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Abstract Background Testicular microlithiasis in children was defined for the first time in 1961 based on histological criteria. There should be more than 5 calcifications per testicle in order to say that the patient has testicular microlithiasis. It has three different echographic grades depending on the number of calcifications. However, this disease is uncommon, with inaccurate prevalence and no certain information about its evolution or etiology. Main body We studied 4 clinical cases of children diagnosed with testicular microlithiasis, in light of the conducted review of the literature, and we defined the characteristics of this disease and proposed a management and monitoring framework based on the clinical observations. Conclusion There is a link between testicular microlithiasis and testicular cancer. Therefore, it is recommended to make a regular follow-up of children who present testicular microlithiasis with the presence of risk factors.

Background: Trichobezoar is an uncommon clinical entity in which ingested hair mass accumulates within the digestive tract. It is generally observed in children and young females with psychological disorders. It can either be found as an isolated mass in the stomach or may extend into the intestine. Untreated cases may lead to grave complications. Material and Methods: We retrospectively analyzed the clinical data of six patients treated for trichobezoar in Monastir pediatric surgery department during 16-year-period between 2004 and 2019. Imaging (abdominal computed tomography and upper gastroduodenal opacification) and gastroduodenal endoscopy were tools of diagnosis. Results: Our study involved 6 girls aged 4 to 12. Symptoms were epigastric pain associated with vomiting of recently ingested food in 3 cases and weight loss in one case. Physical examination found a hard epigastric mass in all cases. The trichobezoar was confined to the stomach in 4 cases. An extension into the jejunum was observed in 2 cases. Surgery was indicated in all patients. In two cases, the attempt of endoscopic extraction failed and patients were then operated on. All patients had gastrotomy to extract the whole bezoar even those with jejunal extension. Psychiatric follow-up was indicated in all cases. The six girls have evolved well and did not present any recurrence. Conclusion: open surgery still plays a crucial role in Trichobezoard management . After successful treatment, psychiatric consultation is imperative to prevent reccurrence and improve long term prognosis

Abstract Background Cystic echinococcosis (CE) affects predominantly young patients in highly endemic areas. Improved serological methods are needed for the follow-up of CE cases, especially given the high rates of post-surgical relapse that require detection as soon as possible. Methods We designed a study to investigate the value of antigenic proteins extracted from Echinococcus granulosus (E. granulosus) protoscoleces, and of recombinant B2t and 2B2t proteins, for assessing the efficacy of surgical treatment carried out on CE-affected children. This study was performed on 278 plasma samples collected from 59 Tunisian children surgically treated for CE and monitored for 3 years post-surgery. The patients were classified according to post-surgical outcomes into a “non-relapsed” (NRCE) and a “relapsed” (RCE) group. We performed in-house ELISAs to measure anti-B2t and anti-2B2t IgG and immunoblotting for the detection of IgG against SDS-PAGE-resolved E. granulosus protoscoleces-specific antigens. The Wilcoxon test was applied to assess anti-B2t and anti-2B2t IgG levels. We applied the Cochran Q test to compare the distribution of immunoblotting antigenic bands between 1-month and 1-year post-surgery. Results The probability of being “relapse-free” when a decrease in antibody titers occurred between 1 month and 1 year post-surgery was 81% and 75%, respectively, for anti-B2t and anti-2B2t IgG. We identified five protoscolex protein bands of 20, 26/27, 30, 40 and 46 kDa as highly immunoreactive by immunoblot for both RCE and NRCE patients at 1 month post-surgery, and significantly lower immunoreactivity after 1 year (p

Peritoneal hydatid cysts are rare in children even in endemic areas. The primary or secondary origin of this site remains controversial, especially in children. Secondary peritoneal hydatid cysts are mainly the result of spontaneous or traumatic rupture of concomitant liver cysts or the leakage of cystic content during surgery. The purpose of our study is to present the largest case series of peritoneal hydatidosis in children. In addition, we aimed to assess the clinical and paraclinical findings as well as the management of echinococcosis at this location in children. The present case series is a study of ten children with peritoneal hydatid cysts, who underwent surgical intervention between 2013 and 2018 in the Pediatric Surgery Department, University of Monastir (Monastir, Tunisia). The mean age of the children was six years. All children presented abdominal pain, and underwent ultrasonography and contrast-enhanced computed tomography of the abdomen. Two patients had been operated on for lung hydatid cysts six months prior to the study. In two cases, radiologic investigations revealed the presence of an uncomplicated hepatic hydatid cyst located in segments II and IV. All patients underwent surgery, of which four underwent laparoscopy. Post-surgery, all patients received albendazole for three months, and the follow-up period was uneventful. Currently, all patients are in good health. Peritoneal hydatid disease is frequently secondary to the rupture of a primary hepatic cyst. Diagnosis is performed by abdominal ultrasound, computed tomography, and a positive serology result. Open or laparoscopic excision can be combined with medical treatment.

Background: Femoral hernias are an uncommon groin pathology among pediatric patients. Therefore, they are frequently misdiagnosed. In the present study, we review our experience with this rare surgical entity during the past 25 years. Methods: The medical records of 19 patients who underwent 22 femoral hernia repairs between January 1994 and December 2019 were retrospectively analysed. Results: Patients' age ranged from 2 to 12 years (mean age was 5. 5 years) with an approximately equal sex ratio (10 girls/9 boys). There were three bilateral cases identified separately. They were discovered and managed at different times. All the children were referred with a groin lump, but the correct pre-operative diagnosis was made in only 13 cases (59%). In the remaining cases, four were identified intraoperatively following negative exploration for a supposed inguinal hernia. The other five were found to have a femoral hernia 1 month to 12 months after ipsilateral inguinal hernia repair. All patients underwent elective surgery. The femoral canal was closed using either Lytle or McVay procedure. Recurrence occurred in only one patient 2 months after initial repair. Conclusion: Femoral hernias are often misdiagnosed. Pre-operative diagnosis can be obtained through careful clinical assessment. In equivocal cases, ultrasonography and laparoscopy could be useful. A correct pre-operative diagnosis will lead to suitable treatment, thus avoiding unnecessary reoperations and their related complications.

Splenogonadal fusion, which is adherence of splenic tissue to gonads, is an uncommon congenital anomaly which mainly affects males. Herein, we report a case of splenogonadal fusion in a 20-month-old boy presenting with acute scrotal pain and inflammation. With the suspicion of left testicular torsion, an emergent left scrotal exploration was carried out. It revealed a necrotic left testicle along with a 360° rotation of the spermatic cord and three accessory structures in the lower pole of the testicle. Histology showed the presence of a splenic tissue. Splenogonadal fusion can present as an acute condition mimicking a testicular torsion. But, one should always bear in mind the possibility of this association. Splenogonadal fusion should be included in differential diagnosis of testicular mass to avoid unnecessary orchidectomy.

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Introduction: Retroperitoneal cystic immature teratoma (RCIT) is a rare disease. Its diagnosis and management are challenging. Although, the prognosis is relatively favorable, the post-operative morbidity is not rare.We hereby report a case of RCIT in an infant and describe the difficulties in diagnosis and pre-, per- and postoperative treatment. Case presentation: Our patient was a 50-day-old female born at 35 weeks of gestation without prenatal diagnosis. She was admitted for abdominal distension noticed a few days earlier. Physical examination revealed a large abdominal mass located between the right hypochondrium and the left flank. Computerized tomography showed a 10*12*11 cm heterogeneous retroperitoneal mass with fat components and calcification responsible for the compression of the right kidney. Due to the respiratory distress caused by the tumor, we decided to operate the patient urgently prior to the anatomopathological examination result. The surgical procedure consisted in a large resection of the tumor which necessitated the removal of the right kidney. Postoperatively, our patient developed chylous ascites which was managed with total parenteral nutrition and continuous intravenous infusion of Octreotide. The follow up was uneventful with no recurrence so far. Conclusion: RCIT is a clinically rare disease. The mainstay treatment remains the complete surgical resection of the tumor which could be a complicated procedure. Chylous ascites constitute a rare postoperative complication which can be managed safely by parenteral nutrition and continuous intravenous infusion of Octreotide.

L´urétérocèle est une dilatation pseudo-kystique de l´uretère terminal sous muqueux. C´est une uropathie malformative rare surtout si elle survient sur un uretère simplex. Il s´agit d´une étude rétrospective menée sur dix ans, de 12 dossiers de malades colligés au Service de Chirurgie Pédiatrique de l´Hôpital Fattouma Bourguiba de Monastir entre 2006 et 2016. L´âge moyen de nos malades est de 2,7 ans avec des limites allant de 7 jours à 11 ans, le sex ratio est de 1. Le tableau clinique a été dominé par la fièvre en rapport avec une infection urinaire haute. Le diagnostic a été posé essentiellement par l´échographie rénale et vésicale, l´urographie intraveineuse (UIV) et l´uréthro-cystographie rétrograde (UCR). L´urétérocèle était unilatéral dans 10 cas et bilatérale dans 2 cas soit un total de 14 cas d´urétérocèles. Tous ont été sur uretère simplex et ont été opérées par voie endoscopique. Aucun incident peropératoire n´a été noté. Les suites opératoires étaient simples. Une amélioration clinique et radiologique a été obtenue dans tous les cas. L´urétérocèle sur uretère simplex est une malformation urinaire très rare. Non diagnostiquée à temps, elle peut retentir sur le haut appareil. Le traitement endoscopique est une alternative séduisante avec des résultats satisfaisants.

Foreign bodies ingestion is considered as a common pediatric problem, it is mostly encountred in infants between 6months and 2 years. Ingestion of magnets was documented in only few reports. We report two uncommon cases of bowel perforations owing to magnets ingestion. Patients were respectively aged of 10 months and 20 months .they were successfully managed. Once ingested, magnetic objects would attach each other through intestinal wall leading subsequently to intestinal necrosis. Thus their surgical removal is unavoidable.

Surgical management of long-gap esophageal atresia (LGEA) remains challenging. Yet, there is a consensus among pediatric surgeons to preserve native esophagus. We used a new surgical technique to successfully manage three children diagnosed with LGEA. This technique consists of a combined thoracic and cervical approach to the EA repair using the patient's native esophagus. All patients initially had had gastrostomy and continuous upper pouch suction while awaiting surgery. This new technique has the potential to become the choice method in LGEA management.

Sternal cleft is a rare congenital anomaly which is generally observed at birth. The aetiology remains obscure. Superior clefts are more frequent than inferior ones, and isolated central clefts are extremely rare. Surgery is recommended to protect the heart and other mediastinal contents from trauma and also to improve respiratory dynamics. We present the case of a newborn with isolated central clefts and we will give a review of the literature.

Objectives: The purpose of this study was to document clinical features of inguinal hernia (IH) in the pediatric population. It provides data to evaluate associated risk factors of incarcerated hernia, its recurrence as well as the occurrence of contralateral metachronous hernia. Materials and Methods: We report a retrospective analytic study including 922 children presenting with IH and operated from 2010 to 2013 in our pediatric surgery department. Results: We managed 143 girls (16%) and 779 boys (84%). The mean age was 2 years; the right side was predominantly affected (66.8%, n = 616). Incarcerated hernia was documented in 16% of cases with an incidence of 33% in neonates. The incarceration occurrence was 15.5% in males versus 2.09% in females. The surgical repair was done according to Forgue technique. Postoperatively, four cases of hernia recurrence were documented, and contralateral metachronous hernia was reported in 33 children with 7.7% females versus 2.8% males. Forty-five percent of them were infants. The mean follow-up period was 4 years. We think that incarceration can be related to several risk factors such as feminine gender, prematurity, and the initial left side surgical repair of the hernia. Conclusion: IH occurs mainly in male infants. Prematurity and male gender were identified as risk factors of incarceration. Contralateral metachronous hernia was reported, especially in female infants and after a left side surgical repair of the hernia.

Complete tubular colonic duplication is exceedingly rare. A second ectopic opening in the perineum other than a normally cited anus could be an unusual presentation. We report an unusual case of recto-colonic duplication in a 16-day-old girl who presented with fecal discharge from a vestibular opening in addition to a normally situated anus. The diagnosis of total recto-colonic tubular duplication associated with a rectovestibular fistula and a normal anus was confirmed by barium enema and computed tomography scan with double contrast. At operation, we performed a long transanal incision of the common septum to create an anastomosis between the normal and duplicated colon with complete submucosal excision of the rectovestibular fistula. The patient was doing well at 3-year follow-up examination.

Introduction: We report the case of a 4 years old girl who present a cervico-thoracic ganglioneuroblastome with none response to chemotherapy and radiotherapy Case presentation: The girl was operated using the Cormier Dartevelle-Grünenwald incision which helped to remove the tumor completely with optimal control of noble elements. The follow up was uneventful. Conclusion: The Cormier Dartevelle-Grünenwald incision can be a good option in case of big cervico-thoracic malignant tumors.

Congenital esophageal web is a rare disorder that presents a diagnostic and management challenge. In a female infant born at 31 weeks of gestation, significant secretions and respiratory distress were noted at birth. Chest X-ray demonstrated the nasogastric tube in the esogastric junction with no distal bowel gas. Esophagogram showed a congenital web near the esogastric junction. An endoscopic examination under general anesthesia showed a complete, thick membrane on the distal esophageal lumen. Endoscopic incision and cauterization of the web through the midline were performed, improving the clinical symptoms and esophageal stenosis.

Solitary intestinal myofibromatosis (SIF) is a very rare condition affecting the pediatric population and carries good prognosis following adequate management based on segmental resection. We describe a rare case who presented with features of neonatal intestinal obstruction due to a solitary stenosing fibrotic lesion originating from the ileum and compatible with SIF.

Background: Congenital epidermolysis bullosa (CEB) is a rare genodermatosis. The digestive system is very frequently associated with skin manifestations. Pyloric atresia (PA) and oesophageal stenosis (OS) are considered the most serious digestive lesions to occur.The aim of this work is to study the management and the outcome of digestive lesions associated to CEB in four children and to compare our results to the literature. Patients and Methods: A retrospective study of four observations: Two cases of PA and two cases of OS associated to CEB managed in the Paediatric Surgery Department of Fattouma Bourguiba Teaching Hospital in Monastir, Tunisia. Results: Four patients, two of them are 11 and 8 years old, diagnosed as having a dystrophic epidermolysis bullosa since the neonatal period. They were admitted for the investigation of progressive dysphagia. Oesophageal stenosis was confirmed by an upper contrast study. Pneumatic dilation was the advocated therapeutic method for both patients with afavourable outcome. The two other patients are newborns, diagnosed to have a CEB because of association of PA with bullous skin lesions with erosive scars. Both patients had a complete diaphragm excision with pyloroplasty. They died at the age of 4 and 3 months of severe diarrhoea resistant to medical treatment. Conclusion: Digestive lesions associated to CEB represent an aggravating factor of a serious disease. OS complicating CEB is severe with difficult management. Pneumatic dilatation is the gold standard treatment method. However, the mortality rate in PA with CEB is high. Prenatal diagnosis of PA is possible, and it can help avoiding lethal forms.

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Near total aganglionosis represents the most extreme and rare form of Hirschsprung's disease. It can affect more than one member of family. We report three cases of near total intestinal aganglionosis in a family presenting with intestinal obstruction at birth. All of them were operated and a jejunostomy was performed. Outcome was dismal.

Background: The definitive treatment of Hirschsprung′s disease is the removal of the aganglionic bowel by a pull-through surgery. In most cases, this surgery is performed in infancy or in the neonatal period as presentation in older children and adulthood is uncommon. Materials and Methods: It is a retrospective study of 20 patients above two-year-old who underwent a transanal Soave one-stage endorectal pull-through procedure for Hirschsprung′s disease between January 2002 and December 2010. Results: Twenty patients were recruited in this study. Fourteen were males and six were females. Patient ages ranged from 2 to 14 years (median age: five years and three months). All patients presented with persistent constipation and abdominal distension. Two of them had an intestinal obstruction that required colostomy. Ten patients (50%) had a recto-sigmoid Hirschsprung′s disease. All patients were operated on using a Soave one-stage endorectal pull-through procedure. The laparoscopy was necessary during the pull-through in three cases. The average duration of the intervention was 240 minutes. That represents almost the double of the duration of the same procedure in newborns and infants in our department (130 minutes). Early postoperative complications included one case of anastomosis leakage and one case of intussusception. Late postoperative complications were perineum irritation in five cases (25%), anal stenosis in four cases (20%) and enterocolitis in one case (5%). None of our patients developed fecal incontinence. Soiling was reported in four cases (20%). There was no death. Conclusion: Soave transanal one-stage endorectal pull-through is safely feasible in children of more than two years of age. Laparoscopy may be necessary whenever there are difficulties in the pull-through.

We present a case of male newborn presented with respiratory distress at 21 hours of life. The patient was operated for right congenital diaphragmatic hernia (CDH). Hepatic pulmonary fusion (HPF) was found at surgery.

Background: Although the association of urinary lithiasis and urinary tract malformation is not rare, their management poses challenges. The aim of this study was to evaluate the relationship between urolithiasis and malformations of the urinary system. There were 34 patients (19 males and 15 females) with a mean age of 4.8 years (range, 2 months to 14 years). All patients had urinary lithiasis with a urinary tract malformation. Abdominal pain was the most frequent clinical symptom (38%). Urinary infection was found in 7 patients (21%) and macroscopic haematuria was present in 10 patients (29%). The most frequent urinary tract malformations were megaureter (8 cases), uretero-pelvic junction obstruction (7 cases) and vesico-ureteric reflux (8 cases), but its malformative origin could not be confirmed. Treatment consisted of lithiasis extraction in 32 cases associated with specific treatment of the uropathy in 27 cases. Postoperative outcome was uneventful in all cases. In fact, urinary lithiasis and urinary tract malformation association is not rare. Indeed, 9-34% of urinary lithiasis are noted to be associated with urinary tract malformation. Positive diagnosis relies specifically on kidney ultrasound, intravenous urography, and urethrocystography. Treatment depends on the type of urinary tract malformation, localisation and size of the urinary lithiasis. Conclusion: In conclusion, urinary lithiasis and urinary tract malformation association is a frequent eventuality. Surgical intervention is the usual mode of treatment.

Background: Wound infection is the most frequent complication in burn patients. There is a lack of guidelines on the use of systemic antibiotics in children to prevent this complication. Patients and Methods: A prospective study is carried out on 80 patients to evaluate the role of antibiotic prophylaxis in the control of infections. Results: The mean age was 34 months (9 months to 8 years). There was a male predominance with sex ratio of 1.66. The mean burn surface size burn was 26.5% with total burn surface area ranging from 5% to 33%, respectively. According to American Burn Association 37% (30/80) were severe burns with second and third degree burns >10% of the total surface body area in children aged

Background: Lipoblastoma is a rare benign mesenchymal tumour of embryonal fat that occurs almost exclusively in infants and children. This determined the epidemiological, clinical and therapeutic aspect of this disease. Materials and Methods: A total of 10 cases of pathologically proven lipoblastoma from 2003 to 2012 were reviewed. Results: There were six boys and four girls ranging in age from 7 months to 9 years. A soft-tissue mass was the main complain in nine patients. The various locations of the mass were mediastinal, thigh, buttock, inguino-scrotal, the greater omentum and the Latissimus dorsi. Lesions measured 5-15 cm. complete excision was done. The median time of follow-up was 42 months (ranges between 18 and 84 months). There were no recurrences. Conclusion: It is important to consider lipoblastoma in the diagnosis of a rapidly enlarging fatty mass in children. Complete resection is the only definitive treatment and should not be delayed when impingement on surrounding structures is imminent. There is a tendency for these lesions to recur despite presumed complete excision. Therefore, follow-up for a minimum of 5 years is recommended.

Context: We will try to show an outline of the clinical and biological characteristics of pediatric urolithiasis among Tunisian children in the coastal region. Materials and Methods: This retrospective study included 168 children below 16 years (100 boys and 68 girls) presented with urinary stones. Patients were reviewed in a multi-centric study with regard to age at diagnosis, sexual, historical, physical, laboratory, and radiologic findings. The physical and chemical analysis of stones was carried out by a stereomicroscope and infra-red spectroscopy respectively. Statistical Analysis: Statistical analysis of data was carried out using software SPSS 11.0 for Windows. Statistical significance was determined using chi-square test. Results: The sex ratio was 1.47. Clinical presentation of this pathology was dominated by abdominal pain (28%), hematuria (25.6%), dysuria (16.7%) and urinary tract infection (14.3%). Stones were located in the upper urinary tract in 75.6% of cases. Of the urine cultures, 14.3% were positive. Whewellite is found more frequently in children stones than infants (P < 0.05) and was the main component in 46.4% of stone section and 55.4 % of stone surface. Stuvite stones were more frequent among boys stones than girls′ (11 Vs 2.9%) (P < 0.05). Conclusions: The male prevalence of pediatric urolithiasis is less obvious in Tunisia. Calcium oxalate is the most frequent chemical compound in Tunisian pediatric urolithiasis.

Background: Recurrent intussusceptions in child and infants are problematic and there are controversies about its management. The aim of this study is to determine the details of the clinical diagnosis of recurrent intussusception and to determine the aetiology of recurrent intussusceptions. Patients and Methods: It′s a retrospective study of 28 cases of recurrent intussusception treated in the paediatric surgery department of Monastir (Tunisia) between January 1998 and December 2011. Results: During the study period, 505 patients were treated for 544 episodes of intussusception; there were 39 episodes of recurrent intussusceptions in 28 patients; the rate of patients with recurrence was 5.5%. With comparison to the initial episode, clinical features were similar to the recurrent episode, except bloody stool that was absent in the recurrent group (P = 0,016). Only one patient had a pathologic local point. Conclusion: In recurrent intussusception, patients are less symptomatic and consult quickly. Systematic surgical exploration is not needed as recurrent intussusceptions are easily reduced by air or hydrostatic enema and are not associated with a high rate of pathologic leading points.

Pyloric atresia (PA) is uncommon. It occurs in 1:100000 live births. Neonates usually present soon after birth with copious non-bilious vomiting. The treatment is surgical and its prognosis is poor, especially, when it is associated with epidermolysis bullosa (EB). The aim of this study was to evaluate the clinical presentation, diagnosis, operative management, post-operative courses, and outcome in infant with PA, based in our cases and literature review. Charts of 10 patients who underwent surgery for PA in the department of paediatric surgery in a Teaching Hospital in Tunisia (Monastir) between 1990 and 2012 were reviewed. Data were analysed for demographic, clinical, therapeutic, and prognostic characteristics. The average of age at presentation was 2 days and there were six males and four females. The main presenting symptoms were non-bilious vomiting in 90% of cases. Abdominal X-ray showed gastric dilatation with an absence of gas in the rest of the intestinal tract in 90%, and a pneumoperitoneum in one. The surgical approach was laparotomy in all cases. Gastric perforation was observed in one patient and was completely repaired. The distribution of the anatomic variations was type A in nine cases and type B in one. Five patients underwent excision of the diaphragm and Heineke-Mikulicz pyloroplasty and gastroduodenostomy in the other five cases. Identified associated anomalies were Down′s syndrome in one and EB in 2 (20%), one family has three affected sibling. Post-operative mortality rate was 70%. No standard surgical approach can be adopted a better management of PA or the associated anomalies depends on an early diagnosis and the availability of neonatal intensive care unit.

Idiopathic neonatal priapism is rarely published. We report the case of a newborn presenting with priapism on the first day of life and reviewed the published data on the management and the follow up of this condition.

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