Prise en charge chirurgicale des infections cutanées communes de l’enfant

The cutaneous infectious pathology of the child is varied and frequent. Authors deal with surgical infections seen in current pediatrics, which often have to appeal to a plastic pediatric surgeon for their treatment. Superficial infections of skin and pilo-sebaceous follicles are common in big children. The folliculitis and the boil are the most frequent. Their treatment is medical and surgical and does not require an antibiotic treatment in most of the cases. The primitive abscesses or following an anterior lesion recover from a similar treatment. Some localizations or risky context need a particular follow-up. The whitlow is a particular example and needs to have a particular follow-up because of the risk of hand cellulitis. Nails embodied of the child require a specialized notice because of their numerous clinical forms, which must be distinguished according to the age. Finally the necrotizing cellulitis and fasciitis are surgical emergencies and have a well-codified treatment. These infections in children must benefit from an attentive care because when they are badly treated, they can involve the aesthetic, functional and vital forecast.     

An overview of pediatric peritoneal dialysis and renal replacement therapy in infants: A review for the general pediatric surgeon

Currently, there are about 10,000 pediatric patients in the United States who rely on dialysis for renal replacement therapy. Dialysis allows children with chronic kidney disease a means of support until renal transplant is feasible. All forms of renal replacement therapy require a surgical intervention, whether the modality is hemodialysis or peritoneal dialysis. Despite peritoneal dialysis being the most common modality of dialysis in children, there is not prospectively collected much evidence in the literature which can guide the pediatric surgeon about best practices on access placement, management of complications, and timing of removal. Most available studies are small, single-center retrospective reviews. This limits the power of the data collected to help guide decision-making in the management of peritoneal dialysis catheters.The purpose of this review is to provide a consolidated source of best available evidence and identify important areas for future study. Furthermore, this is an area of pediatric surgical care that lacks up to date outcomes research with robust surgeon participation. Lack of coordinated, evidence-based best practices likely results in heterogenous surgical practices and uneven strategies for managing complications. Furthermore, with improvements in neonatal critical care and fetal interventions available for obstructive uropathies and other congenital kidney disorders, there is increased likelihood of the need for dialysis access in more infants, who represent a particularly vulnerable patient population. Importantly, peritoneal dialysis access should be instituted into the national PEDScore curriculum for pediatric surgical fellows, as this procedure is common enough that any pediatric surgeon could be consulted for catheter placement and management. Surgeon awareness of, and participation in the formulation, of guidelines and prospective studies is of paramount importance to ensure optimal care of this vulnerable population of children.     

Endorectal pull-through for Hirschsprung's disease: 17-year review of results in Ukraine

Several surgical procedures are available for the treatment of Hirschsprung's disease (HD) the choice often depends on the surgeon's preference. The procedure that is most convenient for the surgeon is not necessarily the optimal one for the patient, however, and complications and mortality need to be considered. We reviewed our series of 275 children operated upon for HD by endorectal pull-through after Soave-Boley dissection of the seromuscular cuff followed by a hand-sutured (HSA) (210) or stapled (SA) (65) primary perineal colorectal anastomosis. Early postoperative complications were documented in 13 children with a HSA and 5 with a SA Follow-up was from 6 months to 15 years for HSA patients with and from 1 month to 3 years after SA. Results were good or satisfactory; there were no unsatisfactory results. On long-term follow-up the complication rate after SA (13.8%) was comparable to that after HSA (20.5%). The overall complication rate on long-term follow-up was 2.91%, which is comparable to results published in the literature. The SA is particularly convenient for surgeon, as it allows a simpler and shorter operation than with the traditional HSA.     

Rectal burkitt lymphoma in childhood

Lymphomas are the third most common cancer in children and Burkitt lymphoma (BL) accounts for about 40% of them. The rectum is extremely seldom involved in BL: 91 children were treated at our institution for BL between 1987 and June 2006, but none of them had involved the rectum. We report here on a 9-year-old boy who presented with bowel bleeding and subocclusion, which proved due to a BL of the rectum. The role of surgery for this tumor is limited nowadays, except for surgical emergencies, biopsies, and second-look surgery in selected cases.     

Paediatric problems in a paediatric surgical department

It is not unusual for paediatric surgical patients to suffer from paediatric diseases in addition to their surgical problems. These diseases demand further diagnostic procedures and pre- or postoperative therapy. The aim of this study was to discover how many and what kinds of additional paediatric diseases are seen in our paediatric surgical inpatients. We retrospectively evaluated the hospital charts of all inpatients for 1 year. The following data were collected: cause of admission, therapeutic procedure (conservative/operative), surgical discharge diagnosis, additional paediatric diagnoses, and transfer to other departments. A total number of 5,026 hospital stays for 5,840 operations in 4,300 children was evaluated. In 38% of all hospital stays, the children had one or more paediatric diseases. These could be divided into two groups: acute diseases and chronic conditions. In the acute group, 638 children suffered from acute infectious diseases such as respiratory infections and enteritis/gastroenteritis. The most common chronic conditions were allergy, asthma, epilepsy, anaemia, and mental retardation. A special group of patients consists of 21% of the children admitted because of suspected appendicitis. These children not only had a significantly higher incidence of additional paediatric diseases (mostly acute infectious diseases), but also a higher incidence of atopic diseases compared with the patients admitted for other reasons. The early diagnosis and treatment of additional paediatric diseases is essential for the success of paediatric surgery. The paediatrician has a significant role in caring for surgical patients and assisting in the perioperative management, but the paediatric surgeon should also be aware of the spectrum of medical diseases.     

儿童消化道异物的外科治疗

消化道异物是指经口摄入滞留在消化道内无法吸收的物体,是儿童常见急诊状况之一,对儿童健康造成较大危害。依靠病史、临床表现及X线检查一般可以明确诊断,特殊异物需要CT及内镜诊断。内镜治疗是消化道异物的首要诊疗手段,但对内镜治疗失败、合并有严重并发症的患者,手术也是必要的治疗措施,应综合分析异物性质、大小、滞留时间、术中情况等因素,制定个性化手术方案。     

Informing schools about children's chronic illnesses: parents' opinions

Parents of 217 chronically ill children and adolescents were surveyed concerning their opinions about disclosing medical information to schools. The sample consisted of parents of more than one third of the children and adolescents meeting inclusion criteria who were seen at a university-based pediatric clinic during a 10-week period. Parents were asked (1) whether schools need information about 16 health items, (2) who in the school should know, and (3) who should provide this information. Parents' willingness to disclose information was compared with family and child demographic data. Parents strongly believed that (1) teachers need to be informed and (2) parents should be the primary informers. The consensus that schools need information did not vary with family and child demographics. However, parents of children with poor illness prognosis, greater likelihood of emergencies, and visible illnesses were more supportive of disclosure. Most parents indicated that physicians should provide information on 10 of the 16 items. Physicians were viewed as particularly appropriate informers about recognizing emergencies and medication effects. Only 21% of the parents were aware of any prior contact between the medical care giver and the school concerning their child's illness. Thus, parents want schools informed and believe physicians should be involved in providing information.     

A pediatric emergencies training program for emergency medical services

Accidents are the leading cause of death in children, accounting for more pediatric deaths than all other causes combined. Accidents also account for 21.7 million injuries to children that require medical care annually. Despite recognition of this major public health problem, little emphasis is directed toward the pediatric patient in emergency medical services education. In response to this need, Children's Hospital National Medical Center developed a three-day training program in pediatric emergencies for field emergency medical technicians, intermediate paramedics, and paramedics. The course consists of 18 hours of lectures and skill stations focusing on medical emergencies, care of the injured child, the special needs of the infant, and the emotional response of the child and family in an emergency. Test evaluations before and after the course from the 190 participants demonstrate a significant improvement in their knowledge and skills in treating pediatric emergencies (P less than 0.001).     

Main timetables of pediatric emergencies. Experience at the Lenval hospital in 1999]

OBJECTIVE: The purpose of the present study was to determine the main schedules of a visit in a paediatric emergency ward. PATIENTS AND METHODS: A prospective survey concerning the main schedules of the children examined in the paediatric emergency ward of the Lenval's hospital in Nice in 1999 was implemented. The study was conducted over a period of 84 days, one week per month, and included 6038 children analysed recording to the following criteria: 1) duration of the waiting; 2) duration of the radiological period; 3) duration of the medical advice and/or treatment period; 4) total time course of the visit. RESULTS: Data were collected in 66.6% of all cases for waiting (n = 4022), 52.1% for medical advice (n = 3149), in 44.1% for radiological time (n = 833 of 1888 children having radiological examination), in 58.1% for the total time course of the visit. Waiting for not severe emergencies was about one time out of three less than five minutes, more than one time out of two less than 15 minutes, and more than three times out of four less than 30 minutes. Mean radiological time course was 20 to 25 minutes. Mean medical advice was 15 minutes, for medical consultations such as surgical ones. Total time course of the visit was less than 30 minutes in 23.1% of all cases, 30 to 60 minutes in 38.5%, one to two hours in 31.3%, two to four hours in 6.8%, and more than four hours in 0.3% of all cases. Mean total time course of the visit was 45 minutes for medical emergencies and 55 minutes for surgical ones. CONCLUSION: This study shows the main schedules of a visit in a paediatric emergency ward which took care of 26,726 children in 1999. The results of this survey confirmed that waiting before consultation, for not severe emergencies, is sometimes long or very long because of a constant increasing number of patients and their preferential breakdown according to specific periods (weekends, public or school holidays, winter) which are the result of demographic, social and economic changes. At present, the only available possibility to control both phenomena consists in adjusting and adopting medical tools and staffs to crowds and flows. This study also confirms the usefulness for paediatric emergency ward to have a short hospitalization unit.     

The management of immune thrombocytopenic purpura

The most common cause of thrombocytopenia in childhood is immune. The diagnosis must be carefully considered, as there are no specific diagnostic tests. Most children have an acute disease with spontaneous remission within a few weeks. Although the platelet count may be very low, bleeding symptoms are rarely severe, and most often restricted to the skin and mucous membranes. Most children do not require active treatment, but can be managed with good advice, ongoing support and a 24-h contact point. Children with significant bleeding problems may be treated with oral steroids, reserving intravenous immunoglobulin for emergencies or to cover injuries and surgery. About 20% of children continue with thrombocytopenia beyond 6 months (chronic ITP), but expectant management can continue, treatment is rarely required. Splenectomy is rarely required and should be reserved for the very rare child with serious bleeding persisting beyond 6 or 12 months.     

Sedation with intranasal midazolam of Angolan children undergoing invasive procedures

Aim: Ambulatory surgery is a daily requirement in poor countries, and limited means and insufficient trained staff lead to the lack of attention to the patient’s pain. Midazolam is a rapid‐onset, short‐acting benzodiazepine which is used safely to reduce pain in children. We evaluated the practicability of intranasal midazolam sedation in a suburban hospital in Luanda (Angola), during the surgical procedures. Methods: Intranasal midazolam solution was administered at a dose of 0.5 mg/kg. Using the Ramsay’s reactivity score, we gave a score to four different types of children’s behaviour: moaning, shouting, crying and struggling, and the surgeon evaluated the ease of completing the surgical procedure using scores from 0 (very easy) to 3 (managing with difficulty). Results: Eighty children (median age, 3 years) were recruited, and 140 surgical procedures were performed. Fifty‐two children were treated with midazolam during 85 procedures, and 28 children were not treated during 55 procedures. We found a significant difference between the two groups on the shouting, crying and struggling parameters (p < 0.001). The mean score of the ease of completing the procedures was significantly different among the two groups (p < 0.0001). Conclusion: These results provide a model of procedural sedation in ambulatory surgical procedures in poor countries, thus abolishing pain and making the surgeon’s job easier.     

Common Conditions in Pediatric Surgery

Primary care physicians are generally the first contacts of the parents of children with any disease. Management protocols and methods of the surgical conditions in children have undergone changes over time and the aim of this review is to update the knowledge base of clinicians. New technologies like laparoscopy and endoscopic surgery are available for management. The optimal treatment of any surgical condition requires that appropriate procedure is performed at the optimal time by a pediatric surgeon who is best trained for management of these conditions.     

Pediatric surgical missions in Bangladesh

Bangladesh is one of the poorest countries in the world, with a population of more than 120 million people living in a territory of only 55,000 square miles. Pediatric surgery is not recognized as an independent branch of surgery: the Dhaka Shishu Hospital is the only pediatric hospital in the country. Sponsored by the World Organization for Pediatric Surgery in Emerging Countries and Azienda Ospedaliera di Parma, the authors performed four surgical missions in Bangladesh in the city of Khulna from 1991 to 1995. During these missions 395 operations were performed on children with general surgical urological, or maxillofacial problems. Besides the humanitarian significance of these missions, it is very edifying for a Western surgeon to observe the natural evolution of untreated congenital malformations.     

儿童重症脑炎惊厥性癫痫持续状态处理

儿童重症脑炎惊厥性癫痫持续状态是危及生命的急症之一。近年来对惊厥性癫痫持续状态的管理已经有了新的认识,与传统观点相比,不仅惊厥的时间窗与定义发生了改变,而且一些新型药物的使用也取得了良好疗效。本文着重介绍关于惊厥性癫痫持续状态的定义和治疗的新进展。     

Fixation of perineal dressing

A satisfactory method of fixation of a perineal dressing has been elusive to the pediatric surgeon. A simple and effective means of holding gauze and packing in the region of the perineum in infants and young children is described using a disposable surgical mask.     

Malrotation discovered during routine radionuclide gastric emptying study

In infants with recurrent vomiting, and especially bilious vomiting, the algorithmic approach is to perform conventional barium upper gastrointestinal radiography to rule out malrotation and midgut volvulus, which are surgical emergencies. However, children with protracted vomiting and failure to thrive are candidates for medical treatment. These children are often evaluated by radionuclide gastric emptying studies to assess gastric emptying. Three patients are presented in whom the radionuclide gastric emptying study revealed the presence of a malrotation anomaly which had been undetected by antecedent barium gastrointestinal radiographic studies.     

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??Convulsive status epilepticus ??CSE?? in severe encephalitis is one of the most common medical emergencies in children. Recently?? there has been some understanding on the management of convulsive status epilepticus. Not only have the definition and time frame of a seizure changed but many new drugs have been introduced. The aim of this review is to present the current definition of CSE and treatment options it     

Surgical Volume-to-Outcome Relationship and Monitoring of Technical Performance in Pediatric Cardiac Surgery

A significant inverse relationship of surgical institutional and surgeon volumes to outcome has been demonstrated in many high-stakes surgical specialties. By and large, the same results were found in pediatric cardiac surgery, for which a more thorough analysis has shown that this relationship depends on case complexity and type of surgical procedures. Lower-volume programs tend to underperform larger-volume programs as case complexity increases. High-volume pediatric cardiac surgeons also tend to have better results than low-volume surgeons, especially at the more complex end of the surgery spectrum (e.g., the Norwood procedure). Nevertheless, this trend for lower mortality rates at larger centers is not universal. All larger programs do not perform better than all smaller programs. Moreover, surgical volume seems to account for only a small proportion of the overall between-center variation in outcome. Intraoperative technical performance is one of the most important parts, if not the most important part, of the therapeutic process and a critical component of postoperative outcome. Thus, the use of center-specific, risk-adjusted outcome as a tool for quality assessment together with monitoring of technical performance using a specific score may be more reliable than relying on volume alone. However, the relationship between surgical volume and outcome in pediatric cardiac surgery is strong enough that it ought to support adapted and well-balanced health care strategies that take advantage of the positive influence that higher center and surgeon volumes have on outcome.     

Rotary atlanto-axial subluxation with torticollis following central-venous catheter insertion

Atlanto-axial subluxation with torticollis is an uncommon condition that occurs in children usually as a result of pharyngeal infection, minor trauma, or neck surgery. Passive motion of the head and neck during general anesthesia is probably another etiologic factor. Torticollis is the most common presenting physical finding. Pain may or may not be present, but is commonly present with passive neck motion. Neurologic sequelae are uncommon. Our case illustrates this condition as a complication of central venous catheter (CVC) insertion in a child under general anesthesia. The surgeon should suspect this pathology when a child presents with torticollis following CVC placement. Precautions should be taken in the operating room to avoid aggressive rotation and extension of the child's neck while under general anesthesia whether or not cervical inflammation is present. Special attention to head and neck positioning should be taken in patients with Down's syndrome since they are at increased risk for atlanto-axial subluxation. The prognosis is excellent when diagnosed early. A delay in diagnosis can result in the need for surgical intervention. Accepted: 7 May 1999     

Common anorectal problems

Children, just as adults, have a variety of common anorectal problems that can be quite bothersome. The presentation of these problems may be age-specific. Abscesses, fistulas, and fissures appear more commonly in infants and young children, whereas hemorrhoids and pilonidal disease are more common in teens and young adults. Fissures often can be treated medically but may require surgical treatment with lateral internal sphincterotomy. Abscesses and fistulas are common in infant males, especially robust infants who are breastfed. They may resolve with medical therapy but anal fistulotomy is not infrequently required. Hemorrhoids are rare in young children but may be an issue for teenagers. Acute symptomatic lesions may require excision if local measures cannot control the symptoms. Finally, pilonidal disease is a difficult problem for the patient and the surgeon. Persistently symptomatic lesions demand some type of surgical treatment but wound healing is poor in the intergluteal cleft region. More extensive procedures requiring the transfer of fasciocutaneous flaps may be necessary to provide definitive relief. Anorectal problems in infants and children are frequent and bothersome. Although most are not associated with tremendous morbidity, they can lead to much patient and parent anxiety as well as frequent medical consultation until the problem is successfully treated or resolves.