Management of severe gastroesophageal reflux in children.

To evaluate response to fundoplication, clinical results for 66 consecutive pediatric patients operated on for gastroesophageal reflux were retrospectively reviewed. Indications for operation were gastroesophageal reflux with apnea, repeated emesis, recurrent pneumonia, failure to thrive, stricture, and esophagitis. All patients had preoperative documentation of significant gastroesophageal reflux by either cinefluoroscopic reflux esophagogram or reflux nuclear scan. Fundoplication was effective in 56 (87%) of 64 patients. None of the patients considered to be operative failures had persistent gastroesophageal reflux. Operative failures occurred primarily in patients with gastroesophageal reflux and apnea or recurrent pneumonia. More advanced diagnostic tests, such as pH monitoring, may help to select patients whose symptoms of apnea and recurrent pneumonia are truly due to reflux. Gastroesophageal reflux produces significant morbidity in pediatric patients and is well treated operatively by fundoplication.

Isolated aneurysm of the internal jugular vein: a report of three cases.

Isolated venous aneurysms are rare in children. Three patients presented with progressively enlarging cervical masses that proved to be fusiform aneurysms of the internal jugular vein. Surgical excision was carried out in each instance. Histopathologic examination revealed changes suggesting elastic tissue dysplasia similar to that previously described in abnormal carotid arteries of some children.

Tracheal diverticulum with recurrent apnea and segmental pulmonary atelectasis.

A patient presented with recurrent episodes of apnea and segmental pulmonary atelectasis. These episodes persisted following repair of esophageal atresia and tracheoesophageal fistula and repair of vascular ring causing tracheal compression. A tracheal diverticulum was identified and resected. The patient's symptoms disappeared following surgery.

Neurofibrosarcoma at irradiation site in a patient with neurofibromatosis and Wilms' tumor.

A female patient with neurofibromatosis had nephrectomy performed because of Wilms' tumor at the age of four and a half. She received radiation therapy and chemotherapy (actinomycin D) after surgery. She had subsequent local recurrence and lung metastasis, which were surgically excised and successfully treated with additional radiation therapy and chemotherapy (vincristine and actinomycin D). However, neurofibrosarcoma at the irradiation site developed seven years after radiation therapy. She died 22 months later because of recurrence and metastasis of neurofibrosarcoma. Radiation therapy's association with malignant transformation of neurofibroma is discussed.

[Limbs acute ischemia. Late complications of exuberant callus and pseudarthrosis (author's transl)]. / Ischémies aiguës des membres. Complications tardives de cals hypertrophiques et de pseudarthroses.

Three acute peripheral arterial occlusions occurred 60, 38 and 12 years after imperfect reduction of fractures. In two cases the embolus originated from an aneurysm induced by an hypertrophic callus of the clavicle. In the third case, acute thrombosis appeared as the consequence of leg arteries compression by a tibial osteomyelitic callus. Arterial reconstruction in the two first cases and thrombolysis in the third case were associated to surgical treatment of the causal injuries and were successful.

Ovarian tumor as manifestation of relapse in acute lymphoblastic leukemia.

Acute lymphoblastic leukemia (ALL) was initially diagnosed in a 12-year-old girl. Maintenance chemotherapy was discontinued after 32 months of continuous remission. Relapse of ALL occurred ten months after cessation of chemotherapy. Twenty-one months after relapse, she presented with a large ovarian tumor due to leukemic infiltration while her bone marrow and central nervous system (CNS) were still in remission. She remained in bone marrow and CNS remission when disseminated leukemic infiltration of the peritoneum was found seven months later. She died of bone marrow relapse 11 months after ovarian relapse, six years and two months after the initial diagnosis. In contrast to testicular relapse, ovarian relapses in acute lymphoblastic leukemia are rarely reported.

[Reliability and value of arterial blood-flow monitoring during operation (author's transl)]. / Fiabilité et intérêt de la débimétrie artérielle per-opératoire.

The predictive values of blood-flow monitoring using the Doppler effect during operation, to detect anatomical causes of correctable low blood flow or early thrombosis in the absence of correction, was studied in 309 cases of revascularization. When employed under precise conditions, this technique was found to be of high predictive value. Flow rates can be classified in four risk zones: very high, high, low, or nil. In practice, whenever values fall below a critical threshold of 130 ml/min at the iliofemoral level or 55 ml/min at the femoropopliteal level, arteriography should be conducted to establish the cause of the reduced flow, and to enable immediate correction of any technical fault, or improvement in distal flow. The value of this method is shown by the fact that of 44 cases with reduced flow, 22 could not be improved, and early thrombosis occurred in 70% while, in 20 cases, improvement was obtained, and early thrombosis occurred in only 10%. The use of blood-flow monitoring techniques during operation can be assumed to have reduced the incidence of early thrombosis by 27% in those cases with diminished flow, and by 4% in the overall group.

[Iliac endarterectomy for widespread obliteration. 10 years follow-up of 200 operations (author's transl)]. / L'endartériectomie pour traitement d'oblitérations iliaques étendues a propose de 200 interventions suivies avec un recul de l à 10 ans.

Results of 200 iliac endarterectomies performed in 174 atheromatous patients were as follows: 15% mortality, 97% immediate good results, patency in 86% after 5 and 83.5% after 10 years. Five year survival was 62%. Contralateral atheroma progression was not marked, operation was required at an early stage in 5% and secondarily in 10% of cases. Results depend mainly on the operative technique employed, which is discussed. Mortality is lower after endarterectomy than when bifemoral-aortic prostheses are inserted, because of the reduced risk of infection and better respiratory tolerance of the retroperitoneal approach. This method should, therefore, be given preference whenever possible.

[Arterial complications of inguinal surgery: value of vein replacement in situ (author's transl)]. / Complications artérielles de la chirurgie inguinale. Intérêt du remplacement veineux in situ.

Two cases of arterial complications after inguinal hernia repair were revealed by a post-operative septic hemorragia and in the other case by a late intermittent claudication complicated by a distal emboly. Both were cured by replacement of the damaged artery with an autologous saphena. Twenty-three similar cases were found in literature. They were discovered either during operation, or post-operatively, or after recovery. In post-operative course, a late diagnosis in some cases lead to amputations or death. Actual treatment is arterial replacement by autologous vena because the length of arterial damagement and good resistance of vena in septic area. Prevention during inguinal hernia repair needs a correct exposure, the use of small needles and widening of the exposure in case of hemorragia.

Nesidioblastosis in children.

Three cases in which seizure disorder was first noticed were examined in the last seven years; low fasting glucose and high serum insulin levels then led to the diagnosis of severe hypoglycemia secondary to nesidioblastosis. Hypoglycemic episodes were uncontrolled by frequent oral feedings and intravenous administration of dextrose, glucagon, and diazoxide. Within three weeks after diagnosis, all three patients underwent subtotal pancreatectomy; all three survived and have been followed-up for two to seven years. Two remain euglycemic and have no evidence of CNS damage. The third has occasional fasting hypoglycemia that is treated with diazoxide; he continues to have a seizure disorder and is mentally retarded. Neonatal hypoglycemia secondary to hyperinsulinism requires prompt recognition and aggressive treatment to avoid irreversible CNS damage. Subtotal pancreatectomy safely and effectively restores the euglycemic state.

Jejunal intussusception in children.

Jejunal intussusception in children is an uncommon form of intussusception often presenting with chronic intermittent abdominal pain and weight loss. Two cases of jejunal intussusception caused by enteric duplication are presented. It is concluded that in the absence of generalized small bowel disease, enteric duplication is the most likely cause of jejunal intussusception in children.

[Substernal goitre. Report of 45 cases (author's transl)]. / Les goitres compressifs. A propos de 45 cas.

Among 1,000 operated goiters excluding hyperthyroidism, 45 were compressives (4,5%). Epidemiologic factors were elderly patients, ancient unoperated goiters and recidivism of formerly operated goiters. 1. Prognosis is not hopeless since 60% of compressive goiters were benign. On the other hand, the 40% carcinoma growed swiftly, being either anaplastic or follicular but with local or metastatic extension. 2. Clinical aspect is of no use to ascertain benignity or malignity. Extemporaneous histological examination may be falsely reassuring; but the discovery of a carcinoma allows more appropriate operation. 3. In case of acute dyspnea, only tracheal intubation has to be done in emergency. Intubation is always possible. But the operation has to be done later in better technical conditions. Technique and errors to avoid are exposed in details. 4. Complications are scarce. Tracheomalacia never occured. But laryngeal edema or recurential palsy may need a few days intubation. Technical aspects in order to avoid compressive hematoma as well as sequelae are described.

[Acute ischemic lesions in young women taking oral contraceptives. A report on 5 cases (author's transl)]. / Sévérité des ischémies aiguës survenant chez des femmes jeunes sous contraceptifs oraux. A propos de 5 observations.

Severe ischemic lesions were observed in 5 cases among women aged between 35 and 43 years taking the contraceptive pill over a period of 4 years. Three of these patients developed sudden severe ischemia of the lower limbs after the unrecognized appearance of intermittent claudication for periods of from 2 to 10 months, and amputation was necessary after various ineffective treatments. Recovery occurred in the two other patients, one of whom developed ischemia in the upper limb, the other in the lower limb, who were treated at an early stage. The young age of these women and the absence of atheroma were factors that suggested that the oral contraceptives, taken for periods of from 6 months to 4 years, were at least partially responsible for the lesions, and this hypothesis was supported by the discovery of anti-ethinyl estradiol antibodies in the serum. This was probably not the only causative factor, however, as all the patients were smokers. These cases demonstrate the danger of associating smoking with the taking of oral contraceptives, that the latter should be discontinued when signs suggestive of peripheral arterial insufficiency appear, and that urgent thrombectomy should be conducted in cases of severe ischemic lesions.

Esophageal atresia and tracheoesophageal fistula: preoperative assessment and reduced mortality.

One hundred twenty-nine infants with esophageal atresia and tracheoesophageal fistula were reviewed from 1955 to 1978. The overall mortality was 38%. Factors associated with the increased mortality include prematurity, pneumonia, and congenital defects other than this anomaly. A classification based on these factors in introduced, which provides the clinician with a prognostic survival rate greater than 90% with only physical examination, chest and abdominal roentgenography, and intravenous pyelography. Postoperative mortality was reduced to 11% in the last five years of the study; this is attributed to the exclusive use of the retropleural approach to the esophagus, more intensive postoperative ventilatory support, and routine use of parenteral nutrition.