Post-appendectomy intra-abdominal abscesses--can they successfully be managed with the sole use of antibiotic therapy?

PURPOSE: Controversy persists concerning the management of post-appendectomy intra-abdominal abscesses. We hypothesised that most of these abscesses can be successfully managed by antibiotic treatment alone, avoiding the complications of surgical treatment. METHODS: Hospital records of children treated in our unit for intra-abdominal post-appendectomy abscesses over a 6-year period were reviewed retrospectively. RESULTS: This study investigates a series of 26 children from 2 to 15 years of age presenting with one or more post-appendectomy intra-abdominal abscesses. After an average delay of 7 days after initial surgery, 23 children had developed an isolated abscess, while 3 children had multiple abscesses. Twenty-two patients (84.8 %) were treated conservatively by intravenous triple antibiotic therapy alone. Complete clinical, radiological and biological resolution of the abscesses was obtained in all of these children after a mean hospitalisation of 8 days. Four children (15.2 %) were treated surgically: three children with a stable patient status and one child with septic shock requiring urgent surgery. CONCLUSION: The results suggest that intravenous triple antibiotic therapy alone is an efficacious first-line treatment in children developing intra-abdominal abscesses following appendectomy. Surgical intervention is rarely necessary except in patients with an alarming patient status or with signs of septic shock.

Early laparoscopic Kasai's procedure in a low weight newborn.

The authors present an early laparoscopic treatment in a newborn with biliary atresia. They describe the technical details of the Kasai laparoscopic procedure. A 10-day-old girl, weight 2.4 kg, was admitted with a history of jaundice and fecal acholia since birth, with elevated total bilirubin and abnormal hepatic test. Abdominal ultrasound showed a small gallbladder with hyperechogenicity in porta hepatis and absence of biliary principal duct. Other metabolic and hematological tests were normal. The procedure was performed at 20-day-old by laparoscopy. The cholangiography confirmed the biliary atresia and Kasai's procedure was continued by laparoscopy and transumbilical extracorporeal Roux-Y approach. The duration of the procedure was 220 min, with good tolerance of pneumoperitoneum due to the laparoscopy. Feedings of breast milk began on the third day postoperative, presenting normal colored stools, with normalization of the hepatic test. A 20 months follow-up was without complications.

Benefits of the thoracoscopic approach for short- or long-gap esophageal atresia.

OBJECTIVE: To evaluate the feasibility and results of thoracoscopy in various types of esophageal atresia (EA). MATERIALS AND METHODS: From April 2001 to August 2002, 5 patients with EA were treated by thoracoscopy. Their mean gestational age was 38 weeks and mean birth weight was 2700 g. Two patients had short-gap atresia with tracheo-esophageal fistula (type III according to Ladd's classification). Three had long-gap atresia: 2 with low fistula to the carina (type IV) and 1 without fistula (type I). Patients were placed in a prone position with the right side elevated at 80 degrees . Four intrapleural ports were necessary. The fistula when present was dissected and sutured with intrathoracic knots and esophageal anastomosis performed in the same manner. RESULTS: Positive airway pressure increased in all patients after insufflation but was kept in a safe range to prevent lung injury. An esophageal anastomosis was performed in 3 cases (2 short gaps and 1 long gap). Oral feeding started on day 6, and their mean length of hospital stay was 14 days. For one child with type IV EA, the anastomosis was impossible because of a long gap confirmed by an immediate thoracotomy. The ends were just approximated. A "spontaneous" fistula developed, and normal feeding was possible 2.5 months later. For the child with type I EA, the pouches could be only approximated at 2 months of age. A spontaneous fistula developed with a stenosis. A redo anastomosis by open surgery allowed for normal feeding. CONCLUSION: The thoracoscopic repair of an esophageal atresia is a reasonable choice for experienced surgeons treating patients, including those with long gaps.

[What a hidden testicle can hide?...or the clinical traps of cryptorchidism]. / Que peut cacher un testicule caché?...ou les pièges cliniques de la cryptorchidie.

Although cryptorchidism is probably the most frequent genital anomaly encountered in boys, this pathology remains largely unexplained and its long-term prognosis is still uncertain. Despite the relative easiness of this diagnosis, attention should be paid to some clinical traps, which can mislead the sexual identity. Indeed, beside the isolated common cryptorchidism, many troubles of the testicular migration can be associated with various malformative syndromes and can be named as "cryptorchidism symptoms". Most of these syndromes are obvious, but some can be suspected only by the way of an abnormal descent of testis. Cryptorchidism, which is systematically screened out during any pediatric consultation, should play the role of clinical marker for various endocrine or genetic disorders. Among them, the intersex states should be underlined to avoid the harmful effects of misdiagnosis. We dealt with this subject through a clinical and practical approach.

[A comparative study of the feasibility and limits of ambulatory surgery in infants under and over one year of age]. / Etude comparative de la faisabilité et des limites de la chirurgie ambulatoire chez le nourrisson et chez l'enfant de plus d'un an.

OBJECTIVE: Outpatient surgery in pediatrics is attractive for several reasons. Although 6-8 months has been generally acknowledged as the lower age limit, no minimal age has been clearly established. This study evaluated the outcomes and limits of outpatient surgery in infants from 4 months to 1 year of age. MATERIAL AND METHODS: Between 1996 and 2003, 935 patients were admitted to our hospital for outpatient surgery; of these, 152 were between 4 months and 1 year (mean: 6 months). The indications were essentially surgery to the external genitalia and surgery to remove hernias. The following were exclusion criteria: age below 4 months, ASA scores equal to or above 3, and premature birth with either respiratory distress syndrome or a near-miss of sudden death. RESULTS: More than 98% of the infants met the criteria for outpatient surgery. Cancellations (1.97 vs. 0.51%, P > 0.05), conversions to classic hospitalization (0.65 vs. 0.37%, P > 0.05), postoperative complications (0.65 vs. 0.25%, P > 0.05), rehospitalization (0.65 vs.0.25%, P > 0.05) and relapse of the initial pathology (0.65 vs. 0.63%, P > 0.05) were not more frequent in these infants than in infants over 1 year. CONCLUSION: Pediatric outpatient surgery can be proposed from the age of 4 months without increasing the postoperative risk, either anesthetic or surgical, included for selected former premature infants.

Ideal timing of thoracoscopic decortication and drainage for empyema in children.

BACKGROUND: Thoracoscopy may be required for resistant empyema in children. This study aimed to determine the advantages of thoracoscopy performed soon after diagnosis and its ideal timing. METHODS: Between 1996 and 2002, 21 children who had undergone thoracoscopy as an initial procedure or after failure of medical treatment were retrospectively reviewed. The study compared outcome of early thoracoscopy (fewer than 4 days after diagnosis) and that of later surgery. The 4-day limit was chosen for physiopathologic reasons (organization of pleuresia in 72 h). RESULTS: In the early thoracoscopy group, the findings showed shorter operative time (p = 0.03) and postoperative hospital stay (p < 0.05), fewer technical difficulties, fewer complications, and no recourse to other surgical procedures. CONCLUSIONS: Early thoracoscopy is greatly beneficial for children with empyema by shortening disease progression. An initial short trial of medical treatment for nonorganising empyema may be attempted on the condition that thoracoscopy not be delayed more than 4 days.

Conditions required for laparoscopic repair of subacute volvulus of the midgut in neonates with intestinal malrotation: 5 cases.

BACKGROUND: This study aimed to evaluate the optimal conditions for laparoscopic management of neonatal subacute volvulus with malrotation. METHODS: Between 1994 and 2002, 13 neonates with midgut volvulus and malrotation entered the authors' institution. Five of these neonates met the eligibility criteria for laparoscopy: good hemodynamic parameters, no gut perforation, and no severe ischemic distress of the bowel shown on preoperative ultrasonography. RESULTS: The results were excellent for only three infants, associated with a shorter postoperative course. One underwent reoperation for a residual duodenal band, and one conversion to open laparotomy was necessary. The predictors of success were no difficulty identifying the abnormal anatomy, no important chylous stasis, and the learning curve of the surgeon. CONCLUSIONS: Despite its previously reported feasibility, neonatal laparoscopy for volvulus with intestinal malrotation is appropriate only for a small number of patients. Strict selection criteria with a clear understanding of the optimal conditions for success may improve the outcome.

Blunt traumatic injuries of the gastrointestinal and biliary tract in childhood. Analysis of 16 cases.

BACKGROUND: Little attention has been given to abdominal hollow viscus injuries in pediatric literature. The purpose of this report is to describe their main features, and the current methods of diagnosis and treatment. METHODS: We reviewed our experience with 16 cases of blunt injuries involving the gastrointestinal (GI) and biliary tract in the last seven years. RESULTS: Male to female ratio was 0.68 and mean age 9.4 years. The site of injury was the stomach in 2 cases, duodenum in 5, jejunum or ileum in 7, caecum in 2, left mesocolon in 2, and gallbladder in 1. Diagnosis of the 8 perforations was clinically suspected in 6, and confirmed by radiography in 6 or surgery in 2, with a mean delay of 0.42 days. Diagnosis of the 11 hematomas was clinically suspected in 6, and confirmed by radiography in 9 or surgery in 2, with a mean delay of 12.6 days. Hematomas were managed nonoperatively, and perforations were surgically or laparoscopically closed. Mortality was 1/16 by pancreatic injury, and morbidity was 4/16. CONCLUSION: Incidence of blunt hollow viscus injuries is low in children. Hematomas are easily recognized by modern radiography, and simply managed nonoperatively. Diagnosis of perforations still remains difficult. This results in dangerous delays for lesions which need prompt repair.

[Anorectal traumas by impalement in children. Apropos of 3 cases]. / Les traumatismes ano-rectaux par empalement chez l'enfant. A propos de trois observations.

Traumatic impalement is an exceptional cause of anorectal lesions in the child. The clinical diagnosis is sometimes difficult and associated lesions raise the problem of the most appropriate exploratory examination. Based on our experience with three cases, we would emphasize the usefulness of hydrosoluble enema study prudently performed by the surgeon during the preoperative work-up. The precise localization of the lesions must be obtained with careful emergency exploration before repair. Treatment of the trauma includes lavage, drainage and sometimes colostomy. Antibiotics must always be prescribed. Early complications are dominated by infection and long-term sequellae, requiring a long follow-up.