or 11-dehydro-TXB(2) excretion. CONCLUSIONS: Supplementation with pharmacological doses of vitamin E has no detectable effects on lipid peroxidation and thromboxane biosynthesis in vivo in healthy subjects with a mild degree of oxidant stress. These findings are consistent with the hypothesis that the basal rate of lipid peroxidation is a major determinant of the response to vitamin E supplementation and have implications for the use of vitamin E in healthy subjects as well as for the design and interpretation of clinical trials of antioxidant intervention.

Effects of gemfibrozil on insulin sensitivity and on haemostatic variables in hypertriglyceridemic patients.

In order to assess the efficacy of gemfibrozil on lipid and haemostatic parameters in patients with plurimetabolic syndrome, a multicenter double-blind placebo controlled, parallel study was carried out in 56 patients with primary hypertriglyceridemia and glucose intolerance. These patients had elevated PAI activity and antigen and t-PA antigen levels at rest and after venous occlusion. Gemfibrozil reduced plasma triglyceride levels (P<0.001), whereas it increased free fatty acids (P<0.05) and high density lipoprotein cholesterol levels (P<0.05). In those patients reaching normalization of plasma triglyceride levels (triglyceride reduction > or =50%) (n=15), insulin levels (P<0.05) as well as the insulin resistance index were reduced by gemfibrozil treatment, suggesting an improvement of the insulin resistance index in this patient subgroup. Gemfibrozil treatment did not affect plasma fibrinolysis or fibrinogen levels, despite marked reduction of plasma triglycerides and improvement of the insulin sensitivity associated with triglyceride normalization.

Hypertriglyceridemia is associated with increased insulin resistance in subjects with normal glucose tolerance: evaluation in a large cohort of subjects assessed with the 1999 World Health Organization criteria for the classification of diabetes.

The current study retrospectively examined the association between insulin resistance and plasma triglycerides (TG) in a group of subjects with normal glucose tolerance. Among 1,434 subjects consecutively undergoing a standard oral glucose tolerance test (OGTT) between 1993 and 1998, 567 (age, 15 to 78 years) were classified as having a normal glucose tolerance according to the 1999 World Health Organization (WHO) criteria and were selected for the study. Serum insulin was measured by radioimmunoassay (INSI-CTK, Dia Sorin, Saluggia, Italy). Intra-assay and interassay coefficients of variation for the method were less than 4% and less than 8.5%, respectively. Insulin resistance was calculated by a homeostasis model assessment (HOMA(IR) = fasting serum insulin [mU/mL] x fasting blood glucose [mmol/L]/22.5). A very significant correlation was found between HOMA(IR) and plasma TG (r = 0.27, P < 1.02E(-10)). Multiple regression analyses confirmed plasma TG as independent variables explicative of HOMA(IR). When subjects were evaluated according to tertiles of TG, those in the upper two tertiles were older (P <.001) and presented higher body mass index (BMI) values (P <.0001) in comparison to subjects in the lower tertile. A positive trend (analysis of variance [ANOVA]) was found in regard to systolic (P <.05) and diastolic blood pressure (P <.0001), fasting blood glucose (P <.01), fasting serum insulin (P <.0001), and total cholesterol (P <.0001), while a negative trend was found in regard to high-density lipoprotein cholesterol (HDL-C) (P <.0001). Insulin resistance, calculated as HOMA(IR), was higher in the upper two tertiles of TG in comparison to the lower tertile (P <.001 and P <.0001, respectively), with a statistically significant trend for the entire group (first tertile, 1.85 +/- 0.94; second tertile, 2.28 +/- 1.10; third tertile, 2.65 +/- 1.71; ANOVA: P <.0001). In conclusion, this study shows an association between high levels of circulating TG and insulin resistance in patients with normal glucose tolerance seen in an atherosclerosis prevention clinic. This association is also present at levels of plasma TG considered to be normal and is associated with a cluster of cardiovascular risk factors.

Effects of acetylsalicylic acid and indomethacin on growth hormone secretion in man.

To investigate the possibility that prostaglandins (PG) take part in the control of growth hormone (GH) secretion in humans, we have studied the effects of protracted and acute administration of acetylsalicylic acid (ASA) and indomethacin (ID), two PG synthesis inhibitors, on basal and insulin-stimulated GH secretion in normal volunteers. In eight subjects, oral administration of 3-2 g daily of ASA for 4 days clearly reached GH response to insulin hypoglycemia (p less than 0.01, ANOVA). In six additional subjects, GH response to hypoglycemia was not modified by a 4-day oral treatment with 300 mg daily of ID. The pattern of plasma free fatty acids (FFA) and blood glucose during the insulin tolerance test was not significantly affected by ASA treatment. After ID the O time value of the above parameters was somewhat higher than under basal conditions, while the drop of blood glucose, but not to FFA, was slightly more pronounced. Acute oral administration of 1.5 g ASA in 12 subjects did not appreciably modify baseline plasma GH, FFA, and blood glucose levels. By contrast, a single oral dose of 100 mg ID in 12 subjects caused a moderate but significant rise (p less than 0.05) of plasma GH levels together with a clear elevation (p less than 0.01) of plasma FFA and blood glucose levels with respect to a group of controls treated with a placebo. Collectively these results are compatible with the possibility that PG play a physiologic stimulating role in the control of GH secretion, although an effect of ASA and ID unrelated to PG inhibition cannot be ruled out, In any event, in view of the number of endocrine and metabolic alterations induced by ASA and ID, these drugs seem to merit further study.

Physiologic variables affecting thromboxane B2 production in human whole blood.

Thrombin-induced thromboxane (TX) A2 production in whole blood, as reflected by serum TXB2 measurements, has proven to be a simple and reproducible capacity-related index of platelet TXA2 production ex vivo. In the present study we have determined the influence of a number of physiologic variables on serum TXB2 measurements performed by radioimmunoassay in a group of 177 subjects undergoing evaluation for atherosclerosis risk factors. Serum TXB2 averaged 300 +/- 108 ng/ml in the whole group, with a normal distribution. No statistically significant correlation was found between serum TXB2 and the continuous variables examined (age, BMI, blood pressure, cigarettes, serum cholesterol, triglyceride, glucose and wine consumption) except for the number of platelets. Platelet TXB2 production did not differ between men and women (296 +/- 119 vs 302 +/- 100 ng/ml). We conclude that, within the limits of the examined variables, serum TXB2 is an easily measurable and highly reproducible capacity index primarily related to platelet cyclooxygenase and TX-synthase activity, which can be used for monitoring drug- or disease-induced changes of these enzyme activities.

Gastric duplication communicating with an aberrant pancreas.

A case of gastric duplication in connection with an aberrant pancreas in a 14 months old boy is related. The non-specificity of signs and symptoms explains why the diagnosis of these lesions has been often mislead and usually made at laparotomy. Ultrasound and technetium scan could adequately characterize these anomalies pre-operatively. Simple excision is the treatment of choice.

[Abdominal cystic lymphangiomas in children. Clinical, diagnostic and therapeutic aspects: apropos of 21 cases]. / Les lymphangiomes kystiques abdominaux de l'enfant. Aspects cliniques, diagnostiques et thérapeutiques: à propos de 21 observations.

Twenty-one abdominal cystic lymphangiomas were observed in paediatric patients during a 15-year period, in 11 boys and 10 girls. Diagnosis was prenatal in 2 cases; the mean age of the other 19 children was 4.7 years (range: 3 months-8 years). Tumours were intraperitoneal in 16 cases and retroperitoneal in 5 cases. Symptoms were variable: abdominal pain in 15 cases, palpable tumour in 6 cases (excluding the two cases of prenatal diagnosis). Complications included obstruction in 7 cases (including 3 by volvulus), infection in 6 cases, and intracystic haemorrhage in 3 cases. Abdominal ultrasonography correctly established the diagnosis in all children. Surgical treatment included 20 complete resections and one incomplete resection, including 6 with bowel resections. With a follow-up ranging from 6 months to 10 years, one recurrence occurred and was successfully reoperated. Intraabdominal cystic lymphangioma in childhood is a rare tumour with a variable presentation. An accurate diagnosis can be established by abdominal ultrasound. Complete resection should be performed whenever possible.

[Tumorlike form of bladder schistosomiasis in children]. / Forme pseudotumorale de bilharziose vésicale de l'enfant: à propos de 2 observations récentes.

Two tumorlike forms of urinary schistosomiasis are reported. Diagnosis was suspected as the patients exerted haematuria while they originated from a geographic area where schistosomiasis is endemic. Terminal urine samples were positive for Schistosoma haematobium. Cystoscopy revealed an hemorrhagic granulomatous polyp in one case and villous polyps in the other case, associated with suggestive lesions of schistosomiasis. Schistosoma haematobium infection in children is uncommon in Europe and rarely considered in the diagnosis of haematuria.

[Bilateral vas deferens agenesis and inguinal hernia in a child. A rare, early presentation of cystic fibrosis]. / Agénésie déférentielle bilatérale et hernie inguinale chez un enfant. Une présentation précoce rare de la mucoviscidose.

UNLABELLED: Epididymal and ductal anomalies can be discovered incidentally during inguinal herniorraphy in children. The congenital bilateral absence of vas deferens is frequently associated with cystic fibrosis. CASE REPORT: This agenesia of vas deferens was detected in a 5-month-old boy who underwent an inguinal herniorraphy. Although the child did not present any symptoms, he actually presented cystic fibrosis: the sudoral test showed high levels of chloride (95 mmol/L) and an isolated homozygous delta F 508 deletion on the gene CFTR was evidenced on genetic investigations. CONCLUSION: The congenital bilateral absence of vas deferens is the most frequent anomaly of the male genital tract discovered in adults investigated for azoospermia. Relations with cystic fibrosis are well established but congenital bilateral absence of vas deferens discovered during infancy is an exceptional situation that requires genetic investigations to show evidence of a likely underlying cystic fibrosis.