Judicial handling of cases of non-accidental head trauma in infants: Review and analysis of expert assessments.

INTRODUCTION: Good practice guidelines help clinicians to establish a suspected diagnosis of non-accidental head injury (NAHI) and help forensic experts to establish a level of certainty for the diagnosis. The objective of this study was to assess how the French Health Authority (HAS) guidelines contribute to the process of producing an expert assessment, on causation and certainty in cases of suspected NAHI. METHOD: A retrospective study was conducted of the expert assessments that were conducted by a paediatric surgeon and forensic expert attached to our local court between 2002 and 2018, with the aim of determining the causal mechanism of the lesions and express a degree of certainty regarding the diagnosis. RESULTS: In our study, we found that, despite the HAS guidelines, a number of documents deemed essential for the forensic expert were sometimes missing, and that, by applying these guidelines, the decisions reached in some expert assessments could been reclassified and certain factors formerly described as risk factors for injury could be excluded. A precise dating of the traumatic event was proposed in half of cases. CONCLUSION: Our study highlights the vital role of the HAS guidelines, not only for patient management but also to ensure high-quality expert assessments. Unfortunately, guidelines were not yet being properly adhered to by medical teams.

Multicentric evaluation of the adherence to Peristeen® transanal irrigation system in children.

BACKGROUND: Since 2009 in France, the Peristeen® transanal irrigation (TAI) device has represented an alternative treatment of faecal incontinence (FI). OBJECTIVE: The primary objective of this study was to assess the mid-term adherence to TAI in paediatric patients. The secondary objective was to identify factors determining TAI continuation. METHODS: This observational study conducted in 5 French paediatric centres prospectively reviewed from March to May 2012 all children educated in TAI for at least 9months. RESULTS: We included 149 children (mean [SD] age 10.6 [4.1] years) educated in TAI. Children mainly had neurogenic disorders (52.3%) or congenital malformations (30.9%). The main symptoms motivating TAI initiation were recurring faecaloma (59.7%) and daily FI (65.1%). At last follow-up (mean 14 [7.4] months), 129 (86.6%) children continued the TAI procedure, independent of pathology or age. The main motivation was resolution of FI and/or constipation (77.3%). In total, 107 (82.9%) children fulfilled the initial therapeutic contract established with their healthcare professional before TAI initiation was met. Twenty children had stopped the TAI when they answered the questionnaire, at a mean duration of 16 (8.4) months. The reasons were mainly "lack of motivation" (45%), "poor tolerance" (35%), "difficulties" performing the procedure (35%) and "inefficacy" (30%). Factors related to continuation were performing at least one TAI procedure under a nurse's supervision during the initial training and prescribing TAI at a daily frequency (P=0.014 and P=0.04). Continuing constipation treatment after the training session was a factor in discontinuation (P=0.024). CONCLUSION: This study reports a very high mid-term adherence to TAI in a paediatric cohort, provided that the training is pragmatic, personalized and repeated.

Intestinal loop lengthening: early treatment of vanishing bowel.

Bianchi's procedure experience for short bowel syndrome in children is positive. This technique is generally performed after the first year of life. Here the authors propose a case of gastroschisis with prenatal spontaneous closure of abdominal defect and vanishing gut presenting as intestinal atresia, absence of ileo-cecal valve, and residual short intestinal dilatation, treated by early gut lengthening (ILP).

Transumbilical approach for shunt insertion in the pediatric population: an improvement in cosmetic results.

OBJECTIVE: In spite of the recent interest in endoscopic third ventriculostomy, ventriculoperitoneal (VP) shunt is still the gold standard in treating non-obstructive hydrocephalus in children. The peritoneal cavity remains the optimal site for cerebrospinal fluid (CSF) diversion. Shunt insertion and re-interventions carry a high risk of inaesthetic abdominal scars and long-term morbidity. We report a technique of transumbilical shunt insertion, which provides better cosmetic results and without many more complications. This approach has been performed for a long period in a wide variety of intra-abdominal conditions by pediatric surgeons. METHODS: Between March and October 2003, we inserted 12 VP shunts in children. For eight consecutively treated children the follow-up is more than 3 months. All the shunts were inserted through the umbilicus. These eight children are the subjects of this study. Indications for shunting were: communicating hydrocephalus (6 cases), subdural hematoma (1 case), and hygroma associated with an arachnoid cyst (1 case). The population consisted of 7 boys and 1 girl, ranging in age between 6 weeks and 47 months (mean age: 15 months), and their body weights varied between 2,110 g and 18,000 g (mean weight: 8,470 g). All children were examined twice a day for 3 days, and wounds were examined daily to check for the absence of sepsis or dehiscence. Clinical controls were performed 1 month after discharge. The operating surgeon was invited to comment on any difficulties encountered in making or closing this incision afterwards. RESULTS: The average length of clinical follow-up was 6 months (range 4-7 months). One infection of the VP shunt occurred. It was treated with external drainage and antibiotics. After 1 week, a second VP shunt was inserted using the same technique without particular difficulty and with a nice cosmetic result. Concerning the seven other children, the cosmetic results were optimal, with no puckered abdominal scars or wound dehiscence, and with no perioperative or long-term complications related to the umbilical approach. CONCLUSION: At this early follow-up, umbilical incision for shunt insertion is a safe and easy technique. It provides an optimal cosmetic result, even in cases of re-intervention. This minimally invasive surgery does not require long specialized training. We have not shown an increase in complications associated with a "learning curve." Longer follow-up is needed to evaluate the risk of infection.

Sacral neuromodulation for neurogenic bladder dysfunction in children.

PURPOSE: We report a prospective randomized controlled study to evaluate the possible benefits of sacral neuromodulation (SNM) for the management of neurogenic bladder dysfunction in children. MATERIALS AND METHODS: We included in the study subjects between the ages of 5 and 21 years presenting with urinary incontinence due to neurogenic bladder. Before study inclusion all previous treatment was discontinued. Patients were randomly divided into the control group treated conventionally and the implant group treated with SNM. Treatment outcome was compared every 3 months for a minimum of 12 months based on clinical examination, voiding diary and urodynamic evaluation. RESULTS: A total of 26 boys and 16 girls with a mean age of 11.9 years were enrolled in this study. There were 21 patients in each group. The main underlying etiology was spina bifida. The 2 groups were comparable with regard to sex, age and urodynamic variables. Total disappearance of urinary leakage was observed in 1 patient who underwent implantation but he still required intermittent catheterization. Comparison of urodynamic variables disclosed no significant statistical difference except with regard to functional bladder capacity which was better in the control group and the leak point pressure which was better in the implant group (p <0.05). Evaluation of interindividual variations in the implant group revealed significant improvement in compliance and functional bladder capacity at 6 and 9 months but not at 12 months. Nine patients in the implant group reported improvement in intestinal transit, 5 total disappearance of urinary infection and 6 persistent sensation of a full bladder. No patient in the control group reported any improvement. Revision surgery was required in 3 cases due to lead migration, faulty connection and wound infection. CONCLUSIONS: SNM is a promising new therapeutic modality. Implant placement is minimally invasive, nondestructive and reversible. Use in children with neurogenic bladder has not been previously reported. Although some improvement was noted in patients treated with SNM, the difference with the control group was not significant. A larger multicenter study is warranted to evaluate SNM.

Value of electrophysiological assessment after surgical treatment of spinal dysraphism.

PURPOSE: This study was conducted in children treated surgically for spinal dysraphism between 1994 and 2000 to determine the value of electrophysiological parameters for followup in comparison with clinical, radiological and urodynamic findings. MATERIALS AND METHODS: Electrophysiological examination was performed based on electromyographic detection of perineal muscle activity with evaluation of the sacral reflexes and measurement of lower limb and perineal evoked potentials. Clinical and radiological assessment consisted of physical examination, kidney ultrasonography and retrograde cystouretrography. Urodynamic assessment included determination of urethral pressure profile, bladder activity, compliance, voiding pressure and sphincter synergy. A total of 45 children were included in the study. In 28 cases electrophysiological assessment was performed routinely in 20 children (group 1) before and after (6 months and annually thereafter) surgical treatment (mean followup 30 months) and in 8 children (group 2) only after surgical treatment (mean followup 65 months). Electrophysiological findings were correlated with the urodynamic and clinical findings. Sensitivity, specificity and positive and negative predictive values were calculated. In 17 children (group 3) electrophysiological assessment was performed only once either before or after surgery. RESULTS: Electrophysiological assessment with combined electromyographic detection and perineal evoked potentials was highly sensitive in predicting urodynamic impairment, particularly vesico-sphincter dyssynergia (sensitivity 100%) or bladder dysmotility (sensitivity 86%). Specificity of perineal evoked potentials for detecting urodynamic dysfunction was 90%. Electromyographic detection and perineal evoked potentials also demonstrated satisfactory sensitivity in confirming urological impairment (sensitivity 79%, negative predictive value 90%). CONCLUSIONS: Electromyographic detection and perineal evoked potentials are valuable for assessment of patients after surgical treatment of spinal dysraphism. Because these techniques are minimally invasive and highly reproducible, they are suitable for baseline assessment in most cases (tethered cord, lipoma, syringomyelic cavities). Urodynamic assessment should be reserved for patients at high risk for secondary neurogenic bladder dysfunction such as myelomeningocele or sacral agenesis.

[Antenatal diagnosis of ovarian cyst: perinatal management]. / Diagnostic anténatal de kyste de l'ovaire: conduite à tenir périnatale.

More than 85% of prenatal ovarian cysts have a follicular or luteal origin. Their natural history is a spontaneous involution. However, adnexal torsion resulting in the loss of the ovary can occur at any time of the evolution. Pre and postnatal changes in the sonographic aspects allow to choose the appropriate therapeutical indications: conservative approach, laparoscopic surgery, or percutaneous aspiration. Prenatal aspiration must be avoided. The last prenatal sonographic examination should be performed as close as possible from the end of the gestation, and the first postnatal echography within the first 24 hours of life. Surgery of prenatal complicated cysts has to be planned a few days after birth. Uncomplicated prenatal cysts will be treated depending on size and echographic patterns at birth.

Endoscopic treatment of urinary incontinence: long-term evaluation of the results.

PURPOSE: We report on the use of polydimethylsiloxane for endoscopic treatment of urinary incontinence in children with neurogenic bladder and discuss our results to determine optimal criteria for patient selection. MATERIALS AND METHODS: A total of 44 children (19 males) have been treated endoscopically for urinary incontinence since 1995. Etiology was spina bifida in 35 cases. Previous surgery had been performed on 24 patients, including bladder neck reconstruction with (17) or without bladder augmentation. Mean patient age at injection was 13 years (range 7 to 17). A single transurethral injection was given in 23 cases, 2 in 17 and 3 or more in 4. Mean volume at each injection was 3.5 cc and for each patient the total volume injected was 5.7 cc. Mean delay between 2 injections was 6 months (range 3 to 15). RESULTS: Followup ranged from 6 to 53 months (median 28). Of the patients 15 (34%) are dry (continent greater than 4 hours, no urinary pad during the day), 11 (25%) are improved (continent 2 to 3 hours, occasional pad) and 18 had poor results. In the entire series only gender and preoperative hyperactivity influenced the results, as the best results were achieved in females with a stable bladder (44% of girls versus 21% of boys were cured). Good results persisted at 12-month followup in patients treated with only 1 injection (until 36 months for older patients) and after the last of 2 injections. Of the patients treated with 3 or more injections 1 was dry at 12-month followup and treatment failed in 3. CONCLUSIONS: Injection of polydimethylsiloxane at the bladder neck achieved continence in 34% of neurogenic bladder cases. Results were better in girls with a stable bladder. Results deteriorated in the first 12 months of followup. No more than 3 injections are advised if a satisfactory result is not achieved.

[Use of polydimethylsiloxane in the endoscopic treatment of urinary incontinence of neurologic origin in children]. / Utilisation du polydiméthylsiloxane dans le traitement endoscopique de l'incontinence urinaire d'origine neurologique chez l'enfant.

AIM: We report the use of polydimethylsiloxane (PDS-Macroplastique) in endoscopic treatment of urinary incontinence in children with neurogenic bladder and try to determine optimal criteria for patient selection. METHODS: Forty four children (19 males, 25 females) have been treated since 1995. Aetiology was mainly spina bifida (n = 36). Previous surgery had been performed in 26 patients, including bladder neck reconstruction in 21 cases and bladder augmentation in 15 cases. Mean age at injection was 13 years (7 to 17). Only one injection was performed in 27 patients, two injections in 4 cases, and three and more injections in 3 cases. Mean volume at each injection was 3.6 cc. Mean interval between two injections was 6 months (3-15 m). All injections were performed transurethrally. RESULTS: Follow-up ranged from 6 to 41 months (median: 23). Fifteen patients (34%) are dry (continence > 4 hours, no urinary pad during the day) and 11 (25%) are improved (continence from 2 to 3 hours, minimal pad). Eighteen patients obtained poor results. In the entire series previous bladder neck surgery or preoperative detrusor hyperactivity did not interfere with the results. The only difference concerns the sex-ratio: the good results were mainly seen in females: 44% of girls are cured versus 21% of boys. CONCLUSION: Injection of PDS in the bladder neck achieve the goal of continence in 34% of the cases in neurogenic bladder. Better results are seen in girls. Injection does not compromise other surgical procedures. The use of PDS seems more suitable than bovine collagen in view of the potential problems of prions.

Pediatric endoscopic surgery: pride and prejudice.

82 endoscopic surgical procedures (abdominal: 77; thoracic: 5) were performed by the same surgeon on 75 children aged from 1 month to 17 years (median 8.1 years) during the two-year period from January 1991 to December 1992. Due to the multispecialization of the Children's Hospital, a variety of pathologies were explored or treated with appendectomy accounting for 33% (27/82). There were no perioperative deaths. Three major complications occurred (1 post-appendectomy peritonitis, 1 hemorrhage during splenectomy and 1 post-operative occlusion). 14 patients required conversion to open surgery. Indications for endoscopic exploration of advanced lesions, prospective indications, and policy when confronted with a healthy appendix are discussed.

Fetal chest wall hamartoma: a case report.

A fetal chest wall hamartoma successfully treated by surgical resection after birth is described. Ultrasonography showing a heterogeneous partially calcified thoracic tumor allowed in utero diagnosis.

Tracheomalacia caused by arterial compression in esophageal atresia.

After surgical repair of esophageal atresia (EA), any persistent respiratory distress unexplained by operative complications should lead to performance of tracheoscopy to evaluate the possibility of tracheomalacia. In a review of 46 cases of EA repair, 12 patients developed severe airway problems, manifested mainly by acute apneic episodes. These were related to an anterior extrinsic tracheal compression from vascular structures: the innominate artery alone in 8 patients, and in combination with the aortic arch in 4 patients. Aortopexy, evaluated by intraoperative tracheoscopy, provided good results in 10 patients with a mean follow-up of 2 years. After EA repair, respiratory symptoms, often related to feeding, should be recognized as a possible indication of severe compression of the trachea by the great vessels. The analysis of endoscopic features should allow consideration of patients as candidates for aortopexy, as long as they have resolved their symptoms after conservative therapy, and after investigation of all other possible sources of pulmonary problems. Gastroesophageal reflux must be recognized (7 cases in the series), but does not contraindicate aortopexy if the latter is deemed necessary. In selected cases, the relief of compression, controlled by intraoperative endoscopy, is considered a key component of a comprehensive program to treat children after EA repair.