[Proton pump inhibitors (PPI): may be not as harmless as believed]. / Inhibiteurs de la pompe è protons (IPP): peut-être pas si inoffensifs que cela.

Proton pump inhibitors (PPIs) are among the most widely prescribed medications worldwide and their use is increasing. Their efficiency has been proven and the short term tolerance is good with few reversible side effects. However concerns about possible long term side effects continue to arise. This article reviews proven and potential side effects associated with PPI especially on the long term use.

[Acute abdominal pains in children: when to refer to the surgeon?]. / Douleurs abdominales de l'enfant: quand appeler le chirurgien?

Children presenting with acute abdominal pains at emergency rooms are frequent, but few of them require a pediatric surgeon. However it can be dangerous for the patient (and for the physician = major cause of prosecutions) to misdiagnose those cases. Children with "classic" gastroenteritis may prove to have a perforated appendicitis, while those with tender abdomens may suffer pneumonia or streptococcal pharyngitis, and a comatous child may have an intussusception and not a metabolic disease. We review the diagnostic and management of some common causes of surgical abominal pains in children to help the physicians to avoid some pitfalls, and to involve the pediatric surgeons at an early stage.

[Pediatrics]. / Pédiatrie.

This article summarizes the medical progress achieved in 2 frequent and 2 rare pathologies: 1. Cryptorchidism should be operated around 12 months of age and hormonal treatment abandoned in order to maintain fertility and avoid development of testicular tumors. 2. For the treatment of streptococcal pharyngitis oral cephalosporins for 4 to 5 days are equivalent to a Penicillin treatment of 10 days. 3. Thanks to carvedilol (a beta-blocker agent), levosimendan (a calcium sensibiliser) and nesiritide (an analog to the natriuretic peptide) a new hormonal approach to cardiac failure is possible. 4. Corticosteroids allow to improve quality of live and life expectancy in Duchenne muscular dystrophy, provided treatment starts early and a multidisciplinary approach is assured.

A 16-month-old boy vomits a double tongue: intraluminal duplication of the cervical esophagus in children.

A 16-month-old boy presented with a story of stridor, solid dysphagia and a history of spectacular protrusion underneath his tongue which was mistaken by the parents for a snake's tongue! The radiological examinations showed a filling defect of the upper and middle third esophagus which compressed the cervical trachea. This was found to be an intraluminal tubular esophageal duplication. Treatment by cervicotomy and unusual histological facts are presented.

Interstitial cells of Cajal are normally distributed in both ganglionated and aganglionic bowel in Hirschsprung's disease.

Surgery for Hirschsprung's disease is often complicated by post-operative bowel motility disorders. The impact of intestinal neural histology on the surgical outcome has been previously studied, but no information is available concerning the influence of the distribution of interstitial cells of Cajal (ICC) on these complications. These cells are considered to be pacemakers in the gastrointestinal tract. The aim of this study was to assess the distribution of ICC in the proximal segment of resected bowel in Hirschsprung's disease and confront these results with the clinical outcome. Using immunohistochemistry for light microscopy, we compared the pattern of distribution of ICC in the proximal segment of resected bowel in Hirschsprung's disease with that in normal colon. We correlated these results with the corresponding neural intestinal histology determined by CD56 and the protein gene product 9.5 immunohistochemistry. The distribution of ICC in the proximal segment of resected bowel is identical to that of normal colon, regardless of normal or abnormal colon innervation. ICC distribution does not seem to contribute to post-operative bowel motility disorders in patients operated for Hirschsprung's disease

Open or closed pinning for distal humerus fractures in children?

INTRODUCTION: In children, the choice between percutaneous pinning (PP) and open pinning fixation (OPF) for the surgical treatment of fractures of the distal humerus remains controversial, especially the PP method for internal humeral condylar (IHC) fractures. PATIENTS AND METHODS: Eighty fractures of the distal humerus in children were treated surgically in our hospital over a ten year period. 47% (n = 38) were supracondylar (SC), 20% (n = 16) comminuted (COM), 18% (n = 14) internal humeral condylar (IHC), and 15% (n = 12) lateral humeral condylar (LHC). We used PP, OPF and three times osteosynthesis with screws. RESULTS: In comparison to OPF, PP reduced the length of hospitalization in SC fractures (2.8 versus 6.1 days) and IHC fractures (2.4 versus five days). It reduced the risk of extension deficiency (11.1% versus 15%) and of cubitus valgus (0% versus 20%) in SC fractures, and of cubitus varus in IHC fractures (0% versus 11.1%). However it induced a higher rate of cubitus valgus (11.1% versus 20%) in IHC fractures, one persistent neurological motor deficiency (radial nerve) and four cases of transitional neurological involvement (ulnar nerve). CONCLUSIONS: PP is a good surgical method for SC and for also for IHC fractures, if performed by experienced surgeons so as to avoid neurological damage.

Imaging of blunt arterial trauma of the upper extremity in children.

We report four patients with blunt arterial trauma of the upper limb following unusual mechanisms of injury in two patients (one fell on the handlebars of his bicycle, the second was crushed by a moving lawn mower) and due to bicycle accidents in two further patients. The use of digital subtraction angiography (DSA) in all patients, together with colour Doppler imaging (CDI) in one patient, provided optimum preoperative identification and localisation of the arterial lesions.

[Accident prevention in early childhood]. / Prévention des accidents de la petite enfance.

Accidents are the first cause of mortality and morbidity in children and adolescents of both sexes as from their first month of life. Also they are the first cause of hospitalization and thus have an important economical impact. The knowledge of the mechanisms of injury can neither be transposed from a place to another nor be extrapolated with time. For this reason we developed in 1989 a prospective data base for injuries of children and adolescents from 0 to 16 years of age occurring in our state (canton de Vaud, Switzerland). From Jan 1st, 1990 to Dec 31st, 1999, we recorded more than 28,000 cases. Infants and young children are involved in domestic injuries, accidents on playgrounds and in traffic accidents being pedestrians or passengers. We analyze the circumstances of accidents and point out their prevention programs and their efficiency. We try to demonstrate why children injuries are not fatalities but depend on mechanisms which can be predicted inarticular by an adequate information.

Laparoscopic surgery for gastroesophageal reflux disease during the first year of life.

BACKGROUND: Very few children need gastroesophageal antireflux surgery during their first year of life; hence, no series has been published so far. The authors report their experience in 3 centers. METHODS: From January 1993 to December 1998, 36 infants between 23 days and 13 months of age, suffering from gastroesophageal reflux disease (GERD), underwent surgery by a laparoscopic approach. The patients' weights ranged from 2.4 to 8.5 kg. Preoperative diagnostic studies included esophagograms, manometries, endoscopies, and pH-metries. Fifteen babies (41.6%) had associated anomalies, and 10 (27.7%) were neurologically impaired. Thirty-six laparoscopic fundoplications were performed according to either Toupet's procedure (17 of 36), Rossetti's (10 of 36), Nissen's (8 of 36) or Lortat-Jacob's (1 of 36). Four infants previously had undergone a gastrostomy, whereas 6 needed one during the antireflux procedure. RESULTS: There was no mortality in our series. Three infants (8.3%) had an intraoperative complication: 1 lesion of a diaphragmatic vessel, 1 pneumothorax, and 1 case of severe hiatal hernia requiring conversion to open surgery. During the median follow-up of 22 months, 4 redo procedures were performed (11.1%). CONCLUSIONS: This experience shows the feasibility of laparoscopic fundoplication even in children below 1 year of age. An accurate preoperative diagnostic study is mandatory, because 50% of these patients presented associated anomalies. A long and accurate follow-up is necessary to evaluate long-term results and detect possible complications, which can occur as late as 1 year after surgery. In addition, we believe that redo antireflux surgery is possible by the laparoscopic approach without major difficulties, based on our larger experience with older children.

Tracheobronchial ruptures from blunt thoracic trauma in children.

BACKGROUND/PURPOSE: Tracheobronchial ruptures in blunt thoracic trauma in children are rare. The aim of this study was to suggest the means of an early diagnosis and a conservative management as often as possible. METHODS: Sixteen cases of tracheobronchial ruptures by blunt thoracic trauma were observed over 26 years in 9 regional pediatric centers. RESULTS: There were 12 boys and 4 girls, from ages 1 hour to 17 years. Nine children presented with associated lesions. Fibroscopy established the following diagnosis: 8 tracheal wounds and 8 bronchial wounds. Six children were operated on within 18 hours (on average) after installation of a thoracic drainage. Two lobectomies, 3 ideal tracheal sutures, and 1 bronchial suture were performed. Seven children were treated exclusively by thoracic drainage. Two of them were intubated through the lesion, leading to a transitory endoprothesis accompanied or not by an external thoracic drainage. One infant recovered spontaneously. There were no deaths in this series. Two recurrent postoperative nerve injuries were noted, one of which was a transitory spontaneously resolutive scar bud and one a granuloma treated by laser. Three times, a stenosis occurred after a conservative management. Two were operated on. CONCLUSIONS: Tracheobronchial ruptures in children are rare. An early fibroscopy holds an important place in the approach of this pathology. Treatment is variable, based on thoracic lesions, their tolerance by the child, and associated lesions. Surgery is not the only therapy because conservative treatment by simple thoracic drainage or lesion intubation has proved effective.

Esophageal replacement in children: evaluation of the one-stage procedure with colic transplants.

After having practiced two-stage esophagoplasties by retrosternal Iso-peristaltic colic transplant since 1966, we introduced the one-stage procedure in 1989, placing the transplant in the posterior mediastinum following a closed-chest esophagectomy. We have performed 121 such esophagoplasties in children until now. To evaluate the possible effects of the different techniques as accurately as possible, we recorded two uniform series of 32 and 41 esocoloplasties carried out under identical conditions by two operators respectively. All of the children, aged 1.2 to 13.9 years (mean age: 4.3 years and 4.8 years, limits 1.2-13.9 years), were operated upon for caustic burns of the esophagus. The general concept of both interventions is the same. Improvements such as optimizing the proximal and the colo-gastric anastomosis and the creation of an anterior anti-reflux hemi-valve were aimed for. The one-stage esophagoplasty has become a shorter procedure (mean 4.9 h) than the two-stage one (mean 5.7 h). The one-stage procedure has no higher rate of per-operative complications than those observed during the two-steps of the staged operation. One-stage esophagoplasty provides better morphological results. The redundancy of the transposed colon, the narrowing effect of the upper cervical passage and of the point of re-entry into the abdominal cavity are avoided. The mediastinal colon is straighter, which allows better emptying by gravity. The improvement of the lower anastomosis decreases the reflux rate in the transplant to 12%. Postoperative care demands a longer stay in the intensive care unit because of pharyngeal and left pulmonary respiratory complications. For these reasons we kept our patients intubated for a period of 2 to 5 days (mean period: 3.4 days). All patients survived the intervention.