Factors associated with empyema in children with community acquired pneumonia.

AIM: Empyema is a potential complication of community acquired pneumonia but factors predicting this complication are lacking. METHODS: A retrospective study of all previously healthy pediatric patients admitted between January 2007 and July 2009 with CAP. Patients with non-lobar pneumonia, RSV bronchiolitis, underlying chronic disease, or hospital-acquired pneumonia were excluded. Preadmission, clinical characteristics on admission, and outcome were compared between patients with and without empyema. Management strategies in patients with empyema were also compared. RESULTS: Overall 356 patients were included. Median age was 3.8 ± 3.54 years and 60.7% were males. A total of 43 patients (12%) were diagnosed with empyema. The development of empyema was independently associated, on multivariate analysis, with older age, female gender and antibiotic therapy prior to admission, and with dyspnea, thrombocytopenia and involvement of more than one lobe on chest radiograph on admission. Patients who developed empyema had a longer and more complicated course. Hypoxemia on admission was significantly less frequent in patients with empyema who were treated with antibiotic therapy alone, compared to those treated with chest tube or video-assisted thoracoscopic surgery. CONCLUSION: Early identification of dyspnea and thrombocytopenia in patients with community acquired pneumonia could alert physicians on the potential development of empyema. Antibiotic therapy alone may be sufficient in patients with empyema who are mildly hypoxemic on admission.

Laparoscopic approach as primary treatment of common bile duct stones in children.

BACKGROUND: Preoperative endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy (ES) are an effective strategy for choledocholithiasis, but complications such as pancreatitis and outcome in children are unknown. The laparoscopic cholecystectomy became the new gold standard in children for cholelithiasis. For the choledocholithiasis in children, the attitude is more controversial. We analyzed our series of laparoscopic approach for the management of choledocholithiasis in children to determine if it is an effective procedure. PATIENTS AND METHOD: Between 1996 and 2001, 126 children were treated for cholelithiasis in our institution; 13 children (10.3%) were managed for a choledocholithiasis. We reviewed age at symptom onset results of paraclinical examinations, the type of laparoscopic management, and postoperative outcome. RESULTS: The mean age at clinical signs was 9.9 years (range, 3 months-15.5 years). One child was excluded because he had a preoperative ES. Twelve children had a laparoscopic cholecystectomy and cholangiogram at the same time. A choledocholithiasis was found in 10 cases. A flush of the common bile duct (CBD) was performed in all cases with a 3F or 5F ureteral catheter; the stone was pushed into the duodenum in 3 cases and successfully extracted in 3 with a 4F Dormia or Fogarty catheter. One child needed a conversion to open surgery. Three times, an ES was necessary in postoperative course in each case for clinical and biologic signs of CBD obstruction or pancreatitis (30%). All children are symptom-free with an average follow-up of 28 months. CONCLUSION: Laparoscopic CBD exploration for choledocholithiasis can be performed safely in children at the time of cholecystectomy and can clear all of the stones in the CBD in two thirds of cases. If there is residual obstruction, a postoperative ES can be performed. We suggest primary treatment of choledocholithiasis by laparoscopic approach in children.

Reimplantation of oesophageal bronchus following a type III oesophageal atresia repair.

Oesophageal atresia can be associated with communicating bronchopulmonary foregut malformations, the most common being the oesophageal bronchus. Lung resection may be mandatory, but conservative treatment correcting the abnormal airway has been proposed, raising the difficult issue of perioperative ventilatory support. The authors report a case of successful reimplantation of oesophageal bronchus revealed after surgical cure of an oesophageal atresia with tracheo-oesophageal fistula.

Left thoracoscopic thymectomy in children.

BACKGROUND: In the management of autoimmune myasthenia, thymectomy is recognized as effective surgical therapy. The necessity of complete radical thymectomy to achieve maximal improvement has been emphasized. Video-assisted thoracoscopic surgery has been successfully used for thymectomy in adults, and more recently in children, and has been described as achieving the same radicality and functional improvement as median sternotomy or as transcervical thymectomy. The aim of this work is to report our first thoracoscopic experience in this indication. METHODS: Patients with myasthenia gravis on anticholinesterase drugs and/or steroids are discussed for surgery in case of clinical deterioration despite increasing doses of medication or in case of no improvement. We decided to perform thoracoscopic thymectomies by a left-sided approach. Preoperative localization of thymic tissue is done by a thoracic CT exam. Patients are placed on their right side with a thoracic tilt under the thorax. Four thoracoscopic ports are used, a 10-mm for the camera and three 5-mm operating ports. The left lung was collapsed by selective intubation (double-lumen endotrachial intubation). RESULTS: Two boys, 7.5 and 14 years old, were addressed by the department of neurology for radical thymectomy. They presented an ocular myasthenia gravis for 2 years and a mild general myasthenia gravis for 7 years. The operative times were 120 and 240 min. There was no intraoperative or postoperative complication. Duration of thoracic drainage was 2 days. The children were discharged on the third postoperative day. For the second procedure, an ultrasound exam during surgery was necessary to localize the thymus exactly, thus enabling its complete resection without the need for a conversion. The follow-up is 19 and 7 months with a clinical improvement enabling the diminution of medication for both children, the end of ptosis for the first child, and the general improvement of muscle strength for the second. CONCLUSIONS: Thoracoscopic thymectomy in children with juvenile myasthenia gravis seems to offer a complete surgical resection, as do open techniques. In case of difficulties in finding the thymus, an ultrasound exam is feasible to enable complete resection. The left-sided thoracoscopic approach gives a good mediastinal and cervical exposition. Furthermore, being less painful in the postoperative period, it presents a less pronounced impairment of pulmonary function, and it presents good cosmetic effect.

Elective laparoscopic cholecystectomy.

BACKGROUND: Gallbladder stones are very common in patients with sickle cell disease and are the cause of recurrent abdominal pain. Their management has been highly controversial, especially for children. Nonoperated patients and those treated on an emergency basis have a very high rate of morbidity (>50%). METHODS: We performed a retrospective review of a series of 29 homozygous SS sickle cell children who underwent laparoscopic cholecystectomy between 1991 and April 1998. RESULTS: Only in one case a conversion was necessary (early in the series). Exploration of the common bile duct was done via intraoperative cholangiography. There were no mortalities. The morbidity rate was 17%; (however, of the five patients concerned, four suffered from hyperthermia for 2 days. All of the children were improved and enjoyed resolution of their abdominal pain. CONCLUSIONS: We believe that elective laparoscopic cholecystectomy at the earliest time possible, along with correct perioperative management, is the treatment of choice for cholelithiasis in children with sickle cell disease.

GDNF expression in Wilms tumor.

PURPOSE: Wilms tumor or nephroblastoma is a developmental tumor of the kidney and one of the most frequent solid tumors in childhood. It derives from metanephrotic blastema and mimics nephrogenesis in a disorganized manner, offering an adequate model for study of human nephrogenesis. GDNF (glial cell line derived neurotrophic factor), a potent proliferation and survival factor of dopaminergic neurons, has recently been shown to have an early and major role in nephrogenesis. We studied the expression of GDNF in Wilms tumor. MATERIALS AND METHODS: The study included 20 patients with nephroblastoma whose age at surgery ranged from 2 months to 13 years. Expression of GDNF protein was analyzed by an immunohistochemical technique using anti-GDNF antibody. Presence of GDNF-messenger (m)RNA and receptors GFRalpha1 and GFRalpha2-mRNA was analyzed by reverse transcription polymerase chain reaction. Specimens were also studied to evaluate apoptosis, proliferation index and Bcl-2 expression. RESULTS: GDNF expression was mainly found in the epithelial cells of the most differentiated tubes, GDNF and co-receptors mRNA were found in specimens and proliferative activity was found on the same tubes as GDNF expression. Bcl-2 was expressed strongly in epithelial cells, in an intermediate fashion in the blastema and faintly in mesenchyma. Apoptosis was of low frequency in structures strongly expressing GDNF. CONCLUSIONS: We have shown that GDNF is expressed by nephroblastoma tissue of human kidneys. This expression is mainly in the differentiated epithelial component of the nephroblastoma. We have also shown that tissue strongly expressing GDNF is positively proliferative and has less apoptotic activity. We speculate that the role of GDNF may not be limited to normal nephrogenesis but may interact with other factors in the process of proliferation and apoptosis involved in nephroblastoma tumorigenesis.

The Mitrofanoff procedure: 20 years later.

PURPOSE: We review our initial cases of continent cystostomy to assess long-term functional results and complications after a minimum of 15 years of followup. MATERIALS AND METHODS: Between 1976 and 1984, 23 continent cystostomies were performed on 15 boys and 8 girls with neuropathic bladders. Mean patient age at surgery was 8 years and 4 months (range 3 to 16) and mean followup was 20 years (range 15 to 23). The neurological lesions were due to 21 myelomeningocele (2 associated with an imperforated anus in 21 cases), spinal neuroblastoma in 1 and complex genitourinary malformation associated with an imperforated anus in 1. Closure of the bladder neck was performed in 21 cases (16 during the same procedure, 5 secondarily) and 2 did not undergo this procedure. The appendix was used as the catheterizable conduit in 20 cases, 1 ureter in 2 and a bladder tube in 1. Bladder augmentation was performed during the same procedure in 2 cases and at a later stage in 8. Five patients presented with unilateral or bilateral secondary vesicoureteral reflux. RESULTS: One death occurred after conversion to cutaneous diversion due to a postoperative infection leading to a ventriculoperitoneal valve infection. The remaining 22 patients were followed every 6 to 12 months. No metabolic disorder, secondary malignancy or spontaneous bladder perforation was noted. Bilateral upper tract deterioration was found in 10 cases leading to secondary bladder augmentation by enterocystoplasty in 6 and creation of noncontinent diversion in 4. Leakage occurred after bladder neck closure in 5 patients. Bladder stones were found in 5 patients (2 had prior bladder augmentation). Complications related to the conduit included stomal stenosis or persistent leakage in 11 cases, which required surgical revision and/or repeated dilations and 1 noncontinent diversion after revision failure. Five patients presented with intestinal occlusion due to volvulus in 3 and adhesion in 2. We noted that after 10 years of followup complications were rare and concerned mostly the catheterizable conduit. Therefore, 16 patients had a good and stable result while 6 have noncontinent diversion. CONCLUSIONS: The rate of complications has a tendency to decrease with time. The results obtained in this series may appear less satisfactory than those of more recent series, which may be due to the fact that these oldest continent cystostomies correspond to acquisition of experience of this novel approach, and to a period when the concept of low pressure reservoir was not yet established and bladder augmentations were not routinely performed. Since 1984 no continent cystostomy performed at our institution was converted into a noncontinent diversion. This series with long followup demonstrates that continent cystostomy is a procedure with lasting efficiency.

Temporary high diversion for posterior urethral valves.

PURPOSE: Temporary high diversion for posterior urethral valves remains controversial. Even in the most severe cases some physicians deny the efficacy of this treatment. They assert that high diversion does not change the outcome of kidney function and has an iatrogenic, deleterious effect on the bladder. We believe that these 2 assertions may be inaccurate. MATERIALS AND METHODS: We evaluated 17 of 120 boys with posterior urethral valves who underwent temporary high diversion via Sober-en-T ureterostomy. This procedure immediately decompresses the upper urinary tract and leaves the bladder functional. Mean duration of diversion was 13 months. Bladder function results were good and diversion clearly had no deleterious effect. However, our series was too small to conclude with certainty that renal function improved due to diversion and not to valve resection only. Rapid improvement in creatinine was noted in all cases after diversion. RESULTS: In this study we reviewed opposing opinions. It appears clearly evident that physicians who believe that ureterostomy creates a valve bladder are considering only loop diversion, which temporarily defunctionalizes the bladder. On the contrary, Sober-en-T diversion preserves bladder cycling. In addition, those who report poor kidney function after high diversion fail to mention that this procedure is usually performed only in the most severe cases. CONCLUSIONS: For severe cases of posterior urethral valves one should not hesitate to create temporary high diversion, which may possibly improve renal function. Sober-en-T ureterostomy does not damage the bladder.