Ultrasound assessment of gastric contents in children before general anaesthesia for acute appendicitis.

There is increasing evidence that a minority of adults with acute appendicitis have gastric contents, posing an increased risk of pulmonary aspiration. This study aimed to evaluate the proportion of children with acute appendicitis who have gastric contents considered to pose a higher risk of pulmonary aspiration. We analysed point-of-care gastric ultrasound data routinely collected in children before emergency appendicectomy in a specialist paediatric hospital over a 30-month period. Based on qualitative and quantitative antral assessment in the supine and right lateral decubitus positions, gastric contents were classified as 'higher-risk' (clear liquid with calculated gastric fluid volume > 0.8 ml.kg-1 , thick liquid or solid) or 'lower-risk' of pulmonary aspiration. The 115 children studied had a mean (SD) age of 11 (3) years; 37 (32%; 95%CI: 24-42%) presented with higher-risk gastric contents, including 15 (13%; 95%CI: 8-21%) with solid/thick liquid contents. Gastric contents could not be determined in 13 children as ultrasound examination was not feasible in the right lateral decubitus position. No cases of pulmonary aspiration occurred. This study shows that gastric ultrasound is feasible in children before emergency appendicectomy. This technique showed a range of gastric content measurements, which could contribute towards defining the risk of pulmonary aspiration.

An inferior vena cava discontinuity with an hepato-renal accessory vein development: A radio-anatomical morphometric case study.

PURPOSE: Inferior vena cava (IVC) agenesis is an uncommon congenital vascular anomaly stemming from aberrant development during embryogenesis. It results from the failure of one or more of the supracardinal veins, subcardinal veins, vitelline veins or postcardinal veins to connect. The symptomatology resulting from this vascular malformation can be either absent or extremely rich and varied. METHODS: Thoracoabdominal-pelvic CT scan projections following iodine-based contrast product injection were analyzed and a three-dimensional model of vascularization constructed. RESULTS: Herein, an asymptomatic case of IVC agenesis with absence of the suprarenal and renal segments, with azygos continuation, presenting an accessory hepatorenal vein is reported. The presence of this type of accessory vein has never been described in the literature to date. The etiology of this case of IVC agenesis is explored in depth. We also analyzed the morphometric parameters of the IVC remnant segments and the azygos vein in order to quantify the dilatation of the collateral venous pathway overdeveloped to handle blood return. CONCLUSION: Using the findings from this case and those reported in the literature, we provide general recommendations that should be taken into account before managing a patient, symptomatic or asymptomatic, admitted to the hospital with IVC agenesis.

Anatomical study of the thoracic duct and its clinical implications in thoracic and pediatric surgery, a 70 cases cadaveric study.

INTRODUCTION: Given the high variability and fragility of the thoracic duct, good knowledge of its anatomy is essential for its repair or to prevent iatrogenic postoperative chylothorax. The objective of this study was to define a site where the thoracic duct is consistently found for its ligation. The second objective was to define an anatomically safe surgical pathway to prevent iatrogenic chylothorax in surgery for aortic arch anomalies with vascular ring, through better knowledge of the anatomical relationships of the thoracic duct. METHODS: Seventy adult formalin-fixed cadavers were dissected. The anatomical relationships of the thoracic duct were reported at the postero-inferior mediastinum, at levels T3 and T4. RESULTS: The thoracic duct was consistently situated between the left anterolateral border of the azygos vein and the right border of the aorta between levels T9 and T10, whether it was simple, double, or plexiform. It was located medially, anteromedially, or posteriorly to the left subclavian artery in 51%, 21%, and 28% of the cases, respectively, at the level of T3. At T4, it was posteromedial in 27% of the cases or had no direct relationship with the aortic arch. CONCLUSION: These results favor mass ligation of the thoracic duct at levels T9-T10 between the right border of the aorta and the azygos vein, eventually including the latter. To prevent iatrogenic postoperative chylothorax in aortic arch anomalies with vascular ring surgery, we recommend remaining strictly lateral to the left subclavian artery at the level of T3 to reach the aortic arch anomalies with vascular ring at T4.

Functional impact of osteosuture in medial bilateral clavicular physeal fracture in teenagers.

INTRODUCTION: Proximal physeal fracture of the medial clavicular physis is a rare specific injury occurring in the immature skeletal. Several studies describe unilateral cases with posterior or anterior displacement and the following complications (vascular and mediastinal compression). An immediate diagnosis and management are necessary to avoid complications. The clinical diagnostic might be obvious or difficult, pain and swelling in the sternoclavicular joint area, sometimes a deformity and focal tenderness. A chest X-Ray may help and a three-dimensional reconstructed computed tomography scan has to be done to evaluate the lesions before surgery. The imaging is useful to confirm and specify the diagnostic and the displacement. PRESENTATION OF CASE: This case report presents 4 cases of proximal physeal fracture of the medial clavicular physis in 2 male-teenagers with bilateral displacement, one posterior and the other asymmetric. DISCUSSION: After reviewing the literature of the unilateral clavicular physeal fracture, we can conclude that the ideal management of these injuries has not been well described. An open reduction associated an osteosuture with non-resorbable suture was performed. One-year follow-up, both of them had full recovery without any functional impact or any complains. This management of the proximal physeal fracture of the medial clavicle on children shows an excellent result according our cases and the literature. CONCLUSION: The purpose of this study is to evaluate the functional impact of osteosuture in medial bilateral clavicular physeal fracture in teenagers after 1-year follow-up.

Pediatric pheochromocytoma in association with Von Hippel-Lindau disease: Focus on screening strategies.

INTRODUCTION: Von Hippel-Lindau disease (VHL) is a syndrome of familial predisposition to the development of malignant and benign tumours, due to mutations in the VHL tumour suppressor gene. Pheochromocytoma is a tumour that develops in the adrenal gland, rare in pediatric age, and may be associated with genetic abnormalities including mutations in the VHL gene. Systematic screening of pheochromocytoma in children carrying a VHL mutation has been proposed. However, some VHL patients who have been screened may develop symptoms associated with pheochromocytoma despite screening. Here, we report on such a case. CLINICAL CASE: A 13-year-old boy, known to be a carrier of a mutation of the VHL gene, undergoing annual screening, was admitted to our hospital for clinical symptoms related to a right adrenal pheochromocytoma discovered on abdominal imaging. After hemodynamic stabilisation, the pheochromocytoma was surgically resected. Histology confirmed the diagnosis of pheochromocytoma. The postoperative care was simple. The event-free period is currently 2 years. DISCUSSION: The present case has led us to reflect on the French and international screening strategies for pheochromocytoma in children carrying a mutation of the VHL gene. Between 2013 and 2018, six different recommendations were proposed for pheochromocytoma screening in secondary prevention for children with a VHL mutation, with variability regarding the age of onset and complementary examinations to be carried out. Despite the existence of these recommendations, our case demonstrates that a pheochromocytoma can develop by escaping well-performed screening. The role of early abdominal imaging should be redefined to improve the efficiency of screening. CONCLUSION: The discovery of a pheochromocytoma in a child must be systematically investigated for an underlying genetic cause. In the particular case of children carrying a mutation of the VHL gene, annual abdominal imaging should be included in the pheochromocytoma screening protocol from the age of 5 years.

Level of inferior mesenteric artery ligation in low rectal cancer surgery: high tie preferred over low tie.

BACKGROUND: There is no demonstrated benefit of high-tie versus low-tie vascular transections in low rectal cancer surgery. The aim of this study was to compare the effects of high tie and low tie of the inferior mesenteric artery on colonic length. METHODS: This study was conducted in a surgical anatomy research laboratory. Anatomical dissections were performed on 11 human cadavers. We performed full left colonic mobilization, section of the descending-sigmoid junction, and high and low ligation of the inferior mesenteric artery. Distance from the proximal colon limb to the lower edge of the pubis symphysis was recorded after each step of vascular division. Three measurements were successively performed: before vascular section, after inferior mesenteric artery ligation, and after inferior mesenteric artery and vein section. RESULTS: Before vascular section, the mean distance between colonic end and lower edge of the symphysis pubis was - 1.9 ± 3.5 cm. After combined artery and vein section, the mean distance was + 10.7 ± 4.6 cm for high tie and + 1.5 ± 3 cm for low tie. A limitation of this study is the use of embalmed anatomical specimens, rather than live patients, and the small number of specimens. This study also does not evaluate colon limb vascularization or the impact of proximal lymph node dissection on survival rates. CONCLUSIONS: High tie of the inferior mesenteric artery at its aortic origin allows a gain of extra length of about 9 cm over low tie.

Anatomy and histology of the scrotal ligament in adults: inconsistency and variability of the gubernaculum testis.

PURPOSE: The anatomy of gubernaculum testis (GT) is often discussed; however, the postnatal anatomy of the GT or scrotal ligament (SL) is rarely described. Hence, we performed an anatomical and histological study to analyze histologically the structures between testis and scrotum. METHODS: We performed anatomical dissections on 25 human fresh cadavers' testes. Each testis was removed with its envelopes and macroscopically analyzed. Then samples were included for histological study. Finally, they were analyzed under microscope, looking for attachments between testis, epididymis and scrotal envelopes. RESULTS: The absence of proximal and distal attachment was found in 56.0% of cases. Looking at the proximal attachment of the SL, the main one found is the epididymal attachment (28.0%), whereas no cases of testis attachment was found. Distally, there are more variations with scrotal attachment (12%) and cremaster attachment (12.0%). We found a significant prevalence of multiple adherences in 16.0% of cases too. Finally, in 15 cases (57.7%) an attachment is present between testis and epididymis, as it is commonly described. CONCLUSIONS: In the majority of cases there is no attachment of the lower pole of the testis and epididymis and these structures remain free. So it seems that the SL disappears with aging. Moreover, there is not only one kind of ligamentous attachment, but a high variability of attachments at the lower pole of the testiculo-epididymal structure. When it exists, this structure is never a real ligament and it seems more appropriate to use the term "attachments".

Spica cast as an alternative to general anesthesia for lower limb MRI in young children.

BACKGROUND: The conventional approach for MRI procedures in very young children is to use general anesthesia which comes with inherent risks. Non-pharmacological strategies to reduce anxiety in children have also been described, but they all require patient cooperation. The purpose of the study was to evaluate the ability to complete diagnosis using temporary spica cast immobilization (TSCI) in children less than 3 years old undergoing MRI procedures for lower limb disorders. MATERIALS AND METHODS: A retrospective review identified 14 children under 3 years old that had required an MRI for a lower limb disorder, using TSCI. The MRI procedure was performed for evaluation of hip dysplasia, bone infections, limping, evaluation of soft tissue tumor and femoral head osteonecrosis. A spica cast was fitted by the pediatric orthopedic team. The MRI procedure was subsequently performed. RESULTS: Diagnosis was achieved in all cases. The radiologist identified movement artifacts (14 %) that did not impair the image quality enough to prevent interpretation. CONCLUSION: TSCI is a safe, effective and costless procedure avoiding general anesthesia for young patients under 3 years old who require MRI for pelvis or lower limb disorders. LEVEL OF EVIDENCE: IV.