[Retrotracheal left pulmonary artery: case report with an embryologic and anatomic update]

The accidental discovery of a retrotracheal left pulmonary artery in a 4-month-old infant encouraged us to review the various embryologic theories concerning this very rare anomaly and perform an anatomic update in order to better define surgical treatment. Nathan underwent surgery for a bilateral inguinal hernia at the age of 4 months. The postoperative period was marked by malaise associated with dyspnoea, stridor, tachycardia and sweating. A X-ray of the thorax, oesophageal transit and angio scan presented an intertracheo-oesophageal left pulmonary artery and a reimplantation of the left pulmonary artery was successfully performed. A retrotracheal left pulmonary artery is a very rare malformation. From development of pulmonary vascularisation, three embryologic theories have been advanced to explain this anomaly. From an anatomic point of view, Landing et al. proposed in 1982 a classification system of retrotracheal left pulmonary artery. Today, current radiological techniques not only provide a precise diagnosis but also make it possible to define appropriate care for the different types of this malformation.

Congenital anterior urethrocutaneous fistula associated with a stenosis of the bulbar urethra in the context of high anorectal malformation without fistula

SUMMARY

Congenital anterior urethrocutaneous fistulas are infrequent. We report a case of a congenital anterior urethrocutaneous fistula associated with a stenosis of the bulbar urethra in the context of a high anorectal malformation. We describe the surgical technique for the reconstruction of the urethra.

Relationships of the palmar cutaneous branch of the median nerve: a morphometric study

Treatment of carpal tunnel syndrome consists in decompression of the median nerve by section of the flexor retinaculum. Usually, this surgery improves the disease with disappearance of the symptoms. However, some painful sequelae may remain such as painful discharges, paresthesiae or permanent anesthesia of the base of the thumb or of the scar related to an injury of the palmar cutaneous branch of the median nerve (PCBm). This study was performed to define the accurate emergence and the anatomic characteristics of this nerve in relation to stable landmarks. Moreover, it assessed the importance of the visual identification of the branch during section of the flexor retinaculum. Thirty-five hands were dissected under macroscopic examination and under magnification of the thinnest branches. Measurements were performed with a caliper and the forearm in supination. Determination of the bistyloid line showed variability in the location of the distal wrist crease. Thus, it could not be used as a landmark to locate the PCBm. The palmar cutaneous branch is the distal collateral branch of the median nerve in the forearm. It emerges on its radial side, on average 44.3 mm before the bistyloid line. It courses in line with the third finger and perforates the antebrachial aponeurosis about 5.7 mm from the bistyloid line. This emergence can be located in the palm, where it can be injured if the incision is performed in line with the third finger. The PCBm usually ends in the palm by division into two or three branches. The lateral branch supplies the skin of the thenar eminence while the medial, usually shorter branch supplies the midline part of the palm. This study has shown the importance of performing the cutaneous incision in line with the fourth finger to avoid injury to the PCBm.

Relationships of the palmar cutaneous branch of the median nerve: a morphometric study

Treatment of carpal tunnel syndrome consists in decompression of the median nerve by section of the flexor retinaculum. Usually, this surgery improves the disease with disappearance of the symptoms. However, some painful sequelae may remain such as painful discharges, paresthesiae or permanent anesthesia of the base of the thumb or of the scar related to an injury of the palmar cutaneous branch of the median nerve (PCBm). This study was performed to define the accurate emergence and the anatomic characteristics of this nerve in relation to stable landmarks. Moreover, it assessed the importance of the visual identification of the branch during section of the flexor retinaculum. Thirty-five hands were dissected under macroscopic examination and under magnification of the thinnest branches. Measurements were performed with a caliper and the forearm in supination. Determination of the bistyloid line showed variability in the location of the distal wrist crease. Thus, it could not be used as a landmark to locate the PCBm. The palmar cutaneous branch is the distal collateral branch of the median nerve in the forearm. It emerges on its radial side, on average 44.3 mm before the bistyloid line. It courses in line with the third finger and perforates the antebrachial aponeurosis about 5.7 mm from the bistyloid line. This emergence can be located in the palm, where it can be injured if the incision is performed in line with the third finger. The PCBm usually ends in the palm by division into two or three branches. The lateral branch supplies the skin of the thenar eminence while the medial, usually shorter branch supplies the midline part of the palm. This study has shown the importance of performing the cutaneous incision in line with the fourth finger to avoid injury to the PCBm.

Vertebral pedicle anatomy in relation to pedicle screw fixation: a cadaver study

New techniques to stabilize and correct the thoracic and lumbar spine have been developed in recent years. In view of the wide variety and complexity of fixation devices, the optimum configuration of spinal instrumentation systems needs to be defined. Linear and angular measurements of both vertebral pedicles were made in ten complete thoracic and lumbar cadaveric spines using callipers and a goniometer. The vertical interpedicular distance gradually increased along the spine up to L5. The transverse interpedicular distance was larger at both ends of the spine. Pedicular height gradually increased from T1 to L5, plateauing between T3 and T9, being widest at the thoracolumbar junction. Pedicular width was greatest at the three junctional regions of the spine. The sagittal pedicular angle decreased along the length of the spine to zero at L5. The transverse pedicular angle decreased from T1 to T12 and then increased to L5. Of the pedicular measurements only width limits the diameter of fixation screws. The vertical interpedicular distance determines the distance between the holes of plates, while the length of the transfixator is related to the transverse interpedicular distance. The pedicular angles enable triangulation of screws and determine the stability of the fixation.

Functional anatomy of the medial ligamentous complex of the elbow. Its role in anterior posterior instability

The question remains unanswered regarding the role of repair of medial ligament injuries associated with subluxation of the elbow and non-reconstructable radial head fracture and whether or not this will decrease the risk of chronic instability and cubitus valgus. The goal of this study was to define the role of the medial ligamentous complex of the elbow in elbow instability and to describe the anatomy of the complex in 35 fresh-frozen cadaver elbows. We documented medial ligamentous complex anatomy and compared our results to those in the literature. 25 elbows were dissected in order to describe the different bundles of the medial ligament complex and to precise the positions of the elbow that placed each in tension; section of the different ligamentous bundles was done to study the role of each in elbow stability. 10 other elbows were dissected and used for the ligamentous section studies which were performed subcutaneously. We found two bundles at the level of the anterior portion and termed them superficial and deep. Section of the anterior bundle lead to posterior subluxation of the elbow at 30-100 degrees flexion in both supination and pronation. Posterior subluxation was obtained after an anterior capsulotomy; medial epicondylectomy did not compromise the stability of the elbow after a complete section of the insertion of the deep fibers of the anterior bundle. Elements thus required for stability of the elbow are integrity of the articular surface of the humerus and the ulna, and the anterior bundle of the medial ligamentous complex.

Contribution to the study of the venous vasculature of the penis

The penile veins are thought to be responsible for some erectile disorders. The aim of this study was to describe the anatomy and function of these veins. The venous systems of 25 cadaveric penises were studied by various anatomic and histologic techniques. The superficial veins arising from the tegumentary layers drain into the superficial dorsal vein which in three-quarters of cases empties into the left great saphenous vein. The veins of the deep internal system, running below the deep fascia of the penis, emerge from the erectile bodies and can be divided into two systems, one anterosuperior and the other posteroinferior. The anterosuperior system comprises the veins of the glans which will form the deep dorsal vein; the latter receives blood from the medial portion of the corpus spongiosum and from the free portion of the corpora cavernosum mainly via the circumflex veins. It ends in the pre-prostatic plexus. The posteroinferior system, issuing from the posterior portion of the erectile bodies, is composed of the bulbar, cavernous and crural veins which drain towards the pre-prostatic plexus and the internal pudendal veins. Anastomoses link the two networks, superficial and deep. Study of the structure of the veins of the deep system reveals the presence of muscular cushions, which we have shown to have adrenergic innervation. These findings are compared with those of the literature, which show variations which are mainly of number. The place of veins in the mechanism of erection is discussed.

Molecular biology and pharmacology of multiple NPY Y5 receptor species homologs

NPY is a 36-amino acid peptide which exerts its physiological effects through the activation of a family of G-protein coupled receptors. In vivo and in vitro characterization of the recently cloned rat Y5 receptor suggests that it is a primary mediator of NPY-induced feeding (Gerald et al., Nature 1996;382:168-171). We now report the molecular cloning and pharmacological characterization of the human, dog and mouse homologs of the Y5 receptor. With the exception of a 21 amino acid repeat in the amino terminus of the mouse Y5 receptor, the sequence of the four species homologs appear to be highly conserved, with 88% to 97% amino acid identities between any two species. Similarly, the pharmacological profiles of the four species homologs as determined in porcine 125I-PYY binding assays show a great deal of conservation, with the following rank order of affinity: human or porcine NPY, PYY, [Leu31,Pro34]NPY, NPY(2-36), human PP > human [D-Trp32]NPY > rat PP, C2-NPY. Northern blot analysis reveals that the Y5 receptor is widely distributed in the human brain, with the strongest signals detected in the cortex, putamen and caudate nucleus. The chromosomal localization of the human Y5 receptor, previously shown to be overlapping and in the opposite orientation to the Y1 receptor, is determined to be 4q31, the same locus as previously demonstrated for the human Y1 receptor (Herzog et al., J Biol Chem 1993;268:6703-6707), suggesting that these receptors may be coregulated. These Y5 species homologs along with corresponding animal models may be useful in the search for novel therapeutics in the treatment of obesity and related feeding disorders.

Microsurgical anatomy of the internal vertebral venous plexuses

Few studies have been done about the venous vascularization of the spine since neuroradiologic studies in the 1960s and 70s. The aim of this study was to clarify the topography of the internal vertebral venous plexuses in relation to the posterior longitudinal ligament and the dura. The relationships of the vv. were studied at different levels of the spine. The internal vertebral venous system of seven cadavers was injected with a blue bicomponent silicon rubber. It consisted with an anterior and a posterior venous plexus. At the cervical level, the anterior longitudinal vv. are located in a dehiscence of the periosteal layer, in the lateral part of the spinal canal. At each level, they joined the contralateral one at the midline by a retrocorporeal v. located behind the posterior longitudinal ligament. No vv. were found in the epidural space. There was a major development of the retrocorporeal v. of the axis, but it did not receive any venous drainage from the vertebral body. At the thoracic and lumbar levels, the anterior venous plexuses remain within a dehiscence of the periosteal layer, which is thinner. The retrocorporeal vv. become pre-ligamentous. We did not find any posterior venous plexuses at the cervical level, but they were evident at the thoracic level and became more voluminous and sinusoidal in the lumbar region.

Uncommon complication of gastric duplication in a three-year-old child

We describe a very uncommon case of gastric duplication with heterotopic pancreas suggested by an acute pancreatitis and complicated by pseudocyst formation. Diagnostics, hypothesis and management are discussed.

[Utilization of thermosettable compounds in anatomic research]

The authors described a method of vascular injection with a coloured silicon rubber. The injected material was a biocomponent silicon elastomer, with ambiant temperature room vulcanizing. It was supple, easily dissequable and diffuse well into all small caliber vessels. The soft pressure injection did not cause neither material collection by vessels rupture nor anatomic structure distortion. This material could constitute an excellent alternative to coloured latex injection.

A receptor subtype involved in neuropeptide-Y-induced food intake

Neuropeptide Y (NPY) is a powerful stimulant of food intake and is proposed to activate a hypothalamic 'feeding' receptor distinct from previously cloned Y-type receptors. This receptor was first suggested to explain a feeding response to NPY and related peptides, including NPY2-36, that differed from their activities at the Y1 receptor. Here we report the expression cloning of a novel Y-type receptor from rat hypothalamus, which we name Y5. The complementary DNA encodes a 456-amino-acid protein with less than 35% overall identity to known Y-type receptors. The messenger RNA is found primarily in the central nervous system, including the paraventricular nucleus of the hypothalamus. The extent to which selected peptides can inhibit adenylate cyclase through the Y5 receptor and stimulate food intake in rats correspond well. Our data support the idea that the Y5 receptor is the postulated 'feeding' receptor, and may provide a new method for the study and treatment of obesity and eating disorders.

[Retro-iliac ureter. Report of a case lumbosacral agenesis]

The authors report a case of retro-iliac ureter associated with a lumbo-sacral agenesis. Retro-iliac ureter seems in relation with abnormal constitution of aortic division and/or ilio-cava confluence when the metanephros migrates. Lumbosacral agenesis is the most severe state of sacral agenesis and is a part of the syndrome of caudal regression. The association of the two malformations have never been described and could be fortuitous. Nevertheless, the vertebral malformation could induce a perturbation in the formation of vascular structures and so an abnormal migration of the metanephros.

[3H]5-hydroxytryptamine labels the agonist high affinity state of the cloned rat 5-HT4 receptor

We have used the cloned rat 5-HT4 receptor, and determined that the single protein product produced is able to bind both [3H]5-HT and [3H]GR113808 ([1-[(2-methyl sulphonyl) amino] ethyl-4-piperidinyl] methyl-1-methyl-1H-indole-3-carboxylate) with high affinity. The affinities of agonists for the [3H]5-HT (agonist)-labelled receptor were significantly higher than for the [3H]GR113808 (antagonist)-labelled receptor. Furthermore, [3H]5-HT binding was reduced by addition of guanyl nucleotides. These results strongly support the hypothesis that the 5-HT4 receptor displays two interconvertible affinity states (high and low) for agonists, characteristic of many G protein coupled receptors. [3H]5-HT, at the concentration employed, therefore labels the agonist high affinity state of the 5-HT4 receptor in systems in which high densities of this receptor are found.

Abdominal cystic lymphangioma in children: benign lesions that can have a proliferative course

Twenty-one pediatric cases of abdominal cystic lymphangioma (CL) treated in the past 20 years are reviewed. To date, this is the largest reported series. CL is a rare congenital malformation that presents either with chronic abdominal distension (and is detected by palpation of a cystic mass) or acutely with bowel obstruction or signs of peritonitis. It is more common among boys and most often occurs in children under 5 years of age. Abdominal ultrasonography is the procedure of choice for establishing the diagnosis. Acute cases with intracystic hemorrhage are more difficult to diagnose. Computed tomography and celioscopy may be useful. With these techniques, a correct diagnosis should be achieved in nearly every case. Enucleation (when feasible) or segmental intestinal resection (when the cyst is intimate to the bowel) is effective treatment. In a few cases the malformation is diffuse, and extensive bowel resection is necessary, with the risk of short bowel syndrome.

Laparoscopy and impalpable testis--a prospective multicentric study (232 cases). GECI. Groupe d'Etude en Coeliochirurgie Infantile

The value of laparoscopy in managing the impalpable testis remains controversial. Several reports have been published on this topic but series are usually short and rather heterogeneous in their presentation, so that critical analysis is not easy to perform. Therefore, the Groupe d'Etude en Coeliochirurgie Infantile started a multicentric prospective study in May 1991 with two objectives: what are the laparoscopic findings and what are the correlations between laparoscopy and surgery? In addition, this study tried to estimate the therapeutic implications. Two hundred and one boys underwent laparoscopy accounting for two hundred and thirty-two impalpable testis. Laparoscopic findings were mainly of three types: intra-abdominal testis (36%), abdominal blind ending cord structures (14%) and cord structures entering the deep inguinal ring (49%); rarely, there was absence of testis and cord structures (1%). Crossed testicular ectopia was not found in this series. One hundred and eighty-seven impalpable testis were operated on to control laparoscopic findings and correlations laparoscopy-surgery were excellent provided that laparoscopic exploration could be entirely performed in good conditions. Moreover, it could be evaluated that forty-seven per cent of impalpable testes could take advantage of laparoscopy.

Laparoscopic appendicectomy: case reports of vascular injury in 2 children

The authors report 2 similar cases of serious vascular injury occurring during laparoscopic appendicectomy. These cases stress the potential risk of major accidents with laparoscopic surgery. There should be great care in the choice of indications and during the procedures.

Contribution to the study of the tributaries and the termination of the external jugular vein

The dissection of 100 external jugular veins in 50 cadavers was the object of this anatomic study. A certain number of notions concerning the afferent veins, the mode of termination and the valvular system of this vessel were defined. 1) Afferent veins. Along its pathway toward the deep venous system, the external jugular vein successively received: the transverse cervical vein in 88 cases (88%), usually opposite the intersection of the external jugular vein with the dorsal border of the sterno- cleidomastoid muscle; the suprascapular vein in 47 cases (47%); the anterior jugular vein in 46 cases (46%); the cervical vein or anastomosis with the latter in 13 cases (13%). 2) Mode of termination. Forty-three subjects presented a symmetric mechanism. 100 anastomoses can be classed into three types: in 60 cases (60%), the external jugular vein flowed into the jugulo-subclavian venous confluence; in 36 cases (36%), in to the subclavian vein at a distance from its junction with the internal jugular vein; in 4 cases (4%) in to the trunk of the internal jugular vein. 3) Study of the valves. There were studied in 25 subjects (50 external jugular veins). The valves were found in the ostial and paraostial position in 49 out of 50 veins.

Cloning of a novel human serotonin receptor (5-HT7) positively linked to adenylate cyclase

An intron-containing gene encoding a novel human serotonin (5-HT) receptor was isolated from human genomic and cDNA libraries with probes directed to transmembrane regions of the adenylate cyclase stimulatory Drosophila serotonin receptor gene, 5-HTdrol. Membranes harvested from transiently transfected Cos-7 cells displayed high affinity (Kd = 8.5 nM), saturable (Bmax = 6.6 pmol/mg protein) [3H]5-HT binding. The rank order of potencies for serotonergic ligands to displace specific [3H]5-HT binding was: 5-carboxamido-tryptamine > methiothepin > metergoline > 5-HT > 8-hydroxy-2-(di-n-propylamino)tetralin > sumatriptan > ketanserin > zacopride. 5-HT produced a dose-dependent (EC50 = 992 nM) stimulation (approximately 20-fold) of cAMP accumulation in transiently transfected cells, and this response was antagonized by the nonselective 5-HT antagonist methiothepin. RNA for this gene was predominantly detected in the human brain and a subset of peripheral tissues including coronary artery and several tissues of the gastrointestinal tract. The molecular biological and pharmacological properties of this receptor suggest that it is the first member of a new serotonin receptor subfamily (5-HT7). The second messenger coupling, and tissue distribution indicate a possible identity to 5-HT receptors that mediate relaxant responses in certain isolated blood vessels.

[Malignant neonatal tumors]

Malignant neonatal tumors are rare (2% of childhood cancers, 1-2 cases/30,000 births). However, specificities in diagnosis and therapy must be underlined at this period of life; furthermore, the possibilities of antenatal sonographic diagnosis are improving and it may contribute to increase their incidence. Topographic analysis allows etiologic investigations since these tumors have the same diagnostic features as compared with older children, except Pepper's syndrome and leukemias. Therapeutic management depends on a rather good prognosis and fragility of such newborn. Indeed, surgical excision is the main step of treatment. Radiotherapy must be avoided whenever possible. Chemotherapy may be indicated (metastatic or unresectable tumors, omission or delay of irradiation in brain tumors) and has to be elaborated cautiously, according to the peculiar physiology of the neonate. Whatever the therapeutic strategy is, neonatal homeostasis must be well balanced, which implies a multidisciplinary specialized team. Respecting these conditions will help to cure more than the present 50% and better for future well being of such children.

Anatomic basis for use of a gracilis muscle flap

The aim of this study was to specify certain anatomic features of the gracilis m. with a view to the use of muscular or myocutaneous flaps. It was based on dissection of 84 gracilis muscles in 42 subjects as well as selective injection of the main pedicle of 20 muscles. This established the following points: 1) The arterial supply is abundant, consisting of several pedicles reaching the muscle on its deep aspect. The main neurovascular pedicle arises from the deep vessels of the thigh, via either the a. of the adductors (73%), the medial circumflex a. (19.2%) or as a double supply from both arteries (7.7%); 2) The cutaneous vascularisation over the gracilis m., derived from the solitary main pedicle, is inconstant. In 20 injections, it was satisfactory in 11 cases, poor in 5 and absent in 4; 3) The distal tendon of the gracilis m. is closely related to the posterior branch of the saphenous n. to the leg, which it crosses in an elongated X; 4) A simple method of calculation based on the distance between the upper border of the pubis and the medial femoral epicondyle allows quite precise determination of the point of entry of the main pedicle into the gracilis m. 5) Complete dissection of the main pedicle adds to the available length of the muscle flap.

Increase in testicular temperature in case of cryptorchidism in boys

Temperature of the undescended testis, measured in its cryptorchid location during surgical procedure for orchidopexy in 46 boys, 13- to 180-months-old, was significantly higher (34.4 +/- 0.9 degrees C) than that of the contralateral normally descended testicle (33.2 +/- 1.2 degrees C; P < 0.001). Temperature significantly declined from the Bogros' space (35.3 +/- 0.5 degrees C) to the inguinal canal (34.7 +/- 0.7 degrees C) and from the latter to the empty scrotal cavity (31.1 +/- 1.8 degrees C). The physiological descent of the testicle is associated with a marked cooling of its thermal environment. When this process is interrupted for any reason, temperature of the cryptorchid testis is significantly increased. This rise in temperature could be either a concomitant or a main factor for the impairement of testicular functions associated with cryptorchidism.

Pyloric obstruction with complicated pancreatic heterotopia

A case of pyloric obstruction associated with pancreatic heterotopia is described in an 18-day old child. The association of several pathologic processes like acute pancreatitis and abscess formation in the heterotopic mass and the long-term follow-up are the main points of interest in this report.

Fatty acid composition of adipocyte membrane phospholipids and stored triglycerides in infants receiving total parenteral nutrition

Fatty acid (FA) composition of membrane phospholipids (PL) and stored triglycerides (TG) from adipose tissue was studied in eight infants aged 1 to 4 months receiving total parenteral nutrition (TPN) since birth. During this period, essential fatty acid (EFA) intake consisted exclusively of soybean oil emulsion administered by intravenous route (Intralipid 20%) representing 301 +/- 88 mg/kg/24 hr of linoleic acid and 58 +/- 18 mg/kg/24 hr of alpha-linolenic acid, or 2.3 +/- 0.6% and 0.4 +/- 0.1%, respectively, of total energy intake. The results were compared with those of eight control infants of the same age receiving orally a normal milk diet with an intake of 660 +/- 260 mg/kg/24 hr of linoleic acid and 101 +/- 35 mg/kg/24 hr of alpha-linolenic acid, or 4.5 +/- 0.7% and 0.7 +/- 0.3%, respectively, of total energy intake. Although their EFA intake was significantly lower (p less than 0.01) and administered only parenterally, after 1 to 4 months the infants receiving TPN still had a membrane phospholipid FA pattern of adipose tissue which was not significantly different from that of normal children of the same age. In stored adipocyte TG, the percentage of linoleic acid was significantly lower (p less than 0.01) in infants receiving TPN. This is probably of nutritional importance as at this stage of life the child builds up its stores of EFA. The proportion of the other fatty acids in adipocyte TG was not significantly modified.

[Intra- and extra-pelvic venous connections. Anatomical study]

Regarding to clinical diseases, the authors emphasize the important part of pelvic veins as collateral flows when iliac channels are occluded. They point out the three mains streams of this collateral network: the obturator veins, the gluteal veins, and the pudendal veins. Longitudinal anastomoses are connected each other by transversal veins such as Santorini plexus, and sacral veins; they allow venous supply from one side to the other when two levels or more are involved.

The diagnostic value of acetylcholinesterase/butyrylcholinesterase ratio in Hirschsprung's disease

Aganglionosis of large bowel (Hirschsprung's disease; HD) is associated with higher acetylcholinesterase activity (AChE activity). Occasionally, especially in the neonatal period, the AChE activity may not be of diagnostic value. The authors previously reported that simultaneous estimation of butyrylcholinesterase activity (BChE activity) and the determination of AChE/BChE ratio may have discriminatory diagnostic value. They extended this finding to 31 cases of HD, in 16 of which resected tissue was available for study. All cases had histologic confirmation of aganglionosis. The AChE/BChE ratio was found to be higher than 2.0, with the exception of a case in which the biopsy weight was low (i.e., less than 3 mg), even when the AChE activity was normal or borderline. The estimation of AChE/BChE ratio is easy, rapid, and, in the author's experience, of discriminatory diagnostic value.

Cholinesterase activities in resected bowel specimens from children with Hirschsprung's disease

We have measured acetylcholinesterase (AChE) and the butyrylcholinesterase (BChE) activities along strips of resected bowel specimens from thirteen children with Hirschsprung's disease. The AChE activity was variable along the length of the resected bowel, while the BChE activity remained constant. By contrast, the AChE/BChE ratio decreased rapidly to low levels when ganglion cells were present. We suggest that this ratio can be used to determine the normal segments of the bowel, to specify the anatomic forms (i.e. rectal or rectosigmoid) and may be useful in determining the anastomotic level.

[Value of the assay of cholinesterase activity in superficial biopsies of the rectum in the diagnosis of Hirschsprung's disease]

Cholinesterase activity have been estimated in rectal biopsies of 19 children with Hirschsprung's disease and 80 normal children. A high level of acetyl-cholinesterase is a strong argument for the diagnosis of aganglionosis. However the ratio acetylcholinesterase over butyrylcholinesterase seems to be a better sign allowing a right diagnosis in 99% of the cases.

The ureterovesical junction

The ureterovesical junction was studied by dissection and serial sections in 50 post mortem specimens. Three points are considered in this paper: the structure of the terminal ureter, the anatomical arrangement of the ureteral hiatus and the ureteral sheath. Study of the structure of the intramural segment of the ureter demonstrated on one hand, the perfect continuity of the terminal ureter with the trigone and on the other hand, the abundance of the fibroelastic connective fibers which like the muscle fibers run longitudinally. The compliance of the intravesical ureter is dependent on the balance between these two components. The modification of this balance can lead to the creation of a functional obstacle. The anatomical arrangement of the ureteral hiatus is described. The inner muscle layer of the detrusor extends almost to the ureteral orifice, the truly submucosal part of the ureter thus being very small. The constitution of the ureteral orifice and its relations to the ureter account for the different positions of juxtaureteral diverticula and transhiatal herniae of the bladder mucosa. The many descriptions of the ureteral sheath appearing in the literature are reviewed in light of the findings from the present study. The juxtavesical segment of the ureter is surrounded by a fibroconjunctive sheath which fixes the ureter to the bladder wall. The transparietal segment of the ureter is ensheathed in its adventitia, whereas a fibromuscular sheath cannot be truly individualized over this ureteral segment.

[Hydrocephalus during central parenteral feeding. Role of vitamin A poisoning]

Five children receiving central parenteral nutrition presented between the 6th and 16th day of renutrition with hydrocephalus unrelated to intercurrent neurologic disorder. Repeated determinations of plasma retinol and of the transport complex components made the proof of vitamin A intoxication in 2 cases. Vitamin A had been provided in the form of a water-soluble vitamin-solution incorporated in the nutrition mixture (doses: 1,500 micrograms and 3,000 micrograms retinol equivalent respectively). These 2 case reports have to be compared with 3 other cases of hydrocephalus occurring during total parenteral nutrition. One child presented with bilateral jugular thrombosis secondary to percutaneous venous approach trials, while the 2 other were probably within the framework of an accelerated weight recovery following nutritional marasmus.

[Treatment of anterior hypospadias. Balanoplasty]

The authors present their experience of balanoplasty in the treatment of anterior hypospadias. These forms of hypospadias are defined as those where the meatus is situated at the base of the glans, at the level of the balano-preputial groove or just before, without any real chordee. The treatment involves re-siting the meatus in the penis. These forms represent 70% of all cases of hypospadias. This type of hypospadias is corrected by an extensive meatoplasty towards the tip with reconstitution of the glans and re-centering of the sheath of the penis. This gives good aesthetic and functional results. This technique was designed by J. W. Duckett who named it M.A.G.P.I. (meatal advancement and glanduloplasty incorporated) and has been used in 78 cases; the indications, the method and the results are presented.

[Megaesophagus by achalasia in children (seven cases) (author's transl)]

The authors reported seven cases of megaesophagus by achalasia in children treated by transabdominal esophagomyotomy. There were five girls and two boys. Nor infantile neither familial forms were seen. Five children were cured clinically and radiologically at the third post operative month. Two failures were successfully treated by Thal's procedure. We concluded: (1) Infantile achalasia is not rare in recent literature; recurrent respiratory troubles and familial forms are frequent; prognosis is serious in this age groups. (2) Esophagus's width divided by thoracic vertebral corpus's height is a more objective criteria to appreciate megaesophagus's importance than esophagus's width alone. (3) Endoscopic biopsy is inadequate to detect tracheo bronchial remnants. (4) Appropriate treatment in children is surgical esophagomyotomy with fundoplication.

[The gastro-phrenic ligament]

The present study was carried out in order to investigate if 1) the gastrophrenic ligament was involved in gastric stabilization, 2) the surface of this ligament might be influenced by fundus distension induced by the first deglutition of the newborn. In a series of 23 subjects (15 adults, 8 foetuses) the surface of the gastrophrenic ligament was expressed in % of the postero-inferior surface of the stomach. The gastrophrenic ligament consisted of loose areolar tissue and its surface was rather small (5,89% +/- 3,8 in adults; 4,3% +/- 1,5 in the foetus). These facts led us to conclude that this ligament did not play a very important role in gastric stabilization. Furthermore the difference between adults and foetuses was not statistically significant; so the surface of the ligament could not have been changed at birth.