Abdominal lymphangiomas in children: interest of the laparoscopic approach

BACKGROUND

Lymphangiomas are rare benign lesions of the lymphatic system. The most common symptoms are abdominal tumor or "acute abdomen" in children. The treatment of choice is complete surgical resection, but the recurrence rate with incomplete resection is high, and laparotomy exposes the patient to adhesions. The authors report their experience with the lymphangioma laparoscopic approach.

METHODS

This retrospective study examined 15 consecutive operations for lymphangiomas in children, ages 5 months to 14 years, treated during the 5-year period from 1999 to 2004.

RESULTS

Six patients were treated using the primary laparotomy approach, and nine patients underwent the laparoscopic procedure, six successfully. Three conversions were necessary (1 case requiring partial colectomy, 1 retroperitoneal case with adherence on the aorta and vena cava, 1 case with partial volvulus). Morbidity included two cases of acute occlusion caused by adhesions after laparotomy. There was no recurrence of lymphangioma during a mean follow-up period of 35 months.

CONCLUSION

The laparoscopy procedure could be used successfully for abdominal lymphangioma, even in an emergency. When the laparoscopic resection is impossible, laparotomy or sclerotherapy can be discussed.

Ability of a new oral nicotine substitute to reduce smoking urge in moderate smokers

The aim of this study was to assess the effectiveness of a new nicotine lozenge ( Nicopass 1.5 mg) in reducing smoking urge after an overnight abstinence. Twenty-four moderate smokers participated in a randomized, double-blind, placebo-controlled, 2-period crossover trial. The results showed that 1.5 mg-nicotine lozenge is superior to placebo in reducing smoking urge (p = 0.0001). In addition, nicotine lozenge, but not placebo, significantly improved vigilance and psychomotor performances (p < 0.05) and displayed a cardiac chronotropic effect. Thus, the 1.5-mg nicotine lozenge appears as an effective aid to alleviate acute tobacco withdrawal symptoms in moderate smokers.

Optimizing the surgical management of lung nodules in children with osteosarcoma: thoracoscopy for biopsies, thoracotomy for resections

BACKGROUND

The goal of this study was to assess the role of thoracoscopy (TS) and thoracotomy (TT) in the management of lung nodules in children with osteosarcoma.

METHODS

Charts of 16 osteosarcoma patients undergoing surgery for lung nodules were retrospectively analyzed for a correlation between nodule localization at CT scan, findings at surgery, and pathology.

RESULTS

Fourteen TSs were performed in 10 children, eight of which were converted: two for technical problems, and six for inconsistency between CT scan and intraoperative findings. In three converted cases, TT allowed detection of more nodules than CT scan and/or TS. Eight TTs were performed as primary intention in seven children, in one as secondary surgery after a previous TS. In three cases, TT detected more nodules than CT scan. Overall, TT detected more nodules than CT scan in seven of 16 cases (sensitivity, 56.2%), six of whom had a predicted bilateral involvement. Neoplastic tissue was present in lung samples of all but three patients (86.4%).

CONCLUSIONS

Lung nodules in osteosarcoma patients are usually metastases. CT scan is unreliable in detecting all the nodules, especially in the case of predicted bilateral involvement. If excision of all metastases is considered the goal of surgery, a TT approach should be chosen in patients with more than one thoracic nodule.

The cholecystocolic bypass with jejunal interposition graft for bile acid depletion in bile and portal blood in guinea pigs

Ileal bypass and cholecystostomy are used in children with selected cholestatic diseases to lower the bile acid (BA) levels in bile and blood and improve outcome. The efficacy of a cholecystocolic bypass in achieving the same goals was investigated in guinea pigs. In the study group (n=7), a cholecystocolic bypass was performed using a jejunal graft interposed between the gallbladder and the cecum. In the control group (n=5), a cholecystojejunal bypass was performed with a similar graft implanted in the proximal jejunum. Total BA concentration was measured in bile and portal blood at surgery (D0) and 30 days later (D30) by pooling the concentrations of 7 individual BA. D30/D0 BA ratios were compared. All animals developed normally without clinical symptoms. A 76% reduction in the bile T-BA levels was observed in both groups (p<0.05). A 80% decrease of T-BA levels was observed in portal vein in study group (p<0.05), suggesting that ileal bile flow and BA ileal reabsorption were highly impaired. No change in portal vein BA levels was observed in control group. Cholecystocolic bypass led to a significant loss of bile acids in guinea pigs and might be considered for bile diversion in pediatric patients with selected cholestatic diseases.

[Antenatal diagnosis of ovarian cyst: perinatal management]

More than 85% of prenatal ovarian cysts have a follicular or luteal origin. Their natural history is a spontaneous involution. However, adnexal torsion resulting in the loss of the ovary can occur at any time of the evolution. Pre and postnatal changes in the sonographic aspects allow to choose the appropriate therapeutical indications: conservative approach, laparoscopic surgery, or percutaneous aspiration. Prenatal aspiration must be avoided. The last prenatal sonographic examination should be performed as close as possible from the end of the gestation, and the first postnatal echography within the first 24 hours of life. Surgery of prenatal complicated cysts has to be planned a few days after birth. Uncomplicated prenatal cysts will be treated depending on size and echographic patterns at birth.

Costal cartilage grafting for repair of a recurrent tracheoesophageal fistula in a 1.6-kg baby with esophageal atresia

A large intraoperative tracheal tear occurred during correction of a type III esophageal atresia in a 1,630-g premature baby. It was repaired by primary suture. Recurrence of the tracheoesophageal fistula (TEF) was treated operatively with esophageal exclusion and costal cartilage grafting (CCG) onto the tracheal defect. At 3 months of age, successful esophageal reconstruction was performed using a posterior mediastinal colonic interposition. On 27-month follow-up, the child was symptom-free and thriving. Surgical options for TEF recurrence and intraoperative management of the tracheal air leak are discussed. CCG is advocated as an attractive material for tracheal repair even in low-weight prematures.

[Bilateral vas deferens agenesis and inguinal hernia in a child. A rare, early presentation of cystic fibrosis]

Epididymal and ductal anomalies can be discovered incidentally during inguinal herniorraphy in children. The congenital bilateral absence of vas deferens is frequently associated with cystic fibrosis.

CASE REPORT

This agenesia of vas deferens was detected in a 5-month-old boy who underwent an inguinal herniorraphy. Although the child did not present any symptoms, he actually presented cystic fibrosis: the sudoral test showed high levels of chloride (95 mmol/L) and an isolated homozygous delta F 508 deletion on the gene CFTR was evidenced on genetic investigations.

CONCLUSION

The congenital bilateral absence of vas deferens is the most frequent anomaly of the male genital tract discovered in adults investigated for azoospermia. Relations with cystic fibrosis are well established but congenital bilateral absence of vas deferens discovered during infancy is an exceptional situation that requires genetic investigations to show evidence of a likely underlying cystic fibrosis.

Is the appendix graft suitable for routine biliary surgery in children?

BACKGROUND/PURPOSE

The appendix graft (AG) is used widely for urinary tract replacement in children. Biliary tract replacement is less common. The purpose of this retrospective multicentric study was to evaluate the safety of appendix grafting for biliary reconstruction.

METHODS

The files of 33 patients treated at 7 European pediatric centers were reviewed. Indications included choledochal cyst (CC) in 5 cases, biliary trauma (BT) in 1, and biliary atresia (BA) in 27. In CC and BT patients, the graft was inserted isoperistaltically between the proximal biliary duct and second duodenum. In all but one of the BA patients, the graft was placed antiperistaltically by patching its cecal end onto the porta hepatis.

RESULTS

Postoperatively, all CC and BT patients initially became asymptomatic but developed laboratory evidence of anicteric cholestasis within 1 year. The most common manifestation was increased gamma-glutamyl-transpeptidase level (GGT), whereas histologic findings showed liver damage (mainly fibrosis). Reoperation has been carried out in 4 CC and 1 BT patients within a mean period of 19 months after appendix grafting. The graft procedure was converted to hepaticojejunostomy (HJ) in 4 and to choledocoduodenostomy in 1. Surgical exploration showed kinking in 1 patient and stenosis in 1. In the remaining 3 cases, there was no discernible cause of cholestasis, and appendix histology findings were normal. In all 5 reoperated patients, liver function findings returned to normal within 1 month. Reoperation is scheduled for the remaining CC patient who currently requires ursodesoxycholic medication to maintain normal liver function and presents histologic evidence of "de novo" sclerosing cholangitis. Results of appendix grafting also were poor in the 27 BA patients. Procedure-related perioperative complications occurred in 4 (15%) including 1 early death from graft necrosis. Another early death resulted from intestinal hemorrhage. Jaundice cleared in only 8 (28%).

CONCLUSIONS

The findings of this study suggest that the AG is unsuitable for routine biliary repair in children. It should be used only as a salvage technique when conventional HJ repair is contraindicated. Because of the high risk of graft dysfunction, we recommend screening tests to detect biochemical or histologic cholestasis in any patient previously treated with appendix grafting.

Delayed cure of an omphalocele requiring abdominosternoplasty, right hepatectomy and partial splenectomy

A large ventral hernia resulting from the primary treatment of an omphalocele according to the Gross technique was repaired at age 16. The girl presented with extra-abdominal development of the liver and the spleen along with hypotrophy of the abdominal and thoracic cavities. The operation included enlargement sternoplasty, liver and spleen-size reduction and prosthetic abdominal closure. The cosmetic and functional results are good and stable on 7-year follow-up. Surgical issues and blood transfusion policy are discussed. A multi-disciplinary pediatric surgical approach is advocated.

Inappropriate liver transplantation in a child with Alpers-Huttenlocher syndrome misdiagnosed as valproate-induced acute liver failure

A 3-yr-old boy received valproic acid (VPA) for recurrent seizures. He developed coma and acute liver failure that were attributed to VPA toxicity, and underwent emergency orthotopic liver transplantation (OLTx). Despite good graft function, his neurological state worsened and led to death a few months later. The diagnosis of Alpers-Huttenlocher Syndrome (AHS) was suspected, subsequently to liver Tx, in view of ongoing neurologic deterioration and magnetic resonance imaging (MRI) findings. The syndrome, recessively inherited, associates brain degeneration with liver failure, and is now considered a mitochondrial disease. Enzyme activity deficiencies of the respiratory chain were identified in muscle mitochondria, as well as morphologic abnormalities of mitochondria in the explanted liver. Guidelines for diagnosis are presented, in order to differentiate the liver failure in AHS from that induced by genuine VPA toxicity. It is recommended to avoid liver Tx in patients with AHS given the fatal neurological course of the disease.

Use of polydimethylsiloxane for endoscopic treatment of neurogenic urinary incontinence in children

PURPOSE

We report on the injection of polydimethylsiloxane for endoscopic treatment of urinary incontinence in children with neurogenic bladder and determine the optimal criteria for patient selection.

MATERIALS AND METHODS

We have treated 17 boys and 16 girls since 1995. The etiology of incontinence was spina bifida in 24 cases. Previous surgery was performed in 18 patients, including bladder neck reconstruction in 15 and bladder augmentation in 9. Mean patient age at injection was 13 years (range 7 to 17). We administered 1, 2 and 3 injections in 21, 11 and 1 patients, respectively. Mean volume at each injection was 3.2 cc. Mean interval between injections was 6 months (range 3 to 15). In all cases injection was done transurethrally.

RESULTS

Followup ranged from 6 to 41 months (median 16). A total of 11 patients (33.3%) are dry (continence for greater than 4 hours and no urinary pad use during the day) and 8 (24.2%) are improved (continence for 2 to 3 hours and minimal pad use). Results are poor in 14 cases. Overall previous bladder neck surgery or preoperative detrusor hyperactivity did not influence results. Good results were mainly associated with female gender (47.4% of girls versus 10.5% of boys achieved cure).

CONCLUSIONS

Injection of polydimethylsiloxane at the bladder neck resulted in continence in 33% of neurogenic bladder cases. Better results occurred in girls and injection did not compromise other surgical procedures. Polydimethylsiloxane seems more suitable than bovine collagen due to potential problems with biological product use.

[Iterative fractures in type I primary hyperoxaluria. Report of 2 cases]

PURPOSE OF THE STUDY

Type I primary hyperoxaluria is a rare autosomal recessive disease linked to a deficit in an hepatic enzyme. The purpose of this study was to analyze orthopedics problems caused by type I primary hyperoxaluria before and after liver and kidney transplantation.

MATERIAL AND METHODS

Two cases of children carrying this type I primary hyperoxaluria followed up after liver kidney transplantation are presented and compared to last publications.

RESULTS

Combined transplantation progressively corrected osseous lesions and aspect of the stroma. However it did not provide protection against fractures particularly for femoral neck fractures.

DISCUSSION

In type I hyperoxaluria overproduction of calcium oxalate causes its accumulation in the whole organism and particularly in bone. Osseous fragility favors pathological fractures. Only combined liverkidney transplantation can save and cure these children. Frequency of this fracture after transplantation indicates preventive plating at first pain, possibly at the same time as transplantation. Kidney transplant failure puts the patient in a "congealed" clinical state where the bone is very rich in oxalate and where the hemodialysis does not eliminate oxalate salts.

CONCLUSION

Type I primary hyperoxaluria is a very rare disease. Fractures are very common even after liver and kidney transplantation and especialy femoral neck fractures. We think that preventive plating must be done at first pain. We do not have any explanation for bony weakness after liver-kidney transplantation.

[Contralateral transinguinal laparoscopy in unilateral inguinal hernia]

BACKGROUND

Indication for surgical exploration of the contralateral groin during unilateral herniorraphy in children is the subject of a worldwide debate. Routine exploration based on the likelihood of a patent processus vaginalis (PV) according to age, gender or side to some extent leads to unnecessary procedures, while routine abstention may leave a peritoneal sac, likely to later induce a symptomatic hernia in about 10% of cases.

METHODS AND PATIENTS

One hundred and twenty-five children aged from 1 month to 15 years underwent transinguinal laparoscopic assessment of the contralateral groin, using a 3 mm trocar and a 70 degrees telescope gently introduced through the exposed PV. Surgical exploration was performed only in those patients who exhibited a patent PV, and in patients where the groin was poorly visualized due to technical problems.

RESULTS

Regardless of age, contralateral surgery was not considered in 88 (70%) of the 125 children. Among the 37 patients that were operated upon, eight had a negative exploration due to an erroneous endoscopic evaluation. Surgery was avoided in 35 (56%) of the 62 infants aged less than 2 years, including nine of the 13 prematures who were previously routinely operated upon. Conversely, in the 63 older patients who were readily spared from surgical exploration, the videoscopic evaluation allowed appropriate selection for contralateral surgery in six.

CONCLUSION

A routine policy, either of surgery or observation, is no longer indicated as a quick, safe and cost-effective method is available to detect a patent PV. The transinguinal laparoscopy is safe and could be easily performed by surgeons already skilled in pediatric herniorraphy. Therefore, the videoscopic transinguinal contralateral evaluation is worth being promoted to ensure an appropriate surgery tailored to the anatomical features.

Antenatal rupture of a diverticular rectal duplication with neonatal perineal fistulization

A cystic pelvic malformation was found in a fetus on antenatal sonography (US) at 26 weeks of gestational age that was no longer present 3 weeks later on control US. The male child presented at birth with a right-sided perineal mass that fistulized with meconial drainage. A radiopaque enema showed a low posterior rectal fistula filling a poorly delineated pouch. Surgery performed through a posterior sagittal approach allowed identification and closure of the fistula and pouch drainage. The diagnosis of a diverticular rectal duplication was considered, although no intestinal lining was observed macroscopically or histologically. The child's anorectal function was normal after a 20-month follow-up. Labeling of the malformation and embryological hypotheses are discussed since the case does not fulfill all the criteria of an intestinal duplication. Surgical techniques are discussed, with an emphasis on the sagittal posterior approach.

Comparative bioavailability study of codeine and ibuprofen after administration of the two products alone or in association to 24 healthy volunteers

The study objective was to compare the bioavailability of codeine and ibuprofen after oral administration of the two drugs alone or in association. The study was performed in three different periods, each separated by a wash-out of 6 days. Plasma concentrations were measured in 24 healthy volunteers after administration of a single oral dose of codeine phosphate (25 mg) and/or ibuprofen (200 mg). Codeine and ibuprofen assays were performed using two different HPLC methods. The relative bioavailabilities of codeine and ibuprofen (alone or in association) were 106 +/- 24% (mean +/- sd) and 101 +/- 19%, respectively. The results obtained demonstrated that bioavailabilities of codeine and ibuprofen were not modified when the two drugs were administrated alone or in association.

[Atypical mesoblastic nephroma with metastases right away?]

The diagnosis of a metastatic kidney tumor arising in a 2-month infant is discussed between atypical mesoblastic nephroma and clear cell sarcoma. The precocity of distant metastases, their location in bone marrow, liver and thoracic soft tissues, and their association with myelofibrosis set up an original clinical presentation which seems to have never been described elsewhere. Treatment strategy with surgery of the primary followed by a polychemotherapy combining vincristin-etoposide-ifosfamide and the short term follow-up are reported.

Imaging of pulmonary disease in rheumatoid arthritis using J001X scintigraphy: preliminary results

The purpose of this study was to determine the ability of technetium-99m J001X scintigraphy to image active pulmonary involvement in patients suffering from rheumatoid arthritis (RA). J001X is a fully characterized acylated poly(1,3)galactoside, isolated from Klebsiella membranes, which is able to bind recruited macrophages after aerosol administration. J001X scintigraphy was compared with high-resolution computed tomography (HRCT), pulmonary function tests (PFTs) and bronchoalveolar lavage (BAL) in 15 patients suffering from RA. Patients were considered to have pulmonary involvement when they had an interstitial syndrome on HRCT and a decrease of 20% in TCO/VE (transfer coefficient) on PFTs and/or an abnormal BAL (lymphocytosis higher than 20% and/or percentage of neutrophils higher than 10%). Pulmonary involvement was present in eight patients, and absent in seven. Of the eight patients with pulmonary involvement, all had abnormal BAL, two had an interstitial syndrome on HRCT, two had decreased TCO/VE and three had positive J001X scintigraphy. Of the seven patients without pulmonary involvement, six had normal BAL (not available in one), two had an interstitial syndrome on HRCT, one had decreased TCO/VE and two had positive J001X scintigraphy. According to our gold standard of pulmonary involvement, the sensitivity of J001X scintigraphy for the detection of pulmonary involvement in RA was 37.5%, the specificity was 71.4% and the positive predictive value was 60%. The ability of J001X scintigraphy to detect active pulmonary involvement during RA appears unclear in this study but it may detect processes unnoticed by the other modalities. These patients will be followed 12 and 24 months later and the changes in J001X scintigraphy, HRCT and PFTs will be compared to demonstrate whether J001X scintigraphy is able to assess an active process in the pulmonary involvement during RA and to specify its predictive value.

Ultrasonographic diagnosis and laparoscopic surgical treatment of Meckel's diverticulum

A two-year-old boy was admitted for melena. Ultrasonography depicted an abnormal intestinal structure in the right iliac fossa and the diagnosis of Meckel's diverticulum was suggested. Laparoscopic approach confirmed the diagnosis and allowed resection.

Pediatric endoscopic surgery: pride and prejudice

82 endoscopic surgical procedures (abdominal: 77; thoracic: 5) were performed by the same surgeon on 75 children aged from 1 month to 17 years (median 8.1 years) during the two-year period from January 1991 to December 1992. Due to the multispecialization of the Children's Hospital, a variety of pathologies were explored or treated with appendectomy accounting for 33% (27/82). There were no perioperative deaths. Three major complications occurred (1 post-appendectomy peritonitis, 1 hemorrhage during splenectomy and 1 post-operative occlusion). 14 patients required conversion to open surgery. Indications for endoscopic exploration of advanced lesions, prospective indications, and policy when confronted with a healthy appendix are discussed.

Imaging of pulmonary disease in scleroderma with J001X scintigraphy

BACKGROUND

J001X is an acylated poly-galactoside isolated from the membrane of Klebsiella and able to interact with macrophages, mainly in their activated state. The aim of the present study was to determine the ability of 99m-labelled technetium (99mTc)-J001X scintigraphy to image pulmonary disease, defined by high resolution computed tomographic scanning and pulmonary function tests, in patients suffering from scleroderma.

METHODS

Patients were considered to have pulmonary disease when they had at least two positive signs on high resolution computed tomography, or a decrease in lung volume and single breath carbon monoxide transfer, or both, with no disease process other than scleroderma in their medical history. Positive J001X scintigraphic imaging was defined by symmetrical bilateral pulmonary fixation three and five hours after inhalation of 99mTc-J001X. J001X scintigraphic results were compared with disease activity as indicated by bronchoalveolar lavage (BAL) fluid lymphocytosis.

RESULTS

Seventeen patients were studied, in 12 of whom J001X scintigraphy was positive. There was no correlation between BAL lymphocytosis and J001X scintigraphic findings, nor between BAL and pulmonary scleroderma. This was not surprising because of the high specificity of macrophage targeting by J001X.

CONCLUSIONS

Follow up of a larger population over a longer period is needed to establish whether there is a prognostic value for positive J001X scintigraphic findings in scleroderma.