Biliary Lithiasis with Choledocolithiasis in Children.

Although biliary lithiasis has been considered a less common pathology in the pediatric population than in adults, in recent years, it has increasingly been diagnosed in children, with a prevalence of between 0.13 to 0.22. The elective treatment of symptomatic biliary lithiasis is cholecystectomy, the laparoscopic approach being considered the œgold standard. We present 3 cases referred to our clinic with biliary lithiasis, in which we performed laparoscopic cholecystectomy. We performed intraoperative cholangiography with a 4 Fr transcystic catheter. In the first case, the cholangiography showed a dilated CBD, without obstruction. Considering the patient'™s history, with recurrent episodes of choledocal lithiasis, we decided to perform a transcystic drainage. In the second case, cholangiography showed a normal CBD and no obstruction. In the third case cholangiography could not be performed due to technical issues. In all cases we performed retrograde laparoscopic cholecystectomy. The postoperative evolution in all cases was favorable. Studies conducted in the last years showed that laparoscopic cholecystectomy is a safe and efficient approach in the management of symptomatic biliary lithiasis in the paediatric age group. The management of choledocolithiasis is still not well defined: perioperative ERCP with ES, intraoperative cholangiography or intraoperative ultrasound were proposed as options in exploring the biliary tree.

Osteosynthesis in Osteogenesis Imperfecta, telescopic versus non-telescopic nailing.

The paper refers to a pediatric patient suffering from Osteogenesis Imperfecta that was diagnosed soon after birth, after suffering from an intrauterine fracture of the femur in the 7th month of pregnancy. The beginning of the presentation contains some general considerations regarding the illness and the treatment done up to the point when the first telescopic rod was used. Following the evolution of the child from birth to the age of 7 years, we could trace a line of evolution under several methods of treatment, surgical or conservative, and also on different surgical treatment variants and their outcome during growth. Together with the X-rays that documented each step of the treatment, we could affirm for sure that both clinically and radiologically, the best results were obtained after the last 4 interventions, when all 4 major bones of the lower limbs were operated on. Until the moment Fassier-Duval nails were used, the evolution of the illness and the complications that appeared after certain surgery procedures were not so good. Several procedures had to be revised because of nail or pin displacement and eventually the patient lost the walking capability. The main problem with non telescopic treatment was the lack of stability that the bone needed to have after an open surgery for deformity correction, and up to that moment, the methods used were not designed to work on the long term; even in the best circumstances, the patient had to go to the OR for nail replacement after the bone outgrew it.

Early telescopic rod osteosynthesis for Osteogenesis Imperfecta patients.

Osteogenesis imperfecta is a genetically determined pathology that implies bone variability and osteoporosis with early onset of fractures after low energy trauma. For a better understanding of the clinical problems, Sillence and Danks created a classification. The study group consisted of 12 patients both males and females, with ages ranging from 2 years and 3 months to 12 years. All of them came to the hospital late, after walking, after several fractures occurred and the only treatment they underwent was with prolonged cast immobilization that caused rapid bone demineralization, axial deformations of the affected bones, increased number of fractures and eventually loss of ambulation. Following the discharged patients, we appreciated that the open bone alignment and Fassier Duval osteosynthesis were the best way to treat a patient with Lobstein disease. The results showed that by using these two techniques a lot of time is saved on a long term because all the great complications associated with older techniques are gone and a rapid ambulation is possible due to the soft tissue damage that is kept to a minimum.

Complex malformation of the inferior vena cava.

Malformations of the inferior vena cava (IVC) are rare presentations, exceptional in children, and are usually asymptomatic.They are caused by disturbances in the embryological formation of the venous system or can develop as a result of perinatal venous thrombosis with secondary impairment of the venous development. We report the case of a 14 year old boy,admitted for pediatric evaluation before undergoing plastic surgery in order to remove superficial varicose veins of the lower abdomen. The patient presents with inequality in circumference and length of the legs. Laboratory investigations are normal and the abdominal ultrasound describes hypoplasia of the retrohepatic segment of the inferior vena cava. The diagnosis of complex malformation of the abdominal deep venous system (retrohepatic vena cava atresia, cavo-caval anastomosis through azygos veins, abnormal formation of the inferior vena cava with the absence of the left iliac vein) was established through a CT angiography. The presence of abdominal varicose dilations should indicate the necessity to closely look for malformations of the portal and/or caval venous systems.

Associated type IIIB and type IV multiple intestinal atresia in a pediatric patient.

Multiple intestinal atresia (MIA) is a complex congenital defect which represents a challenge for the pediatric surgeon,especially in the rare event of encountering type IIIb or apple peel atresia, which has a high mortality rate. The surgeon's aim is to preserve as much bowel length as possible, to avoid postoperative sepsis and to prevent long-term complications such as short bowel syndrome. Access to a good neonatal intensive care unit and to parenteral nutritional support is crucial in the survival of these children. We report a rare case of multiple intestinal atresia associated with an apple peel atresia, which was managed by multiple intestinal resections and anastomosis without the placement of transanastomotic tubes or stomas.

Clinical and surgical aspects in necrotizing enterocolitis.

BACKGROUND: The purpose of the paper is to establish whether clinical and radiological parameters can predict the progression of the pathology, the necessity of performing laparotomy for patients with peritoneal drain and the mortality in surgically treated neonatal necrotizing enterocolitis patients. MATERIAL AND METHODS: A number of 51 cases with necrotizing enterocolitis from our institution were reviewed (from 2005 to 2011) and information on patient demographics and data about the clinical and radiological parameters was collected. RESULTS: Of the 51 patients, 29 were (56.8%) males and 22 (43.2%) females. Age at presentation ranges between 1 and 87 days, with a mean 18.71 days. Birth weight varies between 400- 4700g (mean 1979.6 g ± 1012.5). The mortality rate in our study was 45% (23 patients out of 51). CONCLUSIONS: The mortality rate in our series was 45%. Even though Bell stage III patients have clear indications for surgery, the procedure involves high fatality. Patients who undergo surgery are more likely to die than the ones who do not. We found that a later debut of symptoms should be an alarm sign for both the severity of the condition and for its outcome.

Neurovascular abnormalities in Gartland III supracondylar fractures in children.

The most common elbow injuries in pediatric trauma practice are supracondylar fractures of the humerus. Posteriorly displaced fractures may be angulated or displaced medially or laterally with associated internal or external rotation. We compared two groups of patients, each with grade III supracondylar fractures after Gartland. The goal of this study was to see if reduction and pinning maneuvers create neurovascular abnormalities and if there are any differences in terms of neurovascular consequences for reducing grade III Gartland supracondylar fractures of the humerus using reduction in supination or pronation of the forearm. We formed two study groups based on the reduction method used. Concretely: patients who needed reduction in pronation were included in the first group and patients who needed reduction in supination were included in the second group. Patients were added to each group until every group reached 40, to have equal and comparable groups. No statistically significant differences on clinical outcome and neurovascular complications appeared between the two methods of closed reduction. We can say that both methods used are correct.

Anomalies associated with anorectal malformations.

BACKGROUND: The purpose of the paper is to review the incidence of associated congenital anomalies that are encountered in patients presenting anorectal malformations and compare these results with those previously published. MATERIAL AND METHODS: A number of 50 cases with ARM from our institution were reviewed (from 2005 to 2012) and information was collected on patient demographics, type of ARM and associated congenital anomalies, the latter being then categorized according to organ systems. RESULTS: Out of 50 newborns, 28 were males and 22 females (1.27:1). 34 (68%) had at least one associated abnormality. The majority of patients (40%) had imperforated anus without fistula. The most frequent seen anomalies were gastrointestinal (36%), urogenital (24%) and cardiovascular (16%). CONCLUSIONS: More than half of the children included in our series have other associated abnormalities. We found gastrointestinal anomalies to be the most common associated congenital defects in our patients. A higher incidence of this type of anomalies was encountered in newborns with persistent cloacal anomaly. The rectovestibular fistula group was most likely to present cardiac abnormalities. The incidence of genitourinary anomalies in the perineal fistula group is higher than the one described in other studies.

Use of minimally invasive (percutaneous) Fassier-Duval telescopic rod on an 8 year old patient with Lobstein disease.

Lobstein disease is a severe disease characterized primarily by bone fragility which causes numerous fractures, especially in long bones. Multiple fracture of a bone will cause in time a deformity with consecutive functional impotence. The treatment for Lobstein disease in children must take into account both increasing bone strength and fracture prevention and treatment of possible fractures. Regarding the choice of synthesis material, in children, there are many constraints related to the small size of the bones, presence of growth plate and the risk of periosteal blood supply infringement. Currently, for the long-term fixation of long bone fractures in children, telescopic Fassier Duval rods are used, allowing reinforcement throughout growth. In this article we present an 8 years old patient, with a femoral fracture and Lobstein disease, who underwent initial intramedullar fixation with a Kirschner pin which was subsequently replaced by a Fassier Duval telescopic rod. Mounting the telescopic rod was performed minimally invasively through a technique improved in our service. We believe that this method can be applied in all cases where other types of fracture stabilization was used, and to ensure straightness of the medullar canal.

Intestinal occlusion through extrinsec stenosis of transverse colon associated with internal right mesocolic hernia.

RATIONALE: The incidence of malrotation has been estimated at 1 in 600 live births. An increased incidence of 0,2% has been found in barium swallow studies, whereas autopsy studies estimate that the true incidence may be high as 1% of the total population. The clinical manifestations are elusive; therefore, the diagnosis must be based on the presence or absence of the acute obstruction. Radiologic investigations, especially those using contrast substances, are the ones used most often in the diagnosis of malrotation. Laparoscopy may give the clinician a valuable tool that will help him diagnose the rotational anomalies and correct the potentially obstructing lesions with minimal surgical trauma to the patient. The role of the surgical treatment is to prevent volvulus and to treat any kind of obstruction. Ladd's procedure provides all the elements for reaching this goal. OBJECTIVE: The following report describes a particular case of one female patient, 8 years old, admitted in our clinic with signs of intestinal obstruction. She had similar episodes in the last three months, but the symptoms had resolved spontaneously. METHODS AND RESULTS: Upper gastrointestinal series showed an anomaly of rotation and barium enema discovered a tight stenosis on the transverse colon. Emergency surgery using laparotomy enabled diagnosis. Intraoperatively, a right mesocolic hernia and a transverse colon extrinsic stenosis due to abnormal peritoneal attachments were noted. DISCUSSION: Colon obstruction due to peritoneal bands is extremely rare. The clinical manifestations are not specific and we need radiologic procedures to help diagnose the disease. The cause of the obstruction is not always evident despite the availability of modern imaging techniques. Since preoperative diagnosis is difficult, morbidity and mortality can be decreased by an early surgical intervention.

A new case of lower extremity glomus tumor up-to date review and case report.

Glomus tumor (glomus cell tumor) is a rare, hamartomatous, usually benign neoplasm, whose cells resemble the modified smooth muscle cells of the normal glomus body. The diagnosis of a lower extremity is often delayed, due to the lack of awareness and low level of suspicion, by the treating physician. The glomus tumor (GT) often involves the nail beds. The unusual location of the lower extremity often leads to missed or delayed diagnosis and management. There is a paucy of information about GT in general, especially among orthopedic surgeons. The aim of this article is to make the surgical community more aware of this disease.

The modern treatment of the simple bone cysts.

This study was performed between 2007-2012 and encompasses 94 patients. The patients were divided in two groups. The first group included the patients who have benefited from surgical treatment (42 cases) and the second one included patients who benefited from conservative treatment. Out of the total number of cases, 63 cases showed an intact simple bone cyst that was most of the time an accidental discovery. 31 patients presented with fracture sustained on a simple bone cyst. There were 63 boys and 31 girls. Their mean age was 9.9 +/- 2.34 years. Single injection was performed for 49 patients; the rest had double or triple injections. The mean follow-up was 34.5 +/- 6.6 months. The procedure succeeded in obtaining healing in 77 cysts (82%). Cyst index of more than five and cortical index of less than 1 mm were significantly prone to pathological fractures and had significant poor results after treatment. Our results suggested that an autogenous bone marrow injection is a safe and effective treatment method for simple bone cysts, when compared with the surgical management, but sometimes-repeated injections are necessary. Cyst index and cortical width are good indicators for treatment outcome.

[The diagnosis and surgical treatment in the case of 2 rare sites of hydatid cyst in children]. / Diagnostic si tratament chirurgical în cazul a 2 localizari rare de chist hidatic la copil.

In the Clinic of Paediatric surgery of the Hospital "Gr. Alexandrescu" there have been hospitalized and operated 2 cases of hydatic cyst within 1990-1993. The both patients had tumoural structures, one of them being placed on left axillary area (S.E.--11 years old) and the other on the left thigh (M.S.--5 years old). The both patients have been surgically operated, the said tumoural structures being eradicated. The anatomic-pathological examination attested that for the both patients the diagnosis was the hydatic cysts are localized on pulmonary, hepatic or splenic areas, we considered to be interesting to inform you about details of two rare localization of this disease.

[Adrenal tumors in children]. / Tumorile suprarenale la copil.

11 children (age 2-14 years) with adrenal tumors were treated between 1988-1995. 7 patients had adrenal cortical tumors (2 adenomas and 5 carcinomas) while 4 patients had medullar tumors (3 pheochromocytomas and 1 sympathoblastoma). Clinically, 3 patients presented Cushing syndrome, 4 had adreno-genital syndrome and 3 had paroxysmal tachycardia and hypertension. The surgical treatment consisted in adrenalectomy using a transverse incision in the right or left hypochondrium (Bazy).