[Stenosis of the upper renal pelvis: rare complication of an incomplete ureteral duplicity. Embryological investigation]. / La sténose du pyélon supérieur : complication rare d'une bifidité urétérale. Enquête embryologique.

A stenosis of the upper pole of an incomplete renal duplication is presented. The prenatal diagnosis of a right renal ureteropyelic junction syndrome, isolated, with a normal amniotic liquid was confirmed at birth. Intravenous pyelogram 8 days after birth showed three right dilated calical groups with a dilated renal ureteropyelic junction, but an normal inferior calical group suspected a renal bifidity. Renal MagIII scintigraphy evaluated the anatomical and functional stenosis and indicated surgery. Postoperative followings were simple and results good 3 years after. From this rare case, embryogenesis is discussed.

[Congenital prenatal hemangioma: diagnosis and treatment]. / Hémangiome congénital à révélation anténatale.

An echogenic tumor (22 x 22 mm) isolated from the anterior part of the left leg at 27 WA of pregnancy suggested an angiomatous structure. This mass appeared to be well vascularized on Doppler examination. Three-dimensional imaging showed connections with adjacent tissues. The limbs were mobile. Delivery of a 3990-g-boy occurred normally. On the anterior part of the left leg, there was a plate-shaped mass with a pink hole at the superior part. Excision under general anesthesia was performed at the first month because of the risk of rupture and bleeding. The dissection was easy with the deep plane. Healing was complete 10 days after the surgical procedure and the aesthetic aspect was good 1 year later. Histological findings of the suspect mass emphasize the vascular aspect of the tumor. A hemangioma capillary with venous structures in the dermal hypodermic area was found.

Anatomical and sonographical studies on the development of fecal continence and sphincter development in human fetuses.

The aim of this study was to specify the sonographic, anatomical and morphological aspects of the fetal anal sphincter and to compare them with pathological and physiological findings. The sphincter was examined by serial sectioning and staining of embryo and fetal tissue and by real-time ultrasound. Its function was analysed using amniotic fluid digestive enzyme assays in cases of anorectal atresia and cystic fibrosis. Morphological findings indicate that the functional components of the anal sphincter do not differentiate before 30 weeks and therefore do not account for the observed anal continence at 22 weeks. Ultrasound measurements of the sphincter indicate three developmental phases: 1) slow growth from 14 to 19 weeks; 2) rapid growth from 19 to 30 weeks; 3) subsequently, no further increase, but contractions indicative of peristaltism. Amniotic fluid digestive enzyme assays indicate that anal sphincter maturation begins with perforation of the anal membrane at 12 weeks. Comparison of pathological cases (anorectal atresia and cystic fibrosis) suggests two possible explanations of fetal anal obstruction: increasing viscosity of digestive secretion or the presence of the three anal sphincter muscles, even if still immature. Our results clarify the evacuation and retention of meconium during fetal life and the role of the terminal part of the digestive tract, notably the anal sphincter. Prenatal diagnosis of anorectal atresia is therefore possible before 20 weeks of gestation by measurement of amniotic fluid digestive enzymes and ultrasonography, thus enabling better neonatal management.

[Role of laparoscopic surgery in the treatment of abdominal pain in children]. / Miesto laparoskopickej chirurgie v liecbe bolestí brucha u detí.

Principal indications of the coelioscopy in pediatric surgery is the laparoscopic appendectomy. In compare with classic techniques it has several advantages but as well as some limitations. During decision about eventual laparoscopic intervention in children is important to take into the consideration personal and material facilities of the unit or hospital for pediatric coelioscopic interventions, their accessibility as well as longer operating time and higher price of the operation. It is amoral to use the laparoscopic appendectomy as a method of teaching surgeon and team to the technique. The authors consider the laparoscopic exploration of the peritoneal cavity with subsequent appendectomy to be a very suitable technique for examination and treatment of pre-pubertal and pubertal girls or young women with chronic or repeated abdominal pain of the uncertain origin, however, its indication in indubitable acute appendicitis of a boy is questionable.

Flexible stable intramedullary pinning technique in the treatment of pediatric fractures.

We report our 12 years' experience with the treatment of 308 fractures of the long bones in children using the flexible stable intramedullary pinning technique (FSIMP). This technique is a simple, rapid, and reliable procedure with minimal complications. It assures correct reposition and sufficient stable fixation of fragments, needs only small incisions, and most of all, allowed early mobilization of a child, thus avoiding long hospitalization and permitting his rapid normal activity and return to the school. The results are very encouraging for children up to age 5 years. The age limit is caused by the volume of the intramedullary space.

[Dorso-ventral gradient of maturation for puborectalis muscle]. / Gradient dorso-ventral de maturation du muscle puborectalis.

Foetal maturation of the skeletal fibers in the anorectal sphincter and in the vesico-urethral sphincter follows a dorso-ventral gradient, in parallel with the development of their motor innervation. The anatomical situation of the m. puborectalis, which early development plays an important role in the establishment of the foetal anal continence, suggests that this muscle should also be submitted to this gradient. We have studied in parallel the development of both the ventral and the dorsal parts of the m. puborectalis in human foetuses aged between 19 and 40 weeks of pregnancy. The results indicate that the transversal thickness of the muscle increases progressively during pregnancy, with a dorsal part being always thicker than the ventral one. More interestingly, the increase in the diameter of the muscle fibers becomes significantly more important at the level of the dorsal part between 25 and 40 weeks of pregnancy. This last result confirms the existence of a dorso-ventral gradient of growth and maturation of the m. puborectalis, as part of the global mechanisms involved in the development of the striated musculature of the pelvic organs.

[Intrication of smooth and striated muscle during the development of the ano-rectal sphincter]. / Intrication de muscle lisse et de muscle strié au cours du développement du sphincter ano-rectal.

The development of the foetal anorectal continence is related to the appearance of the anatomical components of the sphincter. The present study has been carried out in order to analyse the development of the smooth and striated components of the anorectal sphincter, in a series of 7 embryo and foetuses aged from 10 to 40 weeks of pregnancy. Our results indicate that the external sphincter, the puborectalis muscle and the internal sphincter are present before 24 weeks, although they obviously play variable roles in the establishment of the foetal continence. The internal sphincter becomes quantitatively important after 14 weeks, and is likely to be responsible for the establishment of the initial continence. The growth of the striated components during the foetal period corresponds to the maturation of the innervation and of the voluntary mechanisms controlling continence. Intrication of smooth and striated muscle components in the external sphincter starts after the end of the embryonic period. All the anatomical components of the anorectal sphincter are present at birth.

[Embryological study of the mechanism of antenatal lower urinary tract obstruction]. / Obstruction anténatale du bas appareil urinaire: étude embryologique de son mécanisme.

Closure of the embryonic bladder based on the results of the study of 25 human embryos (Crown-Rump length: 5mm-60mm) and 8 Born's reconstructions, is presented. It is a complex but well regulated stage of organogenesis. Division of the cloaca depends on caudal regression, development of the genital tubercle and growth of the urorectal fold which joins the cloacal membrane. The didermal cloacal membrane (composed of the ecto and endodermal layers) opens on its caudal part. On the cranial part, there is a cloacal plug, composed of packed cells, which strengthens the inferior part of the genital tubercle. After progressive vacuolation, this plug is colonized by mesodermal tissue derived from the urorectal fold, which assumes the development of the anterior perineum. This stage depends on cranial growth of the genital tubercle. On a human embryo (31 mm Crown-Rump length, 52 days, 10 Weeks of amenorrhea), the bladder is closed, urachus obturated and urethra patent. The vesico-ureteral junction, and prostatic utricle are present and the colliculus seminalis is well developed. A temporary obstruction (caused by asynchronism between urachus closure and urethral opening) can induce antenatal vesicoureteral reflux which could regress after birth. However if urethral obstruction is definitive (posterior urethral valves or atresia), reflux persists. Antenatal sonographic bladder identification is possible after 10 weeks of amenorrhea with visualisation of the two umbilical arteries by color duplex ultrasound. If the urachus remains patent, it can be visualized inside the arterial umbilical triangle, on a transverse view.

Principal modifications of the Duhamel procedure in the treatment of Hirschsprung's disease. Analysis based on results of an international retrospective study of 2,430 patients.

In the literature, many articles refer to the DUHAMEL technique or some of its modifications in the treatment of Hirschsprung's disease, however, no complete review of all of them has been published to date. The authors present an analysis of the principal modifications of this technique based on the results of an international retrospective survey that evaluated a series of 2,430 patients as well as data from the literature. The important role of the internal anal sphincter in the physiology of continence is emphasized; understanding its function is an imperative prerequisite for a successful Duhamel procedure. The original technique, which used two crushing Kocher clamps as proposed by Duhamel in 1956, as well as a majority of the modifications with various spur-crushing instruments are no longer in use. At present, surgeons generally use staplers for the colorectal anastomosis.

Duhamel operation 40 years after: a multicentric study.

The authors present the results of an international retrospective study evaluating the present situation in using Duhamel's technique or its modifications in the treatment of Hirschsprung's disease on the basis a series of 2430 patients. After evaluation of all important criteria and discussion with data from the literature it is concluded that the techniques is simple, fast, less shocking, logical, reliable, respecting the rectal anatomy and physiology, ingenious in its principle, without serious complications. The rectum is preserved in place with all its vascular drainage and innervation. This technique can be performed by every sufficiently experienced surgeon.

Incarcerated umbilical hernia in children.

Over a period of 5 years, four cases of incarcerated (one strangulated) umbilical hernia (UH) in children were observed and treated in Saint-Denis, France. In a review of the literature, only 45 descriptions of complicated UHs in children were found worldwide. Incarceration of UHs is considered to be very rare in children, however, it appears to occur more frequently than it is generally believed. Therefore, a more active therapeutic approach is recommended even in smaller hernias, from more than an aesthetic point of view.

Fracture of the femoral shaft in children: advantages of the descending medullary nailing.

In a 7-year period, 70 children aged 5-15 years (mean 9.2 years) were treated for a fracture of the femoral shaft (73 fractures: 71 closed and 2 open) by flexible medullary nailing, either ascending (12 cases) or descending (61 cases). Although the classic treatment is use of the ascending route described by the Nancy team, the subtrochanteric descending route was preferred for its simplicity. Noninvolvement of the knee by the insertion of the nail allows earlier autonomy in children. Results were satisfactory and no complications related to the method were observed. Biomechanical principles are also respected by such treatment.

[Replacement continent bladder in dogs by opening an antro-pyloric graft onto the abdominal wall (seven cases between 1980 and 1983)]. / Etude d'une vessie continente de remplacement chez le chien par ouverture à la paroi abdominale d'un greffon antro-pylorique (sept cas réalisés de 1980 à 1983).

To determine the usefulness of antral bladder controlled by the pyloric sphincter denervated for urological applications, bladder replacement was performed in 17 dogs using the antral segment with its own sphincter, initially with the pylorus supplied by the left gastro-epiploic artery, and later by the right gastro-epiploic artery. The smooth pyloric muscle was denervated to obtain permanent spasm and pulled through the striated anterior abdominal muscle. Both ureters were anastomosed by a Cohen's procedure. The best results were obtained with a gastric pouch supplied by the right gastro-epiploic artery; dissection and reimplantation of the ureters in the gastric wall are difficult. IVP and cystography indicated good function of the antral pouch, with no reflux. The antral bladder controlled by the denervated pyloric sphincter could be a possible alternative in the surgical management of neurogenic or exstrophic bladder.

[Constipation in children. Value of anorectal sphincteromyectomy]. / Constipation de l'enfant. Intérêt de la sphinctéromyectomie anorectale.

Anorectal sphincteromyectomy is a suitable answer to the problem of the chronic constipation in childhood. It took a long time to be recognized beside others methods as biofeedack. This surgical procedure has been described for the first time by B. Duhamel in 1965; we still remained faithful and proud of this idea. We wanted to understand and to explain the basis of the conception of anorectal achalasia. Several works about the fetal development of the anorectal sphincter tried to explain it. A good exposition makes the technique less difficult and the dissection of the internal sphincter easier. We have analysed our 22 recent children. In 21 cases, we noticed a good result. The histological study of the fragment of the myomectomy showed a normal cytology of the smooth muscular tissue, a normal intrinsic innervation and arterial vascularisation. The surgical procedure is efficient because it relieves the functional disorder of the internal anal sphincter. It is a mechanical action; the external sphincter finds again its normal function, or is allowed to be reeducated.

Arterial vascularisation of the extrahepatic biliary tract.

The aim of this study was to establish a plan of the arterial distribution to the main supraduodenal biliary tract in order to draw practical conclusions for biliary surgery, especially in bilio-alimentary and bilio-biliary anastomoses and liver transplantation. It was based on a study of 60 fresh subjects and was carried out using four different methods: dissection after injection of colored latex into the superior mesenteric a. (10 subjects), radiography and dissection after injection of Micropaque into the celiac trunk (10), dissection after injection of Indian ink into the common hepatic a. (10) and radiography and dissection after selective injection of the right hepatic a. or the gastroduodenal a. (30). Analysis of the results leads to definition of three types of vascularisation and two territories, superior and inferior, overlapping at the level of the mouth of the cystic duct. The practical implications for biliary surgery and liver transplantation are discussed.

[Appendicitis in children]. / L'appendicite de l'enfant.

In 1992, appendicitis is still common among children. Mortality due to a belated or erroneous diagnosis is far from being nil. The disease must always be present in the clinician's mind, and its diagnosis is purely clinical. No significant advance has been made on this subject, and clinical findings remain of paramount importance. Hospitalization for observation at the slightest doubt and emergency surgery when the diagnosis is probable are the best means of improving the management of appendicitis in children.

Fetal development of the urethral sphincter.

A morphological study was carried out on 25 human embryos (3-60 mm CR) and 20 human fetuses (15-40 weeks). The anatomical analysis was completed by immunocytochemical studies of different markers of muscle differentiation (vimentin, desmin, titin and isoforms of the myosin heavy chains). A mesenchymal condensation forms around the urethra after the division of the cloaca (E.H. 12-15 mm CR). The m. pubo-rectalis appears in 20-30 mm CR embryos, following the opening of the anal membrane. Striated muscle fibers can be clearly differentiated at 15 weeks. At this time, the smooth muscle layer also becomes thicker at the level of the bladder neck and forms the inner part of the urethral musculature. The urethral sphincter is a functional unit composed of central smooth muscle fibers and peripheral striated muscle fibers. In the human fetus, this musculature mainly develops in the anterior wall of the urethra. We analysed the expression of smooth and skeletal markers as an original approach to the muscular development in this region.

Fetal development of the pyloric muscle.

The fetal development of the pyloric muscle was studied in five human embryos (crown-rump length 5 to 31 mm) and in ten fetuses aged 3 to 9 months. Samples of pyloric muscle were obtained during operation for pyloric stenosis in two infants aged six weeks. Anatomo-radiologic, morphologic and immunohistochemical studies were made on this material, from which it emerged that the pylorus is identifiable by means of specific markers from the 40th day. Its two-layered muscular structure is described in detail. The mechanism of sphincteric function is reviewed. This study assumes clinical importance in the context of the etiopathogenesis of hypertrophic stenosis of the pylorus.

[Fracture of the femoral shaft in children. Ascending or descending medullary nailing? A choice of principle or necessity?]. / Fracture de la diaphyse fémorale chez l'enfant. Embrochage centro-médullaire ascendant ou descendant? Un choix de principe ou de nécessité?

Over a period of 4 years, 40 children between the ages of 6 and 14 years (mean: 10 years) were treated for a fracture of the femoral shaft (39 closed fractures and 1 Cauchoix type I open fracture) by flexible medullary nailing, either ascending (5 cases) or descending (35 cases). Although it is classical to use the ascending route described by the Nancy team, the sub-trochanteric descending route was preferred for its simplicity; non-involvement of the knee by the insertion of the nail allows earlier autonomy in children. The results have been found to be satisfactory; no complications related to the method were observed. The biomechanical principles are also conserved.