Bronchial trifurcation in a congenital pulmonary venolobar syndrome.

Congenital malformations of the tracheobronchal tree and the related arterial blood supply are a complex group of lesions in which there are abnormalities of the venous drainage and lung parenchyma. These malformations are examples of congenital pulmonary venolobar syndrome (CPVS). Tracheal trifurcation is an extremely rare anomaly associated with CPVS. We report on an unusual case of lower right extralobar sequestration connected to the trachea, plus a type I posterior laryngeal cleft, an aberrant systemic artery, and an anomalous route of the phrenic nerve. This paper discusses the place of this unusual abnormality in the spectrum of congenital bronchopulmonary vascular malformations.

Laparoscopic retroperitoneal nephrectomy in high risk children.

PURPOSE: Nephrectomy may be indicated in children with end stage renal disease before transplantation. We studied the feasibility and results of nephrectomy performed via a retroperitoneal laparoscopic approach in these high risk children. MATERIALS AND METHODS: We performed 12 nephrectomies in 9 children with end stage renal disease and a mean age of 7 years (range 7 months to 13 years) through a 3 trocar retroperitoneal laparoscopic approach. Cases were classified as American Society of Anesthesiologists grade III and presented with end stage renal disease, hypertension, thrombocytopenia and/or the nephrotic syndrome. The renal artery and vein were ligated separately with endocorporeal knots and clips. Mean size of the kidney was 8 cm. (range 5 to 12). Bilateral nephrectomy was performed simultaneously in 2 patients 7 and 12 months old, respectively. Cardiorespiratory changes related to retroperitoneal gas insufflation were assessed prospectively. To compare laparoscopic versus open nephrectomy we retrospectively analyzed the data of 12 open nephrectomies performed in 9 children with similar nephrological indications. RESULTS: The procedure was feasible in all cases without conversion to open surgery, and no intraoperative incident occurred. Mean operative time of laparoscopic nephrectomy was 2 hours (range 1 hour 20 minutes to 3 hours 10 minutes). After retroperitoneal carbon dioxide insufflation systolic arterial pressure and end-tidal carbon dioxide were significantly increased without the need for specific measure to correct these modifications. Hemodialysis began 1 day postoperatively and feeding began 2 days postoperatively. Mean hospital stay was 5.2 days (range 3 to 7). The comparative study of the open nephrectomy group showed no significant difference in mean operating time (p = 0.07), and hospital stay was significantly shorter for the laparoscopic group (p <0.001). CONCLUSIONS: Retroperitoneal laparoscopic nephrectomy is safe and feasible for high risk children. The relatively long operating time is necessary for hemostasis in these children at risk for hemorrhagic complications.

Situs inversus and bowel malrotation: contribution of prenatal diagnosis and laparoscopy.

The authors report 3 different cases of prenatal diagnosis of situs inversus associated with bowel malrotation. Heterotaxy existed in 2 cardiosplenic syndromes (1 left and 1 right isomerism), and 1 isolated situs inversus. Bowel malrotation was detected at birth by ultrasonography and intestinal contrast study. Patients underwent laparoscopic LADD's procedure and abdominal exploration in the neonatal period. The authors advocate neonatal screening and early surgical management of bowel malrotation in prenatally diagnosed heterotaxic syndromes.

Thoracic pheochromocytoma revealed by ventricular tachycardia. Clinical case and review of the literature.

A case of thoracic extra-adrenal pheochromocytoma was observed in a 13-year-old girl. The initial clinical symptoms consisted of her being unwell after effort over a period of 3 years. The diagnosis was suggested after a recorded episode of paroxysmal ventricular tachycardia with concomitant hypertension, which reproduced the characteristic symptoms. Biochemical analysis confirmed hypersecretion of catecholamines and morphological examinations showed the presence of an isolated left median thoracic tumor. One year after surgical excision, the patient remained completely asymptomatic, in spite of resuming intense sporting activity. The diagnosis of ectopic pheochromocytoma should be considered as a possible etiology of cardiac rhythm disturbances or hypertension in children. Thorough biochemical and radiological examination including MIBG radioisotope scanning should be carried out systematically before surgical excision; pheochromocytomas in children are frequently extra-adrenal (30%), multifocal (50%) or associated with multiple endocrine neoplasms (NEM).

High incidence of hypophosphatemia in surgical intensive care patients: efficacy of phosphorus therapy on myocardial function.

OBJECTIVE: To determine the incidence of hypophosphatemia in a surgical intensive care unit and to determine whether or not a phosphorus challenge causes a change in cardiac performance in hypophosphatemic patients. DESIGN: Prospective clinical study and case reports. SETTING: Surgical intensive care unit in an university hospital. PATIENTS: A total of 208 consecutive patients admitted to the surgical ICU were evaluated over a 6 months period. INTERVENTIONS: All classical risk factors for hypophosphatemia were recorded. A group of 8 moderate or severe hypophosphatemic patients were evaluated for hemodynamic data before and after a phosphorus load. Glucose phosphate was given over 30 min by the intravenous route. Dosage regimen was 0.4 mmol/kg weight for moderate hypophosphatemia and 0.8 mmol/kg weight for severe hypophosphatemia. RESULTS: Risk factors were present in 134 patients and 60 patients were hypophosphatemic (44.8%). Only 3 risk factors were discriminant for hypophosphatemia: sepsis, diuretics and total parenteral nutrition. The mortality was higher in the hypophosphatemic group than in the normophosphatemic group (30% versus 15.2%; p < 0.05). Cardiac performance improved after phosphatemia normalization in all patients (cardiac index: 3.82 +/- 1.87 versus 4.52 +/- 1.83 1/min.m2; p < 0.01). CONCLUSION: This study underlines the high incidence (28.8%) of hypophosphatemia in surgical intensive care patients and its association with a high mortality rate (30%). A short course of phosphotherapy improves cardiac index (+18%).

[Eye movements: initial dynamic approach in high resolution magnetic resonance imaging]. / Mouvements oculaires: première approche dynamique en imagerie par résonance magnétique (I.R.M.) de haute résolution.

New MR softwares allow a dynamic display of different fonctionnal anatomical regions. This work is a first attempt to visualize the ocular movements. A video tape constitute the support of our results. Technically, the work is performed on a Signa 1,5 T GE CGR System. During each MR acquisition, the subject is asked to fix his gaze successively on each spot of a scale set inside the bore of the magnet. Twenty four images are performed to show the entire lateral course of the globes. The examination time is about half an hour. The video display show the movements of agonist and antagonist muscles, the eyeballs and the optic nerves displacements, in the axial neuro-ocular plane (NOP). Different clinical applications of this new method are discussed (muscular surgery...).