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This study aimed to assess malpractice in paediatric minimally invasive surgery (MIS), and attitudes, prevention strategies and mechanisms to support surgeons while they are under investigation. An observational, multicentric, questionnaire-based study was conducted. The survey questionnaire was sent via mail, and it comprised four sections. Twenty-four paediatric surgeons (average age 54.6 years), from 13 different countries, participated in this study. The majority had >15 years of experience in MIS. Three (12.5%) surgeons reported a total of five malpractice claims regarding their MIS activity. The reasons for the claims were a postoperative complication in 3/5 (60%) cases, a delayed/failed diagnosis in 1/5 (20%) cases and the death of the patient in 1/5 (20%) cases. The claims concluded with the absolution of the surgeon in all cases, and monetary compensation to the claimant in two (40%) cases. Eleven (45.8%) surgeons were invited as expert counsels in medico-legal actions. Medico-legal aspects have a minimal impact on the MIS activity of paediatric surgeons. In this series, claims concluded with the absolution of the surgeon in all cases, but they had a negative effect on the surgeon's reputation and finances. A key element in supporting surgeons while they are under investigation is always to choose a surgeon who is an expert in paediatric MIS as legal counsel. A constant update on innovations in paediatric MIS and appropriate professional liability insurance may also play a key role in reducing medico-legal consequences.

Purpose: The aim of this paper was to propose structured guidelines for a European pediatric MIS training program created by ESPES., Methods: A questionnaire, focused on how the pediatric training program in MIS has to be structured, was proposed to all participants at the ESPES Congress in Marseille in 2013., Results: We received 178 questionnaires but only 139 questionnaires were fully completed and analyzed. All respondents agree that the training program has to be divided into 4 steps: (1) theoretical part: 2 theoretical courses in laparoscopy (101/139 respondents, 72.7 %), 1 theoretical course in retroperitoneoscopy (99/139 respondents, 71.2 %) and 1 in thoracoscopy (91/139 respondents, 65.5 %); (2) experimental part: 10-20 h of training on pelvic trainer (103/139 respondents, 74.1 %) and 10 h of training on animal models (91/139 respondents, 65.5 %); (3) stages in European centers of reference for MIS: a 1-3 months stage (96/139 respondents, 69.1 %); (4) personal experience: 30 procedures as cameraman (98/139 respondents, 70.5 %) and >50 basic MIS procedures as main surgeon under supervision (114/139 respondents, 82 %)., Conclusions: On the basis of our survey ESPES MIS training curriculum for pediatric surgeons must contain the following educational components: (1) theoretical knowledge; (2) practice-based learning and improvement in experimental setting; (3) stages in European centers of reference for MIS; (4) personal operative experience. At the end of the training program, ESPES will analyze the candidate training booklet and release for each applicant an ESPES certification after an exam.

Background: Surgeons are at risk for developing work-related musculoskeletal symptoms (WMS). The present study aims to examine the physical factors and their association with WMS among pediatric laparoscopic surgeons., Methods: A questionnaire consisting of 21 questions was created and mailed to 25 pediatric laparoscopic surgeons (LG). 23/25 surgeons (92%) completed the survey. The questionnaire was analyzed and then split into 2 groups. Group 1 (LG1) included surgeons with greater laparoscopic experience, and group 2 (LG2) included surgeons with less important laparoscopic experience. In addition, we constructed and sent to the same surgeons a similar questionnaire focused on WMS after an open procedure (OG) with the aim to compare results of LG with OG., Results: The prevalence rate of WMS with shoulder symptoms was 78.2% in surgeons that performed laparoscopy for more than 10 years, with 60.8% also reporting other pain. In 66.6% this pain is evident only after a long-lasting procedure. Forty-four percent of these surgeons require painkillers at least twice a week. Fifty percent of these surgeons also suffer at home. Fifty-five and one half percent of surgeons indicate that this pain is related to their laparoscopic activity. Forty-three and a half percent think that laparoscopy is beneficial only for the patient but has a bad ergonomic effect for surgeons. Sixty-five and two-tenths percent think that robotic surgery can be helpful to improve ergonomics. Comparing the groups, WMS occur more frequently in LG (78.2%) than in OG (56.5%), but this difference was not statistically significant (χ(2)=0.05). In addition, WMS occur more frequently in LG1 (84.6%) than in LG2 (70%), but this difference was not statistically significant (χ(2)=0.05)., Conclusions: These results confirmed a strong association between WMS and the number of laparoscopic procedures performed. Skilled laparoscopic surgeons have more pain than less skilled laparoscopic surgeons. WMS in the same group of surgeons are more frequent after laparoscopy than after open procedures. The majority of surgeons refer to shoulder symptoms., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Alimentary tract duplications (ATD) are a rare cause of intestinal obstruction in childhood. There are many case reports but few series about laparoscopy or thoracoscopy for ATD. The aim of our study was to report the outcome of minimally invasive surgery (MIS) for ATD., Methods: This was a retrospective multicenter study from the GECI (Groupe d'Etude en Coeliochirurgie Infantile). We reviewed the charts of 114 patients operated on by MIS for ATD from 1994 to 2009., Results: Sixty-two patients (54 %) had a prenatal diagnosis. Forty-nine patients (43 %) were symptomatic before surgery: 33 of those patients (63 %) with postnatal diagnosis compared to 16 (25 %) with prenatal diagnosis (P < 0.01). In this last group, the median age at onset of symptoms was 16 days (range = 0-972). One hundred and two patients had laparoscopy (esophageal to rectal duplications) and 12 patients had thoracoscopy for esophageal duplications. The mean operative time was 90 min (range = 82-98). There were 32 (28 %) resection anastomoses, 55 (48 %) enucleations, and 27 (24 %) unroofings. The conversion rate was 32 %, and in a multivariate analysis, it was significantly higher, up to 41 % for patients weighing <10 kg (P < 0.01). Ten patients (8 %) had unintentional perioperative opening of the digestive tract during the dissection. Eight patients had nine postoperative complications, including six small bowel obstructions. The median length of hospital stay was 4 days (range = 1-21) without conversion and 6 days (range = 1-27) with conversion (P = 0.01). The median follow-up was 3 months (range = 1-120). Eighteen of the 27 patients who underwent partial surgery had an ultrasound examination during follow-up. Five (18 %) of them had macroscopic residue., Conclusion: This study showed that MIS for ATD is feasible with a low rate of complications. Patients with prenatal diagnosis should have prompt surgery to prevent symptoms, despite a high rate of conversion in small infants.

Background: Laparoscopic inguinal hernia repair is rarely reported in pediatric patients. We report our 15-year experience on this topic to show the long-term results of this technique., Methods: During a 15-year period, we operated 596 boys for unilateral inguinal hernia using laparoscopy. The age range was variable from 6 months to 15 years (median, 54 months), with a median body weight of 18.5 (range, 8-54) kg. Preoperatively, 352 boys had a right hernia and 172 had a left hernia. We always used three trocars. We used the laparoscopic herniorrhaphy described by our group 15 years ago; it consists of sectioning the sac distally to the inguinal ring and performing a pursestring suture around the periorificial peritoneum using a 4/0 nonresorbable suture., Results: The median operating time was 19 min. All procedures were performed in a day-hospital setting. As for laparoscopic findings in 95 of 596 patients (15.9%), we found a contralateral patency of the processus vaginalis. In these 95 cases, we performed bilateral herniorrhaphy. In 7 of 596 patients (1.2%), we discovered a direct hernia. With follow-up between 1 and 15 years, we have only 11 recurrences (1.5%)-all reoperated by laparoscopy., Conclusions: We believe that laparoscopic repair of inguinal hernia performed by expert hands is a safe and effective procedure to perform with long-term follow-up. Its ability to repair simultaneously all forms of inguinal hernias together with contralateral patencies has cemented its role as a viable alternative to conventional repair.

Wandering spleen in children is a rare condition. The diagnosis is difficult, and any delay can cause splenic ischemia. An epidemiologic, semiological, and surgical diagnosis questionnaire on incidence of wandering spleen in children was sent to several French surgical teams. We report the results of this multicenter retrospective study. Fourteen cases (6 girls, 8 boys) were reported between 1984 and 2009; the age range varies between 1-day-old and 15 years; 86% were seen in the emergency department. Ninety-three percent had diffuse abdominal pain. For 57% of the cases, it was their first symptomatic episode of this type. No diagnosis was established based on the clinical results alone. All patients had presurgical imaging diagnosis. Open surgery was performed on 64% cases. Forty-three had splenectomy for splenic ischemia. Thirty-six percent had splenopexy, 14% had laparoscopic gastropexy, and 7% had spleen repositioning and regeneration. Complications were noted in 60% of the cases resulting in postsplenopexy splenic ischemia. Early diagnosis and surgery are the best guarantee for spleen preservation. Even if the choice of one technique, splenopexy or gastropexy, can be argued, gastropexy has the advantage of avoiding splenic manipulation and restoring proper physiologic anatomy. When there is no history of abdominal surgery, laparoscopy surgery seems the best procedure., (Copyright 2010 Elsevier Inc. All rights reserved.)

The management of acute appendicitis in the pediatric patient has undergone radical rethinking in recent years. It has been shown that simple uncomplicated acute appendicitis can be successfully managed with antibiotic therapy and may not even require interval appendectomy. Appendicitis complicated by perforation, abscess, or inflammatory phlegmon can be successfully treated by initial antibiotic therapy (with or without percutaneous drainage) and delayed interval appendectomy. While the laparoscopic approach has proved to be well-adapted to many other pediatric surgical procedures, its utility in the treatment of uncomplicated acute appendicitis remains open to debate; compared to standard open appendectomy, it offers only minimal advantages with regard to post-operative care, length of hospital stay, and complications. Children can be managed either by general surgeons or pediatric surgeons depending on the organization of the emergency service; there may be a higher incidence of removal of a normal appendix in non-specialized services.

Background: Nissen fundoplication is the most popular laparoscopic operation for the management of gastroesophageal reflux disease (GERD). Partial fundoplications seem to be associated with a lower incidence of postoperative dysphagia, and thus a better quality of life for patients. The aim of this study was to compare the long-term outcome in neurologically normal children who underwent laparoscopic Nissen, Toupet, or Thal procedures in three European centers with a large experience in laparoscopic antireflux procedures., Methods: This study retrospectively analyzed the data of 300 consecutive patients with GERD who underwent laparoscopic surgery. The first 100 cases were recorded for each team, with the first team using the Toupet, the second team using the Thal, and the third team using the Nissen procedure. The only exclusion criteria for this study was neurologic impairment. For this reason, 66 neurologically impaired children (52 Thal, 10 Nissen, 4 Toupet) were excluded from the study. This evaluation focuses on the data for the remaining 238 neurologically normal children. The patients varied in age from 5 months to 16 years (median, 58 months). The median weight was 20 kg. All the children underwent a complete preoperative workup, and all had well-documented GERD. The position of the trocars and the dissection phase were similar in all the procedures, as was the posterior approximation of the crura. The short gastric vessels were divided in only six patients (2.5%). The only difference in the surgical procedures was the type of antireflux valve created., Results: The median duration of surgery was 70 min. There was no mortality and no conversion in this series. A total of 12 (5%) intraoperative complications (5 Nissen, 5 Toupet, 2 Thal) and 13 (5.4%) postoperative complications (3 Toupet, 4 Nissen, 6 Thal) were recorded. Only six (2.5%) redo procedures (2 Thal, 2 Toupet, 2 Nissen) were performed. After a minimum follow-up period of 5 years, all the children were free of symptoms except nine (3.7%), who sometimes still require medication. The incidence of complications and redo surgery for the three procedures analyzed with the Mann-Whitney U test are not statistically significant., Conclusions: For pediatric patients with GERD, laparoscopic Nissen, Toupet, and Thal antireflux procedures yielded satisfactory results, and none of the approaches led to increased dysphagia. The 5% rate for intraoperative complications seems linked to the learning curve period. The authors consider the three procedures as extremely effective for the treatment of children with GERD, and they believe that the choice of one procedure over the other depends only on the surgeon's experience. Parental satisfaction with laparoscopic treatment was very high in all the three series.

We determine the feasibility of laparoscopic revision surgery in children following previous open and laparoscopic antireflux operations. To give an objective overview about this topic, we analyzed the outcome of 15 children (8 girls and 7 boys) who had undergone attempted laparoscopic revision between 4 and 72 months (median 16 months) after a previous antireflux operation. Seven patients had previously undergone an open antireflux procedure (4 Nissen fundoplication; 3 Thal procedure) and 8 a laparoscopic procedure (5 Nissen; 3 Toupet's procedure). Two of these children were mentally handicapped. The indications for revision were: recurrent reflux, 5; valve migration, 5; valve dismount, 5. Eight procedures comprised construction of a new Nissen fundoplication and in 7 cases a Toupet's procedure was performed. Revision was successfully completed laparoscopically in 10 cases, 7 of 8 patients following a previous laparoscopic procedure and in 3 of 7 following a previous open operation. Operating time ranged between 70 and 140 minutes (median 90 minutes). No perioperative complications occurred in either group. All patients were discharged within 3 to 4 days after the redo procedure. Follow-up time varied between 6 months and 7 yrs. Preoperative symptoms were relieved in all patients and all antireflux medication has been discontinued, except in two cases that still had rare symptoms. Although technically challenging, laparoscopic reoperation for recurrent gastroesophageal reflux disease can be performed safely and with good results, in the hands of experienced endoscopic surgeons. Reoperation is likely to be more difficult following failure of an open procedure than after failure of a laparoscopic one. Concerning the type of procedure, redo surgery is more difficult to perform after Nissen's than after Toupet's or Thal's procedure., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Laparoscopic fundoplication is performed commonly in children, and it represents "the gold standard" in children with gastroesophageal reflux disease (GERD) refractory to medical therapy. We present a single surgeon's experience with a posterior partial valve. Between May 1993 and May 2002, we operated on 574 children using Toupet's procedure. Among the patients, 24 were younger than 1 year of age, and 17 others were neurologically impaired. The average duration of the surgery was 1 hour. Complications were limited to 3 eviscerations of omentum through the port wounds. Relapse of GERD secondary to valve failure occurred in 6 patients, 1 neurologically impaired and 1 with mucoviscidosis. All six patients have been reoperated on laparoscopically, and Toupet fundoplication was performed again with good results. We think that the 270-degree posterior valve, according to Toupet, is a good procedure to adopt in children with GERD with a low rate of recurrence at long-term follow-up., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Background/purpose: Laparoscopic inguinal herniorrhaphy has been introduced recently as an alternative to conventional open repair in children. This study was undertaken to evaluate the safety, efficacy, and reproducibility of this minimally invasive approach., Methods: A total of 933 laparoscopic inguinal herniorrhaphies were performed on 666 children (597 boys and 69 girls), ranging in age from 3 weeks to 14 years (median, 3.2 years). A 5-mm laparoscope was placed through an umbilical incision, and two 2-mm or 3-mm needle drivers were inserted through the lateral abdominal wall. The neck of the sac was closed with a 4-0 monofilament suture. The needle was inserted directly through the abdominal wall, and removed together with the trocar. Only the umbilical fascia was closed with an absorbable suture. No skin sutures were applied., Results: A total of 911 indirect inguinal hernia sacs were closed (337 right, 172 left, 402 bilateral) and 22 direct inguinal hernias were repaired (14 boys, 3 girls; 11 right, 3 left, 4 bilateral). The median operating time was 22 minutes (range, unilateral, 7 to 45 min; bilateral, 9 to 51 min). With experience, this time gradually decreased. There were no intraoperative complications. The contralateral asymptomatic processus was unexpectedly open on the left side in 137 of the boys (23%) and 10 of the girls (15%), and on the right side in 131 of the boys (22%) and 21 of the girls (32%). In 16% of the children, the final procedure was modified on the basis of the anatomic findings. No hernia was found in 13 children (1.9%). The recurrence rate was 3.4% (follow-up time ranged from 2 months to 7 years). Hydroceles were observed in 4 children, and a subtle change in testicular position and size was noted in one boy., Conclusions: Laparoscopic inguinal repair in children proved safe and reproducible, although the recurrence rate was slightly higher than with the open approach. However, laparoscopy allows easy and precise identification of the type of defect and its correction. In this series, the incidence of direct inguinal hernias was higher, and the incidence of a patent contralateral processus vaginalis was lower than previously reported., (Copyright 2002 by W.B. Saunders Company.)

Background: Very few children need gastroesophageal antireflux surgery during their first year of life; hence, no series has been published so far. The authors report their experience in 3 centers., Methods: From January 1993 to December 1998, 36 infants between 23 days and 13 months of age, suffering from gastroesophageal reflux disease (GERD), underwent surgery by a laparoscopic approach. The patients' weights ranged from 2.4 to 8.5 kg. Preoperative diagnostic studies included esophagograms, manometries, endoscopies, and pH-metries. Fifteen babies (41.6%) had associated anomalies, and 10 (27.7%) were neurologically impaired. Thirty-six laparoscopic fundoplications were performed according to either Toupet's procedure (17 of 36), Rossetti's (10 of 36), Nissen's (8 of 36) or Lortat-Jacob's (1 of 36). Four infants previously had undergone a gastrostomy, whereas 6 needed one during the antireflux procedure., Results: There was no mortality in our series. Three infants (8.3%) had an intraoperative complication: 1 lesion of a diaphragmatic vessel, 1 pneumothorax, and 1 case of severe hiatal hernia requiring conversion to open surgery. During the median follow-up of 22 months, 4 redo procedures were performed (11.1%)., Conclusions: This experience shows the feasibility of laparoscopic fundoplication even in children below 1 year of age. An accurate preoperative diagnostic study is mandatory, because 50% of these patients presented associated anomalies. A long and accurate follow-up is necessary to evaluate long-term results and detect possible complications, which can occur as late as 1 year after surgery. In addition, we believe that redo antireflux surgery is possible by the laparoscopic approach without major difficulties, based on our larger experience with older children., (Copyright 2001 by W.B. Saunders Company.)

Background/purpose: The laparoscopic splenectomy (LS) often is adopted to treat children affected by hematologic diseases. Many of the pitfalls of LS are related to the 2 steps-dissection and extraction. Although various methods have been adopted, the conversion rate still is too high during the learning curve period. The authors analyse their experience in 54 laparoscopic splenectomies performed by their teams in 3 European countries., Methods: From 1995 to 1999, 54 children underwent laparoscopic splenectomy, 4 of whom also underwent a concomitant cholecystectomy. There were 29 girls and 25 boys with ages ranging between 4 and 19 years (median, 8.1 years). All patients underwent an elective laparoscopic splenectomy: Thirty children had hereditary spherocytosis, 13 had an idiopathic thrombocytopenic purpura, 10 were affected by a beta thalassemia, and 1 child had sickle cell disease., Results: Mean operating time was 140 minutes (range, 100 to 250 minutes). Hospital stay ranged from 2 to 6 days (median, 3 days). In 7 patients the spleen was removed through a 7-cm minilaparotomy; in another 46 cases the spleen was captured into an extraction bag, fragmented, and then removed through the umbilical or left orifice. There was one conversion to open surgery because of a camera failure during the operation., Conclusions: On the basis of our experience we believe that the operating time of LS is still too long compared with open surgery, and the extraction phase still not simple enough. A perfect control of hemostasis is fundamental because severe complications can arise from even a slight bleeding episode. It also is very important to search for and remove any accessory spleens. In our series this occurred in 7 patients, one of whom had 3 accessory spleens. The laparoscopic approach is today a good alternative to open splenectomy.

Background: The aim of this study was to assess the complications associated with the laparoscopic treatment of gastroesophageal reflux disease (GERD) in children., Methods: From March 1992 to March 1998, we used the laparoscopic approach to treat 289 children affected by gastroesophageal reflux disease. The patients' ages ranged between 4 months and 17 years (median, 4.3 years), and their body weight ranged between 5 and 52 kg. In 148 children (51.3%), we adopted a Nissen-Rossetti procedure and in 141 (48.7%) a Toupet technique., Results: The duration of surgery ranged between 40 and 180 min (median, 70). There were no deaths and no anesthesiological complications in our series. We recorded 15 (5.1%) intraoperative complications: six pleural perforations, four lesions of the posterior vagus nerve, two esophageal perforations, two gastric perforations, and one pericardiac perforation. Conversion to open surgery was necessary in only four cases (1.3%). We recorded 10 (3.4%) postoperative complications: one peritonitis due to an esophageal perforation not detected during the intervention that required a reoperation, five cases of herniation of the epiploon through a trocar orifice, three cases of dysphagia that disappeared spontaneously after a few months, and one case of delayed gastric emptying that subsequently required a pyloroplasty. We had six recurrences of GERD (2.1%). In two cases, a new fundoplication was performed using the laparoscopic approach; in the other four, the GERD was controlled with medical therapy., Conclusion: Our results show that laparoscopic fundoplication is an adequate treatment for children with GERD that has a low rate of complications. When severe complications do occur, they can be treated effectively via the laparoscopic approach.

Background/purpose: The aim of this study was to evaluate the incidence and management of the complications that occurred in some children who underwent laparoscopic Heller's esophagocardiomyotomy in the authors' institutions., Methods: Between March 1993 and October 1998, the files of all the children with achalasia who underwent laparoscopic Heller's esophagocardiomyotomy in a community hospital in Naples, Italy, and a private hospital in Paris, France, were reviewed. A 5-port technique was used associating Heller's esophagocardiomyotomy to an antireflux surgical mechanism (Dor's or Toupet's) in all cases. Intra- and postoperative complications, as well as the postoperative outcome, were evaluated., Results: Ten laparoscopic Heller's esophagocardiomyotomies were performed in 5 girls and 5 boys with achalasia. Age ranged between 2 and 13 years. Mean operating time was 120 minutes. Hospital stay ranged between 3 and 41 days. Complications were recorded in 3 patients: in 2 an esophageal mucosal perforation and in 1 a prolonged dysphagia. Two of these complications occurred in the last patients operated on. Follow-up varied from 6 months to 6 years. All children were free of symptoms., Conclusions: The results show that laparoscopic Heller's esophagocardiomyotomy in children is a feasible procedure. Assessment of mucosal integrity immediately after the myotomy must be performed. Complications can happen even if the operation is performed by expert laparoscopic surgeons.

Background: Albeit rare in children, achalasia is a disorder with severe symptoms that causes growth impairment. The treatment of choice in children is the esophagomyotomy, although there are variations in the surgical approaches available and differences of opinion regarding the inclusion of an adjunctive antireflux procedure. The recent advent of the laparoscopic approach has had a profound impact on the treatment of achalasia in both adults and children., Methods: In this report, we describe eight patients with severe achalasia who were treated by laparoscopic Heller's operation associated with a fundoplication according to either Dor's or Toupet's technique. The patients' ages ranged between 2 and 13 years. A five-port technique was used: a 10-mm port placed infraumbilically for the optics and four 5-mm ports. One was placed in the right abdominal quadrant for retraction of the left hepatic lobe, one in the left abdominal quadrant for the first operative instrument, one below the xyphoid appendix for the second operative instrument, and the last one to introduce a 5-mm cannula laterally to the umbilicus to retract the stomach below. A 7-8-cm laparoscopic Heller esophagomyotomy was completed, followed by an anterior Dor fundoplication in six cases and a Toupet in two. The longitudinal division of the anterior esophageal musculature was performed with a scalpel or scissors. The myotomy was made along the stomach, extending for >/=2-3 cm., Results: Mean operating time was 120 mins. Three complications were recorded. There were two perforations of the gastroesophageal mucosa; the first was sutured in laparoscopy and the second required a second operation. The third complication was a case of dysphagia resolved by dismounting a fundoplication that was too tight. At follow-up, which lasted from 6 months to 5 years, the children were all free of symptoms., Conclusions: Laparoscopic Heller esophagomyotomy appears to be a complex and difficult operation, but it is as safe and effective as laparotomy in children with achalasia. However, complications can be numerous and severe at the beginning of a surgeon's experience.

Purpose: The authors report their experience in the laparoscopic treatment of congenital inguinal hernia in children., Methods: Between September 1994 and September 1995, 45 boys between 8 months and 13 years of age (mean, 4 years) were treated laparoscopically for hydroceles, spermatic cord cysts, or hernias. Twenty-six (57.8%) boys showed a right inguinal hernia, 17 (37.8%) a left hernia, and two cases (4.4%) presented the clinical data of a bilateral pathology. The approach used for small hernias was the placement of purse-string suture around the internal orifice of the inguinal canal (28 cases). As to hernias exceeding 4 to 5 mm in diameter, the external hemicircumference of the neck was opened to bring the conjoined tendon closer to the crural arch with a nonresorbable suture (17 cases). There was never need to use a prosthesis., Results: Surgery lasted from 15 to 45 minutes with the duration decreasing with experience. There were no intra- or postsurgical complications. Two patients (4.4%) experienced a recurrent inguinal hernia, which was successfully operated on again with laparoscopy., Conclusion: The early results of these authors suggest that laparoscopic surgery is a feasible and safe technique for the treatment of patent peritoneal vaginal canal (PVC) and inguinal hernia in children.

The authors report their experience with the laparoscopic treatment of recurrent inguinal hernia in children. Between April 1993 and January 1998, 225 boys aged 8 months to 14 years (mean 4.4 years) were treated laparoscopically for a hydrocele, spermatic-cord cyst, or hernia. Ten boys had recurrent inguinal hernias after conventional surgery, in one case bilateral. The technique requires 3 trocars: a 0 degrees, 5-mm telescope inserted through the umbilicus and two 3-mm trocars placed 3-4 cm below the umbilicus on either side. Simple patency of the peritoneal vaginal duct (dpv) was found in eight cases and a direct inguinal hernia in three. In cases with an open dpv, we opened the external hemicircumference of the neck in order to bring the conjoined tendon closer to the crural arch with a non-resorbable 4/0 suture, and then placed a 3/0 resorbable pursestring suture around the peritoneum of the internal orifice of the inguinal canal. In direct inguinal hernias the orifice was closed by placing 2-3 nonabsorbable 3/0 sutures between the two muscular sides of the hernial defect. There were no intra- or postsurgical complications. All patients, at a maximum follow-up of 3 years showed total recovery from the hernia. Our early results suggest that laparoscopic surgery is a feasible and safe technique for the treatment of recurrent inguinal hernia in children. Key words Recurrent inguinal hernia. Laparoscopy. Children

Background/purpose: The development of thoracoscopic surgery has made many procedures possible, including the treatment of mediastinal cysts in children. The authors report their experience with this procedure between 1992 and 1997., Methods: Surgery was performed on 22 children aged from 1 month to 9 years (median, 27 months), weighing 5 to 49 kg (median, 12.5 kg). Diagnosis was made by antenatal ultrasound scan in six cases (27%), with a chest x-ray performed for respiratory symptoms in 14 cases, and with a chest x-ray performed for positive tuberculin intradermoreaction in two cases. Decision to resect the cyst was determined by thoracoscopy in 21 of the 22 cases, and by open surgery in one case only (subcarinal compressive cyst with left lung distension and a mediastinal shift)., Results: Eighteen of the 21 (86%) cases were treated successfully by thoracoscopy. In three cases of bronchogenic cysts, we performed an associated thoracotomy because the dissection was too difficult and dangerous. In three cases, a small part of a common wall between the cyst and the bronchus was not removed. The pathological diagnosis was bronchogenic cysts in 15 cases (71%), pleuropericardiat cysts in three cases (14%), esophageal duplication in two cases (10%), and cystic hygroma in one case (5%). Two postoperative complications were observed: one esophageal wound and a case of recurrent pneumothorax after chest tube removal. Patients were discharged after 2 to 11 days (median, 3 days). Follow-up was uneventful., Conclusions: Treatment of mediastinal cyst by thoracoscopy is feasible in most cases. Compressive cysts with lung distension and mediastinal shift remain a contraindication. If the cysts have a common wall with the bronchus or esophagus, or if they are subcarinal, the dissection may be difficult and dangerous, and thoracotomy may be preferable.

The aim of this work is to determine the influence of age, extrahepatic biliary lesions pattern (EHBP) and association to polysplenia syndrome (PS) on 10 years outcome of 164 patients with biliary atresia (BA) treated from 1984 to 1992 by initial Kasai operation (KO) and secondary liver transplantation (LT) when necessary. Actuarial crude survival without or after LT (CS), actuarial survival with native liver (NLS) and jaundice-free actuarial survival with native liver (JFS) were calculated from 1 to 10 years versus age (under/over 45 days), EHBP (favorable/ unfavorable) and PS (no/yes). Overall 10-year CS is 70%, overall 10-year NLS and JFS are 14%. In univariate analysis, age at KO under 46 days, favorable EHBP (BA with patent gallbladder, and/or cystic dilatation of extrahepatic bile duct, or BA restricted to choledocus), and absence of PS are significant determinants of a better outcome regarding CS, NLS and JFS. EHBP is more discriminant than age. Influence of PS in this series is redundant with that of EHBP since 11/11 patients with PS had unfavorable EHBP.

Laparoscopic nephrectomy is a new procedure that must be evaluated in adults and children. This technique allows a reduction in complications and sequelae. The majority of indications, such as renal dysplasia and destroyed kidneys due to obstructive or refluxing uropathy, are suitable for laparoscopic nephrectomy. Contraindications are Wilms' tumor and trauma, which represent only 20 percent of nephrectomies in our experience. As in open surgery, to perform nephroureterectomy for benign disease, a retroperitoneal approach seems more logical than transperitoneal approach, which is the usual approach for laparoscopic surgeons. We have attempted six retroperitoneal laparoscopic nephrectomies in children from 3 months to 14 years old. The patient is positioned in a lateral position after creation of a retropneumoperitoneum under visual control; three or four ports are needed and renal vessels are dissected then clipped, or coagulated if small. Destroyed kidneys are generally of small size, so they can be extracted via a 10- or 12-mm cannula site without morcellation. Operative time ranges from 35 to 210 mm (median 120 mm). We have had no complications or conversions. Retroperitoneal laparoscopic nephrectomy in children is a feasible and safe procedure in well-trained hands.

Laparoscopic nephrectomy is a new procedure which remains to be evaluated in adults and children. This technique enables the reduction of parietal complications and sequelae. The majority of indications, e.g. renal dysplasia, destroyed kidneys due to obstructive or refluxing uropathy, are suitable for laparoscopic nephrectomy. Contraindications are Wilm's tumor and trauma which represent only 20% of nephrectomies in our experience. As in open surgery, a retroperitoneal approach seems more logical and better adapted than a transperitoneal approach to perform nephroureterectomy for benign disease. From August 1993 to December 1995, we attempted 18 retroperitoneal laparoscopic nephrectomies in children aged from 3 months to 14 years. The patient is placed in a lateral position, and after creation of a retropneumoperitoneum under direct vision control without balloon dissection, three or four ports are needed, renal vessels are dissected, then clipped or coagulated if small. Destroyed kidneys are generally of small size, so they can be extracted via a 10- or 12-mm cannula site without morcellation. Operative time is 35-210 min (median 106 min). There were no major complications and only one conversion. In conclusion, retroperitoneal laparoscopic nephrectomy in children is a feasible and safe procedure in well-trained hands.

The authors present a retrospective analysis of 1,379 pediatric laparoscopic appendectomies. The patients' average age was 10 years (range, 2 to 16 years). On gross examination, 90% of the appendixes appeared inflamed; on microscopic examination, 93% had evidence of acute appendicitis. The incidence of appendiceal peritonitis was 16%. Nonappendiceal lesions were identified in 10% of patients. The incidence of minor intraoperative events was 2.1%, and the postoperative complication rate was 1.5%; 0.7% of patients required a subsequent laparotomy or additional laparoscopic procedure. There were no deaths. The children were discharged after a 2-day (average) hospitalization and returned to unrestricted activities 1 week after surgery. The advantages of laparoscopic appendectomy are its easy and rapid localization of the appendix, the ability to explore the entire abdominal cavity, the ability to lavage completely the contaminated peritoneal cavity, and a reduction in the incidence of intraperitoneal abscesses and postoperative adhesions. Laparoscopic appendectomy offers reduced parietal scarring, a shorter hospital stay, and an earlier return to normal activities, even in cases of complicated acute appendicitis. Our experience confirms that laparoscopic appendectomy is safe and effective in children.

Nowadays, liver reduction techniques make it possible to use livers obtained from adults or adolescents for implantation in children. These techniques have been evaluated by analysis of 100 liver transplantations performed between January 1988 and October 1991 in 85 children. Forty-six full-size grafts implanted in 38 children (group 1) were compared with 54 reduced-size grafts implanted in 47 children (group 2). The overall actuarial survival at 4 years was 86 percent. There was no statistical significant difference between the two groups as regards the rates of death (8 versus 19 percent), reoperation (54 versus 64 percent), retransplantation (15 versus 16 percent), hepatic artery thrombosis (13 versus 15 percent) and graft survival (82 versus 70 percent) respectively. Haemorrhage was significantly more frequent in group 1 than in group 2 (P = 0.04), irrespective of whether transplantation was performed urgently or electively. Using reduced-size livers considerably increases the number of liver grafts available to children. Apart from a greater risk of haemorrhage, the results obtained with reduced-size livers were identical with those obtained with full-size livers.

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

The authors present a retrospective analysis of 465 pediatric laparoscopic appendectomies. The ages of these patients ranged from 3 to 16 years, with a mean age of 10 years. The diagnosis of acute appendicitis was based on one or more of the following: the initial or repeated physical examination, abdominal radiographs, leukocyte blood count, and ultrasonography. On gross examination, 90% of appendices appeared inflamed, while on microscopic examination, 93% showed evidence of acute inflammation. There was a 3.6% incidence of minor intraoperative incidents and a 3.0% postoperative complication rate with 1.3% of patients requiring a subsequent laparotomy or repeat laparoscopic procedure. There were no deaths. The advantages of laparoscopic appendectomy include easy and rapid localization of the appendix, regardless of its location, the ability to explore the entire abdominal cavity through the same laparoscopic portals used for appendix removal, the ability to lavage completely the contaminated peritoneal cavity, a reduction in the incidence of intraperitoneal abscesses, and a probable reduction in postoperative adhesions. In addition, laparoscopic appendectomy is associated with less cutaneous scarring and a more rapid return of intestinal function and normal activities. In our experience, these results are better than those obtained with classical surgery.

The authors report a retrospective series of 465 appendectomies with intraoperative celioscopy in children under age 16. The technical issues and the indications are discussed. The results are the following: No death, 3.6% intraoperative incidents of no consequence, 3% postoperative complications, including 1.3% requiring second surgery or celioscopy. These results are better than those obtained with conventional surgery. The advantages of appendicectomy with intraoperative celioscopy are the following: easy, quick search for the appendix, whatever its location, exploration of the entire abdominal cavity, possibility to perform a complete peritoneal washing, suppression of parietal complications, and almost no skin scar, definite reduction in the number of intraperitoneal residual abscesses, and likely reduction of postoperative adhesions, which are a cause of obstruction, of chronic pain and of infertility in girls, rapid resumption of transit and of all activities, including sports.

The gallbladder, the cystic and the choledocal ducts are patent in one fifth of biliary atresia cases, and can be used for the corrective operation. The main interest of this hepatoportocholecystostomy (HPC) is to prevent the cholangitis episodes which are the most severe complication of successful hepatoportoenterostomies (HPE). However a singular complication of HPC has been noticed by previous authors: the choleperitonitis. We report a recent case in which this complication was diagnosed by a routine ultrasonography at the 3rd week of the uneventful postoperative course of a HPC performed in an 1 1/2 month old infant. An early reoperation (HPE) had a good result with restoration of a satisfactory bile flow. The child is anicteric with a follow-up of one year. In our experience with 208 corrective operations between 1969 and 1981, HPC was used in 38 cases, with restoration of bile flow in 17 cases. A choleperitonitis was noticed in 4 cases in this series, and in a 5th additional recent case. Three children were not suitable for reoperation because of very poor condition and died within 3 to 17 months after HPC. Two children were reoperated upon early with a good result. We advocate the HPC procedure despite the risk of choleperitonitis and emphasize the interest of early postoperative routine ultrasonography, especially when stools remain acholic at the 4th postoperative week.

Foetus in foetu is a very unusual cause of abdominal mass in the infancy. Twenty cases only have been quoted in the literature. Two others cases are added, concerning two girls: a three months infant, second born from a genuine twin pregnancy, and a four weeks newborn whose the mass was discovered before the birth, on routine ultrasonography. In together, the diagnosis was made in operating room, then confirmed by pathologic studies. Literature data are recorded, and the difference between teratomas and foetus in foetu is point. The pathogeny remains obscure. It could result from the inclusion of a parasite twin in his bearer, become during embryologic stage of the delimitation.

In 125 cases (30,6%) the tumour could not be removed, mainly because of peritoneal metastases and posterior extra-gastric extension. Tumoral resection was performed in 283 cases (69.4%), being palliative in 76 and considered as curative in 216 (52.9%). There were 177 distal gastrectomies, 40 proximal and 66 total gastrectomies with oesophageal resection adapted to the extent of the tumour. Operative mortality was 2.1% after resection and 8% after exploratory and derivative surgery. The five-year survival rates among 213 patients operated upon before December 1973, were 50.8% after curative resection, 39% for all resections and 27.7% for all patients who underwent surgery. The long-term prognosis was evaluated in relation to the site of the lesion, its depth of penetration into the gastric wall and its extension to the lymph nodes. Spreading superficial carcinomas had a five-year survival rate of 89.6% and their incidence (14% of all operated patients) did not change in recent years despite the increasing use of gastric endoscopy. Extension to the lymph nodes was a very important prognostic factor, since the five-year survival rate was 75% in patients with non-invaded primary lymph nodes, as opposed to 32% in patients with invaded primary lymph nodes and only 5% in patients with secondary node involvement.

The management of chylous ascites presenting in association with primary lymphedema of the limbs and possibly lymphatic malformation in the lungs is difficult when the increasing abdominal distension causes respiratory distress. Laparotomy may be useful in traumatic chylous ascites or in intestinal lymphangiectasia localized to a segment of the bowel. It would seem that when conservative management such as diuretics, diet, and repeated abdominal paracentesis do not improve the respiratory distress, a peritoneo-venous shunt is logical. This report of two patients with severe chylous ascites and generalized lymphatic malformations causing or accentuating respiratory distress, stresses the possibility that peritoneo-venous shunts may not have the same long term function as seen in cirrhotic ascites. Long-term follow-up on the use of these shunts specifically for chylous ascites is not available.

From 1982 to 1986, 53 newborns (26 boys and 27 girls) were referred to the authors for the management of a congenital anomaly of the urinary tract, following a prenatal ultrasonographic diagnosis. The postnatal diagnosis was hydronephrosis in 27 children (10/27 bilateral cases), unilateral multicystic dysplasia in 11, ureteral duplication in 6, primary megaureter or orthotopic ureterocele in 5 (1/5 bilateral case) and posterior urethral valves in 4. An early urinary tract infection was noticed in 5 cases only and 2 boys with urethral valves had an altered renal function at birth. Eight children with a mild lesion were not operated. A radical procedure was performed in 15 cases: excision of a multicystic kidney (10 cases) or heminephrectomy of an upper non-functioning pyelon (5 cases: 3 with heterotopic ureterocele and 2 with ectopic ureter). Thirty children were submitted to a corrective procedure: electrocoagulation of urethral valves (4 cases), ureteroneocystostomy (6 cases) or pyeloplasty (19 unilateral and 1 bilateral procedure). Except in a case of pyeloplasty the result of the reconstructive surgery was considered as good or satisfactory from a radiological point of view, with a mean follow-up of 1.5 year. The essential point of discussion is the evaluation of the factors which must be taken in account to plan an early reconstructive surgical treatment. The main factor, I.e. the natural history of these congenital anomalies remains at yet difficult to predict in a great number of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

The medical records and surgical slides of 58 patients with the diagnosis of thyroid nodules (solitary nodule in 50 patients) are reviewed. The most common cause of thyroid nodules in this series is follicular adenoma (27 patients or 46%). A nuclear scan (technetium or radioactive iodine) was performed in 55 patients, of which 40 showed a cold nodule. Twelve of the 40 cold nodules were malignant (30%). However, for solitary nodules the incidence of cancer is 27%. This last figure is significantly greater than the one recently reported by Hung et al (18.5%). Available diagnostic methods are reviewed and the clinical management as derived from our experience is presented.

Seven cases of calyceal diverticula were seen from 1967 to 1981 in children aged 2 to 16 years at the moment of diagnosis. Symptoms were: gross hematuria (2 cases), urinary infection (2 cases), recurrent abdominal pain (2 cases) or enuresia. All children had a single diverticulum. Five of the 7 diverticula were located at upper renal pole. One of the children presenting with hematuria and renal colic had an oxalic calculous within diverticulum. Three small diverticula did not require treatment and remained uncomplicated with a follow-up of 14,18 and 60 months. Four complicated diverticula (1 from oxalolithiasis, 1 from hematuria and 2 from urinary infection) required surgical removal, by partial nephrectomy (1 case) or deroofing operation with intradiverticular ligation of the communication channel (3 cases). Results were good in 3 children. Removal of adjacent parenchyma with a residual cavity was necessary 5 years later in the fourth child. The majority of children calyceal diverticula seem to be from congenital origin, but some authors suggest that the y could result from vesico-tubular reflux. The possibility of late complications from small and asymptomatic diverticula has been emphasized by many authors. The deroofing operation is certainly the elective procedure when a large or complicated diverticulum requires surgical treatment.

We reviewed our experience with endoscopic sub-ureteral injection of polytetrafluoroethylene (PTFE) in 337 children (84% females, 16% males). Four hundred and ninety one refluxing ureters were injected (93% primary reflux, 7% secondary reflux after reimplantation, correction of exstrophy of the bladder or neurogenic bladder). Reflux was: - stage I: 7.8% - stage II: 32% - stage III: 38% - stage IV: 20% - stage V: 2.2% Follow-up cystograms were performed one 428 ureters, 6 to 30 months after injection. 80% of children are cured after one injection while 4% required two injections in order to attain the same result. Improvement in the grade of reflux (minimal residual disease) was noted in 10% of the patients and in 6% the procedure failed. In the latter group, 16 children were operated on without difficulty; lymphatic migration of PTFE was noted in two cases. In the 33 patients with secondary reflux, the endoscopic treatment was associated with an 80% cure rate, in the 26 patients presenting a reflux on duplex systems, cure rate was 65%. This is a simple procedure performed on an outpatient basis; in our experience with 491 injections there were no complications at the time of injection nor there any postoperative ureteric obstruction. Endoscopic PTFE injections are less efficient than surgical reimplantation in the treatment of vesico-ureteral reflux. Teflon paste may not be the ideal material, other substances are presently being investigated. This technic is limited by the caliber of the urethra in young boys (Charrière 14).

The authors present a multisource study of 29 kidneys tumors (Wilms excepted) in children. The most common types (18 cases) are tumors from metanephrogen blastema (congenital mesoblastic nephroma, nephroblastomatosis and nodular renal blastema, multilocular cystic nephromas. Mature kidney tumors are much more rare in childhood (8 cases): they are epithelial tumors (adenoma or adenocarcinoma) or mesenchymal neoplasms. In one case, histological study don't permit to list a malignant tumor to one of previous categories. Finely, among secondary tumors, two localisations of hemopathy are reported. After a limited exposure of cases and review of the literatures the authors emphasize the anatomo-clinical aspects, the value of paraclinical exams and the treatment of each type of tumor.

In a preterm infant (28 week gestation), the chest film performed at 1 hour of life because of mild respiratory insufficiency showed a massive opacity of the right hemithorax. Congenital cystic adenomatoid malformation was suspected on the basis of ultrasonographic findings of multiple cysts. It was confirmed by further X ray examination and pathologic findings. This unusual case shows the ultrasonographic pattern and X ray evolution of this rare malformation.

Twenty seven children aged 1 to 15 years were admitted from 1981 to 1987 for the investigation and/or the surgical treatment of a primary liver malignancy (25 hepatoblastomas and 2 hepatocellular carcinomas). All were submitted to preoperative multidrug chemotherapy. One child died from circulatory failure early after the diagnosis and two children considered to be non operable died also. A macroscopically satisfactory resection could be achieved in 24/27 cases. Sixteen out of these 24 children are alive and disease free, 11 of them with a follow-up over 2 years. Two of these 16 survivors underwent a second operation for resection of a local recurrence. Four children died after a massive unresectable hepatic relapse, two after a second relapse and a one after the onset of pulmonary metastases during her chemotherapeutic postoperative course. One further child is at yet in a critical situation because of a late small secondary hepatic relapse. Two factors contributed to improvement of survival an cure rates during the past ten years: 1. Routine preoperative chemotherapy, which may help in controlling the disease and greatly facilitates surgery by shrinking of massive tumors. 2. Better surgical management and especially the total hepatic vascular exclusion, used in 13 cases of this series. Three situations still have a poor outlook: 1. Hepatocellular carcinoma 2. Hepatoblastoma with a low response to chemotherapy 3. Multifocal tumors and those involving the main hepatic vessels. The feasibility of a liver transplantation in some selected cases is discussed.

From 1960 to 1981, 31 children, 18 boys and 13 girls, have been treated at Ste-Justine Hospital for extra-hepatic portal hypertension. Age at the onset of gastro-intestinal bleeding 3 1/2 months and 13 years. Splenomegaly with hypersplenism, hematemesis and melena have been the most frequent clinical manifestations. Percutaneous splenoportography be coelio-mesenteric arteriography confirmed the diagnosis of cavernomatous transformation of the portal vein. Among the 31 children, 28 bled from their varices, the 3 others did not to date. Among the 28 patients with active bleeding complication, 7 have been treated conservatively, 11 had sclerotherapy (sclerosing injections of varices). On the surgical point of view, 7 had ligation of varices with intra-thoracic transposition of the spleen in 5 of them. Portosystemic shunts were performed in 10 patients, 3 central spleno-renal and 7 cavo-mesenteric shunt. Each of these 28 patients had an average of 9,5 episodes of gastro-intestinal bleeding, 8.7 hospitalizations, and received 7.5 liter of blood. Medical treatment, sclerotherapy, ligature of varices and intra-thoracic transposition of the spleen are palliative measures. Nevertheless the procedures are time and life savers, allowing improvement and development of natural porto-systemic shunts. Follow up of unshunted patients on a period of 8 to 17 years revealed a decreasing frequency and intensity of the hemorrhagic manifestations. Operative risks and morbidity of recurrent bleeding should be the guidelines for surgery. Natural course of illness and possible neuro-psychiatric consequences of a porto-caval shunt should also be considered.

The only surgical treatment currently available for patients with extrahepatic biliary atresia is portoenterostomy or portocholecystostomy, the Kasai operation. Seventeen such patients were operated upon at the Hôpital Sainte-Justine; 11 had bile excretion. Eight are still alive 12 to 60 months after operation. They have good to fair bile excretion. Twelve of the 17 patients had infectious or hemorrhagic complications and hepatic deficiency is evident in 6 of the 8 living patients. The progressive deterioration of liver function in the majority of the patients still alive raises the question of whether the Kasai procedure should be considered a curative or only a palliative procedure.

From 1981 to 1987, 86 children aged 16 months to 16 years underwent a portosystemic shunt procedure using an autologous venous graft (internal jugular vein in 80 cases). Fifty-five mesocaval, 20 splenorenal, 4 portacaval, and 7 makeshift shunts were constructed. The indication for shunting was an extrahepatic portal obstruction in 59 cases, intrahepatic portal obstruction in 23 cases (including 6 cases of congenital hepatic fibrosis), and Budd-Chiari syndrome in 4 cases. One patient of the latter group died early from intractable ascites with a nonfunctioning shunt, and a second child died 2 months after operation from unknown reasons with a patent shunt. With a follow-up over 1 year for 58 of the 84 survivors, 78 successes and 6 failures were recorded according to the clinical outcome and the findings of ultrasonic and endoscopic examinations. Three of the six children with a failed shunt have been submitted to a second successful H-type shunt operation. No case of encephalopathy was recorded in this series. Thus, with an approximate success rate of 95%, the H-type shunt with a venous graft should be recommended for treatment of portal hypertension of extrahepatic origin, especially in young children.

During the last 2 years an open lung biopsy was performed in 16 children aged from 2 to 14 years. Fourteen of these had a chemotherapeutic induced immunodeficiency and a radiological picture of diffuse pulmonary infiltrate. A definite diagnosis was established in 11 cases: 5 pneumocystis carinii pneumonitis, 2 CMV infections, 2 pneumocalcinosis, 1 neoplastic pulmonary lymphangitis and 1 staphylococcal infection. Three had a non-specific interstitial pneumonitis. In this series there was no post-operative death and the single complication was a wound infection. The tracheal tube could be removed within the hours following the intervention in 14 of the 16 children. The review of the recent literature suggests that the open lung biopsy is a safe and accurate way for the diagnosis of pulmonary infiltrates in pediatric immunocompromised patients. It is however a very invasive procedure and it is expectable that in the next year the bronchoalveolar lavage with a fiberoptic flexible bronchoscope will be systematically attempted prior to the open biopsy.

The charts of 92 children with urinary calculi were reviewed. There were 69 boys (75%) and 23 girls (25%), 20 (22%) were infants. Calculi were in kidney (74 times but were often multifocal. Fourteen children (15%) presented with a lithogenic metabolic disorder, 28 (30%) had a malformation of the urinary tract, in 4 (4.3%) a permanent urinary derivation had been performed for the treatment of a malformation or a neurologic bladder. The other children presented with apparently idiopathic lithiasis. However, urinary tract infection was found in 70%. Predisposing factors, whether stasis, urinary tract infection or some urinary malformations, were often intricate. The spontaneous elimination of calculi was rare. Even when difficult, the extraction of calculi had generally moderate functional consequences. There was one secondary renal atrophy. Relapse occurred in 11 patients. Etiologic inquiry, bacteriologic monitoring of urines and ultrasonography supervision over years are the essential means to a better evaluation of the risk of relapse.