Cerebral germinoma revealed through a polydipsic polyuric syndrome in a 10-year-old girl: case report

Cerebral germinoma is rare. Although the imaging of the germinoma is very evocative, it's very polymorphic clinical expression is at the origin of misguided diagnosis, as illustrated in our case. We report the case of a 10-year-old girl with diabetes insipidus evolving for 12 months associated with a decrease in visual acuity. Brain MRI (Magnetic Resonance Imaging) revealed a tumor process in the suprasellar region. The stereotaxic biopsy of the tumor confirmed the diagnosis of the hypothalamic germinoma, which allowed the patient to be treated by radiotherapy and chemotherapy. The incidence of cerebral germinoma, its clinical (principally diabetes insipidus) and radiological features as well as therapeutic strategies are discussed hereby.

[Management of vascular anomalies in children]

Vascular anomalies, which are broadly identified as "angiomas", are rare entities and often unknown by the medical sphere. They are divided in two different categories which carry different prognosis and management: "vascular tumors" and "vascular malformations". Their precise identification is crucial and involves a good knowledge of the biological classification published by Mulliken and Glowacki and that has recently been updated by the International Society for the Study of Vascular Anomalies (ISSVA). Vascular tumors are benign, common, inborn or not and most of the time disappear with growth. Vascular malformations are always congenital and growth with the child. They can involve type of vessels solely or combined with others. A rheologic differentiation between slow and fast flow malformations is essential in order to characterize the seriousness of the lesion. Frequently, their diagnosis is clinically established and the anamnesis is conducted to answer three questions that are the time of revelation of the lesion ("When?"), its aspect ("What?") and its evolution ("How?"). Further investigations are usually not required but a non-invasive imaging technique such as Doppler ultrasound could be useful if a doubt exists. Surgery is not mandatory and must always be well thought because its consequences might be disastrous. It must be left to cosmetic sequelae of these lesions or to lesions that are totally resectable without causing any unacceptable deformation.

Tumeurs et malformations vasculaires, classification anatomopathologique et imagerie

The understanding of vascular anomalies (vascular tumours and vascular malformations) was obscured, for a long time, by confusion and uncertainties in nosology and terminology. The International Society for the Study of Vascular Anomalies (ISSVA) recently adopted a classification scheme, clearly separating vascular tumours (hemangiomas of different types) which result from active cell proliferation, from vascular malformations, which are inborn defects in vascular morphogenesis. These two types of lesions have different clinical behaviour and require different diagnostic and therapeutic strategies. The most frequent vascular tumour is infantile hemangioma. Its clinical aspects and evolution are well-known. New data have been recently obtained concerning the phenotype of tumour cells and its histogenesis. Of the numerous new vascular tumours, which have been recently described, only the congenital hemangiomas, the vascular tumours associated with the Maffucci syndrome and the tumours that may be complicated by a profound thrombocytopenia (Kasabach and Merritt phenomenon) will be considered. Vascular malformations can be classified according to the vessel(s) types they are composed of. A classification table is presented, separating the malformations of vascular trunks from tissular malformations which are more intimately embedded in the surrounding tissues. The different syndromes associated with vascular anomalies take also place in this table. The clinical, imaging and histological aspects of the most frequent malformations (capillary, venous, lymphatic and arteriovenous) are presented. This classification intend to clarify the nosology and terminology of the complex field of vascular tumours and malformation and to offer a common language to the different physicians and specialists contributing, preferably with a interdisciplinary approach, to the diagnosis and treatment of these difficult lesions.

[Subacute osteomyelitis of the acetabulum]

A 15-months-old girl presented an excentration of the hip associated with a defect image of the acetabulum. Arthrography revealed a communication between the hip joint and the acetabular defect. Bacteriological specimens of the articular fluid were negative. The radiographic images were compatible with subacute osteomyelitis. Relative immobilization using an Atlanta abduction devise was undertaken. No medical treatment was prescribed for this adolescent who had received antibiotics for polymicrobial urinary tract infections and for pharyngitis prior to detection of the orthopedic disorder. Outcome was satisfactory with progressive filling of the acetabular defect but also with development of a subluxating coxa valga which required varus osteotomy of the femur. This case appears to illustrate a particular form of subacute osteomyelitis which is not described in earlier classifications.

The paediatric liver transplantation program at the Université catholique de Louvain

The Paediatric Liver Transplant Program at Saint-Luc University Clinics constitutes a substantial single centre experience, including 667 transplantations performed between March 1984 and April 2003, and the history of this program reflects the tremendous progress in this field since twenty years. Liver transplantation in children constitutes a considerable undertaking and its results depend on multiple, intermingled risk factors. An analysis of the respective impact of several surgical and immunological parameters on patient/graft outcome and allograft rejection after paediatric liver transplantation showed a significant learning curve effect as well as the respective impact of pre-transplant diagnosis on survival and of primary immunosuppression on the rejection incidence. The introduction of living related liver transplantation in 1993 not only permitted to provide access to liver replacement in as many as 74% more candidate recipients, but also resulted in better graft survival and reduced retransplantation rate. The results of a recent pilot study suggest that steroid avoidance is not harmful, and could even be beneficial for paediatric liver recipients, particularly regarding growth, and that combining tacrolimus with basiliximab (anti-CD25 chimeric monoclonal antibody) for steroid substitution appears to constitute a safe alternative in this context. The long-term issues represent the main future challenges in the field, including the possibility of a full rehabilitation through immunosuppression withdrawal and tolerance induction, the development of adolescence transplant medicine, and the risk of early atherogenesis in the adulthood.

[Choanal atresia: a retrospective study of 39 cases]

The purpose of this study was to investigate the clinical characteristics and the surgical management in patients with choanal atresia. We performed a retrospective study at the Saint-Luc University hospital, Brussels, between January 1988 and June 2000. Surgical corrections were performed using different approach (transnasal endoscopic, transpalatal) and different instrumentations (urethral sounds, laser nd-YAG, laser CO2, microdebrider). Portex endotracheal tubes were inserted as nasal stents in the vast majority of the patients with bilateral choanal atresia. Thirty-nine children with choanal atresia (22 unilateral and 17 bilateral) (9: M, 30: F) were studied. 38 of them were surgically managed. Based on clinical inspection and On CT-Scan, choanal atresia was defined as membranous for 4 patients, osseous for 6 and mixte for 29. Associated congenital anomalies were found in 22.7% of unilateral and in 70.5% of bilateral choanal atresia (Total: 43.5%). Of those children with bilateral choanal atresia, 75% were asymptomatic after four surgical procedures. In children with unilateral choanal atresia, 45% were asymptomatic after one surgical correction and 100% after three surgical corrections. Four patients were managed using an endoscopic endonasal approach with the microdebrider and showed no evidence of recurrence. Outcome analyses of factors that may influence the results of surgery are difficult to establish since many different surgical options were taken during this period. However, it seems that bilateral choanal atresia is associated with more surgical corrections before achieving a normal nasal breathing than unilateral choanal atresia. After this review, our current strategy regarding the choanal atresia will be to begin with the endoscopic endonasal approach using the microdebrider (stents if bilateral) and to propose the transpalatal approach in case of recurrence.

[Diagnosis and follow-up of a large intrahepatic portocaval fistula in a newborn]

Portocaval fistulas are rare and only exceptionally discovered in newborns. We report the case of a large portocaval fistula associated with portal hypoperfusion detected at Doppler US imaging in an otherwise asymptomatic 5 week old infant. The patient remained asymptomatic over the following two years. At that time, preoperative angiogram showed a normal portal venous system and the fistula was surgically closed. Postoperative US showed a normal and patent portal system, without evidence of portal hypertension.

Unusual evolution of an Epstein-Barr virus-associated leiomyosarcoma occurring after liver transplantation

We report the case of a child who developed, 2 yr after orthotopic liver transplantation (OLTx) for biliary atresia, a multi-focal hepatic tumor with lymphonodular metastases, identified as an Epstein-Barr virus (EBV)-associated leiomyosarcoma. Chemotherapy was given without tumor response. Subsequently, slow growth of the tumor was observed. Immunosuppression was tapered and stopped 9 yr after transplantation. At the present time, 12 yr after the discovery of the first hepatic lesions, the patient is alive and completely symptom-free, the abdominal masses are stable, and liver function tests are completely normal. Smooth muscle tumors are increasingly recognized in children with various immunodeficiencies occurring after organ transplantation. This unusual evolution of a clinically aggressive tumor into a stable disease after restoration of immunity confirms that the immune status of the patient is a crucial factor.

Lymphatic malformations of the head and neck: a retrospective review and a support for staging

BACKGROUND

Lymphatic malformations (LM) are rare benign congenital tumors appearing mainly in the head and neck with a considerably variable outcome. A need exists to validate a staging system, taking into account the prognosis of the malformation, including preoperative and postoperative complications, long-term sequelae, and persistence of the disease to improve parental counseling and evaluate the outcome of a surgical treatment of such tumors.

METHODS

Twenty-two patients treated for LM were selected from a series of 129 patients operated on for congenital malformations of the head and neck between 1986 and 1997 at St-Luc University Hospital, Brussels, Belgium. Their charts were reviewed retrospectively, with a special focus on the anatomic location of the lesions and all the complications reported. According to de Serres et al, LM up to now have been divided into six possible categories according to their unilateral or bilateral infrahyoid and/or suprahyoid locations.

RESULTS

Stage I (unilateral infrahyoid): nine patients, 11% of complications (without mediastinal extension: 0%, with mediastinal extension: 50%); stage II (unilateral suprahyoid): three patients, 33% of complications; stage III (unilateral suprahyoid and infrahyoid): eight patients, 75% of complications; stage V (bilateral suprahyoid and infrahyoid): two patients, 100% of complications. None of the children was initially seen with stage IV (bilateral suprahyoid) or stage VI (bilateral infrahyoid) LM. Overall complications, preoperative complications, postoperative com- plications, and long-term morbidity showed a significant in- crease from stage I to V (p <.01, p =.002, p =.02, and p =.03, respectively).

CONCLUSIONS

A staging system of cervicofacial LM based on the anatomic location can be reliably used for prognostic purposes, allowing a more accurate assessment of the global risk of complications and determination of surgical outcome. Mediastinal extension in stage I patients seems to be associated with a higher rate of complications. Such information can be used to inform parents more appropriately regarding the management and long-term prognosis of their children's malformation.

Living-related liver transplantation in children at Saint-Luc University Clinics: a seven year experience in 77 recipients

The Brussels series of living related liver transplantation (LRLT) in 77 children (< 15 years) is reviewed. Median (range) recipient age at liver transplantation was 1.1 year (0.4-13.1). The main indication for LT was biliary atresia in 55/77 cases (71%). The living-related donor was one of the parents in 74 instances. Hepatic segments 2-3 (n = 67) or 2-3-4 (n = 10) were implanted orthotopically, with a median (range) graft weight to recipient body weight ratio of 3.17% (0.91-8.08). No severe complications or significant long-term sequelae were encountered in the living donors. One and five year survival rates were 92% and 89% for the patients, and 90% and 86% for the grafts, respectively. The retransplantation rate was 2/77 (2.6%), the indication being chronic rejection in both instances. In conclusion, LRLT is now a validated procedure in the living donors as well as in pediatric recipients with chronic or acute liver diseases. In the current context of organ shortage, it provides a valuable alternative to cadaveric LT.

Spinal neurenteric cyst presenting in infancy with chronic fever and acute myelopathy

The authors describe the clinical, radiologic, and pathologic features of a neonatal spinal neurenteric cyst (NC) presenting with long-lasting fever and acute myelopathy, and compare this observation with other infants reported in the literature. This observation shows that NC must be considered in the differential diagnosis of acute myelopathy with persistent fever in infancy. Fever is attributed to degenerative changes in the NC, triggering inflammatory cell infiltration and tumor necrosis factor alpha secretion.

Treatment of extrahepatic portal hypertension in children by mesenteric-to-left portal vein bypass: a new physiological procedure

OBJECTIVE

To achieve hepatic portal revascularisation and decompression of extrahepatic portal hypertension in children with cavernoma and obstruction caused by idiopathic portal vein thrombosis.

DESIGN

Selected cases.

SETTING

Teaching hospitals. Belgium and Italy.

SUBJECTS

11 children who weighed between 5.9 and 54 kg (2 emergencies) with symptomatic extrahepatic portal hypertension.

INTERVENTION

Interposition of venous autograft between the superior mesenteric vein and the distal (umbilical) portion of the left portal vein.

MAIN OUTCOME MEASURES

Improvements in symptoms and endoscopic appearance after operation.

RESULTS

2 bypasses had to be redone because they stenosed; all 11 were patent at the time of writing (median follow-up 6 months, range 1-32 months).

CONCLUSION

The bypass effectively relieved symptoms of extrahepatic portal hypertension by restoring normal hepatic portal blood flow.

Urachal neuroblastoma: first case report

Tumours of the urachus are exceptional in children. They represent 0.01% of all tumours and consist of mucosecretory adenocarcinoma and, more rarely, transitional cell carcinoma. We report a 6-month-old child with a urachal mass which, following biopsy, was shown to be a neuroblastoma.

Cricopharyngeal achalasia: case reports and review of the literature

Primary cricopharyngeal achalasia (a = absence, chalasia = relaxation) is a rare cause of swallowing disorders in newborns. Two cases are reported which were successfully treated by a myotomy of the cricopharyngeal muscle. A thorough history is essential in differential diagnosis as well as observation of the feeding infant. Presence of anatomical obstruction to swallowing and existence of neurological defects should be ruled out. Cineradiography with lateral views by an experienced radiologist is the best diagnostic technique. Esophageal manometry may provide information regarding other esophageal dyskinetic problems. However, these studies are difficult to perform in neonates and infants. Endoscopy may be helpful to exclude vocal cord paralysis or mechanical obstruction. Balloon dilatation has been reported as being successful in several reports; however no comparison of efficacy has been made in any series between dilatation of the upper esophagus and surgical myotomy which remains in our mind, the optimal treatment of cricopharyngeal achalasia.

Congenital fistula of the fourth branchial pouch

Between 1986 and 1995, 128 patients were treated for various head and neck congenital malformations at Saint-Luc University Hospital, Louvain. We report three cases of fourth branchial pouch cysts requiring surgical removal. One of these cases presented with a third branchial pouch remnant on the same side and subsequently a fourth branchial pouch sinus. To our knowledge, this is the first case published in the literature. A fourth branchial pouch sinus tract can become manifest clinically by recurrent episodes of neck abscess or acute suppurative thyroiditis (especially in infants). The tract can be identified with a barium swallow during the period of latency and hypopharyngeal endoscopy under general anesthesia. Total excision of the fistula with dissection up to the pyriform sinus with or without a left thyroid gland lobectomy and isthmectomy is the treatment of choice.

Pediatric liver transplantation: from the full-size liver graft to reduced, split, and living related liver transplantation

Between 1984 and 1996, the authors performed 499 liver transplants in 416 children less than 15 years old. The overall patient survival at 10 years was 76.5%. It was 71.3% for the 209 children grafted in 1984-1990; 78.5% for biliary atresia (n = 286), 87.3% for metabolic diseases (n = 59), and 72.7% for acute liver failure (n = 22). The 5-year survival was 73.6% for the 209 children grafted in 1984-1990 and 85% for the 206 grafted in 1991-1996. Scarcity of size-matched donors led to the development of innovative techniques: 174 children who electively received a reduced liver as a first graft in our center had a 5-year survival of 76% while 168 who received a full-size graft had a survival of 85% (NS). Results of the European Split Liver Registry showed 6-month graft survival similar to results obtained with full-size grafts collected by the European Liver Transplant Registry. Extensive use of these techniques allowed the mortality while waiting to be reduced from 16.5% in 1984-1990 to 10% in 1991-1992. It rose again to 17% in 1993, leading the authors to develop a program of living related liver transplantation (LRLT). The legal and ethical aspects are analyzed. Between July 1993 and October 1997, the authors performed 53 LRLTs with 90% survival. In elective cases, a detailed analysis was made of the 45 children listed for LRLT between July 1993 and March 1997 and the 79 registered on the cadaveric waiting list during the same period. Mortality while waiting was 2% and 14.5% for the LRLT and cadaveric lists, respectively. The retransplantation rate was 4.6% and 16.1% for LRLT and cadaveric transplants, respectively. Overall post-transplant survival was 88% and 82% for children who received a LRLT or a cadaveric graft, respectively. Overall survival from the date of registration was 86% and 70% (P < 0.05) for LRLT or cadaveric LT respectively. The 2-year post-transplant survival in children less than 1 year of age at transplantation was 88.8% and 80. 3% with a LRLT or cadaveric graft, respectively; patient survival after 3 months post-transplant was 95.8% and 91.9% for stable children waiting at home, 93.7% and 93.7% in children hospitalized for complications of their disease, and 89.5% and 77.7% for children hospitalized in an intensive care unit at the time of transplantation for children who received a LRLT or cadaveric graft, respectively. It is concluded that LRLT seems to be justified for multidisciplinary teams having a large experience with reduced and split liver grafting.

Urodynamic and electrophysiological testing in pediatric neurourology

In our institution, children with voiding disorders are submitted to a detailed evaluation comprising a careful clinical examination, laboratory tests, imaging (kidney ultrasonography and voiding cystourethrography) and urodynamic tests. Depending on the etiology of voiding dysfunction, children are subjected to a non invasive or an invasive urodynamic evaluation. Non invasive urodynamic testing comprises a free urinary flowmetry associated or not with an EMG recording of the pelvic floor. Invasive urodynamic testing consists of a pressure-flow study or a video-XR-urodynamic test. In rare instances, genitourinary electrophysiological investigations will be performed. Herein we describe these different urodynamic and electrophysiologic tests.

Direct bypassing of extrahepatic portal venous obstruction in children: a new technique for combined hepatic portal revascularization and treatment of extrahepatic portal hypertension

BACKGROUND

Decompression of extrahepatic portal hypertension by directly bypassing the thrombosed portal vein has never been reported in cases of children with idiopathic (or neonatal) portal vein obstruction and cavernoma.

METHODS

Seven children (15 years or younger) with portal vein obstruction requiring surgical decompression (urgently in two cases), and in whom preoperative Doppler had shown that the intrahepatic portal branches were hypoplastic but free of thrombus, were included in a pilot study. The cavernoma was bypassed by interposing a venous jugular autograft between the superior mesenteric vein and the distal portion of the left portal vein. Patients received follow-up using routine clinical parameters, upper gastrointestinal endoscopy, and Doppler ultrasound.

RESULTS

The mesenterico-portal bypass restored a direct (physiological) hepatopetal portal flow. The operation resulted in effective portal decompression as demonstrated by decrease of the pressure gradient, rapid regression of clinical signs of portal hypertension, and definitive control of bleeding.

CONCLUSIONS

This study shows that direct bypassing of portal cavernoma is possible and results in effective portal decompression. Restoration of the hepatic portal flow is a major advantage compared with conventional surgical shunting procedures. This new technique is potentially applicable to two thirds of children with portal vein thrombosis and should be considered when shunting procedures are indicated.

Multiple aggressive vertebral haemangiomas in an adolescent: a case report

We describe a neurologically symptom-free adolescent with aggressive vertebral body haemangiomas at two sites.

Madelung deformity as a feature of the Leri-Layani-Weill syndrome or dyschondrosteosis

We report and discuss a case of a Madelung's deformity seen on a wrist roentgenogram of a young girl who is referred for short stature evaluation, which led to the diagnosis of Léri-Weill syndrome or dyschondrosteosis. The authors stress that it is possible to make an accurate diagnosis on a single standard roentgenogram, at low cost, if the different diagnostic criteria are known.

Arteriomesenteric syndrome as a cause of duodenal obstruction in children with cerebral palsy

Two cases of gastroduodenal outlet obstruction caused by arteriomesenteric compression in children who have cerebral palsy are reported. Clinical symptoms of gastrointestinal obstruction include recurrent postprandial nausea and vomiting, upper abdominal distension, and pain. In such patients, multiple predisposing factors can contribute to the development of arteriomesenteric compression, including marked weight loss, supine position, and severe scoliosis. Upper gastrointestinal x-rays using barium contrast allow diagnostic confirmation. In our experience, this cause of acute gastroduodenal outlet obstruction may usually resolve after conservative treatment using a jejunal feeding tube passed beyond the compression, left lateral positioning, and renutrition.

Hirschsprung's disease: a 20-year experience

During the period from 1972 to 1992, 59 children received surgical treatment at the University of Louvain Medical School for biopsy-proven Hirschsprung's disease (HD). The extent of aganglionosis was as follows: short segment restricted to the rectosigmoid or descending colon (n = 44, 75%); long segment (n = 9,15%); ultra-short segment (n = 3, 5%); unknown length because of death without autopsy (n = 3, 5%). The median age at operation was 7 months for short-segment disease compared with 14 months for those with long-segment disease. Surgical procedures used for short-segment disease were Swenson with colostomy (n = 16), Swenson-Pellerin without colostomy (n = 27), Duhamel (n = 1), and for long-segment disease were Martin (n = 3), Swenson-Deloyers (n = 2), Swenson-Boley (n = 2) and ileostomy only in = 2). Lynn's sphincteromyotomy was performed in the three ultra-short cases. There were six deaths (10%) at a median age of 86 days (range, 28 to 1545 days), three had long-segment disease, and the others were not classified because of death before curative surgery. Enterocolitis (EC) was the most common cause of death (five cases) and was also the major source of morbidity after curative surgery (12 of 44, 27%) in short-segment patients, three of seven (43%) in long-segment patients. The functional success of the procedure was evaluated in 70% of the surviving patients (37 of 53; mean follow-up, 8.7 years; range, 1.2 to 21.5), using a novel semiquantitative scoring system, specifically designed for children who have HD. This system assesses normal stool evacuation, abdominal distention, soiling, and severe incontinence. The results were compared with those from a population of 39 healthy children and adolescents and demonstrated progressive improvement in function during childhood and adolescence (P = .04) for patients treated for short-segment disease. However, function was found to be consistently poorer in all age groups when compared with healthy controls (5 to 10 years, P < .01; 10 to 15 years, P < .05; > 15 years, P < .01).

Megaureter in childhood: conservative or surgical management?

Antenatal and incidentally diagnosed megaureters can be safely treated conservatively after careful work up by combined imaging technics. Serial and repeated imaging are non the less usually necessary to confirm the diagnosis. This aspect could be fastidious and expensive. In case of symptoms, breakthrough infections or loss of kidney function, surgical treatment should be considered and good results can be expected. Refluxing megaureter has to be considered as high grade reflux and surgical approach is more often suggested. The authors have reviewed the experience of 139 patients with megaureters treated in the last decade to illustrate those facts.

Radiographic skeletal survey and radionuclide bone scan in Langerhans cell histiocytosis of bone

BACKGROUND

The lack of a consensus in the literature on the imaging strategy in Langerhans cell histiocytosis (LCH) bone lesions in childhood.

OBJECTIVE

To evaluate the relative value of radionuclide bone scan (RBS) and radiographic skeletal survey (RSS) in the detection of LCH bone lesions, both in the initial work-up of the disease and during the follow-up period.

MATERIALS AND METHODS

Ten children with bone lesions evaluated by means of RSS and RBS in a retrospective study (1984-1993).

RESULTS

Fifty radiologically and/or scintigraphically abnormal foci were detected: 27 anomalies in the initial work-up (12 by both RSS and RBS, 8 by RSS only and 7 by RBS only) and 23 additional anomalies during follow-up (10 by both RSS and RBS, 10 by RSS only and 3 by RBS only). RSS+/RBS- lesions (n = 18) are more frequently encountered in the skull (P = 0.038), and more frequently lack radiologic signs of osteoblastic activity (P = 0.020), than RSS+/RBS+ lesions (n = 22). RSS-/ RBS+ abnormalities (n = 10) were most frequently insignificant.

CONCLUSION

In the initial work-up both RSS and RBS should be carried out, while in the follow-up only RSS should be performed.

[Treatment of hypospadias: 15-year experience]

Numerous hypospadias correction techniques were described in the literature. The technique varies according to the position of the meatus and the importance of the chordee. These new techniques and the care taken in the manipulation of the tissues tend to decrease complications like stenoses and fistulas, frequent in the long urethroplasty. The correction of hypospadias should conform to aesthetic and plastic surgery. More than 300 corrections were carried out in our service. Surgical technique varied in the long run. Currently, we choose as often as possible a correction in one time: release of the chordae and urethroplasty. Straightening of the penis is obtained on one hand by release of the cutaneous chordae and wide dissection of the hypoplastic urethral plate and one or more dorsal plications according to Nesbit are carried out if it proves necessary. In the distal, glandular and coronal forms, the correction is of type M.A.G.P.I. (meatal advancement, glanduloplasty). The complication rate is extremely low. The aesthetic and functional result is very satisfactory. In the proximal forms, Duckett technique is used only in the obligatory cases given the large number of complications. It is generally replaced by Onlay technique. The urethral plate is left in continuity and serves as support to the pedicled and vascularized flap. In the intermediate situations with a middle shaft hypospadias, Mathieu technique is again of application. The aesthetic and functional result of this type of surgery requires good knowledge and careful application of the technique adapted to each case.

A new familial short stature syndrome: Brussels type

A new association of congenital familial short stature with facial dysmorphism and osteochondrodysplastic lesions is described in two siblings. Clinical abnormalities include severe prenatal and postnatal growth failure and facial dysmorphism. Radiographs show osteochondrodysplastic lesions with a narrow thorax, short ribs, epiphyseal maturation delay and slightly deformed metaphyses. Microscopic analysis of the skeleton shows pathological features.

Primary calcification in post-transplantation lymphoproliferative disorder involving the hepatic graft: an exceptional finding

Calcification within active post-transplantation lymphoproliferative disorders has, to our knowledge, never been described. We report the case of a 14-month-old boy who presented 4 months after orthotopic liver transplantation with a primary calcification in a lymphoproliferative nodule involving the hepatic graft. This calcification was detected by routine ultrasonography, visible on plain radiographs, and the post-transplantation lymphoproliferative disorder was histologically proved.

[Quality control in pediatric radiology]

The authors recall the fundamentals of an adequate use of the X-rays considering to the ALARA (As Low As Reasonably Achievable) principle. The article deals more specifically with radiation protection and quality control in radiopediatrics, as this age group is essentially concerned with stochastic hazards, i.e. cancer induction and genetic injurious effects. The major elements of X-ray equipment are reviewed, including the X-ray generator, device, film-screen, radiogenic tube, automatic exposure device, and so on... The influence of technical parameters on dosimetry in terms of radiation protection as well as dosis variation, according to the type of disorder, are demonstrated. Reference is made to the radiologic techniques proposed by the Lake Starnberg Group.

[Primary tumor calcification in a case of Burkitt's lymphoma]

A case of abdominal Burkitt lymphoma in a 8-year-old boy is reported. The authors discuss a very unusual feature of this untreated lesion, intratumoral calcification remaining unchanged after 4 years of follow-up.

[Laparoscopic treatment of recurrence and embolization failure of varicocele]

Varicocele is a benign pathology, for which the less invasive treatment is percutaneous embolisation. Literature reports results from 70 to 85% (1,2). Laparoscopic treatment seems to be a good alternative for patients suffering from a recurrence, or patients who can not be embolised. We report our experience concerning the first 13 patients treated with laparoscopic technic. In all 13 cases it was possible to practice the technic, and patients were cured.

[Epipadiac duplication of the urethra]

Urethral duplication is a less frequent malformation. The Williams classification, which is currently admit, classifies them in sagital, hypospadias or complex and collateral duplications. They can be complete, incomplete or reduced to an incomplete sinus. The most severe cases are often accompanied by multi-abnormality syndromes. Clinical manifestations are various: asymptomatic, urinary infection, incontinence, double urinary stream,... We will report two new cases of incomplete epispadias duplication. The first case presents a purulent flow from the fistula, the second a frank epispadiac status. In both cases, corrective surgical treatment was performed, after a complete balance-sheet. The embryological, diagnostical and therapeutical aspects of the different forms of urethral duplication will be studied based on data from literature.

Percutaneous transjugular intrahepatic stent shunt for treatment of intractable varicose bleeding in paediatric patients

Two 10-year and 11-year-old children with oesophageal and gastric varicose haemorrhage unresponsive to medical treatment and repeated endoscopic sclerotherapy underwent percutaneous transjugular intrahepatic portosystemic shunting (TIPSS). A newly developed introducing system was used. The procedure was performed to avoid the increased risk of emergency liver transplantation in children with hepatic failure. Immediately after the procedure bleeding stopped and the patient's condition improved. Ascites disappeared and liver function improved. The stent shunt was shown to be patent by angiography and Doppler ultrasound for a follow up period of more than 1 year.

CONCLUSION

TIPSS may be of benefit in children with severe portal hypertension. It allows control of intractable bleeding, and stabilizes the patients preparing them for subsequent elective orthotopic liver transplantation.

[The role of ultrasonography in abdominal pain in children in the emergency room]

Our retrospective study aims at defining the influence of ultrasonography on the management of acute abdominal pain in a pediatric population. This technique appears to be essential in the diagnosis of intussusception and thus, should be recommended in all cases of acute abdominal pain in the population at risk for this disorder. On the other hand, ultrasonography only plays a minor role in the management of the other diseases we observed, especially in acute appendicitis.

[Urethral stenosis in children. Apropos of 33 pediatric cases]

Urethral stenosis in children is rare. Between 1961 and 1993, only five specific retrospective studies were published. Between January 1987 and December 1992, thirty-three children, i.e. thirty boys and three girls, were observed in our institution for urethral stenosis. Their ages ranged from two and half months to seventeen years. Etiology was congenital in six, traumatic in two, inflammatory in two and iatrogenic in thirteen patients. In additions, ten stenoses were consecutive with hypospadias repair. Seventeen patients underwent first-line endoscopic internal urethrotomy. Success rate was ninety-one percent. Two patients underwent a successful second similar procedure. Repeating this procedure more than twice and second-line urethrotomy doesn't improve success rate. It appeared that internal urethrotomy proved to be more effective in short and recent stenosis. Fourteen patients underwent urethroplasty by using various techniques, of whom only five first-line urethroplasty. Its indication in case of multioperated or complicated stenoses may explain the poor global success rate of about fifty percent.

Sonographic evaluation of traumatic spinal cord lesions in the newborn infant

We present a case of spinal cord injury due to birth trauma and assess the value of sonography for diagnosis, lesion characterization, and follow-up. Sonography is a non-invasive and easily reproducible imaging method for examining a ventilated child, and its initial sensitivity is comparable to that of MRI. Sonography is the method of choice for guiding diagnosis in this type of traumatic lesion to the newborn.

Autosomal dominant polycystic kidney disease in the first year of life. Report of a case with no family history

Autosomal recessive polycystic kidney disease (RPKD) (also called infantile polycystic kidney disease) and autosomal dominant polycystic kidney disease (DPKD) (or adult form) are the two main types of genetic polycystic kidney diseases (PKD) encountered in children and infants. We report here a case of DPKD with no family history and discuss the main features leading to the differential diagnosis between these two types of PKD, their prognosis and the importance of making the right diagnosis for the genetic counselling.

Management of intra-abdominal organ injury following blunt abdominal trauma in children

OBJECTIVE

To evaluate the strategy of a combined diagnostic and therapeutic approach in children with intra-abdominal organ injury following blunt abdominal trauma.

DESIGN

Retrospective clinical study.

SETTING

Pediatric intensive care unit of an university hospital.

PATIENTS

38 children with documented intra-abdominal injury.

INTERVENTION

Initial non-surgical treatment by a team of pediatric intensivists, radiologists and surgeons.

MEASUREMENTS AND RESULTS

Physical examination, oriented blood and urine tests, plain abdominal film, abdominal ultrasound (US) and computed tomography (CT) with contrast. US documented intra-abdominal fluid in 30 and initial organ lesion in 14 out of 31 patients evaluated. Abdominal CT demonstrated the precise organ lesion in 34 out of 36 patients examined with solid organ lesion. Early laparotomy was needed in 7 because of severe shock, pneumoperitoneum and ruptured diaphragm, and delayed surgery in 6 patients. All 38 patients regained a normal life.

CONCLUSIONS

The stepped diagnostic approach combined with initial non-surgical treatment by a team provided accurate diagnosis and appropriate treatment. Abdominal US, by demonstrating free intra-abdominal fluid is very sensitive to detect patients with intra-abdominal organ injury, CT scan with contrast is needed to give precise information of specific organ lesions.

Intestinal hemorrhage three years after incidental appendectomy by total inversion

A late hemorrhagic complication of incidental appendectomy by entire inversion is reported in a liver transplant child. The use of proper surgical technique for inversion appendectomy is emphasized, including total devascularization of the appendix before inverting it.

Hemihypertrophy, bilateral Wilms' tumor, and clear-cell adenocarcinoma of the uterine cervix in a young girl

We report the case of a young girl who had hemihypertrophy and developed Wilms' tumor in both kidneys and clear-cell adenocarcinoma of the uterine cervix with no maternal history of stilbestrol ingestion during pregnancy. Karyotype on the second Wilms' tumor showed monosomy 22. The link between hemihypertrophy and Wilms' tumor is well known, but their association with clear-cell carcinoma of the cervix has not been previously described.