Self extrusion on an ingested foreign body: a case report.

Foreign body ingestion is a frequent issue in paediatrician's practice. Foreign bodies often pass the gastro-intestinal tract spontaneously but can sometimes generate complications (1% of the cases). The migration of ingested foreign bodies is rare, but their spontaneous extrusion through the skin is even rarer and was previously described only in the neck. We report an unusual case of a spontaneous extrusion of an ingested foreign body through the skin of the lower abdomen. Observation: A 2 year-old boy, presented with a 2cm inflammatory swelling of the hypogastric region. Laboratory analysis showed hyperleukocytosis (16 7770 /mm3) and high C reactive protein level at 12mg/L. Ultrasonography and computed tomography allowed us to diagnose a parietal foreign body extruding through the skin and to eliminate associated complication (perforation, vascular fistula…). The foreign body was extracted by a surgical incision. This observation is very rare but it is also uncommon because of the nature of the ingested foreign body which was a wooden piece. Its ingestion was explained by a paediatric mental disorder.

A case report of multiple foreign body ingestion with a ring-like configuration: The magnetic effect.

INTRODUCTION: Magnetic foreign body (FB) ingestion represents a significant health hazard among children. The increasing use of small attractive magnets as toys or parts of various household accessories makes it easily accessible to children. The aim of this report is to raise awareness of public authorities and parents around exposing children to magnetic toys. CASE PRESENTATION: We report a case of multiple FB ingestion in a 3-year-old child. Radiological imaging revealed multiple round objects arranged in a circular shape resembling a ring. Surgical exploration showed multiple intestinal perforations attributed to the magnetic attraction between the objects. CLINICAL DISCUSSION: Although more than 99 % of ingested FB pass without surgical intervention, ingestion of multiple magnetic FB provides a substantially higher risk of injury due to self-association and therefore requires a more aggressive clinical approach. A stable or clinically benign condition, though common, does not necessarily mean a safe situation in the abdomen. Literature review suggests that emergency surgical intervention should be pursued to avoid potentially life-threatening complications; perforation and peritonitis. CONCLUSION: Multiple magnet ingestion is rare, but can result in serious complications. We recommend early surgical intervention before gastrointestinal complications develop.

Liver injuries in children: the role of selective non-operative management.

BACKGROUND: Trauma remains the leading cause of mortality in the pediatric population. Liver injuries occur commonly in blunt abdominal trauma. AIM: To assess the selective non-operative management of liver injuries in children. METHODS: A retrospective review of 51 patients with a discharge diagnosis of traumatic liver injuries at Tunis Children's Hospital, over a 14-year period from 1996 to 2009. RESULTS: We identified 51 patients with liver trauma. The median age was 7 years. Boys accounted for 58% (n= 30), and the most common cause was traffic accident. Head injuries were the most common associated injuries. Forty-nine patients (96%) required non-operative management without complications. The mean in-hospital stay was 10 days in this group. The ultrasound demonstrated complete resolution and healing after 3-6 months. Two patients underwent surgery for hemodynamic instability. The mortality rate was 0.2 %. CONCLUSION: Safe, non-operative management involves careful serial examination, a CT scanning facility and close monitoring of the patient in a fully equipped high-dependency unit with trained staff to run it. Even though most patients can be treated non-operatively the challenge is to identify the severely injured child early and institute aggressive resuscitation and expedite laparotomy.

[Acute gastric volvulus complicating congenital diaphragmatic hernia in a 3-month-old infant: a case report]. / Volvulus gastrique aigu compliquant une hernie diaphragmatique congénitale chez un nourrisson de 3 mois: à propos d'un cas.

Gastric volvulus is a rare mode of revelation of congenital diaphragmatic hernia. This is an uncommon condition that may be difficult to diagnose in the paediatric population. We here report the case of a three-month-old infant presenting with a rapid worsening of acute dyspnoea. Chest X-ray showed image clarity and ascending gastric air sac. Thoraco-abdominal CT scan showed gastric volvulus complicating left congenital diaphragmatic hernia. Surgical treatment consisted of gastric devolvulation followed by complete reduction of the herniated viscera and closure of the diaphragmatic defect. Patient´s outcome was favourable. Congenital diaphragmatic hernia complicated by gastric volvulus should be considered as a diagnostic and therapeutic emergency due to the risk of life-threatening gastric necrosis.

Persistent omphalomesenteric duct causing small bowel obstruction in children.

BACKGROUND: Small bowel obstruction is a common surgical emergency and a frequently encountered problem in abdominal surgery, but persistent omphalomesenteric duct as a cause of this condition is an exceptional finding. AIM: To report through this observation an omphalomesenteric duct causing small bowel obstruction in children. REPORT: A 10-years-old male patient without medical history, and specially without umbilical secretion or umbilicoileal fistula, presented with colicky abdominal pain, vomiting, absence of passage of gas and feces, and abdominal distension of 24 hours duration. Physical examination and blood tests were normal. Abdominal X-ray showed small bowel obstruction. In exploratory laparotomy, persistent omphalomesenteric duct (10cm) causing volvulus of small bowel was identified and resected. The patient had an uneventful recovery and was discharged on the 5th postoperative day. CONCLUSION: Although persistent omphalomesenteric duct is an extremely infrequent cause of small bowel obstruction in children patients. The practitioner has to think of this etiology in front of every patient without surgical histories presenting an occlusive syndrome to avoid the complications: occlusion and hemorrhage.

Volvulus of the small intestine associated with left paraduodenal hernia: a case report.

AIM: To report a rare case of a left paraduodenal hernia presenting as volvulus of the small intestine associated to an intestinal malrotation. CASE REPORT: A 2 months-old girl presented with history of bilious vomiting, sonography showed signs of volvulus and emergency laparotomy was performed and confirmed left paraduodenal hernia containing a part of the ileon, coecum with right colon and volvulus of the small intestine out of the hernia sac. CONCLUSION: Paraduodenal hernia is an uncommon cause of small bowel volvulus. It can be suspected by clinical and radiological findings, surgery is always required to prevent small bowel necrosis and to repair the defect.

Management of perineal ectopic testes.

BACKGROUND: Perineal ectopic testis (PET) is a rare congenital anomaly in which the testis is abnormally situated between the penoscrotal raphe and the genitofemoral fold. AIM: we report six patients treated for PET. The epidemiological, clinical, radiological and therapeutic aspects of this rare entity are discussed in light of data of the literature. RESULTS: Between 2000 and 2009, six patients (0, 2%) treated for PET were diagnosed among 2156 patients operated upon for undescended testes in unity of paediatric surgery in Tunis children's hospital. The mean age was 21+/- 25 months. The abnormality was associated with an inguinal hernia in two cases. The diagnosis was based on the presence of an empty scrotum or perineal swelling. In all, orchidopexy in a dartos pouch was easily performed through an inguinal skin crease incision.The length of the testicular vessels and vas deferens was adequate with a favourable course in every case. Although the complications of undescended testes are the same as for PET, the timing of surgery should be different. CONCLUSION: It is generally accepted that children must not be below 6 months of age for surgical correction of undescended testes, but there is no need to delay surgery in PET, which can easily be diagnosed by physical examination in the neonatal period. Surgery is indicated even if there is no hernia present. The functional prognosis, always difficult to define, appears to be identical to that of other sites.

Congenital salivary gland anlage tumor of the nasopharynx.

Nasal and upper respiratory tract obstruction in the neonatal period can result from a variety of conditions, and may be present with variable symptoms. Salivary gland anlage tumor, also referred as congenital pleomorphic adenoma, is a very rare benign congenital tumor of the nasopharynx, which may produce nasal obstruction and other associated, nonspecific symptoms. We report a case of congenital salivary gland anlage tumor causing a severe neonatal respiratory distress with pulmonary hypertension. The tumor was removed and the outcome was favourable without recurrence at five years of the follow up.

Indications for nephrectomy in children: what has changed?

BACKGROUND: The last decade has witnessed significant refinements in preoperative diagnostic evaluation and an improvement in surgical techniques and postoperative management for paediatric patients. There has been an improvement in our understanding of the natural history of some congenital renal anomalies which has caused some changes in management approach. AIM: To review the indications for nephrectomy in children between 1996 and 2008, at the departement of paediatric surgery, children's hospital in Tunis. METHODS: There were 80 nephrectomies. A retrospective review of the patients' notes was performed. The 13-year period was divided into two halves (1996-2000 and 2001-2008) which were then compared. RESULTS: The total number of nephrectomies per year significantly increased over the period of the study (4, 6 and 8 nephrectomies per year for 1996-2000 and 2001-2008, respectively; P < 0.05), as did the number of nephrectomies for Multicystic dysplastic kidney (MCDK) (zero and 5 for 1996-2000 and 2001-2008, respectively) and wilms'tumour (8.3% and 29,16% for 1996 - 2000 and 2001 - 2008, respectively). Wilms' tumour, vesico-ureteric reflux (VUR) and pelvi-ureteric junction (PUJ) obstruction accounted for more than half of the nephrectomies (80% and 58% for 1996-2000 and 2001-2008, respectively). The proportion of nephrectomies performed for VUR did not change (15% and 12% for 1996-2000 and 2001-2008, respectively) but fewer nephrectomies were performed for pelvi-ureteric junction (PUJ) obstruction in the second half of the study period (44% and 4,16% for 1996-2000 and 2001-2008, respectively ; P < 0.05). CONCLUSION: The total number of nephrectomies, including partial nephrectomies, has increased significantly. The decrease in nephrectomies for PUJ obstruction could be accounted for by a more aggressive approach in the management and follow up of prenatally diagnosed hydronephrosis. Of note is that there was no significant change in the proportion of nephrectomies performed for VUR. On the contrary, the proportion of nephrectomies increased for neoplastic lesions and MCDK.

Congenital urethrocele in children. A case report.

INTRODUCTION: Congenital urethrocele is a rare disease in children. The diagnosis is often easy but the management remain difficult due to the risk of urethral stenosis form. CASE PRESENTATION: We report a case of a 19-month-old child presenting with a penoscrotal mass. Cystourethroscopy confirmed the diagnosis of an urethrocele of the anterior urethra. Urethrocele repair was performed with good results. We propose to discuss clinical, paraclinical and therapeutic characteristics of congenital urethrocele in children. CONCLUSION: An early, precise diagnosis and awareness of the anterior urethral diverticulum in boys with obstructive symptoms can reduce incidence of advanced uropathies.

Extra-pulmonary tuberculosis in children: a study of 41 cases.

BACKGROUND: Extrapulmonary tuberculosis accounts for up to one third of all cases of tuberculosis and children show a higher predisposition to the development of extra-pulmonary tuberculosis. AIM: To review the clinical features of the extrapulmonary tuberculosis in children. METHODS: forty one children with extrapulmonary tuberculosis followed in the Children Hospital of Tunis between January 1995 and December 2007 were reviewed. RESULTS: Extrapulmonary tuberculosis constitutes 57.9% of all cases of tuberculosis. Male to female ratio was 0.7 and the mean age was 7.5 years. The most commonly involved sites were the peripheral lymphadenitis (14 cases) followed by abdominal (11 cases), central nervous system (7 cases), osteoarticular (5 cases) and multifocal (4 cases). A positive family history of active tuberculosis was detected in 22.5% of the cases. Diagnosis delay was 4.7 months. Sequelae observed during the follow up were: neurosensory in 5 cases, and vertebral deformation in 1 case. CONCLUSION: extrapulmonary tuberculosis represents an important fraction of tuberculosis in our study. The most common form is lymph nodes localization followed by abdominal and central system nervous forms. Neurosensory sequelae were frequent in central system nervous tuberculosis.

[The adnexal torsion in children]. / La torsion d'annexes chez la petite fille.

BACKGROUND: Adnexal torsion is the most frequent gynaecological emergency in children. It requires an early diagnosis and an urgent surgical treatment. PURPOSE: to study the clinical, paraclinical and therapeutic aspect of adnexal torsion in paediatric population. METHODS: This is a retrospective review of nine girls with the diagnosis of ovarian torsion observed over a 7 years period (January 1999 to December 2005). RESULTS: The average age is 9 years (extreme 6 to 13 years). This pathology was located in 5 cases on the right side and in 3 cases on the left side; a case of bilateral torsion of poly-cystic ovary was encountered in a girl with down syndrome. Clinical presentation is made in all the cases by abdominal pains and vomiting. The disorders of the transit and the urinary signs are associated in 3 and 2 cases respectively, the clinical examination objectified a pelvic defense in all the cases and an abdominal mass in 2 cases. Pelvic ultra-sonography was made in 6 observations and give the diagnosis of torsion of the ovary in 4 cases, whereas it was doubtful in the 2 remaining cases when an ovarian mass was observed. In the 3 remaining cases, this examination was not performed since one the diagnosis of acute appendicitis was retained and the patient operated in emergency. All the children of our series were operated; in 1/3 of the cases we found a necrosis of the ovary. 4 cases out of 9 present a torsion on pathologic ovary (cyst, dysplasia), whereas in the 5 remaining cases, we noted a torsion on healthy ovary. 4 young girls have undergoes a annexectomy, of which one was bilateral. The evolution was favorable in all the cases. CONCLUSION: Adnexal torsion is a surgical emergency that need an early diagnosis and management to preserve ovarian function in girls and Doppler sonography every must be done every time there is a pelvic pain without fever in girls

[Infantile hypertrophic pyloric stenosis. Report of 142 cases]. / La sténose hypertrophique du pylore du nourrisson: a propos de 142 cas.

BACKGROUND: Hypertrophic pyloric stenosis (HPS) is a common condition affecting infants before the first three months of life. AIM: Analysis of our results and comparison with literature to determine particularities of HPS in our country. METHODS: We conducted a retrospective review of 142 patients presenting HPS, between 1990 and 2003. RESULTS: In this study male sex was predominant, with a sex-ratio of 3.8/1. The classical symptom of projectile vomiting was always present, a pyloric tumor was palpated in 19.7% of the cases, metabolic disturbance was noted in 44.3% of patients. The diagnosis was confirmed by ultrasonography and sometimes contrast upper gastrointestinal study. All the infants were treated surgically unless three patients dying before operation, because of a late diagnosis. Postoperative courses were uneventful in 87.4% of cases. Three patients were dead after operation, because of medical complication. CONCLUSION: The cause of HPS is unknown. The diagnosis is suggested by clinic features and confirmed by imaging. Early diagnosis prevents from metabolic complications due to vomiting. Surgical treatment allows early feeding and is associated with a low complication rate and a good long-term outcome.

Concordant posterior urethral valves in male monochorionic twins with secondary prune belly syndrome.

BACKGROUND: Posterior urethral valves (PUVs), the most common congenital cause of lower urinary tract obstruction, have been described to occur in identical and nonidentical twins. Until now, reports have been published on 15 cases of PUVs. AIM: We report a new case of concordant PUVs in one set of male monochorionic twins with secondary Prune Belly Syndrome. CASE REPORT: The twins were born by elective cesarean section at 38 weeks of gestation to a 36-year-old mother, gravida 6, para 6. On ultrasound perfomed at 18 weeks's gestation, both fetuses showed signs of PUVs. At birth, physical examination of both revealed a secondary Prune Belly Syndrome (PBS). Postnatal renal ultrasound confirmed the diagnosis of PUV. The two infants underwent transurethral resection of the valves after a cystoscopic evaluation of the urethra. Since this procedure, their voiding has been unremarkable with stable renal function and sterile urine until their discharge. CONCLUSION: We have documented a rare association between VUP and PBS in two monochiorionic twins. More studies are needed to throw light on the significance of the present associated anomalies.

[To study the safety and effectiveness of heminephroureterectomy by horizontal lumbar posterior approach for duplicated systems in infants]. / Néphro-urétérectomie polaire pour duplication pyélo-urétérale par voie lombaire postérieure chez le nourrisson.

PURPOSE: To study the safety and effectiveness of heminephroureterectomy by horizontal lumbar posterior approach for duplicated systems in infants. MATERIALS AND METHODS: Thirty-three heminephroureterectomies by lumbar posterior approach were performed in 31 infants at a mean age of 6.7 +/- 5.5 months (range: 1 to 26 months) from January 1994 to December 2005. RESULTS: The mean operative time was 121 +/- 35 minutes (range: 60 to 190 minutes). No intra-operative complication was observed. Blood loss was minimal (< 20 ml) in all cases. The mean hospital stay was 4.6 days (range: 2 to 7 days). No postoperative complication (urinoma, infection or haemotoma) occurred. No atrophy or major functional loss of the remaining moiety was observed. The mean follow-up was 52.6 +/- 40 months (range: 1 to 151 months). CONCLUSIONS: The lumbar posterior approach is safe and reproducible and provides an obvious cosmetic benefit in comparison to the standard anterolateral lumbotomy. It represents a procedure of choice for open heminephroureterectomy in infants.