[Bariatric surgery in adolescent with morbid obesity : what role for the child psychiatrist?] / Prise en charge chirurgicale de l'obésité morbide chez l'adolescent : quel rôle pour le pédopsychiatre ?

The prevalence of obesity has grown steadily in recent years, making it almost an epidemic. Obesity is a chronic condition whose prognosis is burdened by severe comorbidities. Both the quality of life and the life expectancy are affected. The medical management of morbid obesity is still the rule, but surgical practices are developing rapidly. While bariatric surgery in adults is common and gives excellent results, in adolescents, its practice is less prevalent. Beyond issues specific to this developmental period, this question raises ethical issues. In this context, the pluridiscplinary team faces diverse determinants and challenges and the child and adolescent psychiatrist (CAP) is, the psychiatrist is summoned for psychopathological aspects but also for embarrassing questions. In this work, we are going to specify the role of the CAP in the practice of bariatric surgery.

L'obésité dont la prévalence n'a cessé de croître ces dernières années, est en passe de devenir une véritable épidémie. Affection chronique, le pronostic de l'obésité morbide est grevé de co- morbidités sévères altérant la qualité de vie des patients et amputant leur espérance de vie. Les prises en charge diététique et médicale restent les plus répandues. Cependant, les pratiques chirurgicales n'ont cessé de se développer. Alors que la chirurgie bariatrique chez l'adulte est devenue courante, sa pratique chez l'adolescent est moins fréquente et se prête moins à la banalisation. Au-delà des enjeux développe- mentaux spécifiques à la période particulière qu'est l'adolescence, cette question soulève des considérations éthiques et suscite des positionnements extrêmes. Dans ce contexte aux déterminants flous et aux enjeux tant sociétaux que médicaux, le pédopsychiatre peut être convoqué, au-delà de la question psycho- pathologique, pour statuer sur des questions relevant plus de la morale que de la science. Nous nous attèlerons donc, au long de ce travail, à définir les différents objets de soins somatiques ou psychiques qui rassemblent les praticiens de différents bords au chevet de l'obésité et à expliciter la fonction psy dans ces prises en charge.

[Diagnosis and management of a particular caseof intractable constipation]. / Diagnostic et gestion d'un cas particulier de constipation opiniâtre.

Constipation is a very common pattern in childhood. There are multiple reasons for constipation including one very rare : chronic intestinal pseudo-obstruction syndrome. We report the case of a young patient monitored for multiple incidents of intestinal pseudo- obstruction with intractable constipation. The patient underwent several surgical interventions to relieve his symptoms because the non operative treatments, based on liquid diet and laxatives, didn't show great effectiveness. We will review the differential diagnosis of chronic constipation and we will discuss the particular diagnostic entity of this patient. We will also discuss the different treatments that allowed to provide tolerance to oral feeding.

La constipation est un motif de consultation pédiatrique très courant. Les étiologies sont multiples mais le syndrome de pseudo- obstruction intestinale chronique, une cause de constipation chronique, est très rare. Nous rapportons le cas d'un jeune patient suivi pour de multiples épisodes de pseudo- obstruction intestinale avec une constipation opiniâtre. Le patient a subi plusieurs interven- tions chirurgicales pour soulager ses symptômes car les traitements à base de diète liquide et de laxatifs ne se sont pas toujours montrés efficaces. Nous reverrons les diagnostics différentiels d'une constipation chronique et nous discuterons de l'entité diagnostique particulière de ce jeune patient. Nous discuterons également des différents traitements entrepris pour lui permettre de continuer à s'alimenter normalement.

Perioperative spleen embolization as a useful tool in laparoscopic splenectomy for simple and massive splenomegaly in children: a prospective study.

OBJECTIVE: The purpose of this prospective study is to evaluate the efficiency of perioperative spleen embolization prior to laparoscopic splenectomy indicated for hypersplenism. METHODS: We conducted a prospective study exploring a technique combining ultra-selective perioperative embolization and splenectomy. Between January 2008 and March 2013, 16 splenectomies were performed in children suffering from hypersplenism due to varying hematologic diseases. Spleen embolization was performed by an interventional radiologist in the operating room (OR) just before splenectomy and during the same general anesthesia. Ages varied from 3 to 17 years. Spleen volume was measured by preoperative ultrasound. One patient underwent a laparotomy because of suspected adhesions due to previous surgery. All other operations were performed laparoscopically. RESULTS: One complication arose from embolization: a perforation of the splenic artery. After immediately placing a platinum coil proximal to the perforation, the splenectomy was carried out as usual. Fourteen children (87.5 %) had splenomegaly, of which eight (50 %) had massive splenomegaly. There were no deaths, no conversions to laparotomy, no reoperations and none of these patients had to be transfused. CONCLUSIONS: Perioperative spleen embolization performed in the OR by an interventional radiologist makes laparoscopic splenectomy a safer procedure. We propose a preoperative method for spleen measurement that is adapted to children: simple and massive splenomegaly is defined through patient body weight and a preoperative ultrasound. We conclude that spleen size is no more a limiting factor for laparoscopic splenectomy in children.

Transvesicoscopic Cohen ureteric reimplantation for vesicoureteral reflux in children: a single-centre 5-year experience.

PURPOSE: To evaluate our results with a new method of intravesical ureteric reimplantation using laparoscopic pneumovesicum in children. MATERIALS AND METHODS: Seventy-two patients (mean age 4.2 years, range 0.5-20 years) with primary vesicoureteral reflux (VUR) underwent a laparoscopic transtrigonal ureteric reimplantation with CO(2) pneumovesicum. Ports were inserted suprapubically - 5mm for the camera and two 3-5-mm working ports. Having mobilized the ureter(s) intravesically, a submucosal tunnel is created and ureteric reimplantation performed with 5/0 and 6/0 absorbable sutures. Bladder drainage was maintained for 2-3 days postoperatively. Patients were followed up with clinical assessment and renal ultrasonography+/-voiding cystourethrogram. RESULTS: Ninety percent had VUR grade > or =3. A total of 113 ureters were reimplanted. The mean operative time was 82min for unilateral and 130min for bilateral reimplantation. Four cases (6%) were converted. Three patients presented with temporary ureteric dilatation without symptoms on follow-up renal ultrasound. Seven patients had postoperative urinary tract infection without persistent reflux on cystography. Follow-up cystogram was performed in 50 patients (81 ureters). Reflux persisted in four patients (8%). CONCLUSIONS: Laparoscopic ureteric reimplantation with CO(2) pneumovesicum is technically feasible with a high success rate (92%). The role of this new technique in the treatment of VUR remains to be determined.

Retroperitoneoscopic vs open dismembered pyeloplasty for ureteropelvic junction obstruction in children.

PURPOSE: To compare the effectiveness, potential advantages and complications of classical open pyeloplasty with retroperitoneoscopic pyeloplasty in children. MATERIALS AND METHODS: Two patient cohorts with confirmed ureteropelvic junction obstruction (UPJO) undergoing open or retroperitoneoscopic pyeloplasty over a 7-year period were analysed comparatively. RESULTS: Operative time was significantly longer in the retroperitoneoscopic group (mean 155 min) compared to the open pyeloplasty group (mean 98 min, P<0.05). Mean hospital stay was shorter in the retroperitoneoscopic group (mean 4.1 days, compared to 5.1 days, open). Complication rates were similar (open, 27% vs retroperitoneoscopic, 29%). These included anastomotic urinary leakage, stenosis and infection. Anastomotic leakage was more common in the retroperitoneoscopic group. There was a 6.6% conversion rate in the retroperitoneoscopic group. Success, defined as improved ultrasonic or renographic parameters, with resolution of symptoms where discernable, was noted in 96% of the open group and 97% of the retroperitoneoscopic group with a mean follow up of 38 and 25 months, respectively. CONCLUSIONS: Retroperitoneoscopic pyeloplasty is as safe and effective as open pyeloplasty. This technique is now our procedure of choice for children>4 months old. The advantages are more obvious in children over 4 years than in infants. This technique remains difficult to perform and teach.

Triple intussusception involving heterotopic pancreatic tissue: a case report.

INTRODUCTION: Intussusception involving heterotopic pancreatic tissue is a rare condition where a portion of the bowel telescopes into an adjacent segment with intraluminal pancreatic tissue as the lead point. Cases of heterotopic pancreas are most often described in the upper intestinal tract, particularly the stomach. CASE PRESENTATION: We present the case of a five-month-old boy of Caucasian ethnicity suffering acute abdominal pain and vomiting with an abdominal mass in the upper right quadrant. Work-up including ultrasound scan confirmed the intussusception. Repeated attempts at radiological reduction and two laparoscopic procedures were performed within 24 hours, which eventually led to the diagnosis of a triple intussusception. CONCLUSION: To our knowledge, such a case of triple intussusception involving isolated heterotopic pancreatic tissue is previously unreported.

Minimally invasive urologic surgery in children: an overview of what can be done.

PURPOSE: Laparoscopy has emerged as a feasible and effective alternative for abdominal pathologies in children. Urological minimally invasive surgery is now commonly used for basic operations in most centres and is just beginning to expand its use in more complex operations in several selected centres around the world. We present the current state of the art of minimally invasive surgery in children. MATERIAL AND METHODS: We first reviewed all the urological pathologies treated with minimally invasive surgery in our institution. Secondly we reviewed the literature in order to highlight and discuss certain relevant articles and compare them with our own experience. RESULTS: Since beginning to use minimally invasive surgery at our institution we have operated more than 550 cases with urological pathologies. We used three approaches: the transperitoneal, the retroperitoneal and the transvesical approach. Our preferred indications for each approach are discussed. DISCUSSION: Non palpable testis, varicocele surgery, nephrectomy and adrenalectomy are, in our opinion, established minimally invasive procedures. Hemi-nephrectomy, pyeloplasty and Cohen antireflux surgery are probably excellent indications when minimally invasive surgery is carried out by expert hands. Stone management should not be forgotten in cases of contraindication or failure of ESWL. Even the most complex urological operations may be safely carried out using a minimally invasive approach, although most of the cases described are case reports. CONCLUSION: More papers are published on ablative or reconstructive urological minimally invasive surgery. Transperitoneal and retroperitoneal approaches are used with the same results. Transvesicoscopic surgery should rapidly grow to become a standard approach for Cohen reimplantation. It is anticipated that technical progress will provide the opportunity for more paediatric urologists to develop a minimally invasive approach.

[Conservative treatment of traumatic rupture of the biliary ducts: a case report]. / Traitement conservateur des ruptures traumatiques des voies biliaires: à propos d'un cas.

The diagnosis of a biliary duct transection after blunt trauma is difficult in children. Surgery is often performed late and therefore complicated. We present a case of mini-invasive approach for biliary duct transection in a 12-year-old child and review the literature. Transhepatic cholangiography is at the moment the most used technique to make the diagnosis but necessitates general anaesthesia. Stent placement is possible by the way. Endoscopic retrograde cholangiogram (ERCP) has been proposed even in children. Stent placement may be easier by this technique. For the diagnosis, Technetium 99m dimethylminodiacetic acid (HIDA) scanning seems interesting in terms of both sensitivity and specificity. Another promising diagnostic technique is MRI with 3D reconstruction.

Retroperitoneoscopic approach to the adrenal glands and retroperitoneal tumours in children: where do we stand?

Choosing the best way to approach adrenal gland and retroperitoneal tumours is still difficult. We reviewed our first 10 cases operated on by retroperitoneoscopy and compared this approach with other possible ways described in the literature. There were 2 intraoperative complications: 1 opening of the diaphragm and 1 bleeding. Tumour resection was always complete. There was no conversion. There were no postoperative complications. The retroperitoneoscopic approach for adrenalectomy and retroperitoneal tumour resection is increasingly being used. In children, operation is quite fast, without much blood loss and with spectacular postoperative recovery results. Even for the right side we advocate this approach, due to the particular anatomy (small tumour size, less fat, thinner muscle layers) in this age group. Trained surgeons are, of course, mandatory.

Long-term outcome of laparoscopic Nissen and Toupet fundoplication in normal and neurologically impaired children.

BACKGROUND: Laparoscopic fundoplication is a commonly performed procedure in children. This report describes the incidence of long-term recurrence and complications after laparoscopic Nissen or Toupet fundoplication in neurologically impaired and normal children. METHODS: Fifty-three children operated on before 1999 were reviewed. All children were evaluated clinically and with a barium meal study thereafter. Symptomatic children and those with abnormal barium meal underwent 24 h pH monitoring. RESULTS: A total of 45 patients were included in the study. The mean follow-up was 4.5 years. All, except one asymptomatic child that declined, had a barium meal. Four were abnormal (2 parahiatal hernias and 2 slight episodes of reflux). Four patients had symptoms related to the operation and 2 to clinical recurrence. Only 1 asymptomatic child with slight reflux at barium meal revealed abnormal 24 h pH monitoring. Finally, 6.6% patients were found to have late recurrence (2 clinical and 1 pHmetry). There was an obvious increase in children's weight, especially in neurologically impaired patients. CONCLUSION: Laparoscopic antireflux surgery is of value in children with gastroesophageal reflux disease. The long-term results are comparable with open surgery, and there was no difference in term of wrap failure between neurologically impaired and normal children.

Diaphragmatic duodenal atresia: laparoscopic repair.

Stenosis due to a diaphragm is a type of intrinsic duodenal obstruction in newborns and even in childhood, when obstruction is partial. We present a case of a 13-month-old girl with diaphragmatic stenosis associated with a dilated first and second duodenum. Surgical management consisted of a partial excision of the diaphragm after vertical incision of the anterior part of the second duodenum followed by a transverse suture. This diamond-shaped anastomosis was successfully carried out laparoscopically. No tapering of the duodenum was performed as some authors suggest in cases of megaduodenum. The rapid resumption of peristalsis and fewer adherences than expected after such a minimally invasive approach could make a more invasive procedure unnecessary. Only long-term follow-up and greater experience will show which procedure is most suitable.

[Mini-invasive surgery of the retroperitoneal space in children]. / Chirurgie mini-invasive de l'espace rétropéritonéal chez l'enfant.

UNLABELLED: Although laparoscopic surgery now represents today an essential surgical technique, its use remains limited in urology and especially in pediatric urology for many reasons, main because of the lack of indications. After a large experience acquired in abdominal laparoscopic surgery, and because we were convinced of the advantages offered by this new mini-invasive approach, we have tried to develop it for the retroperitoneal space. METHODS: Over a five-year period we performed 88 retroperitoneal procedures in children:--50 nephrectomies (44 total, 10 partial) for the following indications: 15 polycystic dysplastic kidney, 13 kidney destroyed by reflux, 18 by obstruction, hypertensive uropathy 3, pyonephrosis 1.--5 renal cystectomies, 3 pyelolithotomies, 2 pyeloureteral obstructions, 2 adrenalectomies, 1 retrocaval ureter, 25 varicoceles. The age range was 2 months to 16 years (mean: 3.7 years, 25 children under 1 year). The patients were placed in the lateral debubitus. The retroperitoneal space was created by dissection under direct vision, then insufflation was performed directly in the retroperitoneal space without balloon. Three or four ports were used except for varicocelectomy which was performed with only one port and an operating channel telescope. RESULTS: Follow-up range was 6 months to 5 years. The mean operating time was 96 minutes (35 to 210 min.). Average postoperative stay was 2 days. Conversion was needed in 7 cases (8%). Operative incidents consisted of one duodenal perforation, one ureteral burn, 21 peritoneal perforations (24%). There were 5 postoperative complications (2 urinomas after partial nephrectomy, 1 hydrocele, 1 varicocele recurrence, 1 recurrent stones) not related to the technique. 3 cases needed reoperation (ureteral injury, varicocele recurrence, recurrence of cystine stones) with good result. CONCLUSION: Like other laparoscopic techniques, retroperitoneoscopy requires a training: it remains delicate in children because of the reduced working space and the fragility of the peritoneum. However the advantages seem sufficiently obvious for us to recommend and promote this procedure.

[Benign testicular tumors in children. Value of simple tumorectomy]. / Tumeurs bénignes du testis chez l'enfant. Intérêt de la tumorectomie simple.

From 1984 to 1999, the authors observed 18 intratesticular tumours, 13 of which corresponded to benign lesions. The objective of this study is to define preoperative and intraoperative criteria of benign lesions in order to allow conservative management (simple excision or enucleation) and to analyse the results of this treatment. The 13 boys of this series were between the ages of 5 months and 14 years (mean: 7.1 years). The lesion presented as scrotal swelling in 12 cases and gynaecomastia in 1 case. Tumour markers (alphafoetoprotein, beta HCG) were at the limit of normal for age. Ultrasonography was performed in every case. In each case, treatment consisted of primary exposure of the pediclc with clamping then exteriorization and macroscopic examination of the lesion. Frozen section examination was performed in 11 cases. Treatment consisted of 9 enucleations and 4 orchidectomies. The final histology concluded on epidermoid cyst or simplified teratoma with exclusively ectodermal development in 4 cases, multi-differentiated teratoma in 2 cases, sex cord tumour in 2 cases, simple cyst in 2 cases, rete testis dysplasia in 1 case, cavernous haemangioma in 1 case, and vestigial cyst in 1 case. There was no discordance between the final histological examination and the frozen section examination. The mean follow-up is 4.4 years. No secondary atrophy and no local or distant recurrence was observed in the 9 cases of enucleation. In conclusion, testicular tumours are often benign in children. Selection based on a body of clinical, laboratory, radiological and frozen section histological evidence should allow carcinologically safe conservative surgery with an aesthetic, psychological and functional benefit for the child.

Laparoscopic appendectomy in children: sense or nonsense?

The authors present a retrospective analysis of their first 1.500 paediatric laparoscopic appendectomies. Three types of techniques (OUT, MIXED, IN) are described. The average age of the patients was 8 years (range: 2 to 16 years). In case of acute appendicitis the postoperative complication rate was 0.6%. In case of peritonitis the postoperative complication rate raised to 13.3%. Conversion rate was 3.3%. There were no death. Mean hospital stay was 1.8 days for acute appendicitis and 6.5 days for peritonitis. Laparoscopic appendectomy in children has an unquestionable diagnostic interest, decreases the parietal complications and has a better cosmetic result in case of peritonitis or ectopic appendicitis. Benefits are highest in case of peritonitis by decreasing postoperative pain and length of hospital stay. The teaching value for learning laparoscopic surgeons is obvious. Increase of intraperitoneal residual abscesses, as well as increasing cost, remain controversial. This series is a plea for laparoscopic appendectomy in children.

[Fetal endoscopic surgery: between dreams and reality. (South-East medicine and prenatal research)]. / Chirurgie endoscopique foetale: entre rêve et réalité. SEMERA (Sud-Est médecine et recherche anténatale).

"Open" fetal surgery has had little success in the management of fetal malformations, and is limited by two important unresolved difficulties: control of the operating stress on the fetus and maternal tocolysis. The "mini-invasive" approach by endoscopic surgery circumvents these difficulties and appears promising. Decision making with the dilemma between prenatal or postnatal surgery remains critical.

Umbilical one-puncture laparoscopic-assisted appendectomy in children.

To perform a laparoscopic appendectomy, three trocars are usually needed. In order to reduce abdominal wall trauma, we have adopted an umbilical one-puncture laparoscopic-assisted appendectomy (UOPLAA). We did a retrospective study of UOPLAA performed during last 2 years on 200 children aged from 5 to 18 years (median, 9 years). The patients were selected after clinical examination. No child with advanced generalized peritonitis or an abscess with a palpable mass was a candidate for this technique. UOPLAA was successful in 184 patients (92%). In 16 cases (8%), an additional trocar was required to manage perforated or retrocecal appendicitis. The mean operative time was 15 min, and the mean hospital stay was 2 days. There were no intraoperative complications. There were 10 (5%) postoperative complications (three parietal and seven intraabdominal). Four patients (2%) needed reoperation under general anesthesia. The UOPLAA is our preference in cases of acute nonperforated appendicitis because it is simple and fast, with good cosmetic results; but in 8% of our cases, an intraoperative difficulty (retrocecal location, abnormal adhesive band, peritonitis, etc.) arose that required the introduction of additional devices to ensure the safety of the laparoscopic procedure.