[Laparoscopic splenectomy in hematologic diseases in children. Analysis of 11-year experience]. / Esplenectomía laparoscópica por enfermedades hematológicas en niños. Análisis de 11 años.

OBJECTIVES: A common indication for splenectomy in children is hematologic diseases. Indications, clinical course and complications of laparoscopic splenectomy are shown; factors associated with open conversion are analyzed. MATERIAL AND METHODS: Retrospective, longitudinal, descriptive series of laparoscopic splenectomy during 11 years and its long-term follow-up. RESULTS: We studied 88 laparoscopic splenectomies. Average age was 9 years and weight 30 kg. The indication was hemolytic anemia in 77% and thrombocytopenic purpura in 18%. Eleven percent was operated with severe thrombocytopenia and two patients urgently; cholecystectomy was done in 13%. The median surgical time was 180 minutes and bleeding 100 ml. Conversion rate was 5.7% mainly because of persistent bleeding, being risk bleeding greater than 300 ml and the need for red cell concentrate transfusion. The median length of stay was 3 days, longer in those affected by purpura. Three patients developed pneumonia and one, intra-abdominal abscess. Follow-up was 3.6 years average with two late complications. Treatment response was cure in 72%, improvement in 11.3% and failure in 6.8%. DISCUSSION: It is feasible to operate patients under 5 years of age and patients with anemia or thrombocytopenia at the time of surgery without major problems. The conversion rate is low and risk factors for conversion are bleeding more than 300 ml and needing to transfuse erythrocyte concentrate.

INTRODUCCION: Una indicación frecuente de esplenectomía en niños son las enfermedades hematológicas. Se muestran las indicaciones, curso clínico y complicaciones en niños con esplenectomía laparoscópica y se analizan los factores de conversión a cirugía abierta. MATERIAL Y METODOS: Estudio de cohorte, longitudinal, descriptivo de esplenectomía laparoscópica en un periodo de 11 años y su seguimiento a largo plazo. RESULTADOS: Se analizaron 88 esplenectomías laparoscópicas. Edad promedio 9 años y peso 30 kg. La indicación fue anemia hemolítica en el 77% y púrpura trombocitopénica en el 18%. El 11% se operó con trombocitopenia grave y dos pacientes en forma urgente, se hizo colecistectomía en el 13%. La mediana de tiempo quirúrgico fue de 180 minutos con sangrado de 100 ml. Se convirtió el 5,7% por sangrado persistente, siendo los factores de riesgo el sangrado mayor a 300 ml y la necesidad de transfusión de concentrado eritrocitario. La mediana de estancia fue 3 días, superior en los pacientes afectos de púrpura. Tres pacientes desarrollaron neumonía y uno, absceso intra-abdominal. El seguimiento promedio es de 3,6 años con dos complicaciones tardías. Hubo curación con normalización del hemograma y sin necesidad de transfusiones en el 72%, mejoría con necesidad de transfusiones ocasionales en el 11,3% y fallo con requerimientos transfusionales iguales a los preoperatorios en el 6,8% de los pacientes. DISCUSION: Es posible operar a pacientes menores de 5 años y a pacientes con anemia o trombocitopenia en el momento de la cirugía, sin mayor complicación. La tasa de reconversión es baja y los factores de riesgo para reconversión son un sangrado mayor de 300 ml y la necesidad de transfundir concentrado de hematíes.

Esplenectomía laparoscópica por enfermedades hematológicas en niños. Análisis de 11 años / Laparoscopic splenectomy in hematologic diseases in children. Analysis of 11-year experience

Introducción. Una indicación frecuente de esplenectomía en niños son las enfermedades hematológicas. Se muestran las indicaciones, curso clínico y complicaciones en niños con esplenectomía laparoscópica y se analizan los factores de conversión a cirugía abierta. Material y métodos. Estudio de cohorte, longitudinal, descriptivo de esplenectomía laparoscópica en un periodo de 11 años y su seguimiento a largo plazo. Resultados. Se analizaron 88 esplenectomías laparoscópicas. Edad promedio 9 años y peso 30 kg. La indicación fue anemia hemolítica en el 77% y púrpura trombocitopénica en el 18%. El 11% se operó con trombocitopenia grave y dos pacientes en forma urgente, se hizo colecistectomía en el 13%. La mediana de tiempo quirúrgico fue de 180 minutos con sangrado de 100 ml. Se convirtió el 5,7% por sangrado persistente, siendo los factores de riesgo el sangrado mayor a 300 ml y la necesidad de transfusión de concentrado eritrocitario. La mediana de estancia fue 3 días, superior en los pacientes afectos de púrpura. Tres pacientes desarrollaron neumonía y uno, absceso intra-abdominal. El seguimiento promedio es de 3,6 años con dos complicaciones tardías. Hubo curación con normalización del hemograma y sin necesidad de transfusiones en el 72%, mejoría con necesidad de transfusiones ocasionales en el 11,3% y fallo con requerimientos transfusionales iguales a los preoperatorios en el 6,8% de los pacientes. Discusión. Es posible operar a pacientes menores de 5 años y a pacientes con anemia o trombocitopenia en el momento de la cirugía, sin mayor complicación. La tasa de reconversión es baja y los factores de riesgo para reconversión son un sangrado mayor de 300 ml y la necesidad de transfundir concentrado de hematíes

Objectives. A common indication for splenectomy in children is hematologic diseases. Indications, clinical course and complications of laparoscopic splenectomy are shown; factors associated with open conversion are analyzed. Methods. Retrospective, longitudinal, descriptive series of laparoscopic splenectomy during 11 years and its long-term follow-up. Results. We studied 88 laparoscopic splenectomies. Average age was 9 years and weight 30 kg. The indication was hemolytic anemia in 77% and thrombocytopenic purpura in 18%. Eleven percent was operated with severe thrombocytopenia and two patients urgently; cholecystectomy was done in 13%. The median surgical time was 180 minutes and bleeding 100 ml. Conversion rate was 5.7% mainly because of persistent bleeding, being risk bleeding greater than 300 ml and the need for red cell concentrate transfusion. The median length of stay was 3 days, longer in those affected by purpura. Three patients developed pneumonia and one, intra-abdominal abscess. Follow-up was 3.6 years average with two late complications. Treatment response was cure in 72%, improvement in 11.3% and failure in 6.8%.Discussion. It is feasible to operate patients under 5 years of age and patients with anemia or thrombocytopenia at the time of surgery without major problems. The conversion rate is low and risk factors for conversion are bleeding more than 300 ml and needing to transfuse erythrocyte concentrate

Long-term follow-up of patients with type 1 diabetes transplanted with neonatal pig islets.

Pancreas transplantation is an option to achieve better metabolic control and decrease chronic complications in patients with diabetes. Xenotransplantation becomes an important alternative. In this study, we show the clinical outcome of patients with type 1 diabetes transplanted with neonatal pig islets without immunosuppression. In a longitudinal study of 23 patients with type 1 diabetes, who received porcine islets between 2000 and 2004, we registered demographic and clinical characteristics every 3 months and chronic complications evaluation yearly. Porcine C-peptide was measured in urine samples under basal conditions and after stimulation with l-arginine. More than 50% were female, median current age was 20·8 years, median diabetes duration at transplantation 5·5 years, median current diabetes duration 11 years and median time post-transplantation 5·7 years. Their media of glycosylated haemoglobin reduced significantly after the first transplantation. Insulin doses remain with a reduction greater than 33% in more than 50% of the patients. Before transplantation, 14 of the 21 patients presented mild chronic complications and currently only two patients presented these complications. Porcine C-peptide was present in all urine samples under basal conditions and increased post-stimulation with l-arginine. These patients achieved an excellent metabolic control after the first transplantation. This could explain, as well as the remaining function of transplanted cells, the low frequency of chronic complications compared to patients with similar diabetes duration and age.

Should a complex uropathy be a contraindication for renal transplantation in children?

BACKGROUND: Anatomic and functional disorders of the lower urinary tract represent up to 40% of the causes of renal failure in children. Several centers avoid renal transplantation in these patients because of the high risk of complications and lower graft survival. The aim of this work was to determine the frequency of urinary tract abnormalities (UTAs) among our pediatric series, and to compare the frequency of complications, function, and long-term graft survival among patients without versus with UTA. METHODS: This single-center, retrospective study compared outcomes between pediatric recipients with versus without UTA. We analyzed demographic features, etiology, pretransplant protocol, urinary tract rehabilitation, incidence of complications, rejection events, as well as graft function and survival. RESULTS: Among 328 pediatric cases performed between 1998 and 2008, we excluded nine patients due to incomplete medical records, analyzing 319 procedures in 312 patients. Sixty-seven patients (21%) had UTA. The average age, weight, and height at the time of grafting were significantly lower in the urologic group: 11.1 versus 12.6 years, 28.8 versus 34.4 kg; 125.4 versus 138.4 cm, respectively. There were significantly higher frequencies of a transperitoneal approach and vena cavae and aortic anastomoses among patients with UTA (P < .001), posing a greater technical challenge in this population. No differences in creatinine levels were observed at 0.5, 1, 2, 5, and 10 years: 1.3 versus 1.6 at 5 years, and 1.4 versus 1.5 at 8 years. Urologic complications, including urinary tract infections (UTIs), occurred among 80.6% of patients with UTA versus 42.1% in the non-UTA group (P < .001). UTIs appeared predominantly in patients with UTA (62.7% vs 35.3%, P < .001), representing a 2.7-fold risk compared with those children transplanted for other reasons. Rejection incidence was similar in both groups (49.8%). There was no significant difference in 5-y (89.8% vs 85%) or 10-year (83% vs 67%) graft survivals between the groups (P = .162). CONCLUSION: Our results demonstrated that with proper interdisciplinary care, graft and patient survivals of pediatric recipients with UTAs were not affected; therefore, these patients should not be rejected for transplantation.

Three-yr follow-up of a type 1 diabetes mellitus patient with an islet xenotransplant.

In order to alleviate the shortage of human donors, the use of porcine islets of Langerhans for xenotransplantation in diabetic patients has been proposed as a solution. To overcome rejection, we have developed a procedure for protecting the islets by combining them with Sertoli cells and placing them in a novel subcutaneous device, that generates an autologous collagen covering. A type 1 diabetic woman was closely monitored for 10 months, and then transplanted in two devices with two months of difference and a third time after 22 months. Here we present a three-yr follow-up. The close monitoring induced a rapid decrease in exogenous insulin requirements, which stabilized between 19 and 28 IU/d for nine months. After transplantation, the requirements reduced further to below 6 IU/d and for some weeks she was insulin free. Glycosylated hemoglobin levels decreased concomitantly. Porcine insulin could be detected in the serum after a glucose challenge and insulin positive cells inside a removed device after two yr. No complications have arisen and no porcine endogenous retrovirus infection has been detected through PCR and RT-PCR. This case demonstrates the feasibility of using the xenotransplantation of porcine cells to alleviate metabolic complications and insulin requirements in type 1 diabetic patients.

Experience of a successful pediatric liver transplant program in Mexico.

Orthotopic liver transplantation (OLT) has been very difficult to develop in Mexico and for many years its occurrence was anecdotal. This report presents the results of a pediatric liver transplant program, analyzing the variables that affect outcomes. Between June 1998 and March 2004, 35 OLT were performed in 34 recipients including 80% cadaveric whole-organ grafts and 20% segmental grafts, with 11% from cadaveric and 9% from living donors. Most of the recipients were infants or toddlers weighing less than 15 kg. There was only 1 case of arterial thrombosis (2.8%); the graft was saved with a Kasai procedure. Biliary complications were present in 22% of cases, all resolved with reoperations. Posttransplant cytomegalovirus infection or reactivation (28%), acute rejection (25%), or posttransplant lymphoproliferative disorders (5.7%) were not a cause of graft or patient loss. Overall, 1- and 5-year patient survival rates are 77.1% and 74.2%, respectively; however, when the 1998-2000 cohort was compared with the 2001-2004 cohort, there was a significant difference in survival (P = .004). The 1-year patient survival for the later group is 91.6%. We performed the first successful living donor liver transplantation and the first simultaneous liver-kidney transplantation in a child in our country. Our results demonstrate that pediatric liver transplantation is a feasible undertaking in Mexico, with survival rates comparable to those of foreign centers.

Infantile hypertrophic pyloric stenosis: a comparative study of pyloric traumamyoplasty and Fredet-Ramstedt pyloromyotomy.

PURPOSE: The aim of this study was to compare the incidence of surgical complications (duodenal perforation, postoperative vomiting, wound infection or dehiscence, incisional hernia) between 2 different surgical techniques for the resolution of hypertrophic pyloric stenosis in children. METHODS: A clinically controlled, randomized study with follow-up from 24 to 36 months was conducted. One hundred children between 15 days and 2 months old, who underwent surgical resolution of hypertrophic pyloric stenosis, were put randomly into 2 groups: I, pyloric traumamyoplasty (n = 43); II, Fredet-Ramstedt pyloromyotomy (n = 57). Both groups were controlled for the main demographic variables. Postoperative follow-up was blind for the surgical team. Statistical analysis was done with simple frequencies, percentages, Student's t test, and chi(2). RESULTS: There was not a single case of duodenal perforation, incomplete pyloromyotomy, wound infection, dehiscence, or incisional hernia in any group (P value, not significant). Postoperative emesis was present in 8 patients, uniformly distributed between groups. The operating room time for traumamyoplasty was 39.3 +/- 16.4 minutes versus 54 +/- 16.4 minutes for pyloromyotomy (P =.0003). CONCLUSIONS: This controlled study proves that traumamyoplasty is a simple procedure, quicker to perform, and as safe as pyloromyotomy for the treatment of infantile hypertrophic pyloric stenosis in children. For these reasons, the authors believe it should be considered as an alternative.

Intestinal anastomosis in children: a comparative study between two different techniques.

PURPOSE: The aim of this study was to compare the incidence of surgical complications between two different surgical techniques for intestinal anastomosis in children. METHODS: This was a clinically controlled, randomized study with blind follow-up from 18 to 36 months performed at the Reference Government Hospital in Mexico City. Eighty-six children required intestinal anastomosis, ages ranged between 1 month and 16 years, with emergency or elective surgery. Anastomoses of duodenum, rectum, with enteroplasty or protected with a proximal stoma were excluded. Two randomized groups were formed: (1) anastomosis with one layer of suture (Gambee stitches) and (2) with two layers of suture (first with Connel-Mayo stitches then with Lembert). Both groups were controlled in the principal variables without differences, and the follow-up concerning postoperative recovery was blind for the surgical team. RESULTS: Forty-two cases in group 1 and 44 in group 2 were compared. Intestinal dehiscence was found in 5 of 86 (5.8%), two from group I and three from group II (P value, not significant). Surgical time for anastomosis with one layer was an average of 26 minutes versus 43 minutes with two layers (P<.001). There were no stenoses within the follow-up period. CONCLUSIONS: This study proves that intestinal anastomosis with one layer of suture is as safe as anastomosis with two layers in children, and the time spent for completion of the procedure is significantly less with one plane of suture. For those reasons, it is the method of choice for intestinal anastomosis in children.

Gastric perforation with Candida tropicalis invasion in a previously healthy girl.

Fungal cells were observed infiltrating the submucosal margins of an acutely perforated gastric ulceration in an apparently immunocompetent 3-year-old girl. Perforation had occurred 24 h after hospital admission because of pain and vomiting. Colonies of Candida tropicalis were grown from peritoneal fluid and blood cultures. After surgical repair and a 30-day treatment with amphotericin B at a daily dose of 1 mg kg-1 body weight, the child was discharged in good health. No further infections have occurred in the 3 years since treatment.

[Congenital esophageal diverticulum]. / Divertículo esofágico congénito.

The congenital or acquired variety of esophageal diverticulum is a rare childhood disease. Reported is a case-study which deals with a five year old patient who arrived at our hospital complaining of a constricture at the cricopharyngeal level. A month later he returned to the hospital with dysphasia and regurgitation; the X-rays and endoscopic diagnosis showed stenosis of the esophagus and the presence of an esophageal diverticulum. Esophageal dilatations were carried out until an acceptable esophageal diameter was reached. Later on, the surgical removal of the diverticulum was performed without any complications. The histopathological study showed the congenital nature of the diverticulum. The patient's recovery went well and is currently considered as cured.

[Adrenal abscess in the newborn: a case report and review of the literature]. / Absceso adrenal en el recién nacido: informe de un caso y revisión de la literatura.

This is a case report concerning a 22 day newborn referred to us having an abdominal tumor, fever, an irritable nature and feeding refusal, born dystocically due to the retention of the shoulders and having an Apgar score of 5/8. When admitted the presence of the tumor was corroborated in the right flank occupying the right renal fossa and measuring 5 x 8 cm, non-mobile and painless. Studies revealed a diagnosis of calcified right adrenal hemorrhage versus neuroblastoma. During surgery a right adrenal abscess was found which was drained and a biopsy sample was taken for further study. The culture of the pus developed Proteus mirabilis. Pathology reported it to be an abscessed right adrenal hematoma which was partially calcified. The patient's wound became infected but was later sent home under good conditions. Only 15 other cases with this pathology are reported in the literature, this would be the 16th case. An emphasis is placed on including this pathology as part of the differential diagnosis of retroperitoneal tumors in the newborn.