An easy-to-follow algorithm to improve pre-operative diagnosis for appendicitis in children.

GOAL: To evaluate physician compliance with use of a diagnostic algorithm for appendicitis in children. Our secondary objective was to determine the impact of the algorithm on diagnostic accuracy and morbidity. METHODS: We conducted a clustered randomized trial in eight centers. A total of 866 patients were included and, depending on the period of randomization at particular centers, 543 patients were managed before the formal institution of the diagnostic algorithm; their diagnostic management was compared to that of the subsequent 323 patients. RESULTS: There was a 29.1% mean increase in the use of imaging studies included in the algorithm after algorithm set-up, rising from 50.8 to 79.9% (P<0.02). When we used a composite endpoint of "poor results" (grouping patients with incorrect diagnoses and/or post-operative complications), no statistically significant difference was found between the two periods (85/543 (15.6%) before vs. 45/323 (13.9%) after set-up, P=0.5). But when the number of incorrect diagnoses of appendicitis made without the use of the algorithm was compared to that of patients who took advantage of the algorithm, the difference was highly significant (67/332 [20.2%] vs. 63/534 [11.8%], P<0.001), and the rate of unnecessary appendectomy decreased from 11.9 to 5.3% (P<0.01). CONCLUSIONS: Our diagnostic algorithm improved the adherence to good practice for the diagnosis of appendicitis in children, reducing the rates of unnecessary appendectomy and morbidity. This strategy, combining laboratory tests and imaging, should permit pediatric surgeons to adapt their therapeutic approaches to specific cases.

[Impact of the acquisition of a flexible ureteroscope on the management of upper urinary tract stones in children]. / Impact de l'acquisition d'un urétéroscope souple sur le traitement des calculs du haut appareil urinaire chez l'enfant.

INTRODUCTION: Firstly reported in the early 1990s for the treatment of upper urinary tract stones in adult patients, flexible ureteroscopy (F-URS) has been used in children during the past 10 years and is now considered as a viable, but still second-line alternative to extracorporeal shockwave lithotripsy in these patients (ESWL). The aim of this study was to assess the impact of the acquisition of a F-URS on the management of upper urinary tract stones in children. PATIENTS AND METHODS: Data of all ESWL, F-URS and percutaneous nephrolithotomy performed for upper urinary tract stones in children from 0 to 18 years old in a single center from 2000 to 2014 have been collected retrospectively. Patients have been divided into two groups: group 1 before the acquisition of the F-URS (2000-2008) and group 2 after the acquisition of the F-URS (2008-2014). Preoperative data and peri-operative outcomes were compared between both groups using the χ(2) test and Fisher exact test for discrete variables and the Mann-Whitney test for continuous variables. RESULTS: Thirty-seven children have been treated during the first era and 32 during the second one. The two groups were similar in terms of age (7.2 years vs 8.1 years; P=0.54), size of the largest stone (15 mm vs 16.2mm; P=0,56) and number of stones per patient (1.4 vs 2; P=0,07) but the sum of stone diameters was higher in group 2 (16.9 mm vs 24.2mm; P=0,048). The stone-free rates were comparable in both groups (28.1% vs 32.2% after the first procedure; P=0.72), as were the mean number of procedures per patient (2.4 vs 2.5; P=0.78), the total length of stay (2.7 days vs 2.9 days; P=0.77), and the number of patients who experienced at least one complication (37.8% vs 40.6%; P=0.87). CONCLUSION: The acquisition of a F-URS allowed the treatment of more complex stones with a similar efficacy and without increasing morbidity. Further studies are needed to define the role of F-URS in the management of upper urinary tract stones in children.

Preliminary experience with the use of an autologous platelet-rich fibrin membrane for urethroplasty coverage in distal hypospadias surgery.

OBJECTIVE: Platelet-rich fibrin (PRF) has been shown to have structural and biological properties that promote tissue healing. This prospective study evaluated the feasibility, safety, and efficiency of using autologous PRF membrane for urethroplasty coverage in distal hypospadias. MATERIALS AND METHODS: We prospectively included 33 patients with distal hypospadias operated on between June 2010 and September 2011. Urethroplasties were performed using the Duplay technique. During surgery, 5-10 ml of patient's blood was collected and immediately centrifuged. A PRF clot was transformed into a dense fibrin membrane with a particular cell content and architecture. This membrane was applied and sutured over the urethroplasty. The perioperative course and complications were recorded. Outcomes were compared with those in a control group of children undergoing the same procedure, but with another mean of coverage. RESULTS: With a median follow-up of 8 months (range, 6-18 months), urethral fistula occurred in 2/33 patients. No other complication was noted. No complication related to the blood sampling was reported. There was no statistically significant difference with the control group (p = 0.65). CONCLUSION: The PRF patch seems to be a safe and efficient covering technique. Thus, procedure is an additional approach to coverage for hypospadias surgery, and may help to reduce the incidence of postoperative complications when coverage healthy tissue is not available.

Long-term evaluation of respiratory status after esophageal atresia repair.

RATIONALE: Esophageal atresia (EA) is a congenital malformation. Nowadays, its initial prognosis is excellent thanks to improvements in neonatal and surgical management. However, the assessment of long-term respiratory outcome has become necessary in affected children and was thus performed in this study. The benefits of cardiopulmonary function testing were also examined. METHODS: The medical records of 77 children operated on for EA between 1990 and 2004 were reviewed. The results of respiratory function testing and cardiopulmonary response to effort were collected, together with neonatal and anthropometric data. RESULTS: Acceptable measurements were obtained in 31 children with EA. These children were comparable to the ones lost during follow-up. The results of pulmonary function tests (PFTs) were abnormal in 21 cases (68%). A poor ventilatory response was detected in 14 children (45%) by cardiopulmonary function testing. Ten children who had abnormal results on PFTs were not under any anti-asthmatic treatment. CONCLUSIONS: Impaired lung function was noted in children with repaired EA. Indeed, cardiopulmonary function tests results correlated with standard spirometric parameters and revealed minimal clinical symptoms. Moreover, many children with EA had a limited ventilatory reserve (VR). These results indicate that respiratory symptoms are often neglected in children with repaired EA and reinforce the need to provide adequate treatment.

Technical problems and complications of a transanal pull-through for Hirschsprung's disease.

BACKGROUND: The purpose of this study was to evaluate the technical difficulties and complications of a transanal pull-through for Hirschsprung's disease. MATERIAL AND METHODS: This report was based on a multicentric retrospective study of 65 cases. Pull-through procedures were transanal Swenson or Soave procedures in 26 and 39 cases, respectively. RESULTS: Evaluation of the aganglionic level, peri-rectal dissection, and anastomosis were the three steps in the procedure where surgeons encountered difficulties. Such difficulties led to serious complications in 3 cases. A patient with a colon biopsy before the pull-through procedure had a postoperative pneumoperitoneum requiring a second laparoscopy for suture and washing. Another patient had peritonitis due to anastomotic leakage. Finally, a difficult rectal dissection in a neonate led to a urethral injury requiring secondary urethral repair. Only 41 of the 65 patients had no abdominal scars (63 %). CONCLUSION: We considered the transanal pull-through for Hirschsprung's disease to be a reliable technique. Nevertheless, it requires an urethral stent, precise dissection, careful anastomosis and selected indications in order to avoid major complications.

Haemodynamic effects of propofol vs thiopental in infants: an echocardiographic study.

Rapid i.v. induction of general anaesthesia is indicated in infants at risk of vomiting or regurgitation to reduce the risk of aspiration of gastric contents. Propofol is an alternative to thiopental in infants, and we have compared cardiovascular changes when propofol or thiopental was used for induction of anaesthesia in infants. Twenty infants, ASA I or II, aged 1-11 months, undergoing elective surgery were allocated randomly to receive either thiopental or propofol for i.v. induction. Cardiovascular and echocardiographic data were recorded in both groups before, during and for 5 min after induction of anaesthesia. Doses required to induce anaesthesia in each group were mean 10.3 (SD 0.9) mg kg-1 of thiopental and 6.1 (0.6) mg kg-1 of propofol. Thiopental did not alter significantly systolic or mean arterial pressure, afterload indices, rate-corrected velocity of circumferential fibre shortening or cardiac index, but decreased shortening fraction at 1 and 5 min after induction compared with awake values. Propofol did not alter heart rate, shortening fraction, rate-corrected velocity of circumferential fibre shortening or cardiac index at 1 and 5 min after i.v. induction compared with awake values. After induction, systolic and mean arterial pressures and afterload indices decreased more after induction with both agents, but did not become abnormal. Thus propofol decreased arterial pressure more than thiopental because of an effect on afterload. Cardiac output remained unchanged with both agents.

Comparative hemodynamic depression of sevoflurane versus halothane in infants: an echocardiographic study.

BACKGROUND: The cardiovascular side effects of volatile anesthetics are one of the chief causes of postoperative complications in children, and infants seem to be at the greatest risk for this. This study compared cardiovascular changes at equipotent concentrations of sevoflurane and halothane in infants. METHODS: Thirty infants classified as American Society of Anesthesiologists physical status I or II who required elective surgery were randomized to receive either halothane or sevoflurane for inhalation induction. Cardiovascular and echocardiographic data were recorded in both groups at baseline and at end-tidal concentrations of 1 and 1.5 minimum alveolar concentration (MAC). RESULTS: Sevoflurane did not alter heart rate or cardiac index at all concentrations compared with awake values. Sevoflurane significantly decreased blood pressure and systemic vascular resistance compared with awake values at all concentrations. Shortening fraction and rate-corrected velocity of circumferential fiber shortening decreased at 1.5 but not at 1 MAC. Myocardial contractility assessed by stress-velocity index and stress-shortening index decreased significantly at all concentrations, but did not fall into the abnormal range at any concentration. Halothane caused a greater decrease in heart rate, shortening fraction, stress-shortening index, velocity of circumferential fiber shortening, stress-velocity index, and cardiac index at all concentrations than did sevoflurane. CONCLUSION: Sevoflurane causes a lesser decrease in cardiac output than does halothane in infants.

[Total colonic form of Hirschsprung disease. Treatment and long-term follow-up in 16 cases]. / Forme colique totale de la maladie de Hirschsprung. Traitement et suivi á long terme á propos de seize cas.

From 1971 to 1994, 16 cases of total colon Hirschsprung's disease were treated at the University Hospital in Rennes. Diagnosis have been at 2 days to 3 months. Two children had a family history of Hirschsprung disease among which one associated megacolon and multiple endocrine neoplasia. This family had a mutation of the RET proto oncogene. Six children died before complete surgical cure, among whom 4 before total parenteral nutrition. Six were treated according to Lester Martin, 3 according to Duhamel, and 1 to Swenson. Diarrhea and occlusions happened during the first postoperative years. None had any enterocolitis. Eight of 9 followed children are continent. Technique had no influence on long term outcome. Early neonatal occlusion management seems to decrease enterocolitis's incidence. We abandoned Lester's technique and kept Duhamel's technique. The problems encountered during ileostomy period do not encourage us to forward the age of definitive surgery procedure.