Association of epidural analgesia in labor with neurodevelopmental outcomes in premature infants born at <29 weeks of gestational age.

OBJECTIVE: To explore associations between epidural administration to mothers in labor with neurodevelopmental outcomes at 3 years corrected age in preterm infants born <29 weeks gestational age. STUDY DESIGN: Infants born <29 weeks gestational age between 2006 and 2012 were included. Our primary outcome was a composite of death or neurodevelopmental impairment at 3 years corrected age. Infants were divided into those whose mothers did or did not receive epidural analgesia in labor. Univariable and multivariable regression was used for analysis. RESULTS: There were 548 infants in the no epidural analgesia group and 121 in the epidural analgesia group. The adjusted odds ratio (95%CI) of neurodevelopmental impairment or death in the epidural group was 1.25 (0.82-1.93). Propensity score-matched results were 1.32 (0.79-2.22). CONCLUSION: Preterm infants born <29 weeks gestational age to mothers who received epidural analgesia during labor were not associated with poor neurodevelopmental outcomes at 3 years corrected age.

Point-of-care paediatric gastric sonography: can antral cut-off values be used to diagnose an empty stomach?

BACKGROUND: Gastric sonography is emerging as a valuable clinical point-of-care tool to assess aspiration risk. A recent study proposed that a single cut-off cross-sectional area (CSA) in the supine position could diagnose an empty stomach in the parturient. This study establishes the sensitivity and specificity of a single CSA cut-off measurement in both supine and right lateral decubitus (RLD) positions in the diagnosis of an empty antrum in paediatric patients. METHODS: Following induction of anaesthesia, antral sonography was performed in supine and RLD positions in 100 fasted paediatric patients prior to upper endoscopic evaluation. Following upper endoscopy, any residual stomach content was suctioned under direct visualization and antral sonography was immediately performed. Antral CSA values were compared using Wilcoxon signed rank test. Receiver operator characteristic (ROC) curves were plotted to estimate the discriminating power of antral sonography position in the diagnosis of an empty antrum. RESULTS: Significant differences were found between pre-suctioned and post-suctioned CSA values in the RLD position. The cut-off CSAs of the empty antrum in the supine and RLD positions were 2.19 cm2 (sensitivity 75%, specificity 36%) and 3.07 cm2 (sensitivity 76%, specificity 67%), respectively. CONCLUSIONS: The RLD position produces the most sensitive and specific CSA cut-off value where an antral CSA of ≤ 3.07 cm2 in the RLD position presents with acceptable performance in the ability to discriminate an empty antrum in paediatric patients over 1 yr of age. As age increases, the sensitivity and specificity of this test increases in the RLD position.

Pancreatic head enlargement associated with a pancreatitis- induced intrasplenic pseudocyst in a patient with chronic pancreatitis: organ preserving surgical treatment.

Intrasplenic pseudocyst is a rare form of a late complication of chronic pancreatitis. We report the case of a 30-year-old man with an intrasplenic pseudocyst associated with chronic alcoholic pancreatitis. The patient was admitted with the third acute phase of chronic relapsing pancreatitis. Abdominal US and CT showed a large cyst in the pancreatic tail with involvement of the spleen. ERCP revealed marked irregularities of the main pancreatic duct without communication to the large cyst and a narrowing of the distal common bile duct by chronic pancreatitis of the head of the pancreas. Organ preserving surgical treatment with duodenum- preserving resection of the head of the pancreas combined with distal pancreatectomy and splenectomy was performed. This procedure may be indicated in selected patients to preserve functional pancreatic tissue and prevent diabetes. It should be in the armamentarium of the specialized pancreatic surgeon.

Segmental bile duct injury after blunt abdominal trauma: a difficult diagnosis.

Injury to the extrahepatic biliary system after blunt abdominal trauma is rare and may be overlooked due to associated intra-abdominal trauma. We report on a 31-year-old man who, following blunt abdominal trauma, presented with an unusual injury of the extrahepatic left hepatic duct within the umbilical fissure which was diagnosed only at relaparotomy. Whenever injury to the biliary system is suspected, a thorough assessment of the liver, the extrahepatic biliary system including the left ductal system within the umbilical fissure region should be carried out. Diagnosis is facilitated by intra-operative cholangiography.

[Diagnostic surprises in apparently inflammatory masses of the right iliac fossa]. / Surprises diagnostiques dans les masses apparemment inflammatoires de la fosse iliaque droite.

Most patients presenting an inflammatory mass of the right iliac fossa have a medical history suggestive of an acute appendicitis the weeks before and further investigations will confirm the diagnosis of an appendicular abscess. During the last 2 years, we have investigated and treated seven adults presenting such a mass. In a diagnostic purpose, but in way to treat the suspected abscess in the acute phase with a percutaneous drainage too, we have performed a CT of the abdomen and of the pelvis in every case. Only 3 of 7 patients had in fact a true appendicular pathology. One patient had a cecal diverticulitis with severe peri-diverticulitis, 3 other patients had a malignant lesion developed from a small intraluminal tumor but with a wide extension outside the limit of the cecum. These examples show that careful investigations are mandatory in all cases of apparent inflammatory mass of the right iliac fossa.

[The value of conservative therapy, surgical treatment and interventional radiology in perforations and ruptures of the esophagus]. / La place du traitement conservateur, du traitement chirurgical et de la radiologie interventionnelle dans les perforations et ruptures de l'oesophage.

We have reviewed all the records of 23 patients hospitalized in our institution from January 1981 till December 1991 and presenting a confirmed diagnosis of esophageal perforation. We have studied the aetiology, the localization, morbidity and mortality and we discuss the therapeutic management. 9 patients presented a cervical perforation, 13 patients a thoracic perforation and 1 patient an abdominal perforation. Among the patients with cervical perforation 2 patients had a local revision with drainage, 3 patients a primary suture and 4 patients were treated conservatively. No complication was found in this group. The patients with thoracic perforation have been treated as follow: 3 conservatively, 8 with thoracotomy, primary suture +/- patch, drainage, 2 patients with thoracotomy and drainage alone. All complications happened in this group: 2 gastro-intestinal bleeding, 2 ARDS, 3 mediastinitis, 1 pneumonia. 2 patients in a very poor general condition died, one with a metastatic breast carcinoma, the other after a CVI with a massive gastro-intestinal bleeding. The cervical perforations have an excellent prognosis and can be treated conservatively if they are asymptomatic and do not display a pleural lesion. The thoracic perforations can be treated surgically if they are diagnosed early before septic complications. If not, they will be better treated conservatively with drainage. The intraabdominal perforations have to be treated as every intraabdominal perforation. In this case, we perform a primary suture completed with fundoplication.

[Mirizzi syndrome--a contraindication for laparoscopic surgery]. / Le syndrome de Mirizzi--une contre-indication à la chirurgie laparoscopique.

The Mirizzi syndrome refers to a benign obstruction of the common hepatic duct by a stone impacted within the cystic duct or the neck of the gallbladder causing an obstructive jaundice. According to McSherry's subclassification based on endoscopic retrograde cholangio-pancreatography we distinguish a type I, involving an external compression of the common hepatic duct by a large stone impacted in the cystic duct or Hartmann's pouch without lesion of the gallbladder or the common hepatic duct wall. In type II a cholecysto-choledochal fistula is present, caused by a calculous which has already eroded partly or completely into the common bile duct. The type I is better treated with a partial cholecystectomy, the type II with a partial cholecystectomy and a bilio-digestive anastomosis. Due to a severe inflammatory process with dense adhesions and odematous changes of the hepato-duodenal ligament, it is dangerous to prepare the Calot's triangle, in case of conventional cholecystectomy and/or in case of laparoscopic cholecystectomy. From 1986-1991 we have successfully treated 10 patients according to this concept (7 patients with type II, 3 patients with type I). We have no mortality and no lesion of the biliary system. One patient has been reoperated because of a postoperative hemorrhage and biliary fistula. One patient developed a benign stricture which could be dilated two months after the procedure. Two patients were found with an incidental carcinoma of the gallbladder.