Left thoracoscopic thymectomy in children.

BACKGROUND: In the management of autoimmune myasthenia, thymectomy is recognized as effective surgical therapy. The necessity of complete radical thymectomy to achieve maximal improvement has been emphasized. Video-assisted thoracoscopic surgery has been successfully used for thymectomy in adults, and more recently in children, and has been described as achieving the same radicality and functional improvement as median sternotomy or as transcervical thymectomy. The aim of this work is to report our first thoracoscopic experience in this indication. METHODS: Patients with myasthenia gravis on anticholinesterase drugs and/or steroids are discussed for surgery in case of clinical deterioration despite increasing doses of medication or in case of no improvement. We decided to perform thoracoscopic thymectomies by a left-sided approach. Preoperative localization of thymic tissue is done by a thoracic CT exam. Patients are placed on their right side with a thoracic tilt under the thorax. Four thoracoscopic ports are used, a 10-mm for the camera and three 5-mm operating ports. The left lung was collapsed by selective intubation (double-lumen endotrachial intubation). RESULTS: Two boys, 7.5 and 14 years old, were addressed by the department of neurology for radical thymectomy. They presented an ocular myasthenia gravis for 2 years and a mild general myasthenia gravis for 7 years. The operative times were 120 and 240 min. There was no intraoperative or postoperative complication. Duration of thoracic drainage was 2 days. The children were discharged on the third postoperative day. For the second procedure, an ultrasound exam during surgery was necessary to localize the thymus exactly, thus enabling its complete resection without the need for a conversion. The follow-up is 19 and 7 months with a clinical improvement enabling the diminution of medication for both children, the end of ptosis for the first child, and the general improvement of muscle strength for the second. CONCLUSIONS: Thoracoscopic thymectomy in children with juvenile myasthenia gravis seems to offer a complete surgical resection, as do open techniques. In case of difficulties in finding the thymus, an ultrasound exam is feasible to enable complete resection. The left-sided thoracoscopic approach gives a good mediastinal and cervical exposition. Furthermore, being less painful in the postoperative period, it presents a less pronounced impairment of pulmonary function, and it presents good cosmetic effect.

Pediatric laparoscopic splenectomy: benefits of the anterior approach.

INTRODUCTION: Splenectomy is frequently performed in children for various hematologic and autoimmune disorders. We reviewed our indication for splenectomy, our technique of laparoscopic, splenectomy, and our results. The aim of this study was to show if an anterior approach with elective vessel endoligature in a patient in decubitus position was a better and safer approach than the other techniques previously published. PATIENTS AND METHODS: Between January 1996 and December 2002, 54 children underwent laparoscopic splenectomy. We use the anterior pedicle approach and elective vessel endoligature in order to prevent persistence of any exogenous material. Sixteen children also had a concomitant cholecystectomy. Their age ranged between 1 and 18 years (mean 7.5 years). Twenty children had hereditary spherocytosis, 15 were affected by sickle cell disease, six had an idiopathic thrombocytopenia, four had beta-thalassemia, and nine another hemolytic disease. RESULTS: Mean operative time was 150 min (range, 115-230 min). Hospital stays ranged from 3 to 15 days (mean: 5.4). Seven patients had complications (four pneumonia and three deep abscess with successful antibiotic treatment). Median follow-up was 42 months (2 months-6 years) without problems regarding procedure. DISCUSSION: With this technique consisting in first elective arterial and secondary venal ligature, we preserved blood splenic sequestration and pancreatic tail lesion. The procedure is safer. For us, considering the low complication rate for this type of patient, and the advantages of a small abdominal trauma in the postoperative period, laparoscopy with anterior approach for elective splenectomy and eventual cholecystectomy in hematologic disorders is the best technique.

Primary aldosteronism and adrenal incidentaloma.

Adrenal incidentaloma are usually found during the assessment of non adrenal disease. In this paper we report the association between a bilateral adrenal hyperplasia and a macronodule of adrenal cortex (adrenal incidentaloma) which is a rare and misleading cause of primary aldosteronism. In the light of this association even if it is likely to remain rare and of those previously published, its existence is an additional reason for suggesting surgical treatment of primary aldosteronism only to patients who satisfy the following criteria: 1) satisfactory control with spironolactone; 2) poor spironolactone tolerance and poor control with other drugs; 3) accept to be operated on and the risk of a possible error.

[Radionuclide ejection fraction at rest and in exercise in chronic aortic insufficiency. Pre- and postoperative study in asymptomatic or paucisymptomatic patients]. / Fraction d'éjection isotopique du ventricle gauche au repos et à l'effort dans l'insuffisance aortique chronique. Etude pré- et postopératoire chez les patients a- ou paucisymptomatiques.

Twenty patients (17 men and 3 women: average age 50 +/- 14 years) with asymptomatic or paucisymptomatic aortic regurgitation were studied to compare the values of radionuclide left ventricular ejection fraction (EF) at rest and on exercise before (1) and 6 +/- 1 months (2) and 5.7 +/- 1.1 years (3) after surgery. The resting EF was similar at all three examinations: 53 +/- 8 (1); 57 +/- 8 (2); 55 +/- 16 (3). However, it increased significantly on exercise from 40 +/- 10 (1) to 54 +/- 12 (2) (p < 0.001) and to 52 +/- 20 (3) (p = 0.036 versus 1). In the 7 patients with resting EF greater than 55 before surgery, there was no postoperative improvement: 61 +/- 6 (1); 61 +/- 5 (2); 65 +/- 9 (3). However, the exercise EF increased from 44 +/- 13 (1) to 55 +/- 17 (2) and 69 +/- 11 (3) (p = 0.004 vs 1). In 13 patients with resting EF < 55%, the value increased in the early postoperative phase but not later: resting: 49 +/- 5 (1); 55 +/- 8 (2) (p = 0.04); 49 +/- 17 (3) (NS vs 1); effort: 38 +/- 7 (1); 54 +/- 10 (2) (p < 0.001); 40 +/- 16 (3) (NS vs 1). Left ventricular systolic function only returns to normal and exercise after surgery in patients with resting preoperative EF > or = 55%, but nothing indicates that this normalisation is an absolute condition for a successful surgical result in aortic insufficiency in terms of survival and quality of life.

The adhesiveness of monocytic U937 cells is stimulated by pro-inflammatory agents and inhibited by adenosine 3':5'-cyclic monophosphate.

We investigated the regulation of the adhesiveness of the human promonocytic cell line U-937, differentiated along the monocytic pathway either by 1,25-(OH)2-cholecalciferol or a combination of retinoic acid and dibutyryl cAMP. Adhesion to untreated polystyrene plastic was induced by inflammatory agents like PAF, fMLP or LTB4. The response to PAF first appeared after 48hr of differentiation and was inhibited by PAF antagonists and protein kinase C inhibitors indicating involvement of the phosphatidyl-inositol pathway in the stimulating effect. On the other hand, all the c-AMP raising agents tested inhibited PAF-induced cell adhesion, whatever their target membrane receptors, the Gs transducing protein, the catalytic unit of adenylate cyclase or cAMP phosphodiesterase. Direct stimulation of protein kinase A by Br8-cAMP had a similar effect. Moreover, PAF was able to increase cAMP levels. This suggests the existence of a cAMP based negative control mechanism limiting the action of PAF.

[Choice of first-line antibiotic therapy in the treatment of bone and joint infections in children]. / Choix de l'antibiothérapie de première intention dans le traitement des infections osseuses et articulaires de l'enfant.

Because of the frequency of Haemophilus influenzae and Staphylococcus aureus in joint and bone sepsis in children, a prospective study of first line antibiotic therapy was performed. In a series of 23 cases, including 8 osteomyelitis and 15 arthritis, Gram stain on joint fluid or antigen detection was helpful in reaching a decision about initial therapy in only 3 cases (Haemophilus influenzae). In 20 of the 23 patients, the first line antibiotic therapy was cefotaxime (100 mg/kg/day) and fosfomycin (100 mg/kg/day) in combination. In 6 of them, the bacteriologic culture was positive (3 Staphylococcus aureus, 1 Haemophilus influenzae and 2 Streptococcus pneumoniae) and the initial antibiotic therapy was changed according to the antibiotic susceptibility testing. In the others 14 cases, from whom no agent was isolated, this combination was continued during about 15 days, then followed by pristinamycin and amoxicillin-clavulanic acid in combination during one month. The C. reactive protein dosage was performed in each patient. All children cured. In view of these first results, cefotaxime and fosfomycin in combination seems to us to be interesting in first line antibiotic treatment without initial orientation.

[Anaesthesia for laryngoscopy in suspension in the child (author's transl)]. / Anesthésie pour laryngoscopie en suspension chez l'enfant.

After reviewing the different methods of ventilation by pulsed oxygen used for anaesthesia during laryngoscopy in suspension in the child, the authors describe a technique of introduction of the endotracheal catheter which makes it possible to reduce the risk of alveolar hyperpressure at the time of installation of the laryngoscope and at the time of waking.

Dispersions of lamellar phases of non-ionic lipids in cosmetic products.

Synopsis Although aqueous dispersions of lipids in the form of particles having a lamellar structure (liposomes) are already known as excellent vehicles for pharmaceutical substances, their usefulness in cosmetic formulations has not been demonstrated. The present work shows the advantages obtained by application of such systems to the skin, and in particular the use of non-ionic lipids in aqueous dispersions. Thus, in comparison with classical formulations such as emulsions, these systems exhibit lower toxicity and permit closer control of the availability of active substances at the stratum corneum. As examples, compositions suitable for skin moisturising and for tanning products are presented.