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Resume Buts Analyser les modalites de la prise en charge conservatrice des fractures severes du rein de l’enfant ainsi que leur pronostic fonctionnel a distance. Patients et methodes Il s’agissait d’une etude retrospective de 22 enfants admis pour une fracture du rein severe (grade V) dans deux services de chirurgie pediatrique sur une periode de 16 ans. Un traitement conservateur initial a ete realise chez 19 patients (86,5 %). Trois enfants presentant une lesion vasculaire ont eu un traitement par radiologie interventionnelle. L’aspect morphologique et fonctionnel du rein lese ont ete determines par une scintigraphie au DMSA et/ou une Uro-IRM. Resultats Vingt et un patients (95,5 %) ont eu une scintigraphie au DMSA dont deux ont ete associees a une Uro-IRM, un patient a eu uniquement une Uro-IRM. Dix enfants (45,5 %) ont eu une restitution ad integrum du parenchyme renal ; on notait sept atrophies polaires superieures (30 %), une atrophie polaire inferieure (4,5 %), deux atrophies renales completes (9 %) et deux patients (9 %) pour lesquels on n’avait aucune precision. Six patients (27 %) ont presente un urinome qui a necessite un drainage dans cinq cas et une simple surveillance chez un enfant. On ne notait aucun pseudokyste renal secondaire ni d’hypertension arterielle. La moitie des lesions renales grades V (50 %) (11 sur 22 patients) avait une fonction normale apres un recul moyen de 19 mois. Conclusion La prise en charge non operatoire des traumatismes severes du rein a ete efficace avec parfois la necessite d’un drainage interne ou percutane afin de reduire l’urinome. Le pronostic fonctionnel renal etabli par imagerie etait satisfaisant avec une restitution ad integrum chez un patient sur deux.

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.

Resume Les valves de l’uretre posterieur (VUP) peuvent constituer, en presence de signes antenatals de gravite, un motif d’interruption medicale de grossesse (IMG). Le but de cette etude etait d’evaluer le retentissement du diagnostic prenatal sur l’epidemiologie et l’evolution de cette pathologie. Patients et methodes Quarante-trois diagnostics de VUP ont ete realises entre 1998 et 2007 dans la region Languedoc-Roussillon, aboutissant dans 15 cas a une IMG. Nous detaillons les donnees prenatales, neonatales et l’evolution de ces enfants avec un suivi moyen de 7,6 annees. Resultats Six enfants sur 26 etaient insuffisants renaux a la fin de l’etude mais 1 seul avait necessite d’une transplantation renale. Onze patients avaient presente des troubles mictionnels. Trois quarts des sujets ont eu au moins 1 episode de pyelonephrite aigue. En revanche, l’hypertension arterielle et la proteinurie etaient rares. Discussion et conclusion Le depistage antenatal, associe a l’amelioration des therapeutiques, a permis une nette modification du pronostic de ces enfants. Parmi les facteurs pronostiques etudies, le plus fiable reste la valeur de la fonction renale a l’âge de 1 an. Parallelement, le depistage antenatal des VUP peut poser un probleme difficile du fait de l’absence de consensus sur les criteres amenant a proposer une IMG aux parents concernes.

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.

The transverse outer preputial (TOP) island flap, a simple procedure inspired by the double-faced island flap, is proposed as a substitute for the Byars repair to provide skin coverage for most of the current reconstructive techniques for hypospadias.From 1996 to 2003, 108 consecutive children (aged 1-8 years) had a primary repair of various forms of hypospadias with different degrees of chordee; the TOP island flap was used in 66. The surgical technique is based on the use of a dorsal transverse skin flap mobilized with its own vascular pedicle from the outer foreskin, then ventrally rotated longitudinally after removing the inner part of the prepuce.Partial necrosis of the lateral border of the flap was infrequent (2%) and did not induce urethral complications. There was no total necrosis in the series. The rate of fistula was comparable with children operated using other techniques (8%). The cosmesis was good, with no ventral bulkiness or hypertrophic scarring.The TOP island flap is a safe method for covering a new urethra and penile skin defects, with good cosmetic results.

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.

Ultrasonography has radically changed the approach of these rare malformations, still diagnosed with difficulties in spite of modern iconography. Bladder anomalies may easily be discovered when associated with otherwise obvious malformations of genitalia. The rest must be suspected for non-specific signs as micturition troubles, multiple urinary tract infections, chronic renal failure. The abnormal bladder is the only common feature of a polymorphic spectrum of diseases including complete or partial duplication or septum, congenital diverticula, vesicovaginal fistula, agenesis and urachal anomalies. Treatment must be accorded to each case and it needs perfect knowledge of open and endoscopic bladder surgery.

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...

From January 1986 to February 1994, 198 children were operated on for hypertrophic pyloric stenosis (HPS). Postoperative follow-up have been carried out in 194 cases. The children were divided into two groups: group A (n = 134; 69.1%): without any postoperative diet troubles (n = 52) or simple regurgitations (n = 82), and group B (n = 60; 30.9%) presenting more significant vomiting requiring medical treatment (n = 52) or a prolongation of parental nutrition (n = 8). A retrospective study of the different factors which can possibly explain this postoperative vomiting was carried out. The criteria having an influence are: the age (44.5 days in group A; 35.7 days in group B; (p < 0.001) the weight at the time of the operation (3921) g in group A; 3647 in group B; p = 0.01) the thickness of the pylorus at the pre-operative ultrasound scan (5.2 mm in group A; 47 in group B; p < 0.015). The other studied criteria (prematurity, birth weight, delay in diagnosis, weight loss, hydroelectrolytic abnormalities, surgical approach way-subcostal or umbilical-, surgical difficulties and operation duration) are not statistically significant. The young age (and therefore the low weight) at the time of the pyloromyotomy can easily explain the post-operative vomiting through the physiological immaturity of the lower sphincter of the esophagus. It is more paradoxical to note that these difficulties are all the more frequent because the pyloric tumor is less thick at the ultrasound scan. But this criterion is also directly related to the child's age (average thickness of 4.5 mm before the age of one month and 5.8 mm after the age of two months; p < 0.0001). These data suggest the importance of systematic medical treatment to prevent postoperative vomiting in high-risk children, in order to decrease hospital stay (4.14 days in group A; 5.20 days in group B; p < 0.0001).

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.

To analyze the results of treatment of major renal injuries according imaging data in order to determine their function after follow-up.This is a retrospective study of 22 cases of fracture of the kidney (grade V) in two pediatric surgical services that were reviewed over a period of 16 years. After initial conservative treatment in 19 patients (86.5%), a scan and/or Uro-MRI were realized in all patients in monitoring evolving. Three children with vascular injury were treated by interventional radiology. The morphology and functional evolution of the injured kidney were determined.A DMSA scan investigation was performed in 21 patients (95.5%) associated with Uro-MRI in two cases; one patient was only explored with Uro-MRI. A complete restitution of the renal parenchyma was confirmed in 10 children (45.5%), we noted an atrophy of the upper pole in 30%, a lower pole atrophy in 4.5%, two complete renal atrophy in 9%. An urinoma was present in six patients (27%) that required drainage in five cases and declined during the surveillance in one case. Normal function of the injured kidney was noticed in half of grade V (11 of 22 patients) with a mean follow-up of 19 months. None of our patients did present hypertension.Non-operative conservative treatment in severe renal trauma was efficient, morphological and functional sequelae were present in 50% on scintigraphy and/or Uro-MRI.

To evaluate the impact of prenatal diagnosis on the epidemiology and outcome of children with posterior urethral valves (PUV), considering that today termination of pregnancy may be proposed in the most severe cases.Forty-three cases of patients with PUV were diagnosed between 1998 and 2007 in the Languedoc-Roussillon region. In this study, we detailed the prenatal data and postnatal outcome of those patients with a mean follow-up period of 7.6 years.Medical interruption of pregnancy was performed in 15 severe cases. One death in utero was also observed. Twenty-seven patients were managed postnatally and one child died during the neonatal period because of lung hypoplasia. For the 26 remaining patients at the end of the follow-up period, 5 had mild renal insufficiency with a creatinine clearance calculated with the Schwartz formula of less than 80 ml/min/1.73 m2. One reached end-stage renal failure at the age of 7 years. Proteinuria and hypertension were rare.Today, because of the increase in medical termination of pregnancy in the most severe cases, most of the children born alive with PUV experienced a better renal prognosis when compared with previous data. Prenatal diagnosis and therapeutic progress significantly modified the epidemiology and outcome of this disease. Nevertheless, the best predictor of renal outcome remains renal function at 1 year of age.

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.

Although cryptorchidism is probably the most frequent genital anomaly encountered in boys, this pathology remains largely unexplained and its long-term prognosis is still uncertain. Despite the relative easiness of this diagnosis, attention should be paid to some clinical traps, which can mislead the sexual identity. Indeed, beside the isolated common cryptorchidism, many troubles of the testicular migration can be associated with various malformative syndromes and can be named as "cryptorchidism symptoms". Most of these syndromes are obvious, but some can be suspected only by the way of an abnormal descent of testis. Cryptorchidism, which is systematically screened out during any pediatric consultation, should play the role of clinical marker for various endocrine or genetic disorders. Among them, the intersex states should be underlined to avoid the harmful effects of misdiagnosis. We dealt with this subject through a clinical and practical approach.

Ultrasonography has radically changed the approach of these rare malformations, still diagnosed with difficulties in spite of modern iconography. Bladder anomalies may easily be discovered when associated with otherwise obvious malformations of genitalia. The rest must be suspected for non-specific signs as micturition troubles, multiple urinary tract infections, chronic renal failure. The abnormal bladder is the only common feature of a polymorphic spectrum of diseases including complete or partial duplication or septum, congenital diverticula, vesicovaginal fistula, agenesis and urachal anomalies. Treatment must be accorded to each case and it needs perfect knowledge of open and endoscopic bladder surgery.

In a multicentre trial we compared the clinical efficacy of amoxicillin/clavulanate used as a single-agent therapy with that of the three-agent combination usually prescribed in the post-operative period for appendicular peritonitis in children. Only bacteriologically documented peritoneal infections were included. Sixty-four patients were randomly distributed between two groups: Group A (29 cases) treated with amoxicillin/clavulanate, first administered iv (100 mg/kg/d), followed by conversion to the oral route (50 mg/kg/d) once the patient had been afebrile for 48 hours; Group B (35 cases) first treated by the iv route with benzylpenicillin (100,000 IU/kg/d) plus netilmicin (5 mg/kg/d) plus metronidazole (30 mg/kg/d), followed by conversion to the oral route for metronidazole (30 mg/kg/d). In both groups, the total duration of parenteral and oral treatment was not less than 5 days. One hundred and seventy nine bacterial strains were recovered from peritoneal fluid samples obtained during surgery; 86% of these were sensitive to amoxicillin/clavulanate. Clinical efficacy, assessed on the basis of time until return to normal temperature and gut transit and duration of hospitalization, was identical in both groups, with follow-up monitoring on day 30 showing recovery in all cases. Cure was obtained without any problems of infection in 25/29 patients in group A and in 34/35 patients in group B (non significant difference). Tolerance was excellent and identical in the two groups with the exception of three cases of thrombophlebitis which occurred in group B. The results of this study suggest that amoxicillin/clavulanate may be useful as single-agent therapy as a first-line curative treatment for appendicular peritonitis in children.

The authors report the case of a tetralogy of Fallot associated with a neuroblastoma secreting large quantities of noradrenaline. Anoxic decompensation of the tetralogy of Fallot occurred early at the age of 4 months with cyanotic crises associated with an impression of abdominal pain. A systemic-pulmonary anastomosis was performed and the cyanosis regressed but the crises persisted and investigations showed the presence of a neuroblastoma. The tumour was treated by surgery and chemotherapy and has not recurred after 2 years' follow-up. Complete repair of the tetralogy of Fallot was performed secondarily at the age of 2. In this case, the high concentration of circulating catecholamines was probably a factor of early decompensation of the tetralogy of Fallot by infundibular spasm. A review of the literature revealed 26 cases of cardiac disease with a peripheral neurogenic tumour. Two pathogenic mechanisms are suggested: an embryological abnormality of cardiac cell migration from the neural crest and chronic stimulation of neuroblastic cells by chronic hypoxia.

During the past ten years, we have treated 26 children with closed renal injuries. Hematuria appeared in 19 cases, but was not detected in 7 other cases, 6 of which corresponded to severe, especially pedicular, lesions. The diagnostic means for the lesion included IVP in 24 cases, ultrasonography in 23, angiography in 8 and computed tomography in 7. The treatment was medical for 18 children and surgical for 8. Observation revealed 4 cases of renal atrophy, including 1 of general atrophy without residual arterial hypertension. On the basis of this series and of a review of the literature, we study the evolution of the diagnosis and treatment of this condition with the development of new medical imaging techniques, especially of CT.

This review deals with the various anatomo-clinical features and the embryogenesis of utero-vaginal malformations. Three anatomo-clinical groups are distinguished from the vaginal malformations: vaginal aplasia, vaginal septa and hydrometrocolpos. Similarly, there are 3 types of uterine malformations, each corresponding to a chronologically different embryopathological anomaly: mullerian aplasia, most often responsible for utero-vaginal aplasia, mullerian fusion defects leading to bicornuate uterus, and resorption defects of the mullerian septum resulting in uterine septum. Only the utero-vaginal malformations with a vaginal component, mainly neonatal hydrometrocolpos, can really be detected during infancy and childhood, provided that the examination of the external genitalia is systematically and carefully performed. Due to their usual clinical latency during childhood, most malformations are only discovered by the end of puberty or after menarche, the main clinical signs being primary amenorrhea, cryptomenorrhea, unilateral dysmenorrhea or isolated dyspareunia. After the clinical gynecological examination, ultrasound diagnosis is very useful to explore the internal genitalia and to search for a frequently associated anomaly of the urinary tract.

During the past ten years, we have treated 26 children with closed renal injuries. Hematuria appeared in 19 cases, but was not detected in 7 other cases, 6 of which corresponded to severe, especially pedicular, lesions. The diagnostic means for the lesion included IVP in 24 cases, ultrasonography in 23, angiography in 8 and computed tomography in 7. The treatment was medical for 18 children and surgical for 8. Observation revealed 4 cases of renal atrophy, including 1 of general atrophy without residual arterial hypertension. On the basis of this series and of a review of the literature, we study the evolution of the diagnosis and treatment of this condition with the development of new medical imaging techniques, especially of CT.

This is a case report of a two years old young boy whose abdominal tumor was discovered by a routine examination. The mass was a huge, solid and painless one, located anteriorly in the right upper quadrant of the abdomen. Abdominal X-ray, IVP and ultrasonography showed a calcified mass with a normal right kidney. Urinary catecholamine excretion was significantly increased and the diagnosis of extrasurrenal prerenal sympathoblastoma was preoperatively suspected. Transverse laparotomy founded an encapsulated solid tumor, widening the duodenal loop and developing in the head of the pancreas. A cephalic duodenopancreatectomy was performed with an un eventful post-operative course. Histopathological examination confirmed it was a ganglioneuroblastoma of the head of the pancreas with lymphatic metastasis and local invasion of the neighbouring pancreas with immature tissues. The child was then treated with radiotherapy (35 Grays) and chemotherapy (Oncovin-Endoxan alternated with Oncovin-Adriamycine). The boy is now in good health with a two years follow up. Malignant pancreatic tumors are exceedingly rare in the pediatric age group (about 40 cases in the literature). Most of them are carcinoma and sympathoblastoma is quite exceptional (Research has yielded only one case : Bienaymé, 1976). The presence of a nervous tumor in such an unusual position explains the lack of precision in the preoperative location and brings up the difficult question of prognosis. It leads to pathogenic hypothesis.

In a six weeks old infant an hepatic abscess with several affected areas is diagnosed by ultrasonography confirmed by scintillation scanning. Closed percutaneous needle aspiration and antibiotherapy permitted a good outcome avoiding surgical drainage or excision.

Seventy-seven children with gastro-esophageal reflux have been operated upon during the last 21 years. Gradually added to the classical digestive symptoms and signs were those of respiratory disorders varying between asthma and the "missed sudden death" syndrome. Analysis of anatomical forms showed a predominance of cardio-antral malpositionings (58%) in this age group (mainly young babies). Surgical treatment, presently based on that of Toupet, apart from classical formal indications, is conducted after 3 to 4 months of medicopostural therapy when there is persistence of reflux and/or of esophagitis on fibroscopy in cardio-antral malpositions. Particularly as results of this surgery are good (disappearance of reflux in 83% of cases).

The persistent cloaca is one of the most complex and challenging developmental malformation. It is a rare anomaly occuring only in the female newborn and represented by the association of a urogenital sinus with an anorectal malformation. We report here three cases seen and recently treated in Montpellier (France) in the unit of visceral pediatric surgery (Pr J.G. Pous) between 1981 and 1983. A precise knowledge of normal embryology is very helpful in order to understand these complex anatomical situations. Every case is probably unique, but some main principles of management can be stressed. Neonatal loop colostomy is probably safer in most cases and can allow temporizing until the child is 6 months to 1 year of age. Interim management is often needed: intermittent catheterisation of the bladder and/or urine-filled vagina via the uro-genital sinus, avoiding urinary diversions, except possible temporary supra-pubic cystostomy. Definitive reconstruction is often a long and complex procedure, strictly dependent on absolutely thorough radio-endoscopic pre-operative investigations. It is vital to know exactly the length of the cloacal canal and of the urethra, because surgical reconstruction will vary according to the level at which the various structures converge. Cloacas represent a wide anatomic spectrum: as the severity of the defect increases, there is urogenital sinus with anterior anus ("Near cloacal malformation"), low and high confluence of all three systems. The goal of surgery is to perform in a single operation, the separation of the different conduits and to preserve all the sphincteric mechanisms for urinary-anal continence and genital functions.(ABSTRACT TRUNCATED AT 250 WORDS)

The Authors report three unpublished cases of tumoral abscess of the liver in infants and children. Two different situations are considered:--clinical findings, laboratory tests and intraoperative examination can be more in favor of a tumor at times. Means of avoiding needless excisions are outlined.--two uncommon types of abscess are considered. One type has an areolar structure whereas the other is in fact inflammatory tumoral fibrosis. This abscess is a true tumor and must be treated accordingly. Pathological studies, etiology, bacteriology and clinical aspects of such abscess of the liver are reviewed.

Among infantile fibromatosis, isolated intra-abdominal forms are the most unusual. The authors report two cases, a hepatic fibromatosis in an eleven year old girl, and a desmoïd tumor located in the jejunal mesentery in a ten month old infant. Pre-operative diagnosis is very difficult and histologic findings show a benign fibroblastic proliferation that tends to infiltrate surrounding tissues and often recur after surgical excision.

The different clinical manifestations resulting from abnormalities of the development of the peritoneovaginal process are reviewed: inguinal hernias, abnormal testicular descent, herniated ovary, hydrocele of the tunica vaginalis, hydrocele of the spermatic cord. The pathogenesis is studied on the basis of the embryology of the vaginal processus. The surgical aspects are discussed.

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

This multicentre trial compared the clinical efficacy of amoxycillin/clavulanate used as a single-agent therapy with that of the three-agent combination usually prescribed in the post-operative period for appendicular peritonitis in children. Only bacteriologically documented peritoneal infections were included. Sixty-four patients were randomly distributed between two groups: Group A (29 cases) treated with amoxycillin/clavulanate, first administered iv (100 mg/kg/day) followed by conversion to the oral route (50 mg/kg/day) once the patient had been afebrile for 48 h; Group B (35 cases) first treated by the iv route with benzylpenicillin (100,000 IU/kg/day) plus netilmicin (5 mg/kg/day) plus metronidazole (30 mg/kg/day) followed by conversion to the oral route for metronidazole (30 mg/kg/day). In both groups, the total duration of parenteral and oral treatment was not less than five days. A total of 180 bacterial strains were recovered from peritoneal fluid samples obtained during surgery; 86% of these were sensitive to amoxycillin/clavulanate. Clinical efficacy, assessed on the basis of time until return to normal temperature and gut transit and duration of hospitalization, was identical in both groups, with follow-up monitoring on day 30 showing recovery in all cases. Cure was obtained without any problems of infection in 25/29 patients in group A and in 34/35 patients in group B (non-significant difference). Tolerance was excellent and identical in the two groups with the exception of three cases of thrombophlebitis which occurred in group B. The results of this study suggest that amoxycillin/clavulanate may be useful as single-agent therapy as a first-line curative treatment for appendicular peritonitis in children.

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

This is a survey of the French South-East Group of Research in Pediatric Surgery (GRECPSE) concerning 18 Solid Adrenal Tumors, observed during a 20-years period (1969-1989) in 11 boys and 8 girls. 13 are tumors of the adrenal cortex (9 adenomas and 4 carcinomas). Clinical virilization is found in 7, cushing's syndrome in 3; while feminizing tumor, Conn's syndrome and non hormone-secreting form are quite exceptional (1 case each, respectively). 5 are adrenal pheochromocytomas (4 benign tumors and 1 malignant with local invasion). Ultrasonography, CT Scan and MIBG Scintigraphy are modern procedures which permit localization of the small and non palpable tumors with high accuracy. They make easier surgical management. Differentiation between benign and malignant tumors of the adrenal glands still remains the main problem. The course of the disease is surely the only distinguishing parameter. However weight tumor and selective histopathological characteristics are useful in predicting the prognosis and behavior of such tumors = Mitotic activity for adrenocortical tumors, extensive areas of necrosis and small cells for pheochromocytomas have the highest discriminating value.

A boy aged 12 years is described who had eosinophilic gastroenteritis, a rare condition in childhood and one that is difficult to diagnose. Eosinophilia in the peripheral blood is a useful diagnostic clue. Although the histological appearances suggest an allergic process, the aetiology is unknown.

Pulmonary blastoma is an exceedingly rare primary neoplasm in the paediatric age group. Pre-operative diagnosis is impossible because of its lack of specificity in clinical and radiological signs. The only diagnosis is the histopathological one. It is a malignant tumor capable of metastasis with a poor prognosis. The best method of treatment is still unknown but at the present time, the only survivals are the result of a complete and early surgical excision. The authors report 2 paediatric cases which have been observed at the hospital of Montpellier (France) for a 20 years period. They try to determine why children's pulmonary blastoma is slightly different from the adults one. They ask the question of histogenesis.

Abdominal tumors in childhood are diagnosed almost always by palpation only, the retroperitoneal localization of these are confirmed by I.V.P. The new gray scale ultrasound machine seem to be very useful in the staging of the masses before the surgical operation. For the correct appreciation of the sensibility of gray-scale ultrasound, 6 Wilm's tumors, 6 neuroblastoma and 1 malignant retroperitoneal fibroma were reviewed. These children were echographied just before the surgical procedure and the surgeon's reports were compared with ultrasonics findings. If the sensibility is good to give measurement of the masse and to establish the situation of the tumor toward the midline of the abdominal cavity, the visualisation of the great vessels was not so obvious. However these hepatic structures were well established in all cases. The renal vein was never seen. At the end of this report it's possible to describe differential echographic findings between Wilm's tumor and neuroblastoma. --A Wilm's tumor is a mass well limited in periphery, confused with the kidney and with a frequent sonolucent rim sign. --A Neuroblastoma is a very irregular tumor well separated of the kidney without sonolucent area in its limit. U.S. made after an I.V.P. is in all cases very useful to surgeons. The two methods with their additional findings make almost always arteriography without interest.

Bronchial atresia of a segment in the lung is a very uncommon cause of pulmonary disorder. The diagnosis is very easy. The plain film is sufficient. Distension of a segment with air trapping during the inspiratory phase with one or more tumor in the hile due to the impaction of mucous secretion of the bronchi above the obstruction. Frequently asymptomatic the revelation is accidental during the evolution of a communal upper respiratory tract infection. The treatment is surgical.

This is the case report of a 13 years old white young girl in whom numerous moving abdominal calcifications are discovered during investigation for chronic anemia. Because of the existence of a severe vascular malformation of the face, a digestive arteriography is performed with no evidence of a calcified angiomatosis of the intestine tract. Preoperative diagnosis was intestinal duplication with enterolithiasis. Exploratory laparotomy confirmed that it was a huge communicating ileal duplication with numerous intestinal calculi and alimentary fragments. Surgical excision was easy and post-operative course, uneventful. This is a standard association but never reported in the pediatric literature. The authors stress on the different diagnosis of calcifications encountered in abdominal X rays in children and on chronic intestinal stasis which is the main factor in enteroliths formation.

Primary malignant tumors of the stomach are rare in children. They are chiefly sarcomas and lymphomas, carcinomas being quite exceptional. Leiomyoblastomas are mesenchymal tumors arising from smooth muscles. Histologic differentiation between benign and malignant leiomatous tumor is difficult. However, an histopathologic grade of malignancy can be assigned to each tumor according to the degree of hypercellularity, nuclear abnormality, mitotic rate, tumor size and invasion of adjacent organs. Moreover, some of these tumors are noted in conjunction with Carney's triad, associated with a pulmonary chondroma and an extra-adrenal para-ganglioma. Pre-operative correct diagnosis is seldom made, although the incidence of gastro-intestinal bleeding and anemia is much higher in smooth muscle tumors than in others. Wide surgical excision must be performed, whenever a chance to completely remove the tumor exists. Gastric resection is well tolerated in children and does not significantly alter the child's normal growth and development. The high risk of local or metastatic recurrence, the chance for a Carney's triad to appear imply a poor prognosis and neccesitate a long follow-up period. We here describe the case of a 15-year-old boy, whose gastric tumor was found on the fact of an important melena and anemia. Gastroscopy showed an ulcerative tumor of the lesser curvature and roentgenogram from a barium study described an important and irregular defect in gastric body with a central ulcer overlying the mass. At operation, the tumor appeared to be unlimited and total gastrectomy was performed. Histologic findings showed an epithelioid leiomyosarcoma with some unfavorable microscopic factors.(ABSTRACT TRUNCATED AT 250 WORDS)

This is a case report concerning an 11 month old young boy with a pyloric duplication resulting in an acute gastric outlet obstruction. Pyloric duplications are rare anomalies of the gastro intestinal tract, usually cystic and few have been reported with pancreatic heterotopia and cytosteatonecrosis. Pathogenesis is quite uncertain. Most of them are discovered in the first year of life, mimicking an hypertrophic pyloric stenosis or resulting in an emergency like our case. The treatment is surgical and must choose between radical excision with sometimes partial gastrectomy or antro-pylorectomy, and incomplete resection because of its benign condition.

Based on their experience and on a review of the literature, the authors study the surgical aspects of the undescended testis. A precise definition excluding the retractile testis is essential. Although the understanding of the pathogenesis remained incomplete, the present data give support to an early orchidopexy performed by a specialized surgeon following the failure of a human chorionic gonadotropin test.