Cambios cardiovasculares y ventilatorios durante la laparoscopia en neonatos y lactantes pequeños / Cardiovascular and respiratory changes during laparoscopy in neonates and infants

El neumoperitoneo necesario para la laparoscopia provoca modificaciones, fundamentalmente a nivel cardiorrespiratorio, que se deben conocer para realizar procedimientos laparoscópicos en neonatos y lactantes pequeños. El objetivo de este trabajo es describir los cambios hemodinámicos y ventilatorios que se producen en una serie de estos pacientes sometidos a un procedimiento laparoscópico estándar. Para ello, hemos realizado una revisión retrospectiva de pacientes sometidos a piloromiotomía laparoscópica en nuestro centro. Se han recogido datos demográficos, datos de la intervención, evolución y complicaciones, y parámetros hemodinámicos (frecuencia cardiaca -FC- y tensión arterial -TA-) y respiratorios (saturación de O2 -SO2- y CO2 espirado -ECO2-) en distintos momentos de la cirugía. Se ha realizado un análisis estadístico de los mismos. Un total de 55 pacientes fueron incluidos, con una edad media de 34 días y peso medio de 3.785 g. En todos los pacientes se utilizó ventilación controlada por presión y recibieron sueroterapia de mantenimiento. Tanto la TA como la FC y la SO2 se mantuvieron estables a lo largo de la cirugía, sin mostrar diferencias significativas. El ECO2 presentó un incremento significativo tras la insuflación, que se controló aumentando la frecuencia respiratoria. En conclusión, la respuesta hemodinámica y ventilatoria en estos pacientes es controlable con medidas anestésicas y quirúrgicas, pero es importante tener en cuenta las posibles consecuencias del neumoperitoneo en pacientes tan pequeños (AU)

The pneumoperitoneum induced during laparoscopy has cardiovascular and respiratory effects that have to be taken into account to perform laparoscopic procedures in neonates and small infants. The aim of this paper is to describe the hemodynamic and ventilatory changes that occur in a group of these patients undergoing standard laparoscopic procedure. We performed a retrospective review of patients undergoing laparoscopic pyloromyotomy in our institution. We collected demographic data, data from the intervention, outcome and complications and hemodynamic parameters (heart rate -HR- and blood pressure -BP-) and respiratory (O2 saturation -SO2- and exhaled CO2 -ECO2-) at different times during surgery. We performed statistical analysis of these data. We reviewed a total of 55 charts. Mean age was 34 days and average weight 3,785 g. All patients were ventilated with pressure control mode and received maintenance fluid therapy. BP, HR and SO2 were stable throughout the surgery not showing significant differences. The ECO2 increased significantly after inflation, however it was controlled by increasig respiratory rate. In conclusion, the hemodynamic and ventilatory response in these patients is controllable with anesthetic and surgical measures but it is important to consider the possible consequences of pneumoperitoneum in this group of patients (AU)

[Cardiovascular and respiratory changes during laparoscopy in neonates and infants]. / Cambios cardiovasculares y ventilatorios durante la laparoscopia en neonatos y lactantes pequeños.

The pneumoperitoneum induced during laparoscopy has cardiovascular and respiratory effects that have to be taken into account to perform laparoscopic procedures in neonates and small infants. The aim of this paper is to describe the hemodynamic and ventilatory changes that occur in a group of these patients undergoing standard laparoscopic procedure. We performed a retrospective review of patients undergoing laparoscopic pyloromyotomy in our institution. We collected demographic data, data from the intervention, outcome and complications and hemodynamic parameters (heart rate--HR--and blood pressure--BP--) and respiratory (O2 saturation--SO2--and exhaled CO2--ECO2--) at different times during surgery. We performed statistical analysis of these data. We reviewed a total of 55 charts. Mean age was 34 days and average weight 3,785 g. All patients were ventilated with pressure control mode and received maintenance fluid therapy. BP, HR and SO2 were stable throughout the surgery not showing significant differences. The ECO2 increased significantly after inflation, however it was controlled by increasig respiratory rate. In conclusion, the hemodynamic and ventilatory response in these patients is controllable with anesthetic and surgical measures but it is important to consider the possible consequences of pneumoperitoneum in this group of patients.

[Laparoscopy as diagnostic-therapeutic method in abdominal traumatism in the pediatric age]. / Laparoscopia como método diagnóstico-terapéutico en el traumatismo abdominal en la edad pediátrica.

The management of blunt abdominal traumatism with a moderate amount of free peritoneal fluid and without solid organ injury as well as the one of minimal penetrating trauma is controversial. We present three cases of blunt abdominal trauma and two of penetrating trauma that underwent diagnostic laparoscopy in our department. We found a small bowel perforation in one of the cases of blunt trauma that was repaired by externalization of the jejuna loop by one of the ports. In the other two cases we found intestinal and mesenteric contusions and free fluid that were treated by peritoneal drainage. One of the cases of penetrating trauma presented omentum evisceration with no other injuries and the second presented a gastric perforation that needed reconversion to laparotomy. In our experience and according to literature, laparoscopy should be taken into account as a diagnostic procedure and sometimes also therapeutic in selected cases of both blunt and penetrating abdominal trauma in pediatric population.

Laparoscopia como método diagnóstico-terapéuticoen el traumatismo abdominal en la edad pediátrica / Laparoscopy as diagnostic-therapeutic method in abdominal traumatism in the pediatric age

El trauma abdominal cerrado con líquido libre sin evidencia de lesión de víscera sólida, así como el penetrante con dudosa afectación peritoneal suponen un reto diagnóstico y terapéutico. Presentamos tres casos de traumatismo abdominal cerrado y dos penetrante que fueron sometidos en nuestro centro a laparoscopia diagnóstica. Los cinco pacientes se encontraban hemodinámicamente estables. De los traumatismos cerrados, en uno se evidenció una perforación a nivel de íleondistal que fue reparada. Los otros dos casos presentaban distensión de asas y líquido que se drenó sin evidenciar otras lesiones. De los dos casos de traumatismo penetrante en uno de ellos se redujo el epiplón eviscerado por la herida sin evidenciar otras lesiones y en el otro se diagnosticó una perforación a nivel gástrico que se reparó mediante laparotomía La laparoscopia, por tanto, puede tener un papel diagnóstico y en ocasiones también terapéutico en casos seleccionados de traumatismo abdominal tanto penetrante como cerrado (AU)

The management of blunt abdominal traumatism with a moderate amount of free peritoneal fluid and without solid organ injury as wellas the one of minimal penetrating trauma is controversial. We present three cases of blunt abdominal trauma and two of penetrating trauma that underwent diagnostic laparoscopy in our department. We found as mall bowel perforation in one of the cases of blunt trauma that was repaired by externalization of the jejuna loop by one of the ports. In the other two cases we found intestinal and mesenteric contusions and free fluid that were treated by peritoneal drainage. One of the cases of penetrating trauma presented omentum evisceration with no other injuries and the second presented a gastric perforation that needed reconversion to laparotomy. In our experience and according to literature, laparoscopy should be taken into account as a diagnostic procedure and sometimes also therapeutic in selected cases of both blunt and penetrating abdominal trauma in pediatric population (AU)

Cirugía laparoscópica en pacientes con válvula de derivación ventrículo-peritoneal / Minimally invasive surgery in pediatric patients with ventriculo-peritoneal shunts

Clásicamente ha existido controversia en cuanto a la realización de intervenciones laparoscópicas en los pacientes portadores de válvulas de derivación ventrículo-peritoneales (VDVP), por la posibilidad de desarrollo de hipertensión intracraneal durante la cirugía, el riesgo deinfecciones del sistema de derivación o la presencia de adherencias peritoneales. Presentamos los resultados de los pacientes de estas características tratados en nuestro centro. Se han realizado 16 intervenciones laparoscópicas en pacientes portadores de VDVP. El procedimiento más frecuente fue la cirugía antirreflujo. Durante las intervenciones no se evidenciaron episodios de hipertensión intracraneal. Durante 2 de las cirugías programadas la presencia de adherencias y líquido tabicado aumentó la complejidad del procedimiento. No hubo complicaciones intraoperatorias. En los seis meses siguientes sólo fue preciso recambiar una de las válvulas en los casos de cirugía limpia y limpia-contaminada. Según nuestra experiencia, por tanto, la laparoscopia en portadoresde VDVP es factible, puede resultar más compleja pero no parece aumentar la tasa de infecciones del sistema. Estos niños pueden por consiguiente beneficiarse de las ventajas de la laparoscopia y sus indicaciones (AU)

The use of laparoscopy in patients with ventriculo-peritoneals hunts has been controversial. There is concern about the risk malfunction or infection of the shunt as well as about the possibility of adhesions that could make the surgical procedures too difficult to be undertaken by minimally invasive surgery. We present our results inpediatric patients with ventriculoperitoneal shunts that have undergonel aparoscopic procedures in our department. We have performed16 surgical procedures. The most frequent indication was fundoplication. During surgery there were no complications or intracranial hypertension episodes. Two of the procedures were considered by the surgeons more difficult and longer than usual. None of them required conversion to open technique. One shunt had to be replaced after surgery because of infection. According to our experience minimallyinvasive surgery is feasible and safe in pediatric patients with ventriculo-peritoneal shunts (AU)

[Minimally invasive surgery in pediatric patients with ventriculo-peritoneal shunts]. / Cirugía laparoscópica en pacientes con válvula de derivación ventrículo-peritoneal.

The use of laparoscopy in patients with ventriculo-peritoneal shunts has been controversial. There is concern about the risk malfunction or infection of the shunt as well as about the possibility of adhesions that could make the surgical procedures too difficult to be undertaken by minimally invasive surgery. We present our results in pediatric patients with ventriculoperitoneal shunts that have undergone laparoscopic procedures in our department. We have performed 16 surgical procedures. The most frequent indication was fundoplication. During surgery there were no complications or intracranial hypertension episodes. Two of the procedures were considered by the surgeons more difficult and longer than usual. None of them required conversion to open technique. One shunt had to be replaced after surgery because of infection. According to our experience minimally invasive surgery is feasible and safe in pediatric patients with ventriculo-peritoneal shunts.

Tumor estromal gástrico de estirpe neural: ¿neoplasia aislada o primera manifestación del complejo de Carney? / Gastrointestinal autonomic nerve tumor: isolated neoplasm or first manifestation of Carney’s complex?

Los tumores gastrointestinales de naturaleza estromal son especialmente infrecuentes en niños. Presentan de forma genérica 2 vías de diferenciación: hacia la estirpe muscular (variante mioide) o como célula neural. Carney publicó en 1978 el primer caso de un tumor de este tipo asociado a neoplasia pulmonar (condroma) y neural (paraganglioma extradrenal). Los 3 tumores presentan un origen ectodérmico común, lo que daría origen a la aparición sinérgica o secuencial de éstos a lo largo de la vida del individuo, y obligaría a realizar un estudio completo ante la aparición de cualquiera de ellos. Comunicamos el caso de una niña de 11 años que presentó un tumor estromal gástrico, cuya única manifestación clínica fue una anemia sintomática

Gastrointestinal stromal tumors (GIST) are highly uncommon in childhood. There are two specific differentiation patterns: toward a smooth muscle cell lineage (myoid variant) or toward a neural lineage (gastrointestinal autonomic nerve tumors [GANT]). In 1978, Carney reported the first case of this type of tumor associated with two other neoplasms, pulmonary chondroma and extraadrenal paraganglioma. All three tumors seem to have a common ectodermal origin, and their synergic or sequential presentation throughout the individual’s life may be observed. Thus, the detection of any of these three tumors should lead to a complete study of the patient. We report the case of an eleven-year-old girl with a GIST in whom the only clinical sign at presentation was symptomatic anemia

Infección de herida quirúrgica profunda en pacientes intervenidos por artroplastia de cadera y rodilla en un hospital comarcal de la Comunidad Valenciana / No disponible

Objetivos: Estimar la incidencia de infección de herida quirúrgica (IHQ) profunda tras artroplastia de cadera o rodillo en los pacientes intervenidos en un hospital comarcal durante el trienio 2002-2004. Identificar los factores de riesgo asociados y estimar el exceso de recambios de prótesis y de utilización de los servicios sanitarios asociado a ese tipo de infección. Material y métodos: Estudio de incidencia de los casos de IHQ profunda en pacientes intervenidos en 2002-2004 seguidos durante al menos 1 año tras la operación. La identificación de los factores de riesgo de IHQ se realizó mediante un estudio de casos y controles. Las variables estudiadas incluyeron factores relacionados con el paciente, la intervención, con el traumatólogo responsable del acto quirúrgico y con su manejo postoperatorio. La fuerza de la asociación se determinó mediante el Odds Ratio (OR) y su intervalo de confianza del 95%. Resultados: La incidencia acumulada global fue de 3,7% (IC95% 2,2-5,1%): 3,4% para cadera (IC95% 1,4-5,3%) 4,05% para rodilla (IC9% 1,7-6,4%). Entre los factores analizados, además de la comorbilidad se observó un mayor riesgo de IHQ además de la comorbilidad se observó un mayor riesgo de IHQ asociado a la participación de un traumatólogo, aunque sin llegar a la significación estadística. Esta asociación fue independiente del riesgo quirúrgico del paciente y del manejo postoperatorio del mismo. De los casos, un 88% reingresaron y más de la mitad fueron reintervenidos. Conclusiones: La incidencia de IHQ profunda en nuestro hospital está por encima de los deseable para este tipo de infecciones. Entre las variables que se asocian a un mayor riesgo de IHQ, además de la gravedad previa del paciente, se encuentra la posible influencia de las prácticas ligadas al cirujano responsable. El impacto de este tipo de infecciones supone un incremento importante en el número de reintervenciones y de reingresos (AU)

Objetives: To estimate the incidence of deep surgical site infection (DSSI) after Hip or Knee replancements during 2002-2004. To identify the risk factors associated cosnidering the excess of reinteventions and use o healthy services. Material an methods: Study of incidence of the cases of DSSI in orthopedic patients in 2002-2004 followed during at least 1 year after the intervention. The identification of DSSI risk factors was made by means of a cse control study. The studied variables included factors related to the patient, the surgical procedure, included the surgeon responsible and the postoperating handling. The magnitude of association was determined by Odds Ratio (OR) and its interval of confidence of 95%. Results: The global accumulated incidence of DSSI was 3,7% (CI95% 2.2-5.1%): 3,4" for hip relancements (CI95% 1.4-5.3%) and 4.05% for knee replacements (CI95% 1.7-6.4%). Among the anlyzed factors, in addition to patient comorbidity, a greater risk of DSSI was associated with a surgeon (OR=2,06; CI95%:0.77-5.48). This association was independent of the preoperative risk and postoperative management. In the cases of DSSI, a 88% were rehospitalised and above a half reoperated. Conclusions: The incidence of deep SSI in our hospital is over the standars for this type of infections. The variables that are associated to a greater risk of SSI depende, in addition to the previous severity of the patient, of the reponsible surgeon. DSSI was associated with a great impact in hospitalisations and reinterventions (AU)

Detection of specific antibodies to pigeon serum and bloom antigens by enzyme linked immunosorbent assay in pigeon breeder's disease.

BACKGROUND: Pigeon breeder's disease is an extrinsic allergic alveolitis in the lungs of sensitised people, caused by hypersensitivity reactions to inhaled pigeon antigens. Antigens from different sources of the animal are used for diagnostic purposes, with serum being the most widely used. Bloom is rarely used; very little is known of its antigenicity and diagnostic performance, particularly when used with the enzyme linked immunosorbent assay (ELISA) method, which is the most popular test as it permits measurement of the antibody response. METHODS: To (a) standardise an ELISA for the measurement of specific IgG against pigeon serum and pigeon bloom extract; (b) to establish reference values for specific IgG in 73 non-exposed controls, (c) to show the presence of specific IgG against pigeon serum and bloom in serum samples of 17 patients with bird fancier's lung and 11 asymptomatic fanciers, and (d) to study the similarity of the two antigen sources by cross reactivity experiments. RESULTS: Reference values of specific IgG were defined with the 97.5 percentile (367.9 U/ml for pigeon serum and 953.7 U/ml for pigeon bloom extract). Of symptomatic patients 100% had values higher than the cut off for both antigens. In asymptomatic fanciers values were higher than the cut off for pigeon serum in 45% and bloom extract in 54%. Cross reactivity experiments showed that the two antigens differed in antigenic content although some components may be common to both. CONCLUSION: The ELISA methods used proved to be useful tools for evaluating specific IgG antibody responses against both antigens. The diagnostic performance of both ELISA methods performed with these antigen sources was similar, showing very high sensitivity but moderate specificity. Although some antigenic similarity was found between pigeon serum and bloom extract, cross reactivity studies showed that various antigens seemed to be specific to the bloom extract. However, the antigens responsible for pigeon breeder's disease seem to be present in both antigenic sources.

Results of the Azizkhan procedure for long-term suprastomal tracheomalacia.

One of the reasons of failure to decannulate patients after airway surgery or long-term tracheostomy is suprastomal tracheomalacia. We present 7 cases with long-term tracheostomies treated by an anterior cricoid suspension described by Azizkhan in 1993. Prior to surgery, other causes of airway obstruction, as well as the presence of gastroesophageal reflux disease should be ruled out. All of them are decannulated. This procedure is a safe surgical technique, easily reproducible and with low costs.

Oesophageal narrowing in chronic granulomatous disease.

A 14 year-old boy with X-linked chronic granulomatous disease (CGD) developed a long smooth narrowing at the mid oesophagus with severe dysphagia. Endoscopy revealed a normal mucosa and biopsy showed non-specific acute inflammatory changes. Bacterial cultures of the biopsy specimens were sterile. Combined treatment with antibiotics and steroids resulted in a transitory remission, but symptoms recurred after 2.5 months. One second course of steroids and antibiotics lead to a long-term remission. Oesophagogram was more useful than endoscopy to evaluate the severity of the stricture.

[The treatment of the tracheobronchomalacia in pediatric age]. / Tratamiento de la traqueobroncomalacia en la edad pediátrica.

OBJECTIVE: Aortopexy is the more extended treatment for severe tracheomalacia, when it fails, reintervention and other procedures are necessary. We present our experience in the treatment of this pathology. MATERIAL AND METHODS: Tracheomalacia, bronchomalacia and tracheobroncomalacia cases during a twelve year period (1983-1995) were reviewed (type, age, symptoms, surgical procedures and results were collected). RESULTS: Nineteen patients (9 males, 10 females) presented tracheobronchomalacia in our Hospital. Diagnosis was made by bronchoscopy in all of them: nine cases of tracheomalacia, five bronchomalacias and five suprastomal malacias were found. Mean diagnosis age was twenty four months (newborn-twelve years). Ten patients were managed nonoperatively, five with anterior cricoideal suspension and two cases were treated by aortopexy; one of them, after 2 months of respiratory stridor and recurrent respiratory arrest, needed an endoscopically placed intraluminal expandable Palmaz Prothesis. This prothesis was removed two years later. In this moment, the patient is doing well without stridor or respiratory symptoms.

[Our experience in neonatal surgery in a 15-year period. Follow-up of 1,003 cases]. / Nuestra experiencia en cirugía neonatal a lo largo de 15 años. Seguimiento de 1.003 casos.

From 1982 to 1994, 1.003 cases of surgical newborns have been retrospectively studied. Frequency and epidemiology have been evaluated, so as associated malformations. Prenatal diagnosis was made in 72 cases (7.1%). The most frequent entity was intestinal atresia, with 122 cases (12.1%), followed by necrotizing enterocolitis in 80 cases (7.9%), nevertheless this last one was the most frequent finding in preterm newborns. Esophageal atresia was found in 57 cases (5.6%). Association with other malformations was found in 127 cases (12.6%), and 32 cases of them (3.1%) constituted congenital malformations syndromes. The number of surgical newborns has increased in the last years, mainly due to ambulatory surgery. Global mortality of operated patients was 62 cases (5.9%); the highest mortality index was for congenital diaphragmatic hernia (33.5%), followed by necrotizing enterocolitis (28%). Mortality rate has decreased in recent years, due to improving in management and treatment of these patients, and the consolidation of surgical newborn units. Future efforts should be aimed for decreasing in mortality and improving the standard of life of these patients.

Treatment of esophageal varices by endoscopic ligation in children.

Endoscopic variceal ligation (EVL) is an alternative technique to endoscopic variceal sclerotherapy (EVS) to treat esophageal varices. This method consists of mechanical ligature and thrombosis of varices using elastic rubber rings. During an 11-month period, nine pediatric patients with esophageal varices secondary to portal hypertension were treated by EVL. Extrahepatic portal vein obstruction was the cause of portal hypertension in 5 patients and in 4 cases the cause was intrahepatic disease. The average age of the patients was 8 years (range: 2-15). Five patients had bled from esophageal varices previously. Two were actively bleeding at the time of the procedure. Endoligature was performed prophylactically in four patients. Fifty varix ligations were performed in 26 separate sessions. In children older than ten years, EVL was performed under intravenous sedation. Two mild rebleeds have occurred in this group and responded to repeated ligature. Varices were reduced in grade in all patients. Six patients achieved variceal eradication. Recurrence of varices was not encountered. No major complications occurred and there were no treatment failures. These early results suggest that endoscopic ligation is a safe and effective method for the control of esophageal varices in children.

[Ambulatory surgery. Experience at a pediatric surgery department]. / Cirugía de corta estancia. Experiencia de un servicio de cirugía pediátrica.

In October 1987 we opened an Outpatient Surgical Unit, since January 1988 to December 1993 we have treated 8232 patients with an mean age (range of 2 weeks to 17 years). All the patients were given general anesthesia, loco-regional anesthetics or deep sedation. 33.5 percent of the total number of patients operated in our hospital were treated in this Unit, being 41.4 percent if related to programmed surgery. Only 2.5 percent of them were admitted in the inpatient area with no significant complications.

[Hiatal hernia following T.E.F. repair (author's transl)]. / La hernia hiatal en el postoperatorio de la atresia de esófago.

Hiatal hernia and/or gastroesophageal reflux are studied in 182 pediatric patients after surgical correction of esophageal atresia. Clinical and radiological aspects, along with postoperative complications, are reviewed. Special stress is given to late stenosis that does not cure with conventional treatment and are originated by undiagnosed reflux. Hiatal disfunction screening is proposed in following up patients of esophageal atresia in avoidance of disphagic and aspirative complications.

Diaphragmatic hernia associated with double pulmonary sequestration.

The association of pulmonary sequestration with diaphragmatic hernia is an infrequent but well known situation. We report a rare case in which the diaphragmatic malformation was accompanied by two extralobar pulmonary sequestrations.

[Internal hernia through Treves' avascular field defect (author's transl)]. / Hernias internas en el área avascular de Treves.

Authors report two cases of internal hernia through Treves avascular field defects, at the ileal level and another case in which this mesenteric mishape was incidentally found during operation for intestinal obstruction due to adhesions. In this particular case it can be speculated that the defect could have been the cause of a former neonatal obstruction for which operation did not offer an explanation. This type of internal hernia is one of the rarest in pediatric surgical practice. The clinical picture is that of an intestinal strangulation and therefore diagnosis can hardly be made preoperatively. The ileal terminal location of the strangulated loop can, in their opinion, justify a resection extending to the caecum in order to avoid vascular risks on the anastomosis in spite of the sacrifice of the ileo-cecal valve. The three patients survived. Literature on this topic is briefly reviewed.