Transpyloric Tube Placement Shortens Time to Full Feeding in Left Congenital Diaphragmatic Hernia.

BACKGROUND: Nutritional complications have an impact in both short- and long-term morbidity of patients with congenital diaphragmatic hernia (CDH). We aimed to compare time to full enteral tube feeding depending on route -gastric (GT) or transpyloric (TPT)- in newborns with left CDH (L-CDH). METHODS: Retrospective cohort study of L-CDH patients admitted to a referral tertiary care NICU between January 2007 and December 2014. Lethal chromosomal abnormalities and death before initiation of enteral nutrition were exclusion criteria. RESULTS: 37 patients were fed through GT, 46 by TPT. TPT children took 11.0 (6.8) days to reach full enteral tube feeding and spent 16.6 (8.1) days on parenteral nutrition vs 16.8 (14.7) days (p = 0.041) and 22.7 (13.5) days (p = 0.020) of GT patients. TPT children had 3.9 (2.4) days of fasting due to GI issues and 20% had episodes of decreased rates of enteral nutrition for extra-GI complications vs 11.4 (11.1) days (p = 0.028) and 49% (p = 0.006). According to the best fitting model (R2 0.383, p < 0.001), the TPT-group achieved full enteral feeding 8.4 days earlier than the GT-group (95% CI -14.76 to - 2.02 days), after adjustment by severity of illness during the first days, o/e LHR_liver and class of diaphragmatic defect. There were no differences in growth outcomes and length of stay between survivors of GT and TPT groups. CONCLUSION: TPT shortens time to full enteral nutrition, especially in the most severe L-CDH patients. We propose that placement of a TPT at the end of the surgical repair procedure should be considered, especially in higher-risk patients. LEVEL OF EVIDENCE: Treatment study, Level III. Retrospective comparative, case-control study.

Duplicación quística intestinal: Caso clínico / Intestinal cystic duplication: Case report

Las duplicaciones intestinales quísticas son anomalías congénitas infrecuentes, con incidencia de 1:4500 autopsias y etiopatogenia incierta. Son estructuras quísticas, tubulares o diverticulares revestidas de mucosa gastrointestinal con pared de músculo liso, adheridas al tracto gastrointestinal, pero no suelen comunicar con la luz intestinal. Los quistes de duplicación gástrica representan el 7-9% de los quistes de duplicación intestinal. Pueden diagnosticarse intraútero mediante ecografía y la resonancia magnética fetal permite caracterizar el quiste y descartar patologías concomitantes. La ecografía posnatal revela una imagen quística de "doble pared". Los neonatos suelen permanecer asintomáticos, pero pueden presentar desde síntomas gastrointestinales inespecíficos hasta síntomas de obstrucción por efecto masa, torsión o infección. En pacientes asintomáticos, se aconseja el seguimiento clínico y estudios de imagen periódicos. El tratamiento es la resección quirúrgica electiva, de manera preferente, con técnicas mínimamente invasivas. Se presenta un caso con sospecha prenatal de quiste de duplicación enteral.

Intestinal cystic duplications are rare congenital anomalies, with an estimated incidence of approximately 1:4500 autopsies. The etiopathogenesis is uncertain. These duplications are cystic, tubular or diverticular structures lined with gastrointestinal mucosa. They share a common smooth muscle wall with the gastrointestinal tract but usually their lumens do not communicate with each other. Gastric duplication cysts represent 7-9% of the gastrointestinal tract duplication. They can be diagnosed prenatally by fetal ultrasound; magnetic resonance imaging characterizes the cyst and excludes other malformations. Postnatal ultrasound shows a characteristic double walled cyst. Newborns are usually asymptomatic, although nonspecific gastrointestinal symptoms, intestinal obstruction due to mass effect, volvulus or infection are described. In asymptomatic patients, clinical follow-up and periodic image controls are recommended. Elective surgical resection is the treatment of choice, using minimally invasive technique whenever possible. A case of prenatally suspected intestinal cystic duplication is presented.

[Intestinal cystic duplication. Case report]. / Duplicación quística intestinal. Caso clínico.

Intestinal cystic duplications are rare congenital anomalies, with an estimated incidence of approximately 1:4500 autopsies. The etiopathogenesis is uncertain. These duplications are cystic, tubular or diverticular structures lined with gastrointestinal mucosa. They share a common smooth muscle wall with the gastrointestinal tract but usually their lumens do not communicate with each other. Gastric duplication cysts represent 7-9% of the gastrointestinal tract duplication. They can be diagnosed prenatally by fetal ultrasound; magnetic resonance imaging characterizes the cyst and excludes other malformations. Postnatal ultrasound shows a characteristic double walled cyst. Newborns are usually asymptomatic, although nonspecific gastrointestinal symptoms, intestinal obstruction due to mass effect, volvulus or infection are described. In asymptomatic patients, clinical follow-up and periodic image controls are recommended. Elective surgical resection is the treatment of choice, using minimally invasive technique whenever possible. A case of prenatally suspected intestinal cystic duplication is presented.

Las duplicaciones intestinales quísticas son anomalías congénitas infrecuentes, con incidencia de 1:4500 autopsias y etiopatogenia incierta. Son estructuras quísticas, tubulares o diverticulares revestidas de mucosa gastrointestinal con pared de músculo liso, adheridas al tracto gastrointestinal, pero no suelen comunicar con la luz intestinal. Los quistes de duplicación gástrica representan el 7-9% de los quistes de duplicación intestinal. Pueden diagnosticarse intraútero mediante ecografía y la resonancia magnética fetal permite caracterizar el quiste y descartar patologías concomitantes. La ecografía posnatal revela una imagen quística de "doble pared". Los neonatos suelen permanecer asintomáticos, pero pueden presentar desde síntomas gastrointestinales inespecíficos hasta síntomas de obstrucción por efecto masa, torsión o infección. En pacientes asintomáticos, se aconseja el seguimiento clínico y estudios de imagen periódicos. El tratamiento es la resección quirúrgica electiva, de manera preferente, con técnicas mínimamente invasivas. Se presenta un caso con sospecha prenatal de quiste de duplicación enteral.

Long term outcome of preterm infants with isolated intestinal perforation: A comparison between primary anastomosis and ileostomy.

AIM OF THE STUDY: Management of isolated intestinal perforation (IIP) poses a challenge for the pediatric surgeon. Intestinal resection and primary anastomosis is considered to be as good as the classical approach, namely, intestinal diversion by ileostomy. However, few reports compare primary anastomosis and ileostomy as IIP treatment. In our institution we favored primary anastomosis as first line treatment whenever patient's condition permitted. Our purpose is to retrospectively compare the outcomes of preterm infants treated with primary anastomosis or ileostomy during a laparotomy in which an IIP was found. METHOD: We identified all newborns who had abdominal operations for IIP from 2000 through 2013. Patients with extensive necrotizing entorocolitis and comorbidities were excluded, as well as those who died in the first 24h. Demographics, type of treatment and complications were reviewed. Major complications included the need for an urgent reoperation, development of late NEC and death. RESULTS: Twenty-three patients with a median gestational age (GA) of 27weeks and median birth weight (BW) of 883g had receive two types of treatment: group I included 9 patients who had intestinal resection of the affected bowel and ileostomy; group PA consisted of 14 patients who had intestinal resection and primary anastomosis. The decision to perform PA or I was based on the surgeon's judgment, in the absence of a specific protocol. There were no significant differences in GA and BW between both groups. Overall mortality was 30.4%. However mortality was restricted to group PA (n=7 cases; 50%) (p=0.019). Most major complications occurred in group PA (71% vs. 11%, p=0.029). There were six cases of late NEC, all in group PA (p=0.048), and four of those patients died. Other than the type of treatment, no differences could be identified between both groups. CONCLUSION: Preterm newborns with IIP are at a higher risk for developing life-threatening complications if treated with primary anastomosis than with ileostomy.

Tratamiento del hipospadias proximal en un tiempo quirúrgico / Treatment of proximal hypospadias in one single surgical stage

Introducción. La corrección quirúrgica de los hipospadias proximalesgraves, especialmente los que se asocian con transposiciónpeno-escrotal (pene enterrado) es un reto para el cirujano pediá-Tractament d’hipospàdies proximals en un tempsquirúrgicMontserrat Castañón García-Alix, Jordi Prat Ortells, M. Elena Muñoz Fernández,Freud Cáceres Aucatoma, Josep Maria Ribó CruzServei de Cirurgia Pediàtrica. Unitat integrada Hospital Sant Joan de Déu-Clínic. Barcelona.trico. El tratamiento secuencial, con el fin de preservar la vascularizaciónde la neouretra y prevenir la lesión de la cobertura peneana,está ampliamente aceptado.Método. Entre 1997 i 2007, se han intervenido 88 pacientes con hipospadiasproximal grave. Desde el 2005, en los hipospadias contransposición, hemos asociado a la uretroplastia un nuevo diseñode la plastia cutánea.Resultados. La edad a la intervención se ha situado entre 15 y 64meses (mediana 29); 19 pacientes presentaban malformacionesasociadas (21,6%); 14 eran prematuros (16%). Todos fueron reparadosen un único tiempo quirúrgico. Uretroplastia tipos Ducketten 10, colgajo tipo Onlay en 74, injerto de mucosa oral tipo Onlayen 2 e injerto de mucosa vesical en 2. Complicaciones: 15 casos defístula uretro-cutánea (17%), 5 pacientes con estenosis uretral(5,7%) y 3 casos (3,4%) de necrosis del colgajo cutáneo (necesitaronuna nueva uretroplastia). Antes del 2005, 5 de los 22 pacientescon transposición peno-escrotal necesitaron una nueva plastiacutánea (asociada en 2 de ellos a una plicatura dorsal de Nesbitt).Desde el 2005, ninguno de los 11 pacientes con transposición hanecesitado una plastia peneana posterior. El seguimiento va de 1mes a 10 años (mediana 54 meses). Actualmente, el chorro urinarioes correcto en todos los casos y el pene permanece fuera delescroto, excepto en un paciente...(AU)

Background. The surgical correction of proximal severe hypospadias,particularly those associated with penoscrotal transposition(penis buried in scrotum), represents a major challenge for pediatricsurgeons. A sequential approach is widely accepted, with theaim of preserving the vascularization of the neourethra and avoidingdamage to the coverage of the penis.Method. Between 1997 and 2007, 88 patients with proximal severehypospadias underwent surgical correction. After 2005, for patientswith hypospadias with penoscrotal transposition, we performed asingle-stage urethroplasty in association with a new cutaneoplasty.Results. Age at the time of surgery ranged from 15 to 64 months(mean 29 months). Associated malformations were present in 19patients (21.6%), and 14 patients (16%) were premature. All patientsunderwent repair in one single surgical intervention. We performedDukett-type urethroplasty in 10 patients, Onlay-type flap in74, Onlay with oral mucosa in 2, and vesical mucosa urethroplastyin 2. The fistula rate was 17%; urethral stenosis was present in 5 patients(5.7%), and partial necrosis of the skin flap in 3 patients(3.4%) needing a re-urethroplasty. Before 2005, of the 22 patienswith penoscrotal transposition, 5 needed a new cutaneoplasty,which was associated to a dorsal Nesbitt plicature in 2 cases. After2005, none of the 11 patients presenting with penoscrotal transpositionneeded a posterior cutaneoplasty. With a median followupis 54 months (range 1 month to 10 years), urine flow and spurtare normal in all cases, and the penis is located outside of the scrotalbag in all but one patient. We consider that the esthetic resultswere satisfactory in most of the cases.Discussion. In our experience, all cases of hypospadias, includingthose associated with buried penis, can be repaired in one singlesurgical intervention(AU)