Post-traumatic arterial priapism in the child: a study of four cases.

The authors report four cases of arterial priapism in the child, a rare condition since only 13 cases are described in the literature. High-flow priapism follows perineal or penile injury with damage to a cavernosal artery and formation of an arteriosinusoidal fistula. The onset may be immediate but more often occurs after a few days. Arterial priapism is painless, as the corpora cavernosa are less tumescent in the anterior third of the penis. The clinical appearance and circumstances of onset suggest the diagnosis. Doppler ultrasound is the complementary investigation of choice, confirming and localising the fistula. Various methods of treatment have been proposed. Injections of alphastimulant seem ineffective in most cases and are not without danger. Surgery, which is potentially damaging, has been used only in the adult. Most authors propose embolising with resorbable material the artery which feeds the fistula. However, priapism may resolve spontaneously in less than three weeks, as occurred in our cases, without recurrence or subsequent erectile dysfunction. We thus consider the condition may initially be managed by observation alone, with recourse to embolisation if priapism does not resolve after a period of time which however remains to be defined.

Abdominal cystic lymphangioma in children: benign lesions that can have a proliferative course.

Twenty-one pediatric cases of abdominal cystic lymphangioma (CL) treated in the past 20 years are reviewed. To date, this is the largest reported series. CL is a rare congenital malformation that presents either with chronic abdominal distension (and is detected by palpation of a cystic mass) or acutely with bowel obstruction or signs of peritonitis. It is more common among boys and most often occurs in children under 5 years of age. Abdominal ultrasonography is the procedure of choice for establishing the diagnosis. Acute cases with intracystic hemorrhage are more difficult to diagnose. Computed tomography and celioscopy may be useful. With these techniques, a correct diagnosis should be achieved in nearly every case. Enucleation (when feasible) or segmental intestinal resection (when the cyst is intimate to the bowel) is effective treatment. In a few cases the malformation is diffuse, and extensive bowel resection is necessary, with the risk of short bowel syndrome.

[Decisional criteria in the management of vesico-ureteral reflux in children with congenital neurogenic bladder]. / Critères décisionnels dans la prise en charge des reflux vésico-urétéraux chez l'enfant porteur d'une neurovessie congénitale.

OBJECTIVES: To determine, in the particular case of neurogenic bladder, the best criteria for selection and grading of the modalities available for the treatment of vesicoureteric reflux, which is often associated. METHODS: 194 patients with congenital neurogenic bladder, including 76 cases with vesicoureteric reflux were retrospectively reviewed. The various treatments applied, their results and their complications were reviewed. Conclusions are drawn and proposals are made for the optimal management of vesicoureteric reflux in the particular context of congenital neurogenic bladder. RESULTS: This series included 8 grade I, 28 grade II, 49 grade III and 23 grade IV and V. In more than 50% of cases, reflux was detected on during routine assessment of congenital neurogenic bladder, demonstrating the value of this assessment (25% of cases of reflux were detected before the age of one year). Management initially consisted of vesical drainage, often by intermittent catheterization, from the age of 2 to 3 years and antibiotic prophylaxis. This treatment was sufficient to correct reflux in 9 cases and to control it in 16 cases (no urinary tract infection, no deterioration of the upper tract). An elective anti-reflux operation was decided in 69 cases of VUR (1 grade I, 15 grade II, 38 grade III, 16 grade IV or V). Cohen's technique was performed in 3 cases and endoscopic injection of PTFE was performed in 3 cases. Most of these refluxing bladders were hypertonic and/or presented an abnormally high closing pressure. The operative criteria were: symptomatic reflux; persistent reflux; renal deterioration; non-compliance with treatment. Several complications were observed and are described. CONCLUSION: Vesicoureteric reflux in the context of congenital neurogenic bladder plays a major role in the deterioration of renal function. These forms of reflux usually occur in hypertonic bladders. Urodynamic studies appear essential before deciding treatment. Intermittent catheterization is able to control or even correct a certain number of these cases of reflux and should be introduced by the age of 2 or 3 years. When surgery is required, Cohen's operation is the easiest to perform, but is associated with an increased complication rate. Injection of PTFE or macroplastic could constitute a good indication.

Laparoscopic appendicectomy: case reports of vascular injury in 2 children.

The authors report 2 similar cases of serious vascular injury occurring during laparoscopic appendicectomy. These cases stress the potential risk of major accidents with laparoscopic surgery. There should be great care in the choice of indications and during the procedures.

Increase in testicular temperature in case of cryptorchidism in boys.

Temperature of the undescended testis, measured in its cryptorchid location during surgical procedure for orchidopexy in 46 boys, 13- to 180-months-old, was significantly higher (34.4 +/- 0.9 degrees C) than that of the contralateral normally descended testicle (33.2 +/- 1.2 degrees C; P < 0.001). Temperature significantly declined from the Bogros' space (35.3 +/- 0.5 degrees C) to the inguinal canal (34.7 +/- 0.7 degrees C) and from the latter to the empty scrotal cavity (31.1 +/- 1.8 degrees C). The physiological descent of the testicle is associated with a marked cooling of its thermal environment. When this process is interrupted for any reason, temperature of the cryptorchid testis is significantly increased. This rise in temperature could be either a concomitant or a main factor for the impairement of testicular functions associated with cryptorchidism.

Anatomic basis for use of a gracilis muscle flap.

The aim of this study was to specify certain anatomic features of the gracilis m. with a view to the use of muscular or myocutaneous flaps. It was based on dissection of 84 gracilis muscles in 42 subjects as well as selective injection of the main pedicle of 20 muscles. This established the following points: 1) The arterial supply is abundant, consisting of several pedicles reaching the muscle on its deep aspect. The main neurovascular pedicle arises from the deep vessels of the thigh, via either the a. of the adductors (73%), the medial circumflex a. (19.2%) or as a double supply from both arteries (7.7%); 2) The cutaneous vascularisation over the gracilis m., derived from the solitary main pedicle, is inconstant. In 20 injections, it was satisfactory in 11 cases, poor in 5 and absent in 4; 3) The distal tendon of the gracilis m. is closely related to the posterior branch of the saphenous n. to the leg, which it crosses in an elongated X; 4) A simple method of calculation based on the distance between the upper border of the pubis and the medial femoral epicondyle allows quite precise determination of the point of entry of the main pedicle into the gracilis m. 5) Complete dissection of the main pedicle adds to the available length of the muscle flap.

[Gracilis muscle in man]. / Muscle gracile chez l'homme.

This study is based upon the dissection of 84 gracilis muscles in 42 cadavers. It allowed to emphasize the following features: 1-The proximal insertion of the muscle is a strong tendinous lamina arising from the anterior aspect of the pubis and from the ischio-pubic branch; the distal insertion to the tibia is common to both the gracilis and the semi-tendinous muscles. 2-The distal tendon of the gracilis is tightly connected to the posterior branch of the internal saphenous nerve which crosses the muscle behind the medial femoral condyle. 3-The arterial supply (52 dissections) appears to be very rich, consisting in various pedicles entering the muscle by is lateral side. The main neurovascular bundle is issued from the profound vessels of the thigh, coming either from the adductors artery (73%), either from the medial circumflex artery (19.2%), either from both networks (7.7%). The site of penetration of the vessels in the muscle is remarkably constant. The remaining pedicles (2 to 4, one of which is quite constant at the musculotendinous junction) arise from the muscular branches of the femoral artery. 4-There is a good correlation between the measured length of the muscle and the distance between the superior aspect of the pubic arch and the medial epicondyle. A 0.37 corrective factor applied to this latter distance allows to determine the exact sit of penetration of the main neurovascular bundle in the muscle.

Pyloric obstruction with complicated pancreatic heterotopia.

A case of pyloric obstruction associated with pancreatic heterotopia is described in an 18-day old child. The association of several pathologic processes like acute pancreatitis and abscess formation in the heterotopic mass and the long-term follow-up are the main points of interest in this report.

[Non-palpable testes. Apropos of 161 cases]. / Testicules impalpables. A propos de 161 observations.

A series of 161 boys with 178 impalpable testes is reviewed. Extended inguinal exploration was the main form of investigation and treatment. Hormone injections and studies were performed in bilateral cases. Sonography was unhelpful. Laparoscopy was not used. Impalpables testes account for 7% of all boys with an anomaly of testicular descent and 8.5% of operated boys. One hundred and twenty six testes were found, 58 in the abdomen, 68 in the inguinal canal. Thirty one nodular vestige were found and all 25 with histopathology were spermatic duct residue. In 21 boys no trace of testes or spermatic duct remnant were found. Ninety five testes were successfully brought to the scrotum with one (85) or two (10) stage procedure. Anomalies of the upper urinary tract in 13 of 21 cases without testes or spermatic duct remnant were very rare. In bilateral cases it looks better to search a testes whatever the biological responses to gonadotropin stimulation.

[Anatomic study of 2 sternopagus. Is the separation possible?]. / Etude anatomique de 2 sternopages. Leur séparation est-elle possible?

Trough two cases of Sternopagus, study of classification of conjoined twins with precise definition of anatomic characteristic of Sternopagus. Description of our own subject and review of literature. At the end of this study, it is evident that the heart and vascular fusion is always complicated. So, the true Sternopagus are inseparable and no likely to live, in opposition with Xiphopagus and Thoracopagus.

[Long-term evolution of esophago-gastric junctions surgically treated to correct gastro-esophageal reflux. 111 cases]. / Devenir à long terme des jonctions oeso-gastriques opérées pour correction d'un reflux gastro-oesophagien. 111 observations.

One hundred eleven patients underwent a surgical procedure for correction of intractable gastroesophageal reflux. Twenty children were severely mentally retarded. The range of follow up was 6 months to 15 years. Upper gastro-intestinal series was realised at tenth post-operative day for 111 children, then during the first year for 97 children, between the first and fifth year for 62 children and after the fifth year for 25 children. The first upper gastro-intestinal control (at tenth day) was normal for 111 patients. Next controls revealed, usually during the first post-operative year, an esophago-gastric junction anomaly for 49 patients (44%). Most of them are light (41/111 = 37%): occasional reflux (9 children; more frequent without pyloroplasty) of little paraesophageal hernia (32 children; more frequent with closure of esophageal hiatus by two suture lines, with esophageal fixation on median arcuatum ligament or without esophageal fixation on esophageal hiatus); these light anomalies are symptom free and sometimes transitories. Rarely, anomalies are important (8/111 = 7%): big paraesophageal hernia of recurrence (more frequent with partial posterior fundoplication and in children severely mentally retarded); five patients were symptomatic and had to be reoperated. Also now, we don't use partial posterior fundoplication and in mentally retarded children we prefer a Collis procedure.

[110 surgical arteriovenous fistulas in 89 children]. / Etude de 110 fistules artério-veineuses chirurgicales chez 89 enfants.

110 arteriovenous fistulas made for hemodialysis, chemotherapy and extended parenteral nutrition are studied. For authors, the side-end radial arteriovenous fistula is the main used, followed by the humero-basilic shunt. The immediately functional fistula's percentage was of 81% with a net progress in the last year since it is now at 92%. Thrombosis prevails in early complications. 32% of delayed complications are minutely studied. They include thrombosis, infections, trophic disturbance of hands, secondary stenosis, hyper-flow with cardiac consequences. Others more unusual delayed complications are described ("Stealing" syndrome, no venous distention, bleeding, pseudo-aneurysm). The authors advice the side-end arteriovenous fistula for hemodialysis and humero-basilic shunt with immediately basilic superficialization for infant's hemodialysis, for chemotherapy and parenteral nutrition.

[Value of magnetic resonance imaging in the follow-up of children operated for portal hypertension]. / Intérêt de l'examen par résonance magnétique dans la surveillance de l'hypertension portale opérée chez l'enfant.

The authors report their experience concerning nuclear magnetic resonance imaging (NMR) in 7 children. They emphasize its importance in the post-operative study of portal hypertension. All those children got surgically created porto-systemic shunts. NMR imaging is easy, safe and trustable. It is able to visualise the shunt itself and to demonstrate the patency of this shunt. So, it is interesting when the usual controls have failed, particularly abdominal ultrasonography.

[Ureteral triplication]. / Triplicité urétérale.

Two cases of ureteral triplication are reported, on in a child of 4 years the other in a 2-week-old baby. In both cases the triplication was associated with one or two ureteroceles. A literature review is used as a basis for describing the characteristics of this rare malformation.

[Diagnostic value of cholinesterase activity in superficial biopsies of the rectum]. / Efficacité diagnostique des activités cholinestérasiques dans les biopsies superficielles du rectum.

Quantitative assay of acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) activities have been estimated in superficial rectal biopsies from 168 neonates or children suspected of having Hirschsprung's disease. The AChE activity made the diagnosis in 93% of the cases. The ratio AChE/BChE improved both the specificity and the sensitivity and confirmed the diagnosis on the first series of biopsies in 99% of the cases.

[Esophageal stenosis with tracheo-bronchial heterotopy. Apropos of 3 cases]. / Sténose oesophagienne avec hétérotopie trachéo-bronchique. A propos de 3 observations.

Three cases of esophageal stenosis with tracheo-bronchial remnants within the wall of the esophagus, near the cardia, are reported: two girls and one boy; in three, this anomaly contains cartilage remnants. After various procedures, esophagoplasty was necessary when the boy of the first case was fourteen. Two girls was cured by a Thal procedure with follow-up of five and four years respectively. A survey of the references found 43 other cases. This anomaly is more frequent in girls. Tracheo-bronchial remnants are located usually in the esophagus near the cardia and contains cartilage. Rarely the respiratory inclusion is seen in the middle part of the esophagus and no cartilage is then identified. The stenotic segment is lined by squamous cell epithelium and the heterotopic tracheo-bronchial structures are intramural implants. The diagnosis should be suspected in cases of esophageal obstruction presenting in childhood or adult life with a history dating back to infancy or childhood. Radiologically a short stenotic non relaxing segment is the hallmark in the distal esophageal localisation. Resection of the stenotic segment with primary anastomosis is the method of choice in the middle part of the esophagus. That procedure is a good alternative in the distal esophagus.