[Pseudo-"isolated" intestinal perforation in a very low birth weight infant: exceptional presentation of Hirschsprung's disease]. / Perforation intestinale du grand prématuré en apparence "isolée": mode de révélation exceptionnel de la maladie de Hirschsprung.

Intestinal perforations in preterm newborn are characterized with high morbidity and mortality rates. They often are associated with necrotizing enterocolitis and seldom correspond to idiopathic spontaneous intestinal perforation. Perforations upstream of an intestinal organic obstruction (atresia), or of a functionnal obstruction (meconium-ileus, Hirschsprung disease) have been considered to be rare in preterm newborns. We report a case of caecal perforation with a pneumoperitoneum which occurred at 5 days of life, in a 28-week gestational age infant, that was treated by cecostomy. There were no signs of necrotizing enterocolitis. At 43 days of life, the preoperative contrast enema study revealed a left colon transition zone, suggesting a Hirschsprung disease, which was confirmed by rectal biopsies. Transanal pull-through was performed. There were no postoperative complication. This case demonstrates that an isolated intestinal perforation in very preterm newborn can reveal a Hirschsprung disease, especially if it occurs in the caecum.

Feasibility of retroperitoneal pelvic lymph node exploration in cervical carcinoma. Assessment of morbidity in 33 cases treated by combined radio-surgery or definitive radiotherapy.

BACKGROUND AND PURPOSE: Laparoscopic modalities by selective biopsies permit a better assessment of the pelvic lymph nodes status than imaging procedures in cervix carcinoma. They could enable the radiation oncologist to adapt the target volume of external irradiation, provided the feasibility of such procedures is good and the toxicity reduced as much as possible. MATERIAL AND METHODS: From June 1980 to May 1993, 52 women with a mean age of 49, underwent a retroperitoneal pelvic lymph node laparoscopic procedure for cervix carcinoma classified according to FIGO as stages IA2 (14), IB (12), IIA (6), IIB (14), IIIB (3) and IVA (3). Two techniques were used: retroperitoneoscopy (RPS) in 16 cases, and a panoramic retroperitoneal pelviscopy (PRPP) in 36 cases. RESULTS: Intra-operative and post-surgical morbidity were equivalent in the two procedures. Among the 33 patients who had external irradiation, one Grade 3 urinary late morbidity (3%) due to an overtreatment was observed; no Grade 3/4 morbidity of the gastro-intestinal tract, no lymphoedema of the lower extremities, no parietal tumor cells implantation were noticed. CONCLUSIONS: These procedures can be used safely to better know the prognosis and to define the pelvic lymph node planning target volume and its radiation management with accuracy.

Anal canal duplication in infants and children--a series of 6 cases.

The authors present a series of six anal canal duplications (ACD), duplications of the alimentary tract located along the posterior side of the anal canal, with a perineal opening just behind the anus. Five asymptomatic duplications were diagnosed before the age of one year, by simple perineal inspection. A twelve-year-old girl presented with perineal and anal pains and diarrhoea. Fistulography revealed a tubular structure in five cases and a cystic structure in one case, behind the normal anal canal, in one case communicating with it. A presacral sacrococcygeal teratoma was found in two children and in one case it was visualised by preoperative US in an infant with a lumbosacral myelomeningocele. Surgical excision was performed by a perineal approach in 5 cases, by a combined sacral and perineal approach in the last case, because of the associated teratoma. Non-invasive preoperative investigations, consisting of a pelvic X-ray, US examination, barium enema and fistulography, are sufficient in most cases; MRI is reserved for special indications. Surgical treatment restores a normal perineal aspect, without sequelae, and avoids complications like those described in other types of digestive duplications: infection, ulceration, bleeding, malignant changes during later adult life. Associated anomalies are frequently described in the literature, especially presacral tumours (16%) and anorectal malformations (21%); they can influence the management, the surgical approach and the functional prognosis.

Mesenteric adenitis caused by Yersinia pseudotuberculosis presenting as an abdominal mass.

Infection by Yersinia pseudotuberculosis has become of increasing pathological importance. Patients normally present with symptoms similar to those of appendicitis, due to mesenteric adenitis. We present the case of 3 patients infected by Yersinia pseudotuberculosis who in addition to fever and abdominal pain had a palpable abdominal mass, so great was the enlargement of the mesenteric nodes. In 2 patients a laparotomy was carried out, followed by biopsy of a mesenteric lymph node. The diagnosis of Yersinia infection was confirmed by bacterial culture of the biopsied material and also by serology. In the third patient, serological studies and ultrasonic imaging of the abdomen led to early diagnosis and surgery was avoided. We suggest that a diagnosis of mesenteric adenitis due to Yersinia pseudotuberculosis should now be considered in all patients presenting with an abdominal mass, and in whom there is an appropriate clinical and epidemiological history. The diagnosis should be confirmed by abdominal ultrasound (alternatively Computerised Axial Tomography or Magnetic Resonance Imaging) and serological studies. In this way, unnecessary surgery can be avoided.

Single-stage correction of posterior hypospadias (178 cases). Comparison of three techniques: free skin graft, free bladder mucosal graft, transverse pedicle preputial graft.

Three techniques have been developed for single-stage repair of posterior hypospadias: free skin grafts, free bladder mucosal grafts, and pedicle preputial grafts. This multicenter retrospective study of 178 children who underwent surgery for posterior hypospadias was designed to compare the results achieved with these procedures. Free skin grafts (15 cases) resulted in the most frequent complications, and in particular the most severe strictures; in our opinion this technique should be abandoned. Pedicle preputial grafts (133 cases) gave the greatest number of successes from the outset, and should be preferred whenever the dimensions of the prepuce are sufficient for urethroplasty. Results with bladder mucosal grafts (30 cases) were not as good as with preputial grafts, but this technique remains the only solution when the meatus is in a very posterior position, and for children who have already undergone multiple operations.

[Left pulmonary artery sling associated with right pulmonary hypoplasia and ventricular septal defect]. / Artère pulmonaire gauche aberrante associée à une hypoplasie pulmonaire droite et á une communication interventriculaire.

The pulmonary artery sling is a congenital malformation where the left pulmonary artery forms a vascular sling that bends around the right border of the lower trachea. Its clinical manifestations are signs of tracheal compression in the first months of life. The diagnosis of this rare anomaly is suspected on radiological and echocardiographic grounds and confirmed by oesophagography, tracheoscopy and angiocardiography. Diagnostic problems may be encountered when the condition is associated with tracheobronchial (50% of the cases) or cardiovascular malformations. In the case reported here respiratory symptoms and heart failure were present in a 1-month hypotrophic infant who also had ventricular septal defect and dextrocardia due to right lung hypoplasia. The pulmonary artery sling was diagnosed by angiography. The severity of the clinical signs precluded all attempts at surgical repair of the cardiovascular anomalies. The child died at the age of 2 1/2 months.

[Computed tomography of the mediastinum: normal anatomy and non pathologic variations in the adult (author's transl)]. / Aspects normaux et variations non pathologiques en tomodensitométrie du médiastin chez l'adulte.

This work is based on the separate study of a triple material: axial gross body sections from cadavers (4); normal and conventional radiographs with or without opacification; in vivo scans (210). Authors have selectionned thriteen scans patterns according to several regional levels: supra-aortic scans (n08 1, 2, 3); scan through the horizontal part of aortic arch (n0 4B); the scan of the aorto-pulmonary window (n0 4B); supra-cardiac scans through intra and extra-pericardic parts of great vessels: vena cava, aorta and pulmonary artery (n08 5, 6, 7); heart and cardiac cavities scans (n08 8, 9, 10, 11); scan through the retro-crural space (n0 12). Knowing these regional scan patterns, makes it possible to the radiologist to manage a topographic approach quite adapted to the technical mode of direct scannography through the area of interest, already tested by some constructors. The non pathologic variations are numerous. Mediastinal lipomatosis, dilated and tortuous great vessels in the older and atheromatic individual, constitutional variations of the vessels topography. Limits found out during this work concern heart examination and hilum study; great strides are to be achieved in these fields because of the unceasing technical improvments.

[An unusual care of intestinal invagination: jejunojejunal invagination]. / Un cas rare d'invagination intestinale: l'invagination jéjunojéjunale.

BACKGROUND: Jejunal intussusception is uncommon in comparison with ileocolic form. It is more frequent in children over 2 years of age and has an atypical subacute presentation. An underlying anatomical cause is usually found. CASE REPORT: A 14-year-old boy was admitted for abdominal pain with bilious vomiting. The physical examination was normal, with only the ultrasonography showing an intussusception in the left hypochondrium. At laparotomy the diagnosis of jejunal intussusception was made; its reduction was impossible. A resection and end to end anastomosis was performed. The anatomopathology examination found a polyp in ectopic gastric mucosa. CONCLUSION: Jejunal intussusception must be better understood as its diagnosis could be made too late. Surgical exploration is the treatment of choice because of the usual underlying anatomical cause.

[Surgical aspects of intussusception due to lymphoma in children]. / Aspects chirurgicaux des invaginations intestinales sur lymphome chez l'enfant.

BACKGROUND: Intussusception due to lymphoma is a challenging condition for pediatric surgeons. The aim of this study is to report seven cases of this entity and to discuss its management. CASE REPORT: Six boys and one girl, 3-15-years-old, were admitted for intussusception secondary to a lymphoma. All patients underwent laparotomy: biopsy of massive abdominal tumor 6 and 8 weeks following resection of an intussusception (two cases), ileal resection of non-reductible intussusception (one case), right hemicolectomy for tumor of the appendix (one case), tumorectomy of localized ileal tumor (two cases), enlarged mesenteric lymph node biopsy associated with simple reduction of intussusception (one case). All children were successfully treated with protocol chemotherapy with a 15-month to 13-year follow-up. No relapse was observed. CONCLUSION: Surgeons should be aware of operative sights of ileal lymphomas. Diagnosis of lymphoma may be difficult after manual reduction of intussusception. A sample of any abnormality (mesenteric lymph node, peritoneal fluid) should be taken. Intestinal resection allows to reduce the intensity of chemotherapy but must be as limited as possible: ileal resection in cases of complicated intussusception, tumorectomy "in sano" in cases of ileal parietal isolated tumor. Reduction of intussusception alone (with no resection of ileal tumor) seems to be effective if diagnosis of lymphoma is possible from peripheral samples (peritoneal fluid, pleural effusion, mesenteric lymph node, bone marrow biopsy...).

[Mediastinoscopy]. / La médiastinoscopie.

Mediastinoscopy was initiated by E. Carlens in 1959 and enabled the exploration of the mediastinal tissues, above all the lymphatics with both a diagnostic and a prognostic aim. Surgical intervention was performed most often under general anaesthesia and cervical mediastinoscopy was carried out under direct visual inspection thanks to a thoracoscope with its own light source so that the mediastinal axis, the thymic area and also the peripheral mediastinum could be examined. The examination can be completed or even replaced by antero-lateral mediastinoscopy. Biopsies with forceps are in general of good quality. Side effects or complications are rare (1-3.8%) and the mortality is practically nil (0-0.5%). Diagnostic mediastinoscopy is indicated in cases of isolated or multiple mediastinal adenopathy, mediastinal tumours in particular those of the thymus whose extent is not evident. And finally certain miscellaneous pulmonary conditions. The sensitivity is 95-99% in sarcoidosis or metastatic lymphadenopathy and a little less in malignant lymphomas or thymic tumours. Mediastinoscopy is used to assess prognosis as regards the extension of broncho-pulmonary cancer. The existence and the site of metastatic nodes can be precisely assessed possibly on the contralateral side too, and influences the therapeutic orientation. The rare failures of mediastinoscopy leave a remaining 5% for an exploratory thoracotomy. Computered tomography does not seem to replace mediastinoscopy but rather guides its application. It is also part of the assessment of malignant lymphomas in certain situations.

[Respiratory obstruction during anesthesia in cases of mediastinal malignant lymphoma]. / Obstruction respiratoire peranesthésique en cas de lymphome malin médiastinal.

Three cases of asphyxia at the beginning of general anaesthesia for mediastinoscopy or biopsy of adenopathy are described in patients with malignant lymphoma. One of them died in spite of endobronchial intubation, artificial ventilation and steroids. The two others recovered when specific chemotherapy was added to the same symptomatic treatment. The risk of respiratory obstruction seems higher in non-Hodgkin than in Hodgkin lymphomas. This kind of obstruction is not relieved by an antiasthmatic therapy. Pulmonary lymphatic filtration may be hindered in case of mediastinal lymphoma, especially during anaesthetic induction, and pulmonary interstitial congestion may occur impeding gas propagation. Specific chemotherapy according to the histological type of the tumour may relieve the compression and respiratory obstruction in a few hours.

[A case of thymolipoma in a child (author's transl)]. / Un cas de thymolipome chez l'enfant.

A new case of asymptomatic thymolipoma in a 4.5 years old girl is reported. It was discovered during systematic medical investigation. Its radiological characteristics and the lack of evolutivity made the authors suspect the diagnosis before operating. A total surgical extraction of the 300 g weighing tumor was performed through a right thoracotomy. No complication occurred in the post-operative time. Others authors already indicated the scarcity of this affection (less than 10 cases in children) as well as the special radiological characteristics of this tumor and the noticeable clinical tolerance often despite a large bulk. Histologically the tumor is made of an infiltrating of the normal thymic tissue by proliferating adipose adulte cells, the benignity of which is demonstrated by the evolution. In this study a differential diagnosis between thymolipoma and other mediastinal tumors is made and also some pathogenic assessments. Surgery always is required for treatment.

[The lymphatic drainage of the stomach (author's transl)]. / Le drainage lymphatique de l'estomac.

The authors became interested in the lymphatic drainage of the stomach in order to attempt to determine for each region the type of drainage and the risk of cancer spread. They studied 132 dissections including 97 injections, 210 cases records of gastric carcinoma, 8 lymphographies by ultrafluid Lipiodol and 17 peroperative injections of vital staining. The system of drainage proposed by Rouvière was on the whole confirmed; however, one should emphasise the doubling of the hepatic chain, the existence of long collectors which bypass a relay in the left gastric artery, the importance of the posterior gastric artery which transmits the lymphatics of the splenic chain. Finally, the authors emphasise the existence of 3 longitudinal areas on the stomach where the presence or agsence of valvules in the subserous collectors orients the lymph towards the lesser or greater curvature of the stomach, which easily explains the onset of isolated carcinomatous adenopathy, situated on the curvature opposite the neoplasm.

[The injection of the lymphatic system of the stomach during surgery by vital staining dye: an anatomical or surgical interest? (author's transl)]. / L'injection per-opératoire du système lymphatique de l'estomac par colorant vital. Intérêt anatomique ou intérêt chirurgical? A propos de 20 cas.

The authors present the report of their experience of 20 injections of the lymphatic system of the stomach during surgery by vital staining dye: 19 times by Pontamine sky blue 6 BX, 1 time by patent blue violet. The results of this study are analysed; the anatomical interest is specified. Nevertheless, this technique presents no surgical interest concerning the stomach, in spite of many authors' opinion.

[First-intention surgical treatment of thyroglossal duct cysts in children: apropos of 99 cases]. / Traitement chirurgical de première intention des kystes du tractus thyréoglosse chez l'enfant: à propos de 99 cas.

INTRODUCTION: Thyroglossal duct cyst (TGDcs) is the most common malformation of the neck. The risk of infection and malignant transformation impose its treatment. OBJECTIVES: The purpose of our study were: 1) to specify some points about the symptomatology and preoperative evaluation necessary for TGDcs diagnosis; 2) to analyse the factors who can explain an unsuccessful surgical treatment. PATIENTS AND METHODS: Our study is based on a retrospective review of cases and a review of the literature. From 1981 to 2000, 99 children with a mean age of five years were treated for a TGDcs with a surgical procedure in the Grenoble University Hospital. 3 excision and 96 Sistrunck's procedure were performed. In all cases a histological study was made. RESULTS: Ultrasonography was the most frequent preoperative evaluation. We have had 7 complications: 3 haematoma, 2 abscess and 2 desunited scar. 6 children have had recurrent disease. Among these 6 children, 3 have had an excision and 3 a Sistrunck's procedure. No case of malignant transformation was reported. CONCLUSION: Ultrasonography is the first preoperative evaluation to obtain before surgical treatment of a TGDcs. Sistrunck's procedure is the best surgical treatment with a value of recurrence from 1% to 10%. Areas of surgical failure included breaking of cyst during the dissection, inadequate hyoïd bone resection, an anatomical variation with many ductuli in the base of tongue, inadequate muscles of tongue resection.

[Pancreatic injuries. Report on 42 cases (author's transl)]. / Les traumatismes du pancréas. A propos de 42 observations.

Between 1975 and 1980, 42 pancreatic injuries have been managed, they represented 9.5 per cent of abdominal injuries. Nine patients received penetrating trauma and thirty three patients sustained blunt trauma, the majority of them was a road accident. Associated and concomitant injuries of abdominal organs were present in 81 per cent of cases with the pancreatic trauma. More than 66 per cent have multiple brain, thoraco, abdominal, and bones injuries. Thirty two patients have been treated before the sixth hour. The emergency surgical treatment has been conservative in twenty six patients and a primary resection has been performed in twelve patients, (with eleven partial pancreatectomy and one pancreatoduodenectomy). But four patients died on the operating table because they have extensive injuries to several abdominal organs. Postoperative complications were present in 66 per cent of cases. They obliged the drainage of abscesses, three distal pancreatectomy and one pancreatoduodenectomy. The global mortality is 31 per cent, the secondary mortality is 21.4 per cent. The authors conclude thanks to the study of this series and of literature that the frequency of pancreatic trauma increased, and that its gravity is directly related to the number of other organs damages, missed or delayed diagnostic and to an inappropriate emergency treatment, which let necrosis and infection making their deadly evolution.

[Child proctology. Practical aspects]. / Proctologie infantile. Aspects pratiques.

This review analyses the clinical and therapeutic bases of the various affections of child proctology. The authors emphasizes the need for a careful clinical examination.

[Venous approach in children. Apropos of central venous catheterization in pediatrics. Technics excepted]. / Abord veineux chez l'enfant. A propos du cathétérisme veineux central en pédiatrie. Techniques exceptées.

After a short history report the authors emphasize the mains problems encountered within the central venous catheterization procedures in pediatric intensive care: indications and contraindications, complications, mainly mechanicals and septics. Various kinds of venous access, according to their proper advantages and drawbacks are discussed, and therefore some special applies. A very main strictness is indispensable for good issue and benefits in this high risk technology.