Search

Life Cycle Costing (LCC) is a cost estimating approach for project and asset planning and delivery that considers the direct and indirect costs incurred over the entire life cycle of an asset. This approach can be expanded to the concept of Whole Life Cost (WLC), which additionally considers externalities and benefits. WLC can demonstrate the financial impacts, both positive and negative, of a project on its environment, in other words it can show its complete value. Despite its potential, the approach is still perceived as complex because, among other things, access to data can be difficult and the approach is still not supported by a standardized methodology. Building Information Modeling (BIM) could be used to address these issues as both WLC and BIM are deemed complementary. BIM provides WLC with better data management, improved calculation accuracy and visualization of project impacts. In return, WLC improves project understanding, decision making and reinforces life cycle thinking. This paper aims to study the potential synergies between BIM and WLC through a systematic literature review. The identification of these synergies helped form a frame of reference to better understand the opportunities that this combination can offer. Future studies would be needed to explore the application of BIM and WLC at different project scales and identify the context in which the combination of BIM and WLC is the most beneficial.

Resume L’invagination intestinale aigue (IIA) est l’urgence abdominale la plus frequente du jeune enfant. La penetration d’un segment intestinal dans l’intestin d’aval entraine une obstruction digestive et une compression vasculaire au niveau du collet. L’echographie est l’examen diagnostique. Elle detecte une masse digestive de 20–45 mm de diametre anteroposterieur en « cocarde » ou en « cible » centree par le segment invagine et son meso. Elle permet de determiner le type anatomique du boudin, d’identifier une souffrance digestive, de depister une lesion primitive, et donc de guider la prise en charge therapeutique. La forme ileocolique « idiopathique » (80 % des cas) due a une hyperplasie lymphoide du carrefour ileocaecal, est habituellement reduite par lavement ou insufflation gazeuse. La forme ileoileocolique (10 % des cas) est reperee en cas de souffrance digestive grâce a l’association des deux criteres de gravite : l’occlusion du grele et le liquide piege a la tete du boudin. L’IIA grelo-grelique occlusive (8 % des cas) survient sur un terrain particulier et/ou sur une lesion primitive. Le traitement est chirurgical excepte en cas de lymphome de Burkitt dissemine prouve histologiquement. L’IIA colocolique (2 % des cas) non occlusive facilement reduite par le lavement, recidive en l’absence d’exerese de la cause.

Smooth Muscle Cells (SMC) are unique amongst all muscle cells in their capacity to modulate their phenotype. Indeed, SMCs do not terminally differentiate but instead harbour a remarkable capacity to dedifferentiate, switching between a quiescent contractile state and a highly proliferative and migratory phenotype, a quality often associated to SMC dysfunction. However, phenotypic plasticity remains poorly examined in the field of gastroenterology in particular in pathologies in which gut motor activity is impaired. Here, we assessed SMC status in biopsies of infants with chronic intestinal pseudo‐obstruction (CIPO) syndrome, a life‐threatening intestinal motility disorder. We showed that CIPO‐SMCs harbour a decreased level of contractile markers. This phenotype is accompanied by an increase in Platelet‐Derived Growth Factor Receptor‐alpha (PDGFRA) expression. We showed that this modulation occurs without origin‐related differences in CIPO circular and longitudinal‐derived SMCs. As we characterized PDGFRA as a marker of digestive mesenchymal progenitors during embryogenesis, our results suggest a phenotypic switch of the CIPO‐SMC towards an undifferentiated stage. The development of CIPO‐SMC culture and the characterization of SMC phenotypic switch should enable us to design therapeutic approaches to promote SMC differentiation in CIPO.

Objectives The aim of this study was to evaluate the prevalence, the prenatal, and postnatal evolution of isolated fetal splenic cysts. Methods All cases of suspected fetal splenic cyst or abdominal unidentified cyst discovered during routine ultrasound scan, from 2007 to 2017, and referred to a French tertiary care center, were retrospectively collected. For each case, several prenatal parameters and postnatal evolution were reported. Results Among 5450 cases of fetal anomalies, 14 patients (0.3%) had a prenatal diagnosis of fetal splenic cysts. Median gestational age at diagnosis was 30.1 weeks. A unique cyst was present in 78.6%, whereas 2 cysts were observed in 14.3% and 3 cysts in 7.1%. During the pregnancy, cysts remained the same (78.6%) or disappeared (21.4%). Ultrasound scans at 6 months of age found total disappearance of the cysts (36.4%), spontaneous reduction from 2 to 1 cyst (18.2%) or persistence of the cysts (45.4%). Conclusion Fetal splenic cysts are rare images, always isolated, usually unique and mainly found during third trimester of pregnancy. Their evolution is to disappear spontaneously during pregnancy or at 6 months of age leaving only half of them to remain beyond that age but without any symptoms.

In the lifecycle of a building, the longest phase is generally that of operation and maintenance (O&M). The data needed to support O&M is mainly generated during the design, construction, and commissioning of the built asset phases. However, the extraction and transfer of relevant O&M data from the project documents remain a major issue in that it is time consuming and error prone. Nowadays, Building Information Modeling (BIM) allows different project team members to collaborate and share building data in real time. However, as-built models handed-over to the asset management team are quite voluminous and usually lack the necessary information for the O&M phase. This is due to an absence of O&M information requirements specification, and the lack of compliance monitoring and control during the project. This paper presents an action research focused on the issues encountered by a public building owner to manage their BIM processes. It demonstrates issues of BIM readiness and capabilities, both at the project and O&M levels, by mapping the gaps in the existing processes. Building owners rely on the design professionals’ expertise to guide them but do not have the adequate resources, knowledge, and tools to ensure the quality of the models delivered regarding O&M requirements. Major issues in the management of information for O&M were identified, and some recommendations are proposed.

The built asset industry’s notorious productivity gap is being targeted through digitalization, operationalized through Building Information Modelling (BIM), and the application of Lean philosophy to the planning, design, delivery, maintenance, and management of the built environment. While both approaches grow in popularity, their development has remained largely on parallel tracks. Both approaches have existed, for the most part, as two independent initiatives aimed at improving performance and productivity. An increasing amount of work however is pointing to the significant potential that can be achieved through the integration of both approaches. This paper investigates the mutual relations and synergies between BIM and Lean from an information management perspective. The paper also presents the key similarities, differences, synergies, and interactions between these two main drivers of built asset industry reform, while providing an investigation into the principles guiding the application of both within the construction industry.

International audience; OBJECTIVE:To assess specific, direct, and indirect prenatal ultrasound features in cases of fetal midgut volvulus.METHODS:Retrospective case series of neonatal volvulus, based on postnatal and prenatal imaging findings that occurred from 2006-2017. Prenatal and postnatal signs including the specific "whirlpool sign" were computed. Postnatal volvulus was confirmed by pathology examination after surgery or neonatal autopsy.RESULTS:Thirteen cases of midgut volvulus were identified. Though not a specific sign, a decrease in active fetal movements was reported in eight patients (61.5%). The prenatal whirlpool sign was directly seen in 10 cases, while an indirect but suggestive sign, a fluid-filled level within the dilated loops, was present in five cases. No intestinal malrotation was observed. Pregnancy outcomes were two terminations of pregnancy, both associated with cystic fibrosis, one early neonatal death, three prenatal spontaneous regressions, and seven favorable outcomes after neonatal surgery with resection of midgut atresia.CONCLUSIONS:Identification of the whirlpool sign or of a fluid-filled level within the dilated loops improves the accuracy of ultrasound findings for suspected volvulus. In the absence of total volvulus (in cases of intestinal malrotation) or association with cystic fibrosis, the prognosis appears good.

Resume L’invagination intestinale aigue est l’urgence abdominale la plus frequente du nourrisson et du jeune enfant, mais elle peut survenir a n’importe quel âge. La penetration d’un segment digestif dans l’intestin d’aval entraine une obstruction de la lumiere digestive et une compression vasculaire au niveau du collet. Le role du radiologue est essentiel pour le diagnostic mais aussi pour le traitement. L’echographie est devenue l’examen diagnostique de reference. Elle detecte une masse digestive de 20-45 mm de diametre anteroposterieur, en « cocarde » ou en « cible » centree par le segment invagine et son meso. Elle permet d’identifier le type anatomique du boudin, de suspecter une souffrance digestive, de depister une lesion primitive et donc d’orienter la prise en charge therapeutique. Le lavement est realise uniquement a visee therapeutique. L’echographie peut etre egalement indiquee pour guider un lavement hydrostatique, verifier la reduction et dans le suivi pour depister une recidive. L’invagination ileocolique « idiopathique » du nourrisson, de loin la plus frequente, est due a une hyperplasie lymphoide du carrefour ileocaecal. Elle est habituellement reduite par le lavement therapeutique. La chirurgie devrait etre reservee aux formes avec souffrance digestive et/ou avec une lesion primitive (diverticule de Meckel, lymphome de Burkitt localise, duplication kystique, polype). A l’oppose, l’invagination pathologique du grele est tres rare et occlusive. Elle survient sur un terrain particulier (chirurgie recente, purpura rhumatoide, mucoviscidose, syndrome de Peutz-Jeghers) et/ou sur une lesion primitive. Le traitement est chirurgical excepte en cas de lymphome dissemine prouve car la chimiotherapie entraine une reduction spontanee. L’invagination colocolique, exceptionnelle, est secondaire. Facilement reduite au lavement, elle recidive en l’absence d’exerese de la cause locale (polype, tumeur). L’invagination physiologique du grele tres frequente, de petite taille (10 a 19 mm de diametre anteroposterieur), peristaltique, non occlusive et transitoire, doit etre differenciee d’une invagination pathologique.

This series fully validates conservative approach of BLT in hemodynamically stable children. Complications of such approach are uncommon; many can be successfully treated using minimally invasive techniques with very satisfying results.

Intraabdominal cystic lymphangioma is a rare benign lesion with a variable clinical presentation. The aim of this study was to evaluate the natural outcome of this lesion and to propose a decision-making protocol for antenatal suspected intraabdominal lymphangioma. We also would like to emphasize the role of laparoscopy in treatment.This retrospective study examined 14 cases of intraabdominal cystic lymphangioma in children underwent to our observation, at the Pediatric Surgery Department in Lapeyronie Hospital, Montpellier between 1996 and 2007.Of the 14 patients, 12 were operated on (7 by laparoscopy and 5 in open surgery). In 2 patients we didn't perform intervention because the lesion was localized in the mesenteric root: we observed a regression of the lesion on US-scan.The intraabdominal cystic lymphangioma is a rare lesion which is now sometimes suspected on antenatal US scan; consequently we observed at the present time an increasing number of lesion potentially asymptomatic: in these case the management has to be established and a risk-benefit balance has to be made before a surgical intervention. Our experience is limited to a small number of cases, and it is too premature to describe any final conclusion; however our suggestion is that clinical course of cystic abdominal lymphangioma is unknown, and we propose that if no complication occurs, a clinical and ultrasonographic monitoring should be done in case of mesenteric root localisation.

Purpose This retrospective study reports our experience in laparoscopic approach after failure of antireflux surgery. It evaluates the results and circumstances of failure of the initial procedure to understand indications of refundoplication. Methods Four hundred seventeen patients were operated on for a gastroesophageal reflux disease (GERD) by laparoscopy in our unit from August 1993 to February 2005. Thirty redo procedures (7.19%) were performed. The indications were 24 (80%) recurrent reflux resistant to the medical treatment and 6 (20%) severe dysphagia resistant to iterative dilatations. The average age was 57.6 months. Nineteen patients (63%) were males and 11 patients (37%) were females. The time between the first and the redo procedure was an average of 16 months. Ten (33%) of them were neurologically impaired (NI); in 7 patients, a percutaneus gastrostomy was also associated. The techniques previously used were 13 Nissen, 7 Nissen-Rossetti, and 10 Toupet. Results The redo procedure was performed by laparoscopy in 27 cases. A conversion was necessary in 3 children because of a difficult dissection. In the 24 cases of recurrent reflux, we realized a valve disassembly, reconstruction of hiatus and Nissen refundoplication. In 3 cases of dysphagia, the release of the hiatus needed a complete valve redo. The mean operative time was 140 minutes (110 to 240 minutes). The sole complication was a pleural perforation. All patients were fed on the first day. The mean duration of hospitalization was 3.1 days. The follow-up was from 48 months to 12 years. A new recurrent reflux occurred in 6 patients; 5 of them were NI. Conclusion The failure rate of the antireflux laparoscopic surgery is similar to the conventional surgery. The redo procedure is possible by laparoscopic with a success rate similar to the open redo surgery. The rate and morbidity of complications are acceptable and decrease with experienced surgeons. The indications of redo procedures should be similar to conventional surgery.

The authors present an early laparoscopic treatment in a newborn with biliary atresia. They describe the technical details of the Kasai laparoscopic procedure. A 10-day-old girl, weight 2.4 kg, was admitted with a history of jaundice and fecal acholia since birth, with elevated total bilirubin and abnormal hepatic test. Abdominal ultrasound showed a small gallbladder with hyperechogenicity in porta hepatis and absence of biliary principal duct. Other metabolic and hematological tests were normal. The procedure was performed at 20-day-old by laparoscopy. The cholangiography confirmed the biliary atresia and Kasai's procedure was continued by laparoscopy and transumbilical extracorporeal Roux-Y approach. The duration of the procedure was 220 min, with good tolerance of pneumoperitoneum due to the laparoscopy. Feedings of breast milk began on the third day postoperative, presenting normal colored stools, with normalization of the hepatic test. A 20 months follow-up was without complications.

Resume Objectif. – Les enjeux de la chirurgie ambulatoire en pediatrie sont nombreux et seduisants. Si l'âge limite de six a huit mois est jusqu'a present globalement reconnu, l'âge minimum du candidat a la chirurgie ambulatoire n'est pas encore etabli. L'objectif de cette etude est d'evaluer les resultats et les limites de la chirurgie ambulatoire appliquee a la tranche d'âge 4 a 12 mois, et de les comparer a ceux obtenus chez des enfants âges de plus d'un an. Materiel et methodes. – Entre 1996 et 2003, 935 patients ont beneficie d'actes operatoires en ambulatoire. Cent cinquante-deux etaient des nourrissons âges de quatre mois a un an (moyenne : 6 mois). Les indications retenues concernaient essentiellement la chirurgie de la sphere genitale externe et la chirurgie des hernies. Sont exclus les enfants de moins de quatre mois, ceux ayant un score ASA superieur ou egal a 3 et les prematures aux antecedents de detresse respiratoire neonatale ou de mort subite manquee. Resultats. – Quatre-vingt-dix-huit pour cent des nourrissons ont pu etre operes en ambulatoire. Les annulations (1,97 vs 0,51 %, p > 0,05), les conversions en hospitalisation classique (0,65 vs 0,37 %, p > 0,05), les complications postoperatoires (0,65 vs 0,25 %, p > 0,05), les retours a l'hopital (0,65 vs 0,25 %, p > 0,05) et les recidives de la pathologie initiale (0,65 vs 0,63 %, p > 0,05) ne sont pas plus frequents chez le nourrisson que chez l'enfant de plus d'un an. Conclusion. – La chirurgie pediatrique ambulatoire peut etre proposee des l'âge de quatre mois sans augmentation du risque postoperatoire anesthesique ou chirurgical, y compris chez certains anciens prematures.

Background: Thoracoscopy may be required for resistant empyema in children. This study aimed to determine the advantages of thoracoscopy performed soon after diagnosis and its ideal timing. Methods: Between 1996 and 2002, 21 children who had undergone thoracoscopy as an initial procedure or after failure of medical treatment were retrospectively reviewed. The study compared outcome of early thoracoscopy (fewer than 4 days after diagnosis) and that of later surgery. The 4-day limit was chosen for physiopathologic reasons (organization of pleuresia in 72 h). Results: In the early thoracoscopy group, the findings showed shorter operative time (p = 0.03) and postoperative hospital stay (p < 0.05), fewer technical difficulties, fewer complications, and no recourse to other surgical procedures. Conclusions: Early thoracoscopy is greatly beneficial for children with empyema by shortening disease progression. An initial short trial of medical treatment for nonorganising empyema may be attempted on the condition that thoracoscopy not be delayed more than 4 days.

Benign adrenal pathology is rare in children. The authors report on two cases of retroperitoneoscopic adrenalectomy. The first case was a 17-month-old girl weighing 2300 g with clinical hypercortisolism and a normal gland on ultrasonography. The suspected diagnosis was an adrenal hyperplasia. The second case was a 7-year-old girl with hyperaldosteronism and virilism and the diagnosis of a left 25-mm adrenal adenoma on ultrasonography. In both cases, retroperitoneoscopic adrenalectomy was performed in a right lateral position. We used four trocars. A 7- or 10-mm telescope was introduced by a minilumbotomy under the tip of the 12th rib. The retroperitoneal space was created with the telescope and by insufflating CO2 gas at a pressure of 8 mm Hg. Three other 3- and 5-mm trocars were introduced: one above the iliac crest, one at the costospinal angle, and one under the 11th rib to retract the kidney. The dissection went behind the kidney toward the adrenal gland at the upper pole. The adrenalectomy was perfor...

Resume Decrit pour la premiere fois en 1848 par Bochdalek, la hernie diaphragmatique congenitale est plus que jamais un sujet d'actualite. Comment se fait-il que la mortalite d'un simple defect diaphragmatique avoisine encore 50 % en 1997 et ce en depit des progres continus en reanimation neonatale ? Si un certain nombre de problemes restent non resolus, les nombreux travaux experimentaux des 30 dernieres annees ont permis de remettre en question certains dogmes et de mieux comprendre la physiopathologie de la hernie diaphragmatique congenitale. Cet article passe en revue les recentes acquisitions concernant l'etiologie, la pathogenie et la physiopathologie de cette malformation complexe.

Nonoperative treatment is the gold standard approach to treat blunt liver trauma (BLT) in hemodynamically stable children. The purpose of this study was to evaluate the incidence, risk factors, timing for appearance, diagnostic modalities, management and outcome of hepatic complications secondary to such approach.This retrospective study included children admitted at Montpellier University Hospital for BLT over a 10-year period. All hemodynamically stable children were initially conservatively treated.A total of 51 children underwent nonoperative treatment for BLT during the study period. The success rate was 94.1% (48/51). Three patients (5.9%) presented 13 complications related to hepatic injuries and required secondary surgical treatment. These 3 patients presented grade 3 or higher liver lesions. Others factors identified as predictive of complications included initial hemodynamic instability (responding to the first resuscitative measures), presence of peritoneal irritation at first examination, severe hemoperitoneum, an initially low haemoglobin level (8.5 g/dl) and need for important transfusions during the first 48h (10 cc/kg). The median interval for appearance of complications was 19 days after injury (range 1-60 days). Complications were successfully treated using minimally invasive techniques in 69.2% of cases (9/13). The rest of the complications (30.8% : 4/13) were surgically treated. All children included in our study had favourable outcomes (follow-up 1-54 months).This series fully validates conservative approach of BLT in hemodynamically stable children. Complications of such approach are uncommon; many can be successfully treated using minimally invasive techniques with very satisfying results.

Mesoblastic nephroma is by far the most frequent intrarenal fetal tumor. To the best of our knowledge, we report the first case of a newborn with an intrarenal neuroblastoma that was discovered prenatally. An intrarenal echogenic and homogenous mass was observed on routine prenatal ultrasonography, corroborated by magnetic resonance imaging, in a 30-week gestation fetus. A male weighing 3280 g was born with elevated blood pressure and cardiac failure. Postnatal ultrasound confirmed a left intrarenal tumor with microcalcifications and perirenal adenopathy. An open total left nephrectomy by laparotomy was performed. The pathologic study reported that the mass was an intrarenal neuroblastoma with local and regional invasion. Immediate postoperative urine analysis revealed a high level of vanillylmandelic acid, and blood samples showed high levels of normetanephrine. The purpose of this report is to demonstrate that prenatal intrarenal neuroblastoma can clinically and radiologically mimick a mesoblastic nephroma. High blood pressure, calcifications, and lymphadenopathy on ultrasound should raise the index of suspicion for a possible malignant process. Preoperative measurement of urinary vanillylmandelic acid (VMA) and metanephrines should be performed if the diagnosis is in doubt.

Percutaneous suprapubic catheterization is an alternative when placement of a urethral catheter is contraindicated or unsuccessful. We report the case of a 3-day-old newborn, who presented anuric acute renal failure secondary to placement of a suprapubic catheter. An excessive length of catheter had been inserted into the bladder and was obstructing the vesicoureteral junctions. Several measures can be taken to prevent this complication, such as systematic measurement of the length inserted into the bladder, use of a catheter with 1cm gradations or recourse to radiopaque material.

Thoracoscopic treatment of esophageal atresia type 3 has been previously reported to be feasible but no study clearly showed the benefits of thoracoscopy compared to open procedure. The aim of this study was to compare the outcome of esophageal atresia type III treated by thoracoscopic or open procedure.From january 2000 to december 2006, 31 children were operated, 17 by thoracotomy (weight range from 1750 to 4020 g) and 14 by thoracoscopy (weight range from 2110 to 4160 g). Neonatal deaths from an independent condition (3 cases in thoracotomy group) were excluded from the study and we analyzed 14 children in each group. Analyzed data included length of surgery, length of post operative assisted ventilation, length of pleural drainage, length of stay in ICU, delay before oral feeding, length of morphine analgesia, length of hospitalization and rate of complication.Length of morphine analgesia was higher in thoracotomy group than in thoracoscopic group (mean 6.6 days versus 5.3 days, p = 0.16). Length of hospitalization was also higher in thoracotomy group (mean 22.6 days versus 19.1 days, p = 0.3). The rate of complication with thoracoscopy was not higher need of oesophageal dilatation (21% in thoracoscopic group versus 14% in thoracotomy group), need of Nissen fundoplication (21% in thoracoscopic group versus 28% in thoracotomy group).Thoracoscopic treatment of esophageal atresia type III reduces the need of morphine analgesia and the length of stay without increasing the risk of postoperative complications.

But: Des controverses persistent concernant la prise en charge des abces intra-abdominaux apres appendicectomie. Nous pensons que la plupart de ces abces peuvent etre traites avec succes par un traitement antibiotique seul, evitant les complications d'un traitement chirurgical. Methodes: Les dossiers des enfants traites dans notre Unite pour des abces intra-abdominaux post appendicectomie, sur une periode de 6 ans ont ete revus retrospectivement. Resultats: Cette etude rapporte une serie de 26 enfants de 2 a 15 ans d'âge, presentant un ou plusieurs abces intra-abdominaux post appendicectomie. Apres un delai moyen de 7 jours apres la chirurgie initiale, 23 enfants ont developpe un abces isole alors que 3 enfants avaient des abces multiples. 22 patients (84,8%) etaient traites par une triple antibiotherapie intra-veineuse seule. La disparition des manifestations cliniques, radiologiques et biologiques de ces abces etait obtenue avec une moyenne d'hospitalisation de 8 jours. 4 enfants (15,2%) etaient traites chirurgicalement: 3 enfants avaient un etat stable et un enfant presentait un choc septique necessitant un geste chirurgical en urgence. Conclusion: Ces resultats suggerent que la triple antibiotherapie seule est un traitement efficace chez les enfants developpant des abces intra-abdominaux apres appendicectomie. L'intervention chirurgicale est rarement necessaire a l'exception des patients avec des signes d'alarme ou avec des signes de choc septique.

The indications for thoracoscopy remain imprecise in cases of pleural empyema. This study aimed to identify preoperative prognostic factors to help in the surgical decision.From 1996 to 2004, 50 children with parapneumonic pleural empyema underwent thoracoscopy either as the initial procedure (n = 26) or after failure of medical treatment (n = 24). Using multivariate analysis, we tested the prognostic value of clinical and bacteriological data, the ultrasonographic staging of empyema, and the delay before surgery. Outcome measures were technical difficulties, postoperative complications, time to apyrexia, duration of drainage, and length of hospitalization.The clinical and bacterial data did not significantly predict the postoperative course. Echogenicity and the presence of pleural loculations at ultrasonography were not independent significant prognostic factors. A delay between diagnosis and surgery of more than 4 days was significantly correlated (P.05) with more frequent surgical difficulties, longer operative time, more postoperative fever, longer drainage time, longer hospitalization, and more postoperative complications, such as bronchopleural fistula, empyema relapse, and persistent atelectasia.The main prognostic factor for thoracoscopic treatment of pleural empyema is the interval between diagnosis and surgery. A 4-day limit, corresponding to the natural process of empyema organization, is significant. The assessment of loculations by ultrasonography alone is not sufficient to predict the postoperative course.

Complex procedures for managing congenital abnormalities are reported to be feasible. However, neonatal videosurgery involves very specific physiologic constraints. This study evaluated the safety and complication rate of videosurgery during the first month of life and sought to determine both the risk factors of perioperative complications and the most recent trends in practice.From 1993 to 2005, 218 neonates (mean age, 16 days; weight, 3,386 g) from seven European university hospitals were enrolled in a retrospective study. The surgical indications for laparoscopy (n = 204) and thoracoscopy (n = 14) were congenital abnormalities or exploratory procedures.Of the 16 surgical incidents that occurred (7.5%), mainly before 2001, 11 were minor (parietal hematoma, eventration). Three neonates had repeat surgery for incomplete treatment of pyloric stenosis. In two cases, the incidents were more threatening (duodenal wound, diaphragmatic artery injury), but without further consequences. No mortality is reported. The 26 anesthetic incidents (12%) that occurred during insufflation included desaturation (80% despite 100% oxygen ventilation) (n = 8), transient hypotension requiring vascular expansion (n = 7), hypercapnia (45 mmHg) (n = 5), hypothermia (34.9 degrees C) (n = 4), and metabolic acidosis (n = 2). The insufflation had to be stopped in 7% of the cases (transiently in 9 cases, definitively in 6 cases). The significant risk factors for an incident (p0.05) were young age of the patient, low body temperature, thoracic insufflation, high pressure and flow of insufflation, and length of surgery.Despite advances in miniaturizing of instruments and growth in surgeons' experience, the morbidity of neonatal videosurgery is not negligible. A profile of the patient at risk for an insufflation-related incident emerged from this study and may help in the selection of neonates who will benefit most from these techniques in conditions of maximal safety.

To evaluate the feasibility and results of thoracoscopy in various types of esophageal atresia (EA).From April 2001 to August 2002, 5 patients with EA were treated by thoracoscopy. Their mean gestational age was 38 weeks and mean birth weight was 2700 g. Two patients had short-gap atresia with tracheo-esophageal fistula (type III according to Ladd's classification). Three had long-gap atresia: 2 with low fistula to the carina (type IV) and 1 without fistula (type I). Patients were placed in a prone position with the right side elevated at 80 degrees . Four intrapleural ports were necessary. The fistula when present was dissected and sutured with intrathoracic knots and esophageal anastomosis performed in the same manner.Positive airway pressure increased in all patients after insufflation but was kept in a safe range to prevent lung injury. An esophageal anastomosis was performed in 3 cases (2 short gaps and 1 long gap). Oral feeding started on day 6, and their mean length of hospital stay was 14 days. For one child with type IV EA, the anastomosis was impossible because of a long gap confirmed by an immediate thoracotomy. The ends were just approximated. A "spontaneous" fistula developed, and normal feeding was possible 2.5 months later. For the child with type I EA, the pouches could be only approximated at 2 months of age. A spontaneous fistula developed with a stenosis. A redo anastomosis by open surgery allowed for normal feeding.The thoracoscopic repair of an esophageal atresia is a reasonable choice for experienced surgeons treating patients, including those with long gaps.

Objectives. Video-surgery in neonates is recent. Data on the respiratory, hemodynamic, and thermic effects during the first month of life are still sparse. This study aimed to evaluate the tolerance of video-surgery in neonates and to determine the risk factors of per-operative complications.Methods. From 1994 to 2004, 49 neonates (mean age: 11 days; weight: 3285 g) underwent 50 video-surgical procedures. Indications for laparoscopy were duodenal atresias, volvulus with malrotation, pyloric stenosis, gastroesophageal reflux, cystic lymphangiomas, ovarian cysts, biliary atresia, and congenital diaphragmatic hernias; indications for thoracoscopy were esophageal atresias and tracheoesophageal fistula.Results. Median operative time was 79 minutes. Mean insufflation pressure was 6.7 mm Hg (range: 3–13). Oxygen saturation decreased, especially with thoracic insufflation or high-pressure pneumoperitoneum. Systolic arterial pressure, which decreased in 20% of the patients, was controlled easily with vascular expansion. Thermic loss (mean postoperative temperature: 35.6°C) was proportional to the duration of insufflation. No surgical incident was noted. Ten anesthetic incidents occurred (20%), 3 of which required temporary or definitive interruption of insufflation (O2 saturation 100 minutes, thoracic insufflation, and a high oxygen or vascular expansion requirement at the beginning of insufflation.Conclusion. The neonate's high sensitivity to insufflation is an important limiting factor of video-surgery. The described profile of the neonate at risk may help to reduce the frequency of adverse effects of this technique and improve its tolerance.

Cavitary necrosis remains a rare complication of bacterial pneumonia in children. Conservative medical treatment and radical surgical treatment with lung resection are the current therapeutic choices. Evaluation of thoracoscopy for this pathology has not yet been reported. We describe 3 cases.Between January 2001 and January 2002, 3 children (1, 2, and 3 years old) were admitted to our institution with necrotizing pneumonia. The diagnosis was based on injected computed tomography (CT) scan showing pulmonary condensation, intra-parenchymal bullae, and hypovascularization. In addition to an adapted antibiotic therapy, a thoracoscopic approach was decided on within 24 hours of diagnosis, with extensive decortication, ablation of superficial necrotic debris, irrigation, and drainage.No conversion to open thoracotomy or lung resection was needed. Admission to the intensive care unit was unnecessary. On average, apyrexia was reached on postoperative day (POD) 2 and tube drainage was removed on POD 15. Mean follow-up at 16 months showed excellent lung re-expansion with no relapse.On the condition that the decision is made quickly, thoracoscopy may be a valuable treatment option in childhood necrotizing pneumonia, as it hastens recovery and avoids lung resection. Injected CT scan allows an early diagnosis and we propose the first 24 hours after diagnosis as the optimal period for thoracoscopy because of the rapid natural course of lung gangrene.

This study aimed to evaluate the optimal conditions for laparoscopic management of neonatal subacute volvulus with malrotation.Between 1994 and 2002, 13 neonates with midgut volvulus and malrotation entered the authors' institution. Five of these neonates met the eligibility criteria for laparoscopy: good hemodynamic parameters, no gut perforation, and no severe ischemic distress of the bowel shown on preoperative ultrasonography.The results were excellent for only three infants, associated with a shorter postoperative course. One underwent reoperation for a residual duodenal band, and one conversion to open laparotomy was necessary. The predictors of success were no difficulty identifying the abnormal anatomy, no important chylous stasis, and the learning curve of the surgeon.Despite its previously reported feasibility, neonatal laparoscopy for volvulus with intestinal malrotation is appropriate only for a small number of patients. Strict selection criteria with a clear understanding of the optimal conditions for success may improve the outcome.

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

Background and Aim Bilateral surgery was formerly advocated in premature boys with unilateral inguinal hernia to avoid a metachronous contralateral hernia and the risks of recurrent anesthesia. But the recent progress in pediatric anesthesia and the demonstrated morbidity of herniotomy during the neonatal period on fertility now question this attitude. We aimed to compare the morbidity of preventive bilateral vs elective unilateral herniotomy in premature boys with unilateral hernia and to evaluate the incidence of contralateral metachronous hernia. Methods Retrospective multicenter analysis of 966 premature boys presenting with unilateral inguinal hernia. 558 infants benefited from unilateral herniotomy and 408 from bilateral herniotomy with a median follow up of 20 months. Results The rate of contralateral metachronous hernia after unilateral surgery was 11% (10% on right vs 13% on left). Morbidity on the contralateral side was higher in case of preventive bilateral surgery than in metachronous hernia (2% vs 0.2% p=0.003), especially for testicular hypotrophy (0.70% vs 0.18 %, p= 0.3) and secondary cryptorchidism (1% vs 0%, p=0.03) Comparison between the type anesthesias (general anesthesia versus central block) did not show significant differences depending on the type of care (unilateral or bilateral, planned or emergency). Conclusion Systematic bilateral herniotomy is unnecessary in almost 90% of patients and has a higher morbidity than secondary surgery for metachronous hernia. These results, along with the risk of deferential damage and hypofertility reported in later adulthood, justify treating only the symptomatic side in premature boys.

Objectif L’objectif de cette etude etait d’evaluer l’alimentation enterale precoce chez les nouveaux-nes atteints de laparoschisis. Methodes Deux groupes de nouveaux nes ont ete compares; le premier groupe de reference (16 patients nes entre 2000 et 2004) : la nutrition enterale etait debutee apres resolution complete de l’occlusion fonctionnelle. Le second groupe (20 nourrissons nes entre 2004 et 2008) a ete evalue de maniere prospective avec nutrition enterale autour du 5 e jour apres fermeture de la paroi par allaitement au sein. Resultats Le temps d’initialisation de l’alimentation enterale a ete reduit pour le second groupe (5 jours contre 14 jours pour le groupe de reference). Les durees moyennes d’alimentation enterale totale ont ete significativement modifiees (27 jours contre 55 jours). L’incidence des maladies nosocomiales a ete diminuee (15 % contre 38 %) ainsi que la duree d’hospitalisation des patients (38 jours contre 62 jours). Conclusion La nutrition enterale precoce systematique permet de diminuer de maniere significative la duree de nutrition parenterale et donc de diminuer les infections sur catheter central, une des premieres causes de morbidite du laparoschisis. Enfin, la mise au sein precoce favorise la relation mere enfant et preserve l’oralite.

But le traitement non operatoire des traumatismes hepatiques fermes est un gold standard chez l’enfant hemodynamiquement stable, mais il n’est pas denue de complications. Le but de cette etude etait d’evaluer l’incidence, les moyens diagnostiques, le traitement et le devenir de ces complications. Methodes Etude retrospective incluant les patients de moins de 16 ans admis au CHU de Montpellier pour un traumatisme ferme du foie sur une periode de 10 ans. Resultats 51 enfants ont beneficie d’une approche non chirurgicale, avec un taux de succes de 94,1 % (48/51). Trois patients (5,9 %) ont presente un total de 13 complications directement liees a leurs hepatiques. Les complications hepatiques etaient biliaires, hemorragiques, thrombotiques et un syndrome de compartiment. Ces complications ont ete prises en charge par un traitement mini invasif dans 61,5 % des cas (drains percutanes, embolisation) avec succes; Les autres complications ont eu un traitement chirurgical. Tous les enfants ont evolue de maniere favorable avec un recul moyen de 7 mois (2 – 54 mois). Conclusion Les complications du traitement conservateur sont rares mais variees. Beaucoup d’entre elles peuvent etre traitees par des techniques mini invasives avec des resultats tres satisfaisants.

L’objectif etait de creer et de diffuser, a la demande des professionnels de la perinatalite (sages femmes, gynecologues echographistes, obstetriciens, pediatres, autres) des fiches d’information pratiques sur les principales malformations chirurgicales et leur prise en charge neonatale. Les fiches ont ete realisees dans le cadre du Reseau Perinatal Regional Naitre et Grandir en Languedoc Roussillon. Apres appel a participation des chirurgiens infantiles plusieurs reunions ont ete realisees pour definir les themes d’information et le contenu. Douze fiches d’information ont ete etablies pour servir de referentiel. Elles portent sur les malformations chirurgicales les plus frequentes ou celles qui posent le plus de probleme. Pour chaque fiche le meme plan a ete utilise pour faciliter la lecture. Si necessaire l’iconographie echographique prenatale et l’aspect clinique postnatal a ete insere. Apres validation les fiches seront accessibles de facon securisee sur la plate-forme internet du reseau. Les fiches d’information permettront aux professionnels de la perinatalite d’avoir une conduite a tenir pour mieux informer les familles et orienter la prise en charge du nouveau-ne. Cette demarche a ete realisee dans le cadre d’un reseau regional de soins et son utilite devra etre evaluee.

But faisabilite de la voie d’abord peri-ombilicale en fonction des pathologies et de l’âge de l’enfant Materiel et Methode etude retrospective de 31 cas de voie d’abord periombilicale utilise pendant 8 ans (2001-2008). Inclusion : enfants de 1 jour a 18 ans operes pour des pathologies congenitales ou acquises abdominales (a l’exclusion des pathologies pyloriques ou ombilicales). Resultats Cette voie d’abord a pu etre utilisee chez les 31 patients pour 9 pathologies differentes du tube digestif (7 duplications, 5 Meckel compliques, 8 atresies intestinales, 2 lymphangiomes kystiques, 1 ileus meconial, 4 jejunostomies, 2 corps etrangers, 1 invagination, 1 polype jejunal). Dans 21 cas (67 %), elle a ete combinee a une cœlioscopie premiere autorisant une exploration de la lesion et dans certains cas facilitant le traitement par abord periombilical. Nous avons eu 3 complications (9,6%) : un hematome de la paroi du grele, un hematome sous cutane, une occlusion sur plicature de l’anastomose. Conclusion La voie d’abord periombilicale est de realisation et d’apprentissage plus aise que la cœlioscopie avec un benefice cosmetique similaire et une faible morbidite. De plus son association possible avec la coelioscopie premiere permet d’en etendre ses indications.

Objectifs Connaitre la demence diagnostique, basee sur le couple ADP-echographie. Savoir determiner le siege de l’occlusion (duodenal, grele ou colique). Connaitre la semiologie des differentes etiologies. Identifier les signes de gravite imposant une chirurgie d’urgence. Messages a retenir Tout vomissement vert chez un nouveau-ne impose une imagerie. L’etape fondamentale est de rechercher un volvulus sur malrotation. Contrairement a l’ASP, l’echographie differencie toujours obstacles grele et colique. Dans le Hirschsprung neonatal, la disparite de calibre echographique est souvent absente. Le lavement aux hydrosolubles est indispensable devant toute occlusion basse. Resume Tout vomissement vert chez un nouveau-ne fait immediatement suspecter une occlusion. L’etude des vaisseaux mesenteriques, recherchant malposition et spire de torsion, est fondamentale. L’image en « double bulle » est caracteristique d’un obstacle duodenal (atresie, stenose). Devant une occlusion basse, la decouverte echo-graphique d’un microcolon complet traduit un obstacle grele. Au niveau du segment dilate, un meconium adherent a la paroi oriente vers un ileus meconial, une importante distension liquidienne est en faveur d’une atresie. L’ileus du prematurissime est rare. Un colon fonctionnel, uniforme ou avec disparite de calibre, temoigne d’une maladie de Hirschsprung, d’un bouchon meconial ou d’un petit colon gauche. L’indispensable lavement aux hydrosolubles, traite ileus meconial et immaturite colique, et demasque la disparite de calibre brutale d’un Hirschsprung. Le Hirschsprung colique total reste en filigrane de toute occlusion basse. Une peritonite, un epanchement gazeux, un pseudokyste meconial, un volvulus indiquent une chirurgie immediate.

Objectif Nous rapportons ici le cas d’une adolescente de 12 ans, chez laquelle a ete diagnostique un ovaire surnumeraire. Cas clinique Une adolescente agee de 12 ans prepubere, sans antecedents particuliers, beneficie d’une echographie abdomino-pelvienne dans le cadre d’un bilan d’anorexie mentale. Celle-ci retrouve une masse mobile de 37 mm de diametre, echogene, inter utero-ovarienne droite, vascularisee avec des petites formations kystiques de quelques mm. Les marqueurs tumoraux sont negatifs. L’IRM pelvien ne confirme le caractere mobile de cette masse dont les caracteristiques tissulaires evoquent un ovaire surnumeraire. Il est realise une exerese de cette masse sous coelioscopie. L’examen anatomo-pathologique confirme qu’il s’agit d’un ovaire surnumeraire necrose. Discussion L’ovaire surnumeraire est une anomalie gynecologique rare (27 cas recenses dans la litterature dont 3 avant l’âge de 18 ans). Il se definit comme une structure avec du tissu ovarien typique sans connection avec l’ovaire normal. Il peut etre retrouve dans le mesentere, l’epiploon, la cavite pelvienne ou en retroperitoneal. Le plus souvent, il est asymptomatique et de decouverte fortuite (lors d’une laparotomie,d’une lararoscopie ou d’une autopsie). Il peut egalement se compliquer (kyste, torsion, endometriose ou tumeur). Conclusion L’originalite de cette observation est double. D’une part, le diagnostic d’ovaire surnumeraire a ete fait chez une adolescente prepubere. D’autre part, ce diagnostic a ete fait en pre-operatoire sur des donnees d’imagerie.