Antimesenteric gastrointestinal tract duplication undergoing non-ulcerative perforation.

Duplications of the gastrointestinal tract are rare malformations, most commonly presenting as cystic structures growing within the smooth muscle wall. Very rarely, they are completely detached from the tract. Several theories have been proposed regarding their embryological development, but no single one has been able to account for all of the described variants. The most common type of duplication is related to the small bowel and develops at its mesenteric border, assuming a spherical or tubular shape. Their clinical manifestations vary, depending mainly on their localization and size. Most commonly, they cause subacute abdominal pain and intestinal obstruction in children of less than two years of age. We present a case of an 8.5-year-old girl, investigated for right lower quadrant abdominal pain. On ultrasound scan, a cystic mass indicative of a duplication cyst was discovered and she underwent a laparotomy. A tense cystic spherical mass 2.2 cm in diameter was excised from the terminal ileum, 4 cm from the ileocecal valve. The cyst had the characteristics of a gastrointestinal tract duplication, except from the fact that it was located on the antimesenteric border of the intestine. On the other hand, the lesion did not present the characteristic features of a Meckel's diverticulum. According to our knowledge, this is the first report of an intestinal duplication cyst appearing on the antimesenteric intestinal border.

Outcome of alimentary tract duplications operated on by minimally invasive surgery: a retrospective multicenter study by the GECI (Groupe d'Etude en Coeliochirurgie Infantile).

BACKGROUND: Alimentary tract duplications (ATD) are a rare cause of intestinal obstruction in childhood. There are many case reports but few series about laparoscopy or thoracoscopy for ATD. The aim of our study was to report the outcome of minimally invasive surgery (MIS) for ATD. METHODS: This was a retrospective multicenter study from the GECI (Groupe d'Etude en Coeliochirurgie Infantile). We reviewed the charts of 114 patients operated on by MIS for ATD from 1994 to 2009. RESULTS: Sixty-two patients (54 %) had a prenatal diagnosis. Forty-nine patients (43 %) were symptomatic before surgery: 33 of those patients (63 %) with postnatal diagnosis compared to 16 (25 %) with prenatal diagnosis (P < 0.01). In this last group, the median age at onset of symptoms was 16 days (range = 0-972). One hundred and two patients had laparoscopy (esophageal to rectal duplications) and 12 patients had thoracoscopy for esophageal duplications. The mean operative time was 90 min (range = 82-98). There were 32 (28 %) resection anastomoses, 55 (48 %) enucleations, and 27 (24 %) unroofings. The conversion rate was 32 %, and in a multivariate analysis, it was significantly higher, up to 41 % for patients weighing <10 kg (P < 0.01). Ten patients (8 %) had unintentional perioperative opening of the digestive tract during the dissection. Eight patients had nine postoperative complications, including six small bowel obstructions. The median length of hospital stay was 4 days (range = 1-21) without conversion and 6 days (range = 1-27) with conversion (P = 0.01). The median follow-up was 3 months (range = 1-120). Eighteen of the 27 patients who underwent partial surgery had an ultrasound examination during follow-up. Five (18 %) of them had macroscopic residue. CONCLUSION: This study showed that MIS for ATD is feasible with a low rate of complications. Patients with prenatal diagnosis should have prompt surgery to prevent symptoms, despite a high rate of conversion in small infants.

Indications for laparoscopy in the management of intussusception: A multicenter retrospective study conducted by the French Study Group for Pediatric Laparoscopy (GECI).

INTRODUCTION: Surgical management of intussusception is required for cases where enema reduction fails. Some articles report an advantage of the laparoscopic over the open approach, but complications such as serosal tearing and frank perforation have been described. We aim to determine the best indication of laparoscopy in the decisional management tree of intussusception. PATIENT AND METHOD: This is a retrospective chart review of all children with intussusception who failed hydrostatic enema reduction and who underwent immediate laparoscopic management. Cases were compiled from 7 pediatric surgical centers (French Study Group of Pediatric Laparoscopy) between 1992 and 2005. Data collected included age, duration of symptoms, findings on initial assessment, level of intussusceptum after attempted hydrostatic enema reduction, type of laparoscopic approach, operative time, conversion to open surgery, etiology, and postoperative complications. Two groups were analyzed-conversion to open surgery or not. RESULTS: Sixty-nine patients (48 males and 21 females) were reviewed. In total, 22 patients required a conversion to open surgery (31.9%). Eleven of these were converted because of failure of laparoscopic reduction. The risk for conversion to open surgery is directly linked to the length of time between onset of symptoms and diagnosis (1.6 vs 3.1 days for conversion group, P = .048), the presence of signs of peritonitis on the initial clinical assessment (10.6% vs 41% in conversion group, P = .003), and the presence or absence of a pathologic lead point (17% vs 50% in conversion group, P = .004). CONCLUSION: The child seen early after the onset of symptoms (<1.5 days) with no signs of peritonitis is the best candidate for a laparoscopic approach in management of intussusception requiring surgery. Particular attention must be paid to not miss a pathologic lead point, especially as most tactile cues are lost.