Search

Riassunto Le urgenze chirurgiche nei bambini piccoli coprono molte patologie, che possono diventare rapidamente pericolose per la vita e che sono, quindi, importanti da conoscere. Richiedono un trattamento appropriato in un ambiente specializzato, seguendo un processo diagnostico rigoroso basato principalmente sull’eta del paziente e sui sintomi clinici. Nei neonati, sono causate principalmente da malformazioni congenite toraciche, addominali o urinarie. Il miglioramento della diagnosi prenatale ha completamente cambiato le condizioni dell’assistenza iniziale per la maggior parte di loro e consente alle famiglie di essere informate precocemente. Anche la loro prognosi e molto migliorata negli ultimi anni grazie al progresso delle tecniche di rianimazione neonatale e alla perfetta collaborazione medicochirurgica. Nel lattante, le urgenze chirurgiche sono principalmente digestive, comprese la stenosi pilorica, l’invaginazione intestinale acuta, l’ernia strozzata e, meno frequentemente, l’appendicite acuta. L’esame obiettivo e l’ecografia addominale confermano la diagnosi, evitando qualsiasi ritardo terapeutico e garantendo una guarigione senza sequele.

Resumen Las urgencias quirurgicas en los ninos pequenos abarcan muchas patologias, que pueden convertirse rapidamente en una amenaza para la vida y, por lo tanto, es importante tenerlas en cuenta. Necesitan un tratamiento adaptado en un entorno especializado, siguiendo un riguroso proceso de diagnostico basado principalmente en la edad y las manifestaciones clinicas del paciente. En el recien nacido, estan causadas principalmente por malformaciones congenitas del torax, el abdomen o las vias urinarias. Los adelantos en el diagnostico prenatal han cambiado por completo las condiciones para el tratamiento inicial de la mayoria de ellos y permite la informacion temprana de las familias. Su pronostico tambien ha mejorado mucho en los ultimos anos gracias a los avances en las tecnicas de reanimacion neonatal y a la perfecta cooperacion medica y quirurgica. En los lactantes, las urgencias quirurgicas son basicamente digestivas, como la estenosis pilorica, la invaginacion intestinal aguda, la hernia estrangulada y, con menor frecuencia, la apendicitis aguda. La exploracion fisica y la ecografia abdominal pueden confirmar el diagnostico, evitando cualquier retraso terapeutico que garantizaria una curacion sin secuelas.

Hirschsprung disease is a congenital malformation in which, due to lack of neural crest cell migration, the distal part of the bowel has no innervation, leading to functional obstruction. This rare disease (1/5000 live birth) has a complex genetic and physiopathologic background. Depending on the disease level, symptoms vary from distal obstruction to short bowel syndrome. Diagnosis is based on suction rectal biopsy examination and contrast enema. After the obstruction relief, surgical cure aim to remove the aganglionic bowel and to perform laparoscopic or transanal pullthrough. Enterocolitis or anal soiling in childhood can disturb follow up.

INTRODUCTION: High dose buprenorphine (HDB), commonly known as Subutex(®), is nowadays largely prescribed as a replacement therapy for major opiate dependence. Its sublingual administration allows a decrease in the withdrawal syndrome accompanying opiate abuse cessation. Over the past few decades, epidemiological data on people on replacement therapy have emphasized an increase in the misuse of Subutex(®) and more specifically intravenous injections of HDB. These growing practices pave the way to major physical consequences or even death. Several studies have highlighted the infectious, vascular, venous and arterial (pseudo-aneurysm) complications stemming from this habit. Among the possible vascular complications, we can notice the presence of abscess, venous thrombosis, phlegmons, skin necrosis, cellulite, and profound and superficial thrombophlebitis at injection sites. These can evolve into chronic edemas of the tips and subcutaneous nodules. The Popeye syndrome is one of the possible complications of this misuse. This syndrome is characterized by the swelling of both sides of the forearms and hands. These edemas tend to become persistent and to be paired with tissue changes such as skin thickening. Besides, the increase in the hands volume can occur bilaterally or sometimes in an asymmetrical way, accentuated on the hand of the non-dominant limb. This syndrome does not decrease, or just a little, after the stoppage of injections. It can have a psychological, social, psychopathological and esthetic impact. OBJECTIVES: In this article, we will focus on the clinical case of a 43-year-old man, who is hospitalized in an addictology unit for massive injections of HDB. This patient suffers from a Popeye syndrome as well as from an alcoholic dependence. METHOD: Following the description of psychopathological disorders, our analysis will originate from a clarification relative to the specificities of the practice of intravenous HDB injection to better sharpen the understanding of these misuses in their psychopathological and clinical aspects. We will discuss some proposals for interventions aiming at taking better care of the people suffering from a drug addiction characterized by the injection of HDB replacement therapy. RESULTS: Adam requested an admission in an addictology ward for treatment of a self-medication by Subutex started 4 years ago. A certain awkwardness can be perceived when he lays his highly damaged and marked hands on the desk. His upper limbs, thus on display, have tripled in volume: this indicates the presence of a Popeye syndrome, consequence of repeated Subutex injections. These observations lead us to question the function and the sense of this injection behavior in the mental economy, as this repeated behavior engages the body specifically. This bruised body, marked with repeated injection holes has become a place of inscription, of representation that shows the impossibility to access other ways of expression. In this sense, taking action is becoming an act of speech. Within this speech, we can notice the existence of a profound state of uneasiness. To put up with the painful feeling of inner emptiness that is calling for a necessary filling, aiming at re-establishing a frail balance, Adam appeals to repeated injections. However, when the tortured body signifies its incapacity to receive an ultimate injection, thus showing its limits and the destruction it is undergoing, it is no longer possible to resort to Subutex injections. As a consequence, Adam came up with the idea of quitting. The withdrawal was initiated by himself and not coupled with medical care. It has led him to feel a gap, beyond the physical uneasiness. Adam has tried to fill in this unbearable feeling of empty body with tobacco, alcohol and food. The body, highly mobilized, translates the presence of a physical conflict where a massive mental anxiety is expressed in a hidden way. During the interview, Adam also addressed the repetitive familial pattern and the transgeneration effects. He seems to be fully aware of these. DISCUSSION: Several perspectives can be addressed as part of Adam's treatment and especially cognitive-behavioral therapies as they could prove to be of a certain interest. The aim of this therapy would thus be to assess the motivation for change in order to begin a psychotherapeutic work based on personal adherence to the cessation of this misuse. This could be set up in parallel with an anxiety management work. CONCLUSION: A better understanding and an extensive knowledge of the possible complications linked to the misuse of HDB seems necessary to sensitize and better inform people who suffer from high-risk behaviors and also to enable a more adapted care. Language: fr

A bronchial mucoepidermoid carcinoma is a rare malignant tumour. It usually appears in young subjects and most often involves the salivary glands. We report the case of a 14-year-old patient who presented with a pulmonary mucoepidermoid carcinoma that was discovered during the evaluation of a case presenting with recurrent pneumopathies.

Resume L’objectif des deux experiences presentees consiste a explorer le lien entre perception de mouvements elementaires associes a une valence emotionnelle et processus cognitifs-emotionnels. Les resultats obtenus mettent en evidence que la visualisation de mouvement « positif » et « negatif » induit une perception d’ordre emotionnelle qui provoque des modifications sur les processus cognitifs de memorisation et d’execution de tâche de decomptage.

Introduction Les syndromes PELVIS et PHACES associent un hemangiome (HI) segmentaire et de multiples anomalies malformatives, respectivement dans la region abdomino-pelvienne et l’extremite cephalique. Depuis 2014, les HI qui engagent le pronostic vital ou fonctionnel ou qui sont compliques d’ulcerations peuvent etre traites par le propranolol (P) per os. Nous decrivons l’interet de ce traitement dans 3 cas de PELVIS et 1 cas de PHACES. Observations Tous les enfants porteurs d’un PHACES ou d’un PELVIS diagnostiques en 2016 dans notre CHU ont ete traites par P. Aucune dysplasie arterielle susceptible de se compliquer d’une occlusion sous betabloqueur n’etait objectivee en angio-MR. Dans les 4 cas, on introduisait le traitement a une dose initiale de 1 mg/kg/jour, dose que l’on augmentait progressivement jusqu’a 3 mg/kg/jour, en 2 prises par jour. Le P etait bien tolere chez les 4 enfants ( Fig. 1 et Tableau 1 ). Discussion Ces 4 HI syndromiques, parfois compliques localement, ont ete traites avec succes par P. Cette utilisation n’est pas precisee dans l’autorisation de mise sur le marche (AMM) et la duree optimale de traitement n’est pas connue dans ces situations. Dans tous les cas, le P a participe a la reduction globale et rapide du volume de l’HI et a l’amelioration des ulcerations superficielles quand elles etaient presentes. Cette evolution favorable etait constatee des la consultation a 1 mois, delai comparable aux donnees de la litterature pour les HI de taille usuelle. Dans un cas (n o 1), une chirurgie de derivation des selles et des urines a participe a la cicatrisation du siege. Dans les autres cas, la prise en charge dermatologique etait assuree par soins locaux et P seul. La tolerance a ete satisfaisante dans tous les cas. Dans la litterature, les cas d’HI syndromiques traites par P sont rares et concernent surtout des syndromes PHACES mais peu de syndromes PELVIS. L’evolution et la securite d’emploi y paraissent non differentes des HI « classiques ». La limite de nos observations est le caractere non controle de la demonstration d’efficacite, quand l’evolution naturelle d’un HI est de s’ameliorer spontanement. Toutefois, compte tenu de la rarete de ces syndromes il est improbable que des essais comparatifs soient mis en place. Conclusion Nous suggerons que le propranolol figure dans l’algorithme de prise en charge dermatologique des HI segmentaires compliques ou non des syndromes PELVIS et PHACES.

Resume L'enuresie se definit comme une miction active et complete survenant a un moment ou a un endroit inapproprie ou socialement inacceptable (enfant de plus de 5 ans). L'enfant avec une enuresie nocturne urine dans son lit alors qu'il est endormi et n'est generalement pas reveille par le fait d'etre mouille. La forme la plus frequente est l'enuresie nocturne monosymptomatique, ce qui signifie qu'il n'y a pas de symptomes cliniques dans la journee. L'enuresie est un syndrome hereditaire resultant de trois facteurs : la polyurie nocturne, une capacite vesicale fonctionnelle reduite et un trouble de l'eveil. C'est la pathologie chronique de l'enfant la plus frequente dans les pays occidentaux. L'interrogatoire elimine les troubles mictionnels diurnes et precise les conditions de l'enuresie. L'examen clinique elimine une vessie neurologique ou une malformation. Les examens complementaires sont inutiles. Le traitement repose sur les alarmes et/ou la desmopressine. Il est reserve aux enfants et aux familles demandeurs. Le suivi pendant et a l'arret du traitement est un element essentiel du succes qui reste inconstant.

In the last two decades, laparoscopy surgery has been progressively adopted to children. Cardiorespiratory changes induced have been understood and controlled. Abdominal and urological surgery have widely benefited from this technique. Immediate postoperative period is simpler. The risk of small bowel obstruction by bands and adhesions is limited. Nevertheless, laparoscopy is not indicated for all pathologies. In neonatal surgery, more studies are necessary. Maybe the future is robotic surgery.

Resume L'appendicectomie est la premiere intervention digestive chez l'enfant, mais malgre sa frequence il reste parfois difficile de faire le diagnostic formel d'appendicite ou de peritonite appendiculaire. De plus, la morbidite de cette affection est loin d'etre negligeable. Le diagnostic repose essentiellement sur l'examen clinique et des dosages biologiques simples (numeration formule sanguine et proteine C-reactive), en les repetant si necessaire. L'echographie et le scanner sont reserves aux doutes diagnostiques. Une fois le diagnostic fait, le traitement de reference est l'appendicectomie, par laparotomie ou par laparoscopie, associee a une antibiotherapie adaptee a la gravite de l'infection. Les appendicites, en particulier si elles sont perforees, peuvent se compliquer d'abces de paroi ou d'abces intraperitoneaux que l'on traite par un traitement antibiotique eventuellement associe a un drainage chirurgical ou percutane.

La apendicectomia es la primera intervencion digestiva en el nino. Sin embargo, a pesar de su frecuencia, en ocasiones resulta dificil establecer el diagnostico formal de apendicitis o de peritonitis apendicular. Ademas, la morbilidad por esta afeccion es relativamente importante. El diagnostico se basa esencialmente en la exploracion fisica y en pruebas de laboratorio sencillas (hemograma y proteina C reactiva), que se repiten si es necesario. La ecografia y la tomografia computarizada se reservan para las dudas diagnosticas. Una vez establecido el diagnostico, el tratamiento de referencia es la apendicectomia, mediante laparotomia o laparoscopia, asociada a antibioticoterapia adecuada a la gravedad de la infeccion. Las apendicitis, sobre todo si se perforan, pueden complicarse con abscesos de pared o abscesos intraperitoneales, que se tratan con antibioticoterapia eventualmente asociada a drenaje quirurgico o percutaneo.

La enuresis se define como una miccion activa y completa que ocurre en un momento o en un lugar inapropiado, o socialmente inaceptable (nino de mas de 5 anos). El nino que padece enuresis nocturna orina en su cama mientras duerme y no suele despertarse por el hecho de estar mojado. La forma mas frecuente es la enuresis nocturna monosintomatica, lo que significa que no existen sintomas clinicos durante el dia. Esta afeccion es un sindrome hereditario que resulta de tres factores: la poliuria nocturna, una capacidad vesical funcional reducida y un trastorno del sueno. Es la enfermedad cronica del nino mas frecuente en los paises occidentales. El interrogatorio descarta los trastornos miccionales diurnos y concreta las condiciones de la enuresis. El examen clinico elimina una vejiga neurologica o una malformacion. Las pruebas complementarias resultan inutiles. El tratamiento se fundamenta en las alarmas y/o la desmopresina, y se reserva a aquellos ninos y familias que lo solicitan. El seguimiento durante el tratamiento y al cese del mismo constituye un elemento basico del exito, que permanece inconstante.

Evaluate neonatal management and outcome of neonates with either a prenatal or a post-natal diagnosis of EA type III.Population-based study using data from the French National Register for EA from 2008 to 2010. We compared children with prenatal versus post-natal diagnosis in regards to prenatal, maternal and neonatal characteristics. We define a composite variable of morbidity (anastomotic esophageal leaks, recurrent fistula, stenosis) and mortality at 1 year.Four hundred and eight live births with EA type III were recorded with a prenatal diagnosis rate of 18.1%. Transfer after birth was lower in prenatal subset (32.4% versus 81.5%, P0.001). Delay between birth and first intervention was not significantly different. Defect size (2cm vs 1.4cm, P0.001), gastrostomy (21.6% versus 8.7%, P0.001) and length in neonatal unit care were higher in prenatal subset (47.9 days versus 33.6 days, P0.001). The composite variables were higher in prenatal diagnosis subset (38.7% vs 26.1%, P=0.044).Despite the excellent survival rate of EA, cases with antenatal detection have a higher morbidity related to the EA type (longer gap). Even if it does not modify neonatal management and 1-year outcome, prenatal diagnosis allows antenatal parental counseling and avoids post-natal transfer.

La cure chirurgicale de la stenose hypertrophique du pylore, debutee au debut de ce siecle, est actuellement une intervention de routine avec un taux de morbidite faible. L'innovation de ces dernieres annees a porte sur l'amelioration du prejudice esthetique causee par l'incision classique au niveau de l'hypocondre droit. L'abord periombilical recemment decrit permet un acces facile du pylore et diminue considerablement les sequelles cicatricielles de la voie classique. Dans une etude comparative portant sur pres de 240 patients, aucune difference n'a ete notee concernant differents facteurs de morbidite tels que les perforations muqueuses peroperatoires, les vomissements, les infections parietales, les eventrations, ou les recidives postoperatoires, entre l'incision dans l'hypocondre droit et l'approche periombilicale. Cette nouvelle voie d'abord permet donc de rendre cette intervention pleinement efficace, tant sur le plan fonctionnel qu'esthetique, et facilite l'oubli par les parents de cet incident de la vie de leur jeune nourrisson qu'est la stenose hypertrophique du pylore.

Resume L'experience croissante des equipes de diagnostic antenatal permet de depister des anomalies de plus en plus discretes de l'appareil urinaire. Ainsi, un grand nombre de dilatations pyeliques est detecte sans que l'on puisse en affirmer le caractere pathologique. Patients et methodes. — Lors d'une etude retrospective de 78 patients, nous avons determine la valeur predictive positive (VPP) des signes echographiques antenatals d'uropathies malformatives. Resultats. — Cette VPP etait de 27.3 % lorsqu'il s'agissait d'une dilatation pyelique isolee. Elle etait de 100 % s'il s'y associait une dilatation des calices. Le diametre anteroposterieur du pyelon mesure lors du troisieme trimestre de la grossesse peut predire la gravite de l'atteinte renale apres la naissance, puisqu'il etait de 6.7 ± 2.15 mm pour le groupe des dilatations pyeliques postnatales non pathologiques, significativement inferieur aux 13.4 ± 3 mm du groupe des syndromes de jonction pyelo-ureterale de stade I et aux 17 ± 9 mm des autres unites renales pathologiques. L'echographie antenatale a en revanche une mauvaise sensibilite pour la detection du reflux vesico-ureteral, quatre reflux primitifs sur 14 ayant ete depistes en l'absence d'anomalie echographique antenatale homolaterale. Conclusion. — Nous proposons une strategic diagnostique qui tient compte de ces resultats de la morbidite et du cout des differents examens. Une exploration urologique est effectuee devant une dilatation des cavites renales superieure a 10 mm. Si l'echographie de controle apres la naissance montre une dilatation pyelique isolee inferieure a ce seuil, seule une surveillance clinique est prescrite, en signalant aux parents la possibilite d'un reflux vesico-ureteral et done la necessite d'un examen cytobacteriologique des urines devant toute fievre inexpliquee.

High dose buprenorphine (HDB), commonly known as Subutex(®), is nowadays largely prescribed as a replacement therapy for major opiate dependence. Its sublingual administration allows a decrease in the withdrawal syndrome accompanying opiate abuse cessation. Over the past few decades, epidemiological data on people on replacement therapy have emphasized an increase in the misuse of Subutex(®) and more specifically intravenous injections of HDB. These growing practices pave the way to major physical consequences or even death. Several studies have highlighted the infectious, vascular, venous and arterial (pseudo-aneurysm) complications stemming from this habit. Among the possible vascular complications, we can notice the presence of abscess, venous thrombosis, phlegmons, skin necrosis, cellulite, and profound and superficial thrombophlebitis at injection sites. These can evolve into chronic edemas of the tips and subcutaneous nodules. The Popeye syndrome is one of the possible complications of this misuse. This syndrome is characterized by the swelling of both sides of the forearms and hands. These edemas tend to become persistent and to be paired with tissue changes such as skin thickening. Besides, the increase in the hands volume can occur bilaterally or sometimes in an asymmetrical way, accentuated on the hand of the non-dominant limb. This syndrome does not decrease, or just a little, after the stoppage of injections. It can have a psychological, social, psychopathological and esthetic impact.In this article, we will focus on the clinical case of a 43-year-old man, who is hospitalized in an addictology unit for massive injections of HDB. This patient suffers from a Popeye syndrome as well as from an alcoholic dependence.Following the description of psychopathological disorders, our analysis will originate from a clarification relative to the specificities of the practice of intravenous HDB injection to better sharpen the understanding of these misuses in their psychopathological and clinical aspects. We will discuss some proposals for interventions aiming at taking better care of the people suffering from a drug addiction characterized by the injection of HDB replacement therapy.Adam requested an admission in an addictology ward for treatment of a self-medication by Subutex started 4 years ago. A certain awkwardness can be perceived when he lays his highly damaged and marked hands on the desk. His upper limbs, thus on display, have tripled in volume: this indicates the presence of a Popeye syndrome, consequence of repeated Subutex injections. These observations lead us to question the function and the sense of this injection behavior in the mental economy, as this repeated behavior engages the body specifically. This bruised body, marked with repeated injection holes has become a place of inscription, of representation that shows the impossibility to access other ways of expression. In this sense, taking action is becoming an act of speech. Within this speech, we can notice the existence of a profound state of uneasiness. To put up with the painful feeling of inner emptiness that is calling for a necessary filling, aiming at re-establishing a frail balance, Adam appeals to repeated injections. However, when the tortured body signifies its incapacity to receive an ultimate injection, thus showing its limits and the destruction it is undergoing, it is no longer possible to resort to Subutex injections. As a consequence, Adam came up with the idea of quitting. The withdrawal was initiated by himself and not coupled with medical care. It has led him to feel a gap, beyond the physical uneasiness. Adam has tried to fill in this unbearable feeling of empty body with tobacco, alcohol and food. The body, highly mobilized, translates the presence of a physical conflict where a massive mental anxiety is expressed in a hidden way. During the interview, Adam also addressed the repetitive familial pattern and the transgeneration effects. He seems to be fully aware of these.Several perspectives can be addressed as part of Adam's treatment and especially cognitive-behavioral therapies as they could prove to be of a certain interest. The aim of this therapy would thus be to assess the motivation for change in order to begin a psychotherapeutic work based on personal adherence to the cessation of this misuse. This could be set up in parallel with an anxiety management work.A better understanding and an extensive knowledge of the possible complications linked to the misuse of HDB seems necessary to sensitize and better inform people who suffer from high-risk behaviors and also to enable a more adapted care.

Anorectal malformations (ARM) are the result of an abnormal development of the terminal part of the digestive tract interesting anus and/or rectum that occur early between the sixth and tenth week of embryonic development. They carry a malformation spectrum of severity depending on the level of disruption of the anorectal canal and of the associated caudal malformations (sacrum and spine). ARM are associated in over half the cases with other malformations that can be integrated in some cases in known syndromes. If surgical treatment to restore anatomy as normal as possible is indispensable, post-operative care is essential for these patients whose defecation mechanisms are altered, to reach if not continence, at least a socially acceptable cleanliness.

Intercostal lung herniation by non-penetrating chest wall trauma is rare in the pediatric population, and only a few cases are reported in the literature. We described a case of a post-traumatic lung herniation in a 9-year-old child, after closed chest trauma by a bicycle handlebar. The diagnosis was made with chest X-ray and mediastinal ultrasound imaging. Surgery is frequently needed to treat a lung hernia. In our case, given the small size of the lung hernia, conservative medical treatment was sufficient and effective.

A differenza di altre aree in chirurgia pediatrica, la resezione epatica mininvasiva non ha ottenuto ampia popolarita. Le ragioni di cio sono presumibilmente correlate al timore di complicanze intraoperatorie quali sanguinamento o embolismo gassoso. Comunque, i miglioramenti in tecnologia laparoscopica e l’incrementata esperienza nella chirurgia degli adulti a partire dalla prima descrizione nel 1992 ora autorizza le resezioni laparoscopiche epatiche e la ricostruzione del tratto biliare in pazienti pediatrici selezionati.

Bronchial atresia is a rare congenital malformation of the lung. The main-stem segmental or lobar bronchus fails to construct normally, which can lead to accumulation of mucus within the distal bronchi or lung hyperinflation of the obstructed lobe. The prenatal diagnosis is rare and difficult. We report two cases of fetuses who presented pathological examination of the lung on the ultrasonography, at 22 weeks of gestation, suspect of prenatal bronchial atresia diagnosis. We analysed this malformation through a literature review in order to discuss differential diagnosis to be evoked, as well as appropriate perinatal management.

In the last two decades, laparoscopy surgery has been progressively adopted to children. Cardiorespiratory changes induced have been understood and controlled. Abdominal and urological surgery have widely benefited from this technique. Immediate postoperative period is simpler. The risk of small bowel obstruction by bands and adhesions is limited. Nevertheless, laparoscopy is not indicated for all pathologies. In neonatal surgery, more studies are necessary. Maybe the future is robotic surgery.

Staghorn lithiases in the infant are rare. We report a staghorn lithiasis related to high calcium intake due to the exclusive use of the mineral water Hépar.In an eight-month-old infant, an abdominal film performed for repeated urinary symptoms showed a right-sided staghorn lithiasis. Past history revealed that his diet had contained as high as four times the recommended daily intake for calcium (1,750 mg) related to the exclusive use of Hépar mineral water. The latter had been discontinued one month prior to admission. Excessive doses of vitamin D (1,480 U/day) were given at this time. Blood tests were normal. Treatment combined surgical removal of the stone by right pyelolithotomy, and three extracorporeal lithotrity courses. A postoperative infection had a simple course after antibiotics.This staghorn lithiasis is the second case report to complications associated with long-term exclusive intake of Hépar mineral water in an infant. It has been likely favored by excessive doses of vitamin D. It emphasizes the danger of the exclusive use of high-calcium mineral water.

The increasing experience with prenatal ultrasonographic diagnosis allows detection of more and more mild urinary tract anomalies. Thus, the clinical significance of many pyelectasis detected before birth is not known.From a retrospective study of 78 patients, we determined the positive predictive value (PPV) of prenatal ultrasound findings for urinary tract malformations.This PPV was 27.3% when the prenatal pelvic dilatation was isolated, but grew up to 100% if a caliceal dilatation was associated. Renal pelvic diameter in the third trimester of pregnancy could predict the degree of post-natal renal impairment, as pelvic size was 6.7 +/- 2.15 mm for the post-natal pyelectasis group, significatively smaller than 13.4 +/- 3 mm in the ureteropelvic junction obstruction group (grade 1) and than 17 +/- 9 mm in other pathological renal units. On the other hand, antenatal ultrasound had a bad sensibility for vesico-ureteral reflux detection, four primary reflux among 14 being detected without homolateral antenatal ultrasound anomaly.According these results, we propose a post-natal diagnostic strategy. Urological explorations are performed when the prenatal renal pelvic diameter is larger than 10 mm. If the postnatal ultrasound shows an isolated pyelectasis below this level, a clinical follow-up is advised, the parents being informed of the possibility of vesico-ureteral reflux and of the necessity to perform a cytobacteriological exam of urines in case of unexplained fever.

Objectifs Alors que la laparoscopie est devenue une technique de reference dans de nombreuses indications en chirurgie pediatrique, il existe peu de grandes series de nephrectomie partielles dans la litterature. Nous rapportons notre experience de cette technique. Patients et Methodes Etude retrospective de 48 nephrectomies partielles (36 nephrectomies polaires superieures (NPS) et 12 polaires inferieures (NPI) chez l’enfant, realisees consecutivement de 1993 a 2007. L’âge median au moment de l’intervention etait de 8,6 mois (5,7 mois pour les NPS, 17 mois pour les NPI). L’enfant etait place en decubitus lateral dans 31 cas, et en decubitus ventral pour les 17 derniers cas. Resultats La duree mediane d’intervention etait de 120 minutes (extr 71-215). Dix conversions (21 %) ont ete necessaires, essentiellement au debut de l’experience (1/20 dans les 20 derniers cas, vs 8/20 pour les 20 premiers). Pour les NPI, 3/4 ont ete converties pour des difficultes lors de la section du parenchyme, a l’epoque ou elle etait realisee a la bipolaire. Six NPS ont ete converties, a chaque fois chez des petits nourrissons, d’âge median 3,25 mois (1,5-8), pour des difficultes d’exposition et de visualisation de la vascularisation du pole inferieur restant, difficultes majorees par une dilatation ureterale importante (>15mm, n = 3) ou un pneumoperitoine (n = 2). Le suivi median est de 14 mois (4-125). Nous avons observe 1 cas de perte fonctionnelle du pole restant (cas n °4). Conclusions La nephrectomie partielle par laparoscopie retroperitoneale reste faisable quelque soit l’âge. Il s’agit d’une intervention techniquement difficile, en particulier chez des petits nourrissons avec une voie excretrice tres dilatee. Le risque d’alteration fonctionnelle definitive du pyelon restant doit etre connu, et doit imposer la conversion lorsqu’une comprehension parfaite de l’anatomie vasculaire n’est pas certaine.