Thoracoscopic Guided Pericostal Sutures as a Solid Fixation for Primary Closure of Congenital Diaphragmatic Hernias.

Purpose: To describe a minimally invasive technique with primary closure and strong suture connection that is feasible in cases of larger, most common type B defects of congenital diaphragmatic hernia (CDH). Background: The thoracoscopic approach (TA) is a favorable technique for the repair of CDH and is still evolving globally. A common issue is finding the optimal suture technique for secure closure in order to prevent recurrences. Whether a defect can be closed only by sutures or by using a patch depends on the size of CDH, the presence of a muscular rim along the inner thoracic surface and finally on the surgeon's experience. From a geometrical point of view, the challenge is to transform the circular defect into a line, without tension, with a strong compound and preferably without additional material. To address this, we apply a setting of the sutures in a "T-shape" and a way to lead the sutures around the rib bones in order to increase stability. This method allows for the primary closure of CDHs and also applies to larger defects. Cases: We present seven newborns with posterolateral CDH on the left side. The defects were solely repaired by TA and by the suturing technique described in detail.

Transanal Endoscopic-Assisted Pull-Through Colectomy for Children with High Intestinal Aganglionosis.

Intestinal aganglionosis in children is a common cause of neonatal and infantile obstruction or ileus. Diagnosis is based on a histologically proven absence of enteric ganglion cells in deep biopsies of the gut wall. Therapeutic goal is a one-stage repair with a resection of the affected segment. The endorectal pull-through (ERP) can be performed entirely transanally in a lot of the cases. In patients with difficult preparation or a high aganglionosis ERP often needs to be assisted by laparoscopy or laparotomy. We present two cases with a technical modification performing a totally transanal pull-through colectomy without any trocars other than an umbilical camera trocar. The procedure starts with a classical endorectal technique. Usually, the transanal preparation is limited by reaching the colon descendens. A camera trocar is inserted and under laparoscopic vision the preparation is completed placing the instruments directly via the opened anus. After reaching the healthy colon segment, the pull-through is completed transanally. One of the main advantages of ERP is the sparing dissection. Our modification combines advantages of laparoscopy and ERP. The umbilical camera allows an excellent view while the instruments for dissection are used like with ERP without any further trocar or traction of the anal sphincter. The dispensation of any transanal trocar allows a higher grade of freedom in preparation and possibly a smaller trauma on the distal anal channel.

["Frühe Hilfen": what must pediatricians know?] / Frühe Hilfen: Was müssen Kinderärzte wissen?

In early childhood, essential foundations are laid for healthy growing up and long-term quality of life and health. Stressful life situations can disrupt good early childhood development, therefore early support is essential. Early childhood interventions like "Frühe Hilfen" provide support systems with coordinated services for parents and children during early childhood. They are particularly aimed at families in stressful life situations and thus counteract the long-term consequences of negative childhood experiences and promote healthy growing up. Pediatricians are important cooperation partners of "Frühe Hilfen", especially with respect to access to the services. Early life care is an interdisciplinary and integrative concept that aims to promote optimal conditions for families around the desire to have children, pregnancy, birth and early childhood, among other things, with a view to risk situations.

Experiences and well-being of healthcare professionals working in the field of ultrasound in obstetrics and gynaecology as the SARS-CoV-2 pandemic were evolving: a cross-sectional survey study.

OBJECTIVE: Assess experience of healthcare professionals (HCPs) working with ultrasound in obstetrics and gynaecology during the evolving SARS-CoV-2 pandemic, given the new and unprecedented challenges involving viral exposure, personal protective equipment (PPE) and well-being. DESIGN: Prospective cross-sectional survey study. SETTING: Online international survey. Single-best, open box and Hospital Anxiety and Depression Scale (HADS) questions. PARTICIPANTS: The survey was sent to 35 509 HCPs in 124 countries and was open from 7 to 21 May 2020. 2237/3237 (69.1%) HCPs from 115 countries who consented to participate completed the survey. 1058 (47.3%) completed the HADS. PRIMARY OUTCOME MEASURES: Overall prevalence of SARS-CoV-2, depression and anxiety among HCPs in relation to country and PPE availability. ANALYSES: Univariate analyses were used to investigate associations without generating erroneous causal conclusions. RESULTS: Confirmed/suspected SARS-CoV-2 prevalence was 13.0%. PPE provision concerns were raised by 74.1% of participants; highest among trainees/resident physicians (83.9%) and among HCPs in Spain (89.7%). Most participants worked in self-perceived high-risk areas with SARS-CoV-2 (67.5%-87.0%), with proportionately more trainees interacting with suspected/confirmed infected patients (57.1% vs 24.2%-40.6%) and sonographers seeing more patients who did not wear a mask (33.3% vs 13.9%-7.9%). The most frequent PPE combination used was gloves and a surgical mask (22.3%). UK and US respondents reported spending less time self-isolating (8.8 days) and lower satisfaction with their national pandemic response (37.0%-43.0%). 19.8% and 8.8% of respondents met the criteria for moderate to severe anxiety and depression, respectively. CONCLUSIONS: Reported prevalence of SARS-CoV-2 in HCPs is consistent with literature findings. Most respondents used gloves and a surgical mask, with a greater SARS-CoV-2 prevalence compared with those using 'full' PPE. HCPs with the least agency (trainees and sonographers) were not only more likely to see high-risk patients but also less likely to be protected. A fifth of respondents reported moderate to severe anxiety.

Pilot Study of a Software-Supported Protocol for Second-Trimester Ultrasound Screening.

OBJECTIVES: To evaluate the feasibility and impact of using a software-supported protocol for routine second-trimester ultrasound scanning. METHODS: We conducted a comparative observational study of 2 sets of 25 randomly selected normal routine second-trimester examinations performed by the same expert sonographer before and 1 year after the introduction of a software-supported protocol. The scanning protocol was identical during both periods and conformed to International Society of Ultrasound in Obstetrics and Gynecology guidelines. Two independent expert sonographers reviewed the temporal sequences of fetal anatomic visualization. The examination duration, number of images, time per stored image, and number of recorded anatomic features according to the International Society of Ultrasound in Obstetrics and Gynecology guidelines were compared between the periods. RESULTS: The mean examination duration and the number of images stored ± SD were both significantly higher during the period with the software-supported protocol than during the previous period (18.9 ± 5.3 versus 15.3 ± 2.8 minutes, respectively; P = .005; and 52.0 ± 2.4 versus 35.2 ± 3.4; P < .001). The mean time per image was also shorter with the software-supported protocol (19 ± 7 versus 26 ± 4 seconds; P < .001). Recording of the placental location, amniotic fluid quantification, cavum septi pellucidi, thoracic shape, both kidneys, both arms, and genitalia was significantly more consistent with the software-supported protocol (P < .001; P = .001; P = .022; P = .050; P = .022; P < .001; and P = .048). CONCLUSIONS: This pilot study suggests that a software-supported protocol standardizing image acquisition may improve operator efficiency during second-trimester ultrasound scans.

Value of three-dimensional contrast-enhanced power Doppler ultrasound for characterizing adnexal masses.

AIMS: The aim of this study was to assess the diagnostic performance of 3-D contrast-enhanced power Doppler ultrasonography (3-D CEPDUS) for differentiating benign and malignant adnexal masses. MATERIAL AND METHODS: Consecutive patients with adnexal masses were included prospectively and underwent 2-D ultrasonography and 3-D CEPDUS in a tertiary centre in Paris, France. The main outcome measure was the diagnostic accuracy of 3-D CEPDUS to diagnose malignant and borderline adnexal masses. The reference standard was the final histological examination. Two-dimensional ultrasonography and 3-D CEPDUS were compared using semiquantitative scores. Three-dimensional CEPDUS assessed vessel density, vessel pattern, and three vascular indexes in a 5-mL region of interest (vascularization index [VI], flow index [FI], and vascularization flow index [VFI]). The 2-D and 3-D examinations were done by different sonographers who were blinded to the other test. The pathologist was blinded to ultrasonography findings. RESULTS: Of 99 patients, 88 had benign tumors and were compared to the 11 patients with borderline (n = 5) or malignant (n = 6) tumors. The sensitivity of the subjective 2-D score was 55% (95% confidence interval [CI], 25-84) and specificity 94% (95%CI, 89-99). The sensitivity of the subjective 3-D score was 82% (95%CI, 58-100) and specificity 90% (95%CI, 83-96). Improvement of detection of malignant or borderline tumors by subjective 3-D score was 150%. Vessel density and patterns were not more efficient than the subjective 3-D score. The mean vascular index values were significantly different between benign and borderline/malignant groups: VI, 7.2 versus 35.5 (P < 0.0001); FI, 37.0 versus 48.2 (P = 0.003); and VFI, 2.9 versus 17.6 (P < 0.0001), respectively. CONCLUSIONS: 3-D CEPDUS improves detection of malignant and borderline adnexal masses.

Embryology of the midgut.

In most textbooks of embryology and pediatric surgery, the puzzling spectrum of midgut "malrotations" is explained by an "impaired" process of rotation of the midgut. However, this "process of rotation" is explained in a rather schematic way and aims more to explain pathologic findings whereas detailed embryologic investigations are still rare in this field. Good animal models which would allow the comparison of normal and abnormal midgut development are missing. In this paper we describe the development of the midgut in form of an atlas. Scanning electron microscopy is used in rat embryos to illustrate the crucial embryologic processes of midgut development. The main result shown in these illustrations is that clear signs of a process of rotation are missing.

Contribution of ultrasonography to endometrial cancer screening in patients with hereditary nonpolyposis colorectal cancer/Lynch syndrome.

OBJECTIVES: Screening for endometrial cancer is recommended in women at risk for hereditary nonpolyposis colorectal cancer/Lynch syndrome. No screening tool has been validated. The objective of this study was to assess the performance of ultrasonography used to screen for atypical hyperplasia and cancer in women at risk for hereditary nonpolyposis colorectal cancer/Lynch syndrome. Endometrial biopsy was the reference standard. MATERIALS AND METHODS: Of 85 women with mismatch repair gene mutations or Amsterdam II criteria who were studied prospectively at our institution, 58 had 96 paired ultrasound-biopsy evaluations and were included in the study. Transvaginal or transabdominal ultrasonographic finding was considered normal if no polyps or intrauterine abnormalities were seen and if the maximum endometrial thickness was less than 4 mm in postmenopausal women not receiving hormonal replacement therapy or less than 6 mm in other women. Endometrial biopsy results were categorized as not interpretable, normal, or showing atypical hyperplasia or cancer. Sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio of ultrasonography were computed. RESULTS: The 58 patients had a mean age of 42.5 years and a median follow-up duration of 51.4 months (range, 17-106 months; 246 patient exposure years). Cancer was diagnosed in 2 patients. Ultrasonography had 100% sensitivity and 100% negative predictive value, 2.2 positive likelihood ratio, and 0 negative likelihood ratio. No interval cancers occurred. CONCLUSIONS: Ultrasonography had high sensitivity and an excellent negative likelihood ratio in this study. Further studies are needed, and ultrasonography should be compared with clinical follow-up, diagnostic hysteroscopy, or endometrial biopsy alone.

Malignant transformation of Gartner cyst.

Vaginal cysts are common lesions that include Gartner cysts, which develop from the wolffian duct remnants in the vaginal wall. Malignant transformation of Gartner cysts is exceedingly rare. Our case was diagnosed upon evaluation of vaginal bleeding in a 67-year-old woman. Histologic examination showed a clear cell carcinoma. Treatment consisted of surgical excision and radiation therapy. Treatment quality, stage, and pelvic node status are the main prognostic factors. Regular long-term follow-up is crucial.

Hysteroscopic findings in women at risk of HNPCC. Results of a prospective observational study.

OBJECTIVES: To report the feasibility and results of diagnostic hysteroscopy in women at risk of HNPCC. METHODS: Fifty-seven women with mismatch repair gene mutations (n = 11) or Amsterdam II criteria (n = 46) were followed-up prospectively from January 1999 to March 2005. Flexible hysteroscopy was performed once a year. The endometrium was sampled routinely. RESULTS: Of 91 attempted hysteroscopies, 10 failed. The endometrial mucosa appeared normal in 34 cases. Polyps were seen in 12 cases, atrophy in 11, hypertrophy in 10, and fibroids in 7; two hysteroscopies suspected malignancy. A micropolypoid appearance was visualized during five hysteroscopies (5/81, 6%). Of the 86 endometrial biopsy attempts, 64 were successful and showed atrophy (n = 14), proliferation (n = 12), secretion (n = 27), polyps (n = 6), simple hyperplasia without atypia (n = 3), or cancer (n = 2). Micropolypoid appearance was not associated with a specific histological pattern. Operative hysteroscopy was done in 24 cases; in two patients with apparently benign focal lesions the results showed simple hyperplasia without atypias. Five patients underwent hysterectomy (simple hyperplasia without atypias, n = 2; endometrioid adenocarcinoma, n = 2; or secretory mucosa, n = 1). This study led to diagnosis of endometrial simple hyperplasia in 6% of cases and of cancer in 3%. CONCLUSIONS: In patients at risk of HNPCC, hysteroscopy appears feasible to screen endometrial pathology. Two cancers have been diagnosed over 91 patient-years at risk. Hysteroscopy should be compared to sonography as a screening tool in women at risk of HNPCC.

Endometriosis with FDG uptake on PET.

BACKGROUND: The value of [18F]fluorodeoxyglucose positron emission tomography (FDG-PET) uptake in endometriosis has not yet been extensively reported. CASE REPORT: A 32-year-old woman was examined to find an explanation for right pelvic pain associated with right subcostal pain. A computerised tomography (CT) scan was compatible with a haemangioma or a focus of endometriosis in the liver. Transvaginal sonography and magnetic resonance imaging (MRI) showed a complex ovarian cyst on the left. Blood CA125 levels were elevated. FDG-PET revealed a focus of uptake in the right paravesical area. Laparoscopy showed a left endometrioma associated with diffuse inflammatory pelvic adhesions. After surgery and 3 months GnRH agonist treatment the pain had disappeared and neither MRI nor FDG-PET showed any pelvic abnormality. The patient subsequently presented with dyspareunia and rectal pain resulting from a right uterosacral nodule and a rectal nodule. These were resected laparoscopically. After a 1-year follow-up, the patient is doing well. CONCLUSION: Endometriosis can give rise to false-positive results on FDG-PET. However, the FDG uptake in this particular case of endometriosis seems to have been due to inflammation rather than to a cyst. This report highlights the relationship between some of the biological features of endometriosis and some observed in neoplastic lesions.

Sono-guided endometrial biopsy: comparison with hysteroscopy biopsy. Sono-guided endometrial biopsy using the Bernard catheter had no impact on endometrial assessment by sonohysterography.

OBJECTIVE: To assess the feasibility, tolerance and diagnostic accuracy of endometrial biopsy (EB) during sonohysterography (SH) compared to EB after hysteroscopy (HSC) in endometrial disorders. METHODS: 105 consecutive patients with irregular uterine bleeding were included prospectively in the calendar year 2001. SH and flexible HSC were performed in an office setting, subsequently and in a random order, by two different practitioners blind to the former experiment. SH-EB was performed using a 3.1-mm ultrasound-guided Bernard catheter in the uterine cavity still partly distended and with a gentle 20-ml syringe vacuum aspiration. The biopsy was directed on focal lesions or else randomly when no targets had previously been found. A Cornier Pipelle was used to perform EB after HSC. We investigated all patients by biopsy, independent of the endometrial thickness. HSC-EB was the gold standard. RESULTS: For both methods, cervical catheterism was impossible in 20 patients, 75 of them successfully underwent both exams. Duration and tolerance were similar. SH was effective in the distinction between normal and pathologic cavities, as well as in the diagnosis of polyps. Endometrium appeared significantly thinner with HSC (1.8 mm) when compared to SH (2.9 mm, p < 0.05). Histological endometrial assessment failed in 30 cases of SH-EB and in 22 cases in HSC-EB (NS). There was a poor correlation of the histological results of both techniques. Hyperplasia has never been diagnosed by SH-EB, whereas 3 EB issued from HSC-EB brought up this diagnosis. CONCLUSION: SH-EB with our technique did not improve the diagnostic potential of SH and severe diagnosis was missed. Histological assessment should fail less when we exclude endometrial atrophy. The diameter of the catheter and the aspiration technique must be revised and the learning curve must be considered. Our technique cannot replace EB by HSC.

[Ovarian cancer: diagnosis of early stages, referral of patients and management]. / Cancer de l'ovaire: diagnostic des formes précoces, orientation des malades et prise en charge.

Early ovarian cancers account for 25 to 30% of cases. They constitute the only curable cases. There is no specific clinical symptom of early ovarian cancer. Paraneoplasic syndroms, especially phlebitis, are of major importance when they occur in young women. In most of cases, the diagnosis is performed during the management of a complex ovarian cysts. Quality of the preoperative work-up, especially sonography, and management by a specialised team are the best factors to provide an early diagnosis and a comprehensive staging. These two factors are known as predictive of good prognosis. Chemotherapy is frequently indicated post-operatively. In young women, a conservative management can be proposed to preserve their fertility.