Ovarian-sparing surgery for ovarian teratoma in children.

BACKGROUND: Ovarian teratoma (OT) is the most common ovarian neoplasm in children. Oophorectomy has been the standard treatment but may impair fertility. The aim of this study was to investigate the feasibility and outcome of ovarian-sparing surgery (OSS) for OT. PROCEDURE: We retrospectively studied all children treated for OT at a pediatric teaching hospital in Paris, France, between March 1992 and July 2006. OSS was performed when deemed technically feasible in patients who had no lymphadenopathy by preoperative imaging or surgical exploration, normal tumor marker levels, and calcifications on radiographs. RESULTS: We identified 30 patients, including 29 with unilateral OT and 1 with synchronous bilateral OT. Emergent surgery was performed in five patients, among whom four had ovarian torsion requiring oophorectomy and one underwent OSS. Of the 26 OTs in the 25 remaining patients, 10 were managed with OSS and 16 with oophorectomy. Subsequently, ultrasound monitoring detected OT development in the contralateral ovary in 4 (14%) patients, after a median of 3 years (range, 1-14 years); OSS was performed in all four cases. The patient with bilateral synchronous OT, managed by OSS initially, underwent unilateral oophorectomy 3 years later for a recurrence. Overall OSS was performed for 15 (42%) OTs. CONCLUSIONS: Our results suggest recommendations for preserving fertility whenever possible without compromising the oncological prognosis. In particular, OSS should be reserved for patients who meet all criteria for localized mature teratoma. Long-term follow-up is crucial.

[Laparoscopic surgery of Meckel's diverticulum]. / Chirurgie coelioscopique du diverticule de Meckel.

Meckel's diverticulum is an evolution of omphalomesentric channel one of the most frequent embryologic abnormality of digestive tract. It is observed in two circumstances: during a routine exploration or after a complication: intestinal obstruction, peritonitis, recurrent abdominal pain. Only open or laparoscopic explorations allow a diagnosis. Resection of the diverticulum is recommended in children because the complications are frequent and serious. The preferred therapeutic method is the bowel resection with immediate anastomosis.

[Postnatal management of urinary tract anomalies after antenatal diagnosis]. / Prise en charge post-natale des uropathies de découverte anténatale.

PURPOSE: Antenatal diagnosis of urinary tract anomalies raises the question of appropriate therapeutic management. Two risks should be avoided: excessive treatment, belated treatment. Postnatal management of these infants should be determined before birth. The aim of this study is to define indications more precisely. MATERIALS AND METHODS: A comprehensive review of the literature on postnatal treatment of antenatally diagnosed urinary tract anomalies was performed in order to propose a model of immediate management. RESULTS: Neonates with hydronephrosis should be placed on antibiotic prophylaxis. Postnatal sonographic exploration should be done immediately after birth in case of bilateral pathology, and if renal function is compromised: posterior urethral valves, bilateral dilatation with parenchymal thinning; exploration is done at day 10 in other cases, when diuresis is normalized. Voiding cystourethrogram is performed soon after birth if posterior urethral valves are suspected, later in other cases. In cases of intermittent renal pelvic dilatation, often an indirect sign of reflux, the need for a voiding cystogram is controversial. Diuretic renogram with mercaptoacetyl triglycine (MAG 3) is used to access renal function and efficiency of kidney drainage, both are needed for later monitoring. Surgical treatment is indicated in the event of deteriorated renal function with permanent obstruction. The most common uropathies are ureteropelvic junction obstruction, vesicoureteral reflux, posterior urethral valves, and primary obstructive megaureter. CONCLUSION: Antenatal diagnosis of urinary tract anomalies allowed immediate prophylactic treatment of urinary infections, and decrease the risk of severe complications previously observed. Long-term beneficial effects on preserving the renal parenchyma are yet to be determined.

[Pickrell intervention in children for anal incontinence secondary to anorectal malformation]. / Intervention de Pickrell chez l'enfant pour incontinence anale secondaire à une malformation anorectale.

STUDY AIM: The aim of this study was to report the results of unilateral Pickrell procedure in children with fecal incontinence secondary to anal atresia. PATIENTS AND METHOD: Twenty three children were operated between 1975 and 1997. The mean age at the time of the operation was 8.5 years. Functional results were systematically evaluated by Kelly's clinical score and by anal sphincter electromyography and anal manometry for some patients. RESULTS: There was no postoperative mortality. One colostomy was performed for recurrent local sepsis. The functional result with a mean follow-up of 6 years was estimated to be good in 25%, intermediate in 45% and poor in 30%. Clinical improvement of continence was obtained in 70% of cases. CONCLUSION: The improvement of continence after Pickrell procedure essentially depends on the patient selection criteria, pre- and postoperative rehabilitation and regular enemas. In the case of poor results, the authors propose bilateral Pickrell procedure which improved the results in eight out of nine children in this group.

[Treatment of appendiceal peritonitis in children by video laparoscopic conversion: conversion is not a one-way procedure]. / Traitement de la péritonite appendiculaire de l'enfant par conversion en vidéolaparoscopie: la conversion n'est pas à sens unique.

PATIENTS AND METHODS: This method was used in 14 children, seven boys and seven girls, aged from 2.7 to 14 years, with acute appendicitis and peritonitis. RESULTS: Conversion to median laparotomy was necessary in order to perform adhesiolysis in two cases in which small bowel was observed. Postoperative complications occurred in four patients involving three wound infections and one mechanical intestinal obstruction. There was no intra-abdominal abscess. CONCLUSION: This procedure allows appendectomy by an open classical approach to be performed, and subsequently allows the treatment of the generalized peritonitis by video laparoscopy, usually without median laparotomy.

A case of malrotation and situs ambiguus.

Isolated levocardia is a rare condition in which intestinal malrotation may be encountered. The case herein reported is particularly uncommon and raises a number of questions about the development of abdominal symmetry.

[A survey of the contralateral inguinal hernial sac in infants less than 1 year of age using laparoscopy with anatomic verification using peritoneal radiography or surgery]. / Recherche du sac herniaire inguinal controlatéral chez le nourrisson de moins de 1 an par laparoscopie avec vérification anatomique par péritonéographie ou chirurgie.

STUDY AIM: The aim of this prospective study was to evaluate the laparoscopic diagnosis of contralateral patent processus vaginalis in children with unilateral inguinal hernia. PATIENTS AND METHOD: Between November 1995 and February 1998, 91 consecutive children (78 boys, 13 girls) under the age of 1 year were operated on for a unilateral inguinal hernia. A contralateral hernia was diagnosed by a laparoscopy through the inguinal hernia sac before ligation. Results of this technique were correlated with those of herniography (79 cases) or with inguinal exploration (12 emergency). RESULTS: Laparoscopy was performed in 88 patients. Laparoscopy was impossible in three cases: one inguinal sac too thin, two cases of ectopic testis in the inguinal canal. Sensitivity was 73% and specificity 92%. The only complication arising from the procedure was wound infection in two patients. CONCLUSION: This method is a simple, safe and accurate procedure in order to select children for contralateral surgical exploration.

The value of split renal function in severe neonatal and infant pelviureteric obstruction managed by percutaneous nephrostomy.

A percutaneous nephrostomy (PCN) was inserted as part of the management in 17 newborns and infants with severe pelviureteric junction obstruction between 1981 and 1993. Nephrectomy was performed in eight cases and pyeloplasty in nine cases, successfully in six cases (mean follow-up: 7.7 years). PCN was useful for predicting that no non-functioning kidney on intravenous pyelography (IVP) in this series should have been preserved. Among the kidneys with a high excretion delay on IVP, PCN showed that only those that had a split creatinine clearance of more than 1 ml/min/1.73 m2, or theoretical clearance for age and weight of over 6%, should be preserved.

[Laparoscopic radical nephrectomy and ureterectomy in a child. A case report]. / La néphrectomie et l'urétérectomie étendue par coelio-chirurgie chez l'enfant. A propos d'un cas.

The authors report a case of laparoscopic nephroureterectomy in a four year old girl with a small kidney destroyed by vesicoureteric reflux.

Histiocytosis X revealed by complex anal fistula.

A very unusual clinical case of histiocytosis X in a young girl with no unusual medical history, is presented. The patient presented with chronic suppuration of the groin and complex anal fistulae and multiple recurrent abscesses, despite surgical treatment (abscess drainage, terminal colostomy). Intestinal and immunologic evaluation were normal. Only histology made the diagnosis. Chemotherapy (vinblastine) resulted in healing and the colostomy was closed.

[Tumors of the testis in children]. / Les tumeurs du testicule de l'enfant.

Tumours of the testicle are rare in children (about one case in 100,000 male children). Their histological type usually leads to favourable outcome. We report here our series of 12 cases together with an analysis of the large published series in order to review the prognosis and therapeutic indications which depend on the histology. The most frequent intratesticular tumours in the child are nonseminoma malignant germ cell tumours. At birth the tumour is usually a mature or mixed teratoma. Between the ages of 1 and 3 years the most frequently observed tumour arises from the vitelline sac representing about 50% of all tumours of the testicle in the child. From 3 years to puberty, paratesticular rhabdomyocarsomas and Leydig cell tumours are the most frequently encountered. Finally, at puberty, tumours of the testicle are the same as those observed in the adult, notably seminomas which are not observed before puberty. Other tumours occur only exceptionally. Orchiectomy after ligature of the spermatic cord is the usual treatment. Complementary chemotherapy and node dissection are not required as first intention therapy when the tumour is well localized (complete exeresis, no lymph node invasion, no pulmonary metastasis), but are reserved for relapse or residual tumours revealed by a secondary rise in alpha foetoprotein levels or by extension from the initial site. A present, in 80% of the patients with localized tumours, outcome is favourable without lymph node dissection or chemotherapy. The three-year survival rate is approximately 90%.

[Renal transplantation in children. Surgical aspects]. / La transplantation rénale chez l'enfant. Aspects chirurgicaux.

The renal transplantation in children has some specificities: urologic anomalies (vesico ureteral reflux, posterior urethral valves) are frequently the cause of the renal failure, and necessitate a thorough surgical preparation before transplantation (nephrectomy, reconstitution of urinary tract). The child must have a sterile, compliant and continent urinary tract on the day of the operation. In small children (< 15 kg), it is often necessary to operate through a transperitoneal incision, especially if the donor is an adult: the anastomoses will then concern the aorta and vena cava. The results are good, even better than in adults, except for very young children (under six years of age). Transplantation with living related donor (LRD) give the best results. Currently, the graft survival is 87% to 90% after three years with LRD, versus 65 to 77% with cadaveric donors.

[Genital prognosis of boys with bladder exstrophy or epispadias with incontinence. Apropos of 14 cases]. / Avenir génital des garçons atteints d'exstrophie vésicale ou d'épispadias avec incontinence. A propos de quatorze cas.

Bladder exstrophy and epispadias with incontinence are associated with urinary tract and genital anomalies. The genital and sexual aspects were studied in 14 adolescent or adult males (12 exstrophies and 2 epispadias). The appearance of the penis was satisfactory in fifty percent of cases. Erections were always preserved but normal ejaculations were present in only one half of cases. Fertility potential was reduced. The improvement of surgical technique, and especially penile lengthening, has greatly improved sexual intercourse for these patients.

[Genital prognosis of girls with bladder exstrophy or epispadias]. / Avenir génital des filles atteintes d'exstrophie vésicale ou d'épispadias.

The authors report ten cases of women with previous exstrophy of the bladder or epispadias with incontinence followed up to child-bearing age. Six of the ten females had urinary diversion and four retained their bladder and were continent. Three key aspects are considered: physical appearance of the external genitalia which was satisfactory in all cases; preservation of sexual function, known in only four of the ten cases and which was reported by these patients to be satisfactory, and finally, the ability to bear children. Three patients became pregnant resulting in four normal births (one patient had twins). Cesarean sections were recommended in patients with pregnancies at term. Cesarean should be performed systematically in patients with bladder reconstruction.

[Surgery for lung metastases in children]. / Chirurgie des métastases pulmonaires de l'enfant.

The authors report a series of 76 children with lung metastases followed from 1974 to 1989. Forty-four children were operated on with 64 thoracotomies (50 wedge resections, 5 segmentectomies, 2 pneumonectomies, 6 biopsies, 1 excision of an inflammatory granuloma): 23 of these children are alive, and 17 of them without any adjuvant radiotherapy. Thirty-two were not operated on; of the 13 that are alive, 7 had no adjuvant radiotherapy. The indications for surgery were: to treat a complication of the metastasis, to verify persistent images on CT-scan, but essentially to avoid more aggressive treatment (chemotherapy, radiotherapy) with its risk of sequelae in children.