[Proton pump inhibitors (PPI): may be not as harmless as believed]. / Inhibiteurs de la pompe è protons (IPP): peut-être pas si inoffensifs que cela.

Proton pump inhibitors (PPIs) are among the most widely prescribed medications worldwide and their use is increasing. Their efficiency has been proven and the short term tolerance is good with few reversible side effects. However concerns about possible long term side effects continue to arise. This article reviews proven and potential side effects associated with PPI especially on the long term use.

[Acute abdominal pains in children: when to refer to the surgeon?]. / Douleurs abdominales de l'enfant: quand appeler le chirurgien?

Children presenting with acute abdominal pains at emergency rooms are frequent, but few of them require a pediatric surgeon. However it can be dangerous for the patient (and for the physician = major cause of prosecutions) to misdiagnose those cases. Children with "classic" gastroenteritis may prove to have a perforated appendicitis, while those with tender abdomens may suffer pneumonia or streptococcal pharyngitis, and a comatous child may have an intussusception and not a metabolic disease. We review the diagnostic and management of some common causes of surgical abominal pains in children to help the physicians to avoid some pitfalls, and to involve the pediatric surgeons at an early stage.

A 16-month-old boy vomits a double tongue: intraluminal duplication of the cervical esophagus in children.

A 16-month-old boy presented with a story of stridor, solid dysphagia and a history of spectacular protrusion underneath his tongue which was mistaken by the parents for a snake's tongue! The radiological examinations showed a filling defect of the upper and middle third esophagus which compressed the cervical trachea. This was found to be an intraluminal tubular esophageal duplication. Treatment by cervicotomy and unusual histological facts are presented.

[Pediatrics]. / Pédiatrie.

This article summarizes the medical progress achieved in 2 frequent and 2 rare pathologies: 1. Cryptorchidism should be operated around 12 months of age and hormonal treatment abandoned in order to maintain fertility and avoid development of testicular tumors. 2. For the treatment of streptococcal pharyngitis oral cephalosporins for 4 to 5 days are equivalent to a Penicillin treatment of 10 days. 3. Thanks to carvedilol (a beta-blocker agent), levosimendan (a calcium sensibiliser) and nesiritide (an analog to the natriuretic peptide) a new hormonal approach to cardiac failure is possible. 4. Corticosteroids allow to improve quality of live and life expectancy in Duchenne muscular dystrophy, provided treatment starts early and a multidisciplinary approach is assured.

Biliary calculi caused by hemobilia.

Formation of biliary calculi caused by hemobilia is rare. Including the two cases reported here, there are only a total of four in the literature. The characteristics of these calculi in vitro, on computerized tomographic scan, and cholecystography are described. The condition for the occurrence seems to be that blood clots remain in the gallbladder sufficiently long (about 6 months) to become encrusted with bile constituents. Patients with hemobilia with clots in the gallbladder should be observed for this complication.

Major perineal trauma in children.

Between 1976 and 1987, 22 children aged 3 to 17 years (mean age, 9.5 years) were admitted to our institution with major perineal trauma. There were 14 urethral ruptures and 9 rectal lesions. The lesions were multiple and combined: vaginal and urethral or vaginal and rectal injuries were found in 10 females, while only 1 of 12 males had both urethral and rectal lesions. In most instances, perineal physical signs did not reflect the severity of the lesion. Among the patients with urethral lesions, there was no sex or age predominance; complete rupture occurred in four females and eight males. The insertion of a urethral catheter was of no diagnostic help. Retrograde urethrogram demonstrated a lesion in seven of eight cases. The intravenous pyelogram (IVP) showed evidence of extravasation in two of the eight cases, and in four instances there were indirect rupture signs. A suprapubic cystostomy was performed in 12 of the 14 urethral injuries. A primary repair with urethral stenting was carried out twice without bladder drainage. Immediate repair was performed in eight cases and delayed in five others. Within this last group, two patients were cured without sequelae by stenting without suture, while the three others who underwent only cystostomy necessitated multiple reconstructive operations with poor results. It is of interest that the four treatment failures occurred in the youngest patients (4 to 7 years of age). The rectal lesions were related to impalement in seven of nine patients. Rectoscopy allowed localization of perforations but did not permit identification of sphincter injuries when the mucosa was intact. Primary repair was possible in all cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic surgery for gastroesophageal reflux disease during the first year of life.

BACKGROUND: Very few children need gastroesophageal antireflux surgery during their first year of life; hence, no series has been published so far. The authors report their experience in 3 centers. METHODS: From January 1993 to December 1998, 36 infants between 23 days and 13 months of age, suffering from gastroesophageal reflux disease (GERD), underwent surgery by a laparoscopic approach. The patients' weights ranged from 2.4 to 8.5 kg. Preoperative diagnostic studies included esophagograms, manometries, endoscopies, and pH-metries. Fifteen babies (41.6%) had associated anomalies, and 10 (27.7%) were neurologically impaired. Thirty-six laparoscopic fundoplications were performed according to either Toupet's procedure (17 of 36), Rossetti's (10 of 36), Nissen's (8 of 36) or Lortat-Jacob's (1 of 36). Four infants previously had undergone a gastrostomy, whereas 6 needed one during the antireflux procedure. RESULTS: There was no mortality in our series. Three infants (8.3%) had an intraoperative complication: 1 lesion of a diaphragmatic vessel, 1 pneumothorax, and 1 case of severe hiatal hernia requiring conversion to open surgery. During the median follow-up of 22 months, 4 redo procedures were performed (11.1%). CONCLUSIONS: This experience shows the feasibility of laparoscopic fundoplication even in children below 1 year of age. An accurate preoperative diagnostic study is mandatory, because 50% of these patients presented associated anomalies. A long and accurate follow-up is necessary to evaluate long-term results and detect possible complications, which can occur as late as 1 year after surgery. In addition, we believe that redo antireflux surgery is possible by the laparoscopic approach without major difficulties, based on our larger experience with older children.

Gracilis muscle transposition for anal incontinence in children: long-term follow-up.

We report a series of 7 patients, aged 6.5 to 19 years (mean, 12.9), who have been treated for uncontrollable fecal incontinence since 1976: 5 had imperforate anus and multiple subsequent operative procedures, 1 had a low myelomeningocele with bi-sphincteric incontinence, and 1 had a traumatic destruction of the sphincter apparatus. A modified Pickrell procedure was performed, with the gracilis muscle transposed subcutaneously, without constructing a pulley through the median raphe as originally described. All patients were evaluated by anorectal manometry preoperatively and post-operatively. They were followed-up for a period of 0.5 to 12.5 years (mean, 4.4). All patients were continent at follow-up, with a normal defecation pattern and no enemas required. None of the patients had evidence of fibrosis of the muscle or anal canal, and tension in the transposed muscle was maintained. Voluntary contractions remain efficient in all cases. Age was thought to be an important factor: personal motivation and compliance with physiotherapy, essential for a good outcome, is unlikely to be present in the younger child. We conclude that the gracilis sling procedure is an excellent long-term alternative for total fecal incontinence when time and other therapeutic measures have failed.

Esophageal leiomyoma in children: two case reports and review of the literature.

Leiomyoma of the esophagus is not uncommon in the adult population but is rarely seen in children; only 20 cases have been reported in the pediatric population. In this paper we describe two cases of esophageal leiomyoma in female patients aged 6 and 13 years and review previous reports. Several differences were noted between the pediatric and adult population. The mean age in children is 14 years (range, 4 to 20 years). Leiomyoma appears 1.71 times more often in females than in males. Localized lesions are found in only 9%, whereas the diffuse form predominates in 91%. The entire esophagus may be involved 35% of the time, and encroachment on the cardia or upper stomach occurs in 70%. Leiomyomas associated with familial syndromes (familial leiomyoma and Alport's syndrome) occur in 22% of the cases. Major symptoms include dysphagia (86%), dyspnea (36%), vomiting (27%), retrosternal pain (27%), and coughing (22%). The initial diagnosis following contrast studies is most often achalasia. The diagnosis of leiomyoma is made only with subsequent endoscopy. Enucleation was performed in only 11% of the cases; surgical resection (including part of the stomach) was necessary in 78% with a 21% postoperative mortality. Esophageal leiomyoma should be considered in the differential diagnosis of mediastinal masses and esophageal obstruction. Accurate preoperative diagnosis is desirable in order to plan proper surgical treatment.

Tracheobronchial ruptures from blunt thoracic trauma in children.

BACKGROUND/PURPOSE: Tracheobronchial ruptures in blunt thoracic trauma in children are rare. The aim of this study was to suggest the means of an early diagnosis and a conservative management as often as possible. METHODS: Sixteen cases of tracheobronchial ruptures by blunt thoracic trauma were observed over 26 years in 9 regional pediatric centers. RESULTS: There were 12 boys and 4 girls, from ages 1 hour to 17 years. Nine children presented with associated lesions. Fibroscopy established the following diagnosis: 8 tracheal wounds and 8 bronchial wounds. Six children were operated on within 18 hours (on average) after installation of a thoracic drainage. Two lobectomies, 3 ideal tracheal sutures, and 1 bronchial suture were performed. Seven children were treated exclusively by thoracic drainage. Two of them were intubated through the lesion, leading to a transitory endoprothesis accompanied or not by an external thoracic drainage. One infant recovered spontaneously. There were no deaths in this series. Two recurrent postoperative nerve injuries were noted, one of which was a transitory spontaneously resolutive scar bud and one a granuloma treated by laser. Three times, a stenosis occurred after a conservative management. Two were operated on. CONCLUSIONS: Tracheobronchial ruptures in children are rare. An early fibroscopy holds an important place in the approach of this pathology. Treatment is variable, based on thoracic lesions, their tolerance by the child, and associated lesions. Surgery is not the only therapy because conservative treatment by simple thoracic drainage or lesion intubation has proved effective.

Obstetric fractures.

The purpose of this study was to determine the risk factors predisposing to an obstetric fracture, and their long-term outcome. We reviewed 28 obstetric fractures treated in the County of Vaud, Switzerland, between 1976 and 1989. There were 12 fractures of long bones, 10 clavicles and 6 depressed skull fractures. The belief that obstetric fractures occur in large babies or after breech deliveries is no longer valid. The common risk factors of these fractures are obstetric maneuvers during delivery (75% of cases), especially Cesarean sections (35%), prolonged labor (33%), and prematurity (25%). Cephalic presentation (64.2% of cases) is more frequent than breech position (32.1%). Weight, size, age of gestation, age of the mother, parity, gestity, and time of delivery cannot be considered as risk factors for obstetric fractures. For each type of fracture some specific risk factors are pointed out: maneuvers at birth for depressed skull fracture, Cesarean section, breech delivery with assistance and low birth weight for the fractures of long bones. All fractures were treated conservatively, except for skull fractures with a depression of more than 2 cm. Early consolidation is achieved within 2 weeks. Long-term prognosis for obstetric fractures is good without sequelae.

New implantable device for long-term vascular access in children.

We report on our experience in the use of a new system of a totally implantable device for repeated vascular access in children, developed in 1989 by Pharmacia and named P.A.S. Port (Peripheral Access System Port). The P.A.S. Port is far smaller than other systems and has been designed for peripheral location in the arm. This avoids unsightly pectoral scars particularly in girls and allows insertion under local anesthesia. It is an interesting alternative to the Port-a-Cath for children older than 5 years of age. It is easily accepted by the patient as well as by the caring team.

Esophageal replacement in children: evaluation of the one-stage procedure with colic transplants.

After having practiced two-stage esophagoplasties by retrosternal Iso-peristaltic colic transplant since 1966, we introduced the one-stage procedure in 1989, placing the transplant in the posterior mediastinum following a closed-chest esophagectomy. We have performed 121 such esophagoplasties in children until now. To evaluate the possible effects of the different techniques as accurately as possible, we recorded two uniform series of 32 and 41 esocoloplasties carried out under identical conditions by two operators respectively. All of the children, aged 1.2 to 13.9 years (mean age: 4.3 years and 4.8 years, limits 1.2-13.9 years), were operated upon for caustic burns of the esophagus. The general concept of both interventions is the same. Improvements such as optimizing the proximal and the colo-gastric anastomosis and the creation of an anterior anti-reflux hemi-valve were aimed for. The one-stage esophagoplasty has become a shorter procedure (mean 4.9 h) than the two-stage one (mean 5.7 h). The one-stage procedure has no higher rate of per-operative complications than those observed during the two-steps of the staged operation. One-stage esophagoplasty provides better morphological results. The redundancy of the transposed colon, the narrowing effect of the upper cervical passage and of the point of re-entry into the abdominal cavity are avoided. The mediastinal colon is straighter, which allows better emptying by gravity. The improvement of the lower anastomosis decreases the reflux rate in the transplant to 12%. Postoperative care demands a longer stay in the intensive care unit because of pharyngeal and left pulmonary respiratory complications. For these reasons we kept our patients intubated for a period of 2 to 5 days (mean period: 3.4 days). All patients survived the intervention.

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.

[Epilepsy and accidents: what is the risk in children?]. / Epilepsie et accidents: quel risque chez l'enfant?

BACKGROUND: Constant distress and overprotection of parents result from the apprehension and misinformation received, regarding epilepsy of their children and the risk of accidents occurring due to a seizure. Large retrospective studies show that the epileptic children are not more often concerned than the general population. CASE REPORTS: One hundred and ninety-eight epileptic children without permanent motor or mental handicap were followed between 1971 and 1981, covering 1056 years of child's life. They were compared to 3822 injured children admitted to the surgical pediatric emergency unit between 1983 and 1992. RESULTS: Only six accidents occurred because of a seizure in the first group of epileptic children. There were neither deaths nor sequelae. Four of these six accidents revealed an unknown epilepsy. Among the 3,822 injured children, 19 were epileptic but only four of these 19 accidents were caused by a seizure. There were no sequelae. CONCLUSION: The majority of epileptic children without associated handicap are able to have all the normal activities of healthy children. Only severe epilepsies with frequent refractory seizures, some reflex epilepsies and some cases before the seizures are under control require constant supervision.

[Accident prevention in early childhood]. / Prévention des accidents de la petite enfance.

Accidents are the first cause of mortality and morbidity in children and adolescents of both sexes as from their first month of life. Also they are the first cause of hospitalization and thus have an important economical impact. The knowledge of the mechanisms of injury can neither be transposed from a place to another nor be extrapolated with time. For this reason we developed in 1989 a prospective data base for injuries of children and adolescents from 0 to 16 years of age occurring in our state (canton de Vaud, Switzerland). From Jan 1st, 1990 to Dec 31st, 1999, we recorded more than 28,000 cases. Infants and young children are involved in domestic injuries, accidents on playgrounds and in traffic accidents being pedestrians or passengers. We analyze the circumstances of accidents and point out their prevention programs and their efficiency. We try to demonstrate why children injuries are not fatalities but depend on mechanisms which can be predicted inarticular by an adequate information.