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

To report a rare case of a left paraduodenal hernia presenting as volvulus of the small intestine associated to an intestinal malrotation. 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. 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

Persistent omphalomesenteric duct causing small bowel obstruction in children

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. To report through this observation an omphalomesenteric duct causing small bowel obstruction in children. 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. 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

[Management of blunt duodenal and pancreatic injuries in children [about A series of 8 cases]]

The aim of this retrospective study is to report eight cases of blunt duodeno-pancreatic trauma in infants, emphasizing on the role of imaging in acute assessment of the lesions and in further management. We reported eight cases of duodeno-pancreatic injuries between 2006 and 2008, 5 boys and 3 girls with an age ranging from 3 to 12 years [median age:7 years]. Trauma circumstances were: car accident [n=2], domestic injury [n=5] and bicycle's fall injury [n=1]. All patients underwent abdominal ultrasonography and CT scan in the initial evaluation and during the follow-up. Imaging showed the following pancreatic lesions: 3 corporeal fractures, 2 caudal fractures and one between the corporeal and the caudal portions. Four pancreatic haematomas were found. Two isolated duodenal haematomas were found. Two patients improved spontaneously, the six others developed complications: 4 retroperitoneal collection. Management was chirurgical in one case medical in two cases, endoscopic in 2 cases and three percutaneaous drainages were performed. Blunt duodeno-pancreatic injuries in children have to be evaluated by an early imaging modality, in order to perform acute assessment of the lesions. Primary conservative treatment is advocated while clinic, biologic and imaging follow-up is required to detect complications, which management can be endoscopic percutaneous or surgical

[Interventional endoscopy in the gastrointestinal tract in children]

Interventional endoscopic procedures involving the gastrointestinal [GI] tract in children are very common. Over the last several years the number of procedures in this area has steadily increased. To study indications and results of GI interventional endoscopies performed in a Pediatric GI unit. Retrospective study over a period of 10 years [1999- 2008]. Data were collected from endoscopic files. All procedures were performed endoscopically under general anesthesia. 185 interventional endoscopic procedures were done during this period in 96 patients [58 boys] median age: 4.9 +/- 4.7 years [1 month-13 years]. Indications were as follows: esophageal stenosis [n= 46; 47.9%], rectal polyp resection [n=21; 19.8%], esophageal varices ligation [n=19; 19.7%], foreign body extractions [n= 8; 8.3%] and percutaneous endoscopic gastrostomy [n= 2; 2.1%]. One hundred and thirteen esophageal dilations [61.1% of procedures] were performed in 46 patients: caustic stenosis [n=22; 22.9%], peptic stenosis [n=13; 13.5%] and anastomotic stenosis [n= 11; 11.4%]. The main indication of interventional GI endoscopy in this series was oesophageal stenosis followed by rectal polyp resection, esophageal varices ligation and foreign body extractions

Indications for Nephrectomy in children: what has changed?

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. To review the indications for nephrectomy in children between 1996 and 2008, at the departement of paediatric surgery, children's hospital in Tunis. 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. 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]. 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 lobar emphysema: report of 17 cases]

The aim of this report is to determine frequency and clinical characteristics of Congenital lobar emphysema [CLE] at Children's Hospital of Tunis Cases of CLE managed between January the 1st 1994 until December the 31 St 2004 were reviewed. Amongst 31 cases of cystic pulmonary malformations we report 17 CLE. They were 12 males and 5 females. The mean age at diagnosis was 41/2 months [20 days, 22 months] Symptoms were progressive respiratory distress [n=11]; recurrent attacks of dyspnea [n=5] pulmonary infection [n=1]. Chest X ray and CT scans showed hyper aeration of the affected lobes. Three patients had two affected lobes. CLE was associated to bronchogenic cyst [n=2] and to congenital cardiac anomalies [n=3]. All patients underwent lobectomy. Post operative course was uneventful in 16 children. CLE is an uncommon cause of respiratory distress in neonates and infants. CLE is the most common cystic pulmonary malformation in our institution

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

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. We report a new case of concordant PUVs in one set of male monochorionic twins with secondary Prune Belly Syndrome. 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. 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

[Infantile hypertrophic pyloric stenosis. A 142 cases report]

Hypertrophic pyloric stenosis [HPS] is a common condition affecting infants before the first three months of life. Analysis of our results and comparison with literature to determine particularities of HPS in our country. We conducted a retrospective review of 142 patients presenting HPS, between 1990 and 2003. 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. 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

[Cholestasis in infant: a study of the children's hospital of Tunis]

Cholestasis in infant constitutes an heterogeneous group of disease; diagnosis and management are often difficult. The Aim of the study is to describe clinical, paraclinical characteristics and outcome of infants hospitalized for cholestasis in children's Hospital of Tunis. A retrospective study of 94 infants with cholestasis was conducted. Patients were hospitalized in four departments of paediatrics of our hospital between January 1995 and December 2005. Cholestasis complicating severe sepsis and visceral leishmaniasis were excluded. Incidence of cholestasis was 8.5 cases/year which represented 0.72% of the hospitalizations. Sex ratio was 1.08 and mean age at diagnosis was 105 days [extremes: 1 day- 24 months]. Biliary atresia was the most common cause of extra hepatic cholestasis [13.8%]. Normal A GT cholestasis [11.7%], benign neonatal cholestasis [11.7%] and bile duct hypoplasia [9.5%] represented the most common aetiologies of intra hepatic cholestasis. Aetiology remained unknown in 12.7% of cases. Only three infants with biliary atresia had Kasai operation. After a mean follow-up of 6 years, 18% of patients had portal hypertension, 14.8% had hepatic failure and mortality rate was 14.8%. Cholestasis of unknown aetiologies are frequent in our hospital. Poor prognosis, in our study, is due to delay to diagnosis and difficulties in medical and surgical management

[ adnexal torsion in children]

Adnexal torsion is the most frequent gynaecological emergency in children. It requires an early diagnosis and an urgent surgical treatment. To study the clinical, paraclinical and therapeutic aspect of adnexal torsion in paediatric population 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]. 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's 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. 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

kyste hydatique du poumon chez l'enfant a propos de 54 cas

The purpose of this retrospective study is to clarify the clinical, radiological and evolutionary aspects of the hydatid cyst of the lung. Over a period of 9 years [January, 1983 - December, 2001], we brought together in the pediatric service B of Children's hospital of Tunis, 54 cases of hydatid cyst of the lung. The average age is of 7 years 3 months [extremes 2 and 14 years], and the sex- ratio of 1, 16. 61% of the children are of rural origin. Bronchpulmonary infection is the most frequent circumstance of discovery [72% of cases], hemoptysis is revealing in 37% of cases. Discovery is fortuitous in 7% of cases. The radiography of the chest is of a big diagnostic contribution. The radiological aspects obtained are: a homogeneous opaqueness [61%], a diverse opaqueness [26%], an image of lung abscess [22%], an aspect of floating membrane [4%], a pleural effusion [9%], and an opaqueness with growing gas [4%]. Chest echography was contributory in 77% of cases. 74% of the children were operated without complications. The others were lost