Operative versus conservative treatment for giant omphalocele: Study of French and Ivorian management.

INTRODUCTION: The giant omphalocele is currently a surgical challenge. The morbidity and mortality associated with its care is non-negligible. Nowadays, different studies have revived the debate between conservative and surgical management for giant omphalocele. The purpose of this study is to compare the conservative and surgical management of the giant omphalocele in terms of morbidity and mortality. METHODS: Retrospective study including all giant omphaloceles comparing surgical management (French University hospital centers) and tanning (Ivory Coast University hospital center). Epidemiology was studied as well as medical and surgical managements both intra and post operative. RESULTS: One hundred and forty-seven patients included (98 patients in the "tanning" group and 49 in the "surgery" group). Hospital length of stay is significantly shorter in the "tanning" group as they do not spend time in intensive care unit. Morbidity is higher in "surgery" group. The average duration for oral empowerment was acquired at 179 days in the "surgery" group, whereas in the "tanning" group 90% was immediately and exclusively breastfed. No significant differences in terms of epithelialization time. CONCLUSION: The tanning treatment has its own place in the therapeutic arsenal in the management of the giant omphalocele no matter where it takes place. However, its realization in surgical environments prevents certain complications related to the technique or the pathology.

A systematic review of the learning curve in robotic surgery: range and heterogeneity.

BACKGROUND: With the rapid adoption of the robotic surgery, more and more learning curve (LC) papers are being published but there is no set definition of what should constitute a rigorous analysis and represent a true LC. A systematic review of the robotic surgical literature was undertaken to determine the range and heterogeneity of parameters reported in studies assessing the LC in robotic surgery. METHODS: The search was conducted in July 2017 in PubMed. All studies reporting a LC in robotic surgery were included. 268 (25%) of the identified studies met the inclusion criteria. RESULTS: 102 (38%) studies did not define nor explicitly state the LC with appropriate evidence; 166 studies were considered for quantitative analysis. 46 different parameters of 6 different outcome domains were reported with a median of two parameters (1-8) and 1 domain (1-5) per study. Overall, three domains were only technical and three domains were both technical and clinical/patient-centered outcomes. The two most commonly reported domains were operative time [146 studies (88%)] and intraoperative outcomes [31 studies (19%)]. Postoperative outcomes [16 studies (9%)] and surgical success [11 studies (7%)] were reported infrequently. Purely technical outcomes were the most frequently used to assess LC [131 studies (79%)]. CONCLUSIONS: The outcomes reported in studies assessing LC in robotic surgery are extremely heterogeneous and are most often technical indicators of surgical performance rather than clinical and patient-centered outcomes. There is no single outcome that best represents the surgical success. A standardized multi-outcome approach to assessing LC is recommended.

In-utero aspiration vs expectant management of anechoic fetal ovarian cysts: open randomized controlled trial.

OBJECTIVE: To assess the efficacy and safety of in-utero aspiration (IUA) of anechoic fetal ovarian cysts. METHODS: This multicenter, prospective, randomized open trial in two parallel groups included women from nine outpatient fetal medicine departments with singleton pregnancy ≥ 28 weeks of gestation and a female fetus with an ultrasound-diagnosed simple ovarian cyst, defined as a single fully anechoic cystic structure measuring ≥ 30 mm. They were allocated randomly to IUA under ultrasound guidance or expectant management. All procedures were performed by trained senior obstetricians. Primary outcome was need for neonatal intervention, by laparoscopy, laparotomy or transabdominal aspiration. Secondary outcomes were in-utero involution of the cyst and oophorectomy at birth. Analyses were conducted according to the intention-to-treat principle. RESULTS: Of 61 participants, 34 were allocated to IUA and 27 to expectant management. Three IUA procedures (9%) could not be performed (one due to fetal position and two due to aspirations being dry). The remaining 31 IUA procedures were uneventful. The incidence of neonatal intervention did not differ significantly between the IUA and the expectant management groups (20.6% vs 37.0%; relative risk (RR), 0.55; 95% CI, 0.24-1.27). Nonetheless, IUA was associated with increased incidence of in-utero involution of the cyst (47.1% vs 18.5%; RR, 2.54; 95% CI, 1.07-6.05) and reduced rate of oophorectomy (3.0% vs 22.0%; RR, 0.13; 95% CI, 0.02-1.03) compared with expectant management. CONCLUSION: IUA of anechoic fetal ovarian cysts, compared with expectant management, was not associated with a reduction in overall neonatal interventions but was associated with a reduced oophorectomy rate. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Laparoscopic pyloromyotomy for hypertrophic pyloric stenosis: a survey of 407 children.

INTRODUCTION: Pyloromyotomy is the standard care for hypertrophic pyloric stenosis. The traditional approach for this procedure is a right upper quadrant transverse incision, although other "open" approaches, such as circumumbilical or periumbilical incision have been described. The more recent approach used is laparoscopic pyloromyotomy (LP), but experience feedback is still debated and its benefits remain unproven. The aim of this study was to make a review of all our LP procedures with an objective evaluation according to the literature. METHODS: A retrospective analysis of all the LPs performed in one University Children's Hospital between 1 January 1996, and 30 December 2015 was realized. Information regarding the patient's status, intraoperative and postoperative data was analyzed. RESULTS: 407 patients were included in this study. The mean operative time of the overall procedure was 24 ± 13 min, which significantly increased with the length of the pyloric muscle (p = 0.004) and significantly impacted the full feeding time (p = 0.006). 3.4% required conversion to an open procedure during the LP. We observed a significant correlation between conversion for mucosal perforation and weight loss (p = 0.04) and between conversion for mucosal perforation and preoperative weight (p = 0.002). A redo procedure was indicated in 3.7%, for incomplete pyloromyotomy each time. The mean postoperative hospital length of stay for all procedures was 1.6 ± 0.8 days. There were no inflammatory scars. None had incisional hernias or wound dehiscence. DISCUSSION: LP procedure appeared to be as quick as the open procedure. Our results were similar to others series for intraoperative complications. According to operative time, this technique does not have an impact on operative room utilization. Vomiting duration at presentation in HPS does not seem to have a significant impact on postoperative outcomes. LP procedure causes little pain during the postoperative period. No wound complications were registered.

Fetal median sacral artery anatomy study by micro-CT imaging.

PURPOSE: The median sacral artery (MSA) is the termination of the dorsal aorta, which undergoes a complex regression and remodeling process during embryo and fetal development. The MSA contributes to the pelvic vascularization and may be injured during pelvic surgery. The embryological steps of MSA development, anastomosis formation and anatomical variations are linked, but not fully understood. METHODS: The pelvic vascularization and more precisely the MSA of a human fetus at 22 weeks of gestation (GW) were studied using micro-CT imaging. Image treatment included arterial segmentations and 3D visualization. RESULTS: At 22 GW, the MSA was a well-developed straight artery in front of the sacrum and was longer than the abdominal aorta. Anastomoses between the MSA and the internal pudendal arteries and the superior rectal artery were detected. No evidence was found for the existence of a coccygeal glomus with arteriovenous anastomosis. CONCLUSIONS: Micro-CT imaging and 3D visualization helped us understand the MSA central role in pelvic vascularization through the ilio-aortic anastomotic system. It is essential to know this anastomotic network to treat pathological conditions, such as sacrococcygeal teratomas and parasitic ischiopagus twins (for instance, fetus in fetu and twin-reversed arterial perfusion sequence).

[Tissue expansion in children: Indications and management of complications. A 10-year experience]. / L'expansion cutanée chez l'enfant : indications et gestion des complications. Notre expérience sur 10 ans.

INTRODUCTION: Tissue expansion is a plastic surgery technique which enables optimal quality and skin surface reconstruction in case of soft tissue defect. Despite the good results obtained, both from a functional and aesthetic point of view, there is a high rate of complications whose management seems to be essential to ensure satisfactory results. PATIENTS AND METHODS: We retrospectively reviewed the medical files of 45 children treated in our department between 2002 and 2012: 73 expanders were placed during 51 protocols. RESULTS: The studied protocols gathered a large variety of situations. Varied pathologies were treated: burn sequelae (39 %), giant congenital naevus (GCN) (27 %), scars (20 %), hamartoms (8 %), cutis aplasia (6 %), as well as diverse sites: scalp (45 %), trunk (35 %), head and neck (8 %), lower extremity (8 %), upper extremity (4 %). Complications occurred in 17 protocols representing 26 % of total expanders. GCN is a pathology with a significantly lower complication rate (P=0.013) whereas trunk is an anatomical location with a significantly higher complication rate (P=0.026). Overall, 84 % of reconstructions were evaluated as having a good result. This rate reached 76 % for complicated protocols. CONCLUSION: Tissue expansion in paediatric patients remains an efficient therapy in order to achieve a satisfactory reconstruction. Despite a high complication rate, good results can be obtained even in those complicated cases as long as they are well managed and anticipated. We also think that specific paediatric material would help to reduce supervention of some complications.

[Tissue expansion in management of giant omphalocele parietal sequelae]. / Place de l'expansion cutanée dans le traitement des séquelles pariétales des omphalocèles géantes.

OBJECTIVE: According to major difficulty for the giant omphalocele management in the visceral reintegration and the parietal closure, many teams use currently conservative treatment by topical application. These techniques are suppliers of a covered eventration and a scar sequela requiring a complementary treatment. We report the place of the tissue expansion as complementary treatment. PATIENTS AND METHODS: Two patients with a giant omphalocele benefited from a protocol of cutaneous expansion for the correction of their abdominal scar±of their residual eventration. RESULTS: An eventration closure was possible thanks to this protocol. The skin expansion allowed the complete excision of the abdominal scar and the defect cover. An additional skin graft was necessary in the first case. CONCLUSION: The cutaneous expansion in the parietal sequela management of the giant omphaloceles seems to be an interesting alternative. This technique should be realized remotely and except any septic context.

High pressure balloon dilatation of the ureterovesical junction in primary obstructive megaureter: Infectious morbidity.

INTRODUCTION: The objective of this study is to investigate the infectious morbidity associated with high-pressure balloon dilatation (HPBD) and an indwelling double J stent, in primary obstructive megaureter. METHODS: We reviewed the cases of 12 patients undergoing endoscopic treatment for primary obstructive megaureter from January 2012 to January 2015. The characteristics of the infection and data concerning the patient and the intervention were analyzed. RESULTS: The frequency of preoperative urinary tract infection (UTI) was 58%. The procedure was feasible in 100% of cases. Two patients required a second dilatation. One patient underwent Cohen's ureteral reimplantation after failure of the second dilatation. The frequency of postoperative UTI was 25%. All these infections occurred in patients with a double J stent. None of the patients had UTI after stent removal. None of the patients developed postoperative vesicoureteral reflux (VUR) after HPBD. CONCLUSION: Endoscopic balloon dilatation has been shown to have good short- mid- and long-term outcomes. In our experience, the morbidity of this procedure mostly results from infections, exclusively related to the use of a double J stent. The placement of a double J stent has a significant medical and economic impact. A definitive decision about the utility of double J stents will require studies of further dilatation without the placement of a double J stent. LEVEL OF EVIDENCE: 4.

[Imaging of anorectal malformations in the neonatal period]. / Imagerie des malformations anorectales en période néonatale.

PURPOSE: The classification of anorectal malformations (ARM) as high or low is based on clinical and anatomical characteristics. It has an impact on the surgical management but also on the functional prognosis. In the absence of consensus, our goal was to determine the value of imaging in the neonatal period for diagnosis and management of infants with ARM. MATERIALS AND METHODS: Retrospective study of 43 infants imaged over a 9 year period. The different imaging studies (abdominal and pelvic ultrasound, radiographs, percutaneous opacifications and fistulograms) performed for each infant were collected and analyzed then correlated to clinical and surgical findings. RESULTS: Clinical evaluation could classify 30 ARM as low and 4 ARM as high while 9 ARM without fistula remained indeterminate. Imaging findings were mixed: on ultrasound, the rectal cul-de-sac to perineum distance did not appear to be determinant, contrary to published data. Pelvimetry showed limitations, irrespective of the technique. Morphological evaluation provided the following data: presence of fistula, sphincter anatomy, rectal cul-de-sac to perineum distance. CONCLUSION: Classification relies on clinical evaluation in most cases. Opacification techniques and ultrasound remain useful in some cases. MRI could become the preferred imaging modality.

Weight-for-height Z-score improves in half of undernourished children hospitalized in surgical wards.

BACKGROUND: Overall, 10-15% of hospitalized children are undernourished. The present study focuses on pediatric surgical wards. We assessed the impact of undernutrition upon admission on the weight-for-height Z-score (Z-WFH) during hospitalization for surgery. Secondary aims were to investigate the influence of associated factors and to report on the use of nutritional support. METHODS: All children hospitalized for a surgical procedure between July 2015 and March 2016 were included in this monocentric, prospective study. Children were divided into two groups: whether the Z-WFH upon admission was below -2 standard deviations (undernourished) or not (not undernourished). RESULTS: A total of 161 of 278 eligible children were included; 27 were undernourished (17%). The change in Z-WFH during hospitalization was greater in undernourished children (0.31±0.11 vs. -0.05±0.05, P=0.005). Of undernourished children, 49% recovered a Z-WFH above -2 SD during hospitalization. There was no difference between undernourished children and not undernourished children regarding age, length of hospital stay, pre- and post-operative duration of nil per os, duration of surgical procedure, ASA score, emergency level of the surgical procedure, and enteral/parenteral nutrition. CONCLUSION: Our data suggest that the Z-WFH of undernourished children upon admission improved during hospitalization.

Carbohydrate supply as a regulator of rat liver phosphoenolpyruvate carboxykinase activity.

Administration of glucose, fructose, and glycerol to fasted rats produced a significant depression of liver phosphoenolpyruvate carboxykinase activity within 4 to 8 hours; galactose and ribose were much less effective. All the compounds yielded appreciable quantities of liver glycogen. The depression of phosphoenolpyruvate carboxykinase activity by glucose and glycerol was diminished by the concomitant administration of 2-deoxyglucose. The latter depressed glycogen formation from administered carbohydrate in muscle but not in liver. In rats made diabetic by alloxan, depression of elevated phosphoenolpyruvate carboxykinase activity by insulin was dependent upon a dietary source of carbohydrate. These results were interpreted to indicate that depression of certain gluconeogenic enzymes after carbohydrate ingestion is initiated by the metabolism of carbohydrate in some extrahepatic site.

Inhibition of phosphofructokinase by quinone methide and alpha-methylene lactone tumor inhibitors.

The plant-derived tumor inhibitors taxodone, taxodione, vernolepin, eupacunin, and euparotin acetate each inhibit the sulfhydryl enzyme, phosphofructokinase. The substrates, fructose-6-phosphate and adenosine triphosphate, protect the enzyme from this, inhibition as does the addition of dithiothreitol to the inhibitors. Incubation of taxodione with phosphofructokinase is associated with the loss of about one sulfhydryl group per inhibitor molecule, and the substrates protect six sulfhydryl groups per protomer of 93,000 daltons.

Compressive chylothorax after lumbar spine fracture.

A 14-year-old boy was admitted to the hospital after an episode of blunt trauma to the thorax, resulting in a Chance fracture of L1 and a compressive chylothorax 72h after admission. After initial drainage in the operating room, conservative management was successful. This case study documents one of the rare complications of spinal fractures in the context of high-energy blunt trauma. It is the first detailing a noniatrogenic post-traumatic compressive chylothorax in pediatrics responding positively to conservative management. Drainage should be considered the first-line procedure for both therapeutic and diagnostic purposes. Surgery is required if the leakage is still present after parenteral feeding and the implementation of a fat-free diet for 5-7 days.

[Prenatal spontaneous closure of gastroschisis: a paradoxal evolution with poor outcome]. / Disparition prénatale spontanée d'un laparoschisis: une évolution de mauvais pronostic.

Usually considered as an isolated malformation carrying a rather good postnatal prognosis, gastroschisis may however occasionally bear an unfavourable outcome despite reassuring ultrasound follow-up. We report on the case of a fetus with gastroschisis diagnosed at 13 weeks of gestation followed by a progressive bowel absorption and closure of the abdominal defect at 24 weeks, associated with a 10 to 15mm intra-abdominal bowel tract dilatation. At birth, the infant did not show any recognizable ventral wall defect or scar. Surgical exploration was decided due to the presence of a high level bowel tract occlusion associated with a dilated proximal jejunum on standard abdominal X-ray radiograph. Long-segment atresia of the midintestine without any possible surgical option was observed. The infant died at day 5.

The learning curve of robot-assisted laparoscopic pyeloplasty in children: a multi-outcome approach.

INTRODUCTION: Few studies have evaluated the learning curve (LC) for robot-assisted laparoscopic pyeloplasty (RALP) for ureteropelvic junction obstruction in children. It was attempted to assess the LC of this procedure using a multi-outcome approach, accounting for patient complexity. MATERIAL AND METHODS: Data on the first series of children undergoing RALP between November 2007 and December 2017 at the study institution were prospectively collected. Patient complexity factors and peri-operative data including operative time (OT) were retrospectively analyzed. The LC was analyzed using cumulative sum (CUSUM) methodology for OT and a composite parameter (combination of 3 parameters: OT adjusted for patient complexity factors (AOT), complications, and surgical success). RESULTS: Two surgeons without any experience in robotic surgery performed 42 consecutive RALP in 41 patients. Median age at surgery was 5 years (6 months-15 years), and mean OT was 200 ± 72.8 min. Cumulative sum chart demonstrated biphasic LC for OT and multiphasic LC for composite factor. Based on the CUSUM analysis for composite outcome, the LC for RALP could be divided into three different phases: phase 1, the learning period (1-12 cases); phase 2, the consolidation period (13-22 cases); and phase 3, representing the period of increased competence (23-39 cases). Interphase comparison showed a significant reduction in OT, length of stay, and postoperative pain (P = 0.0001; P = 0.0076; P = 0.039, respectively) CONCLUSION: Numerous distinctly shaped LCs depending on the outcome measures and well-defined learning phase transition points were demonstrated. Patient complexity factors were accounted for, which can influence surgical outcomes. Because there is no perfect indicator of proficiency, a multi-outcome approach was adopted to provide a comprehensive view of the learning process for RALP. More than 41 cases are needed to achieve mastery.

Robotic-assisted laparoscopic surgery for pediatric tumors: a bicenter experience.

Mini-invasive surgery is more and more integrated in pediatric surgery. The robotic-assisted surgery brought new advantages from which the patient and the surgeon could benefit compared to laparoscopy. Its use in oncological surgery is still controversial. 12 robotic-assisted tumor resections with the da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA) were attempted in 11 children (mean age 7.65 years; age range 0.75-16.75 years; mean weight 30.3 kg; weight range 8.6-62 kg) in two centers. Mean total operative time was 145 min (range 72-263 min). 1 procedure (8.3%) was converted. The pathology included renal tumors (n = 2; one nephroblastoma, one metanephric adenoma), adrenal tumors (n = 9; three neuroblastomas, two pheochromocytomas, two adrenocortical adenomas, one cystic lymphangioma, one paraganglioma) and a pancreatic tumor (n = 1; one pancreatic cyst). 4 tumors (33.3%) were malignant. Every patient underwent a R0 resection. 1 child (8.3%) developed a post operative complication. Mean length of hospitalization was 3.0 days (range 2-5 days). Followup averaged 3.3 years with no recurrence. All children are alive. Robot-assisted MIS seems to be safe and feasible in pediatric tumors. The oncological surgical principles were respected in our series with low morbi/mortality and good long-term results. Robotic surgery and its technical advantages bring potential benefits for children with cancer. It has a role to play in pediatric oncological surgery but its place and indications still need to be better defined.

The position of a written document in preoperative information for pediatric surgery: A randomized controlled trial on parental anxiety, knowledge, and satisfaction.

INTRODUCTION: Preoperative information is a legal and ethical obligation. Very little studies have evaluated the preoperative information method in pediatrics. Having a child operated on is stressful for the parents. Improving information is a way to lower their anxiety. Our study aims to measure the impact of a leaflet, which supports spoken information on parental anxiety, the comprehension-memorization of the information and their satisfaction. MATERIALS & METHODS: Prospective study including 178 patients of outpatient surgery, randomized in two groups: spoken information versus spoken information supported by a leaflet, which is then handed out to the parents. The messages were identical: physiopathology, risks without treatment, surgical technique and its possible complications, description of the hospitalization day, and postoperative care. Parental evaluation was made with self-questionnaires after the preoperative consultation, then on the day of surgery. At each moment we evaluated the level of anxiety, satisfaction of information quality and the comprehension-memorization of the data. RESULTS: Written information significantly improves the scores of comprehension-memorization, parental satisfaction and significantly decreases the level of anxiety. CONCLUSION: Significant impact of the written document as communication support in pediatric surgery, validating the method and encouraging it to be generalized to other pediatric surgery acts. LEVEL OF EVIDENCE: Level I. TYPE OF STUDY: Prognosis study.

Enzymatic adaptation to physical training under beta-blockade in the rat. Evidence of a beta 2-adrenergic mechanism in skeletal muscle.

Nonselective and beta 1-selective adrenergic antagonists were tested for their effects on enzymatic adaptation to exercise training in rats as follows: trained + placebo (TC); trained + propranolol (TP); trained + atenolol (TA); and corresponding sedentary groups, SC and SP. Trained rats ran 1 h/d at 26.8 m/min, 15% grade, 5 d/wk, 10 wk. Both beta-antagonists were given at doses that decreased exercise heart rates by 25%. Training increased skeletal muscle citrate synthase, cytochrome c oxidase (Cyt-Ox), carnitine palmitoyltransferase (CPT), beta-hydroxyacyl coenzyme A dehydrogenase, mitochondrial malate dehydrogenase (MDH), and alanine aminotransferase (ALT) activities significantly in the TC group, but not in TP. These enzyme activities, except Cyt-Ox and CPT, were also significantly increased in TA. Hepatic phosphoenolpyruvate carboxykinase activity did not alter with training or beta-blockade. Fructose 1,6-bisphosphatase activity was lower in TC than in SC, but unchanged in TP or TA. Hepatic mitochondrial MDH and ALT activities increased with training only in TC. It is concluded that beta 2-adrenergic mechanisms play an essential role in the training-induced enzymatic adaptation in skeletal muscle.

[Acquired non hypertrophic pyloric stenosis in children]. / Sténose acquise non hypertrophique du pylore chez l'enfant.

UNLABELLED: Pediatric non hypertrophic pyloric stenosis (NHPS) are uncommon. Their causes and treatments are debated. MATERIAL AND METHOD: Retrospective review of all cases of NHPS from 3 pediatric surgery services during the period 1984-2002. RESULTS: Six children, aged 17 months to 15 years, underwent surgery for NHPS. Clinical symptoms, food vomiting and loss of weight, were present for several weeks before the diagnosis of NHPS was made. The diagnosis was peptic stenosis in 3 cases and has not been established in 3 cases. Search for Helicobacter pylori was negative in all cases. Failure of specific medical treatment and endoscopic dilatations led to pyloric resection in 3 cases and pyloroplasty in 3 cases. Post operative course was uneventful with normal oral feeding and normalisation of weight status. Histologic data were aspecific. No recurrence was observed. DISCUSSION: We discuss the origin of the pyloric stenosis, regarding clinical, operative and pathological data: were the stenosis the cause or consequence of peptic ulcer? Peptic disease is always advocated, but difficult to prove and may be excessively incriminated. Late symptomatic congenital and acquired idiopathic pyloric stenosis should be recalled. In all cases of proved pyloric stenosis, after failure of medical and endoscopic treatment, a simple surgical procedure (pyloroplasty) associated with medical treatment seems to be effective. CONCLUSION: The diagnosis of NHPS should be suspected in a child with food vomiting and loss of weight if his age is not concordant with hypertrophic pyloric stenosis. Upper gastro-intestinal series and endoscopy are diagnostic. The precise cause of the stenosis is more difficult to asses. When the medical treatment fails, a pyloroplasty is usually curative.