SOUS LE PATRONAGE DE MONSIEUR LE MINISTRE DE LA SANTE PUBLIQUE

VIIth CONGRESS OF THE MEDITERRANEAN ASSOCIATION OF PAEDIATRIC SURGERY VIIth CONGRESS OF THE MAGHREBINE FEDERATION OF PAEDIATRIC SURGERY XIIth ANNUAL MEETING OF THE TUNISIAN ASSOCIATION OF PAEDIATRIC SURGERY

Ramada Plaza Tunis Htel. Les Ctes de Carthage Gammarth. October 9th-11th, 2008

Abstracts Book

Lectures, States of the art and Video session

New trends in epidemiology of hypospadias. RB. Galifer, N. Kalfa, C. Sultan. Department of pediatric surgery, La Peyronie hospital. Montpellier, France Hypospadias is the most frequent genital malformation in the male newborn and results from an abnormal penile and urethral development. This process requires a correct genetic program, timeand space-adapted cellular differentiation, complex tissue interactions, and hormonal mediation through enzymatic activities and hormonal transduction signals. Any disturbance of these regulations may induce a defect of virilization of the external genitalia and hypospadias. This malformation thus appears to be at the crossroads of various mechanisms implicat ing genetic, endocrine and environmental factors. Genes of the penile development (HOX, FGF, Shh), genes of the testicular determination (WT1, SRY) and genes regulating the synthesis (LH receptor) and action of androgen (5 reducatse, androgen receptor) can be responsible of hypospadias if altered. Several chromosomal abnormalities and malformative syndromes include hypospadias, from anterior to penoscrotal forms. More recently, CXorf6 and ATF3 have been reported to be involved in the occurrence of this malformation. Beside this genomic and hormonal factors, multiple substances found in the environment can also potentially interfere with male genital development because of their similarity with hormones. The proportion of hypospadias cases for which an etiology is detected varies according to the authors but it remains nevertheless low, especially for less severe cases. An interaction between genetic background and environment is likely.

Continent urinary diversion variations on the ureteric Mitrofanoff conduit Krstic ZD, Smoljanic Z, Vukadinovic V. University Childrens Hospital, Belgrade, Serbia Background: A technique of using the distal ureter to construct a continent catheterizable stoma is described. The method enables the formation of a continent stoma with no intraperitoneal dissection. Methods: Mitrofanoff described the use of a nonrefluxing ureter, which sometimes involves risking the good kidney with a complicated transuretero-ureterostomy. We formed a continent stoma by using the distal part of the refluxing or obstructive ureter/megaureter on the functioning or nonfunctioning kidney. In patients with reflux the continent mechanism was formed by using the Lich-Gregoire technique or Barrys tunneling method, with or without tapering of the distal ureter. Depending on the condition of the ipsilateral urinary tract nephrectomy, ureterocystoneostomy (with or without a psoas hitch), uretrocutaneostomy and in one patient bladder augmentation using the ureter on the proximal circulation, were carried out concurrently. Also, in one patient, simultaneously with bladder augmentation, we performed bilateral ureterocystoneostomy and continentna stoma using the distal ureter from the right side. Previous reimplantation is not a contraindication to the usage of the distal ureter. During the period from 1993 to 2007, the method was applied in 29 patients with neurogenic bladder, posterior urethral valve, bladder extrophy or intraspinal neuroblastoma. Follow up is for 4 months to 14 years. Results: Patients had no stenosis of the ureterocutaneous junction. 24 patients had no leakage. In 5 patients the leakage was solved with sting procedure. In all patients catheterization was easy and painless, and the aesthetic results were excellent. Conclusions: Compared with other techniques for continent stomas this method is quicker, requires less skill and causes few complications, which is the reason why this vesicostomy is most frequently used in our hospital. All consequences that results from urine contacting nonurinary epithelium which occurs in other continent stomas, are excluded. Our experience with extravesical ureterocystoneostomies suggests that there is always enough ureter for continent stoma and ureterocystoneostomy. Avoidance of intraperitoneal dissection is one of its main advantage (especially in patients with ventriculo-peritoneal shunt).

Incontinence is still a taboo topic. A new device to treat anal and urinary incontinence by continence tampons. G.H. Willital1, A. K. Saxena2, C. M. Meier3, J. Tsokas4
1 2

Pediatric Surgical Research Institute, Mnster-Greven (Germany) Pediatric Surgical University Clinic, Graz (Austria) 3 Pediatric Surgical University Clinic, Homburg/Saar (Germany) 4 Pediatric Surgical Outpatients Department - Franziskus-Hospital Mnster (Germany) Introduction: In Germany approximately 3.5 million and in Europe approximately 18,5 million children and adults have continence problems. Main reasons for incontinence are congenital abnormalities of the spine, anorectal anomalies, pelvic traumas, sacral anomalies, pelvic tumors and overflow incontinence. Perirectal muscle insufficiency can be determined by anorectal manometry (fig.1), endoscopy (fig.2), endoanal ultrasound (fig.3) and electromyography. Aims and methods: Supported by the VW-foundation continence tampons have been developed for partial and complete incontinence to occlude the bowel from inside. The tampon has a spongy structure, a high elasticity and consists of polyvinyl foam. The surface of the tampon fits to the anatomical structure of the anal canal. Cohesive and adhesive forces between the surface of the tampon and the bowel develop similar adhesive forces comparable to the resting pressure inside the anal canal in healthy patients. The shape of the tampons is determined by endoscopic impressions. Standard size and individually shaped tampons are available (fig.4). Results: One has to differ between patients who are completely incontinent and those with partial in-continence. In the group of complete incontinent patients (1998-2008 n=125) the tampon occluded the bowel for 5 hours and longer in 58%, 4 to 5 hours in 20% and 2 to 4 hours in 12%. In 10% tampon application was not possible. In the group of partial incontinence the tampon was used for active muscle training: in 425 children and youth the anal resting pressure increased within 15 months from 10 mm Hg to 125 mm Hg, restoring continence. Overflow incontinence caused by anal stenosis or sphincter achalasia could be treated in 43 cases by anal dilatation using anal tampons. No side effects were observed. Conclusions: Anorectal incontinence could be brought under control by continence tampons. Treatment of urinary incontinence in males and females by external compression of the urethra using special tampons is developed currently. Partial incontinence necessitates a long term period of active muscle training using similar tampons. Overflow incontinence caused by anal stenosis or by sphincter achalasia could be treated by anal dilatation using smaller tampons. Fig. 1: Continence grading performed by anorectal manometry of the perirectal muscle layers, using tip-catheters: functional diagnosis of sphincter muscles. Fig. 2: Voluntary contraction of the perirectal muscle layers can be observed by anorectal endoscopy and can be classified in 4 different continence stages. Fig. 3: Determination of perirectal muscle layers/scars by endoanal ultrasound: morphological/anatomical diagnosis of sphincter muscles. Fig. 4: Occlusion of the bowel by continence tampons and safety for involuntary soiling

Fig 1

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Fig.4

New perspectives in the treatment of disorders of sexual differentiation (DSD)

Zoran D. Krsti University children's hospital, Belgrade, Serbia The treatment of children born with disorders of sexual differentiation (DSD) has always been difficult, subject to evolving attitudes and technique and at times controversial. Recent "philosophy" of surgical treatment of DSD can be summarized with 4 basic principles: 1. The basis of surgical treatment is not to coordinate the phenotype and the genotype, but rather to form the external genital organs of the appropriate appearance that will allow functional sexuality 2. It is much easier to make a vagina as a passive organ, rather than an erectile phallus of sufficient dimensions 3. Surgical correction must be made as soon as possible, so as not to prolong the confusion in regard to the sex of the child 4. It is believed that feminizing surgery is more successful both in cosmetic and functional manner. Recently some authors, backed by patient support groups, have claimed that such surgery is damaging and/or mutilating and while it is essentially cosmetic, should not be performed until the fully informed consent of the patient could be obtained. There are few long term data to confirm or refuse the benefit of normalizing the genital appearance. The effects on female children of having severely virilized genitalia throughout childhood are unknown. There are articles pointing out that clitoral surgery interfere sexual function especially when it comes to ability to achieve orgasm. However, unsatisfied sexual life could be consequence of inadequate surgery due to poorly skilled surgeon and not due to operative technique and clitoral surgery. Sexual function can be compromised by involvement of other factors such as shame due to unsatisfied genital appearance. This is in correlation with articles pointing out that more frequent orgasm achievement can be attained by self-stimulation technique. We are suggesting that sexual difficulties may appear independently of surgical intervention that has aim to normalize cosmetic genital appearance. It is nonsense to think that normal and harmonic sexual development is only possible by clitoral preservation. Still, clitoral surgery should be avoided in mild to moderately virilized children. Children leaved to grow in gender limbo will encounter numerous restraints in our highly sexually dysmorphic society. They will be teased and bullied and may grow into adolescence feeling frustrated and sexually inadequate. Many parents find it hard to accept an intersexed child and so will opt for early surgery. Feminizing genitoplasty does not always achieve this goal and in some patients it is completely successful. Personal authors experience is that vaginal reinterventions were not big surgical interventions and were methodized on introitoplastics. Some patients with urogenital sinus complicated by urine stasis and/or infection may demand early surgical intervention. In 2006 a consensus statement was published summarizing key principles for management of DSD: 1. Avoid instantaneous gender assignment before expert evaluation 2. Assessment and longer-term management must be performed in a centre with an experienced multidisciplinary team 3. Full and open communication with affected families is mandatory with the families encouraged to participate in the decision-making. Is there indeed consensus? Gender development is multifactorial and impossible to predict. Detailed, multicentre studies that explore the potentially varied effect of timing and technique of clitoral surgery on psychological, sexual and quality of life outcomes are needed. Bladder tissue engineering in pediatric urology:

Facts or artifacts? Paolo Caione, Renata Boldrini**, Sandra Battaglia, Gabriele Palombaro*, Gianfranco Bottazzo*** Dept of Nephrology and Urology (Head Prof. P.Caione), Div. of Pediatric Urology Bambino Ges Childrens Hospital, Rome, Italy *Dept of Pediatric Surgery (Head Prof. M. Rivosecchi), Div. of Anesthesia Bambino Ges Childrens Hospital, Rome, Italy **Dept. of Pathology (Head Prof. F. Callea), Bambino Ges Childrens Hospital, Rome, Italy ***Research Laboratory of Scientific Direction (Head Prof. G. Bottazzo) Bambino Ges Childrens Hospital, Rome, Italy Gastro-intestinal tracts for bladder augmentation/substitution presents significant morbidity (up to 30%), and long term risk for malignancy. Bladder regeneration by tissue engineering techniques have been proposed, utilizing biodegradable acellular scaffolds, seeded with cultured stem cells and biomolecules. In vitro or in vivo bladder regeneration could represent an effective answer to the specific need (1, 2). Several papers recently appeared in literature during the last few years with discordant results. We experienced in vivo new bladder wall development, both in animal models and in a pilot study on children and review critically the obtained results, using a acellular membrane as bioscaffolds to stimulate. THE EXPERIMENTAL STUDIES Methods and Materials: Ten pigs, 2 months aged, underwent partial cystectomy (40 to 60% of native bladder) under general anesthesia. Bladder wall was replaced by 4 x 5 cm small intestinal submucosa (SIS) graft in 6 of them (Group A). In the remaining 4 pigs (Group B), autologous mesenchymal cells, previously isolated from bone marrow and in vitro expanded, were reimplanted at the SIS/native bladder suture line (T0). A suprapubic drain, emerging from the pig black, was left in place for a 8 days postoperative period. Animals were sacrified at 5 weeks (T1) and 3 months (T2) from surgery. At dead-line, regenerated bladder capacity, macroscopical and histological examination were evaluated and compared with the native bladder status. Chi-square test was adopted for statistical analysis (p < 0.05 = significant). In the results, 3 pigs died and 7 completed the study. Regenerated bladder capacity was moderately reduced at T1 (- 18%, p < 0.05) and almost normal at T2 (+ 2.5%, p = n.s.). At T2, a soft and well vascularized newly regenerated bladder wall was macroscopically observed, without mucous, stones or diverticula, lined by a normally looking urotelium. Histology at T1 showed transitional epitelium fully covering the inner surface, centripetal fibroblasts and muscle cells ingrowth within the SIS membrane, recognised only at the central portion. At T2, the scaffold was not more evident and the newly developed bladder wall was well organized in 3 layers: inner urotelium central fibroblasts and smooth muscle fibres, with thin blood vessels and neurofibrillac, outer well vascularized connective tissue (fig 1 A and B). The collagen/muscle ratio was 72% vs 28% in the Group A, 71% vs 29% in the Group B (p = n.s.) and 56% vs 44% in the native bladder (p < 0.05). No significant difference was observed between Group A and Group B histology findings. The muscular component was imperfect, but the engineered bladder wall was almost regular and not retracted. THE CLINICAL EXPERIENCE

The tissue engineering technique was extended in a pilot clinical study, encouraged by our animal moder results. Methods: Bambino Ges Hospital Ethical Committee approval were obtained. Five exstrophic patients (3 males and 2 females) presenting poor bladder capacity and incontinence after complete repair, underwent bladder wall regeneration using a SIS graft as scaffold and omental wrap (figure). Patients were investigated before (T0) and at 7 months (T1) and 18 months (T2) from surgery by ultrasonography, uroflowmetry, bladder volume/compliance, cystoscopy with cystogram and bladder wall biopsy for histology. Pre-op and post-op results were compared, adopting Wilcoxon test for statistical analysis.

Results: Mean patients age at surgery was 10.4 years (8 to17 years). The SIS graft was 5x4 wide. Postoperative periods were uneventful. Mean follow-up was 2.5 years (6 months to 4,3 years). Bladder capacity and dry intervals at T0 and T1 are reported in table. Bladder capacity resulted significantly increased (p < 0.05), but dry intervals didnt changed significantly (p > 0.05). No bladder stones, mucous or diverticula were observed. At T1 bladder biopsy, SIS membrane was not evident, and normal transitional epitelial mucosa, smooth muscle fascicles, small nerve trunks and vessels were found with abundant collagen and fibroblasts. No long term complications occurred.

Table Age (years)

Bladder Capacity at T0

Dry Intervals at T0

Bladder Capacity at T1

Dry Intervals at T1

8 80 cc 45 mins 85 cc (+ 6%) 45 ( - ) 8 90 cc 90 mins 115 cc (+26%) 100 (+15%) 8 90 cc 45 mins 110 cc (+22%) 50 (+11%) 11 120 cc 90 mins 140 cc (+18%) 100 (+15%) 17 130 cc 60 mins 155 cc (+20%) 75 (+25%) _____________________________________________________________________ p=0.029 p=0.069 DISCUSSION AND CONCLUSIONS Bladder regeneration by bio-engineered techniques is nowadays feasible in animal models, but it is still experimental in humans. Bladder wall regeneration starts from inner transitional epithelium and continues through smooth muscle bundles and fibroblasts with newly developed blood vessels

and peripheral nerves ingrowth. Muscular/connective ratio was found significantly lower than normal, but it could increase with longer follow-up. The pilot experience in children demonstrates that bladder wall regeneration is feasible in humans, offering an option to increase bladder capacity. In our limited experience, no complications occurred at 2 to 3 years follow-up. Functional results were partial satisfying, because the increased volume was not fully adequate and the regenerated wall histology was imperfect, with high collagen and fibroblast components. Anyway, in our experience, grow-factors (TGFbeta), stem cells, myoblasts within newly selected acellular scaffolds could enhance and modulate the autologous regenerative process, opening a new chapter to the Reconstructive Urology. REFERENCES 1. Kropp BP, Eppley BL, Prevel CD et Al. Experimental assessment of small intestinal submucosa as a bladder substitute. J Urol 1994; 151: 401-503. 2. Atala A. Tissue engineering for replacement of organ function in the genitor-urinary system. Am J Transplant 2004;6(suppl):58-73. 3. A. Fierabracci, P. Caione, M. Di Giovine, D. Zavaglia and G. F. Bottazzo. Identification and characterization of adult stem/progenitor cells in the human bladder (bladder spheroids): perspectives of application in pediatric surgery. Pediatr Surg Int, 2007 (23): 837-839, DOI: 10.1007/s00383-007-1096-x 4. Caione P, Capozza N, Zavaglia D, Palombaro G, Boldrini R. In vivo bladder regeneration using small intestinal submucosa: experimental study . Pediat Surg Int 2006;22(7):593-599 5. D. Zavaglia, P. Caione, R. Boldrini, A. Lais, N. Capozza. Bladder regeneration using small intestinal submucosa as scaffold: experience in five children, Atti del XVIII Annual Congress of the ESPU, Brugge (Belgio), 25-28 aprile 2007 Journal of Pediatric Urology, vol 3, 2007, # S10-3, pg 556 (Abstract)

Obesity in children and adolescent and bariatric surgery. Aayed Alqahtani, FRCSC, FACS, FAAP King Saud University, Riyadh , Saudi Arabia qahtani@yahoo.com Obesity prevalence is rapidly increasing among children and adolescents worldwide. It is considered one of the most alarming public health issues facing the world today. Although believed in the past to be less frequently associated with increased morbidity than in adults, obesity in children is now recognized to be associated with insulin resistance, hypertension, hyperlipemia, hepatic steatosis, sleep apnea, and orthopedic complications. The physical and social effects of severe obesity in young people are devastating. The greatest concern and potential public health effects are that obesity during the pediatric age is a strong predictor of obesity in adulthood. Studies show that 50% to 77% of children and adolescents who are obese carry their obesity into adulthood, thus increasing their risks of developing serious and often life-threatening conditions. The risk increases to 80% if one of the parents is also obese. The adult experience has demonstrated that surgery is the only effective means of achieving persistent weight loss in obese patients. However, little is known about bariatric surgery in children and adolescents. This presentation will discuss the bariatric surgery in children and adolescent

Robot-assisted paediatric surgery: our experience in Tours Hubert LARDY, Karim BRAK, Michel ROBERT. Dpartement de chirurgie pdiatrique. Centre de pdiatrie Gatien de Clocheville CHRU Tours. France Video-assisted surgery for children is strongly developed and consists either in laparoscopy, thoracoscopy or retroperitoneoscopy. A new therapeutic challenge for minimal invasive surgery in children is emerging with robotassisted procedures. Seventeen French hospitals are provided with a Da Vinci robotic system (Intuitive Surgical ). The Universitary Hospital Center of Tours was equipped last year. The paediatric robotic surgery program has started in November of 2007 with at least one paediatric procedure per month. Most current procedures are pyelo-ureteric junction repair (Anderson Hynes pyeloplasty or polar vessels transposition), nephrectomies, splenectomies, and fundoplications for primitive gastrooesophageal reflux Four paediatric surgical teams will be able to start robotic surgery in the next few months (Limoges, Lyon, Nantes, and Nice). Indications for robotic surgery will be extended to thoracic surgery and visceral malformative surgery such as choledocal cysts and anorectal malformations. Robotic surgery in children must be based on specific guidelines regarding team mobility, positioning of patient, size of instrumentation and duration of procedures. Robotic surgery is a way to improve minimal invasive surgery in children. However, cost and effectiveness must be strongly assessed in order to select the best indications and develop a new strategy for minimal invasive surgery.

Minimal Access Surgery in neonates and infants Aayed Al-Qahtani, MD, FRCSC, FACS, FAAP Associate Professor, pediatric surgery, King Saud University. Riyadh, Saudi Arabia E-mail: qahtani@yahoo.com Background: Minimal access surgery (MAS) in small infants caries an important consideration. The tolerance of these small babies and the assumed physiological effect of MAS, in addition to the required anesthetic and surgical skills have made it difficult to perform these types of procedures in many international centers. The present article will review our experience with MAS in neonates and infants in the first year of life. Methods: The medical records of all infants who underwent minimal access surgery over a period of three years were retrospectively reviewed for demographic information, procedures, operative time, complications, outcomes and follow-up. Most of the operations were performed with 3-mm instruments and scopes and mean insufflation pressure of 10 mm Hg (range, 4-15mm Hg). Results: 70 infants were included in this study; 19 girls and 51 boys. The weight ranged from 1.3 to 8.2 kg (mean 4.3 kg). The mean age was 93 days (range 1 day to 12 months). 24 of these infants were neonates (34%). Procedures performed included, repair of tracheo-esophageal fistula (TEF), lobectomy, repair of diaphragmatic or hiatus hernias, pull-through for imperforated anus and Hirschsprung's disease plication of the diaphragm, Kasai's procedure, excision of choledochal cyst, pyloromyotomy, ladd's procedure and reduction of intussusceptions .There were two conversions, both in neonates with TEF. All patients tolerated the procedure very well with lesser degrees in neonates undergoing thoracoscopic procedures. Two neonates had Postoperative hypothermia (<35 C) and one neonate had high Pco2 postoperatively. There was one mortality and no morbidities. The follow-up ranged from 1 month to 3 years (mean 19 months). Conclusion: MAS in neonates and infants are safe and well tolerated. Intraoperative monitoring of end-tidal Co2 and core temperature are essential in avoiding unwanted effects of performing these procedures especially in neonates.

Acquired gastric outlet obstruction, New Sharma's classification. K. Sharma. India The gastric outlet obstruction in text books of pediatric surgery is overwhelmingly the description of infantile hypertrophic pyloric stenosis with a small account of other causes, congenital and the acquired both. This has led to an absence of a cohesive thinking on the issue as a whole and thereby there is a need to develop a complete, elaborate and comprehensive classification of the gastric outlet obstruction so that even the rarest entities could be accommodated and discussed as a compact topic. We had devised the same in 1997 and presented the new disease entity called the acquired gastric outlet obstruction during infancy and childhood which is recently being seen in many more parts of the world now. This unusual condition was reported by the author for the first time in 1997 as a series of five unusual cases of gastric outlet obstruction in infancy and children. It is an acquired, non-specific and functional disorder of the pylorus without any extrinsic and intrinsic abnormality; presenting as recurrent, episodic and sometimes intractable, non-bilious projectile vomiting in wide ranging age group (one month to 17 years) causing dehydration, dyselectrolytemia, marasmus or even the growth retardation in long standing instances. All these patients showed visible gastric peristalsis, dilated stomach with delayed gastric emptying time in upper GI series, normal regional anatomy in ultrasound and endoscopic examination, hugely dilated stomach with normal pylorus and surroundings morphologically on exploration and no abnormality histopathologically including the ganglion cells. It has been hypothesized by us that there is some sudden, localized neuromuscular in coordination in the pylorus due to some unspecified agent causing permanent changes in the functioning of this anatomic region making the drainage operation a necessity. We present here the further eight new cases of this new disease entity which has been called as JODHPUR DISEASE, seen after 1996 onwards at our center and present our new Sharmas Classification of Gastric Outlet Obstruction in Children with the review of recent work published on this topic from now almost all over the globe stretching from Japan to Mexico including the western countries.

Laparoscopic management of persistent mllerian duct syndrome Aayed Al-Qahtani, MD, FRCSC, FACS, FAAP Associate Professor, pediatric surgery, King Saud University. Riyadh, Saudi Arabia E-mail: qahtani@yahoo.com A 2-years-old boy presented with a nonpalpable left testis. On examination, the right testis was retractile and the left one was nonpalpable. Otherwise, he has normal male external genitalia. Laparoscopic exploration revealed two testes, uterus and tubes, compatible with persistent Mullerian duct syndrome (PMS). Laparoscpoic division of the persistent mullerian structures was performed, keeping intact the vas deference on both side and bilateral orchidopexy. The video will demonstrate the intra-operative findings and the minimally invasive technique of dealing with this rare entity.

Robotic Pull through for imperforate anus Aayed Al-Qahtani, MD, FRCSC, FACS, FAAP Associate Professor, pediatric surgery, King Saud University. Riyadh, Saudi Arabia E-mail: qahtani@yahoo.com This video will present the first video of its kind describing the technique of robotic pull through for imperforate anus. It will elaborate on the advantages and disadvantages of such technique.

Imaging in the hydatid diseases,Epidemiology, diagnosis and US guided treatment . What is new in 2008 Wiem Douira,2, Azza Hammou,3 , Smia Lahmar,10, Frid Ben Chhida,1, Najia MoussaHaddad,4. Najet Ben Amor, 11, Moncef Gargouri,11, Ibtissem Bellagha 2,, Mohamed H. Daghfous, 5, Fethi Ladeb, 6,Rachid Mechmche, 7, Zoubeir Ben Safta,8, Abdejabbar.Ghorbal,9Tunis Tunisia 1- Radiology Department, Ibn Zohr- 1003- Tunis-Tunisia 2- Radiology Department, Children Hospital-1007- Tunis-Tunisia 3- National Center of Radiation protection Tunis 1007- Tunisia 4- Radiology Department,Clinique CNSS , 1001- Tunis-Tunisia 5- Radiology Department, Habib Thameur Hospital, Tunis-Tunisia 6- Radiology Department, Kassab Institute - Tunis-Tunisia 7- Cardiology Department, La Rabta Hospital - Tunis-Tunisia, 8- Abdominal Surgery Department, La Rabta Hospital Tunis-Tunisia 9- Gastro-Enterology Department, Habib Thameur Hospital- Tunis-Tunisia 10- Parasitology Department, Veterinary School Sidi Thabet Tunisia 11- Gastro-enterology Department Ibn Zohr 1003-Tunis-TunisiaHydatid disease (HD) is a worldwide calamity. During the last 35 years, we proved that medical imaging may play an important role for the eradication of this calamity around the world. Our multidisciplinary team played an important role in this field with a close collaboration and help from French, Italian and Europeans Institutions. 1Medical imaging, mainly US is a wonderful tool for the screening of the asymptomatic population in rural epidemic areas. This technique is well appreciated by the population and adopted by WHO for the epidemiologic studies in other tropical diseases, such as bilharziosis. Our US classification described for the US imaging, in 1981, is worldwide used today for all the others modern imaging modalities, CT and MRI, Formerly, surgery was the only efficient treatment modality. Today, interventional procedure, during endoscopy, or by PAIR procedure (Puncture, Aspiration, Injection of scolicid in the cyst and Reaspiration of the cyst contents). This PAIR technique, introduced by our team in 1982, is used all over the world to day. More than 3000 cases are published as successful treatment for the abdominal, thoracic and small parts location. During these non surgical techniques medical treatment is still used as complementary method. Classic prevention modalities are still used. However, new promising modalities are found, based on the vaccination of intermediary host, sheep, cows, goats and definitive host such as dogs.

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We will present the strategy we suggest for the exploration of HD, using the different imaging modalities available to day.

Multiple echinococcosis in childhood

M. BEN BRAHIM, A. NOURI, A. KSIA, O. EL EZZI, M. MEKKI, M. BELGHITH. Department of pediatric surgery, Monastir. Tunisia Purpose: Multiple echinococcosis (ME) is a severe disease in childhood inaccessible to an initial radical surgical treatment. The aim of this study was to evaluate the efficacy of Albendazole in ME and to discuss the role of surgery in this pathology. Methods: Thirteen patients were included in a prospective study between 1996 and 2006. ME was defined by the presence of 10 or more cysts in the same organ. Albendazole was given as 10 mg/kg daily continuously. Treatment outcome was defined as cure, improvement, stabilization or deterioration. Surgery was discussed after 1 year of treatment. Results: Our patients totalized 331 cysts located essentially on the liver (215 cysts) and the lungs (81 cysts). With exclusive Albendazole therapy, 57.7% pulmonary cysts and 96% peritoneal cysts were considered as cured. This rate was only 31.5% in hepatic localization. After surgical therapy, 60.4% of hepatic cysts were cured. No productive biliary fistula was observed. Two patients were operated laparoscpically. The total treatment duration ranged between 1 and 5 years. Parasitologic examination of operated cysts showed that 30% of them were viable even after 3 years of treatment. Conclusion: Albendazole has proven a strong efficacy in pulmonary and peritoneal localizations. A complementary surgical treatment is often necessary in hepatic localizations and it is facilitated with previous Albenazole therapy. Combination of ABZ and surgery seems to have encouraging results and must be applied for those patients. The high rate of viable cysts after medical therapy is problematic and must incite to develop new antihelminthic agents.

Laparoscopic treatment of hydatid cyst of the liver in children. M. Mekki, K. Maazoun, S. Hidouri, M. Masmoudi, R, Laamari, M. Ben Brahim, J. Chahed, L. Sahnoun, I. Krichene, M. Belghith, A. Nouri. Department of pediatric surgery, Monastir. Tunisia Introduction: Hydatid cyst is a parasitic disease caused by the tape Worm Echinococcus Granulosus or Echinococcus alveolaris. The disease is endemic in Tunisia and many other areas of the world. Laparoscopic treatment of hydatid cyst of the liver remains controversial because of the small number of patients and lack of hindsight series published. The aim of this work is to study the specificities of this approach in the treatment of hydatid cyst of the liver in children. Materials and Methods: This is a prospective study carried- out between September 2001 to July 2004. It includes 34 children who underwent laparoscopic surgery for hydatid disease of the liver at the pediatric surgical center of Monastir, Tunisia. The parents were previously informed and they agreed to participate in this study. All the patients had a chest-X-ray, abdominal sonography, hydatid serology and preoperative biological analysis (blood grouping, blood count, hemostatic analysis). The abdominal tomography and the hepatic analysis werent done for all the patients. Three patients had Albendazole therapy before intervention: two cases for disseminated hydatidose with treatment of five years before and six months after surgery for the first case; and one year before and six months after surgery for the second case. The third patient had a hydatid cyst of the left lung sized 20 mm and undertook Albendazole treatment one year after surgery in the hope of cyst regression, to avoid the surgery. Operative technique: After the induction of general anesthesia, all patients received prophylactic antibiotics. Laparoscopic access of the abdominal cavity is achieved under direct vision after vertical incision directly through the umbilicus by a 10 mm trocar. The CO2 pneumoperitoneum pressure is maintained between 10 and 12 mm/Hg depending on the patients weight. Two other 5 mm trocars are introduced in the right and left hypochondrium. In four cases, a third trocar was necessary to retract the liver. A 0 or 30 degrees telescope is then used depending on the cyst localisation. The cyst is protected by sterile clean pads introduced through the umbilical trocar and filled with hypertonic saline solution. After that, we proceed to a puncture aspiration of the cyst, sterilisation of its content by infusion of hypertonic saline solution during 10 min then reaspiration. The cyst is opened and the proligerous membrane is removed and put in a sack. The puncture-aspiration is done with a 1.6mm diametre needle through one of the trocars or transparietal Veres. The last step is the resection of the dome and the search of biliary fistula. The residual cavity draining is not systematic. The pads and resected pericyst are put in the same sack then exteriorised by the umbilical orifice to prevent the risk of intraperitoneal soiling and contamination. Results: 17 boys and 17 girls were treated by laparoscopic surgery for hydatid disease of the liver. Ages ranged from 3 to 14 years (Average: 7 years 7 months).

The circumstances of diagnosis were abdominal pain in 10 cases, abdominal mass in three and in the check up of on hydatid disease of the lung in 21 cases. Two cases of disseminated hydatidose were treated with Albendazole. The first one had 30 cysts treated medically with involution of 20 cysts; the 10 remaining others were treated by laparoscopic surgery. The second case had 20 cysts; 12 involueted with medical treatment. The Eight remaining cysts were treated by laparoscopic surgery. In the other cases, the number of cysts treated with surgery ranged from 1 to 7 (58 cysts:1,7 cyst/patient). The cyst size was 65,5 mm (ranging from 40 to 150 mm). The right liver was concerned in 35 cysts and the left one in 23 cysts. 46 cysts were of type I, 7 of type II, 3 of type III and 2 of type IV from the Gharbis classification [1]. One case had an associated mesenteric hydatid cyst and an other a splenic hydatid cyst. These associated hydatid cysts were treated at the same time. No peroperative complications were observed and no conversion to an open operation was done. No patient needed a blood transfusion before nor after intervention. The residual cavity draining was done in 27 patients with no declivous cyst cavity. 3 patients had post operative Albendazole treatment, two for fissurated cysts of the liver, one for a small, deepseated cyst of the 7th segment which was not found in peroperative. Its evolution was favourable with medical treatment, as we had a calcified cyst one year later. The patient, who had a hydatid cyst of the left lung sized 20 mm and performed Albendazole treatment before and after surgery, had the same 20 mm sized cyst after one year of medical treatment. Operative time ranged from 30 to 210 min (average 90 min). The alimentation was introduced at the first post operative day. The average hospital stay was 5 days (ranging from 4 to 14 days). No post operative complications were observed after a follow up ranged from 12 to 45 months (a mean of 23 months). Discussion: Many reports of laparoscopic surgery for liver hydatidosis exist in the adult literature [2-3]. We report one of the few pediatric series of hydatid disease of the liver treated by laparoscopic surgery [4]. This technique is controversial in adult studies. For many authors, cysts with biliary communication, deeply located cysts and disseminated liver hydatidosis should be excluded [5-7]. We think that the number and size of the cysts are not contraindications to this operation. Also, the location of the cyst also is not a contraindication as is reported by some authors [6]. In fact, this technique is safe in exploring the dome and cysts located posteriorly with a 30 telescope. Complex cysts were not found to be a contraindication to this operation. The laparoscopic approach can be advantageous because the endoscope can be introducted into the cyst cavity for inspection and to make sure that no daughter cysts or laminated membranes were overlooked [5, 8]. In addition, this approach helps to detect small bile openings [5, 9], with the help of the magnification by telescope; that offers an advantage compared to classic surgery. The advantages of the laparoscopic approach compared with open surgery are good cosmetic results, less time duration and rapid recovery. It allows treatment of other abdominal cysts at the same time. This was the case of two of our patients who had a mesenteric and a splenic hydatid cyst associated to the cyst of the liver. A major disadvantage of laparoscopy is the lack of precautionary measures concerning spillage, especially under high abdominal pressures induced by pneumoperitoneum [3, 10]. However, Bicket and al [11] demonstrated that the increase in intracystic pressure was no greater than the increase in intraabdominal pressure and that the pneumoperitoneum was protective against spillage. As in the open surgery, the indication of cyst cavity drainage is the no declivous residual cavities.

The scolicidal agents are used pre and post operatively by some authors in these situations: disseminated liver hydatidose, spillage of the cyst content in the abdominal cavity, deeply located cysts of small size, small pulmonary associated cysts [6, 10]. This last situation was the case of the patient who had a small pulmonary cyst associated. The conversion rate in our series with 34 patients was 0% while the average rate in other laparoscopic series has been 12 % (range 0 %- 27%) [8, 10, 12, 13, 14]. Factors increasing the risk of conversion include posterior location and advanced stage of the cysts [12]. Post operative follow-up should be the same with the classic surgery. Post operative morbidity in laparoscopic studies ranges from 8% to 25% and includes biliary fistula, infection and peri hepatic fluid collection [8, 12, 13, 14, 15]. Another concern for the laparoscopic approach is the risk of anaphylaxis [8, 16, 17]. In our laparoscopic series, we have not seen any anaphylactic shock. The recurrence rate ranges from 0% to 30% following open surgery for hydatid cysts [18]. The recurrence in laparoscopic studies ranges from 0% to 9% [5, 8, 10]. In our laparoscopic series with a mean follow-up of 23 months, we have not seen any recurrence. Percutaneous aspiration under radiologic guidance has been advocated as an alternative to surgical intervention. The procedure of needle aspiration, injection of scolicidal agent, and catheter drainage has advantages, including relatively short hospitalization, good cosmetic results, and possibility of performing the procedure using local anesthesia [19-21]. Also it may be indicated in the case of deep-seated cysts. However, it is not without drawbacks. Cyst puncture carries the risk of spillage, which because of the procedures percutaneous nature can be uncontrolled, thus leading to dissemination of the disease or anaphylactic shock [22] (anaphylactic shock range from 0.1 % to 0.2 % [23]), the lack of accessibility to extra hepatic cysts, and limitations in treating cysts in proximity to major blood vessels [24-25], the difficulty of eradicating complicated cysts (Gharbi type III and IV)[23,26]. Some authors consider that this procedure is unsuccessful in 20 % of patients. Failures occurred more often with type III and IV cysts [26]. Conclusion: Laparoscopy represents an excellent approach for the treatment of hydatid cyst of the liver in children. Provided the exclusion criteria are observed and the surgeon has a perfect command of the operative technique, results are similar to those obtained in open surgery, with better cosmetic results and a shorter hospital stay. The essential treatment, however, remains the prophylaxy.

Cloning and expression of a c DNA encoding the P29 protein with potential usefulness in serologic follow- up of human cystic echinococcosis

Ben Nouir Nadia1, Naguleswaran Arunasalam2, Nuez Sandra2, Gianinazzi Christian2, Hemphill Andrew2, Mller Norbert2, Nouri Abdellatif3, Babba Hamouda1, Gottstein Bruno2
1

University of Monastir, Faculty of pharmacy, laboratory of parasitologymycologie, 99UR/08-05 1- rue Avicenne, 5000 Monastir Tunisia.

2 3

University of Bern, Institute of parasitology, Lngasse- strasse, 122 CH-3001 Bern, Switzerland CHU Fattouma Bourguiba, 5000 Monastir Tunisia

Human cystic echinococcosis (CE) is one of the world's major zoonoses that still poses diagnostic and follow up problems. The search for new antigen markers for post-treatment follow- up is necessary to prognostically determine the efficacy of treatment and to detect newly growing or relapsing primary cysts as early as possible. Sera of follow-up from CE patients who underwent surgery and/or chemotherapy were analyzed by immunoblotting using protoscoleces soluble protein extracts. The analysis of corresponding profiles yielded an interesting immuno-reactive double band of 27-28 kDa, which progressively disappeared in cured cases, and which, however, strongly persisted till the end point follow up of patients who had still active cysts. Mass spectrometry analyses revealed that this doublet corresponds to the 14-3-3 isofrom 2 and the P-29 protein a metacestode- specific component of Echinococcus granulosus. The full length recombinant P-29 protein, was successfully prepared by cloning the appropriate segment of c DNA into the PET 151/D vector (Invitrogen) and expressed in E. coli as a fusion protein with His-Tag. The serological follow- up value of recombinant P-29 was tested by inmmunoblotting with sera of follow- up from surgically confirmed 28 CE patients. Immunological reactivity of sera from cured patients to recombinant P-29 showed a progressive decrease of intensity starting from 6 months post-treatment and only 7% of cases were immunoreactive at 1 year post-operative. Conversely to non cured patients (active cysts by imagery) who were still positive regards to recombinant protein in 80% of cases. On the other hand, Immunological localization of this antigen on metacesode components was investigated by immunohistochemistry and electron microscopy using polyclonal antiserum. The protein is mostly abundant on protoscoleces' tegument, calcareous corpuscles and the germinal layer. These findings suggest the P-29 protein as new marker of cystic echinococcosis follow-up and further studies are required to investigate this protein in developing laboratory tests for serological monitoring of human cystic echinococcosis.

Fetal surgery: experience of barcelona (spain). Jose l. Peir md, Hospital vall dhebron. Barcelona. Spain. Prenatal image techniques with ultrasounds and mri permit, nowadays, to carry out precise diagnoses of several fetal congenital malformations. After the detection of a fetal anomaly emerges the possibility to carry out an intrauterine treatment to repair or to interfere in the natural evolution of the malformation during the fetal period. At present we have open fetal surgery and less invasive techniques as fetoscopy and the placement of ultrasound-guided shunts to treat different fetal malformations. We present the experience of our center in fetal surgery with the cases treated from January 2002, to analyze the therapeutic possibilities of the intrauterine treatment for the different antenatally diagnosed surgical malformations. We have placed 14 thoraco-amniotic shunts to treat fetal hydrothorax or ccam, 2 shunts for bladder drainage in lower urinary tract obstructions (luto) and one percutaneous valvuloplasty to treat a fetal aortic stenosis of the heart. To date, we have performed 304 fetoscopies. This technique was used in 241 cases to treat twin-to-twin transfusion syndrom (ttts) in biamniotic monochorionic twin gestations by means laser coagulation of communicant placental vessels, in 36 cases for the obliteration of the umbilical cord in cases of discordant monochorionic twins with serious or lethal anomaly in one of the fetuses and for treat the sequence of reversed arterial perfusion (trap). We used fetoscopy in 16 cases for the prenatal treatment of severe congenital diaphragmatic hernia (cdh) by fetal tracheal occlusion with an endotracheal balloon. Finally, fetoscopic laser release of umbilical and extremities amniotic bands were performed in 2 cases. Open fetal surgery is reserved, up to now, to treat the sacroccygeal teratoma, solid ccam and myelomeningocele. We have carried out exit procedure in 16 cases, that proved to be useful to treat fetal giant cervical masses and for the retreat of the tracheal occlusion in the plugged cdh cases. In the experimental field, we are working to develop new strategies for treat by means fetoscopy other malformations as cleft lip-palate, spina bifida and constrictive amniotic bands. Fetal surgery is, at present, a reality that permits to treat or to improve the prognosis of different antenatally detected fetal malformations. It is indispensable to have a multidisciplinary formed medical team very well coordinated to achieve acceptable results in fetal surgery. An accurate prenatal diagnosis is mandatory to select the cases that can benefit of this prenatal therapy. Main limitation of open fetal surgery is preterm labor because uterine dynamics stimulated by surgical aggression. Less invasive surgical techniques as fetoscopy reduce incidence of this problems. Refinement of this technique and technological advances will permit its utilization for other pathologies in the future.

Pectus deformities: changing senario to evaluation and treatment AMULYA K. SAXENA, MD Department of pediatric and adolescent surgery, medical university of Graz, Austria Thoracic wall deformities represent a spectrum of musculoskeletal disorders of the anterior chest wall. Most of these deformities are fortunately not life-threatening and do not manifest in severe functional pathophysiology of the thoracic organs. The management of these deformities has gained more importance in the past decade because of the increased participation in competitive school sports as well as athletics, and the changing trends in the world of fashion which expose more of the chest to the public view. It is important to note that although thoracic wall deformities do not arouse the sympathy generated by limb or cranial anomalies, children with such deformities are viewed with curiosity by their classmates and they are often confronted by teasing remarks. Various open and minimal access surgical techniques have been developed for the reconstruction of the deformed thorax wall. Conventional open surgical techniques have been successfully employed for the management of all forms of thorax deformities: pectus excavatum, pectus carinatum and combined forms. These techniques involve a midline chest skin incision, en-bloc preparation of the musculo-cutaneous flap, resection of parasternal deformed cartilages, bilateral rib osteotomy and sternal wedge osteotomy and stabilization of the deformity using metal struts. As more experience was gained in the surgical reconstruction of the thorax over a 20-year period in 1262 corrections, these procedures have undergone constant improvements to offer reduction in intraoperative and postoperative surgical complications. The modifications in surgical techniques have also played an important role in achieving excellent long-term results. Minimal access surgery has gained popularity in the management of thorax wall deformities. The role of minimal access surgery however has been limited to pectus excavatum, which is the most common of the thorax wall deformities. This technique involves bilateral transverse chest incisions, insertion of an introducer into the chest cavity, careful dissection of the retrosternal cardiac attachments, retrieval of the introducer tip on the contra-lateral chest wall, placement of the pectus bar and stabilization of the bar on the chest wall. Since the introduction of the minimal access correction of pectus deformities improvements have been made in the surgical technique to reduce the risks of complications. The introduction and standardization of thoracoscopy in minimal access surgery of pectus deformities has helped to improve the safety during procedures, however thoracoscopy is associated with many complications most importantly - pneumothorax. Experience from the data collected from 160 minimal access surgeries with regards to complication in thoracoscopy has been presented.

Visceral communications

Hirschsprung disease and Congenital Anomalies of the Kidney and Urinary Tract (CAKUT): A novel syndromic association Pini-Prato Alessio MD1*, Musso Marco MD 2*, Ceccherini Isabella MD 3, Mattioli Girolamo Prof 1,4 , Giunta Camilla MD 1,4, Ghiggeri Gianmarco MD 2, Jasonni Vincenzo Prof 1,4
1 3

Department of Pediatric Surgery, 2Division of Nephrology, Dialysis and Transplantation, Laboratorio di Genetica Molecolare, Giannina Gaslini Institute, Genoa, 4University of Genoa, Italy Introduction: Hirschsprung disease (HSCR) can occur in association with congenital abnormalities of the kidney and urinary tract (CAKUT). Nonetheless, the reported incidence of HSCR+CAKUT seems somehow underestimated. Based on the common genetic background we designed a prospective study aimed at determining the prevalence of CAKUT in patients with HSCR and at identifying RET, GDNF, and GFR1 mutations or haplotypes. Materials and methods: Eighty-four patients with HSCR admitted to our Department of Pediatric Surgery between July 2006 and July 2007 underwent interview, ultrasound screening (further investigation according to the detected anomaly), urinanalysis, and DNA extraction for molecular genetics. Furthermore, 27 consecutive patients with isolated CAKUT were included as control group. Results: Twenty-one HSCR patients (25%) have CAKUT. Six further HSCR patients have other non-CAKUT anomalies of the urinary tract that increased renal involvement to up to 32%. Hydronephrosis and hypoplasia represented the most frequent CAKUT detected in our series. RET mutations were found in 5 patients, GDNF mutations in 3 whereas no GFR1 mutations were found. Finally, HSCR predisposing T aplotype of RET proto-oncogene was found in 64% of HSCR patients, 50% of HSCR+CAKUT patients, and 24% of CAKUT patients. Discussion and conclusions: The incidence of CAKUT in HSCR patients is 4 to 6 fold higher than expected. Moreover, a patient with HSCR has a 3- to 18-fold higher risk of developing a CAKUT if compared to the normal population, particularly hydronephrosis or hypoplasia. The proportion of predisposing aplotype in HSCR+CAKUT patients resembles that of other syndromic HSCR. We could thus speculate that HSCR+CAKUT is a novel syndromic association with low HSCR penetrance (in literature the average incidence of HSCR in CAKUT series accounts for roughly 2%). RET, GNDF and GFR1 seem not to represent causative genes. Nonetheless, RET should act as a modifier gene with other genes involved. If thess results will be confirmed on larger series, it will be mandatory to develop new diagnostic workups for patients with HSCR including renal and urinary tract screening.

Transanal endorectal pull-through procedure in patient with Hirschsprungs disease Marian Vidiscak, Lucia Hustavova Department of Neoanatal and Pediatric Surgery, Slovak Medical University, Childrens Hospital, Bratislava, Slovakia Email: vidiscakm@yahoo.com Purpose: This study presents a technique and results of transanal one stage endorectal pull-through procedure in children with rectosigmoid Hirschsprung's disease. Methods: Between December 2006 and June 2008, 27 patients underwent transanal one stage endorectal pull-through procedure. In all 27 patients transitional zone was suggested by contrast enema and by perioperative full thickness rectal biopsy at 3 cm above the dentate line. Bowel preparation was done using Bisacodyl suppositories. The extent of colonic resection was specified by perioperative biopsy. The length of intestinal resection was between 15 and 42 cm. Aganglionic segment of the colon was resected and normal colon was pulled down to an anastomose with the distal end of anorectal remnant. The colorectal anastomosis was performed according to Swensons technique. Ceftazidine and Metronidasole were used as antibiotics treatment. The paracolic redon suction drain was applied for 24 hours. Results: The bowel movement reestablished within 7-12 hours postoperatively. Oral intake began 24 hours after the operation. All but one patient healed up without complications. The length of hospitalization ranged from 5 to 7 days. In one patient perirectal collection with increased inflammation parameters was treated conservatively by means of antibiotics. Conclusions: Transanal one stage endorectal pull-through operation for rectosigmoid Hirschsprungs disease can be successfully performed in all ages with good results, avoiding abdominal exploration.

Hepatobiliary Surgery: A single centre experience Hanan Said, Seema Menon, Alan Mortell, Chimezie Uchime, Onasegun Owonikoko, Katherine Lannigan, Martin Corbally Department of Paediatric Surgery, Our Ladys Hospital for Sick Children Dublin, Ireland Email: seemamenon@hotmail.com Aim: A retrospective eleven year study of surgical hepatobiliary outcomes in a national Paediatric Unit. Methods: We reviewed the records of 41 patients over an eleven year period spanning 1995-2005 inclusive with surgically treated hepatobiliary pathology in Our Ladys Children Hospital, Dublin, Ireland. Group I included 21 patients who had abnormal pancreatico-choledochal junctions (18 primary and 2 secondary Roux en Y excision and drainage) of the 19 choledochal cysts (17: type one, 2: Carolis disease.) and 2 patients with head of pancreas mass lesions (1 modified Whipple). The majority of this group presented with abdominal pain, jaundice and abdominal mass. Group II included 19 patients who had biliary atresia treated by Kasai (mean age 5.1 weeks). Group III consisted of two patients who had traumatic biliary injury (blunt abdominal trauma in one and traumatic ductal injury in the other). 1 had choledochoduedenostomy, and 1 had CBD exploration. Group IV involved only 1 cystadenoma of the pancreas. Results: Mean follow up for all patients is 3.6 years. Patients in group I and III did well without sequelae. . Group II: 11 are anicteric but 2 has severe portal HT, 6 have undergone OLTx, 1 died on OLTx waiting list, 1 died of cardiac disease. Group IV: The patient with cystadenoma had moderate pancreatic insufficiency following partial pancreatectomy. Conclusion: Our results from the cohort of patients studied are good and are in line with international standards. Paediatric hepatobiliary surgery is complex and must be carried out in a tertiary centre with an experienced and skilled hepatobiliary surgeon.

Pediatric percutaneous endoscopic gastrostomy. C Ulukaya-Durakbasa, H Okur, HM Mutus, A Bas, M Sert, AN Tosyali, V Sehiralti S.B. Istanbul Goztepe Training Hospital, Department of Pediatric Surgery, Turkiye Email: cigdemulukaya@yahoo.com Aims: The experience on pediatric percutaneous endoscopic gastrostomy (PEG) applications is relatively limited in children. An audit regarding PEG indications, complications, outcome and follow up is presented. Methods: A retrospective review of all children who underwent a PEG application was conducted. Results: During a 44 month period, 26 PEG applications were done in 25 children. There were 11 males and 14 females. The median age was 76 months (range, 8 months-14 years). The most frequent indication for PEG insertion was chronic neurological disease (n=18) followed by intracranial tumors (n=6) and cleft palate (n=1). All procedures were done under general anesthesia in the operating suit. Either No early complications were encountered. The mean postoperative follow up is 13 months (range, 1,5-44 months). 10 children died of underlying disorders on an average of 8 months after PEG insertion. The catheter was removed in 2 after a mean of 9 months as the oral feeding was re-established. In one patient, a gastrocolic fistula was detected 4 months after PEG insertion. A Stamm gastrostomy was then performed. In another one gastroesophageal reflux developed 5 months later and an open fundoplication with gastrostomy was done. The remaining 11 children are alive and actively using the PEG catheters. Among these, one patient had a gross leakage at the gastrostomy site that cannot be managed conservatively. He underwent a second PEG insertion with removal of the first one. The initially inserted catheters were replaced with balloon-type silicone replacement catheters at the 4th month. Conclusions: Although not devoid of complications, PEG offers the advantages of being a minimally invasive procedure, being easy to care for and enabling a permanent access for enteral nutrition in handicapped children. Regarding its simplicity, effectiveness and reproducibility, PEG should be the first-line method for providing long-term artificial enteral nutrition.

Extra mucosal pylorotomy by ombilical way Ouslim Rachid, Boukli H Since 1998, we have perfomed extra mucosal pylorotomy by ombilical way in 70 children presenting with congenital hypertrophic pyloric stenosis. Ever since the first cases, the technique and instruments have been adapted. The surgical technique and the precautionary measures are here explained again. This Technique is beneficial for children with a better post operative course and avoidance of any skin scar.

Esogastroplasty: a prospective study about 16 cases N. Sarray, S. Ghorbel, A. Charieg, M. Ben Dhaou, F. Nouira, R. Khemakhem, S. Jlidi, I. Brini, S. Boukthir, B. Chaouachi Department of pediatric surgery "B", Childrens hospital, Tunis. Tunisia Email: awatef_charieg@yahoo.com Introduction: The aim of this study is to analyze the outcome in 16 children undergoing an esophageal replacement with a gastric tube. Materials and methods: During a 4-year period, from 2002 to 2006, 16 children underwent gastric tube esophagoplasty. The most common indications for esopageal replacement included caustic injury (11 cases), failed repair of different varieties of esophageal atresia(4cases), and peptic stricture (1case). Baryum swallow was performed 7 days after the procedure and oesogastric endoscopy nine months after. Results: There were 5 girls and 11 boys undergoing the procedure at a medium age of 4 years (range, 9 months to 14 years). Laparotomy was performed in 16 children, associated to cervicotomy in 14 cases and thoracotomy in 2. In 9 cases, the outcome was considered good to excellent. Anastomotic leakage occurred in 6 patients witch closed spontaneously. 1 case of failure due to early necrosis of the gastric tube witch had been replaced by a colonic interposition. Anastomotic strictures occured in 7 patients all responding to endoscopic dilation. All the children are eating well and thriving without swallowing or respiratory problems. Conclusion: The esophageal replacement by a gastric tube appears to fulfill all the requirement of a good esophageal substitute with less drawbacks and good long-term results.

Hydrostatic reduction of intestinal intussusceptions by saline solution under ultrasonography. CA KARADAG, A CANMEMIS, AF AYDIN, N SEVER, D BASKIN, M YALCIN, AI DOKUCU Sisli Etfal Education and Research Hospital Pediatric Surgery Department, Istanbul, Turkey Email: cakaradag@yahoo.com Aim: Hydrostatic reduction of intestinal intussusceptions by saline solution under ultrasonography is widely accepted procedure in many centers because of non-ionizing therapy mode, short applying time, low cost, low hospital stay, easy and efficiency of the procedure. But the technical details of procedure as applying mode and time, material and reason for fail were not sufficiently investigated. Here we reviewed our experience in our intussusceptions cases treated by this procedure. Patients and Methods: During the period from1995 to 2008, hydrostatic intestinal reduction under ultrasonography was performed for 152 intussusceptions cases. The cases with delayed intestinal obstruction, shock and presence of peritonitis were excluded from the study. Reduction procedure was applied by a radiologist and pediatric surgeon via a Foley catheter put into rectum. Transit of saline solution from caecum to terminal ileum under sonographic vision was accepted as an efficient intestinal reduction. Clinical progress was accepted as an additional sign. We divided our series into two groups. Group I: this is an prospective study group (n: 51) performed during the years 1995 to 2001 via same radiologist and specialist pediatric surgeons. In Group II, the same reduction procedure was performed by different radiologists and pediatric surgeons during the period 2001 to February 2008 and the results of procedures in this group were evaluated retrospectively. Results: The success rate of the procedure was 80 % in group I and 71% in group II. No complication was seen in our series. In the case of fail of the procedure, an exploration was performed: manual reduction was required in 3 cases in GI while in 18 cases in GII. In 7 cases of GI, a spontaneous intestinal reduction was observed in the beginning of exploration. Surgical procedures as resection and anastomosis or ostomy were needed in 5 cases in both groups. Conclusion: Hydrostatic reduction of intestinal intussusceptions by saline solution under ultrasonography is widely accepted, easily applicable and highly successful therapeutic procedure. The most important advantage of the therapy is being non-ionizing one. Because of surgical and radiological collaboration for evaluation of patients signs, the success rate is high. Experience of the team was a factor of high success rate of the procedure.

Splenectomy for children with sickle cell disease. Report of 27 paediatric cases. F. MELLOULI1, Y. TLILI1, N. DHOUIB1, N KAABAR2, M.BEJAOUI1 Email: tlili_yemen@yahoo.fr
1 2

Service dimmuno-hematologie pediatrique, Centre National de Greffe de Moelle Osseuse Tunis Service de chirurgie pediatrique, Hopital Habib THAMEUR, Tunis

Introduction: Sickle cell anemia (SCA) is one of the commonest hereditary blood disorders in Tunisia. Its characterized by the presence of abnormal form of hemoglobin (HbS). In many cases, splenectomy is recommended in the treatment of some evolutive complications of SCA. We retrospectively reviewed our experience in the management of 27 children with SCA who had splenectomy as part of their management, with emphasis given to the indications of splenectomy. Patients and methods: Between January 1998 and December 2006, The medical records of all children with SCA who had splenectomy at our paediatric unit were retrospectively reviewed for the following: age at splenectomy, sex, Hb electrophoresis, indication for splenectomy, type of surgery, spleen weight and postoperative complications. Results: 27 patients with SCA had splenectomy. They are divided on 16 boys and 11 girls. Their mean age is 7.2 years (range, 4.5-9.8 years). 5 patients have an homozygous form of SCA and 22 have sickle--thalassemia. Recurrent acute splenic sequestration crisis (ASSC) was the commonest indication for splenectomy in 24 patients (88.8%), followed by hypersplenism in 3 patients (11.2%). The mean Hb levels befaure splenectomy is 7.69 g/dL. The mean Hb post-splenectomy is 9.07 g/dl. Ten of our patients (37%) had splenectomy and cholecystectomy at the same time. The mean spleen weight was 772.5 g (range, 80-2000 g). There was no mortality, but 3 patients (8.1%) developed postoperative complications (pulmonary infection in 2 cases, and seizures in one case). Conclusion: Splenectomy encourage particularly the increase of erythrocyte lineage and haemoglobin rate. It eliminates the risk of ASSC, and it is a good indication of hypersplenism during sickle-cell anaemia. But, the complete splenectomy exposes to more infectious risks. This complication may be prevented by a good perioperative management.

Omphalomesenteric duct remnants Ulukaya Durakbasa, H. Okur, H.M. Mutus, A. Bas, M.A. zen, V. ehiralt, A.N. Tosyal SB Gztepe Training Hospital, Department of Pediatric Surgery, Istanbul, Turkiye Email: cigdemulukaya@yahoo.com Background: Omphalomesenteric duct remnants (OMDR) are the most common congenital gastrointestinal (GI) anomalies. The reported series on symptomatic children are not diverse. This report gathers experience on the subject with emphasis on modes of presentation, surgical findings and pathological evaluation. Methods: A retrospective search through the years 1992 and 2007 was done for symptomatic presentations. Results: A total of 54 operations were done for symptomatic OMDs. There were 34 males and 10 females. The median age was 48 months. The presenting signs were GI tract obstruction in 22 (41%) patients, acute abdomen in 15 (28%), umbilical abnormalities in 14 (26%) and rectal bleeding in three (6%). The operation revealed inflamed Meckels diverticuli (MD) in 17 patients, obstruction due to band compression, volvulus or intussusception in 17, perforation in three, necrotic MD in two, thickening in the wall of MD in two, umbilical sinus in two and completely patent OMDR in 12 patients. Wedge resection was done in half and segmentary resection in the other half. The postoperative course was uneventful in all. Histopathology revealed ectopic gastric mucosa in 13 (24%) specimens, ectopic pancreatic tissue in one (2%), ectopic pancreatic and gastric tissue in one (2%), inflammation in 24 (44%) and necrosis in five (9%). The remaining 10 specimens were lined by normal mucosa. Conclusions: The presentation of OMDR can vary from mild umbilical abnormalities to complications necessitating extensive resections. Symptomatic OMDRs were more frequent in males. The major complications were found to be GI obstruction and inflammation. Rectal bleeding was not found to be a predominantly leading complaint for OMDRs in children. One fourth of cases had such ectopic gastric mucosa. OMDR can be the underlying etiology in any child with acute abdominal findings and prompt surgical treatment is indicated in all symptomatic cases.

Gastric perforation in the neonate. An eight case report. M. Masmoudi, I. Krichene, R. Jouini, K. Maazoun, L. Sahnoun, M. Ben Brahim, H. Tandia, S. Hidouri, A. Nouri. Department of paediatric eurgery, Monastir. Tunisia. Email: i_krichen@yahoo.fr Introduction: Gastric perforation in the neonate is rare. It is a well-known as a catastrophic abdominal event with high mortality. Methods: The authors reviewed retrospectively eight case of neonatal gastric perforation over a 22-year period. Results: The diagnosis of gastric perforation was made at an average age of 2.4 days (range, 1 to 4 days). The average weight was 2130 g (range, 1050 to 2950 g). There were 5 girls and 3 boys. Four babies were premature and weighting 1050 to 2050 g. They had had asphyxia and required mechanical ventilation at delivery after bag-mask ventilation. Two others infants (full-term baby and premature) underwent brief bag-mask ventilation for respiratory difficulty. The initial clinical finding was abdominal distention in all cases. X-ray examination showed massive pneumoperitoneum in all cases Surgery was performed urgently after a brief resuscitation. Necrosis was localized to the lesser gastric curvature in 4 cases, to the greater curvature in 3 cases and, in one case to the huge rent anterior antrum surface. Associated malformations were noted such as duodenal atresia (2 cases), pyloric atresia (1 case), esophageal atresia with tracheoesophageal fistula (1 case) and malrotation (1 case). The perforation wase closed. Four neonates had a gastrostomy. There were six deaths (3 premature and 3 full-term infants) in the early post-operative period (5 cases) and after five days of operation (1 case) as a result of multiorgan failure. No complication was seen between the survivors during 4 years of follow up. Conclusion: Gastric perforation in the newborn is a rare serious and life-threatening problem. Succes in treatement depends on early diagnosis, prompt resucitation and immediate surgical intervention.

Segmental dilatation of the intestine. Maazoun K, Ben Brahim M, Tandia H, Hidouri S, Sahnoun L, Chahed J, Amiri R, Ajroudi S, Krichene I, Mekki M, Belghith M, Nouri A. Department of paediatric surgery Monastir Tunisia Email: kaismz@yahoo.fr Purpose: The aim of this work is to discuss the pathogenesis of the segmental dilatation of the intestine (SDI) and to review its clinical presentation and the ways to confirm the diagnosis. Methods: Eight cases of pathologically proven SDI from 1987 to 2003 were reviewed and discussed. There were 7 newborns and a 1-year-old boy. Results: Our patients are 5 boys and 3 girls. In all cases, the diagnosis was not suspected before surgery.Two patients presented with a low neonatal bowel obstruction. Six patients were operated for omphalocele, which was the most frequent associated malformation. The SDI involved the ileum in all patients. The treatment consisted on a resection of the dilated segment with an end-toend anastomosis. Histological examination demonstrated the presence of ganglion cells in all cases. The muscular layer was hypertrophied in two cases and very thin in one case. A heterotopic gastric mucosa was observed in one case. No anomalies were observed in 5 cases. The postoperative course was uneventful in 6 cases with a mean follow-up of 5 years. Conclusions: Segmental intestinal dilatation in an exceptional pathology with an unknown etiology and a misleading clinical presentation. The clinical polymorphism and the lack of specifity of radiological investigations explain the difficulties to have a preoperative diagnosis. However, this difficulty is compensated by the favorable evolution after resection of the dilated segment.

Laparoscopic pyloromyotomy. A monocentric study about technical aspects. M. Robert , S. Maurin, H. Lardy Departement de chirurgie pediatrique. Centre de Pediatrie Gatien de Clocheville. CHRU Tours, France Email: h.lardy@chu-tours.fr Aim: To present our series of laparoscopic pyloromyotomy about technical point of view, results, and analyse the complications in order to prevent further difficulties with this demanding procedure. Material and method: During 1995 and 2007, 312 children have been operated on for hypertrophic pyloric stenosis. 277 of them have been made laparoscopically (Original technique). 50 first cases have been operated on by the same surgeon in order to assess the original technique. Further cases have been done by seniors and fellows. Technique: Under general anaesthesia, we use a 5 mm/Hg insufflating pressure. First trocar (2 mm) is introduced with open technique right the umbilicus for optic. Under direct vision, a 3 mm transparietal forceps is introduced without any trocar in the right sub costal area. A 3 mm trocar is introduced in front of the pylore for pyloromyotomy and atraumatic forceps. Results: - 4 conversions for exposure difficulties. - 7 insufficient pyloromyotomies (laparoscopic redo with favourable outcome) - 8 mucosal injuries (3%) closed during initial procedure (4 in 2006). - Mean hospitalization stay: 2,8 days (excluding redo cases). Discussion: Complications may be explained by surgeons inexperience (isolated fellow without a senior mentoring) for insufficient pyloromyotomies, conversion cases or mucosal perforation but also exist with seniors. There was no mortality in this series. Mucosal perforations have always been treated during initial procedure except one case during redo procedure for insufficient pyloromyotomy. Conversion should be recommended in case of difficulty. Insufficient pyloromyotomies may be reoperated laparoscopically. Laparoscopy is a safe technique but remains challenging procedure. Favorable outcome is related to surgeons experience. Difficulties must be avoided with better vision (4 mm optic should be recommended during training for better vision).

Diagnostic and therapeutic laparoscopy in paediatric abdominal trauma. F.ETTAYEBI Surgical emergency unit at childrens hospital of RABAT - MOROCCO Email: ettayebif@yahoo.fr Purpose: The purpose of this study is to assess the role of emergent laparoscopy as a diagnostic and potentially therapeutic modality in pediatric trauma. Laparoscopy provides important information for the treatment of children with abdominal trauma and is accompanied by improved diagnostic accuracy, reduction of non therapeutic laparotomy rates, and a reduction of morbidity. Methods: A 7-year (January 2008-December 2007) retrospective review of pediatric abdominal trauma was performed in the emergency unit of the children hospital of RABAT-MOROCCO., and information regarding patients who had operations for abdominal trauma was abstracted. Demographic variables, mechanism of injury, operative interventions, and patient outcomes were examined. Results: There were 174 abdominal trauma who had abdominal explorations for blunt (88%) and penetrating (12%) trauma. 11 patients had laparoscopy performed. Laparotomy was avoided in 4 patients of these patients. Laparoscopic therapeutic interventions were performed in 6 patients who had intestinal perforation. One patient had jejunal haematoma. No injuries were missed, or technical complications occurred, as a result of laparoscopic explorations. . No patients who underwent laparoscopy died. Conclusion: Laparoscopy in pediatric trauma is a safe method for the evaluation and treatment of selective blunt and penetrating abdominal injuries in hemodynamically stable patients. Laparoscopy serves as a diagnostic tool in abdominal trauma, which reduces the morbidity of a negative laparotomy

Laparoscopic appendectomy in children: 2-year experience AI DOKUCU, CA KARADAG, O KUZDAN, N CEVIZCI, N SEVER, D BASKIN, M YALCIN Sisli Etfal Education and Research Hospital Pediatric Surgery Department, Istanbul, Turkey Email: cakaradag@yahoo.com Aim: Laparoscopic appendectomy is reported safe and efficient in children. But there are some problems of applying of this procedure to whole acute abdominal cases. Here we aimed to present our experience on laparoscopic appendectomy with intention of applying the procedure to whole acute abdominal cases. Patients and method: After obtaining of pediatric laparoscopic equipment in January 2006, we intended to perform laparoscopic intervention in whole patients with acute abdomen. If laparoscopic intervention could not be performed, the reason was noted and open surgery was made. Between January 2006 and December 2008, all patients with appendicitis were reviewed. Demographic data, complaining time of symptoms, postoperative oral intake time, total hospital stay and postoperative complication were investigated. Results: During this period, 569 patients were operated on, 440 of them were not operated laparoscopically because of different reasons (operation in non-working hours, unique laparoscopic set per day, technical reasons, inexperienced surgeon, etc). During this time, 129 cases (86 male, 43 female) were operated laparoscopically via 3 ports (1 optic, 2 working). Appendix was dissected and brought out via umblicus and the stump was ligated extraperitoneally. The mean age was 10,1. Acute appendicitis was 75% while perforated ones 25%. LA was successfully performed in 123 patients while in 6 children, the convert to open surgery was made. Mean operative time was 48 mn for acute and 71mn for perforated cases. Oral intake was started meanly in 1.1 days in acute cases while 1.5 days in perforated ones. Mean hospital stay was 1,5 days for acute, 3.7 days in perforated cases. No peroperative complication was seen. There were 12 postoperative complications: intraabdominal abscess in 3, intestinal adhesions in 2, umblical infection in 5, wound infection in 1 and pleural effusion in 1. Conclusion: LA is a safe and efficient therapeutic option and an acceptable operative time in experienced hands. Postoperative complication rate is not higher than open surgery's rates. The major advantages of LA are not only good cosmetic but lesser postoperative pain and short hospital stay. Applying of procedure to whole acute abdominal cases needs enough laparoscopic equipment, experienced staff and laparoscopy oriented surgical intention.

Laparoscopic assisted transanal endorectal pull-through: is it necessary for all patients BEN BRAHIM Mohamed, EL EZZI Oumama, HIDOURI Saida, MEKKI Mongi, NOURI Abdellatif Department of pediatric surgery. Fattouma Bourguiba Hospital. 5000 Monastir. Tunisia Email: mohamed.benbrahim@voila.fr Introduction: Described in 1998, The transanal endorectal pull-through constituted a revolution in the surgical treatment of Hirschsprungs disease. This relatively simple technique was adopted by the majority of the pediatric surgeons because it allows a radical surgery without an abdominal approach in rectosigmoid aganglionosis. Laparoscopic-assisted transanal endorectal pull-through was reported but its indications are still non consensual. Is it necessary for all patients or must it be reserved for long aganglionic segments? Material and methods: Between 2002 and 2008, 70 TERPT were performed in infants and children. Restosigmoid aganglionosis was noticed in 61 patients. Nine patients had a long aganglionic segment above the rectosigmoid. Results: All the patients with short aganglionosis were operated exclusively by a transanal approach. For the 9 other patients, we used a primary laparoscopy in order to mobilize the descending colon and the splenic flexure. The mean opertaive time was respectively 118 and 146 mn. The post operative course was uneventful for all patients. Discussion and conclusions: Recently, definitive surgery for Hirschsprungs disease has been performed using minimally invasive techniques. The Swenson, Duhamel and Soave endorectal pull-through procedures have all been reported using minimally invasive approaches. The indications of a laparoscopy in TERPT are still non consensual. Some surgeons are rather inclined to a routine laparoscopy even in rectosigmoid aganglionosis. We think that there is no benefit to routine laparoscopic visualization. Laparoscopy may be reserved for those children who are at high risk for longer segment disease

Unusual indications of laparoscopy in pediatric surgery. Paul Daher, Jad El Hachem, Roy Eid. Introduction: Laparoscopic surgery has become the preferred approach for many procedures in pediatric surgery. However some of its nontraditional indications are still controversial. In this article, we relate unusual use of pediatric abdominal laparoscopy in our hospital for the past nine years. Material and methods: Our study is a retrospective review of all laparoscopic procedures at our hospital between April 1999 and July 2008 from which we excluded well known surgical indications (Appendectomy, cholecystectomy, Nissen fundoplication, splenectomy and Heller esophageal myotomy). Results: We found 44 patients that underwent unusual laparoscopic surgery, 12 (27%) of which were emergency procedures and 32 (72%) were elective. The procedures were as follows: 1Undescended testis: 15 patients, 6 (40%) of which had testicular agenesia, 3 had intra abdominal testis and 6 inguinal testis. 2Placement of peritoneal dialysis catheter: 2 cases. 3Revision of peritoneal dialysis catheter with complete adhesiolysis with or without omentectomy: 8 cases. 4Ovarian mass and ovarion torsion: 3 procedures, one of which was converted to open surgery due to tumor size and consistency. 5Ovarian transposition prior to abdominal radiotherapy: 2 cases. 6Adrenalectomy for neuroblastoma: 2 cases. 7Peritonitis (primary or after abdominal surgery): 6 cases, 3 of which followed appendectomy, 2 were due to colonic perforation, and 1 to infectious colitis in a leucemic patient. 8Abdominal trauma: 3 cases. 9Genitourinary malformation: 1 case. 10Sexual ambiguity: 2 cases. Conclusion: Laparoscopic abdominal surgery in pediatrics has found new indications and is increasingly replacing traditional laparotomy for diagnostic and therapeutic procedures; it can even be used safely on patients with a history of prior abdominal surgery.

The impact of thoracoscopy on pulmonary sequestration H. Ahmed, T. Lehnert, R. Metzger, H. Till Department of Paediatric Surgery, University of Leipzig, Germany Introduction: Pulmonary sequestrations (PS) are congenital lung lesions defined as non functioning pulmonary tissue lacking normal communication with the tracheobronchial tree and supplied by a systemic arterial supply from an aberrant aortic branch and are drained by pulmonary veins of the azygous or hemiazygous system. The combination of an aberrant systemic blood supply (identified by color-flow Doppler sonography) and an echogenic lung mass is pathognomonic for the prenatal diagnosis of pulmonary sequestration. Two forms of sequestration are recognized; extrapulmonary which is separated from the lung tissue by a separate lining of pleura, and intrapulmonary which is embedded in the normal lung sharing with it a common pleural investment. Patients and Methods: This study presents three patients with prenatally diagnosed pulmonary sequestrations, one patient with intrapulmonary sequestration (IPS) and two patients with extrapulmonary sequestration (EPS). All patients diagnosed by color flow Doppler sonography and MRI, that showed an abnormal echogenic solid mass in the left lower lobe with an abnormal systemic arterial blood supply. No associated other congenital lung lesions, no associated hydrops fetalis or maternal polyhydramnios. The infant with IPS recieved a thoracotomy at 3 months of age, with atypical resection of segments 8, 9 and 10. The other two infants with EPS had videoassisted thoracoscopic resection with ligasure at 6 months of age. Results: All patients had an uneventful intraoperative and postoperative course. Follow-up at 1, 3 and 6 months revealed that all the three patients were in good clinical condition and had fully expanded lungs on X-ray. Conclusion: Pulmonary sequestrations are a heterogenic group of congenital lung lesions with a favourable outcome. Thoracoscopic assisted resection using Ligasure of EPS seems simple and safe. Open resection remains a valuable option for IPS with a lung spearing strategy.

Thoracoscopy in infants and children: A 5- year experience T. Chouikh, S. Ghorbel, M. Belaiba, M. Bendhaou, A. Charieg, R. Khemekhem, F. Nouira, S. Jlidi, B. Chaouachi Department of pediatric surgery B. Childrens hospital of Tunis. Tunisia Email: awatef_charieg@yahoo.com Introduction: Thoracoscopy brought to the pediatric surgeons a safe and reproducible technique to treat several lesions with low risk of parietal wound and post operative pain. Material and method: From January 2002 to December 2007, 18 thoracoscopy were made in our department, we propose by this study to analyze our experience and describe the main indications of thoracoscopy in our institution. Results: 12 boys and 6 girls were admitted during this period for thoracoscopy, the mean age of the patients was 5 years, (4 month-13 years). The main indication of thoracoscopy in our study was thoracic debridement of empyema in 67% of cases(12 cases), that was loculated in 50% of cases and resistant to antibiotherapy in 50% of cases. The second indication of thoraoscopy was exploration of lung and mediastinal mass in 5 cases (27%). this technique yielded diagnostic pathologic findings (hystiocytosis X after a brushing of pleura as a treatment of a recurrent pneumothorax, pseudo inflammatory tumors, thoracic neuroblastoma). A resection of an esophageal duplication was first attended by thoracoscopy but a conversion was necessary after an esophageal breach. The follow up of the patients was simple and the mean duration of drainage after the surgery was 3 days. Patients were discharged 4 days after drainage. All patients had follow up by clinical exam and chest X-ray 2 weeks and a month after thoracscopy, with near 3 years of hindsight. Conclusion: Thoracoscopy is a good, efficient, reproducible and well tolerated way for management of children loculated empyema and exploration of mediastinal and thoracic mass. It reduces morbidity, pain and hospital stay, and produces better esthetic results. The good results of our study encourage us to promote this safe and easy technique.

The use of the Trapdoor incision for access to thoracic inlet pathology in children. Menon S., Yeap B., Corbally MTC, Department of Paediatric Surgery , Our Ladys Hospital for Sick Children, Dublin, Ireland Aim: Tumours at the thoracic inlet are difficult to access via a thoracic or cervical approach. The use of the anterior cervico-thoracic trapdoor incision has been reported to give good exposure to the anterior superior mediastinum in adults. We report our experience of four cases where a trapdoor incision was used to gain excellent access and exposure to thoracic inlet pathology in children. Method/Results: The charts of four patients were retrospectively reviewed and a literature review was conducted. The location and complexity of thoracic inlet pathology along with the added challenge of adjoining neurovascular structures often makes complete excision difficult due to poor access and exposure. We could only identify one other report in the literature of the use of this incision to access thoracic inlet pathology in children. We successfully used this incision to gain excellent exposure, good cosmetic healing and no morbidities in four individual cases (one neuroblastoma, one cystic hygroma, one mesenchymal hamartoma and a metastatic seminoma from a mature cystic teratoma). Discussion: The Trapdoor incision was initially described in adults, for access to subclavian vessel injury and gives excellent exposure from the C-4 to T-3 vertebral levels. In children, this incision is particularly advantageous as the ribs are more flexible thus allowing for greater retraction of the trapdoor laterally. Conclusion: Studies in adults have shown the trapdoor incision to provide excellent exposure to the superior mediastinal structures. The thoracic inlet in children is a difficult surgical field and we believe the use of the trapdoor incision facilitates complete excision of thoracic inlet pathology in children.

Video Assisted Thoracic Surgery (VATS) and pleural empyema in children: Early management does make a difference: 2 centers experience Mohammed Youssef Alexandria Hospital for Sick Children Email: edini99@yahoo.com The treatment of empyema with pleural drainage is a widely accepted surgical procedure. Currently,VATS (Video assisted thoracoscopic surgery) is gaining acceptance as a primary modality of treatment in cases of early empyema. 64 children aged 1 - 17 years with non tuberculosis acute empyema were treated in 2 centers (TIBA Hospital ,Alexandria, Egypt,and Helios Center for Pediatric Surgery,Berlin.) with early thoracoscopic cleaning and drainage of the pleural cavity . Very good results were obtained for all the patients. VATS has been proven to be associated with a lower morbidity, shorter hospital stay, lower costs, and clinical results similar to those achieved by open surgery.

Lapaoscopic extra mucosal colon biopsies in dysmotility disorders. Cornelia van Tuil MD and Amulya K. Saxena MD* Pediatric Surgical Department of Heidelberg, Germany *Pediatric Surgical Clinic of Graz, Austria Email: cvantuil@gmail.com Introduction: Although Hirschsprungs disease is ruled out in most patients with motility disorders using standard rectal biopsy techniques, dysmotility disorders of the colon are extremely difficult to diagnose in a vast majority of patients. Elaborate diagnosis of such patients is only possible after inspection of thecolon and obtaining multiple biopsies for histopathological investigations. In such cases it was traditionally opted against taking serial colon biopsies due to the invasiveness of the open technique. Material and Methods: The laparoscopic extra mucosal colon biopsy (LEMB) technique has been found suitable for such patient groups. This technique requires no or little colon preparation and can be performed as a day care procedure. LEMB is performed using an umbilical optic port along with two work ports using 3.5 mm or 5 mm instruments depending on the age of the child. The procedure involves identification of pathological colonic segments, incision of the taenia libera using metzenbaum scissors without opening the colonic mucosa, elevation of the biopsy edge and further preparation between the mucosa and serosa using metzenbaum scissors until the desired length of the biopsy has been obtained. In case of bleeding that may obscure vision at the site of biopsy, saline washings are utilized. Results: In none of the cases performed at our former Pediatric Surgical Center of Mnster, Germany, a colon mucosal injury/ perforation was encountered. Discussion and Conclusion: LEMB is a safe technique which is easy to perform. After entering the abdominal cavity it takes an average of 2 - 3 min to take a biopsy. LEMB in our practice is a minimal invasive technique to obtain serial colon biopsies without morbidity for extensive histopathological examinations in severe motility disorders of the colon.

Laparoscopic rectopexy in rectal prolaps. F. ETTAYEBI Department of Paediatric Surgery, Childrens hospital of RABAT- MOROCCO Email: ettayebif@yahoo.fr Rectopexy is one of the accepted forms of treating rectal prolapse in children. A variety of techniques including transanal encircling-the-anus, and transabdominal approaches, have been reported. Recently, the laparoscopic approach has been appllied for rectal prolaps as a less invasive procedure in adults. We report our experience of laparoscopic rectopexy in children. 11 Patients with rectal prolapse (Fig 1) resistant to conservative treatment underwent laparoscopic rectopexy. Three 5mm ports were inserted: one in the umbilicus for a zero degree telescope, one in the left upper quadrant and one in the right iliac fossa. The mobility of the rectum was checked. The peritoneum was incised in the area below the left internal inguinal ring (Fig.2). The rectum is fully stretched and sutured to the psoas muscle with 20 vicryl sutures (Fig. 3a & 3b). Postoperatively feeding was commenced once the patients were awake. The patients were discharged the next day and were followed up after six weeks. Although transanal approaches such as sclerosing therapy and encircling-the-anus have been the preferred procedures of paediatric surgeons, these often fail in cases of full-thickness rectal prolaps. Several laparoscopic approaches have been reported in adults. However, there have been few reports of these laparoscopic procedures in children. In our unit we performed this procedure in patient who had failed transanal approaches. Our results show that laparoscopic rectopexy is feasible and less invasive in children, as it is in adults Laparoscopic rectopexy can be easily performed in children. Our technique is simple and had excellent results. We recommend laparoscopic rectopexy in children with rectal prolapse resistant to conservative management.

Abdominal tuberculosis CHAHED J, BEN BRAHIM M, MAAZOUN K, HIDOURI S, SAHNOUN L KRICHENE I, JOUINI R, MEKKI M, BELGUITH M, Nouri A. Department of pediatric surgery. CHU Monastir. Tunisia Email: j.chahed@voila.fr Introduction: Abdominal tuberculosis is one of the most frequent extra-pulmonary localizations. The diagnosis is difficult to be established and may lead to a delayed prescription of antituberculosis treatment. The aim of our study is to stress on the role of coelioscopy associated to biopsy in the diagnostic confirmation of abdominal tuberculosis particularly in doubtful cases. Patients and methods: We conducted a retrospective study of 11 observations in the paediatric surgery department in Fattouma Bourguiba hospital in Monastir during a six year period (2001-2006). The final diagnosis was established by laparoscopy and histology. Results: 11 cases of abdominal tuberculosis with mean age of 5.6 years diagnosed by laparoscopy and biopsy. It was peritoneal tuberculosis in all cases associated to an intestinal localization in one case. A conversion to laparotomy was practiced in three cases for appendicular plastron in one case, pseudo-tumor aspect of an intestinal loop which needed a resection-anastomosis in another case and appendicectomy and coecum biopsy because of its pathologic aspect. The diagnostic confirmation by histologic study was made on biopsies in 9 cases and on excision piece in other 2 cases. The evolution was favorable with antituberculosis treatment. Conclusion: Abdominal tuberculosis is still frequent in Tunisia. Because of non specific clinical presentation and limited means of investigation, laparoscopy and biopsy should be practiced as first line investigations in case of doubtful abdominal tuberculosis. The prognosis depends on the earliness of establishing the diagnosis and of beginning an adapted antituberculosis treatment.

Limited Urethral Mobilization technique in distal hypospadias repair with satisfactory results Elemen L, Tugay M Kocaeli University, Department of Pediatric Surgery, Kocaeli, Turkey Purpose: To assess outcomes in distal hypospadias repair with Limited Urethral Mobilization (LUM) technique. Patients and Methods: Thirty-five patients were operated for distal hypospadias in 4 years period with LUM technique. Localization of urethral meatus was glanular in 22, coronal in 5 and sub-coronal in 8 patients. Age distribution was 6 months to 15 years with a mean of 2.5 years. One patient had undergone MAGPI, 4 patients TIPU repair and subsequent circumcision. Four patients had minimal chordee and 2 patients had glans tilt related to ventral skin. Following artificial erection test, urethra proximal to the meatus was mobilized circumferentially for a distance sufficient to allow the urethra to reach the tip of the glans without tension. If chordee was present it was released. Glanular bed was prepared and then the mobilized urethra was placed in the deep bed. First dorsal lip of urethra was sutured to the glans tip, glans wings were wrapped around urethra, and then anterior lip of urethra was secured to glans. Urethral catheter was left in place. Circumcision was performed in all native cases. Urethral calibration was performed with 6-8 Fr catheters on the 15th post-operative day. Results: Urethral catheters were removed in 3 to 5 days with a mean of 3.2 days. Five of the patients (1 of whom was the redo case) experienced meatal stenosis which responded to gentle dilatations. No fistula was observed. Neither retraction of the urethral meatus nor chordee was encountered. Follow-up period varied from 6 to 48 months with a mean of 35 months. Conclusion: The LUM technique, in distal hypospadias repair either with or without chordee is simple and effective. As no new urethral tube is constructed there is no risk of fistula. This technique helps relieving chordee by mobilizing the urethral plate into the glans. Slit-like urethral meatus with good functional results were obtained with the use LUM technique.

The tubularized incised plate urethroplasty (Snodgrass) in recurrent distal hypospadias. A prospective study. Ramy Waly Email: ramywaly@yahoo.com Background: Recurrent hypospadias is a major problem in paediatric surgery.Many causes are implicated for high failure rate of redo hypospadias. Snodgrass technique is one of the most common techniques used in distal hypospadias repair nowadays. Purpose: To assess the success rate and postoperative complications of the tubularized incised-plate (Snodgrass) urethroplasty in recurrent distal hypospadias. Patients and methods: Between April 2002 and July 2007, 30 children (mean age = 81.4 months) underwent a redo Snodgrass repair in a prospective study. In the 1st month postoperatively, the early complication rates was as follows: postoperative wound dehiscence rate was 6.7% (2 cases), bleeding, oedema, wound infection and urinary retention rates was 3% for each (one case for each). With 2-10 months of follow-up, the Late complication rates were as follows: repair disruption (whether partial or complete) rate was 50% (15 cases), the fistula formation rate (whither small or large) was 30% (9 cases), penile torsion rate was 10% (3 cases), epidermoid cyst rate was 6.7% (2 cases), urethral stricture and meatal stenosis rates were 3% for each (1 case for each). Conclusion: Although the Snodgrass tubularized incised-plate urethroplasty is one of the first choices in primary distal hypospadias repair. Its rule in recurrent distal hypospadias repair is questionable, especially in cases with previous Snodgrass repair. Good selection of repair type according to each patient criteria is mandatory.

Modified Duplay technique in the treatment of hypospadias. S.Touabti1, H. Dodat2

1 2

Service de chirurgie pdiatrique, unit durologie pdiatrique CHU de Stif Algrie Service de chirurgie pdiatrique, unit durologie pdiatrique Hpital Edouar Herriot, Lyon, France The surgical repair of anterior hypospadias depends on the surgeons custom and the anatomical variations of this anomaly. Most publications agree nowadays on the one-stage surgery. We report on 150 hypospadias operated. Our procedure is based on the Duplay technique, in addition to personal modifications in order to correct the frequently associated penis anomalies. The procedure is described herein. Aesthetic and functional results are reported and seem to be very satisfactory.

Preliminary results of two-stage preputial vascularized tube technique. Yunus Sylet, Ebru Yeilda* , Cem Kara*,S.N. Cenk Byknal University of stanbul, Cerrahpaa Medical Faculty, Department of Pediatric Surgery, Division of Pediatric Urology, * Pediatric Surgery and Urology Center of stanbul. Introduction: While the algorithms of the operative techniques in distal hypospadias are mostly standardized, it still is exacting to decide whether a single-stage or two-stage operation should be carried-on in cases with proximal hypospadias. Many of those who prefer two-stage approach in these patients use genital or buccal mucosa grafts to form the urethral plate. The aim of the study is to evaluate the results of our experience in patients with primary proximal hypospadias in whom two-stage operation was indicated and pediculated rectangular preputial flap was used to form urethral plate in the first-stage. Patients and method: Two-stage operation was performed between 2005 2008, in 10 children with primary proximal hypospadias with severe chordee. The minimum of 6 months is preferred to wait to proceed to the second stage. In the first stage, a rectangular flap was prepared from the preputial mucosa similar to pediculated preputial tube preparation of Duckett. Following the correction of the ventral curvature, this flap, without being tubularized, was lied between the original urethra and glans tip. Few fixation sutures were placed to ease the adhesion with tunica albuginea. Tiny incisions were performed on the flap in order to provide the blood and fluid collection behind it. In the second stage, the urethroplasty was carried-on by tubularizing the flap prepared in the first stage. A urethral catheter was placed in both stages and an elastic dressing was covered over the Mepithel or Bactigrass that was placed right over the wound. Results: The mean age of the cases was found to be 3 years (1 3.5 years). While both stages were completed in 7 of the cases in this series (with an average of 7.5 months between two stages, averaging 6 11 months) 3 patients are still waiting for the next step. The urethral catheter was removed with a mean of 6 days and 10 days after the operation in the first stage and in the second stage, respectively. No complication is detected in the follow-up period ranging between 3 -18 months of the 5 cases in whom both stages were completed. They all are urinating from the glans tip and the cosmetic results are satisfying. In the other 3 cases that wait an average of 2 months for the next step, the flaps have the impression of healthy sources for future urethroplasties. Discussion: Single-stage flap urethroplasties are preferred much than the graft urethroplasties in the correction of primary hypospadias. On the other hand, grafts are much more commonly applied in two-stage operations. Our experiencein a limited number of patients showed that the use of pediculated preputial mucosal flap to form the urethral platein two-stage operations increases the success rate of tubularization procedures in the second stage. We think thatwe benefited from the known advantages of flap applications in the hypospadias surgery in these patients.

Results of the repair of distal hypospadia: Comparison between two techniques. Mahdi Ben Dhaou; Mohamed Jallouli; Houda Kammoun; Nozha Kallel; Riadh Mhiri Department of pediatric surgery, Hedi Chaker Hospital, Sfax ; Tunisia Email: riadh.mhiri@rns.tn hypospadias is one of the most common deformities of the urogenital system. A great diversity of procedures to correct hypospadias is suggested. In our department we use for the correction of the "distal" and "mid-shaft hypospadias defects mainly two different methods; the MATHIEU technique and the spongioplasty. We investigated retrospectively for both methods(MATHIEU group n:52 and spongioplasty group n: 37) the outcome regarding the complication, the cosmetic satisfaction and the voiding and compared the results. We find a good cosmetic look, an adequate voiding and comparable outcome regarding the complication rate.

Spongioplasty in treatment of hypospadias. OUSLIM R. BOUKLI HACENE M.A & Coll Dpartement of peadiatric surgery ORAN UNIVERSITY The authors describe SPONGIOPLASTY prservation of urthral DUPLAY uretroplasty Glanduloplasty Spongious corpse dissection and plasty in middle line

This approche vas perfomed in ORAN HOSPITAL since 1996 with 188 Cases. The result is good in short ant middle term, applied in anterior hypospadia (90%)

Is contralateral exploration necessary in children with unilateral inguinal hernia? Mohamed JALLOULI, Houssem YENGUI, Dalel TRIGUI, Hatem KALLEL*, Riadh MHIRI. Department of pediatric surgery. Hedi Chaker Hospital. 3029 Sfax. Tunisia. Email: mohamed.jallouli@rns.tn Purpose: This study was done to identify risk factors for metachronous manifestation of contralateral inguinal hernia in child with unilateral inguinal hernia. Methods: This is a retrospective study of 565 patients during 9 years period at a single institution. Age, sex, and side of the hernia at presentation were recorded. The incidence of metachronous inguinal hernia and its risk factors were analysed. Results: Of 565 children, 62 (11%) presented with synchronous bilateral hernias. Of the remaining 503, a metachronous contralateral hernia developed in 24 (4.8%). in our study, there is no correlation between the apparition of contralateral hernia and age at surgery, gender, premature and the side of hernia. Conclusion: The low incidence of contralateral hernia regardless of gender or age, does not justify routine contralateral exploration.

Is inguinal exploration a still valid therapeutic option for the impalpable testis? Said H, Menon S, Ghalab A, Corbally MTC Our Ladys Hospital for Sick Children, Crumlin Ireland Aims: We report our experience with boys with clinically impalpable undescended testes and determine the efficacy of examination under anaesthesia (EUA) in the management plan. Patients and methods: This retrospective study included all patients who underwent surgery for undescended testes from 1st of Jan 1990 to 31st of Dec 2005. Data was collected from HIPE and patients charts from a single team at OLCSC Crumlin. Of 716 boys with 792 undescended testes, were treated by one team. 201 testes (25 %) were impalpable at presentation and included in this study. Of these, 23 testes (11 %) were bilateral, 69 (34 %) right sided, 109 (55 %) left sided. Mean follow up was 18 months and mean age was 42 months. Results: 178 boys with 201 impalpable testes underwent EUA which revealed a normal sized testis in 21 (10.5 %), a small sized testis in 34 cases(17 %), a sac or vas like structure in 133 (66 %) and no groin structure (a sac or vas like structure ) in 13 patients (6.5 %) . These 13 patients underwent laparoscopy and four had a blind ending vas, two underwent orchidectomy for an atrophic testis, three had two stage Fowler Stephens (FS) and four had single stage FS. Of 133 patients with a palpable sac or vas like structure, orchidopexy was performed in 50 (25 %), 36 (18 %) underwent single stage FS, 7 (3.5 %) underwent two stage FS and 40 (20 %) underwent excision of testicular (nubbin) or vas remnant. 2 of these 40 patients 1 %) needed re-exploration and subsequent orchidectomy. Of the 55 patients of a palpable testes (i.e. 21 normal and 34 small sized testis), 38 underwent a standard orchidopexy (19 %) and 17 underwent single stage FS (8.5 %). High testicular retraction was noted in 9 cases (4.5%) and 13 (6.5%) cases had mild retraction at the upper half of the scrotum. Conclusion: Meticulous EUA facilitates safe and accurate planning of the surgical approach to the patient with an impalpable testis and should remain part of the surgeons skill base. Laparoscopy should be used for establishing or refuting the diagnosis of an absent testis when no structure is palpable.

Is Fowler-Stephens procedure still indicated for the treatment of intra-abdominal testis? Daher.P, Nabbout.P,Feghali.J,Beyrouthy G. Division of pediatric surgery, Hotel Dieu de France, Beirut, Lebanon Multiple approaches exist for the management of the non palpable testis. In this study we report our experience with orchiopexy performed without dividing the spermatic vessels. Between June 2003 and April 2008, we treated 21 boys with non palpable testis. Average age at presentation was 24 months. Of the non palpable testes 10(47.6%) were on the right side, 6(28.5%) were on the left side and 5(23.9%) were bilateral. In all cases the testis was high in the intra abdominal position. It was identified by abdominal ultrasound or by laparoscopy. All cases were treated through a standard inguinal incision. The operation consisted in sectioning the gubernaculums, with transperitoneal mobilization of the vas and vessels without transection. The testis was then fixed to the scrotum even if there was traction on the spermatic vessels and upward retraction of the scrotal skin. We had no intraoperative complications. All patients were discharged on the same day. In all cases the testis was normal in size and found in the scrotum on follow-up. On the basis of our experience, we believe that the Fowler-Stephens procedure is not indicated anymore in the management of non palpable testes. Orchiopexy without division of the spermatic vessels should be the treatment of choice because it does not affect normal testicular vascularization and is minimally invasive.

Urinary lithisasis and urinary tract malformation J.Chahed, R. Jouini, K. Maazoun, S. Hidouri, M. Ben Brahim, L. Sahnoun, I. Krichene, M. Mekki, M. Belguith, A. Nouri. Department of pediatric surgery. CHU Fattouma Bourguiba, Monastir. Tunisia Email: j.chahed@voila.fr. The association of urinary lithiasis and urinary tract malformation is not rare and deserves to be considered because of its specific management. We report 34 patients (19 males and 15 females) with a mean age of 4.8 years (ranging from 2 months to 14 years old). All of them have a urinary lithiasis with a urinary tract malformation. Abdominal pain was the most frequent clinical symptom (38%). Urinary infection was found in 10 patients (21%) and macroscopic hematurea was present in 10 patients (28%). Diagnostic modalities included the ultrasound, intravenous urography and urethrocystography results. The most frequent urinary tract malformations were megaureter in 8, ureteropelvic junction obstruction in 7, vesico-ureteric reflux was associated to urinary lithiasis in 8 cases but its malformative origine could not be precised. Treatment consisted of lithiasis extraction in 32 cases associated to a specific treatment of the uropathy in 27 cases. Post operative outcome was simple in all cases. In fact urinary lithiasis and urinary tract malformation is not rare; indeed 30 to 39% of urinary lithiasis are associated to urinary tract malformation. Positif diagnosis relies particularly on kidney ultrasound, intravenous urography and retrograde urethrocystography. Treatment depends on the type of urinary tract malformation, localization and size of the urinary lithiasis. In conclusion urinary lithiasis and urinary tract malformation is a frequent eventuality. Its treatment is usually a surgical one.

Non-Wilms renal tumors in children Ajroudi S, Maazoun K, Hidouri S, Tandia H, Masmoudi M, Chahed J, Ben Brahim M, Sahnoun L, Krichne I, Mekki M, Belghith M, Nouri A. Department of paediatric surgery. Monastir Tunisia Email: kaismz@yahoo.fr Renal tumors other than Wilms tumor are infrequent in childhood. The most common non-wilms tumors are clear cell sarcoma of the kidney (CCSK), rhabdoid tumor of the kidney (RTK), renal cell carcinoma (RCC), congenital mesoblastic nephroma (CMN), and multilocular cystic nephroma (MCN). The aim of this work is to specify the epidemilogic, clinical and pathological characteristics of these tumors. Non-wilms renal tumors represented 13 % (13 cases/103) of the pediatric tumors of the kidney. The most frequent clinical sign is the abdominal tumor. At the diagnosis, the metastasis were present in 4 cases.The tumor corresponded to CMN : 4, CCSK : 3, RTK : 1, RCC : 1, MCN : 1, clear cells sarcoma : 1, lymphoma : 2.The follow up ranged from 2 to 10 years, the mortality is 23 %. Non-wilms renal tumors are a heterogeneous group that have distinct presentations. Prognosis depends of the histological diagnosis.

Minimal access surgical treatment of hydatid disease. A simplified approach. Guvenc BH*, Baskin D, Dokucu AI, Yalcin M, Sever N, Karadag CA, Ekingen G Depts. of Pediatric Surgery, Anadolu Medical Center*, Kocaeli & Sisli Etfal Education and Research Hospital, Istanbul, Turkey Aim: Minimal access surgical treatment of hydatid disease is challenging for the pediatric surgeons because of the risk of the spillage of the cyst content. Here we present our experience with the minimal access surgical treatment of thoracal and abdominal hydatid disease. Method: Between 2003 and 2007 minimal access surgical treatment of hydatid cysts were performed in 11 patients (7 abdominal, 4 thoracal) with large cyst either nonresponsive to medical treatment or has a risk of perforation. All patients had preoperative albendazole treatment. Preoperative chest xray, abdominal USG and abdominal CT were taken in all patients. A special laparoscopic puncture needle (1.6 mm) was used to aspirate the contents of the cyst and instillation of hypertonic saline during intervention. After the aspiration of the cyst fluid, cyst was opened, proligerous membrane was removed using an endobag and the dome of the pericyst was excised. A haemovac drain was inserted into the cystic cavity in all cases. Patients continued to take albendazole postoperatively as well. Results: Cysts were unilocular in all patients with a mean diameter of 100 mms. One patient had concurrent hydatid cyst in the left kidney, and another had a cyst in the right lung. Mean operative time was 165 minutes and none was converted to open surgery. One patient with a huge cyst located on the dome of the liver needed 4 trochars, the rest was done with 3 trochar insertions. There was no spillage into the (thoracal/abdominal) cavity. While concurrent kidney cyst was removed during laparoscopy in the same session, lung cyst was removed with thoracoscopy in a separate session. Drains were removed in postoperative mean 3.5 days. Median hospital stay was 5 days (2-13 days). Neither early complication nor (bronchial/biliary) fistula had occurred. Conclusion: Use of a special laparoscopic puncture needle prevents spillage of the cyst content during the aspiration of the cystic fluid and instillation of the scolicidal agent. Insertion of sterile pads into the abdomen for prevention of spillage was not required in our cases. Minimal access surgical removal of large hydatid cysts is a safe and effective procedure.

Minimally invasive surgery (MIS) for children thoracic neuroblastoma. Luciano Mastroianni Paediatric Surgery Unit, Mother and Child Hospital G. Salesi, Ancona, Italy Neuroblastoma is the most common extracranial malignant solid tumour in infancy and childhood. In the first year of life frequent primary tumour sites are the thorax and the neck, afterwards in most cases the tumour arises in the in the adrenal gland. Minimally invasive surgery (MIS) allows biopsy and primary tumour resection for thoracic neuroblastoma avoiding the cosmetic and functional disorders of the thoracotomy. A 12-month-old girl was admitted to our hospital because of a sudden onset of dancing eye syndrome. MRI and computed tomographic scan (CT) showed a left posterior mediastinal mass. The level of the urinary catecholamine metabolites vanillylmandelic acid (VMA) and homovanillic acid (HVA) were elevated. The child underwent a thoracoscopic resection of the mediastinal mass. The histology of the resected tumour showed cystic neuroblastoma. The child was placed in supine position. We used three 5-mm ports: one in the fifth intercostal space on the posterior axillary line and the other two in the third and seventh intercostal space on the mid-axillary line. A 4 mm Hg pressure was used and the operative time was of 120 minutes. Thoracoscopy is the ideal technique for tumour biopsy and to determine tumour resectability for thoracic neuroblastoma; it is a valuable and safe technique, but tumour size has to be between 20 60 mm.

Laparoscopic hemi-hysterectomy: Type II-b uteral anomaly. Case report CA KARADAG, AI DOKUCU, M DEMIR, D BASKIN Sisli Etfal Education and Research Hospital Pediatric Surgery Department, Istanbul, Turkey Email: cakaradag@yahoo.com Disgenesis of Mullerian tract may result in different urogenital anomalies containing uteral malformations. Uteral anomalies exist about 4% of female population and the majority of them are septal (33.6%) or arcuat (32.8%) anomalies of uterus. This type of anomalies may stay without any symptomatology or present symptoms during menstruation or pregnancy. Here we present a teenager girl with an uteral anomaly Type IIb presenting abdominal pain and her laparoscopic treatment. 14 year-old girl presenting right lower abdominal pain during last 48 hours. The pain was occasionally seen and during one period 18 months ago, an open appendectomy was performed because of acute abdomen. First physical examination showed normal abdominal sings. But ultrasonographic and tomographic examinations showed a paraovarian mass, measuring 49x43mm, beside to uterus. Endometriosis or uterus didelfis were suspected as diagnosis and an explorative laparoscopy was programmed. Before laparoscopy, a vaginoscopy was made and found normal. Laparoscopic procedure was performed by 3 ports (10mm at umblicus, 5 mm in both lower abdomen). A solid, thick-walled mass was situated between normal shaped uterus and normal shaped right over, without any connection to vagina. We performed a mass dissection via Ligasure while preserving right over and uturus itself and removed mass by enlarged umblical incision. The mass was opened and a chochalate type liquide seen. Pathologic examination reported typical uteral structure. The patient was discharged at day 2 postoperatively and no complaints then after. Mullerian anomalies may present in a wide spectrum with different symptomatology. Laparoscopic treatments of this kind of anomalies may give more information on pathology and possibility to evaluate therapeutic options. Severe uteral abnormalities as seen in our case should be treated in childhood period before possible occurrence of severe complications. Laparoscopic therapy has several advantages on open surgery in surgical treatment of Mullerian anomalies.

Laparoscopic resection of a sarcoma of the rectum H. Lardy, Z. Benchellal, F. Dommange, M. Boscq, MC. Machet, S. Chapet, M. Robert. Department of pediatric surgery. Centre de pediatrie Gatien de Clocheville, CHRU Tours, France Email: h.lardy@chu-tours.fr Outcome of soft tissue sarcomas depend on initial localization and surgical resectability. Rectal localization is rare and the difficulty lies in proper diagnosis. The treatment demands a multidisciplinary approach. We report the case of a neuroectodermal sarcoma of the rectum treated by neoadjuvant chemotherapy then by coloproctectomy followed by adjuvant radiotherapy and chemotherapy. Clinical history begins by red blood rectal bleeding and constipation. Examination and rectal touch revealed an endoluminal mass infiltrating the right lateral wall of the rectum. The coloscopy showed a polypoid, crumbly, bleeding mass and the biopsy a neuroectodermal sarcoma of the rectum confirmed by molecular biology. Extension bilan was negative. The patient was treated according to the EURO EWING 99 protocol. MRI post chemotherapy assessment showed an important tumor decline of the endoluminal part of the tumor but no effect on the wall of the rectum. After 6 courses of chemotherapy, the patient had a laparoscopic coloproctectomy with coloanal anastomosis and a protective temporary ileostomy. Pathology of the resection showed an 11 % remainder of the initial tumour with healthy safety therapeutic margins. However, the patient received a neoadjuvant chemotherapy and radiotherapy after bilateral laparoscopic ovariopexy. Restoration of the continuity of the gastrointestinal tract followed a surgical intervention 8 months after the first operation. Tumours of the rectum in children are rare and difficult to diagnose. In our case, the rectal touch enabled a diagnosis with certainty. Treatment of these tumors demands a multidisciplinary approach and the collaboration of adult surgeons who are used to these type of tumours. Protective ileostomy is required and enables simple restoration of gastrointestinal tract continuity and a better tolerance of radiotherapy. With more than 2 years since the last chemotherapy, this patient seems to have a favorable outcome although more than 10 % of the tumour remained after neoadjuvant chemotherapy.

Burkitts lymphoma revealed by acute intussusception in children. H.Tandia, M. Mekki, S. Hidouri, K. Maazoun, M. Masmoudi, M. Ben Brahim, L. Sahnoun, J. Chahed, R. Laamira, I. Krichene, M. Belghith, A. Nouri Departement of Paediatric Surgery Monastir. Tunisia Introduction: Burkitts lymphomas are arely revealed by acute intestinal intussusception in children. The aim of this study is to report 10 cases of intussusception due to lymphoma and to determine the clinical, anatomopathogical and therapeutic aspects of intusssception due to lymphoma. Patients and methods: we raport a retrospective study about 10 cases of burkitts lymphoma in children revealed by acute intussusception. Results: Between 2000 and 2007, we studied 7 boys and 3 girls aged from 3 years to 11 years with intussusception due to lymphoma. All were hospitalized for acute abdominal syndrom. Abdominal ultrasonography showed intestinal intussusception and primitive tumor in all cases. Laparotomy was performed on emergency and found the primitive tumor in nine cases, the procedure consisted in ileal resection. One patient was not operated on and the diagnosis was performed through ultrasonography-guided-tumoral puncture. Eight cases were succesfully treated with protocol chemotherapy wiyh 4 years follow-up. Two deths due to chemotherapy complications were noted. Conclusion: Burkitts lymphomas are rarely revealed by acute intestinal intussusception in children but the diagnosis must be suspect in case of an age older than 5 years. Abdominall ultrasonography is the most efficient examination for the diagnosis.The keys for the traitement rest the chemotherapy.

Burkitts lymphoma revealed by intestinal invagination in children. Y. TLILI 1, I. BEL HADJ 1, M. KHEMIRI 1, A. BORGI1, B. CHAOUACHI2, M. HAMZAOUI3, S. SAYED4, F. OUBICH1, S. BARSAOUI1 1- Unit doncologie, service de mdecine infantile A - Hpital denfant de Tunis, Tunisie. 2- Service de chirurgie pdiatrique B - Hpital denfant de Tunis, Tunisie. 3- Service de chirurgie pdiatrique A - Hpital denfant de Tunis, Tunisie. 4- Service de chirurgie pdiatrique - Hpital Habib Thameur, Tunis, Tunisie. Introduction : Burkitts lymphoma is a lymphoblastic B-cell malignant tumor with very aggressive course. Its rarely revealed by acute intestinal invagination in children. We retrospectively reviewed our series of patients with Burkitts lymphoma revealed by intestinal invagination to assess the role of surgery in the treatment of these patients. Patients and methods: Between January 2001 and June 2008, nine children, seven boys and two girls (mean age: 5 years and 6 months) (4 - 10 years) were hospitalized for an acute abdominal syndrome. Abdominal ultrasonography showed intestinal invagination (n =10), primitive tumor (n = 5), mesenteric lymph nodes (n = 3). A laparotomy was performed on emergency in eight patients. The procedure consisted in disinvagination and biopsy (n = 1), intestinal resection (n = 7). One patient was not operated and the diagnosis was performed through ultrasonography guided tumoral puncture. Results: According to the Murphy classification, there were 1 stage II, 5 stage III and 3 stage IV patients. With LMB 2001 protocol chemotherapy, a complete remission was observed with a follow-up longer than one year after the complete remission (median follow-up: 19 months) in 7 cases. At the end of the study, tow patients had died and they have Burkitts lymphoma stage IV. Conclusion: Burkitts lymphoma is extremely sensitive to chemotherapeutic agents that cause an initial rapid tumor dissolution and, often, long-term remission. The diagnostic may be made by ultrasonography guided tumoral puncture. If the lymphoma is not visualized with ultrasonography, Surgery is required to confirm the diagnosis and the intestinal resection for ischaemia.

Intrathoracic masses in children: Five years of experience Elemen L1, orapcolu F2, Tugay M1, Aksu G3, Deveci M2, Mutlu H2, Akansel G4, nan N4, Grbz Y5 Kocaeli University Medical Faculty,1Dept. of Pediatric Surgery,2 Dept. of Pediatric Oncology,3 Dept. of Radiation Oncology,4 Dept. of Radiology,5 Dept. of Pathology, Kocaeli, Turkey Purpose: To asses the five years experience of a Pediatric Oncology Group in intrathoracic masses. Patients and Methods: Fifty-one patients who were treated and followed because of intrathoracic masses were reevaluated retrospectively from the pediatric oncology database. Age, sex, complaints on admission, symptoms, physical examination findings, and radiologic interventions, localization of the masses, surgical operations, complications, histopathologic diagnosis, medical therapy and current situation of the patients were recorded. Results were assessed with SPSS 11.0 statistical evaluation software. Results: Mean age of the patients was 8.5. Thirty patients were males. Forty percent of the patients admitted with symptoms related to vena caval or bronchial compression. Fever, night sweating and weight loss were the most common accompanying symptoms with a rate of 64%. Three patients had anterior; four patients had posterior primary mediastinal masses. The tumors in two patients were widespread with mediastinal involvement. The rest of the patients had anterior and middle mediastinal masses. Resection of the mass was accomplished in 10 patients while biopsies were taken in forty-one. Histopathologic diagnosis was lymphoma in 42, neuroblastic tumor in 4, pleuro-pulmonary blastoma in 2, germ cell tumor in 2 and timoma in 1 patient. Mean follow-up period was 30 months. Forty-three patients are still alive with thirty-nine disease free patients. Three patients are lost from follow-up and five patients were lost due to progressive disease. Discussion: Intrathoracic masses are the one of the most common presentations of childhood cancers. Anterior and posterior mediastinal masses, which are mostly lymphomas, may require surgical intervention. We think that, multidisciplinary approach and treatment is crucial for successful results in childhood intrathoracic masses.

Congenital bilobar emphysema. S. Hidouri, K. Maazoun, M. Masmoudi, H. Tandia, J. Chahed, M Ben Brahim, R. Laamiri, S. Ajroudi, L. Sahnoun, I. Krichene, M. Mekki, , M. Belghuith, A. Nouri. Department of pediatric surgery, Fattouma Bourguiba Hospital Monastir, Tunisia. Congenital lobar emphysema is an infrequent, but important, cause of respiratory distress in the newborn. Congenital emphysema affecting more than one lobe has been rarely reported. Surgical management of bilobar emphysema is controversial. We describe three cases of infantile bilobar emphysema, diagnosed preoperatively in one patient and during the follow-up period in the other two patients.

Congenital lung malformations: hybrid lesions, two cases Abad-Calvo P (1), Bosque-Garca M (2), Bardaj Pascual C (1), Rigol Sanmartin S (1), Asensio De La Cruz O (2), Garca-Gonzalez M (2), Cabezuelo Hernandez MA (3), Combalia Soriano N (3). (1) Paediatric Surgery .Hospital Sabadell . Corporacio Parc Tauli. (2) Paediatric Pneumology .Hospital Sabadell. Corporacio Parc Tauli (3) Pathology .Hospital de Sabadell. Corporaci Parc Tauli. Barcelone. Spain. Introduction: The traditional classification of lung malformations could be difficult to apply antenatally, because it is possible the postnatally confirmation of hybrid lesions. Background/Purpose: We describe two patients with hybrid lesions combining congenital cystic adenomatoid malformation (CCAM) and pulmonary sequestration. Case Report 1: Prenatal diagnosis by ultrasound and MRI of CCAM right lung was made at 21 weeks of gestation. She was born at term, and asymptomatic. CT thorax confirmed macrocystic lesion 3 cm. Clinical course was asymptomatic but CT thorax six months later showed progression of the lesion until 6 cm. Surgery was performed at that time. The hybrid lesion, CCAM type I and pulmonary sequestration was confirmed by pathologist. Case Report 2: Neonate referred to our center for severe respiratory symptoms at birth and needed mechanical ventilation. Prenatal ultrasound was normal in other center. CT thorax showed mediastinal shift and severe pleural effusion, diagnosis of pulmonary sequestration. Surgery performed 24 h later show the hybrid lesion CCAM type II and pulmonary sequestration confirmed by pathologist. Discussion and Conclusions: the hybrid lesions could be explained by a common embryological alteration. In prenatal diagnosis is possible to omit one of them. Surgery is the treatment of both between 3 month and 2 years in asymptomatic patients. Before birth it is better to use the term lung malformations in general. The challenge could be prenatal diagnosis of hybrid lesions.

Imaging features of congenital bronchopulmonary malformations. B. Hmida1, R. Salem1, C. Hafsa1, A. Ben Salem1, MA. Jellali1, K. Maazoun2, M. Ben Brahim2, A. Nouri2, M. Golli1
1

Department of Radiololgy, CHU F.B Monastir Department of pediatric surgery, CHU F.B Monastir

Objectives: The aims of our study are to remind the principal congenital bronchopulmonary malformations (CBPM) in childhood and to illustrate imaging features of each etiology. Materials and methods: We retrospectively reviewed data of 43 cases of CBPM diagnosed during 12 years. The diagnosis was first based on imaging finding: chest radiography was performed in all cases; CT examen was performed in 39 cases and Doppler US for 7 cases. All patients underwent surgery. Results: Our patient group consisted of 18 girls and 25 boys. The age of our patients at diagnosis ranged from 5 days to 14 years. Clinical symptoms revealing the malformation were neonatal respiratory distress and repetitive infectious pneumopathies. The malformations diagnosed are divided as follow: 24 cases of congenital lobar emphysema, 11 cases of cystic adenomatoid malformation, 6 cases of pulmonary sequestration and 2 cases of bronchogenic cyst. Histopathological exam confirmed the radiologic diagnosis in 38 cases. Conclusion: CBPM causes a lot of diagnosis and therapeutic problems. Imaging features are variable. CT exam has a crucial role to examinate CBPM and to differenciate between each etiology. The final diagnosis must be confirmed by histopathological exam.

Lipoblastoma in childhood. Report of 5 cases. S. Hidouri, K. Maazoun, M. Masmoudi, J. Chahed, H. Tandia, M. Ben Brahim, O. El Ezzi, I. Krichene, M Mekki, L. Sahnoun, M Belguith, A. Nouri. Department of Paediatric Surgery, Monastir Tunisia. Our study reports five cases of lipoblastoma carried in the department of Paediatric Surgery of Monastir between 1988 and 2008. The purpose is to determine the epidemiological, clinical and therapeutic aspects of lipoblastoma. It is about two girls and three boys. The age varied from 7 months to 42 months. The tumor was dorsal, femoral, inguinal, epiploique and sacro-coccygien. The surgical treatment consisted of a complete resection in all cases. Evolution was favourable without recurrence after a follow-up of 12 months. The surgical resection is the only treatment of lipoblastoma, it has to be the most complete possible.

What are the advantages of Cyanoacrylate xound closure in circumcision? Elemen L, Tugay M Kocaeli University, Department of Pediatric Surgery, Kocaeli, Turkey Purpose: Despite being the most frequent operation performed in boys, circumcision is not free of complications. Complications vary from bleeding to unsatisfactory cosmetic results. This study aims to compare the 2-octyl-cyanoacrylate (2-octyl-CA) glue with polyglytone 6211 sutures in circumcision wound closure on the basis of operative time, safety, cost affectivity, post-operative comfort and cosmesis. Patients and Methods: Ninety-six boys who underwent circumcision in 18 months period were randomized prospectively and grouped into two. In first group (n=51) 6/0 polyglytone 6211 (Caprosyn, Tyco, USA) sutures and in second group (n=45) 2-octyl-CA glue (Dermabond, Ethicon, UK) were used for wound closure. A scoring system was constructed to evaluate duration of procedures, bleeding status, comfort of child and cosmesis. The SPSS 10.0 (SPSS Inc, Chicago, IL, USA) was used for statistical analyses. Quantitative differences between groups were assessed by Students t test and Mann Whitney U test. Qualitative analyses were performed by 2 test. P was significant at < 0.05. Results: Overall anesthesia time, operation time, per-operative and post-operative bleeding status, postoperative comfort and cosmesis were significantly better in 2-octyl-CA group. Conclusion: Shorter duration of operation, ease of appliance, better cosmesis, earlier recovery to daily activities without complications are advantages of 2-octyl-CA used for circumcision wound closure, those should be evaluated by further studies.

Surgical anomalies with assisted reproductive technologies. An experience of a private pediatrc surgery institution E Yesildag, SNC Buyukunal Pediatric Surgery & Pediatric Urology Center of stanbul, stanbul, Turkey Purpose : To present the variation of congenital anomalies observed in children born with the aid of assisted reproductive technologies(IVF) between January 2003 June 2008. Patients and Methods : The patient records between January 2003 June 2008 were retrospectively evaluated and 86 children among 1584 patients admitted to a pediatric surgical centre were found to be born with the use of in vitro fertilization (IVF). 74 anomalies were detected in 92 cases; 11 of these 86 patient presented with more than 1 anomaly. Results : Inguinal hernia and hydrocele were found to be the most frequently observed anomaly (29 patients: 37 units). Penile anomalies were detected in 18 children (hypospadias was the leading problem with 14 cases). Urinary anomalies were observed in 9 children (hydronephrosis 2 cases and vesicoureteric reflux 2 cases); undescended testicle was detected in 9 cases (11 units). 7 children were admitted with anorectal anomalies, one with anal atresia and one with anterior ectopic anus. 3 children, triplets born with the help of IVF, were operated because of pyloric stenosis. Hemangioma, torticolis, omphalocele, umbilical cord hernia, coarctation of the aorta, VSD and ASD were the other detected congenital anomalies. Discussion : The assisted reproductive technologies are accused for increasing the risk for some anomalies in children. In the presented series, no significant difference is observed when compared with the naturally conceived ones but the higher incidence of inguinal, penile and urinary anomalies gives us a different vision in comparison with the previously published data in the English literature.

Fetal therapy. A new starting program in Spain. De Agustn JC, Antiolo G, Marquez J, Losada A, Cassinello F, Torrejn R, Juan C L Lozano, Carrillo R, Ontanilla A, Jimenez J, F Hurtado. Department of pediatric surgery, Children Hospital, University Hospitals Virgen del Rocio, Seville, Spain Email: juandeagustin@mac.com Introduction: Fetal surgery is a sophisticated area of Pediatric Surgery. A modern society is demanding the highest quality of medical care, including preimplantatory diagnosis, genetic therapy and fetal surgery. In this setting we developed a special dedicated program in fetal therapy at a southern spanish university Center. Objectives: The purpose of this work is to show the organization aspects of an emerging surgical area, and to summarize our most interesting cases treated during 2007. Material and methods: All malformed fetuses diagnosed during prenatal period were evaluated. From all of them two were especially relevant to discuss. Demographic data, prenatal tests, type of surgery and results were analyzed. Results: From a total number of 35 fetuses five were selected for fetal intervention. The first one was a 24th week female fetus that had a high lumbar meningomyelocele. Parents refused abortion and null intervention. Open fetal surgery was done at 26th week and delivery done at 35 week. Hydrocephalus was evident during gestation but unchanged during fetal life. After delivery the lumbar defect was covered by the interposed skin flaps and sphincter function and legs movements were normal. VP valve was necessary. Six months after delivery the neuromuscular development is normal. The second case is a fetus with an epignatus that occludes the airway. This was a twin gestation with otherwise healthy brother. EXIT surgery was done at 34 weeks of gestation. Three amniotic drainages interventions were necessary before the EXIT procedure. During this intervention extraoral tumor was removed and tracheostomy performed. The following day the intraoral tumor was excised and the trachea reconstructed. A second intervention was required to remove completely the tumor 3 weeks later. The patient follow up reveal no tumor recurrence. The other 3 cases were 1 massive pleural effusion and one materno-fetal transfusion. Ultrasonographic guided pigtail was used for the former and laser electrocoagulation for the other. Conclusions: Fetal Therapy programs are completely necessary in selected countries. This program allowed the first intervention on a meningomyelocele for the first time in Europe. The second case represents also the first epignatus presented on twin gestation that was operated during EXIT procedure in the world.

The long-term outcome of prenatally detected posterior urethral valves Gargah Tahar, Labassi Aymen, Derwich Amine, Chebil Mohamed, Lakhoua Mohamed Rachid. Department of pediatric nphrology-department of urology, Charles Nicolle hospital, Tunis, Tunisia Email: tahar.gargah@rns.tn Introduction: Posterior urethral valves are the most common cause of congenital obstructive uropathy, resulting in renal failure in childhood. Nowadays, in most cases, diagnosis is suggested by antenatal ultrasound. Objective: To assess the impact of prenatal diagnosis and evaluation on the outcome of posterior urethral valves we studied all cases of valves detected prenatally. Materials and methods: Between 2000 and 2007, 8 neonates with prenataly detcted posterior were treated in our department. The prenatal parameters analyzed were age of gestation at diagnosis, ultrasonographic appearance of renal parenchyma and amniotic fluid volume. We reviewed the outcome of other neonates treated for posterior urethral valves which were not diagnosed prenatally during the same period. Results: The diagnosis was suspected in the antenatal sonography and confirmed after birth in 8 of them. The main gestational age at diagnosis was 32 weeks (30-34 weeks). Antenatal ultrasonography showed: bilateral uretero-pyelic dilatation (8 cases), oligohydramniosis (4 cases), hydronephrosis (1 case) and a megacystis in one foetus. Postnatal sonography and voiding cystourethrography confirmed the diagnosis. Treatment was based on initial vesicostomy within a mean period of 2 days and secondary, on endoscopic resection within a mean period of 46 days. The mean duration of follow-up was 4 years. Renal failure developed in 5 of 8 patients, including end stage renal disease in 1. Conclusions: The outcome of posterior urethral valves is not yet significantly improved by prenatal diagnosis. Three infants had already renal failure at birth. Clinical outcome improved in two of them. Two of the other five infants developed moderate renal failure.

Scrotal incision. An alternative for better cosmesis. SNC Buyukunal, E Yesildag Pediatric Surgery & Pediatric Urology Center of stanbul, stanbul, Turkey Purpose : To present our experience between February 2004 - June 2008 in operating hydroceles and undescended testicles (UT) through a scrotal incision. Patients and Methods : 76 children with a mean age of 3,4 years (9 months - 11 years) were operated through a scrotal incision between February 2004 - June 2008. The incision was performed vertically on the lateral upper part of the affected hemiscrotum. 29 patients (31 units) had communicating hydrocele (16 right; 11 left; 2 bilateral). 44 cases (70 units) had UT(the testis was; in the superficial inguinal pouch/upper scrotum 47 units; in the inguinal canal 12 units; ascending 6 units; higher in the inguinal canal 4 units; nubbin palpated 1). 3 patients (6 units) had bilateral anomalies with hydroceles on the right side and UT on the left (the testis was; in the superficial inguinal pouch/upper scrotum 2 units; higher in the inguinal canal 1 unit). High ligation was performed in the hydrocele group. Orchidopexy with high ligation was carried on in the UT cases and the testis was fixed with 4/0 Vicryl to the scrotal pouch. In 6 patients with bilateral anomalies, one side was operated with an inguinal approach as the testis was palpated higher in the inguinal canal in 5 and the nubbin was excised in 1). Results : A hydrocele of cord and secondary undescended testis developed one year and 7 months after the operation, respectively in two patients operated for hydrocele and both of them was reoperated through an inguinal incision. No other complication was detected. The morbidity in this series was found to be 2,6% (2/76)in a mean follow-up period of 2 years (2 months - 4 years). Discussion : The testis and hernial sac can sufficiently be prepared through the scrotal incision. This approach not only decreases the early postoperative pain problem observed commonly in inguinal incisions but also increases the cosmesis which is very much apreciated by the parents.

The effect of grape seed Proanthocyanidin in renal ischemia/reperfusion injury. Mustafa Yaar zdamar, Mslim Yurtu, Mehmet Akz, Hatice Toy, Engin Gunel Selcuk university, meram medical faculty, departments of pediatric surgery, biochemistry, and pathology, konya-turkey Background/purpose: To determine the prophylactic effect of grape seed proanthocyanidin extract (gspe) in ischemia/reperfusion (i/r) injury-induced renal tissue damage. Material and methods: forty rats were divided into 4 groups each containing 10 rats: control (c), sham (s), ischemia/reperfusion (i/r), and ischemia/reperfusion plus gspe (i/r+gspe). Both renal pedicles (rp) were explored in c group. Left rp exploration and right nephrectomy were performed in the s group. Occlusion (45 minutes) and reperfusion (60 minutes) of left rp were performed after right nephrectomy was carried out in i/r group. Same procedures were done in the i/r+gspe group, but 15 mg/kg gspe was given with orogastric gavage to this group for 15 days before operation. in the s, i/r, and i/r+gspe groups, left nephrectomies were performed to determine the levels of malondialdehyde (mda), glutathione reductase (gr), and histopathological changes in tissues, and to measure serum urea, creatinine, alaninaminotransferase (ast), and tumor necrotisan factor- (tnf-) levels in blood. Results: The values of mda in the i/r group were higher than those in the s and i/r+gspe groups. The values of gr in the i/r group were lower than those in the s and i/r+gspe groups, and this parameter of the i/r+gspe was lower than those in the s group. Serum urea, creatinine, ast, and tnf- levels in the i/r group were higher than those in the other three groups, and these parametres of i/r+gspe were significantly higher than those in the c and s groups. Vascular dilatation-congestion, tubular vacuolisation, mononuclear cell, and tubular necrosis in the i/r group were higher than those in the s and i/r+gspe groups. Vascular dilatation-congestion and tubular vacuolisation were higher in the i/r+gspe group than the s group. Discussion and conclusions: It was shown that prophylactic gspe treatment prevents renal i/r injury

Achalasia in triple A syndrome. Clinical and genetic analysis of six North African families Kamoun H1,2, Ben Rebeh I3, Belghith N1, Aloulou H4, Sellami D5, Masmoudi S3, Fakhfakh F1
1 2

Medical genetic department, Hedi Chaker hospital, Sfax. Tunisia. Laboratoire de Genetique Moleculaire Humaine, Facult de Mdecine de Sfax ; 3 Unite cibles diagnostiques et therapeutiques dans la pathologie humaine (CBS) 4 Service de Pediatrie - Hopital Hedi Chaker, Sfax; 5 Service dophtalmologie- Hopital Habib Bourguiba, Sfax. Email: hassen.kamoun@rns.tn Triple A syndrome is an autosomal recessive disorder characterized by the triad of adrenal insufficiency, achalasia and alacrima. We report twelve patients from four Tunisian and two Lybian families. Alacrima is the most consistent feature of this syndrome and was observed in all patients. Other features, such as achalasia or adrenal insufficiency, appeared in some cases before adulthood. Some patients also present with progressive neurological degeneration presenting especially lower motor neuropathy. Some other patients present with hyperkeratosis of palms and soles. The molecular analysis of AAAS showed a single homozygote mutation in all affected patients; the IVS14+1G-A mutation. The mutation was identified at first by sequencing then by enzymatic digestion of DNA; this method allows easy detection of heterozygote individuals in a patients family. When achalasia is associated with alacrima in North African families the detection of IVS14+1GA mutation will be helpful for diagnosis and genetic counselling.

The effect of Cyanoacrylate in fistulas following oesophageal anastomosis leakages. Mslim Yurtu, Hamdi Arba, Osman alayan, Mehmet z, Adnan Abasyank Selcuk University, Meram Medical Faculty, Departments of Pediatric Surgery, Otorhinolaryngology Head & Neck Surgery, and Biochemistry, Konya-Turkey Background/Purpose: This study aimed to investigate the effects of tissue glues in fistulas that occurred following oesophageal repairs (ORs). Material and Methods: Twelve New Zealand rabbits were divided equally into two groups: smooth (S) and leakage (L). In the S group the oesophagus was dissected through a cervical midline incision from the trachea and other tissues. A 1-cm smooth circular oesophageal segment was excised, and S anastomosis was performed using nonabsorbable suture material (6-0 polypropylene). The animals were fed parenterally for 6 days and orally on postoperative day 6 on the condition that there was no oesophageal leakage after oesophagographic analysis. In the L group, a 1-cm-long oesophageal segment was incised on the cervical oesophagus, and a single-layer oesophageal fixation to cervical skin tissue was performed using nonabsorbable suture material (6-0 polypropylene) to perform iatrogenic cervical oesophageal fistula. The cervical region was then closed using standard surgical technique and the catheter was extracted in both groups. In the L group the animals were fed orally on postoperative day 2, a 1-cm-long fistula occurred at the cervical oesophagus in all rabbits 2 days later, and cyanoacrylate (C) was installed to the fistula on postoperative day 10. The cervical oesophageal tissues which were excised from the anastomosis and repaired fistula segment were taken to determine bursting pressure (BP), diameters of the oesophageal lumen (DOTOL), and hydroxyprolin (HP) levels in both groups. Results: The values of BP and HP in the S group were significantly higher than those in the L group. The diameters of DOTOL in the L group were significantly greater than those in the S group. Discussion and Conclusions: These experiments provide evidence for the potential and successful use of C in repair of the cervical oesophageal anastomosis leakages.

The effects of feeding on ileal smooth muscle reactivity after anastomosis. An In Vitro Study Tugay M1, Gocmez S2, Yazir Y3, Komsuoglu I2, Elemen L1, Erkus B1, Gacar N2, Utkan T2 1 Dept. of Pediatric Surgery, 2 Dept. of Pharmacology, 3 Dept. of Histology, Kocaeli University, Kocaeli, 4 Dept. of Pediatrics, Acibadem Hospital, Kocaeli, Turkey Purpose: To investigate the effect of feeding on smooth muscle reactivity in isolated rat ileum after resection and anastomosis. Material and Methods: Three groups of rats were used: 1-Sham Group (SG): Laparatomy and intestinal exploration followed by 1 week food restriction and excision of 2 cm of ileal segment. 2- Anastomosis group (AG): Ileal resection-anastomosis followed by food restriction for 1 week and excision of 2 cm ileal segment proximal to anastomosis. 3- Anastomosis and feeding group (FG): Ileal resectionanastomosis followed by food restriction for 1 week, 1 week of re-feeding excision of 2 cm ileal segment proximal to anastomosis. Specimens were studied for their contractile (KCl, Carbachol) and relaxant (EFS, SNP, Papaverine) response to receptor activation in the organ chambers set up. All the specimens were underwent histopathologic study. Results: In AG, ileal wall was thinned with atrophy of microvilli and intestinal epithelium. Fibroblasts and plasma cells were decreased. Composition and thickness of the smooth mucsle cells reduced. KCl induced (non receptor mediated) responses were significantly increased in FG vs SG. Carbachol induced (receptor mediated) contractile response significantly increased in FG compared to SG. The contractile response of carbachol was not significantly changed between the groups AG vs FG and AG vs SG. Conclusion: Our study revealed alterations of receptor-dependent and receptor-independent ileal smooth muscle reactivity following re-feeding which emerges as a dynamic process entailing adaptation of smooth muscle and neuronal structures.

Cleft palate repair by a tongue flap. D. Hantala. Beni Messous. Alger Ten patients have a large defect of the anterior palate.The repair was performed by a tongue flap with anterior pedicule. We have rewiewed 7girls and 3 boys.The average age was 9 years. Twenty one days later, the pedicle was removed by section after verification of the flap viability.

Surgical management of fetal ovarian cyst. A 5 year experience. A. El kadhi, T. Errayes, A.E. Ismail, I. Bassiouny Pediatric Surgery. Hamad Medical Corporation. Doha. Qatar. Ovarian cysts are the most frequent intra-abdominal cysts diagnosed antenatally. Their management is still controversial. We present a retrospective review of 14 cases of neonatal ovarian cyst treated surgically at the Hamad medical Hospital in Qatar from January 2003 to December 2007. Results: All the cysts were confirmed by neonatal ultrasound between the 2nd and 7th day of live. No symptoms were found except in 2 cases. Surgery was performed in the neonatal period except for 3 patients after a follow-up varying from3 to 13 months. 11 patients required laparoscopic assisted surgery and 3 open surgery. The operative findings were an amputated ovary in one case, adnexial torsion in 9 and simple cyst in 4 cases. A simple cystectomy was performed in 4 cases and adnexcectomy in the remaining 10 cases due to necrotic ovary. The post-operative course was uneventful in all cases In conclusion, the laparoscopic management of neonatal ovarian cyst is a good option but doesnt prevent the loss of ovaries. The developpement of antenatal management should prevent this issue.

The protective effects of oral pure immunoglobulin A and G in an experimental necrotizing enterocolitis model. Mslim Yurtu, Bahattin Aydodu, Hatice Toy, Mehmet Grbilek, Engin Gnel Selcuk University, Meram Medical Faculty, Departments of Pediatric Surgery, Pathology, and Biochemistry, Konya-Turkey Background/Purpose: This study aimed to compare the protective effects of oral pure immunoglobulin A (IgA) and G (IgG) in experimental necrotizing enterocolitis (NEC). Material and Methods: Rats were divided randomly into five groups. The control (C) group was breast fed. The NEC (N) group was fed with formula. The treatment IgA (T-IgA) group was fed with formula and 600 mg/kg/day oral Ig A at 4-hour intervals. The treatment IgG (T-IgG) group was fed with formula and 1200 mg/kg/day oral Ig G at 4-hour intervals. The sham (S) group was fed with formula and 0.1 ml/kg/day distilled water. The rats in all groups were weighed and sacrificed on the fourth day. Histopathologic findings such as villus injury, transmural necrosis, and apoptosis, and biochemical parameters such as interleukin-6 (IL6), and tumor necrotizing factor- (TNF-) were evaluated in all segments of the intestine. Results: The rate of mortality was significantly higher in the N, IgG, and S groups compared with the TIgA and C groups. A significant weight increase was identified in the C group compared with the other groups. Villus injury, transmural necrosis, apoptosis, IL-6, and TNF- were lower in the TIgA group compared with the N, IgG, and S groups. There was no significant difference between the T-IgA and C groups according to histopathologic parameters. Discussion and Conclusions: Pure Ig A given orally decreased intestinal damage and prevented NEC in an experimental NEC model histopathologically.

Visceral posters

Ventriculo-peritoneal shunt catheter migrated into bladder. Report of a case. Elemen L1, Etu V2, Tugay M1
1 2

Kocaeli University, Department of Pediatric Surgery, Kocaeli, Turkey Kocaeli University, Department of Neuro Surgery, Kocaeli, Turkey

Purpose: The cerebrospinal fluid shunt operation, from its first realization in 1908 by Kausch till our days, is still of a significant importance for the long-term treatment of the internal hydrocephalus. Well known are many complications connected with the use of the valve systems (malfunction, infectious, over drainage, secondary craniosynostosis and etc.). Here we present the second pediatric case of ventriculo-peritoneal shunt catheter which dislocated into bladder. Patient: A 4-year-old girl was admitted to our clinic with presumptive diagnosis of a ventriculo-peritoneal shunt catheter dislodged into the abdominal cavity. Her mother complained of difficulty in applying clean intermittent catheterization very recently. Her pelvis X-ray and urinary ultrasound examination revealed that the ventriculo-peritoneal shunt catheter was coiled in the bladder. She was taken to operation and the catheter was removed by means of cystoscopy. Bladder was intact. Another ventriculo-peritoneal shunt catheter was inserted to prevent hydrocephalus. Result: She is doing well after the operation and clean intermittent catheterization continuous without difficulty. No bladder repair was required. Conclusion: Migration of ventriculo-peritoneal shunts is well described. The subsequent symptoms relate to under-drainage and blockage, or more rarely to cortical irritation due to proximal migration of the shunt apparatus. Mechanical shunt failure must always be considered when there is a change in the physical aspects of a shunt. Insufficient abdominal cavity resembling the presented case may enforce the shunt catheter to slowly dislodge into the bladder. On the other hand patient might had bladder perforation during clean intermittent catheterization. But this hypothesis is only a speculation and the exact mechanism is not possibly known. A non-absorbable anchor suture may prevent displacement of the proximal shunt apparatus.

Non communicating complete bladder duplication on the coronal plane. Report of a Case Levent Elemen1, Sevin Tugay2, Melih Tugay1 1 Kocaeli University, Department of Pediatric Surgery, Kocaeli, Turkey 2 Acibadem Hospital, Department of Pediatrics, Kocaeli, Turkey Introduction: Duplication of the bladder is a very rare congenital anomaly classified as complete and incomplete forms with well described features. We present a 6-year-old boy with complete bladder duplication without a communication between duplicated bladder and urethra, ureter or primary bladder. Patient and Method: The patient was admitted to our clinic with right flank pain. Abdominal ultrasonography and MR urography demonstrated right hydro-ureteronephrosis. Further investigation with MAG3 scintigraphy revealed right uretero-vesical junction obstruction. The patient was taken to operation with the presumptive diagnosis of a right uretero-vesical junction stenosis. Following mobilization of the ureter, a cystic mass located infero-medial to the bladder was found. No communication with ureter, urethra and bladder was detected. Total excision of the mass and right ureteroneocystostomy was performed. Results: Post-operative course was uneventful and the patient was discharged on the 5th post-operative day. The histopathologic examination was consistent with a bladder duplication. He is still doing well without complications for a follow-up period of 2 years. Discussion: Complete bladder duplication is associated with a duplicated urethra. Each bladder receives its ipsilateral ureter and is drained by an individual urethra. Incomplete duplication consists of two bladder halves separated by a thick muscular wall, both of which drain into a common urethra. The present case is the second case in the English language literature with complete bladder duplication without a communication with urinary system. This rare anomaly should be kept in mind in differential diagnosis of pelvic cystic masses and during surgery of lower urinary system.

Residual dilatation after megaureter treatment in children DR AZZOUNI Samir. Oran, Alger Our service has already acquired some experience in managing megaureters. We face in 30% of our cases the persisting expansion of urinary cavities after medical and surgical treatment and they are a site of urinary stasis, infection and nephritis. This is aretrospective study over the late decade.

Vesico-ureteral reflux after kidney transplantation in children. A report of 4 cases at a single center. Gargah Tahar, Labassi Aymen, Derwich Amine, Chebil Mohamed, Lakhoua Mohamed Rachid Department of pediatric nephrology, department of urolgy, Charles Nicolle hospital, Tunis, Tunisia. Email: tahar.gargah@rns.tn Introduction: Vesicoureteral reflux (VUR) is a risk factor for acute pyelonephritis (APN), and has been claimed to be responsible for 2.7% of end-stage renal disease in childhood. Its prevalence and significance after kidney transplantation (Tx) in children varies widely. We report the experience of our center. Methods: We reviewed retrospectively cases of renal transplantation managed in our department from January 1993 to December 2007. Results: There were 38 children; 13 girls and 15 boys. The main age at transplantation was 12 years. The etiologies of chronic renal failure were: glomerular nephropathy (7cases), inherited nephropathy (10cases), congenital abnormality of the urinary tract (5cases), renal hypoplasia (2cases), vascular pathology (4cases) and indeterminate (10cases). All patients had Lisch-Gregoire implantation of the transplant ureter and insertion of double-J stent. After a mean period of 6 years and 1 month, 12 children (31.5%) developed early urinary tract infection (first month) and 9 patients (23.6%) developed late infections. Sonography and voiding cystourethrography revealed VUR in 5 patients. There were 4 girls and 1 boy. Three of them had indeterminate nephropathy and 2 congenital abnormality of the urinary tract; one child had undergone previous urological surgery. There were 4 living donor and one cadaveric graft. One graft was lost in patient with refractory chronic rejection. Conclusion: Although rejection is the major cause of kidney graft failure, urologic complications, especially VUR, represent a significant source of morbidity. The incidence of VUR in transplanted patients, according to recent literature, varies from 1% to 65%, but its impact on graft survival is controversial.

Change in management of ureteropelvic junction obstruction S.TOUABTI. Z.SOUALILI Chirurgie pediatrique. Clinique mere enfant. CHU SETIF ALGERIA Email: touabtisl@yahoo.fr Purpose: The aim of this study was to evaluate the change in ureterpelvic junctionmanagement,from surgicalcorrection to observation of the hydronephrosis. We checked whether or not is was deleterious for kidney Maretials and Methods: We retrospectively reviewed 100 cases. Initial utrasonography and voiding cystourethrogram were available for all cases. Intravenous urography and diuretic renogrphy were studied when avilable. Minimal follow-up of patients was one year. Patients were divided into three groups: surgery right away, surgery after observation, and observation only. Results: Later was the diagnosis, more significant were the hydronephrosis and impairment of renal function. In group operated on right away, drainage improved, hydronephrosis decreased, but renal function did not improve significantly. Conclusion: Initial non operative management of hydronephrosis was not dangerous for renal function. It is advisable to detect at the earliest all signs of obstruction, because surgery improves renal drainage but not renal function.

Modified use of uretral stent and urinary drainage in hypospadias repair. Lucic Prostran B, Varga J,Dobanovacki D, Starcevic Z, Sarac D,Zivkovic D. Institute for child and youth health care of Vojvodina, Novi Sad, Serbia Introduction: Inherent to most hypospadias repairs is postoperative urinary drainage and use of urethral stents. Common forms of urinary diversion include: perineal urethrostomy, suprapubic cystostomy, transurethral Folley catheter drainage and transurethral dripping stent. Urethal stents may be used without additional urinary diversion, leaving patients to void through the stent. Some authors recommand stent-less procedures for distal hypospadias. Material and methods: With the porpouse to reduce the immediate dysuria in patients with urethral stent wihout urinary diversion, we modified this technique by pulling a thinner catheter through the stent and indwelling it into the bladder. This way we permitted urinary drainage for the first two postoperative days. After that the catheter is pulled out leaving the stent in place, and still permitting early discharge from the hospital. We compared postoperative comfort and the incidence of the complications in patients with this way of stenting and urinary drainage versus patients with suprapublic cystostomy, transurethral folley catheter drainage and stent only. Results: Postoperative disuria was markly deminished in the group with the modified drainage comparing with stent only. The rate of the late complications was not significantly different among the groups. Minor complications related to the urinary drainage (obstructions of the thin catheter and its displacement) were seen in 11.80% patients. Duration of hospitalisation (4.20 days) was longer then in group with stent only (3.10 days), but much shorter in other two groups (8.20 days). Discussion: This method permits initialy healing of the neourethra before contact with urine avoiding invasive procedures and long hospitalisation, without increasing of compilation rate. Minor complications related to the urinary drainage were solved by irrigation of the catheter withthe sterile saline or pulling out the catheter, and later prevented by postoperative rehydration and diluting the urine. Conclusion: Modified use of urethral stent and urinary drainage is a simple, non invasive, comfortable for patients and parents and related with few complications and short hospitalisation.

Fibroepithelial polyp of the posterior urethra. Report of two cases and review of the literature. S. Ajroudi, L. Sahnoun, M. Mekki, S. Hidouri, K. Maazoun, CH. Jamila, M. Ben Brahim, I. Krichene, M. Belghith, A. Nouri Department of pediatric surgery hospital of Monastir. Tunisia. Email: lassaad.sahnoun@rns.tn Purpose: Fibroepithelial polyps of posterior urethra (FEP of PU) are rare benign tumors occurring in young boys. They are an uncommon cause of lower urinary tract obstruction in children and can be difficult to diagnose. In the present study, we present our experience with two boys with FEP of PU along with a literature review. Materials and methods: We retrospectively identified two children with FEP of PU presented between 1983 and 2006 at age 21 and 17 months. Results: Dysuria, urinary retention, hematuria and urinary tract infection were the most common symptoms. The diagnostic work-up (sonography, voiding cystourethrography, urethrocystoscopy) suggested a polypod lesion originating from the veru montanum. Transurethral resection of the polyp was carried out in both boys using a pediatric resectoscope. For the 1st patient, extraction of the polyp was performed via transvesical trocar. Histology showed the lesion to be a fibroepithelial polyp. The two patients were discharged without complaints. Urinary tract infection was observed one month postoperatively for the 1st patient. At follow-up, both boys were cured and urine analyses were normal. Conclusions: Fibroepithelial polyp of posterior urethra is a rare cause of urinary retention in childhood and should be considered in differential diagnosis of obstructive lesions.

Prognostic significance and postnatal management of antenatally isolated fetal pyelectasis. Labidi K*, Ayadi I*, Ben Hmida E*, Ben Hamouda S***, Chaouachi B**, Marrakchi Z*. *Department of Neonatology Charles Nicolle Hospital Tunis **Department of paediatric surgery B HET Tunis *** Department of Obstetrics and Gynecology - Charles Nicolle Hospital - Tunis Background: The ability to detect major malformations of the fetal urinary tract using diagnostic antenatal ultrasound is well-known. The purpose of this study was to evaluate the prognostic significance and the postnatal management of ultrasonographically detected isolated fetal pyelectasis. Material and Methods: A retrospective study of 17 neonatal observations of antenatal isolated pyelectasis was conducted over a 24-month period. Fetuses with additional congenital anomalies and died fetuses were excluded. The degree of antenatal pyelectasis was measured in the anteroposterior renal pelvic diameter. Finding interesting sex, gestational age at diagnosis, echographic aspect, postanatal management and medical follow up were assigned. Results: The majority of the cases were male. An oligoamnios was noted in 4 cases. Bilateral pyelectasis was found in 8 cases. No chromosomal abnormalities were found, and no foetal urinary intervention was assessed in our study. Postnatal exploration revealed a transitional pyelectasis in 7 cases, an ureteropelvic junction obstruction in 6 cases, congenital megauretere in 3 cases, and vesicoureteric reflux (VUR) in only 1 case. Postnatal renal function hasnt decreased in all cases. Postnatal surgery was assessed in 1 case of bilateral megauretere and spontaneous regression under a sequential treatment occurred in the other cases. Conclusion: Isolated fetal pyelectasis can have a pathologic significance. Bilateral pelvis dilation doesnt carry a higher risk for uropathies in our study. Prognosis was related to the degree of pelvic dilatation.

Cystic partially differentiated nephroblastoma. About one case. L. chater, K. atarraf, M. Arroud, K. Khalid, A. Elmadi, M. Rami, A. Mahmoudi, MA. Afifi, Y. Bouabdallah Department of pediatric surgery, CHU Hassan II- Fez. Morocco Email: chaterlamia@yahoo.fr Cystic partially differentiated nephroblastoma (CPDN) is a rare clinico-pathologic entity occurring mainly in children. It is recognized as a tumour with low malignant potential. CPDN constitutes 0.5 % of all Wilms tumours. Usual age of presentation is between 4 and 24 months. We report a case of conventional type, ultrasound showed a multiloculated mass. Absence of any solid area favors the diagnosis of CPDN or cystic nephoma. Primary resection of the tumor is the treatment of choice in such cases. We report a second case of papillonodular type. Ultrasound and CT scan clearly demonstrated the papillonodular projections, distinguishing it from other renal cystic tumors. Twelve cases were reported in literature and only gadolinium-enhanced MRI showed these gross pathologic features previously. Concerning the gender of patients, some studies show a male predominance. Asymptomatic unilateral abdominal mass is the usual presentation. Radiology is helpful in detecting the cystic character of the lesion.It is recommended to treat CPDN with surgery alone. Chemotherapy could be reserved for recurrent disease and tumor rupture. Histopathological examination remains the mainstay of diagnosis. The tumor is a multiloculated and circumscribed lesion. The interior is entirely composed of cysts and septa in the conventional CPDN. Unlike cystic nephroma, the septa contain blastemal cells. The papillonodular type contains characteristic luminal papillonodules. CPDN is distinguished from polycystic Wilms tumor only by the presence of macroscopic nodules of blastema. The prognosis of CPDN after surgical removal is excellent with 100 % survival rate. In view of remote possibility of recurrence, regular follow-up is needed. No case of metastasis is reported.

Congenital cystic disease of the lung. Experience with 30 cases at Childrens Hospital of Tunis. M. Khemiri, Y. Tlili, F. Ben Mansour, A. Borgi, S. Zouari, F. Oubich, B. Chaouachi, M. Hamzaoui, S. Ben Becher, I. Bellagha, A. Hamzaoui, F. Khaldi, S. Barsaoui Background/Purpose: Congenital cystic lung diseases (CCLD) include several malformations with clinical and radiological similarities but distinct histological features. The aim of this report is to describe clinical pictures of CCLD and to discuss problems in diagnosis. Patients and methods: Cases of CCLD enrolled at Childrens Hospital of Tunis between January the 1st 1994 and December the 31st 2004 were reviewed. Results: 33 CCLD were diagnosed in 30 children (17 males and 13 females) aged 20 days to 16 years at diagnosis. CPM were: 17 congenital lobar emphysema (CLE), seven bronchogenic cysts (BC), five cystic adenomatoid malformations (CAM) and four pulmonary sequestrations (PS). Three patients had two associated CCLD. The mean ages at diagnosis varied between two and 88 months. Symptoms were: respiratory distress (n=14), recurrent attacks of respiratory embarrassment (n=6); pulmonary infections (n=8) associated to haemoptysis in two cases, haemothorax (n=1) and fortuitously (n=1). Radiological investigation with CxR/CTs led to diagnosis in CLE and CAM in the whole cases, and contributed to the diagnosis of BC in 4/7 cases and only in of PS. US-doppler suspected the malformation origin of the cystic lesion in 6/11 of cases. MRI led to diagnosis in 5/6 of cases 29 patients required chirurgical treatment with lobectomy (n=22), pneumonectomy (n=2), and cystectomy (n=8). Histopathological examinations confirmed diagnosis in all cases and rectified preoperative diagnosis in four cases. One patient died after lobectomy with acute nosocomial pneumonia. Post operative course was uneventful in 28 children with a mean of follow up of 24 months (4 months- 7 years). Conclusion: Dyspnea and infections are the main revealing symptoms of CCLD. Radiological investigation led to diagnosis in CLE and CAM in the whole cases, but contributed less in the diagnosis of BC and PS. Problems in diagnosis are related specially to evolutive complications of CCLD.

Diagnosis and treatment of congenital pulmonary malformations. A review of 18 cases Maalej B*, Sfaihi Ben mansour L*, Bouraoui A*, Turki H*, Aloulou H*, Chabchoub I*, Aissa Kh*, Mekki M**, Krichen I**, Nouri A**, Kammoun TH*, Hachicha M*. *Paediatric department, Hedi Chaker hospital, Sfax, Tunisia **Paediatric surgery department, Fattouma Bourguiba hospital, Monastir, Tunisia Background: Congenital malformations of the lung are rare and vary widely in their presentation and severity. The evaluation of affected patients frequently requires multiple imaging modalities to diagnose the anomaly and plan surgical correction. Purpose: Analysis of our experience and propositions on the diagnosis and treatment of congenital pulmonary malformations. Population and methods: Retrospective study of PM diagnosed between January 1987 and Mars 2008. Analysis of clinical spectrum, diagnosis tools, treatment, and clinical outcome. Results: During 21 years, 18 patients were diagnosed with congenital malformations of the lung which included bronchogenic cyst (1 case), cystic adenomatoid malformation (3 cases), congenital lobar emphysema (8cases), pulmonary sequestration (1case), pulmonary agenesis (2cases), and pulmonary hypoplasia (2cases). One patient had three simultaneous abnormalities (pulmonary sequestration, bronchogenic cyst and cystic adenomatoid malformation). Common clinical presentations were respiratory distress (2cases), respiratory infections (5cases), and dyspnea (11cases). Diagnostic modalities included chest radiography (18cases), CT scan (14cases), MRI scan (1case), and bronchoscopy (3cases). None case was diagnosis in antenatal. Surgical treatment was performed in 16 patients. Resection was being a cystectomy in 1case, a segmentectomie in 2 cases and a lobectomy in 8 cases. During the follow-up (mean: 3 years), we noted four deaths (23%) were due to pulmonary sequestration (1case), nosocomial infection (1case) and chronic respiratory insufficiency (2cases). Conclusion: These data demonstrate that congenital pulmonary malformations usually can be diagnosed by plain chest x-ray films and computed tomography.

Bronchogenic cysts of mediastinum in children. Five case reports A. Ben Salem11, C. Hafsa1, R. Salem1, B. Hmida1, M.A. Jellali1, I. Krichene2, A. Nouri2, M. Golli1
1 2

Department of Radiology, CHU F.B Monastir Department of pediatric surgery, CHU F.B Monastir

Objectives: The aims of this study are to demonstrate the crucial role of computed Tomography to diagnose bronchogenic cyst and to illustrate the radiologic features of this pathology. Methods: We retrospectively reviewed data of five patients who have a mediastinal bronchogenic cyst. Chest radiography and CT were performed in all cases. Histopathological examination confirmed the diagnosis of bronchogenic cyst in all patients. Resutls: The age of children ranged between one week and five years. In tow cases, the cysts were discovered incidentally on chest radiography, and in the three others, they were revealed by infection or compression symptoms. The cysts were localised in middle mediastinum in three cases and in middle and posterior mediastinum in tow cases. The mean size of cyst was 3.5 cm. CT elucidates the fluid density within the cyst and demonstrates the relation to the other mediastinal structures. All patients underwent surgery by thoracotomy in tow cases and videoassisted thoracoscopy for the others. Conclusion: Bronchogenic cysts are lesions of congenital origin and are most common primary cysts of the mediastinium. The evaluation of affected children requires multiples imaging modalities. CT is the method of choice to study the cysts and should be used before more invasive procedures.

Inflammatory pseudotumors of the lung. Annabi S., R. Khemakhem , K. Bousseta , A. Charieg, S. Ghorbel, F. Nouira, S. Jlidi and B. Chaouachi Email: annabisonia@yahoo.fr Inflammatory pseudotumors are rare, benign solid lesions so named because they mimic malignant tumors clinically and radiologically. They are found most commonly in the lung, but have been described in various other sites. They often occur in children, can grow to a large size, and are often locally invasive, requiring significant pulmonary resection. Complete resection, when possible, is safe and leads to excellent survival. We reviewed our experience with one 9 year old patient who has this unusual pathology. He presents a parasternal mass one month after a thoracic traumatism. The computed tomographic scan shows that a tumor invades the bronchus superior right and the lateral tracheal partition. Surgical biopsy confirms the diagnostic of inflammatory pseudotumors of the lung. The therapeutic choice was difficult. The evolution is favorable after 10 months passing. Inflammatory pseudotumors of the lung are rare and often present a dilemma for the surgeon at time of operation.

Fetus-in-fetu imaging. A case report and a literature review. Nji H*, Allani H*, Kahloul N**, Khattat N**, Khadhraoui MB*, Amri F**, Alouini R* *Imaging department, **Paediatric department. Ibn El Jazzar Hospital. Kairouan E mail: haythemallani@gmail.com Background/ purpose: Fetus-in-fetu is a rare entity complicating a monozygotic monochorionic biamniotic pregnancy. It is now distinguished from teratoma as they havent the same pathogenesis. We report a case of fetus-in-fetu discovered in a new born girl and we discuss how imaging can help in diagnosis and in treatment. Material and methods: The new born girl G.A was referred to paediatric department to explore an asymptomatic abdominal mass. Plain abdominal radiography, ultrasonography and enhanced computed tomography were performed. Results: The abdominal plain radiography showed a water-like abdominal mass including some coarse calcifications. The abdominal ultrasonography found a well-limited heterogeneous abdominal mass, with hypoechoic, hyperechoic areas and some macrocalcifications. The abdominal enhanced computed tomography showed a well defined abdominal mass including fatty areas, tissular areas enhancing after contrast and some bony calcifications. Based on these findings, teratoma was the most likely diagnosis and the mass was surgically removed. The pathologic examination concluded to the fetus-in-fetu diagnosis. Discussion and conclusions: Fetus-in-fetu is thought to be the result of a monozygotic monochorionic biamniotic pregnancy in which a twin is included in the other during the process of ventral folding of the trilaminar embryonic disc. In contrast, teratomas arise from the uncontrolled growth of pluripotent stem cells. Axial skeleton is required for the diagnosis of fetus-in fetu. It occurs predominantly in the upper retroperitoneum and is revealed by an asymptomatic abdominal mass. Imaging can help in diagnosis but its confirmation is based on pathology examination.

Reconstructive thoracoplasty after carcinologic chest wall resection in children H. Lardy, B. De Courtivron, A. Le Touze, K. Braik, M. Robert Departement de Chirurgie pediatrique, Centre de pediatrie Gatien de Clocheville. CHRU Tours, France Email: h.lardy@chu-tours.fr Treatment of chest wall sarcoma type tumours consists in neoadjuvant chemotherapy followed by a chest wall resection taking away the pathological and adjacent rib(s). We report 2 cases of chest wall tumours in 2 children aged 8 and 4 years who underwent surgery based on parietal carcinologic resection and chest wall reconstruction. For both our patients, the first one being considered in complete remission 5 years after initial surgery, the aesthetic and functional result is judged to be in line with expectations A proper follow up of the thoracic growth and in particular of the vertebral one has been set up with the orthopedic pediatric team. Functional respiratory assessment should be proposed. The operation is technically easy but requires a few surgical tricks. Parietal prosthesis has the advantage to have a particular endothoracic face which prevents adherence to the lung. Rib reconstruction allows an almost normal cosmetic aspect and does not compromise the chest wall growth as the cement is located in the anterior and posterior arcs of the ribs using metallic pins.

Management of paediatric tracheobronchial injuries. De Agustn JC, Gonzlez-Valencia JP, Garca-Hernndez JA, Mochn A, Hosseinpour R, Marav A. Department of Paediatric Surgery. Childrens Hospital. Hospitales universitarios Virgen del Roco, Seville, Spain. Background: Rupture of the trachea or main stem bronchi are extremely rare in children. Early surgical intervention is frequently asked for by our paediatric colleagues. But the evidence in the scarcely literature recommends nonoperative management. Objectives: During the last 5 years we treated 3 patients with injuries to the trachea and main stem bronchus. We summarises our experience and review the literature. Methods: Demographic data, clinical, endoscopical image and radiological records are reviewed and analysed. MEDLINE, EMBASE and COCHRANE database were used for literature review (tracheal AND injury AND children: 2000-2008). Results: The first patient is a 1 month old baby who was operated on Transposition of great arteries. After trachea decanulation he started with dyspnoea and hypoxia. Fiberoptic bronchoscopy showed a posterior subglotic tracheal rupture. The posterior tracheal dissection was evident for several centimetres. Prolonged intubation (15 days) bypassing the injury was enough for sealing the defect. One month after diagnosis the trachea was completely healed. The second case was a 8 year old male who developed a massive mediastinal, cervical and facial emphysema after foreign body removal from the right main bronchus. Five days before admission he had had a previous right neumothorax drained elsewhere. Bronchial rupture healed and emphysema spontaneously resolved by the 9th day after observation. The last one was a 5 year old girl with iatrogenic rupture of the trachea after intubation for an amigdalectomy operation performed elsewhere. Neumothorax neumomediastinum and subcutaneous emphysema developed. Complete healing of the lesion took place 15 days later. All patients had an uneventful recovery. 105 abstract were found for a 7 year period. Only 13 showed reliable paediatric data. These along one 1997 historical report (Chest) just identify 4 iatrogenic tracheal injury. Blunt and sharp thoracic and cervical trauma accounts for the rest of them. Conclusions: Suspicion of tracheobronchial injuries were confirmed by early fiberoptic bronchoscopy. So conservative treatment can be undertaken. Distal intubation to the tracheal injury allowed complete healing by air leaking prevention. Bronchial lesion healed spontaneously without mechanical ventilation. The literature review only supports operative treatment for extended and complete airway ruptures and injuries of the tracheobronchial system diagnosed with delay.

Bilateral First and Second Branchial cleft fistula Ana Maria Milln Lopez, Albrerto Garcia Perla, Antonio Hernandez Orgaz Cirugia Pedipatrica. Hospital NISA Sevilla Aljarafe. Spain Email: anamillanlopez@gmail.com First and second branchial arch involvement during embriogenesis results in a wide spectrum of anomalies. We report a child with bilateral first and second branchial arch fistulas, bilateral microtia, macrostomia, palpebral ptosis in association with congenital hypoparathyroidism. Clinical and tridimensional radiological findings are discussed.

End-to-end oblique anastomosis to prevent stricture in oesophageal anastomosis. Mslim Yurtu, Adnan Abasyank , Hamdi Arba, Mehmet z Selcuk University, Meram Medical Faculty, Departments Otorhinolaryngology Head & Neck Surgery, Konya-Turkey of Pediatric Surgery,

Introduction: Oesophageal stricture continues to be a challenging pediatric surgical problem. This study aimed to compare the results of oblique and transvers anastomosis to prevent anastomotic stricture that occurred following oesophageal repairs (ORs). Material and Methods: Twelve New Zealand rabbits were devided equally into 2 groups: oblique (O) and transvers (T). A 1-cm-long tract of the cervical oesophagus was resected through a cervical incision in both groups. Anastomosis was performed in both groups. Oesophagographic analysis was carried out on postoperative day 7 and the animals were fed orally on the same day on the condition that there was no oesophageal leakage. The rabbits were sacrificed to measure diameters of the oesophageal lumen (DOTOL) and bursting pressure (BP) in the anastomosis region 8 weeks later. Results: The diameters of the oesophageal anastomosis lines in the O group were significantly greater than those in the T group. The values of BP in the O group were also significantly higher than those in the T group. Discussion and Conclusions: Our results suggested that oblique anastomosis is a better surgical procedure for preventing oesophageal stricture, as shown by the increased diameters of oesophageal anastomosis lines and BP.

Peritoneal hydatidosis in children. About one case A.MAHMOUDI; M.RAMI; K.KHATTALA; A.ELMADI; K.ATARRAF; M.ARROUD ; A. AFIFI; Y. BOUABDALLAH L.CHATER; M.LECHQAR;

Pediatrics Surgery Department, University Hospital Hassan II of Fez, Morocco. Introduction: Peritoneal hydatidosis is a rare localisation of hydatic disease, most often secondary to a hydatic cyst of the liver. Its primitive form is considered due to haematogenous diffusion through arterial vessels. We report a case of peritoneal hydatidosis, in a 9 year-old boy. Case report: A 9 years boy was referred to our hospital for a clinical profile characterized by an abdominal mass in progressive developing, with no signs of inflammation .the diagnosis was made this patient on ultrasound exam and CT-scan. The surgical exploration found a peritoneal hydatid cyst .Sterilisation and resection of the cyst were the surgical management. Surgical cure has been completed by pharmacologic treatment with the aim of avoiding a relapse. There was no complication reported in the post operative with a follow of 2 years. Conclusion: In the light of this case report, we will discuss clinical aspects, radiological findings, and therapeutic management of this rare localisation of hydatic disease.

Acute abdomen in children as a result of liver hydatid cyst rupture. Marjanovic Z, Slavkovic A, Krstic M, Zivanovic D, Kostic A, Bojovic N Clinic of Pediatric Surgery and Orthopedics, Clinical Centre Nis , Serbia E-mail : niboj@nadlanu.com Background: The rupture of hydatid cyst in children is a rare, but very serious complication of hydatid disease. The cyst may be ruptured after a trauma (usually in children) or spontaneously. The rupture is most often in the abdominal cavity, but can be in other organs or cavities.The signs and symptoms are heterogeneous. It requires immediate diagnostic procedures and surgical treatment. Methods: Two patients were admitted to Pediatric surgery clinic in last six years with the diagnosis of acute abdomen after a simple abdominal trauma. Age, gender, time of surgery from the onset of symptoms, laboratory findings, diagnostic procedures, surgical treatment modalities, intraoperative and patho-histological findings, post-surgical therapy and control examinations were evaluated retrospectively. Results: In the last 15 years we had 21 cases of liver hydatid cyst disease in children. Two of them (~9%) were ruptured on reception. The common presenting symptom was abdominal pain. One patient had symptoms and signs of anaphylactic reaction. Standard laboratory, ultrasound and R examination did not indicate any specific sign of hydatid disease. MSCT revealed intrahepatic cyst with clear borders. Abdominocenthesis was another step in making differential diagnosis. Intraoperative findings were confirmed with PH results. MRI examinations six months to six years after operation did not reveal disease recurrence. Conclusion: Liver cysts in children are usually of parasite origin. Hydatid cyst is usually asymptomatic until its size, space occupation or rupture it presents with signs and symptoms. The cyst can be revealed accidentally by ultrasound or R examination. Endemic area, simple trauma, known liver cyst and intra-abdominal fluid in the patient history are some determining elements of hydatid cyst rupture. Good clinical presentation, up-to-date radiology examination (MRI, MSCT) and emergency surgery are something that we preferred. Otherwise, any postponed or inadequate therapy faces us with numerous complications like secondary peritoneal hydatidosis.

The follow up of child with hydatic disease in the high plateau of Setif. Soualili Z, Touabti S, Choutri H, Smati A, Ait Yahia S, Boughaba A, Laouamri S. Faculty of medicine of Setif - Algeria Email: soualili2001@yahoo.fr The human hydatic cyst ha san impact not only in economy but also in public health. Young populations amongst the most important in the world. Aim is to determine the prevalence of the affection within the juvenile population of the wilaya of Setif. Results show that the prevalence is of 7.1 cases for 1000 and the major part of the children has an age understood between 4 and 12 years. The pulmonary localization is meaningfully more frequent with boys. The hepatic hydatic polykystose ius met in 7.8 % of the cases. The total eradication perspective remains the only hop and would allow the surgeons pediatricians to dedicate itself/themselves more efficiently to other pathologies malformatives .

Hepatic neoplasms in children Bouraoui.A*; Kamoun.Th*; Turki.H*; Mekki.M**; Chabchoub.I*; Nouri.A**, Hachicha.M* * Paediatric department, Hedi Chaker Hospital Sfax, Tunisia; ** Paediatric surgery department, Fattouma Bourguiba Hospital Monastir, Tunisia Email: chabchoubimen@yahoo.fr Introduction: Hepatic neoplasms are rare in children. They constitute only 1-2 % of all paediatric tumours. Of them, 2/3 are malignant. Clinical examination, biology, and imaging have a major role in establishing the diagnosis. Material and methods: Five patients were admitted to a paediatric institution during a period of 21 years, between 19872007, with histologically proven primary liver tumours. Results: The diagnosis was hepatoblastoma in 3 patients, and haemangioendothelioma in 2 children. The median age was 2.6 years range from 15 days to 8 years. The sex-ratio was 0.25 (1 boy and 4 girls). The common presenting clinical features were abdominal mass in 4 children, and hepatomegaly in one case. Serum alpha-foetoprotein was useful to guide a diagnosis in hepatoblastoma and in monitoring disease activity. Computed tomographic scan and ultrasound were useful preoperative investigations for assessing site and resectability of tumour. The patients with haemangioendothelioma had surgical resection, the evolution was favourable. The patients with hepatoblastoma had adequate surgical resection and chemotherapy, one patient only is currently alive (after a decline of 3 years). Conclusion: We conclude that adequate surgical resection and adjuvant chemotherapy can improve disease free survival for children with hpatoblastoma. Optimal treatment has yet to be devised for other malignant hepatic tumours.

Solitary hepatic lymphangioma of a three and half month old infant. Unique case report and review of literature. Mohammed Youssef Alexandria Hospital for Sick Children Email: edini99@yahoo.com Introduction: Hepatic lymphangioma is an extremely rare benign neoplasm that is usually associated with lymphangiomas of other viscera and when found in the pediatric population they are usually found in extra abdominal sites. Aim: Is to highlight a high suspicion index of such a condition in infants and children presented with hepatic masses. Case report: We present a 10 month old female infant presented to our department with severe abdominal distension causing the baby dyspnea , orthopnea and recurrent chest infection, a previous surgery was done to the baby and the parents were told that it was an inoperable liver tumor.Surgery was done to the baby after full laboratory and radiological work up and the mass was totally removed with complete preservation of the liver and a after a follow up period of 6 month till now the baby is doing well with no recurrence or relevant complaint. Conclusion: Infantile hepatic lymphangioma is an extremely rare condition and must be considered in the differential diagnosis of any hepatic mass.

Hepatopulmonary fusion in a neonate. Case report and review of the literature. Mohamed JALLOULI*, Hatem BEN AMAR**, Lilia TRIGUI**, Abdellatif GARGOURI**, Ahmed REKIK**, Emna DOUAD***, Zeineb MNIF***, Riadh MHIRI* * Department of pediatric surgery; **Department of neonatology; ***Department of radiology. Hedi Chaker Hospital. 3029 Sfax. TUNISIA Email: mohamed.jallouli@rns.tn Hepatopulmonary fusion in neonate is very rare entity; only 8 cases are report in the literature. We present the case of a female infant at a gestational age of 41 weeks who presented with a right congenital diaphragmatic hernia. During surgical exploration, right hepatopulmonary fusion was encountered. We review the existing literature on this problem, describe our surgical approach, and review the embryology of this complex lesion.

Pyogenic Liver Abscess: a rare cause of feverish hepatomegaly in child. Trabelsi L, Chabchoub I, Ben Abdallah R, Ben Ameur S, Ben Halima N, Ben Salah M, Mahfoudh A. Service de Pediatrie, Urgence et Reanimation pediatrique. CHU Hedi Chaker Sfax Email: lotfi_try@yahoo.com Introduction: The hepatic abscess is a rare pathology in the child. The incidence varies from 5 to 20% of the hepatic abscesses. The most frequent causal agent is the staphilococcus aureus. A predisposing ground is systematically required in particular a chronic septic granulomatosis, a deficit in IgE, a thrombosis of the portal vein and an intestinal parasitosis. Observation: A 3 years old boy, coming from Ouled Haffouz, was admitted for feverish and painful hepatomegaly evolving since one week. On initial examination, its temperature was 39C, its abdomen was slightly slack, flexible with a painful hepatomegaly to 2 cm of the edge costal. The remainder of the examination was without characteristics. Laboratory tests on admission revealed an inflammatory syndrome with a sedimentation time of 89 mm/h and C-reactive protein level of 23.82 Mg, a normal hepatic assessment, Hemoculture, hydatic serology and amoebic serology was negative. An abdominal ultrasonography objectified a round lesion limited well hypoechogene, heterogeneous containing zones anechogene, non vascularized to Doppler color. An abdominal scanner showed an aspect evoking a cyst hydatic from the infected liver. The child had in urgency a surgical drainage which has objectivity an abscess of the Liver. The bacteriological study of the liquid of drainage insulated a sensitive staphilococcus aureus. The child was put under oxacilline at 200mg / kg/day. A etiologic research was made and was negative (parasitic serologies, immunodeficiency such as granulomatosis, thrombosis of the portal vein). Conclusion: In front of a feverish hepatomegaly in the child, in particular immunodeficient, the pyogenic liver abscess is an etiology to be evoked. Echography and the scanner are means paraclinic interesting for the diagnosis and the follow-up of the patients.

Biliary pancreatitis in childhood. About one case A. MAHMOUDI; M. RAMI; K. KHATTALA; A. ELMADI; L. CHATER; M. LECHQAR; K.TARRAF; M.ARROUD; A. AFIFI; Y. BOUABDALLAH Pediatrics Surgery Department, University Hospital Hassan II of Fez ,Morocco. Introduction: Pancreatitis is an inflammatory process of the pancreas with involvement of various close and distant tissues. It is a rare clinical entity in the childhood, having bleak prognosis and no straight forward treatment management. Case report: Our patient is a young child of 12 year-old, having a past medical history of hepatic colic since one year before the current presentation. The patient presents in our department for acute abdominal pain, associated with vomiting and fever. Clinical examination pointed out fever of 37.8, good hemodynamic condition and sensibility of the right hypochondre. Workshop found the following values: lipasemia 1934 IU (10 x), amylasemia 1664 IU (12x), LDH 599 IU, normal renal function and normal blood formulae count. Abdominal ultrasonography pointed out a thickening of the gall bladder wall (4mm), containing micro-calculs, with dilated principal biliairy duct (14 mm), with normal intra-hepatic biliairy ducts, aspect of the pancreas was homogenous, with presence of collection around the vena cava. Abdominal CT-scan endorsed the ultrasonography findings. MRI of biliairy ducts showed segmental dilatation of the proximal part of the principal biliairy duct (15 mm). The patient sustained a close clinical and biological monitoring, and was administered antibiotics (protected amoxicillin). Nourishment was performed through a nasojejunal probe after relief of abdominal pain. After 3 weeks of follow up, a laparoscopic cholecystectomy was performed with uneventful postoperative course. Conclusion: In the light of this presentation, and through a literature review, we will discuss the different epidemiologic, pathogenic, diagnostic and therapeutic aspects.

Cholelithiasis in children. I. Chabchoub*, B. Maalej*, A. Boukedi*, A. Bouraoui*, H. Aloulou*, L. B. Mansour*, Z. mnif**, I. Beyrouti***, Th. Kamoun*, M. Hachicha* * Paediatric department. Hedi Chaker Hospital. Sfax. Tunisia; ** Department of Radiology. Hedi Chaker Hospital. Sfax. Tunisia; *** General Surgical Department. Habib Bourguiba Hospital. Sfax. Tunisia Email: chabchoubimen@yahoo.fr Background: Even though in the last years following the extensive use of ultrasound scanning, an increasing number of children with cholelithiasis has been identified. In other way, little is known about the epidemiology and the best therapeutic regimen for Cholelithiasis in children. Aim: Remember etiology of cholelithiasis, insist on the utility of abdominal ultrasound scan performed routinely and evaluate the management. Materials and methods: A retrospective study was performed in children with a diagnosis of cholelithiasis between 1987 and 2008 in the paediatric department of UHC Hedi Chaker (Sfax. Tunisia). 15 patients with gallstone were enrolled to the study. Results: There were 8 boys and 7 girls. The median age at diagnosis was 8 years with extremes between 6 months and 15 years. Lithiasis was discovered by chance in 2 cases and by systematic check in 7 cases. It was suspected in symptomatic children in 6 cases. All patients were diagnosed by abdominal ultrasound scan. Idiopathic gallstones were found in 5 patients, 7 had gallstones in association with a hemolytic disease. Tow patients had gallstones in association with biliary sludge (Byler disease and portal cavernoma), and another with dehydration symptoms. Surgery was performed in 13 patients: open cholecystectomy in nine and laparoscopic cholecystectomy in four. None of the patients underwent therapeutic endoscopic retrograde cholangiopancreatography or medical therapy with ursodeoxycholic acid. Conclusion: Cholelithiasis in children is an unusual finding, but is not exceptional. The therapeutic strategies were extremely heterogeneous and guidelines for management are available for adults but not for children.

Pachydermoperiostosis in a young girl. Belghith N, Kamoun H Medical genetic department - Hopital Hedi Chaker Sfax, Tunisia Email: hassen.kamoun@rns.tn Pachydermoperiostosis is a rare hereditary disorder inherited in an autosomal dominant pattern with variable penetrance that is often familial and occurs predominantly in men. We report here a sporadic case of fourteen year old girl with digital clubbing and hyperhidrosis. No similar case was reported in the same family. Clinical examination showed pachydermia, thickening of the facial feature, digital clubbing, seborrhea, oedema with pain, polyarthritis and hyperhidrosis. Radiological analysis showed subperiosteal new bone formation and acroosteolysis. She had a normal caryotype (46 XX) but no other genetic analysis was done. The dermatological manifestations (hyperhidrosis) and rheumatological symptoms (joint effusion, arthritis, acro-osteolysis, periosteal ossification) led to difficulties in walking and using hands. Rheumatologiac symptoms are not always improved by nonsteroidal anti-inflammatory drugs while the dermatological symptoms, the finger clubbing were not improved. These difficulties restricted the girl activities. Pachydermoperiostosis is a rare hereditary disorder with no knows genetic defect; the dermatological manifestations and rheumatological symptoms associated would cause handicap.

Hexadactyly in two cases of defined syndromes: Patau syndrome and Bardet Biedl syndrome. Belghith N, Kamoun H Medical genetic department - Hopital Hedi Chaker - Sfax , Tunisia Email: hassen.kamoun@rns.tn Hexadactyly observed in child could be sporadic or familial; It could be also a single dysmorphic feature or a feature among others in defined syndromes. We report here two cases of syndromes including hexadactyly; the Patau syndrome for the first case and the Bardet Biedl Syndrome for the second. Patau syndrome (Trisomy 13) is a chromosomal anomaly caused by the presence of an extra chromosome 13. The first case had microphthalmia, cleft lip and cleft palate, hexadactyly and systemic anomalies. Cytogenetic analysis confirms the aneuploidy (karyotype : 47,XY,+13). Cardiac malformations and central nervous system anomalies explain the perinatal mortality for this case. Bardet-Biedl syndrome (BBS) syndrome is an autosomal recessively inherited disorder. This syndrome is characterized by genetic heterogeneity;12 causative genes have been identified (BBS 1 to 12). The second case is characterized by obesity, pigmentary retinopathy, hexadactyly, hypogenitalism and learning difficulties. Molecular analysis shows mutation in BBS 8 gene. would also develop renal disorders, diabetes and hypertension. Treatment is symptomatic only. Visual impairment is often severe and its management should be integrated into the global management of child and adult patients. Obesity requires management, with the prescription of a healthy lifestyle and, if necessary, specialised care. Hexadactyly could be due to different genetic defects ranging from chromosomal to molecular defects. Associated clinical features guide genetic analysis to do. The detection of the genetic defect allows genetic counselling.

Prenatal diagnosis of right upper quadrant cyst masses. Ana Maria Miln Lopez, Juan Carlos de Agustin Asensio, Lourdes Gomez Izquierdo, Gema Calderon, Reyes vazquez Rubio, Guillermo Antiolo Gil Servicio de Cirugia Pediatrica, Servicio de Anatoma Patologica, Servicio de Anestesia, Servicio de Neonatologia, Unidad Clnica de genetica , reproduccion y medicina fetal Email: anamillanlopez@gmail.com Duodenal duplications are rare malformations with several anatomical varieties. A case of large subhepatic cyst was identified sonographically in a 30-year old gravida at 20 weeks of gestation. In this fetus the differential diagnosis was foregut malformation, choledochal cyst or omentum cyst. Neonatal computed tomography scan was not definitive. He developed a neonatal gastric outlet obstruction and was operated on day 4. We discuss the accuracy of antenatal US in the right upper quadrant cystic masses and its correlation with the postnatal diagnosis.

New born tumours and pseudo tumours panorama N. BOUGHABA, S. TOUABTI; Z. SOUALILI Pediatric surgery department. CHU Setif. Algeria New born tumour pathology is acknowledged by its curiosity, its specificity, its taking care is most often late because the antenatal diagnostic tacks difficulty of distinction between tumour, pseudo tumour or organomegaly. The most part of these tumours are minor; some can have a clever progressive potential in the majority of cases, the treatment is surgical Across this work, we illustrate some observations of tumours and pseudo tumours met in our service with an analytical study of every type of tumour according to its clinical picture, its siege, its clever or minor type and its taken care.

Abdominal tumour of child. pediatric surgery care;huc of SETIF ALGERIA Email: lsmai2006@yahoo.fr The abdominal tumour of child remain frequent, their diagnosis will be easy cause contribution of the imagery (scanner and the biology;witch permet their reimbursement on the diagnosis,increase the chance of cure and the survival rate on long time. In some case this couple dont give any information, and the passage by first surgery will be comfulsory. We repport a case traited in our care unit of pediatric surgery in HUC of SETIF(ALGERIA), witch have caused a serious problem of diagnosis. It's a girl's case of 14 years old whose have a voluminous abdominal masse revealed by compression sign and objectived by scanner, but her origin has not be detected by scanner. The biology balance-sheet and tumoural markers are normal. We decide to operate this patient and we have find a voluminous abdominal strong masse, beginning in the mesenter root. We have releazed a carcinologic tumourectomy the result of anatomical pathology has revealed a malignant schwanome:neurofibromatose tumour. This Patient has white coffee marks means the recklinghausen illness. The carcinologic surgery permet the recovery but the problem in this case is the risk to have another localizing of tumour again furthery witch the interest to supervise for all the life.

Experience of plastic surgery department of the CHU Oran in the treatment of xeroderma pigmentosum in the child. L ZINAI-DJEBBAR; F. BENRAHAL; F. MERAD; A. MAHMOUDI; N. GUECHAIRI; F. ABDERRAHIM *; R. KAID SLIMANE Service of Plastic Surgery, Centre des Brls, CHU ORAN * Anaesthesia-Reanimation Transformation into Epithlioma is of rule in Xeroderma Pigmentosum, a gnodermatose which sees followin one another, in turn, of the erythemateuses and pigmented lesions then spots of cutaneous atrophy with small telangiectasies and finally of the croteuses and warted lesions. The disease is often family, consanguinity is found in 80% of the cases, it begins in the youth and it is sometimes associated in a particular state neuropsychic. This affection translates a particular sensitivity of the teguments to the light and leads to dead before the 15 years age in two thirds of the cases. Our series comprises 29 cases over one decade (1997-2007) The patients start to arrive in our consultation towards the 4 years age, are seen and operated on average 3 times and let us lose sight of the fact we them towards 11-12 years, 25 % with less than 10 years, only the minor forms arrive at the adulthood, 6 cases in our series. The treatments summarize with the followed exerese directed cicatrisation; the mutilations are the rule considering the advanced state of the lesions and the localizations of these tumours which are in 80 % of the cases of the pithliomas spinocellulaires. The authors plead for an early assumption of responsibility of the disease by explanations lit with the families often delivered to them same in a climate of distress and rejection (by the means of an association " domiciled " with the CHU) and especially of measurements of prevention on the various levels, capable to delay the appearance of large tumours.

Effectiveness of determination of Prothrombin Time (PT) and Activated Partial Thromboplastin Time (APTT) preoperatively E. Vagdatli*, K. Farmakis**, F. Tsikopoulou*, S. Rupakias**, G. Tsikopoulos** *Department of Medical Laboratory Studies, Technological Educational Institution of Thessaloniki **Pediatric Surgical Department, Hippokratio General Hospital, Thessaloniki Introduction: Many children with familial bleeding tendency need a preoperative laboratory study in order to detect an unknown deficiency of coagulation factors. Aim: The aim of this in vitro study is to determine the sensitivity of PT and APTT in such deficiencies and its colleration with commercial reagents. Material and Methods: A plasma pool was created from normal donors and then this pool was separated in two parts. Each of them was diluted with commercial deficient factor V (FV) plasma (A group) and deficient FVIII plasma (group B) in order to achieve progressively diminished concentration of those factors, from undiluted plasma to a 1 to 5 dilutions. At a semiautomatic coagulation analyzer were measured: 1) FV activity at group A, 2) FVIII activity at group B, 3) PT with three different reagents (ISI:1, 1.23 and 1.5) and 4) APTT with two reagents (activator:caolin, and elagic acid) at groups A and B. Normal values were considered: : (pool2sec), :(APTTpool8sec) or Ratio:0.85-1,15 in both, FV:70-120% FVIII:60150%. Results: 1. Abnormal values of PT were observed when the activity of FV was less than 70% with all three commercial reagents, 2. Abnormal values of APTT were observed when the activity of FV was less than 60% (kaolin activator) and 30% (elastic acid), while FVII<36% (kaolin) and <24% (elastic acid). Differences between these values were not normalized with the use of Ratio. Conclusions: 1. PT is sensitive at limited deficiencies of coagulation factors while APTT is not. 2. APTT sensitivity is depended from the commercial reagents. So APTT is not suggested as a preoperative test for patients free of bleeding history as it can not reveal the carriers of coagulation factor deficiencies.

Central Broviac catheter in neonates Report of 22 cases A Ben Thabet*, L Trigui*, M Jallouli**, H Ben Amar*, A Gargouri*, N Hmida*, A Ben Hmad*, R Regaieg*, M Kannou*, R Mhiri**, A Rekik* * Neonatology department- Hedi Chaker hospital ** Paediatric surgery unit- Hedi Chaker hospital Introduction: Broviac catheters are in common use for administration of parenteral nutrition, cancer chemotherapy, and antibiotic therapy within the paediatric population. They are less used in neonates especially when no other central venous access is possible. Patients and methods: This is a retrospective report of all tunnelled Broviac central venous catheters placed in neonates at neonatology department of Sfax over a nearly 4-year period (2005-2008). Single lumen Broviac catheters were used in all cases. They were surgically placed in the paediatric surgery unit of Hedi Chaker hospital. Results: Broviac catheter was placed in 22 patients. There were 10 at term neonates and 12 premature. The mean term of premature neonates was 30 weeks (extremes: 25 36 weeks). The mean weight at birth was 1650 g in the premature group and 2990 g in the at term group. All new-borns were hospitalised at birth because of: - respiratory distress in 15 cases - prenatal diagnosis of digestive malformation in 3 cases - hypoglycaemia in one case - very low weight at birth in one case - parietal abdominal malformation in 2 cases Broviac use was indicated at a mean age of 13,5 days (extremes: 234 days) for different circumstances: - post operative care of digestive surgery in 12 cases - premature babies with nutritional difficulties in 8 cases - persistent respiratory distress in one case - persistent hypoglycaemia in one case (hyperinsulinism) The catheter was maintained for a mean period of 12 days (extremes: 1-34 days). Venous thromboses were noted in 3 cases and infectious complications were confirmed in 5 cases. Ten neonates were dead. Their death wasnt directly depending on Broviac catheters. Conclusion: Neonates in the neonatal intensive care unit often require central venous access for parenteral nutrition, antibiotics, repeated blood sampling, and transfusions. Whenever possible, peripherally introduced central venous catheters (PICC) are used preferentially. Tunnelled and surgically placed central venous catheters are used when long term access is indicated and placement of PICC has failed. Adherence to strict guidelines for insertion and handling can significantly reduce catheter-associated complications.

Unusual case of clitoromegaly Salih Cetinkurgun, Adnan Narci nder ahin, Evrim zkaraca Afyonkarahisar Kocatepe Universitiy Faculty of Medicine Departments of pediatric Surgery and Pahology Email: cetinkursun200@yahoo.com Introduction: can be either congenital or acquired. The congenital forms are caused by hormonal disturbances, tumors or intersex states. Usually they are obvious at birth. Here in we present the unusual case of a 20 month years old with epidermoid cyst of the clitoris. Maternal and Methods: A 20 month year old caucasion girl was referred with clitoromegaly. She was investigated for an intersex disorder before surgical consultation. But hormon profile, chromosomal analysis and pelvic ultrasound were normal. Physical examination was normal with no signs of virilisation. Abdominal examination revealed the presence of approximately 3x3 cm rounded, cystic, mobil and nontender mass at the clitonal region. Tilting the enlarged clitoris upward revealed a normal female introitus. A cystic tunour of the cilitoris was diagnosed and surgical excision recommended. At operation, the cyst was easily dissected from the skin and corpona cavernosa and completely excised. Results: Histopathologic examination showed an epidermoid cyst lined by keratinised stratified squamous epithelium and filed with keratin flakes indicating origin from the epidermis postoperative course was unevenful. Discussion: Clitoral enlargement during childhood is a rare condition that requires careful history and physical examination. Endocrinological evaluations and imaging of the adrenal glands or ovaries can be necessary for diagnosis. If these investigations are negatives, biopsy and/or complete surgical excision of the tumor should be performed. Tumors of the clitoris are uncommon, but include a variety of categories such as fibroma, leiomyoma, angiokeratoma, hemangioma, epidermoid cysts and neurofibroma as clitoral involvement of neurofibromatosis. Conclusion: Although it is very rare, a cystic lesion should be considered in the evaluation of a neonate with an enlarged clitoris.

Inter labial masses in little girls Mohamed JALLOULI*, Lilia TRIGUI**, Abdellatif GARGOURI**, Houda KAMMOUN*, Nedia HMIDA**, Ahmed REKIK**, *, Riadh MHIRI* * Department of pediatric surgery; ** Department of neonatology. Hedi Chaker Hospital. 3029 Sfax. TUNISIA Email: mohamed.jallouli@rns.tn When an interlabial mass is seen on physical examination in a little girl, there is often confusion about its etiology, its applications and what should be done. We present three uncommon interlabial masses; include a vaginal polyp, a urethral polyp and a vaginal prolapse. On the basis of our cases we believe that examination under general anesthesia can precise the exact location and allow a therapeutic approach when necessary. The histological exam is also necessary to establish the right diagnosis.

Bilateral pheochromacytoma. About one case. L. Chater, K. Atarraf, M. Arroud, K. Khalid, A. Elmadi, M. Rami, A. Mahmoudi, MA. Afifi, Y. Bouabdallah Department of pediatric surgery, Elghassani hospital, CHU Hassan II Fez. Morocco Email: chaterlamia@yahoo.fr The pheochromocytoma is a rare tumor in children that could be unilateral and isolated, or, most frequently, bilateral and integrated as a hereditary disease (multiple endocrine neoplasia, Von Hipel Lindau disease, or Von Recklinghausen disease). Its diagnosis depends upon a set of clinical arguments, especially the paroxystic high blood pressure, that may leads the place to its complications, which is the case of our patient, admitted in the paediatric department at CHU Hassan II FEZ; she had an ischemic stroke syndrome, which is a particular way of revelation of the pheochromocytoma. The diagnosis confirmation calls for methods used in the molecular biology. The topographic diagnosis has become easier thanks to the development of the imaging procedures, in particular with the advent of the MIBG scintigraphy. The therapeutic care is multidisciplinary, and the prognosis relies on the speed and the quality of care, along with the related localizations.

Rhabdomyosarcoma of the biliary tree: a rare cause of childhood cholestasis. Y. TLILI1, M. KHEMIRI1, A. BORGI1, M. HAMZAOUI2, K. BEN ROMDHANE3, I. BELLAGHA4, F. OUBICH1, S. BARSAOUI1
1

Unit doncologie, service de mdecine infantile A , 2Service de chirurgie pdiatrique A , Hpital denfant de Tunis, Tunisie. 3 Service danatomie et de cytologie pathologiques, institut Salah Azaeiz, Tunis, Tunisie. 4 Service de radiologie, Hpital denfant de Tunis, Tunisie. Introduction: Rhabdomyosarcoma (RMS) of the extrahepatic bile ducts is a rare cause of jaundice in children. Botryoid RMS is a rare type of mesenchymal neoplasm diagnosed at surgery or by preoperative liver biopsy. We report a new case of botryoid RMS. Case report: A 22-month-old male patient was admitted to the hospital with complaints of progressive jaundice, abdominal distention, and weakness, of 1-month duration. On examination, the child had hepatomegaly and icterus. Liver function tests revealed high alkaline phosphatase (2003IU/l), and bilirubin (227mol/dl) levels. Ultrasonography showed mild enlargement of the liver, a dilated common bile duct (8cm in diameter), and mild dilatation of the main hepatic ducts and intrahepatic bile ducts. Magnetic resonance imaging (MRI) study showed a cystic mass with heterogeneous intensity, measuring 8 cm/4 cm/3 cm in diameter, between the second part of the duodenum and the head of the pancreas. The patient underwent laparotomy with the diagnosis of hydatic cyst. A well-demarcated mass was found in the distal common bile duct. The mass was totally dissected from over the portal vein, and a Roux-en-Y hepaticojejunostomy was done. Histopathologic examination of the specimen concluded in botryoid RMS. The patient was given combined chemotherapy (vincristine, actinomycin-D, and ifosfamide). During 3 year of follow up, there was no finding of recurrence, and the obstructive jaundice resolved. Conclusion: Botryoid rhabdomyosarcoma of the common bile duct is a rare malignancy of childhood. it is important to know that this tumor can simulate hydatic cyst or congenital choledochal cyst. it should be considered in the differential diagnosis of obstructive jaundice in children and a cystic mass within the common bile duct.

Surgery for ovarian masses in children and adolescents : 30 patients treated in a 10- year period M. Belaiba, A. Charieg, M. Bendhaou, S. Ghorbel, F. Nouira, S. Fakhfekh, R. Khemekhem, S. Jlidi, B. Chaouachi Department of pediatric surgery "B". Childrens hospital of Tunis. Tunisia Email: awatef_charieg@yahoo.com purpose: Ovarian pathology, although less frequent in children than adult, must be included in the differential diagnosis of all girls who present with abdominal pain, an abdominal mass or precocious puberty. Time and type of surgery remain difficult to indicate. Methods: To improve clinical appreciation, time and type of surgery of these lesions, we reviewed the presentation, evaluation and outcome of 30 patients with ovarian pathology surgically treated at our institution from January 1998 to April 2008. Results: Thirty girls with a mean age of 9 years (range 2 months to 14 years) underwent surgery for ovarian pathology. Clinical presentation was acute abdominal pain in 27 cases, an abdominal mass in 2 cases and prenatal ultra sonography in 2 cases. 28 of them had ultrasonography before surgery. Of those presenting with acute abdominal pain, 20 (74%) underwent surgery urgently and 23(85%) had ovarian torsion. Of those who had urgent surgery, 13 (65%) had salpingooophorectomy, 5 (25%) had ovarian cystectomiy and 2 had detorsion, with biopsy in 2 cases. Of those who had ovarian torsion, 20 (87%) had benign cysts, 2 mature teratomas and only 1 malignant tumor. 19 patients had adnexectomy. 14 of them had benign cysts, 3 had mature teratomas, and 2 had malignant tumors with one immature teratoma and one juvenile granulosa cell tumor. All patients are now desease free at 6 years mean follow-up. Conclusion: It remains difficult to indicate time and type of surgery in treatment of ovarian masses. Clinical presentation and ultra sonography help to diagnose adnexal torsion. Because most of these lesions are benign, ovarian-preserving surgery should be performed whenever feasible.

Hydrometrocolpos: imaging findings Assa A*, Allani H*, Troudi M**, Khattat N**, Amri F**, Alouini R* * Departement of radiology; ** Departement of paediatrics. Ibn El Jazzar hospital. Kairouan, Tunisia Introduction: Hydrometrocolpos is defined by a cystic dilatation of the vagina and the uterus. It represents the third etiology of the abdomino-pelvic masses in newborn. The purpose of this work is to define the imaging findings (ultrasonography and computed tomography) in this pathology. Material and methods: Retrospective study including 3 patients, 2 newborn and one 14 years old girl, admitted for the exploration of abdomino-pelvic mass. In all cases an ultrasonography and enhanced computed tomography exams of the abdomino-pelvic cavity were performed. Retrograde opacification of the bladder was realized in one case. Results: The ultrasonography exam showed, in all cases, a cystic abdomino-pelvic mass with an echoic content and a proper wall. Dilatation of urinary cavities was found in variable degrees. The CT exam, thanks to the MPR reconstructions, concluded to internal genital related masses. Hydrometrocolpos was the most likely diagnosis. The clinical exam of external genital organs helped to confirm the diagnosis. Discussion and conclusions: Hydrometrocolpos and cystic ovary are the most frequent pelvic cystic masses in girls. Hydrocolpos is defined by a cystic dilatation of the vagina. When it extends to the uterus, it becomes called hydrometrocolpos. This entity is caused by the obstruction of the vagina. The mechanic obstruction is frequently due to a hymen imperforation. Ultrasonography exam can, by itself, confirm the diagnosis. CT exam is indicated in hard cases.

Perinatal prognosis of prenatal and postnatal congenital intestinal obstruction Ayadi I*, Labidi K*, Chaouachi S*, Guesmi M**, Hamzaoui M**, Chaouachi B***, Marrakchi Z*. *Department of Neonatology Charles Nicolle Hospital - Tunis **Department of Paediatric surgery A HET - Tunis ***Department of Paediatric surgery B HET - Tunis Background: Presence of dilated bowel loops antenatally suggests fetal bowel obstruction. Neonatal intestinal obstruction can have different variations in presentation depending on the level and extent of obstruction. The purpose of our study was to evaluate the morbidity and the mortality of congenital intestinal obstruction diagnosed antenatally or only diagnosed after birth. Material and methods: A retrospective study of 10 neonatal observations of congenital intestinal obstruction was conducted over a 7-year period. Neonates with functional obstruction or additional congenital anomalies were excluded. Results: 10 cases of congenital intestinal obstruction were collected. The diagnostic was detected by ultrasonography in 5 cases. Duodenal atresia was the most common intestinal atresia diagnosed in the 5 fetus (4 cases). The other case was a jejunoileal atresia. After birth, when diagnostic wasnt made during pregnancy, clinical features such as vomiting, abdominal distension and delayed meconium passage were suggestive. 2 cases of anorectal malformation were diagnosed at birth. 1 case of intestinal volvulus was found, and complicated by meconium peritonitis. In the 2 other cases duodenal and an "apple peel" atresia were diagnosed. Neonates with antenatal diagnosis have got immediately appropriate surgical treatment during at least 48 hours. Only one died with status of septic shock and neurological distress. Neonates, with unrecognized antenatal intestinal obstruction deteriorate rapidly, show an increase of associated morbidity and mortality and appropriate surgical treatment becomes more hazardous. Conclusion: Antenatal detection of surgically correctable congenital intestinal obstruction would ideally reduce perinatal morbidity and mortality by allowing a planned delivery with early resuscitation and prompt surgical intervention. Surgical advice is often sought when a prenatal diagnosis of gastrointestinal tract obstruction is made.

Chylous ascites in a neonate after repair of congenital diaphragmatic hernia. Treatment with octreotide. Konstantinos Farmakis Taki ikonomidi 44, thessaloniki, Greece Email: kostafarmakis@yahoo.gr Introduction: Chylous ascites is a rare complication after surgical repair of congenital diaphragmatic hernia. Conservative treatment is involving total parenteral nutrition, medium chaine triglycerides and octreotide. We present a case of a neonate with chylous ascites successfully treated with octreotide. Patients and methods: A 3900g male neonate after 38weeks of gestation, delivered with caesarian section developed respiratory distress after birth. Radiographic control discovered a left sided diaphragmatic hernia. The neonate went under surgical repair the second day of life. The neonate was extubated the first postoperative day. Ultrasonographic control at the second postoperative day showed an amount of free fluid into the peritoneal cavity. At the 14th postoperative day the neonate went after a surgical repair of inguinal hernias at both sides. During the operation a great amount of lymph (70cc) was exteriorated. The neonate was treated with total parenteral nutrition, medium chaine triglycerides while octreotide was applied at the second day, subcutaneously, 3g/kg/d in three divided doses. Treatment with octreotide was administered for 10 days. Normal nutrition started right after. Results: Repeated sonograms showed improvement and complete resolution of ascites was achieved after 15 days. Discussion: There is a variety of causes of chylous ascites in neonates such as congenital, obstructive intestinal lesions, lymphangioma, liver disease etc. However, postoperative ascites is infrequent. Some cases will resolve spontaneously. In persistent cases, conservative treatment will prolong hospitalization. Surgical treatment is peritoneovenous shunt, lymphatic duct ligation and fibrin glue application. In these cases morbidity is increased. There is no recommended dosage or duration of treatment with octreotide in neonates so we used similar to other cases. Conclusion Treatment of chylous ascites with octreotide is proved to be a safe option with no complications and short admission period.

Giant umbilical hernia in a patient with Hurlers syndrome. Case report and management principles. Smain AIT YAHIA (*), Zineddine SOUALILI (*), Souham TOUABTI (*), Karima BENDAOUD (*), Zouhir LEMTAI (**), Makhlouf BENZEMIT (***). (*) Department of Pediatric Surgery, University Hospital of Stif, Algeria. (**) Department of Anaesthesia, University Hospital of Stif, Algeria. (***)Department of Otolaryngology, University Hospital of Stif, Algeria. E mail: s.aityahia@yahoo.fr Hurlers syndrome is an inherited lysosomal storage disorder resulting from a deficiency in alphaL-iduronidase. The surgical and anesthetic management of patients with Hurlers syndrome is a challenge because of many medical problems. Umbilical and inguinal hernias are common in this disorder and generally treated conservatively. We report a case of Hurlers syndrome in 14 yearsold girl who presented with obstructed giant umbilical hernia of 18 centimeters in diameter with ischemic skin changes; the fascia defect was 8 centimeters in diameter. After relieving the obstruction conservatively, hernia repair was performed under general anesthesia using a prosthetic mesh. The postoperative course was uneventful. We discuss the various anesthetic and surgical problems faced in this syndrome. We conclude that despite the risk, it may be wise to perform elective hernia repair in selected cases of Hurlers syndrome.

Congenital rare parietal hernia: 4 case reports M. Ben Dhaou, F. Nouira, R. Khemakhem, S. Ghorbel, A. Charieg, S. Jlidi, B. Chaouachi. Department of paediatric surgery B, Childrens Hospital, Tunis. Tunisia. Email: nouirafaouzi@yahoo.fr Introduction: A hernia is a protrusion of a tissue, structure, or part of an organ through the muscular tissue or the membrane by which it is normally contained. Recognition of the typical appearance of various types of abdominal hernias and associated adverse features such as bowel obstruction, perforation, strangulation, or volvulus formation can help in formulating an accurate diagnosis. Purpose: 3 cases reports of Spigelians hernia and a case of Grynfeltt hernia are presented with a review of the pertinent anatomy, varied symptomatology and possible etiology. Cases reports: Spigelians hernia was found in three cases, (new born, 3 and 4 month-old normally developed boys), after a systematic examination. Only a 1-month-old boy presented with occlusif syndrom. The hernia was observed in the right lower abdominal quadrant in three cases. Two patients had cryptorchydy. A left Grynfeltt hernia interested a 2-month-old normally developed boy which was found after a systematic examination too. In all cases Hernia was reduced and the defect was closed. Postoperative outcome was uneventful after 6 months. Conclusion: Spigelians and Grynfeltt hernia are rare but very important because they may mimic other serious conditions. The treatment is surgical, and in the majority of patients, it can be performed with a simple open technique.

Small bowel obstruction caused by congenital mesocolic hernia. 3 case reports. M. Ben Dhaou, F. Nouira, H. Louati*, A. Charieg , R. Khemakhem, S. Ghorbel , S. Jlidi, I. Bellagha* B. Chaouachi. Department of paediatric surgery B, *Radiology department. Childrens hospital, Tunis. Tunisia Email: nouirafaouzi@yahoo.fr Introduction: Transmesocolic hernias are extremely rare. Their exact incidence is still unknown. A strangulated hernia through a mesocolic opening is a rare operative finding. Preoperative diagnosis is still difficult in spite of imaging techniques currently available. We report 3 cases of small bowel obstruction caused by congenital mesocolic hernia with literature review. Case reports: 2 new birth boy, a 12-year-old girl were admited in our departement with occlusif syndrome. On examination, they had an intestinal meteorism, a hard abdomen, painful on deep palpation. Through ultrasound and X-ray examination of the gastrointestinal tract they suspected an obstructed passage in the upper digestive tract. In all cases a laparotomy was performed. Almost all of the small bowels were incarcerated by an internal transmesocolic hernia, which was reduced surgically. The hernial peritoneal sac was excised before closure of the mesocolic defect. Postoperative outcome was uneventful after 6 months. Conclusion: Preoperative diagnosis of bowel obstruction caused by congenital mesocolic hernia remains difficult despite currently available techniques. Thus, the clinical situation requires an emergency procedure that will establish the final diagnosis and treat the patient.

Imaging of neonatal gastro intestinal obstruction A. Besbes; H.Ketata; L. Trigui; M. Jallouli*; S. Haddar; K.B. Mahfoudh; N. Hmida*; Z. Mnif Radio diagnosis department, neonatology department, *pediatric surgery department. Chaker Hospital, Sfax. Tunisia Email: anisbesbesrad@yahoo.fr Introduction: Neonatal intestinal obstruction occurs in 1/1500 live births. The radiological imaging plays a vital role in the evaluation of patients with neonatal gastro intestinal obstruction which requires the use of various imaging modalities for making the correct diagnosis and planning surgical correction. Materials and methods: We retrospectively report 13 cases of neonatal gastro intestinal obstruction between September 2006 and June 2008 in department of Radio diagnosis (Hedi Chaker hospital Sfax). Results: - Patients: 13 sex: 8 male, 5 female - Birth weight: 1400 to 4300 g The delivery: 8 cesarean, 5natural way Preterm delivery: 6 full term: 7 Mother age: 27 to 44years - Mode of presentation: vomiting (6cases); hydramnios (3 cases); delayed meconium (6 cases); bloated abdomen (6 cases). - Imaging modalities: o The plain abdominal X ray is a useful, simple and most inexpensive tool; performed in 8 cases; shows double bubble sign in all cases of duodenal obstruction, dilatation of the small bowel in jejunoileal atresia cases, air fluid levels in one case. o Upper gastro intestinal series is performed in 5 cases and reveal the obstacle level. o Contrast enema is performed in the ileal artesian cases (functional microcolon), meconium ileus and Hirshsprung disease (colonic dilatation, recto-sigmoid transition zone). o Pre and antenatal ultrasonography is performed in 7 cases, shows double bubble sign in one case (duodenal atresia), bowl dilatation (in atresia) with echgenic material (in meconium ileus), the whirlpool sign in a case of volvulus with malrotation. Final diagnosis: duodenal atresia (n=3), ladds band (n=1), duodenal diaphragm (n=1), annular pancreas (n=2), jejuno ileal atresia (n=3), jejunal duplication (n=2), meconium ileus (n=1), volvulus-malrotation (n=1), Hirshsprung disease (n=4). Conclusion: The goal of imaging is to provide an accurate diagnosis and other relevant information to the clinician to plan out the most suitable treatment efficaciously. Hedi

One stage PSARP for recto-vestibular fistula in children : Our initial experience in 5 cases. Mohammed Youssef Alexandria Hospital for Sick Children Email: edini99@yahoo.com Introduction: Rectovestibular fistula in neonates is one of the high anorectal anomalies which was treated in a staged approach starting with colostomy then PSARP at a latter stage and some surgeons do dilatation or cut back till a certain age and then do the definitive procedure. Aim: Aim of the study is to show that one stage approach for these children is safe in good hands. Patients: We present our experience in 5 patients with R.V fistula starting fro 1 month old to 4 years old to whom one stage PSARP was done. Conclusion: One stage PSARP is the best approach to these cases and it is safe in good experienced hands.

Posterior sagittal ano-rectoplasty (Pena) L. Boumelah, M. Lacheheb. Blida, Algeria Since 2001 the posterior anorectoplasty of Pena became the treatement of anorectal malformations in male and female defects: - In male defects with high rectovaginal fistula or rectobulbar fistula or without fistula. - In female defects with high rectovaginal fistula or without fistula In facts, this technic was required when the situation of the rectum is above or in the level that levator muscle. We report in this poster a case of anorectal defect with rectobulbar fistula.

Rare cause of multiple intestinal perforations concerning one case. M OUANANI - AIT ABDESSELAM A six year old hospitalized of acute intestinal obstruction with serious sepsis caused by ileum necrosis of ileum, complicated in four times by peritonitis secondary to perforations of the small intestine. The anatomo-pathological study of fragment at the level of one of the mentioned perforations evokes an ischemic process probably linked to an intestinal infection caused by perfringens clostridium. Transferred to the visceral surgery service of the professor HELARDOT (TROUSSEAU) where continuous parenteral nutrition, laparotomy and irrigation drainage system were done. Favorable evolution. This observation shows its rarity, the super mancy of the parenteral reanimations. Think about the perfringens colostridium when there are repetitive intestinal perforations.

Inflammatory Myofibroblastic Pseudotumor of Stomach: Report of a Case Elemen L1, Tugay M1, Corapcioglu F2
1 2

Kocaeli University, Department of Pediatric Surgery, Kocaeli, Turkey Kocaeli University, Department of of Pediatric Oncology, Kocaeli, Turkey

Purpose: Inflammatory Myofibroblastic Pseudotumor (IMP) is a rare solid tumor of unknown origin, often mimicking a malignant neoplasm. We present a case of abdominal IMP which is rarely seen in children. Patient: A 9-year-old girl presented with a solid mass in the left upper abdomen. Her medical history was significant for weight lost and weakness for a period of 4 months. MRI detected a solid mass with dimensions of 7x8x9 cm located behind the stomach. Intra-operative assessment revealed that the mass was bigger than it had been assumed in the pre-operative radiologic intervention with dimensions of 12x10x8 cm. It was originating from posterior aspect of gastric curvature major, adherent to the spleen and transverse colon. Complete mass resection was possible without opening the gastric mucosa. Results: The patient was discharged on the 4th post-operative day and still remains well without complications for a follow-up period of 36 months. Histopathological examination of the specimen revealed an IMP. Conclusion: Although IMP is usually located in the lungs, review of the literature revealed 13 cases of being gastric origin. As imaging techniques generally have a limited role in differentiating the origin of the mass, pre-operative diagnosis is difficult. Histopathological examination of the resected tissue following the excision is crucial for the prompt diagnosis. Although abdominal IMP tend to recur locally prognosis is usually excellent if total excision is performed. However, we believe that it is possible to cure the tumour without extensive resection.

The effect of two operation techniques on constipation of patients operated because of hydrocephalus. Elemen L1, Etu V2, Tugay M1, Tugay S3, Yasa N2, Akay A1
1

Dept. of Pediatric Surgery, 2Dept. of Neurosurgery, Kocaeli University Medical Faculty, 3 Dept. of Pediatrics, Acibadem Hospital, Kocaeli, Turkey Aim: To asses the incidence of functional constipation in children who were treated for primary hydrocephalus. Patients and Methods: 153 patients who were operated for primary hydrocephalus between January 2002 and January 2008 were divided into two groups according to operation type: Ventriculoperitoneal shunt group (Group VPS) and endoscopic 3rd ventriculostomy group (Group E3V). Patients were evaluated prospectively according to their age, sex, age at operation, duration of constipation, dosage of drugs used for constipation and duration for improvement of constipation. Face to face inquiries and physical examinations accompanied the evaluation. Results were analyzed by means of SPSS 13.0 statistical software system. Results: Group VPS contained 103 patients and Group E3V contained 50 patients. Two groups were comparable according to their age, sex and age at operation. Duration of constipation, dosage of drugs and daily defecation frequency were significantly better in Group E3V (p < 0.05). Discussion: Functional constipation is not an infrequent entity in children. Its incidence changes between 3%-%25. Besides, intractable constipation in children who were treated for primary hydrocephalus is a severe problem encountered in clinical practice. Increased constipation incidence in Group VPS is thought to be due to continuous drainage of cerebrospinal fluid into peritoneal cavity or irritation effect of ventriculoperitoneal shunt catheter. This hypothesis is supported by the relatively decreased incidence of constipation in Group E3V. These results need verification by more detailed clinical and experimental studies.

Segmental dilatation of the intestine Maazoun K, Ben Brahim M, Tandia H, Hidouri S, Sahnoun L, Chahed J, Amiri R, Ajroudi S, Krichene I, Mekki M, Belghith M, Nouri A. Department of paediatric surgery Monastir Tunisia Email: kaismz@yahoo.fr Purpose: the aim of this work is to discuss the pathogenesis of the segmental dilatation of the intestine (SDI) and to review its clinical presentation and the ways to confirm the diagnosis. Methods: Eight cases of pathologically proven SDI from 1987 to 2003 were reviewed and discussed. There were 7 newborns and a 1-year-old boy. Results: Our patients are 5 boys and 3 girls. In all cases, the diagnosis was not suspected before surgery. Two patients presented with a low neonatal bowel obstruction. Six patients were operated for omphalocele, which was the most frequent associated malformation. The SDI involved the ileum in all patients. The treatment consisted on a resection of the dilated segment with an end-to-end anastomosis. Histological examination demonstrated the presence of ganglion cells in all cases. The muscular layer was hypertrophied in two cases and very thin in one case. A heterotopic gastric mucosa was observed in one case. No anomalies were observed in 5 cases. The postoperative course was uneventful in 6 cases with a mean follow-up of 5 years. Conclusions: Segmental intestinal dilatation in an exceptional pathology with an unknown etiology and a misleading clinical presentation. The clinical polymorphism and the lack of specifity of radiological investigations explain the difficulties to have a preoperative diagnosis. However, this difficulty is compensated by the favorable evolution after resection of the dilated segment.

Combined oesophagogastric duplication. A case report BEN BRAHIM Mohamed, KSIA Amine, HIDOURI Saida, TANDIA Hadya, NOURI Abdellatif . Department of paedatric surgery. Fattouma BOURGUIBA Hospital. 5000 Monastir. Tunisia Email: mohamed.benbrahim@voila.fr Introduction: Digestive duplication are unfrequent congenital malformations that commonly become manifest within the first year of life and can present a substantial diagnostic and therapeutic challenge.. To date, only 12 cases of combined oesophagogastric duplication were reported in the world litterature. Case report: An eight month old girl presented with maelena noticed by the mother 3 days ago. This girl was the product of an uneventful pregnancy and no anomalies were seen at obstetrical ultrasonography. Physical examination was normal except an abnormal paleness of the skin. Biology showed a severe microcytic anemia (3g/dl). Oesogastroduodenoscopy was normal. Abdominal US and CT scan showed a retrogastric bilobar cystic mass. The cyst had a mediastinal extension and a well defined muscle wall. A technetium scan did not show any gastric fixation. Upper Gastro-intstinal study did not reveal any communication with the cyst. Surgical exploration noticed combined non communicating esophagogastric duplication. The baby underwent a complete cyst excision. The esophageal part was difficult to enucleate through this abdominal approach. Histology findings confirmed the diagnosis. No heterotopic gastric mucosa was seen into the esophageal part of the duplication. Post operative course was uneventful. Discussion and conclusions: Combined oesophagogastric duplication are extremely rare. Awareness of the full extent of anomalies is necessary in planning the extensive surgical intervention required for correction. Some cases may need a combined thoraco-abdominal approach.

Laparoscopic Ladds procedure in infants with late presentation of malrotation. M Masmoudi, M Mekki, S Hidouri, R Laamiri, H Tandia, S Ajroudi, K Maazoun, M Ben Brahim, J Chahed, L Sahnoun, I Krichne, M Belguith, A Nouri. Department of Paediatric Surgery,Monastir Tunisia. Email: medtun@yahoo.fr Introduction: Intestinal rotation disorders may be discovered during investigation for abdominal symptoms. Our study reports three cases of intestinal Malrotation with late presentation carried in the Department of Paediatric Surgery of Monastir between 2005 and 2008. Purpose: This clinical study was undertaken to examine the feasibility of a laparoscopic approach for the treatment of intestinal rotation abnormalities in children. Methods: The procedure was performed using 3 trocars of 5 mm diameter. Ports were placed in the infra umbilical ring and the right and left mid to lower quadrants. A standard Ladds procedure with appendectomy was performed in all cases. Results: Three patients have undergone laparoscopy. Age ranges between 6 months and 4 years. Symptoms were: abdominal pain and vomiting in all cases. Diagnosis was established by radiologic exams in all cases. There were no complications. All patients had resolution of their symptoms. Conclusion: Laparoscopic Ladds procedure is a safe and effective technique for the management of children with intestinal rotation abnormalities offering potential advantages compared with open surgery.

Prune Belly syndrome. A case report. N. HAMIDOU, F. HADJOU, H. HAOUARI, N. BENMOHAMED, S. RAMDANE, N. MALAH. Service durologie E.H.S. CANASTEL- ORAN ALGERIE It is a case report concerning a newborn of one day of age admitted in our department of paediatric urologic surgery (EHS Canastel Oran) for a prune belly or Eagle-Barrett syndrome. Clinical examination founded a big bell and hypoplasia of abdominal muscles; a bilateral undescended testis Radiological investigation showed a distension of the urinary tract at echography. UCR + UIV founded a massive right reflux level five (5) and a left bladders diverticulum + a bilateral megaureter. Renal function was normal I didnt found any others malformations. The diagnosis of prune belly syndrome was made in front of this triad: big bell + undescended testis and urinary malformation The treatment consisted on prevention of urinary infections by medical treatment and bilateral Orchydopexie at one year. The baby was reviewed every month to control his weight and size as well as his renal function wich stays normal In literature the prune belly syndrome is rare, in 75 per cent others anomalies are founded which was not in this case .The diagnosis is easy in front of this triad: big bell hypoplasia of abdominal muscles + cryptorchidism and urinary malformation. The prognostic depend of the renal function in effect 30 percent of this babies develop chronic renal insuffiency.

Orthopedic programme
Discussion of problematic cases

Surface tumour- like lesion of bone: diagnostic problems M. Ben Maitigue; M. Mtaoumi ; N. Naouar ; R. Frikha ; K. Bouattour ; H. Boughammoura ; R. Ben Hamida ; J. Dahmne ; M. Mseddi ; ML. Ben Ayach. Orthopedic Department - CHU Sahloul- Sousse -Tunisia. Introduction: The surface tumour-like lesion of bone is a rare pathology. Its identification isnt usually easy. We report a case of surface tumour-like lesion of humerus. Observation: A 11 year-old girl presented with a 6- month history of arm swelling. On examination there was a firm swelling 3x 2 cm in size on the lateral aspect of the right arm. It was deep to the fascia. Radiographs showed erosion of the lateral cortices of the proximal humerus. MRI showed a large soft-tissue mass with cortical erosion. The diagnosis of aggressive process was suspected. The patient had an open biopsy. Conclusion: The surface tumour-like lesion of bone poses frequently diagnostic problems. The surgical biopsy is necessary.

Exceptional metaphyso-diaphyseal localization of chondroblastoma. L. chater, K. atarraf, M. Arroud, K. Khalid, A. Elmadi, M. Rami, A. Mahmoudi, MA. Afifi, Y. Bouabdallah pediatric surgery, elghassani hospital, CHU Hassan II Fes Morocco Email: chaterlamia@yahoo.fr Introduction: The chondroblastoma is a very rare benign cartilaginous tumor; it represents less than 1 % of all bone tumors. It is mostly localized at the level of the epiphysis of long bones and it might extend to the metaphysis. Pure metaphyseal localizations without epiphysis affection are very exceptional. Observation: We report a case of a 14 years old female patient presenting pains at the lower limb. The clinical examination found a painless tumefaction of the inferior extremity of the thigh at palpation, no inflammatory signs were observed. The X-Rays showed a metaphyso-diaphyseal gap of 7cm in the main line direction, it had well subscribed internal limits with a bowled over aspect of the cortical and without any periosteal reaction. The biopsy of the tumoral mass recognizes a benign chondroblastoma. The patient was operated, she benefited of curettage of the tumoral mass with osseous transplant. The evaluation was favorable with absence of recurrence in one year recession. Discussion and conclusions: The evolution of the chondroblastoma is mainly dominated by risk of local recurrence which varies between 5 and 38 %. This recurrence is often accessible for a new curettage-transplant treatment approach. However, sometimes it is associated to a tumoral extension in the joint or to adjacent morrow; which require a less conservative and more extensive surgery, this would also weight on the functional prognosis.

Ewing Sarcoma of the fibula: difficulties of diagnosis and of surgical treatment. Moez Trigui, Kamel Ayadi, Fakher Gdoura, Slim Ben Jmaa, Mohamed Zribi, Hassib Keskes. Department of orthopedic surgery and traumatology. CHU Habib Bourguiba, Sfax, Tunisia Email: dr_moez_trigui@yahoo.fr Authors report a case of Ewing sarcoma of the distal fibular metaphysis in a 14 years boy. This Ewing sarcoma was characterized by the difficulty of its diagnosis since it simulated an acute osteomyelitis as well on the clinical presentation as on biology and radiology. The resection of this tumour also posed a problem because we were obliged to remove the lateral side of the tibia without passing through the interosseous membrane to have a complete resection. The reconstruction of the external ligament of the ankle was done by a strip of the tibial periosteum, fixed by staples.

A case of tibial exostosis associeted with a vascular complication. Dridi M, Ben Zid M, Mahfoudhi K, Naanaa T, Mbarek M, Trabelsi M, Ben Hassine H. Centre de traumatologie et des grands brules de Ben Arous. Email: moez.dridi@voila.fr The exostosis is the most frequent tumors that evolution is often good-hearted. Their seat paraarticular can expose to certain complications especially vascular. The authors report an exceptional case of a 13 year old girl followed for exostosis disease with humeral, femoral and tibial locations which consults for a painful tumefaction of the right hollow poplity with a soft consistency. Investigation by ultrasonography showed vascular lesion for the tibial exostosis. It was confirmed with the arteriography which allows the diagnosis of a false aneurysm of the popliteal artery. The patient was treated by resection of the exostosis associated to a stake with flat of the false aneurysm and repair vascular by venous patch. Vascular complications of exostosis are very rare. 90 % of cases are false aneurysm. Microtraumatism by friction on the exostosis can be responsible for thromboses, for embolisms even of arterial break of pejorative preview. Diagnosis, evoked on the cilinic apperence and the ultrasound is easily confirmed with the angio-scan and the artriography. The treatment is surgical; it associats exostosectomy to a vascular gesture with type of venous angioplasty allowing the vascular restoring of the continuance.

Surgical problems of skip lesions in long bone tumors. K. AMARA1 ; M. SMIDA1 ; H. EZZINE1 ; H. LOUATI2 ; M. IDRISS3 ; I. BELLAGHA2 ; K. BEN ROMDHANE3 ; M. BEN GHACHEM1
1 2

Department of Pediatric Orthopaedics - Tunis Childrens Hospital. Tunis - Tunisia Department of Pediatric Radiology - Tunis Childrens Hospital. Tunis - Tunisia 3 Department of Pathology - Salah Azaiz Institute. Tunis - Tunisia. We report here the case of a 14 year-old boy presenting a proximal metaphyseal Ewing sarcoma of the left tibia with longitudinal diaphyseal extension. MRI showed a distal metaphyseal skip lesion. Considering safe margins, 70% of the tibia bone was resected and reconstruction was done with intercalary prosthesis and non vascularized cortical bone graft taken from the controlateral tibia. Bone resection in this patient, extraperiosteal in proximal and subperiosteal in distal, constitutes the originality of the case. In fact and in our knowledge, this type of a mixed resection is not described.

A pediatric case report of an ossifying soft-tissue lesion: Myositis ossificans circumscripta W. Douira*, H. Louati*, L. Ben Hassine*, M. Smida**, M. Idriss***, M. Ben Ghachem**, K. Ben Romdhane***, I. Bellagha*. * Department of Pediatric Radiology - Tunis Childrens Hospital. Tunis - Tunisia ** Department of Pediatric Orthopaedics - Tunis Childrens Hospital. Tunis - Tunisia *** Department of Pathology - Salah Azaiz Institute. Tunis - Tunisia. ibtissem.bellagha@rns.tn Purpose: Illustrate one case of myositis ossificans circumscripta and describe the imaging features. Materiel and methods: An 11-year-old girl was admitted with a history of a painful mass in the proximal right thigh. The patient had no history of injury or specific symptoms. She has no remarkable past medical history. Clinical examination revealed a firm mass in the adductor muscles of the right thigh. Laboratory exams, plain-x ray, Ultrasound (US) and Magnetic Resonance Imaging (MRI) were done. Results: Laboratory results revealed increased blood sedimentation rate. Radiographs obtained at admission showed a large, well-defined, and partially ossified soft-tissue mass. Calcification within the mass was denser peripherally than centrally, with a thin area of decreased opacity separating the mass from the femoral shaft. Periosteal reaction was seen in the adjacent femur. US showed a soft-tissue mass with calcification and increased vascularity. MRI did not contribute any further diagnostic information. An excision biopsy was performed. Histological examination concluded to a myositis ossificans circumscripta. Conclusion: Myositis ossificans circumscripta is a benign pathology of soft tissue occurring in young patients often after localized trauma. Histological and radiological appearances may mimic a malignant neoplasm, mainly sarcoma. Careful consideration is required to ensure the correct diagnosis.

BCG multifocal osteomyelitis. A case report Louati Issam; Hazem Ben Ghozlen; Fawzi Abid; Yadh Zitoun; Noureddine Sassi. Service dOrthopdie Traumatologie. Hpital TAHAR SFAR. Mahdia - Tunisia The anti tuberculosis vaccination by bacillus of Calmette and Gurin (BCG), usually harmless to most part of the children, can be responsible for complications going from simple adeno phlegmon to often mortal generalized infections. The bcgite of bones constitutes a frequent localization. We bring back a case of generalized bcgite at an old infant of 6 months followed since the age of 4 months as recurrent pneumopathy. He was hospitalized in the paediatrics department for dehydration with change of the general status. In the examination the infant was feverish in 39C. Mobilization of the limbs as well as the palpation of all the bones length was painful. A reaction to the point of injection of BCG had been noted. Biology had shown hyper leucocytosis and an increase of CRP. X-rays revealed multiple metaphyseal osteolysis hurts well limited and surrounded by ostocondensation. Bone scintigraphy had objectified one hyper premature and diffuse illegal uptake in bones. The surgical exploration of the hurt site at the superior extremity of the right femur showed a geode containing pus and histological examination identified granulomatosis constituted by macrophages filled with numerous bacilli. The immunizing balance sheet had shown a severe combined immunizing deficit. In spite of an improvement under antituberculeux, immunoglobulins and a transplant of the marrow, the evolution was fatal. In spite of its rarity the osseous bcgite must be evoqued at every infant's presenting signs of generalized infection and has to make look for an immunizing deficit. The diagnosis of certainty bases itself on histological and bacteriological information. The treatment of the osseous bcgite remains still badly codified and bases itself essentially on anti tuberculosis drugs.

Stress fracture of the femoral epiphysis. An exceptional location. Dridi M, Zaraa M, Annabi H, Bakhchali K, Hadj Salah M, Mbarek M, Trabelsi M, Ben Hassine H. Centre de Traumatologie et des Grands bruls de Ben Arous Email: moez.dridi@voila.fr The stress fracture of the superior femoral epiphysis is a location at the same moment exceptional and little reported in the literature. It is about a 12 year old girl, without pathological history, not sportswoman, who appears with a pain of the right hip without fever that happened after an intense physical effort during three week in a colony of vacancy. Biology is normal, the initial radiography showed no abnormality of the superior femoral epiphysis. The scintigraphy shows a hyperfixation of the right femoral head. The diagnosis of fracture of the superior femoral epiphysis was confirmed only with the MRI. The stress fracture of the femoral neck is already an exceptional location. The epiphyseal location in child was never described according to our literature review. Clinical history, bone scintigraphy and especially MRI allows to a not evident diagnosis. Differential diagnosis settles essentially with an infectious or tumors diseases. In this observation the premature functional treatment has allowed clinical and radiological cure strengthening so hypothesis diagnosis.

Myositis ossificans progressiva in childhood. Report of a case and literature review. N. Merazi, R. Benahmed-Kermani, Y. Ladjadj Myositis ossificans progressiva in childhood is an extremely rare inherited disease transmitted as an autosomal dominant defect. The diagnosis could be evoked by the association of progressive ossification of soft tissues with anomalies of the big toes (congenital hallux valgus, microdactyly). We report a case of myositis ossificans progressive in a 4 years old boy, with numerous swellings on the back with large bony masses restricted movement of the neck. The X-rays showed extensive ossification of muscles. Excision of heterotopic bone is futile. It can lead to the stimulation of new sites. Premature death often results from respiratory failure.

Type II tibial hemimelia and surgical problems. A case report. M. KHELIFI ; M. SMIDA ; A. GAALICHE ; N. NESSIB; CH. AMMAR; M. BEN GHACHEM. Department of Pediatric Orthopaedics - Tunis Childrens Hospital. Tunis - Tunisia Tibial hemimelia (THM) is a rare congenital anomaly occurring approximately in one per 1,000,000 live births. It is typically characterized by an absent or hypoplasic tibia with a relatively intact fibula resulting in lower limbs discrepancy and severe club foot in some types. The widely used classification in the literature was proposed by Jones. The aim of this paper is to present difficulties and problems of surgical treatment of type II TMH. Case report: H.H. is a 5-year-old girl presenting a right type II TMH. She had been examined at one year of age and surgery was indicated but her parents had refused the operation and neglected the deformity. At 5 years of age, the girl was reviewed and clinical exam found lower limbs discrepancy and a severe club foot. Below knee amputation and foot preservation were proposed in the medical staff but parents have preferred preservation. By a postero-medial approach, a tibialization of the fibula associated to ankle arthrodeses was done. By preserving the fibular distal growth plate, the arthrodeses was between talus and distal fibular epiphysis. But serious cutaneous complications happened earlier

Dorsal spinal cord injury without radiographic abnormalities. A case report S. BOUMAIZA - M. SAKKA - K. AMRI - W. BEN GHARS M.R. CHERIF Service dOrthopdie Traumatologie. Hpital Habib Nouri. Bizerte - Tunisia The authors report the case of 13 years olds child who was victim of a street accident witch causes crania-facial traumatism with a traumatism of cervical and dorsal spine. The clinical exam poses complete sensitive and motor paraplegia on D 10 level. The plain X-RAY and else computed tomography was normal. MRI of the spine revealed a cervical prevertebral haematoma with rupture of inter spinal ligament in front of 6th and 7th cervical vertebra without signal anomalies of the spinal cord. MRI showed also a medullar contusion in front of the 10th and 11th dorsal vertebra without bones and ligaments lesions. The diagnosis of spinal cord injury without radiographic abnormalities (S.C.I.W.O.R.A.) on the thoracic level was retained. After emergency treatment and stabilisation of general status, the patient was transferred to a special centre of re-education. Actually, after one year of traumatism he has partial motor and especially sensitive recuperation.

Infantile cortical hyperostosis. ZRIG Makram, MNIF Hichem, JAWAHDOU Rafik, HAMMOUDA IMED, ALLAGUI Mohamed , ALOUI Issam, , KOUBAA Mustapha, NOURI Abdellatif*, ABID Abderrazak. Department of Orthopaedic and Traumatic Surgery, Fattouma Bourguiba Hospital, Monastir, Tunisia. * Department of Pediatric suregery, Fattouma Bourguiba Hospital, Monastir, Tunisia. Introduction: Infantile cortical hyperostosis or Caffeys disease is a rare familial disorder of unknown etiology that usually occurs in the first few months of life. It is a rare cause of irritability, bone pain, soft tissue swelling and fever in the infant. Case report: A 1-year-old baby girl presented a 2-day history of acute pain and swelling in the right shoulder. The baby was pyrexial. Laboratory analysis revealed signs of inflammation, including leukocytosis with an elevated erythrocyte sedimentation rate. The radiographic examinations demonstrated bone periosteal reaction in proximal humeral metaphysic. Echographia of shoulder showed denseness of soft tissue and absence of physeal injury. Our chief differential diagnoses at this point were accidental injury, osteomyelitis and sickle cell crisis. After 5 weeks, an important fusiform periosteal reaction of humerus was seen. The diagnosis of Caffeys disease was made following a skeletal survey, which showed similar changes of cortical thickening in the radius and ulna as well as the affected humerus. Conclusions: Caffeys disease is an unusual cause of bone pain in the infant. Symptoms and signs are subtle and the diagnosis is generally made with plain X-rays.

Orthopedic oral Communications

Patterns and course of bone Langerhans cell histiocytosis. Retrospective study at a single center. F. Oubich1, Y. Tlili1, M. Smida2, M. Khemiri1, K. Ben Romdhan3, I. Bellagha4, M. Ben Ghachem2, S. Barsaoui1 1234Service de Mdicine infantile A - Hpital denfants de Tunis, Tunisie Service dOrthopdie Infantile- Hpital denfants de Tunis, Tunisie Service dAnatomopathologie- Institut Salah Azaiz, Tunis - Tunisie Service de Radiologie- Hpital denfant Tunis, Tunisie

Background: Langerhans Cell Histiocytosis (LCH) is a rare disorder with a heterogeneous clinical picture and course. Single system (SS) disease is the most common presentation. Mostly bone is involved whether in SS or multi-system (MS) disease. Authors report clinical profile of children with bone involvement LCH, the outcome and the sequelae presented by survivors. Procedure: We reviewed retrospectively cases of LCH managed at Tunis Pediatric Oncology unit. 48 patients (pts) were diagnosed and followed by standardised schedule, 40 pts (83 %) with bone involvement. The main age at diagnosis was 4 years and 4 months (range 6 months-17 years). Extent of disease was evaluated by laboratory studies, chest-x-ray, abdominal ultrasound and radiological survey of the skeleton. In specific cases, computed tomography scans or MRI of affected areas. Protocol of treatment was LCH II and III. Results: Single bone lesions were most common (56%); followed by multiple bone lesions (23%). Initial organ involvement included bone (80%); ear (23%); liver (23%); skin (21%); lung (8%); diabetes insipidus (8%). Initial complaints in pts with bone disease were mostly described as local pain and/or swelling. The distribution of the initial bone lesion: 42% were found in the skull, 15% in the spine, 19% in the lower extremities, 8% in the upper extremity, 8% in the pelvic, 10% in the upper extremity and 6% in the thoracic bones. Treatment comprised surgery, chemotherapy, irradiation, steroids, anti-inflammatory drugs. Some pts have been followed without treatment. At median follow-up of 5 years (range 2 months-8 years) reactivation restricted to the skeleton occurred in 15%. Three patients had died of progression to multi-system disease, 01 patient of traffic accident. Orthopaedic problems related to lesional sites occurred in 3 patients. Conclusion: The course in bone LCH was benign in case of SS. However, the prognosis in MS depend on others visceral lesions. Bone disease reactivation remained restrictive to skeleton and did not influence survival. These reactivations had impact in morbidity and sequelae correlated to the sites of the lesion.

Malignant bone tumors of the pelvis in young patients. Nouri H, Mascard E, Wicart P, Missnard G, Dubousset J, Seringe R. Saint Vincent de Paul Hospital Paris Email: nourihabib@yahoo.fr Twenty patients with malignant bone tumor of the pelvis underwent a limb-sparing surgery. The mean age was 13.3 years. Nine patients had a type I+II resection, ten a type II+III resection and one had hemipelvectomy. Resections involving the ilium bone were reconstructed by an autologous bone graft between the sacrum and the remaining acetabulum in 5 cases, an allograft in 3 cases, endoprosthesis in 1 case and spine material with prosthesis in 1 case. When sparing the ilium bone, reconstruction was achieved by an ilio-femoral arthrodesis in 6 cases, Saddle prosthesis in 2 cases and allograft in 2 cases. Local recurrence was seen in 2 cases. Four patients developed metastases and 4 patients died within 7 months. Sixteen patients were alive and were reviewed with a mean follow up of 5.7 years. Functional result was assessed by MSTS Score. Ilio-femoral arthrodesis gave the best functional score and the lower complication rate. In case of arthrodesis between the sacrum and the acetabulum, we observed a progressive cranialization of the femoral head. The mean score was 60%. Four allografts were evaluated with a mean follow up of 2.5 years. A deep infection and lymph oedema occurred in one case due to radiation therapy. The mean functional score was 60%. In the case of CD reconstruction, the hip was very instable and there was a loosening of the femoral component. A secondary transposition of the hip was done. Finally, Saddle prosthesis was revised within 9 years and replaced by a composite prosthesis. The ideal method of reconstruction after acetabular resection remains a subject of controversy. To achieve good functional outcome, the femorosacral continuity should be reconstructed. Hip transposition could be a good solution when the primary reconstruction fails. Facing the goal of limb salvage, a certain number of complications must be accepted.

The treatment of the bone cysts in the development age. Petkovic L, Maric D, Gajdobranski DJ, Djan I, Petkovic M Institute for Children and Youth Health Care Vojvodina, Clinic for Paediatric surgery. Novi Sad, Serbie Email: lazmir@neobee.net Introduction: Cysts are usually clinically detected after the trauma and X-ray and CT findings are characteristic. It is important to distinguish solitary (juvenile) bone cyst from aneurismal cyst, nonossificating fibroma, eosinophil granuloma, fibrodysplasia and different bone tumours. Methodology: Diagnostics include clinical, X-ray and CT examinations as well as laboratory analysis. Different orthopaedic and surgical procedures are used in the treatment: percutaneous punctions, fenestrations and curettage with or without osteoplastics, methods of internal fixation (Kirschners wires or elastic nails), arterial scleroembolisation etc. Results and discussion: Solitary juvenile cysts were found in 19 patients (63%), and in 13 patients (37%) there were aneurismal bone cysts. The average age of treated children was 8.6 years. The ratio boys/girls was 1.8/1. In 12 patients (37%) the initial therapeutic procedure included the instillation of methylprednisolone acetate (MPA), once to three times. In 9 patients (28%) the therapeutic procedure that was conducted was the instillation of Aetoxysclerol sol 2% or 3%. In 8 patients (25%) the instillation of bone marrow was performed. The surgical procedure of fenestration and internal fixation was conducted in 3 patients (9%) as the primary treatment and in 3 more patients (9%) where preliminary punction treatment was not successful in total in 6 patients (18%). Conclusion: The standard treatment is fenestration, curettage with the placing of bone graft but due to significant percentage of recurrence, the less invasive approaches were suggested such as percutaneous decompression and instillation of methylprednisolone acetate (MPA). In recent years the percutaneous punction methods as well as the instillation of Aetoxysclerol, especially of the autologous bone, are being used.

Limb salvage in malignant tumours of the knee for young patients. Is it really the solution? H. NOURI* - M. JENZRI** - A. KARDI * - M. OUERTATANI* MESTIRI* M. ZOUARI** M.

* Department of Adult Surgery; ** Department of Paediatric Surgery. KASSAB ORTHOPAEDIC INSTITUTE. MANNOUBA. TUNISIA The knee is the most frequent location of malignant bone sarcomas. In the past, amputation was the definitive treatment of these tumours. However, advanced chemotherapy, radiological imaging and reconstructive surgery have made limb-salvage a safe alternative for the majority of patients. The purpose of this study is to report results of the treatment of malignant bone tumours around the knee by limb-salvage procedure in young patients in order to assess the safety of such procedures in both oncological and functional outcome. Nineteen patients underwent lower limb-sparing surgery for long bone sarcoma around the knee. There were 13 boys and 6 girls with a mean age of 16.6 years. The diagnoses were osteogenic sarcoma in 18 cases and Ewings sarcoma in one case. The tumour was located in the distal femur in 13 cases and in the proximal tibia in 6 cases. Reconstruction was achieved by endoprosthesis in 12 cases and by knee arthrodesis in 7 cases. Patients were reviewed with a mean follow up of 6.21 years. Local recurrence was seen in 4 cases. Two patients developed metastases and one patient died within 3 years. Functional result was assessed according to the musculo skeletal score. Limb sparing surgery is safe procedure in managing malignant bone tumours. Endoprosthesis is the method of choice in the reconstruction of the knee. Although a durable reconstruction is elusive especially in young patients. Long term results showed a high rate of complications and a degradation of the functional result. Knee arthrodesis has the advantage to be a biological reconstruction with a definitive result although the loose of knee motion is usually unacceptable by patients. It remains a solution when endoprosthesis fails. When the growth plate is still open, problems related to growth have to be considered before deciding which indication should be done.

Ultrasonographic diagnosis and sclerosing therapy of popliteal cysts in children. Petkovi L, Gajdobranski , Dobanovaki D, Boriev V Institute for Children and Youth Health Care Vojvodina, Clinic for Pediatric surgery Novi Sad . Serbie E mail: lazmir@neobee.net Introduction: Popliteal cyst, hygroma fossae popliteae, or Bakers cyst diagnosis is made by anamnestic, clinical and ultrasonographic examination. So far the common treatment was surgical excision. Nowadays the most important procedures are punction (tapping) and sclerosation. Methodology: It includes clinical and ultrasonographic diagnosis and follow-up of the effects of the punction therapy in the period of 3-6 weeks. Results and discussion: Comprehensive analysis of five-year period consists of 34 children (37 cysts) with clear clinical and ultrasonographic diagnosis. Therapeutic procedure of punction and sclerosation with 2% or 3% Aetoxysklerol was performed in one act in 5 patients (5 cysts), in two acts in 10 patients (11 cysts) and in three acts in 19 patients (21 cysts) in the period of 3-6 weeks. The complete normalization of the clinical and ultrasonographic examinations was observed in 23 patients (25 cysts), but in 4 cases (4 cysts) cystic formation still existed. For 7 patients (8 cysts) there were no further data about last check-up. There were no serious, not even unpleasant complications during these procedures. Conclusion: Ultrasonography is a first line diagnostic procedure for popliteal cysts in children and punction (tapping) and instillation of sclerotisin substance (Aetoxysklerol 2% or 3%) is the most convenient therapeutic procedure in the whole treatment

Lipomatous tumors of limbs in children. M. KHELIFI1 ; A. GAALICHE1 ; M. SMIDA1 ; H. LOUATI2 ; M. IDRISS3 ; I. BELLAGHA2 ; K. BEN ROMDHANE3 ; M. BEN GHACHEM1
1 2

Department of Pediatric Orthopaedics - Tunis Childrens Hospital. Tunis - Tunisia Department of Pediatric Radiology - Tunis Childrens Hospital. Tunis - Tunisia 3 Department of Pathology - Salah Azaiz Institute. Tunis - Tunisia. Purpose: In children, lipomatous tumors are very rare and often benign. If resected completely, these tumors have an excellent prognosis despite their potential to local invasion. In this work, 13 documented cases of lipomatous tumors are reviewed and the purpose was to evaluate their characteristics. Materials and methods: Thirteen cases of proven lipomatous tumors (9 lipoblastomas, 3 lipomas and one chondrolipoma) treated from 1990 were reviewed. Results: There were 11 boys and two girls ranging in age from 7 months to 14 years. The lower limb was the most frequent localization. In 6 children, the tumor was diagnosed at birth. All the patients presented often a painless mass of soft tissue. In some cases, the tumor was painful. MRI (12 cases) and CT scan (one case) had suggested the diagnosis of lipomatous tumors by revealing characteristic imaging appearance of these rare tumors. In only 4 cases, resection was preceded by a biopsy. In the other cases, tumor resection was done directly. Eleven patients made an uneventful recovery and after 4.5 years median follow-up, there was no recurrence. In 2 patients, recurrence of lipoblastoma happened respectively one and 7 years after surgery and a second surgery was done.

Reconstruction of osteomyelitis bone defects with the Ilizarov method. A report of 9 cases. R. Frikha; M. Mtoumi; M. Ben Maitig; N. Naouer; J. Dahmene; M.L. Ben Ayeche. Orthopaedic Department, Sahloul Hospital. Sousse Tunisia Ilizarov's method, since its description and the obtaining of first results, was gradually adopted in the therapeutic arsenal of reconstruction of bone defects. We present through a retrospective study the results of 9 bone defect cases treated by bone transport using the Ilizarov technique and we suggest some recommendations allowing to improve the quality of the result and to decrease morbidity. The average age was 10 years (6 - 16 years). Reconstruction interested 4 times the tibia, 3 times the femur and twice the ulna. The causes of the bone defects were chronic osteomyelitis. The bone defect average was 8 cms (6 -10 cms). This method allowed a reconstruction of 8 cms on average (22 % of the segment length). The index of external fixation was estimated 45 days / cm. The most frequent major complication was the pseudarthrosis of the docking site functional and anatomical results were good and the consolidation was reached in 88 %. This method gives a good regeneration and getting closer to the normal bone on the biomechanical and anatomical Characteristic. These results strengthen our conviction on the place of this method in the bone reconstruction.

The modified Quad procedure for reconstruction of shoulder abduction and external rotation in late obstetrical brachial plexus palsy. A. Amrani, MA. Dandane, SZ. El Alami, T. El Medhi, H. Gourinda, A. Miri. Pediatric Orthopedics and reconstructive surgery unit. Rabats hospital for Children, Morocco Background: Children with obstetrical palsy have significant functional disability in shoulder, mainly related to residual muscle weakness with soft-tissue contractures which limit the functional range of movement and lead to progressive glenoid dysplasia and joint instability. The objective of this study was to analyze the functional outcome of tendon transfers performed for restoration of shoulder motion in patients with obstetrical palsy. Material and methods: Between June 2006 and January 2008. Forty five patients who had functional deficit of shoulder elevation and external rotation were operated by a senior surgeon (A.A). The surgical procedure was uniform in all cases. Mallet class was recorded preoperatively and postoperatively. Results: Forty five patients; Twenty eight females and Seventeen males, with average age of 36 months at operation were included in this series (range from 1.5 to 12 years). Right shoulder was affected in Twenty nine cases while left in sixteen cases. The mean pre-operative active abduction was 80 degrees (70 degrees to 110 degrees). At a mean follow-up of 11 months (6 to 24 months), there was a significant improvement in abduction, forward flexion and external rotation as compared to preoperative values, statistically significant. The mean active abduction was 160 degrees (130 degrees to 180 degrees) while thirty three (73%) of the patients had active abduction of 160 degrees or more. No decline in abduction was noted. Conclusions: Among many procedures described to improves the functional status of shoulder in late cases of obstetrical brachial plexus Palsy theres the modified Quad procedure that describe by Nath. This procedure involving release of the contracted internal rotators of the shoulder combined with decompression and neurolysis of the axillary nerve greatly improves active abduction in young patients with muscle imbalance secondary to obstetric brachial plexus palsy.

Experience of the department of physical therapy and medical rehabilitation of Kassab institute in the management of the spastic foot in cerebral palsy. Chrifi J; Miri I; Ben Salah F Z; Dziri C Department of physical therapy medical rehabilitation of the Kassab Institute Introduction: The cerebral paralysis is a state responsible for several disabilities; among which neuro-orthopedic disorders and particularly feet spastic. The aim of the study is to emphasize the importance of a premature coverage and to present the various necessary therapeutic means to protect the functional autonomy. Materials and Methods: It is a retrospective study, descriptive, analytical and critical bearing on the children with cerebral palsy hospitalized in the service of physical therapy medical rehabilitation, and whose methods of management were discussed out of multidisciplinary staff. We review the hospitalized children over 2 years (January 2006 - January 2008). All the patients profited from an initial and final evaluation, based on the realization of a complete clinical examination (orthopedic/neurological), like on an analytical and filmed study walk, followed by a discussion of the best therapeutic procedure on a case-by-case basis. Results: - 96 patients were integrated in the study, 33girls and 63 boys. - The Middle Age was of 3 years and 7mois. - 21 patients profited from the realization of successive plaster-casts , 43 patients of a toxin injection preceded by Motor nerve blocks and 32 patients had either a combination plasters/toxin, or another therapeutic method (rehabilitation/postures/surgery). Discussion and Conclusion: The management is variable were among our patients: * Improvment of an awkward spasticity making hygiene difficult to maintain or threatening orthopaedic balance (dislocation of the hip/recurvatum of the knees). * Improvement of the diagram or stability to walk. * * Recovery or improvement of the endurance to loading of the young patients. The essential report which emerges through our work it is the need for a discussion of the patients on a case-by-case basis within the framework of a multidisciplinary center in order to be able to make benefit the patients to the maximum of the benefits from each therapeutic technique. A pre and post-therapeutic rehabilitation preceded by a meticulous clinical evaluation (muscular spasticity/force/walk), are the bases essential and essential to the post-therapeutic profit and the maintenance of best orthopedic balance neuro and the best body diagram.

Osteosynthesis with Kirschner wires in the treatment of unstable supracondylar humeral fractures in children. Gajdobranski Dj., Petkovic L., Maric D., Tatic M. i Mikov A. Clinic of Pediatric Surgery, Clinic of Pediatric Rehabilitation, Novi Sad, Serbia Email: drgajdobranski@gmail.com Introduction: Elbow fractures represent 7-9% of all the fractures in childhood, while supracondylar type of fractures is the most common of them (up to 70%). 84% of all the supracondylar elbow fractures occur up to the age of 10 years (most often between the 5th and 8th year). The aim of this study was to present the technique and results of the treatment of supracondylar fractures with third grade fragment dislocation in pediatric population. Treatment was orthopedic reposition and percutaneous pin fixation. Material and methods: At the Pediatric Surgery Clinic in Novi Sad over the period from 1996-2005, 218 patients were hospitalized due to a supracondylar fracture of the humerus with third grade fragment dislocation. All the patients were aged 3-15 years. Orthopedic reposition and percutaneous pin fixation under the control of the X-rays was performed in 216 patients (99.08%). Results: We analyzed in this paper 151 (69.9%) patients who had full documentation. Extensor type of fracture was verified in 143 patients (94.7%). Male patients predominated over the female patients 113:38. Average follow-up period was 4,5 months. On the basis of clinical examination, and after completion of the rehabilitation, satisfactory result was obtained in 144 patients (95.36%), while in 7 patients the final outcome was unsatisfactory. Discussion: Analysis of the literature points to the advantages of the orthopaedic reposition and percutaneous pin fixation, with certain modifications in the treatment of supracondylar elbow fractures with third grade dislocation. Conclusions: Obtained results in the treatment, all the advantages of this procedure, and our experience, make us conclude that orthopedic reposition and percutaneous pin fixation is a procedure of choice for the treatment of supracondylar elbow fractures with third grade dislocation in childhood.

The Ponseti method for the treatment of congenital clubfeet. Amel Dehou-Mahmoudi; S. Allout; I. Beressa; N. Abdellali; M. Azzouz EHS Boukhroufa AEK route de canastel 31000 ORAN ALGERIE Email: amel_dehou@yahoo.fr Introduction: The Ponseti method for the treatment of congenital clubfeet has been propagated due to the sometimes disappointing functional results after surgical treatment. The aim of our study was to evaluate our early results and experiences with the Ponseti method. Material and methods: It is a prospective study between October 2006 and December 2007. A total of 40 clubfeet in 35 patients were treated using the Ponseti method at our department. . Rate of successful correction without open release surgery, radiological findings, classification according to Dimeglio at the time of the last follow up, recurrence rate and duration of treatment were defined as outcome measures for this prospective study. Results: The mean of the follow up was 15 months. All the patients were corrected without open surgery, 98 % were corrected without other plaster cast. The mean duration of active treatment was 9.83 weeks (8-19 weeks). The mean tibiocalcaneal angle 3-4 weeks after the percutaneous tenotomy of the Achilles tendon, the mean a.-p.-talocalcaneal angle and the lateral talocalcaneal angle are evaluated. A recurrence was seen in one patient with bilateral clubfeet (5 %). Conclusion: Open release surgery can be averted in most cases of idiopathic clubfoot using the Ponseti method. Scarring of the soft tissue and especially of the joint capsule can thereby be avoided.

Shoulder medial rotation contracture in obstetric brachial plexus palsy managed by Nath procedure: triangle tilt surgery': A preliminary results A. Amrani, SZ. El Alami, MA. Dandane, T. El Medhi, H. Gourinda. Paediatric Orthopaedics and Reconstructive Surgery Unit. Childrens Hospita, Rabat. Morocco Email: amraniabdel@menara.ma Background: The medial rotation contracture caused by weak external rotation secondary to obstetric brachial plexus injury leads to deformation of the bones of the shoulder. Scapular hypoplasia, elevation and rotation deformity are accompanied by progressive dislocation of the humeral head. Material and methods: Between June 2006 and December2007, 14 children underwent a surgical procedure called the triangle tilt operation as described by Dr Nath to correct this bony shoulder deformity. Surgical levelling of the distal acromioclavicular triangle combined with anterior release of shoulder. Results: The posture of the arm at rest was improved and active external rotation increased by a mean of 53 degrees (45 degrees to 85 degrees ) in the 9 children who were followed up for more than one year. There was a significant improvement of the Mallet shoulder function score after surgical correction of the bony deformity. Conclusions: The surgical procedure called the triangle tilt surgery as described by Dr Nath improved shoulder function and corrected the glenohumeral axis in these patients.

Neonatal brachial plexus palsy Beressa, Allout, Dehou, Abdelali, Azzouz Department of paediatric orthopaedic surgery EHS Canastel Oran, Algerie Email: ismahene_beressa@yahoo.fr The incidence of obstetrical plexus palsy doesnt decrease during the last century in the word, In Algeria there is no study witch give this incidence. The conventional non operative management is used by some authors, others prefer early microsurgical treatment if there is no biceps recovery at three month. The purpose of this study is to report natural history and to determine the prognostic for bad recovery in patient who were identified at our service as having a neonatal brachial plexus palsy in our department of paediatric orthopaedic surgery (EHS Canastel Oran) Methods: Between (July 2007 to June 2008), 21 new born with neonatal brachial plexus palsy were entered in into a prospective study in witch details of birth and serial clinical examinations were recorded. Patients were grouped according to Narakas classification; Shoulders elbow and hand functions were graded according to Gilberts score. Result: The level of injury was :c5,c6 fourteen (14) cases, c5, c6, c7 four (04) cases, total (01), total+Claude Bernard Horner two (02) cases. The average birth weight was 4171g 07/21 have associated lesion. Only 03 /21 babies have present total recovery 05/19 has recovery biceps at three month. Except for the Claude Bernard Horner sign I found no sign witch can predict bad recovery. I concluded that in this study prognostic of total recovery is not as good as it is found in some articles. If recovery is incomplete by the end of the first month, referral to a multidisciplinary team is necessary.

Osteogenesis imperfecta: therapeutic difficulties. About 21 cases. Jenzri M, Arbi S, Yakoubi N, Hadidane R, Daghfous MS., Zouari O. Infantile Orthopedic Department Kassab Institution Tunis Email: jenzri.mourad@voila.fr Introduction: The Osteogenesis Imperfecta or Lobstein disease is characterized by an osseous fragility which results in numerous fractures arising spontaneously or in the regression of a minor traumatism, and which are responsible for deformations of the members involving the functional prognosis of the patient. Through a series of 21 patients treated in our institution, we describe the difficulties and the results of the coverage. Material and methods: This consists of a retrospective study of 21 patients affected by the Lobstein disease and treated in our department since 1990. Each file was studied by clarifying the following elements: the age in the beginning of the coverage, the sex, the age during the first fracture, the number of fractures and their locations, the presence of deformation and the ability to walk. These elements allowed clarifying the gravity of the disease and the functional state before any coverage. We afterward studied the undertaken treatment and its inherent complications. The appreciation of the result of the treatment was essentially based on the evaluation of the functional state after the treatment. Results: The study concerned 7 boys and 14 girls. The average age during the first consultation was 4 years. The average age during the first surgical treatment was 7,5 years. We distinguished three categories of patients according to the age of the first arisen fracture: 5 grave forms, 3 minor forms and 13 intermediate forms. Eight patients could walk and 13 patients could not during the first orthopedic coverage. All the patients were surgically treated and we did the usual technique of internal fixation with an intramedullary rod according to the technique of SOFIELD. Our results were estimated as follows: Among the 13 patients who initially could not walk, 8 were able to get an autonomous walking back and 5 patients stayed in the same state in spite of the segments of armed members. We noted three infections and a death. Discussion: We discuss in this work the difficulties of the orthopedic coverage of the children affected by the Lobstein disease as well as the interest of the medical treatment of the osseous fragility. Conclusion: The Osteogenesis Imperfecta is characterized by an abnormality of the synthesis of the collagen getting to all the structures of the body conferring him a general character of the affection. The coverage must be multidisciplinary to improve the functional and vital prognosis of these patients.

Orthopedic posters

Peroneal nerve compression resulting from fibular head osteochondroma. MNIF Hichem, ZRIG Makram, HAMMOUDA Imed, ABBADI Abdelmalek, ALLAGUI Mohamed, ALOUI Issam, HAMDI Mohamed Faouzi, KOUBAA Mustapha, ABID Abderrazak. Department of Orthopaedic and Traumatic Surgery, Fattouma Bourguiba Hospital, Monastir, Tunisia. Introduction: Osteochondroma of the proximal fibula is relatively common, but reports of this lesion in conjunction with peroneal nerve compression have been scarce. The authors report a case of a child presented with peroneal nerve compression secondary to fibular head osteochondroma. Case presentation: An 11-year-old boy presented with right peroneal neuropathy, paresthesia, on admission. Physical examination disclosed multiple bony exostosis overlying the ribs, knees, and ankles bilaterally. In particular, a large exostosis was palpated at the right fibular head. The tinel sign could be elicited at that point. The radiological examinations (standard and computed tomography) demonstrated an osteochondroma in the head of the right fibula. The electrodiagnosis findings supported an axonal loss deep peroneal mononeuropathy, sparing the superficial peroneal sensory responses. The patient underwent surgical decompression of the nerve and resection of the osteochondroma. The peroneal nerve was flattened by the exostosis. After a follow-up of 20 months, there was a complete recovery of the deficits. No evidence of recurrence was seen. The electromyography and nerve-conduction studies are normal. Discussion: Osteochondroma is a benign tumor consisting of projecting bone (exostosis) capped by cartilage. It may continue to enlarge throughout childhood, but continued growth beyond that point should raise the suspicion of sarcomatous transformation. These tumors may be solitary or multiple. Multiple tumors occur in the setting of multiple hereditary osteochondroma. These benign tumors remain asymptomatic, although they can produce bony deformities or may also compromise joint motion by compression of the tendons, cause compressive mononeuropathy. Osteochondroma is an uncommon cause of peripheral nerve dysfunction. Peroneal mononeuropathy in children is uncommon. The diagnosis in our patients was not formally made until electro diagnosis studies identified the probable location of the lesions, although plain roentgenographs demonstrated the pathologic findings. This lesion may require surgical intervention.

Closed reduction and stabilization of a completely displaced radial neck fracture. Moez Trigui, Kamel Ayadi, Fakher Gdoura, Slim Ben Jmaa, Mohamed Zribi, Hassib Keskes. Department of Orthopedic and Trauma Surgery, CHU Habib Bourguiba, Sfax, Tunisia Open reduction is usually indicated in completely displaced radial neck fractures, such as in Jeffery II type or very displaced Jeffery I type. Authors report in this paper an exceptional displaced radial neck fracture in a 12 years old child. This fracture involved an anterior displacement of the radius instead of a displacement of the radial epiphysis which preserved his normal connections with humeral condyle. This fracture was not associated to any injury of the ulna or the elbow joint. Mechanism of this injury is probably a compression force on the radial head associated with a violent contraction of the biceps brachialis muscle. In our knowledge, this type of radial neck fracture was not described previously. This fracture was successfully treated by closed reduction with manipulation of the proximal radial metaphysis. Reduction was stabilized with a Kirchner wire and a splint during 1 month. At 2years follow-up, the result was excellent, with a painless elbow and a complete range of motion.

Osteoid osteoma of the talus and simple bone cyst of the homolateral calcaneus. A rare association I. Louati; H. Ben Ghozlen; F. Abid; Y. Zitoun; N. Sassi. Service dOrthopdie Traumatologie. Hpital Mohamed Tahar SFAR. Mahdia - Tunisie Osteoid osteoma and simple bone cyst are readily observed in long bones but are much less common in the short bones of the foot. The association of these tumours the year level of the same foot is unusual. We report the case an association of an osteoid osteoma of the talus and simple bone cyst of the calcaneus of the left foot in a 15-year-old teenager. The patient complained of pain for 4 months which worsened at night. The clinical examination was normal and the X-rays revealed the simple bone cyst of the talus which did not explain the night-and inflammatory pains. Bone scintigraphy and CT scan of the left foot revealed an osteoid osteoma. Resection of the osteoid osteoma and curettage and filling with cancellous bone of the bone cyst was realized. At 3 years follow-up, the patient has been free of recurrence.

Scoliosis and osteoid osteoma of the spine Jenzri M, Ammar A, S, Feki H, Hadidane R, Daghfous MS., Zouari O. Infantile Orthopedic Department Kassab Institution Tunis Email : jenzri.mourad@voila.fr Introduction: The vertebral localization of the Osteoid Osteoma is rare (10 in 20 % of Osteoid Osteoma). It comes along with a scoliosis in 53 in 85 % of the cases according to the series. Through a series of six scoliosis out of 16 vertebral Osteoid Osteoma, we study the particularities of the scoliosis associated to the Osteoid Osteoma. Material and methods: We studied the files of 16 patients presenting Osteoid Osteoma of the spine brought together over a period of 27 years. The study of the files allowed retrieving the epidemiological, clinical and radiological particularities of the Osteoid Osteoma at the level of the rachis. The scoliosis was particularly studied to determine these clinical and radiological characteristics and its evolution after the treatment of the Osteoid Osteoma. Results: The study concerned 11 men and 5 middle-aged women of 18,5 years with extremes from 8 to 50 years. The pain was a constant reason for consultation. The rachidian stiffness was noticed with all patients. A spine curve was found in six cases. Three patients presented a scoliotic attitude and three female patients presented a structural scoliosis with a hump. The standard radiography showed a located sclerosis with a one-eyed peduncle in 15 cases and was considered normal in 1 case. The scintigraphy, practiced to 4 of our patients, showed a hyperfixation. The scanning is the examination of choice to direct the diagnosis and locate the Osteoid Osteoma. The tumor sat in the cervical level in 3 cases, thoracic in 3 cases, lumbar vertebra in 8 cases and sacral in 2 cases. The lesion was pedicular in 6 cases, laminar in 7 cases, articulair in 1 case, and corporeal in only 1 case. The treatment was always surgical by doing the posterior way in 15 cases and the anterior way in a case for the corporeal Osteoid Osteoma of T5. The anatomopathologic examination confirmed the diagnosis in all cases. Three cases required stabilization with transplant: 2 for a resection considered very wide and one for a correction of a structural scoliosis. All our patients saw their pains disappearing 24 hours after the resection. The improvement of the disorders of the static vertebral with disappearance of the stiffness and the deformity was seen on average 7 months after surgery. In the follow-up of 5 years 5 months on average, all our patients are satisfied with disappearance of the pain. We noted a case of pseudoarthrosis of the transplant. Conclusion: The Osteoid Osteoma is a painful mild osseous tumor, the diagnosis of which is classically difficult. It must be evoked in front of a stiff and painful rachis with sometimes a spine curve. The resection of the Osteoid Osteoma allows generally a spontaneous correction of the scoliosis.

Stress fracture of the femoral neck in child with negative bone scintigraphy. H. EZZINE1; M. KHELIFI1; M. SMIDA1; M. BEN HASSINE2; W. DOUIRA2; F. BEN SLIMEN3; M. BEN GHACHEM1.
1 2

Department of Pediatric Orthopaedics - Tunis Childrens Hospital. Tunis - Tunisia Department of Pediatric Radiology - Tunis Childrens Hospital. Tunis - Tunisia 3 Department of Nuclear Medicine - Salah AZAIZ Institute. Tunis - Tunisia Stress fracture of the femoral neck in skeletally immature children is a rare event and only few cases (< 15 cases) have been reported. We present in this paper, the case of 8-year-old boy who sustained a compression-sided femoral neck stress fracture. Initial plain radiographs showed an area of sclerosis along the inferior margin of the femoral neck. The technetium bone scan was negative. MRI was performed later and discovered a femoral neck stress fracture on the compression side. The treatment consisted on restriction of sport activities and walking with crutches. One year late, the patient was asymptomatic and had returned to full activities and there was radiographic evidence of healing of the fracture. This rare and particular clinical observation will be presented with a review of literature.

Vertebral aneurysmal bone cyst. Report of 4 cases. K. Amara*, W. Saied*, W. Douira**, H. Safi*, S. Bouchoucha*, C. Jalel*, MN. Nessib*, C. Ammar*, M. Smida*, I. Bellagha**, M. Ben Ghachem* *: Department of orthopedic surgery, children Hospital, Tunis **: Department of radiology, children Hospital, Tunis

Introduction: Aneurysmal bone cyst (ABC) is an aggressive fast-growing benign tumor. ABC is mainly located in long bone and less frequently in the spine where spinal cord compression, nerve root irritation, scoliosis or instability may occur. The treatment consists on complete tumor resection which offers the best chance for cure. Other techniques could be used such as selective arterial embolization, radiotherapy or injection of ethibloc. Patients and methods: The authors reports four cases of spine ABC. The age of patients ranges between 6 to 12 years. Tow lesions are located in cervical spine (C2 and C7) and tow in the lumbar spine (L1 and L3). For all patients, the clinical presentation consists on pain and spinal cord compression. Diagnostic imaging by CT and MRI revealed an expansive osteolysis. All cases are treated successfully with curettage, decompression, and posterior arthrodeses. At lease four years later, neither recurrence nor sequels are noted. Discussion and conclusion: ABC is a benign but potentially devastating lesion account for 15% of primary tumors of the spine. Initially the lesion involves the posterior arch with an extension to the pedicle and the vertebral body. Neurological complications are frequent and urgent surgical removal is some times needed. MRI is the best exam to analyze the spinal cyst, to show bony walls and liquidliquid levels suggestive of ABC, to evaluate the tumor extension and to search spinal cord compression or nerve root irritation. Both surgical and non surgical management has been advocated for ABC. Surgery is the treatment of choice when stability of the spine is compromised and neurological signs are present. The potential for instability following surgical excision is high, so reconstruction and stabilization of the spine must be complete using bone graft with or without instrumentation. Selective arterial embolization can be used in some localization, for voluminous and very aggressive cysts or as preparation to surgery.

Extra-articular percutaneous excision of benign epiphyseal tumours in children K. AMARA1 ; M. KHELIFI1 ; M. SMIDA1 ; W. SAIED1; L. BEN HASSINE2 ; H. LOUATI2 ; M. IDRISS3 ; S. SASSI3 ; M. BEN GHACHEM1
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Department of Pediatric Orthopaedics - Tunis Childrens Hospital. Tunis - Tunisia Department of Pediatric Radiology - Tunis Childrens Hospital. Tunis - Tunisia 3 Department of Pathology - Salah Azaiz Institute. Tunis - Tunisia. Standard treatment of benign epiphyseal tumors consists of thorough curettage of the lesion, followed by optional bone grafting. Objective: To report 5 cases of benign epiphyseal tumors excised, using a technique of percutaneous extraarticular curettage. Patients: Five children, 3 boys & 2 girls (8 - 13 years), were presenting painful epiphyseal tumors with decreased joint function (four superior femoral epiphysis [3 chondroblastomas & 1 aneurysmal bone cyst] & one superior tibial epiphysis [chondroblastoma]). Excision of the tumors was done by extra-articular percutaneous approach to avoid difficulties of these particular epiphyseal sites and disadvantages of joint opening. Technique: Under radioscopic control, a retrograde guide pin is drilled from the metaphyseal cortex into the tumor within the epiphysis (step 1). A tunnel with sufficient diameter is drilled over the pin using a cannulated drill (step 2). Curettage-biopsy of the tumor is performed by curved curettes (step 3). The residual cavity is then packed with bone graft. Results: At late follow-up, all children were free of pain with normal joint function and radiographs documented complete healing with no recurrence. In the case of superior femoral epiphysis chondroblastoma, precocious iatrogenic epiphysiodesis was happened. Discussion: Chondroblastoma and aneurysmal bone do not undergo spontaneous resolution if left untreated. The extra-articular approach for excision of epiphyseal benign tumors offers several advantages but it has also disadvantages. In spite of our small experience, we believe that extra-articular percutaneous excision of benign epiphyseal tumors is safe, effective and curative technique.

Children muscle avulsion. Report of three cases. L. DAMAK1 ; M. SMIDA1 ; A. GAALICHE1 ; CH. JALEL1; L. BEN HASSINE2 ; W. DOUIRA2 ; M. BEN GHACHEM1
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Department of Pediatric Orthopaedics - Tunis Childrens Hospital. Tunis - Tunisia Department of Pediatric Radiology - Tunis Childrens Hospital. Tunis - Tunisia

The sport of high level is done at ages more and more young exposing children to accidents. The muscle avulsion interested, in the immense majority of cases, apophyseal inserts because of their low resistance. But metaphyso-diaphyseal avulsions inserts represents a rare and special entity. Cases report: We are presenting three cases of muscle avulsion among three children aged respectively 4, 10 and 13 years presenting lateral vastus in one case and adductor insertion avulsion in two cases. The X-Rays has shown a periostal bone reaction below the great trochanter in the first case and in the medial side of femur in the other two cases. In the first case, a surgical biopsy was done to eliminate tumoral lesion. Discussion: The avulsion muscles represent a specific entity of high level sports after a long period of solicitations. In literature, this injury has been rarely reported in children. It interests particularly the insertion one of the adductors muscles and no cases of proximal lateral vastus avulsion have been found. Diagnosis delay is due to a non specific clinical examination. Radiological images show a periosteal reaction without traumatic or septic context. Tumoral aetiology remains the primary diagnosis to eliminate.

Post-traumatic sterno-clavicular dislocation in the childhood. About one case A. MAHMOUDI; M. RAMI; K. KHATTALA; A. ELMADI ; L. CHATER; M. LECHQAR; K. ATARRAF; M.ARROUD ; A. AFIFI; Y. BOUABDALLAH Pediatrics Surgery Department, University Hospital Hassan II of Fez, Morocco. Introduction: The sterno-clavicular dislocation is a rare disease in the childhood, which would be of orthopaedic or surgical management, and is generally of good prognosis. Case report: A young child aged of 14 year-old having sternoclavicular dislocation since the age of 4 year-old, who presented 2 months before hospitalization pain of the right sternoclavicular articulation associated with paresthesis of the upper right limb, physical examination pointed out an instable articulation. Radiographic workshop found an articular diastasis. The patient had been operated by performing pinning of the sternoclavicular articulation, the postoperative course was uneventful. La luxation sterno claviculaire, pathologie rarissime chez lenfant, pose problme de prise en charge avec des difficults opratoires quand lindication est pose. Conclusion: The sternoclavicular dislocation, rare disease in the child, may be challenging when the surgical management is decided.

Traumatic hip dislocation in children. ZRIG Makram, MNIF Hichem, NEJI Nabil, HAMMOUDA Imed, ALOUI Issam, ALLAGUI Mohamed, HAMDI Mohamed Faouzi, KOUBAA Mustapha, ABID Abderrazak. Department of Orthopaedic and Traumatic Surgery, Fattouma Bourguiba Hospital, Monastir, Tunisia. Introduction: Traumatic hip dislocation in children is rare. It is a serious injury with potentially catastrophic consequences such as avascular necrosis. Appropriate evaluation and treatment are necessary to avoid such complications and to optimize patient outcomes. Material and methods: We treated 5 boys between 3 and 14-years-old during 1995 to 2005. The dislocations were unilateral and occurred from minimally traumatic event. All had Thompson and Epstein Type I posterior dislocation of hip without any associated fracture. Closed reduction was performed under general anaesthesia in all cases. Time to reduction was less than 6 hours in 4 cases. After reduction, traction was performed in all children, for 21 days on average. Results: At mean 7 years follow-up, all hips are considered normal clinically. Standard radiographs of all children were normal. Discussion: Traumatic dislocation of the hip differs from injury in adults because it requires less force to produce dislocation and has fewer associated injuries. The diagnosis of posterior dislocation of hip is made promptly by recognition of classical deformity of flexion, adduction, and internal rotation. It is not uncommon to see delayed or missed diagnosis. The vast majority of hip dislocations in children can be managed by closed manipulation and reduction under sedation or general anaesthesia followed. Avascular necrosis of the femoral head is the most serious complication that can occur after traumatic hip dislocation in childhood and accounts for the poor prognosis of this injury. Risk factors are prolonged interval before reduction, older age and the presence of fracturedislocations. Affected children should be followed regularly until skeletal maturity since abnormalities in the development of the hip may only manifest years later.

Mitkovic's external fixator (cd) in the treatment of humeral abbreviation Gajdobranski Dj1, Mitkovic M2, Petkovic L1, Tatic M1, Mikov A3, Marcikic A1. Clinic of Pediatric Surgery1; Clinic of Orthopedic and Traumatology Nis2; Clinic of Pediatric Rehabilitation3. Institute for Children and Youth Health Care of Vojvodina, Novi Sad, Serbia Limb length discrepancy in the childhood is caused for the two group of reason: abbreviation due to slowly growth and elongation due to growth stimulation. As length discrepancy of lower extremity has influence on gait mechanism and disturbed forces in spine and joints of lower extremity, surgical treatment is recommended. However, abbreviation of upper extremity has esthetic and forensic value so the surgical treatment is rare. The aim of this paper is to represent a method of distraction osteogenesis in treatment of upper arm using Mitkovic's CD distracter. In treatment of children with limb discrepancy, we use Mitkovic's CD distracter for transosseal distraction osteogenesis since 2000. Distracter application technique is the same as for external fixation and includes corticotomy in the metaphysis region. We represent a 17 years old boy with abbreviation of right upper arm in length of 9cm after surgical treatment of solitary bone cyst in proximal part of humerus. The functional and esthetic result of this method of treatment is excellent. Mitkovic's CD distracter provides limb elongation without limits and also offers a great possibility for correction. This surgical procedure is minimally invasive and is followed by shortness hospital stay, functional activity of the arm from second postoperative day and reduction of life and work ability with small rate of complication. Distraction process is very simply and it is easy to realize by patients or parents.

Soft tissue cartilaginous tumors in children. Report of 3 cases. A. GAALICHE1 ; M. SMIDA1 ; L. DAMAK1; N. NESSIB1; H. LOUATI2 ; M. IDRISS3 ; S. SASSI3; L. BEN HASSINE2 ; M. BEN GHACHEM1
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Department of Pediatric Orthopaedics - Tunis Childrens Hospital. Tunis - Tunisia Department of Pediatric Radiology - Tunis Childrens Hospital. Tunis - Tunisia 3 Department of Pathology - Salah Azaiz Institute. Tunis - Tunisia. Soft tissue cartilaginous tumors are rare and often seen in adults. We report here three pediatric cases. The first is a soft tissue chondroma of the posterior aspect of the left axilla in a 3-year-old boy. CT scans showed a spherical fatty density soft tissue mass without evident calcifications, attaching the infraspinous muscle. The second patient is a 9-year-old girl presented with a right auricular finger soft tissue chondroma. Radiographs showed several punctuated calcifications with adjacent bone scalloping. MRI revealed a lobulated soft tissue mass attaching the flexor tendons. The tumours were entirely removed. At follow-up, the patients had good functions without evidence of recurrence. The third patient is a 12-year-old boy presented with a left shoulder region chondrolipoma. MRI suggested the diagnosis by showing double fatty and cartilaginous structures of the tumor. The tumours were entirely removed. At follow-up, the patients had good functions without evidence of recurrence.

Monteggia fracture dislocation associated with ipsilateral distal radial metaphyseal fracture. A case report A. GAALICHE; M. SMIDA; K. AMARA ; W. SAIED; M. BEN GHACHEM Department of Pediatric Orthopaedics - Tunis Childrens Hospital. Tunis - Tunisia The association of a Monteggia fracture dislocation and a lesion of the lower extremity of the radius is very rare and there are few reported cases in the literature. Combined Monteggia injury and isolated metaphyseal fracture of the radius in the same forearm had never been described. Case report: An eleven-year-old boy fell from a height of about one meter and sustained an injury of the left forearm. When the child was firstly seen, he had a severe volar angular deformity in the distal part of the forearm without any neurovascular deficit or cutaneous lesion. Roentgenograms showed an anterior dislocation of the head of the radius and a fracture of the middle third of the ulnar diaphysis with volar angulation. In addition, there was a fracture through the radial metaphysis with posterior displacement but without dislocation of the distal radio-ulnar joint. Adequate reduction of both fractures was obtained under general anaesthesia and the extremity was immobilized in a plaster cast and bone union had occurred.

Infantile digital fibromatosis - report of 6 cases. H. EZZINE1; M. KHLIFI1; M. SMIDA1; S. BOUCHOUCHA1; M. IDRISS2; S. SASSI2; M. BEN GHACHEM1
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Service dOrthopdie de lEnfant et lAdolescent. Hpital dEnfants de Tunis. Laboratoire de Cytologie et dAnatomopathologie. Institut Salah AZAIZ.

Infantile digital fibromatosis (IDF) is a rarely encountered benign fibrous tumor. The are approximately 100 case reports in literature. IDF is seen in infants and young children but often appearing during the first 2 years of life. Occurring typically on fingers and toes, the lesions may be solitary or multiple appearing together. Spontaneous regression is possible and surgery is needed when diagnosis is not certain or when the overgrowth of the digital mass is deranging esthetically or functionally. However, the recurrence after removal is frequent. Histopathology is pathognomonic. In this work, the authors will report their experience on 6 cases of IDF collected in the Pediatric Orthopedic Department of Tunis Children Hospital from 1990.

A soft tissue pseudotumor. A case report of calcinosis cutis and review of the literature. L. DAMAK; H. EZZINE; M. SMIDA; S. BOUCHOUCHA; M. BEN GHACHEM Department of Pediatric Orthopaedics - Tunis Childrens Hospital. Tunis - Tunisia Calcinosis cutis, an uncommon disorder, may be classified as idiopathic, metastatic or dystrophic. It has been often described in adults. Here we describe a case of a neonate who developed a dystrophic calcinosis cutis of her left ankle few days after receiving calcium gluconate by an intravenous administration for neonatal hypocalcaemia. The patient was addressed to our department with a suspected diagnosis of tumoral calcinosis, a rare benign soft tissue pseudotumor. Pathophysiological mechanisms, the course, prevention and differential diagnosis of this condition are discussed.

Acrochordon of limbs. About a geant pediatric case K. AMARA1 ; M. SMIDA1 ; L. DAMAK1 ; H. SAFI1; L. BEN HASSINE2 ; H. LOUATI2 ; M. IDRISS3 ; S. SASSI3 ; M. BEN GHACHEM1
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Department of Pediatric Orthopaedics - Tunis Childrens Hospital. Tunis - Tunisia Department of Pediatric Radiology - Tunis Childrens Hospital. Tunis - Tunisia 3 Department of Pathology - Salah Azaiz Institute. Tunis - Tunisia. Acrochordon is a benign soft tissue tumor, affecting preferentially eyelids, neck, armpits and regions under breast. The localization in lower limbs is exceptional. Affecting particularly obese patients, the size tumor doesnt exceed 3cm. Case report: A child of 13 years comes with a skin tumour measuring 6/4 cm, painless with a large base implementation. MRI finds a fatty tumor without deep plans invasion. A complete tumoral remove has been achieved. The histological study highlights an acrochordon in its lipomatous variant. Discussion: The localization of this tumor at the lower limbs, as well as its appearance in a child poses a diagnosis problem. A single case of acrochordon of lower members has been found in literature. The acrochordon is often associated with metabolic disorders or with diabetes mellitus that we should look for. Finally other skin lesions must be searched. Conclusion: This observation is exceptional as well by localization, size and age of occurrence of this tumor. Malignancy procession is an obsession, particularly in the rare location.

Synovial hemangioma of the knee in an 8-year-old boy. MNIF Hichem, ZRIG Makram, ZAMMEL Nizar, SALLAMI David, ALLAGUI Mohamed, ALOUI Issam, MOUSSA Adnene*, KOUBAA Mustapha, ZAKAMA Abdelfateh*, ABID Abderrazak. Department of Orthopaedic and Traumatic Surgery, Fattouma Bourguiba Hospital, Monastir, Tunisia. Introduction: Synovial hemangioma is a rare intra-articular benign tumor that is difficult to diagnose because of its nonspecific symptoms. The condition is very rare in children. We report a case of a boy affected by an intra-articular synovial hemangioma of the knee. Case presentation: An 8-year-old boy presented with a 2-years history of recurrent pain and swelling in the right knee. Physical examination revealed a small painful point adjacent to the lateral side of the patella. Magnetic resonance imaging (MRI) revealed an intra-articular circumscribed tumor. The biopsy confirms the diagnostic of synovial hemangioma. Open complete resection of the circumscribed capillary hemangioma was performed. After a follow-up of 24 months, no evidence of recurrence was seen controlled by MRI and the physical examination of the knee showed normal results. Discussion: Synovial hemangioma is a benign vascular tumor. While mainly affecting the knee, it can also appear in other joints or tissues. A delayed diagnosis is common and due to its unspecific clinical presentation. Final diagnosis can only be obtained with histological examination, although MRI may be useful and arteriography clearly reveals it, if the lesion is extended enough and communicating with the circulation. Treatment is surgical and it consists in complete removal when possible of the hemangioma. The results, particularly in the localized form, are satisfactory; recurrence is infrequent and it is generally due to incomplete excision of the tumor.

Osteogenesis Imperfecta Tarda. A case Report Bahri M, Bellassoued A, Aguir Z, Kahlaoui N, Ladhari M, Essafi Y, Bouferes R, Gavrilov V Orthopaedic Department - Ibn El Jazzar. Kairouan Hospital. 3100 Kairouan-Tunisia. E-mail : bahrimhamed@yahoo.fr The osteogenesis imperfecta known also as "LOBSTEIN" disease is a genetic disease with dominant hereditary transmission. Osteogenesis imperfecta is characterized by the osseous fragility, which causes increasing severe deformities in patients. It affects children and it regresses by puberty. The osteoporosis is responsible for the osseous fragility, which accounts for the frequent fractures even following minor accidents (glass bone disease). We report a particular observation of 16 year old adolescent boy who presented with tardy form of osteogenesis imperfecta. He was treated by intra -medullary nailing. A review of the literature was done.

Fibrous dysplasia at the level of the clavicle. Jenzri M, Ben Hmida MK, Abid A, Hadidane R, Daghfous MS., Zouari O. Infantile Orthopedic Department Kassab Institution Tunis- Tunisia It is about a 12 years old girl, who was hospitalized due to a tumefaction and pains at the level of the internal 1/3 of the left clavicle evolving since 5 months, without the notion of traumatism. Clinical exam: Absence of inflammatory signs facing the tumefaction and the mobility of the shoulder is complete and painless. Rx: Lytic image for the internal 1/3 of the left clavicle with geographic contours. TDM: Aspect in favor of a tumor benign with a vascular cartilaginous component. Surgery: Resection in bloc of the tumor and preserving the internal clavicle epiphysis, reconstruction by a tibial graft. Macroscopy: A clavicle segment which measures 3x2x1,7 cm. The portion shows a white formation not well limited with a firm consistency. The cortical is thin. Besides, we note the presence of small cystic with a haematic containing. These histological aspects evoke the diagnosis of a fibrous dysplasia associated to an aneurismal cyst. The surgical consequences are favourable in 6 months with consolidation of the tibial graft. We discuss in this work, the histological type of the tumor and the undertaken therapeutic conduct.