Is non-operative management of severe blunt splenic injury safer than embolization or surgery? Results from a French prospective multicenter study.

PURPOSE OF THE STUDY: The management of the severe blunt splenic injuries remains debated. The aim of this study is to evaluate the morbidity and mortality of splenic injury according to severity and management (surgery, embolization, non-operative management [NOM]). METHODS: A prospective multicenter study was conducted including patients aged 16 years and older with diagnosed splenic injury. We evaluated severity according to the AAST classification, the presence of hemoperitoneum or a contrast blush on initial CT scan. The initial hemodynamic status, patients co-morbidities, the ISS (injury severity score), management and morbidity were also noted. RESULTS: Between May 2010 and May 2012, 91 patients were included. Thirty-seven patients (41%) had mild splenic injury (AAST I or II and a small hemoperitoneum) while 54 patients (59%) had severe splenic injury (AAST III or greater). The management included 18 splenectomies (20%), 15 embolizations (16%). Among 67 patients undergoing NOM without initial embolization, five (7%) developed secondary bleeding, five required surgery and nine underwent secondary embolization. No patient died and morbidity was 44% (n=40), 13% for mild injuries vs. 65% for severe injuries (P<0.01). For severe injuries, total morbidity was 58% after NOM, 73% after embolization and 70% after surgery. Specific morbidity related to the management was 10% after NOM vs. 47% after embolization (P=0.02). Specific morbidity after surgery was 15%. CONCLUSION: Embolization, because of its important specific morbidity, should not be performed as a prophylactic measure, but only in presence of clinical or laboratory signs of bleeding.

A case of primitive floor of the mouth paraganglioma in a child: an embryological theory unifying viscerocranium appended paragangliomas.

BACKGROUND: Paragangliomas are unusual tumors in the head and neck originating from the paraganglia or glomus cells of neural crest origin. METHODS: We describe the first case of a primitive paraganglioma of the floor of the mouth presenting in childhood. RESULTS: Complete surgical removal was performed after embolization of the left lingual artery. There was no evidence of either persistent or recurrent disease 5 years after surgery. The embryologic and anatomic origins of head and neck paragangliomas are reviewed. CONCLUSIONS: An embryologic theory based on the common neural crest origin and migration pathways of both autonomic viscerocranium appended ganglias and paragangliomas is proposed that unifies the topographically heterogeneous group of viscerocranium-appended paragangliomas.

Abdominal dermolipectomies: early postoperative complications and long-term unfavorable results.

A retrospective study was done on a population of 258 women who had undergone surgery for abdominal dermolipectomy between January of 1991 and May of 1996. The postoperative complications and flaws seen at long-term follow-up are discussed. The surgical techniques used, with or without lipoaspiration, were the infraumbilical plasty and full plasties with horizontal or inverted T scars. Six types of postoperative complications were noted: hemorrhage in 1.2 percent, lymphorrhea in 10.9 percent, infection in 7 percent, skin necrosis in 6.6 percent, secondary dehiscence of the scar in 2.3 percent, and thromboembolic accidents in 1.2 percent. No significant difference was found in the rate of necrosis development between patients who did and did not undergo lipoaspiration. However, a statistically significant difference was seen in the rate of skin necrosis between the T-type plasty (35.5 percent) and the other two procedures (1.43 percent for infraumbilical plasties and 4.60 percent for full plasties with horizontal scar). With regard to the flaws found at long-term follow-up, the rate of above-scar fat folds and/or dog-ears was 27.9 percent, and the rate of defective scars was 26 percent. No significant difference was found with regard to the rate of flaws. The rate of all secondary surgical procedures was 29.1 percent, but performance of secondary procedures depended on the willingness of the patient and on the surgeon's judgment. Abdominoplasty procedures involve a high risk of early complications. The rate of skin necrosis is clearly augmented in cases of T-type plasty. The need for secondary surgical correction is frequent, and the patient should be reminded of this possibility during preoperative consultation.

[The importance of early surgery in preventing the esthetic sequelae of cervicofacial mucocutaneous hemangiomas in children]. / Intérêt de la chirurgie précoce dans la prévention des séquelles esthétiques des hémangiomes cutanéo-muqueux cervico-faciaux de l'enfant.

Infants with cutaneous hemangiomas are classically managed medically, well-defined surgery being planned for esthetic correction at the age of 8 to 10 years. We present a series of 65 cases of early surgery in children with head and neck cutaneous or mucosal hemangiomas where irreversible and unesthetic scars were predictable. The surgical procedure was simple and the cosmetic result was better than could be expected after late surgery, limiting psychological consequences. In our opinion, the abstention rule should be changed. A multidisciplinary check-up at 2 years to identify cases with a predictably unesthetic scar after complete resolution of the angioma would help select cases where early surgical correction, taking advantage of the exceptional quality of skin in these young children, would be most beneficial.

Two unusual tumors in a patient with xeroderma pigmentosum: atypical fibroxanthoma and basosquamous carcinoma.

Xeroderma pigmentosum (XP) is a rare autosomal recessive disease, characterized by a genetic defect in DNA repair. The consequence is a high incidence of skin cancers on sun-exposed cutaneous surfaces of affected children. First lesions appear in the first years of life: telangiectasia, actinic keratosis and keratoacanthomas. Squamous cell and basal cell carcinomas are the most frequent neoplasms. We report the case of a 6-year-old girl affected with XP, who developed two unusual tumors: an atypical fibroxanthoma and a basosquamous carcinoma. In both tumors, immunohistochemical study showed abnormal accumulation of the p53 protein, suggesting the presence of mutation of the p53 tumor suppressor gene. Such p53 mutations may be ultraviolet (UV)-induced, as they are frequently observed in tumors occurring in XP.

Description of cutaneous excision and suture using a mathematical model.

Mathematical models are being developed at a fast rate in industry thanks to computer technology; they are used to simulate motion and deformation over time to test materials and objects in a virtual manner. These modeling techniques are being developed in medicine, but they remain, at this time, in the domain of biomechanical research. We report a mathematical model for cutaneous excision and suture, which we have used to predict the deformations and tensions that result when using four different forms of excision. The results are expressed in numerical and graphic form. The results obtained corresponded with our experience in dermatologic surgery. Uses and limits of this model are discussed.

Branchio-oculo-facial syndrome with cleft lip and bilateral dermal thymus.

OBJECTIVE: The objective of this study was to demonstrate that the branchiooculo-facial (BOF) syndrome is a cervicocephalic neural crest maldevelopment. RESULTS: Using an embryologic study, we linked the clinical features and the level of the neural crest deficiency. We report here two cases of BOF syndrome with a particular branchial cleft presenting as bilateral supernumerary thymus glands on the surface of the skin; one of the cases was associated with tetralogy of Fallot. One patient underwent lip reconstruction at 4 months, combined with excision of bilateral auricular pits and superior labial fistula. The other patient had a surgical correction of the tetralogy of Fallot, and at 2 months, the two stages of the lip reconstruction were performed, combined with bilateral auricular pit excision. Both patients have shown normal developmental patterns to date. CONCLUSION: The BOF syndrome must be considered as a neurocristopathy at different levels, with a tiny mesencephalo-prosencephalic lesion and a severe rhombencephalic lesion that includes seven consecutive hindbrain segments, from rhombomere 2 to rhombomere 8.

[Use of iterative expansion in the early surgical treatment of complex nevi of the head in children]. / Utilisation des expansions itératives dans le traitement chirurgical précoce des naevus complexes céphaliques de l'enfant.

Extensive of congenital pigmented nevi to the face in an infant is an indication for early exeresis to prevent the risk of degeneration. Search for the best esthetic result has led many authors to healthy skin to a maximum, often relying on tissue expansion. The aim of this study was to present the combination of two expansion techniques, prosthetic expansion and differed natural expansion. Five infants with congenital pigmentary nevi extending to more than 50% of a facial anatomic unit were treated. Total treatment was achieved in all patients with three or four procedures. By combining different expansion techniques early treatment can be proposed with good esthetic results and moderate cost.

[Congenital giant blue nevus. Apropos of a case]. / Naevus bleu congénital géant. A propos d'un cas.

A case of a three years old girl showing a congenital giant blue nevus, in the neck and the occipital region, is presented. The giant blue nevus was associated to an important cutaneous nevomatosis. The treatment has consisted of an surgical excision of an surgical excision of the main lesion, and operative continuations have been simple. The literature study showed 11 cases of congenital giant blue nevus and demonstrate the high risk of malignancy, and the importance of an early surgical treatment.

[Complex facial nevus in children treated by combination of prosthetic and deferred natural expansions]. / Naevus complexe facial de l'enfant traité par combinaison des expansions prothétique et naturelle différée.

Congenital pigmented naevi of the face in children represent indications for early excision and the search for the best aesthetic result has led the authors to prefer the use of skin expansion techniques. The case presented here illustrates the combined use of two expansion techniques: prosthetic expansion and natural differed expansion. This procedure gives good cosmetic results at a moderate overall cost.

[Use of deformities in the treatment of facial skin defects in children: "deforming resections". Report of 35 cases]. / L'utilisation des déformations dans le traitement des pertes de substance cutanées faciales de l'enfant: "les exérèses déformantes". A propos de 35 cas.

Spontaneous resolution of deformities after excision of facial skin lesions has been known and used for a long time by plastic surgeons. The resorption mechanism of deformity is based on natural skin expansion, and seems to be directly related to the action of the muscles of facial expression and their skin relations. Natural expansion has been shown to be effective in children. Between 1990 and 1994 excision of skin lesions, including congenital nevi, leading to postoperative deformity of the cheek, labial commissure, nose, eyelid and forehead, was performed on 35 patients, aged from 3 month to 12 years. The average follow-up is 24 months. For 26 patients (74%), natural resorption was observed 4 or 6 weeks later with good aesthetic results. For 6 patients (17%), the deformity persisted 3 or 6 months later, but did not require any further surgery. For 3 patients (9%), a second operation was necessary. Using the skins natural capacity for expansion in the treatment of facial skin defects in children is a method of reconstruction which has already been used for excision in enforced position. The platysma and muscles of facial expression by their action on skin mobilisation, allow natural expansion. A better knowledge of cutaneous biomechanical properties enables plastic surgeons to find an alternative to other classical methods.

[Preservation of sexual innervation in the surgery of rectal cancers]. / Préservation de l'innervation sexuelle dans la chirurgie du cancer du rectum.

Eighteen out of 55 rectal resections for cancer included preservation of sexual innervation, which was complete in 17 cases and partial in one case. Fourteen patients were evaluated by questionnaire one year after resection; 10 out of 14 (71.4%) did not report any sexual disorders.