Laparoscopic distal pancreatectomy for Frantz's tumor in a child

Solid pseudopapillary tumor of the pancreas is a rare pathologic entity. Although the role of laparoscopy in surgery of the pancreas is still controversial, laparoscopic distal pancreatectomy has been reported with good results in adults. We report a laparoscopic spleen-preserving distal pancreatectomy in a 9-year-old boy who presented with a low-grade malignant tumor. Needle biopsy was impossible. A laparoscopic spleen-preserving distal pancreatectomy was performed. We used four trocars, and the operative time was 240 min. Conversion to open surgery was not necessary. The boy's postoperative recovery was uneventful, and he was discharged on the 6th day. CT-scan control at 6 months was normal. This case shows that even in advanced surgical cases, such as spleen-preserving distal pancreatectomy, laparoscopic procedures can be done safely, within a reasonable operative time, in children.

Prenatal management of gastroschisis: the place of the amnioexchange procedure

Gastroschisis is a malformation of the anterior abdominal wall that consists of a right paraumbilical defect with bowel loops bathed in the amniotic fluid. The survival rate is now greater than 90% and the prognosis relies mainly on morbidity attributable to bowel dysfunction. Recent research has examined gastrointestinal waste present in amniotic fluid that induces bowel toxicity and an inflammatory process. The amnioexchange procedure (changing the amniotic fluid regularly) involves a new therapeutic approach: reducing bowel injuries in the fetuses. This article shows that there is an inflammatory reaction in human gastroschisis and in the authors' model, and that the clinical and biological data plead for the practice of amnioexchange in human beings. A randomized, controlled study is now needed.

Laparoscopic adrenal surgery for neuroblastomas in children

PURPOSE

The role of laparoscopy in children with neuroblastomas has not been fully defined. The laparoscopic approach to the adrenal gland is already largely used in adults and a few cases have been reported in children. We report the experience of a single surgical team center with laparoscopic adrenal surgery for neuroblastomas in children.

MATERIALS AND METHODS

Between September 2000 and October 2002 laparoscopic adrenalectomy for neuroblastoma was performed in 9 patients (6 girls and 3 boys) with a mean age of 38 months (range 2 months to 9 years). Two tumors were detected prenatally and 7 postnatally. Preoperative diagnosis was neuroblastoma stage I in 4 cases and stage IV in 3 cases, and nondetermined suprarenal calcified masses in 2 cases. A 4 or 5-trocar transperitoneal approach was used in all cases. The adrenal tumors were completely excised, placed into a plastic bag and removed through the umbilical trocar site.

RESULTS

All of the adrenal tumors were well encapsulated and completely excised. One of the 9 procedures was converted to open surgery because of adhesions to renal vessels. In 1 case a second hepatic localization was removed simultaneously, and in 3 cases 1 or more lymph nodes were resected. Average operative time was 85 minutes (range 45 to 170). There were no deaths. There were no postoperative complications, except 1 port site infection that was treated locally. Blood transfusion was not required. Average hospital stay was 4.5 days (range 2 to 10). Histological analysis of the 9 specimens (maximum length 6 cm) confirmed the diagnosis of neuroblastoma. N-myc status was studied in 8 of the 9 resected neuroblastomas and was amplified in 2 cases (both stage IV with preoperative biopsy). Average postoperative followup was 15 months (range 1 to 25). There was no local recurrence or metastasis, except in the case that required conversion to open surgery (local recurrence 7 months later).

CONCLUSIONS

Laparoscopic adrenalectomy for neuroblastoma is safe and feasible in children, with good results. Experience with advanced laparoscopic surgery is required to achieve this result in optimal oncological conditions. Our short-term results must be reevaluated at long term, and further studies are needed to compare laparoscopy to open surgical techniques.

Follow-up of partial splenectomy in children with hereditary spherocytosis

BACKGROUND/PURPOSE

The aim of this report is to study the short- and long-term consequences of partial splenectomy (PS) in hereditary spherocytosis (HS).

METHODS

The authors reviewed the files of 5 children who underwent PS from 1993 to 1998. The data collected included clinical presentation, age, gender, indication for the operation, radiographic examination, need for blood transfusion and hematologic values, description of surgical procedure, and early- and late-occurring complications.

RESULTS

From 1993 to 1998, 5 children from one year, 9 months to 7 years of age underwent PS. Indications were hypersplenism and severe anemia. The average age at the time of the operation was 3 years, 5 months. The 2 youngest children (one year, 9 months and 2 years old) needed a second operation because of the recurrence of hypersplenism.

CONCLUSIONS

Subtotal splenectomy seems to preserve the immune role of the spleen and can reduce the need for blood transfusion. But PS is associated with a regrowth of the splenic remnant in children suffering from chronic hemolysis with hypersplenism and seems to be effective for a relatively short period only, especially in young children. Thus, a second operation to perform a total splenectomy can be necessary. The decision to perform a PS on young children with HS as an alternative to total splenectomy with appropriate preoperative vaccination and postoperative prophylactic antibiotics therefore should be weighed carefully, keeping in mind, however, the benefit of postponing total splenectomy in these patients.

Esophageal ligature in experimental gastroschisis

BACKGROUND/PURPOSE

Recently, the authors have shown that in human fetuses suffering from gastroschisis, there is an amniotic fluid inflammatory response and that amniotic fluid exchange designed to disrupt the inflammatory loop seems to have a favorable impact on outcome. The authors, therefore, designed in the fetal sheep a model of gastroschisis in which amnioinfusion significantly improved the deleterious process. They hypothesized that regurgitation and presence of digestive enzyme in the amniotic fluid triggers and maintains the process of inflammation.

METHODS

To test this hypothesis, the authors used their model of gastroschisis in the fetal lamb combined with esophageal ligation and compared it with gastroschisis with or without amnioinfusion.

RESULTS

Of 34 fetuses operated on at midgestation (days 70 through 80), 11 died in utero or were stillborn, 8 had gastroschisis and amnioinfusion, 8 had gastroschisis and no amnioinfusion, and 7 had gastroschisis and esophageal ligation. There were 9 control fetuses. Fetuses were killed at day 145 by cesarean section. Extraabdominal bowels with fibrous peel were processed for histologic examination. Thickness of bowel muscularis (micrometers) was 82.7 +/- 19 for controls, 159 +/- 56 for the nonamnioinfused fetuses, 126 +/- 21 for the amnioinfused fetuses (P =.001), and 240 +/- 225.8 for fetuses with esophageal ligature combined with gastroschisis. The same results were obtained for thickness of serous fibrosis and plasma cell infiltration. Assay of amniotic fluid ferritin, lipase, and protein showed that only amnioinfusion lowered ferritin and protein to levels similar to those of controls, thus, illustrating its preventive effect on inflammation and that esophageal ligature did not prevent digestive enzyme presence in the amniotic fluid.

CONCLUSION

In this model of gastroschisis in the fetal sheep, ligature of the esophagus, which was supposed to protect the extruded bowel by preventing oral regurgitation of digestive enzymes and by creating a relative hydramnios, did not improve the inflammatory and deleterious process, which is best prevented by amnioinfusion.

Postnatal management of cystic neuroblastoma

Cystic adrenal neuroblastoma (NB) is highly unusual. We report two cases of cystic NB, detected antenatally and emphasize postnatal strategy management. Case 1: a right cystic mass was detected in a foetus in the 34th week of pregnancy, and checked as the same in the 36th week. Postnatal ultrasonography confirmed the presence of a growing adrenal cystic mass. MRI and MIBG scintigraphy suggested an isolated adrenal tumour, without catecholamine secretion. Surgical resection was decided upon and pathological examination confirmed the diagnosis of cystic NB. Follow-up found a recurrence at 10 months and the patient underwent excision after chemotherapy. Histology confirmed the metastatic origin from NB. Case 2: a right adrenal cystic mass was detected during pregnancy, with no regression of tumour size on postnatal US. MRI, MIBG scintigraphy, and catechol plasma and urinalysis led to the conclusion of an isolated non-secreting lesion. A right adrenalectomy was performed at 1 month. Pathologic examination diagnosed a cystic NB. We would suggest serial US examinations and early removal of any cystic mass with characteristic US signs (thick complex wall) or without regression on one month follow-up. Prenatal diagnosis may provide the best chances for neonatal excision and good prognosis.

Improvement of mesenteric superior artery Doppler velocimetry by amnio-infusion in fetal gastroschisis

This study aimed to analyse the influence of amnio-infusion on superior mesenteric Doppler velocimetry and to correlate Doppler data with outcome in fetuses presenting with gastroschisis. Umbilical and intra- and extra-abdominal superior mesenteric artery Doppler velocimetry was measured prospectively before and after amnio-infusion in fetuses with gastroschisis. Doppler index values and changes were correlated with the following outcome parameters: importance of fibrous coating, duration of hospitalization in the neonatal intensive care unit, total duration of hospitalization, duration of parenteral feeding, duration of ventilatory assistance, and the interval to initiation of oral feeding. A significant improvement of diastolic flow was observed in the extra-abdominal superior mesenteric artery with amnio-infusion. No similar change was seen in the intra-abdominal superior mesenteric or in the umbilical artery. Pre-amnioinfusion extra-abdominal mesenteric Doppler index was correlated with maximal diameter of exteriorized bowel and slightly with duration of hospitalization in the neonatal intensive care unit, but no other relation between Doppler index and outcome parameter could be ascertained. Amnio-infusion induces modifications in the vascularization of exteriorized bowel in gastroschisis. This could partly explain the beneficial effect of this procedure on fetal gut.

Definitive treatment of extended Hirschsprung's disease or total colonic form

BACKGROUND

Between December 1990 and March 1999, five laparoscopic Duhamel pull-through procedures for extended or total aganglionosis were performed in our department, one of which had a rectosigmoid form with a short bowel and a colonic resection due to a volvulus.

METHODS

The aim of this study was to show that even when the extended form of Hirschprung's disease or anatomic difficulties such as a short bowel and anterior colonic resection are encountered, the laparoscopic approach is possible and total colectomy is feasible. The procedure has been described previously. We used one camera port and three working ports. The sigmoid, transverse, and right colon up to the last ileal cove were mobilized laparoscopically. A standard posterior ileo-anal anastomosis was performed, and an endo-GIA stapler was used for the anterior anastomosis.

RESULTS

A total of five patients underwent laparoscopic surgery for Hirschprung's disease. There were three total colonic forms, one rectosigmoid form with a short bowel and colon resection attributed to a volvulus, and one transverse variant that required a Deloyers' maneuver for the pull-through. Three of the infants required total parenteral nutrition (TPN) for an average of 49 days (range, 28-60) from diversion until the time of the definitive procedure. Only one patient did not receive TPN. Postoperatively, there were two complications-one wound infection and one hectic fever. The clinical results were good, with no soiling or stool incontinence and no constipation.

CONCLUSION

The laparoscopic procedure for total aganglionosis or the extended form of Hirschprung's disease is safe, feasible, and reproducible.

[Laparoscopic splenectomy in children: experience and results]

Pediatric laparoscopic splenectomy is a relatively new surgical procedure. Advances in instrumentation and technique now make this procedure possible. Splenectomy is frequently performed in children for various hematologic and autoimmune diseases.

PATIENTS AND METHODS

This article reviews the indication for splenectomy, the technique of laparoscopic splenectomy and our results. Between January 1996 and January 2000, 23 children underwent laparoscopic splenectomy. Three of them also had a concomitant cholecystectomy. Their ages ranged from three to 14 years. Nine children had hereditary spherocytosis, four were affected by sickle cell disease, three had an idiopathic thrombocytopenia and three a hemolytic disease. One patient was converted.

RESULTS

Mean operative time was 170 min (range, 115-230 min). Hospital stay ranged from three to 15 days (median, 6). Five patients had complications (three pneumonia and two deep abscesses). Median follow-up was 20 months (two months to four years) without problems regarding procedure.

CONCLUSION

Regarding the low complication rate for this type of patient and the advantages of a small abdominal trauma in the postoperative period, the laparoscopic approach for elective splenectomy in hematological disorders is the technique of choice.

Bronchial trifurcation in a congenital pulmonary venolobar syndrome

Congenital malformations of the tracheobronchal tree and the related arterial blood supply are a complex group of lesions in which there are abnormalities of the venous drainage and lung parenchyma. These malformations are examples of congenital pulmonary venolobar syndrome (CPVS). Tracheal trifurcation is an extremely rare anomaly associated with CPVS. We report on an unusual case of lower right extralobar sequestration connected to the trachea, plus a type I posterior laryngeal cleft, an aberrant systemic artery, and an anomalous route of the phrenic nerve. This paper discusses the place of this unusual abnormality in the spectrum of congenital bronchopulmonary vascular malformations.

Elective laparoscopic cholecystectomy

BACKGROUND

Gallbladder stones are very common in patients with sickle cell disease and are the cause of recurrent abdominal pain. Their management has been highly controversial, especially for children. Nonoperated patients and those treated on an emergency basis have a very high rate of morbidity (>50%).

METHODS

We performed a retrospective review of a series of 29 homozygous SS sickle cell children who underwent laparoscopic cholecystectomy between 1991 and April 1998.

RESULTS

Only in one case a conversion was necessary (early in the series). Exploration of the common bile duct was done via intraoperative cholangiography. There were no mortalities. The morbidity rate was 17%; (however, of the five patients concerned, four suffered from hyperthermia for 2 days. All of the children were improved and enjoyed resolution of their abdominal pain.

CONCLUSIONS

We believe that elective laparoscopic cholecystectomy at the earliest time possible, along with correct perioperative management, is the treatment of choice for cholelithiasis in children with sickle cell disease.

Laparoscopic adrenalectomy in children

BACKGROUND

The aim of this study was to describe the indications and results of laparoscopic adrenalectomy in children.

METHODS

This retrospective multicenter study included six children (four boys, two girls) aged 2-16 years (mean, 9.5). Three children had hypertension. In three cases, the adrenal mass was discovered incidentally. The tumors were bilateral in two children, right-sided in two cases, and left-sided in two cases. The mean tumor size was 4 cm (range, 1-7). Each child underwent MIBG scintigraphy and MRI before the operation.

RESULTS

Four right and two left adrenal glands were resected by laparoscopy (transperitoneal), and two left glands were resected by retroperitoneoscopy. Two conversions were necessary for two left adrenal glands (one retroperitoneoscopy, one laparoscopy). Two partial resections and six adrenalectomies were performed. Histological examination of the tumors revealed two ganglioneuromas, one neuroblastoma, and five pheochromocytomas (two bilateral). One child had an involved node (pheochromocytoma). Both bilateral pheochromocytomas had von Hippel-Lindau disease. There was no morbidity. Mean hospitalstay was 6 days. Postoperative evaluation at 1 month was normal in all children.

CONCLUSION

The indications for laparoscopic adrenalectomy in children are benign tumors and pheochromocytomas. In these cases, laparoscopic adrenalectomy is feasible and safe, even in cases of pheochromocytoma.

Influence of amnioinfusion in a model of in utero created gastroschisis in the pregnant ewe

OBJECTIVE

Recent studies on the management of human fetal gastroschisis have produced two major findings: (1) there is an inflammatory response in the amniotic fluid of these fetuses, and (2) amniotic fluid exchange designed to disrupt the inflammatory loop seems to have a favorable impact on the immediate and late outcome of these early operated neonates. To test this hypothesis, we used serial amniotic fluid exchanges in a model of gastroschisis developed in the ewe.

METHODS

Gastroschisis was created at midgestation in 21 lamb fetuses by an in utero technique. Saline was amnioinfused in some fetuses every 10 days to term. Fetuses were sacrificed on day 145 by cesarean section. Extra-abdominal bowels with fibrous peel were processed for histologic examination. Comparisons were done between fetuses without gastroschisis (controls), fetuses with gastroschisis and amnioinfusion, and fetuses with gastroschisis without amnioinfusion.

RESULTS

Of 21 fetuses operated, 8 died in utero or were stillborn; 5 were not amnioinfused, and 8 underwent amnioinfusion. Thickness of bowel muscularis (micrometer) was 92.6 +/- 20.2 for controls, 126.2 +/- 21 for the amnioinfused fetuses, and 182.8 +/- 58.3 for the nonamnioinfused fetuses (p = 0.001). The same significant results were obtained for thickness of serous fibrosis (p = 0.02) and plasma cell infiltration (p = 0.015).

CONCLUSIONS

We have created a model of gastroschisis suitable for experimentation in the fetal sheep. Our amnioinfusion data in this model indicate a clear improvement of the deleterious process. This finding correlates well with recent data on amnioinfusion as a therapeutic approach to human gastroschisis.

ET(A)-receptor blockade and ET(B)-receptor stimulation in experimental congenital diaphragmatic hernia

The aim of this study was to assess the role of nitric oxide (NO) and endothelin (ET)-1 in the pathophysiology of persistent pulmonary hypertension of the newborn in fetal lambs with a surgically created congenital diaphragmatic hernia (CDH). The pulmonary vascular response to various agonists and antagonists was assessed in vivo between 128 and 132 days gestation. Age-matched fetal lambs served as control animals. Control and CDH lambs had similar pulmonary vasodilator responses to acetylcholine, sodium nitroprusside, zaprinast, and dipyridamole. The ET(A)-receptor antagonist BQ-123 caused a significantly greater pulmonary vasodilatation in CDH than in control animals. The ET(B)-receptor agonist sarafotoxin 6c induced a biphasic response, with a sustained pulmonary vasoconstriction after a transient pulmonary vasodilatation that was not seen in CDH animals. We conclude that the NO signaling pathway in vivo is intact in experimental CDH. In contrast, ET(A)-receptor blockade and ET(B)-receptor stimulation significantly differed in CDH animals compared with control animals. Imbalance of ET-1-receptor activation favoring pulmonary vasoconstriction rather than altered NO-mediated pulmonary vasodilatation is likely to account for persistent pulmonary hypertension of the newborn in fetal lambs with a surgically created CDH.

Thoracic pheochromocytoma revealed by ventricular tachycardia. Clinical case and review of the literature

A case of thoracic extra-adrenal pheochromocytoma was observed in a 13-year-old girl. The initial clinical symptoms consisted of her being unwell after effort over a period of 3 years. The diagnosis was suggested after a recorded episode of paroxysmal ventricular tachycardia with concomitant hypertension, which reproduced the characteristic symptoms. Biochemical analysis confirmed hypersecretion of catecholamines and morphological examinations showed the presence of an isolated left median thoracic tumor. One year after surgical excision, the patient remained completely asymptomatic, in spite of resuming intense sporting activity. The diagnosis of ectopic pheochromocytoma should be considered as a possible etiology of cardiac rhythm disturbances or hypertension in children. Thorough biochemical and radiological examination including MIBG radioisotope scanning should be carried out systematically before surgical excision; pheochromocytomas in children are frequently extra-adrenal (30%), multifocal (50%) or associated with multiple endocrine neoplasms (NEM).

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.

Laparoscopic Duhamel procedure. Management of 30 cases

BACKGROUND

Between February 1995 and June 1998, 30 laparoscopic Duhamel pull-through procedures were performed in our department.

METHODS

Our main aim was to prove the feasibility of the laparoscopic abdominal Duhamel procedure for different localizations of Hirschsprung disease. We used one camera port and three working ports. The sigmoid colon and posterior rectum were mobilized laparoscopically. A standard posterior colo-anal anastomosis was fashioned and a stapler was used for the anterior anastomosis. The top of the rectum was then closed by endo stapler under laparoscopic vision.

RESULTS

Thirty patients underwent laparoscopic surgery for this procedure. Three laparoscopic procedures were converted because of technical difficulties. The operative time was 100-330 mn. Oral feeding was started at a mean postoperative time of 2.5 days. Mean postoperative hospitalization was 9 days. Early postoperative complications included 1 anastomotic leak, 1 retrorectal abscess, 2 urinary infections, and 1 evisceration (after conversion). No enterocolitis or enterocolitis-like symptoms were noted. All patients now have daily spontaneous bowel movements.

CONCLUSION

The laparoscopic Duhamel procedure can be performed safely, giving good results.

[Congenital malformations of the abdominal wall]

Congenital malformations of the abdominal wall consist of a combination of a parietal opening and visceral abnormalities. The most frequent are omphalocele and laparoschisis. Embryological analysis of the formation of the abdominal wall distinguishes omphalocele, due to absence of differentiation of the lateral folds of the embryo, from laparoschisis, due to absence of differentiation of the mesenchyma at one point of the somatopleural lining. Clinically, omphalocele consists of an opening of the abdominal wall, lined by a double layer (peritoneum and external layer of the amniotic membrane), which may rupture before birth. Laparoschisis is a true antenatal hernia lying to one side of the umbilical cord. The other abnormalities of the abdominal wall are less common: muscle and purely cutaneous aplasia. The treatment of omphaloceles requires multidisplinary management. Several surgical techniques are used, mainly primary closure and rectomyoplasty. Primary closure of the abdominal wall is only possible in one-half or one-third of cases.

Effect of amnioinfusion on the outcome of prenatally diagnosed gastroschisis

OBJECTIVE

Following recent data showing that an inflammatory response exists in the amniotic fluid of gastroschisis-affected fetuses, we hypothesized that amniotic fluid exchange or amnioinfusion would improve the prognosis of prenatally diagnosed gastroschisis.

METHODS

We compared the outcome of prenatally amnioinfused fetuses with gastroschisis to non-amnioinfused fetuses with gastroschisis. 10 patients undergoing this procedure were matched with 10 patients of our previous study. Comparisons were done on data including surgical procedure, follow-up in the NICU and the gastro-pediatric unit.

RESULTS

Our results show that gastroschisis-affected fetuses undergoing amnioinfusion had a lower duration of curarization after surgery (2.2 +/- 1.9 vs. 6.8 +/- 6.9 days, p = 0.019), a shorter delay before full oral feeding (49.7 +/- 21.5 vs. 72.3 +/- 56.6 days, NS), and a shorter overall length of hospitalization (59.5 +/- 19.7 vs. 88.5 +/- 73.6 days, NS). We confirmed our previous data showing that amniotic fluid displays a chronic inflammation profile.

CONCLUSION

Our data suggest that amnioinfusion could improve the outcome of gastroschisis affected fetuses. The hypothesis by which this improvement could be due to a reduction of an inflammatory response remains to be proved.

[Management of Hirschsprung's disease during the neonatal period]

Hirschsprung's disease is one of the common est causes of neonatal intestinal obstruction. Despite progress in the identification of genetic mutations, the pathogenesis of Hirschsprug's disease is not completely resolved. The management consists of septic complications of treatment, and a variable "pull-through" procedure, immediately or at a later date. Long-term follow-up is an important component of patient care.

[Congenital diaphragmatic hernia. I. Simple defect of the diaphragm or anomaly of the pulmonary mesenchyme?]

Described for the first time in 1848 by Bochdalek, congenital diaphragmatic hernia is still a hot topic. How can it be that a simple defect of the diaphragm still has a mortality rate reaching 50% in 1997, and this despite continuous progress in neonatal intensive care? If some problems remain unsolved, experimental studies over the past 30 years have raised some questions concerning the pathogenesis, and have shed some light into the pathophysiology of congenital diaphragmatic hernia. This article reviews the recent knowledge about the aetiology, pathogenesis and pathophysiology of this complex malformation.

[Left aortic arch--right descending aorta--right ductus arteriosus (encircling aortic arch). A rare malformation of the aortic arches]

Abnormalities of the aortic arch which are responsible for tracheobronchial compression are well known. This case demonstrates the value of magnetic resonance imaging (MRI) for diagnosis and suggests that recurrent respiratory symptoms should evoke these abnormalities in infancy.

CASE REPORT

The authors report a very rare malformation of the aortic arch formed by encircling aortic arch, with left aortic arch, right descending aorta and right ligamentum arteriosum. It was revealed by airway disorders due to the compression of tracheobronchial axis by the ligamentum arteriosum. Section of the ligamentum permitted suppression of obstruction. The diagnosis of these abnormalities is usually established by means of oesophagogram, tracheobronchial endoscopy, angiography and MRI.

CONCLUSION

In this case, MRI gave a better picture than angiography. Sections of the ligamentum arteriosum are sometimes ineffective when compression is due to the aorta itself. Aortic uncrossing, a more complex operation, is then necessary.

[Iterative intestinal intussusception and appendiceal mucocele in an infant with mucoviscidosis]

Cystic fibrosis is a common and potentially life-threatening hereditary disease which can affect numerous organs, particularly the digestive tract.

CASE REPORT

A 4.5-year-old boy exhibited two little known clinical manifestations: an appendiceal mucocele and repeated intussusceptions. In spite of an appendectomy, intussusception relapsed and an ileocolic resection was necessary 2 years later.

DISCUSSION

Appendiceal diseases in cystic fibrosis represent a large spectrum, ie, distention on the appendiceal lumen, engorged with sticky mucous matter, which becomes an appendiceal mucocele, peritonitis with an appendiceal perforation due to delayed diagnosis since acute appendicitis is difficult to diagnose in these patients. Intussusception is rarely observed in cystic fibrosis.

CONCLUSION

Appendiceal mucocele could be a cause of intussusception. If an appendectomy is performed, resection of a part of the cecum, around the appendix, could be useful in preventing again mucocele formation.