[Blunt injuries of the pancreas in children]. / Traumatismes fermés du pancréas chez l'enfant.

STUDY AIM: Conservative management is mainly proposed for pancreatic trauma without ductal injuries. The aim of this retrospective study was to assess our experience with traumatic pancreatic injuries and to compare patients with medical or surgical treatment. PATIENTS AND METHOD: From January 1989 to December 1998, 21 children, 13 boys and 8 girls with a mean age of 8 years (range: 1 to 17 years) were treated for pancreatic injuries. Main mechanisms of injuries were bicycle's falls (n = 7), passengers in motor vehicle collision (n = 6), and other road collisions (n = 5). Diagnosis of pancreatic trauma in 17 patients was made through ultrasonography and/or CT scan. In 4 patients, the diagnosis was made intraoperatively. Associated injuries were splenic (n = 6), hepatic (n = 5) and duodenal (n = 5). Thirteen patients had only medical treatment and 8 patients required laparotomy. The two groups were comparable according to the rate of high grade pancreatic lesions. RESULTS: Two complications, a pancreatic fistula and a pseudocyst, occurred in the operative group and improved spontaneously. One death due to a head trauma, one acute pancreatitis and seven pancreatic pseudocysts (six required percutaneous drainage), occurred after medical treatment. The mean hospital stay, shorter after medical treatment, was not significantly different between the two groups (26 days vs 32 days). During the follow-up, no late complications have been observed. CONCLUSION: Traumatic pancreatic injuries are rarely lethal but are often associated with other intra-abdominal injuries. Conservative treatment is advocated for grade 1 to 4 isolated pancreatic injuries. This conservative approach may be associated with the development of post-traumatic pancreatic pseudocysts which are easily cured by percutaneous drainage.

[Surgical treatment of thyroid diseases in children]. / Le traitement chirurgical des pathologies thyroïdiennes chez l'enfant.

UNLABELLED: In order to review the experience of a single institution with thyroid surgery and identify prognostic factors, we did a retrospective chart review of all patients who underwent thyroid surgery between 1980 and 1995. Fifty patients, 32 girls and 18 boys, underwent thyroid surgery. Clinical presentation include a thyroid nodule (36 patients), a family history of MEN syndrome with a positive pentagastrin stimulation test (10), diffuse nodular goitre (3) and a neonatal cervical mass (1). Radiologic investigation include ultrasonography in 58% of cases, radionucleide imaging in 70% of cases. The mean age at surgery was 13.3 years and the delay between onset of symptoms and diagnostic was 13 months. Twenty-one patients had a lobectomy +/- isthmectomy, 19 had a total thyroidectomy and 10 had a subtotal thyroidectomy. Nine patients required a second surgery to complete the surgical treatment, and perform a total or near total thyroidectomy when the final pathology showed a carcinoma. A well differentiated carcinoma was found in 52% of the patients, a medullary carcinoma in 20% and a benign lesion in 28% of cases. Nine patients had local or distant metastases at initial surgery. Post-op treatment consisted of suppressive hormonotherapy in all cases of cancer and radioactive iodine when recurrence occurred in 24% of patients and when metastasis where present. Survival remained at 100%. CONCLUSION: Thyroid nodules should be rapidly investigated in children because of a high potential of cancerous lesions. With an aggressive surgical treatment and post-op I131 for recurrent lesions and metastasis the prognostic remains excellent.

Gastroschisis: are prenatal ultrasonographic findings useful for assessing the prognosis?

OBJECTIVE: The objective of this study was to assess various prenatal patterns in correlation with survival and the occurrence of complications of antenatally recognized gastroschisis (G). MATERIALS AND METHODS: We retrospectively studied 34 cases of G. Mortality and morbidity in the postnatal period were assessed and correlated with the prenatal presence or absence of: (1) bowel and/or stomach dilatation, (2) thickening and/or hyperechogenicity of the intestinal wall, (3) meconium peritonitis (in the abdomen) before 20 weeks of gestation, (4) asymmetrical bowel dilatation, and (5) associated malformations. Morbidity took into account the length of hospitalization and the number of surgical procedures. RESULTS: The overall survival rate was 94%. Neither bowel nor stomach dilatation was significantly correlated with mortality. However, evidence of intestinal dilatation greater than 17 mm had a positive predictive value of 67% for atresia, with a negative predictive value of 86%. Thickening and/or hyperechogenicity of the bowel wall were not significantly associated with mortality. Meconium peritonitis before 20 weeks and asymmetrical bowel dilatation were not statistically significant because of the small sample size. Twelve patients (35.3%) had postnatal complications, with a mean hospital stay of 127 days. Outcome was not modified by the mode of delivery. Associated extradigestive anomalies were present in 20.6% of cases. Chromosomal anomalies were not seen. CONCLUSION: The prognosis of prenatally detected G is excellent despite the frequency of small bowel atresia (67%) in the group with postnatal complications. Meconium peritonitis before 20 weeks of gestation and/ or asymmetrical bowel dilatation also appear to be indicators of atresia (2/4, 50%) or high morbidity (3/4, 75%).

Intra-abdominal sepsis and adrenergic receptor response.

This study measured the adrenergic receptor response of 13 patients with severe intra-abdominal sepsis, who required laparotomy and an open abdominal closure with Marlex mesh. The source of the sepsis was gram-negative organisms of intestinal origin. There were seven survivors and six nonsurvivors. When the patients were stratified into survivors and nonsurvivors, the Septic Severity Score, the APACHE II score, the Acute Physiological Score, and the Glasgow Coma Scale score results were not significantly different between groups. The alpha-2 and beta-1 adrenergic receptor responses were measured in the adipose tissue of the abdominal wall and the small bowel mesentery on day 1 of admission to the intensive care unit. The results demonstrated that the alpha-2 and beta-1 receptors of the nonsurvivors had a significantly decreased receptor response with desensitization and down regulation. The alpha-2 and beta-1 receptors of the survivors had an increased response with hypersensitization and up regulation. This study indicates that the adrenergic receptor pattern is distinctly different between survivors and nonsurvivors with severe abdominal gram-negative sepsis. The pattern differences occurred early (within 24 hours) when the patients had similar physiologic profiles. It is concluded that adrenergic receptor response may be a biologic indicator of the magnitude of the septic injury and a predictor of outcome.

Infectious complications of pediatric liver transplantation.

Twenty-five pediatric orthotopic liver transplantations (OLTs) performed in 22 patients at Sainte-Justine Hospital were reviewed for infections complications. One patient died within 12 hours posttransplantation and is excluded. The patients had an average age of 6.1 years (range, 1.25 to 19 years) and an average weight of 20.4 kg (range, 11 to 55 kg). Two patients (9%) were cytomegalovirus (CMV) seropositive and 9 of 19 patients (48%) were Epstein-Barr virus (EBV) seropositive preoperatively. Five of the donors (20%) were CMV seropositive. The most common indications for OLT were biliary atresia (8) and tyrosinemia (7). There were 4 deaths, for an overall mortality rate of 19%. In 3 patients, deaths were related to infection (CMV hepatitis and duodenitis with aortoduodenal fistula, adult respiratory distress syndrome [ARDS] with Streptococcus viridans pneumonia, Escherichia coli cholangitis with progressive hepatic failure). Fifteen patients (72%) had 41 major infections, most of them bacterial, during the first month posttransplantation. These include pneumonia (25%), line sepsis (17%), cholangitis (14%), and tracheitis (14%). There was only one major viral infection, a CMV hepatitis that occurred in the first month posttransplantation. Three patients had fungal infections (8%) associated with hepatic artery thrombosis and recurrent cholangitis. All three patients required retransplantation. There was only one protozoal infection (Pneumocystis carinii pneumonia) causing life-threatening respiratory failure, from which patient recovered without sequelae. Infection still remains a serious complication of OLT. Bacterial infection is common and is usually associated with technical complications. The low rate of CMV infection is related to low incidence of CMV in the donor pool and the minimal use of strong immunosuppressants.