Spanish primary care in pediatric trauma (AITP) consensus: An AITP checklist. / Consenso AITP español: Una lista de verificación AITP.

INTRODUCTION: The course in Primary Care in Pediatric Trauma (ATIP in Spanish) has been taught in Spain since 1997, and there are currently 9 accredited training centers. Care of polytraumatized pediatric patients often takes place in an environment conducive to errors resulting from forgetfulness, which is why checklists - mnemonic tools widely used in industry and medicine - are particularly useful to avoid such errors. Although several checklists exist for pediatric trauma care, none have been developed within the setting of our course. MATERIALS AND METHODS: The criteria for being selected as an expert in Primary Care in Pediatric Trauma were agreed upon with the scientific polytrauma committee of the Spanish Pediatric Surgery Society. The items that make up the checklist were obtained from a review of the literature and consultation with selected experts, using the Delphi Technique. RESULTS: 10 experts representing the 9 groups or training centers in Primary Care in Pediatric Trauma were selected, and a 28-item checklist was drawn up in accordance with their design recommendations. CONCLUSIONS: With the consensus of all the groups, a checklist for the treatment of polytraumatized pediatric patients was drawn up using the Delphi Technique, an essential requirement for the dissemination of this checklist, which should be adapted and validated for use in each healthcare center.

INTRODUCCION: El curso de Asistencia Inicial al Trauma Pediátrico se imparte en España desde 1997, existiendo en la actualidad 9 centros formadores acreditados. La asistencia al paciente pediátrico politraumatizado se produce muchas veces en un ambiente proclive al error por olvido, por lo que las listas de verificación, como herramientas mnemotécnicas de amplia difusión en la industria y en medicina, serían especialmente útiles para evitarlos. Aunque existen varias listas de verificación para la asistencia al traumatismo pediátrico, ninguna se ha desarrollado en el entorno de nuestro curso. MATERIAL Y METODOS: Se acordaron los criterios para ser seleccionado como experto en Asistencia Inicial al Trauma Pediátrico con la comisión científica de politrauma de la Sociedad Española de Cirugía Pediátrica. Los ítems para formar la lista de verificación se obtuvieron a partir de una revisión bibliográfica y de la consulta a los expertos seleccionados, empleando un método Delphi. RESULTADOS: Se seleccionaron 10 expertos que representan los 9 grupos o centros formadores en Asistencia Inicial al Trauma Pediátrico y se elaboró una lista de verificación con 28 ítems, siguiendo sus recomendaciones de diseño. CONCLUSIONES: Se diseñó una lista de verificación para el manejo del paciente pediátrico politraumatizado, con el consenso de todos los grupos empleando un método Delphi, requisito fundamental para facilitar la difusión de esta lista. Sería preciso adaptar y validar dicha lista para su uso en cada centro asistencial.

Consenso AITP español: Una lista de verificación AITP / Spanish primary care in pediatric trauma (AITP) consensus: An AITP checklist

Introducción: El curso de Asistencia Inicial al Trauma Pediátricose imparte en España desde 1997, existiendo en la actualidad 9 centrosformadores acreditados. La asistencia al paciente pediátrico politraumatizado se produce muchas veces en un ambiente proclive al errorpor olvido, por lo que las listas de verificación, como herramientasmnemotécnicas de amplia difusión en la industria y en medicina, serían especialmente útiles para evitarlos. Aunque existen varias listas deverificación para la asistencia al traumatismo pediátrico, ninguna se hadesarrollado en el entorno de nuestro curso. Material y métodos: Se acordaron los criterios para ser seleccionado como experto en Asistencia Inicial al Trauma Pediátrico con lacomisión científica de politrauma de la Sociedad Española de CirugíaPediátrica. Los ítems para formar la lista de verificación se obtuvierona partir de una revisión bibliográfica y de la consulta a los expertosseleccionados, empleando un método Delphi. Resultados. Se seleccionaron 10 expertos que representan los 9grupos o centros formadores en Asistencia Inicial al Trauma Pediátri-co y se elaboró una lista de verificación con 28 ítems, siguiendo susrecomendaciones de diseño. Conclusiones: Se diseñó una lista de verificación para el manejodel paciente pediátrico politraumatizado, con el consenso de todos losgrupos empleando un método Delphi, requisito fundamental para facilitarla difusión de esta lista. Sería preciso adaptar y validar dicha lista parasu uso en cada centro asistencial.(AU)

Introduction: The course in Primary Care in Pediatric Trauma(ATIP in Spanish) has been taught in Spain since 1997, and there arecurrently 9 accredited training centers. Care of polytraumatized pedi-atric patients often takes place in an environment conducive to errorsresulting from forgetfulness, which is why checklists –mnemonic toolswidely used in industry and medicine– are particularly useful to avoidsuch errors. Although several checklists exist for pediatric trauma care,none have been developed within the setting of our course. Materials and methods: The criteria for being selected as an expertin Primary Care in Pediatric Trauma were agreed upon with the scientific polytrauma committee of the Spanish Pediatric Surgery Society.The items that make up the checklist were obtained from a review ofthe literature and consultation with selected experts, using the DelphiTechnique. Results: 10 experts representing the 9 groups or training centers inPrimary Care in Pediatric Trauma were selected, and a 28-item checklistwas drawn up in accordance with their design recommendations.Conclusions: With the consensus of all the groups, a checklist forthe treatment of polytraumatized pediatric patients was drawn up usingthe Delphi Technique, an essential requirement for the disseminationof this checklist, which should be adapted and validated for use in eachhealthcare center.(AU)

CT-guided hook-wire localization of pulmonary nodules in children prior to atypical resection by thoracoscopy: Practical aspects.

In the multidisciplinary treatment of pediatric oncologic patients, multiple imaging tests, biopsies, and resections are required for diagnosis, initial staging, and posterior restaging. In these patients, pulmonary nodules are not always metastases, so the correct diagnosis of these lesions affects their treatment and the patient's survival. Percutaneous localization of pulmonary nodules is key for two reasons: it enables the surgeon to resect the smallest amount of lung tissue possible and it guarantees that the nodule will be included in the resected specimen. Without percutaneous localization, it can be impossible to accomplish these two objectives in patients with very small nodules that are separated from the pleural surface and therefore impossible to see by thoracoscopy. This article reviews the technique for hook-wire localization of pulmonary nodules and the keys to ensuring the best results.

Wheat and barley can increase grain yield in shade through acclimation of physiological and morphological traits in Mediterranean conditions.

Major cereal yields are expected to decline significantly in coming years due to the effects of climate change temperature rise. Agroforestry systems have been recognized as a useful land management strategy that could mitigate these effects through the shelter provided by trees, but it is unclear how shade affects cereal production. Most cereal species and cultivars have been selected for full light conditions, making it necessary to determine those able to acclimate to low irradiance environments and the traits that drive this acclimation. A greenhouse experiment was conducted in central Spain to assess the photosynthetic response, leaf morphology and grain yield of nine cultivars of winter wheat (Triticum aestivum L.) and barley (Hordeum vulgare L.) at three levels of photosynthetic active radiation (100%, 90% and 50%). Cultivars were selected according to three different precocity categories and were widely used in the studied area. The main objective was to assess whether the species and cultivars could acclimate to partial shade through physiological and morphological acclimations and thus increase their grain yield for cultivation in agroforestry systems. Both species increased grain yield by 19% in shade conditions. However, they used different acclimation strategies. Barley mostly performed a physiological acclimation, while wheat had a major morphological adjustment under shaded environment. Barley had lower dark respiration (42%), lower light compensation point (73%) and higher maximum quantum yield (48%) than wheat in full light conditions, revealing that it was a more shade-tolerant species than wheat. In addition, to acclimate to low irradiance conditions, barley showed a 21% reduction of the carotenoids/chlorophyll ratio in the lowest irradiance level compared to 100% light availability and adjusted the chlorophyll a/b ratio, photosystem II quantum efficiency, electron transport rate and non-photochemical quenching to shade conditions. On the other hand, wheat showed a 48% increase in single leaf area in the 50% irradiance level than in full light to maximize light capture. Our results showed that current commercialized wheat and barley cultivars had sufficient plasticity for adaptation to shade, supporting tree presence as a tool to reduce the negative effects of climate change.

Heterotaxia-poliesplenia, abordaje del hiato esofágico para técnica de Nissen / Heterotaxy-polysplenia, approach to the esophageal hiatus for nissen technique

Introducción. La heterotaxia es un fallo en el desarrollo embrionario para la consecución de una simetría izquierda-derecha .Objetivo. Presentación de un caso de heterotaxia y mostrar una vía de abordaje para la fundoplicatura. Material y métodos. Niña con síndrome de heterotaxia-poliespleniacon reflujo gastroesofágico y dolor abdominal recurrente. Se decide realizar tratamiento antirreflujo laparoscópico con funduplicatura tipo Nissen con acceso derecho al hiato y a los pilares diafragmáticos. Conclusiones. Está en discusión la cirugía en este tipo de síndromes, indicándose únicamente en los casos de dolor abdominal recurrente, cuadros suboclusivos o cuando existe un diagnóstico de reflujo gastroesofágico; el dilema está entre el abordaje laparoscópico o la laparotomía clásica. La mayor dificultad del abordaje laparoscópico es la centralización de un hígado grande y la colocación del estómago a la derecha a pesar de que el hiato esofágico se sitúe normalmente en el lado izquierdo (AU)

Introduction. Heterotaxy is a failure in embryonic development to achieve left-right symmetry. Objective. To report a case of heterotaxy and show a surgical approach for fundoplication. Material and methods. A girl with heterotaxy-polysplenia syndrome with gastroesophageal refl ux and recurrent abdominal pain. It was decided to perform laparoscopic antire flux treatment with Nissen fundoplication with approach by the right side of the diaphragmatichiatus and pillars. Conclusions. Surgery is being discussed in these syndromes, indicatingonly in cases of recurrent abdominal pain, subocclusive lesions or when diagnosis of gastroesophageal refl ux is done. The dilemma is between laparoscopic or classical laparotomy. The main difficulty of the laparoscopic approach is the enlarged liver and stomach placement right despite the esophageal hiatus is normally on the left side (AU)

Distribución de la osteólisis periprotésica en la cadera. Estudio con resonancia magnética / Distribution of periprosthetic osteolysis in the hip: A study using magnetic resonance

Introducción. Con resonancia magnética es posible evaluar las lesiones óseas y de partes blandas secundarias a la producción de partículas de desgaste. Nuestro objetivo ha sido estudiar con este método la distribución de las lesiones en pacientes con un mismo tipo de componente acetabular no cementado. Material y método. Se incluyeron 40 artroplastias de cadera no cementadas con un cotilo poroso revestido de hidroxiapatita y multiperforado para anclaje opcional de tornillos con una evolución media de 13 años. Mediante estudios de imagen con resonancia magnética utilizando secuencias especiales de pulsos para disminuir los artefactos metálicos, se estudió la presencia, extensión y continuidad de la lesión granulomatosa y de las zonas de osteólisis. Resultados. Una cadera no fue susceptible de análisis. Se detectó lesión granulomatosa aislada en tres caderas y asociada a osteólisis en 32, sólo en pelvis en 10, sólo en el fémur en tres y en ambos segmentos en 19. En la pelvis la afectación fue, por zonas: ilion supra-acetabular en 15 caderas, rama isquio-pubiana en 24, isquion en 12 e isquion retro-acetabular en 21. Solo dos caderas y dos tornillos presentaban lesiones centrales aisladas del resto del granuloma. Comentarios y conclusiones. Con resonancia magnética ha sido posible estudiar las lesiones óseas y de partes blandas secundarias a desgaste. La distribución de las zonas de osteólisis ha seguido un patrón periférico propio de cotilos no perforados, destacando la existencia de escasas lesiones aisladas sobre los orificios o alrededor de los tornillos implantados coexistiendo con frecuencia afectación femoral proximal (AU)

Introduction. Magnetic resonance imaging (MRI) is useful in assessing bone and soft tissue lesions due to the production of wear particles. Our objective was to study the distribution of lesions in patients with one type of cementless acetabular component with this technique. Material and methods. We included 40 total hip arthroplasty with press-fitted hydroxyapatite porous-coated cup and multiple optional screw holes performed over a mean of 13years. We studied the presence, extent and continuity of the granulomatous lesion and osteolysis with MRI using special pulse sequences to reduce metal artefacts. Results. One hip was not amenable to analysis. An isolated granulomatous lesion was found in 3 hips, associated osteolysis in 32, in the pelvis only in 10, in the femur only in 3 and in both segments in 19. By zones, the pelvis involvement was supra-acetabular ilium in 15, ischium-pubic branch in 24, ischium in 12 and retro-acetabular ischium in 21. Only two hips and two screws central lesions were isolated from the granulomatous mass. Comments and conclusions. MRI osteolysis and soft tissue lesions secondary to wear to be studied. The distribution of osteolytic areas show a peripheral pattern typical of non-perforated acetabular cups frequently coexisting with proximal femoral involvement, highlighting few isolated lesions in the holes or around the implanted screws (AU)

Trees' role in nitrogen leaching after organic, mineral fertilization: a greenhouse experiment.

New sustainable agriculture techniques are arising in response to the environmental problems caused by intensive agriculture, such as nitrate leaching and surface water eutrophication. Organic fertilization (e.g., with sewage sludge) and agroforestry could be used to reduce nutrient leaching. We assessed the efficiency of establishing trees and pasture species in environmentally sensitive, irrigated Mediterranean grassland soils in controlling nitrate leaching. Four vegetation systems-bare soil, pasture species, cherry trees [ (L.) L.], and pasture-tree mixed plantings-and five fertilization treatments-control, two doses of mineral fertilizer, and two doses of organic fertilizer (sewage sludge)-were tested in a greenhouse experiment over 2 yr. In the experiment, the wet and warm climate characteristics of Mediterranean irrigated croplands and the plant-to-plant and soil-to-plant interactions that occur in open-field agroforestry plantations were simulated. Following a factorial design with six replicates, 120 pots (30-cm radius and 120 cm deep) were filled with a sandy, alluvial soil common in the cultivated fluvial plains of the region. The greatest pasture production and tree growth were obtained with sewage sludge application. Both pasture production and tree growth decreased significantly in the pasture-tree mixed planting. Nitrate leaching was negligible in this latter treatment, except under the highest dose of sewage sludge application. The rapid mineralization of sludge suggested that this organic fertilizer should be used very cautiously in warm, irrigated Mediterranean soils. Mixed planting of pasture species and trees, such as , could be a useful tool for mitigating nitrate leaching from irrigated Mediterranean pastures on sandy soils.

[Heterotaxy-polysplenia, approach to the esophageal hiatus for Nissen technique]. / Heterotaxia-poliesplenia, abordaje del hiato esofágico para técnica de Nissen.

INTRODUCTION: Heterotaxy is a failure in embryonic development to achieve left-right symmetry. OBJECTIVE: To report a case of heterotaxy and show a surgical approach for fundoplication. MATERIAL AND METHODS: A girl with heterotaxy-polysplenia syndrome with gastroesophageal reflux and recurrent abdominal pain. It was decided to perform laparoscopic antireflux treatment with Nissen fundoplication with approach by the right side of the diaphragmatic hiatus and pillars. CONCLUSIONS: Surgery is being discussed in these syndromes, indicating only in cases of recurrent abdominal pain, subocclusive lesions or when diagnosis of gastroesophageal reflux is done. The dilemma is between laparoscopic or classical laparotomy. The main difficulty of the laparoscopic approach is the enlarged liver and stomach placement right despite the esophageal hiatus is normally on the left side.

Endarterectomía retrógrda trans-inguinal en la isquemia crítica de los miembros inferiores / Remote endarterectomy in the critical limb ischaemia

OBJETIVOS. Mostrar los resultados del empleo de la endarterectomia retrógrada trans-inguinal de la ilíaca externa en pacientes con isquemia crítica. MÉTODOS. Se incluyen 15 pacientes, se completaron 13 endarterectomías, se registran complicaciones y seguimiento de la permeabilidad. Se analizaron las variables cualitativas con la prueba de “Chi cuadrado’. La permeabilidad fue seguida por el método de la Tabla de Vida. RESULTADOS. Realizamos 13 endarterectomías, ya que en dos casos no fue posible. Aplicamos procederes adicionales en el 76% de los pacientes: 6 profundaplastias, 2 derivaciones femoropoplíteas y 2 femoroplastias. Las complicaciones fueron las sepsis de la herida quirúrgica 2 pacientes imposibilidad de realizar el proceder dos casos y una amputación mayor. La permeabilidad fue del 92% a los 2 años. CONCLUSIONES. La endarterectomia retrógrada trans-inguinal de iliaca externa es segura y con buenos resultados en pacientes portadores de isquemiacrítica (AU)

PURPOSE. Shows results of trans-inguinal retrograde external iliac endarterectomy in patients with critical limb ischaemia. METHODS. 13 patients of 15 underwent trans-inguinal retrograde external iliac endarterectomy, complications rate and patency were reviewed and demographics analyzed. Chi square was use for categorical variables and patency was determined with table of life methods. RESULTS. Conversion to iliofemoral bypass was required in 2 patients, Initial technical success was achieved in 13 patients. Two of the patients developed surgical wound sepsis and one patient required mayor amputation. Were performed added procedures in 76% of the patients: profundaplasty in 6, femoroplasty in 2 and femoropoliteal bypass in 2. cumulative patience was 92% at 2 years. CONCLUSIONS. Trans-inguinal retrograde external iliac endarterectomy is safe and effective procedure for the patient with critical limb ischaemia (AU)

Tratamiento quirúrgico del nefroma mesoblástico congénito / Surgical treatment of congenital mesoblastic nephroma

Introducción. Los tumores renales son raros en niños menores de 6 meses, siendo el nefroma mesoblástico congénito el más frecuente en este grupo de edad. Presentamos 4 casos tratados en nuestro hospital en los últimos años. Material y métodos. Analizamos la edad, sexo, forma de presentación así como el diagnóstico y tratamiento de los 4 casos, revisando la literatura. Resultados. La edad de presentación osciló entre 0-6 meses. En nuestra serie el sexo que predominó fue el femenino. La clínica ha sido de masa abdominal en todos los casos, asociando hipertensión arterial en 2 de ellos. La ecografía ha sido el método de sospecha diagnóstica, en 2 de ellos deforma prenatal. El diagnóstico se completó con resonancia magnética. El tratamiento fue quirúrgico realizándose cirugía abierta en 3 casos y cirugía laparoscópica en el restante. La evolución ha sido favorable. Conclusión. La baja frecuencia de este tumor limita la experiencia en el diagnóstico y tratamiento. El tratamiento estándar es la nefrectomía radical con márgenes libres. La terapia coadyuvante en enfermedad recurrente puede ser considerada aunque existen pocos estudios. La cirugía laparoscópica comienza a constituir una alternativa al tratamiento clásico de estos tumores, ya que permite la extirpación con buenos márgenes de seguridad (AU)

Background. Renal tumors are rare in infants less than 6 months of age, being congenital mesoblastic nephroma the most frecuent in this age group. We reported 4 cases treated in our hospital in the last years. Methods. We analyze age, sex, the clinical presentation as well as diagnosis and treatment. Results. Range of age at diagnosis was 0-6 months. In our study the predominant sex was female. Clinical presentation was abdominal mass in all of cases with hypertension (HTA) in two of them. Scan ultrasound has been the method of dignostic, that was completed with Magnetic Resonance Imaging (MRI). The tretament was open surgery in three cases and laparoscopic on the last. All patients are alive with no evidence of disease. Conclusions. Low frecuency of this tumor limit the experience ondiagnostic and treatment. Standard treatment is nephroureterectomy radical with free margins. Adjuvant therapy should be considered in recurrent disease although exists few studies. Laparoscopic surgery should be an alternative to clasical treatment since permits excision with good security margins (AU)

[Surgical treatment of congenital mesoblastic nephroma]. / Tratamiento quirúrgico del nefroma mesoblástico congénito.

BACKGROUND: Renal tumors are rare in infants less than 6 months of age, being congenital mesoblastic nephroma the most frecuent in this age group. We reported 4 cases treated in our hospital in the last years. METHODS: We analyze age, sex, the clinical presentation as well as diagnosis and treatment. RESULTS: Range of age at diagnosis was 0-6 months. In our study the predominant sex was female. Clinical presentation was abdominal mass in all of cases with hypertension (HTA) in two of them. Scan ultrasound has been the method of dignostic, that was completed with Magnetic Resonance Imaging (MRI). The tretament was open surgery in three cases and laparoscopic on the last. All patients are alive with no evidence of disease. CONCLUSIONS: Low frecuency of this tumor limit the experience on diagnostic and treatment. Standard treatment is nephroureterectomy radical with free margins. Adjuvant therapy should be considered in recurrent disease although exists few studies. Laparoscopic surgery should be an alternative to clasical treatment since permits excision with good security margins.

Implication of the age in the clinical spectrum of giant cell arteritis.

OBJECTIVE: To assess the potential influence of the age in the clinical spectrum of giant cell arteritis (GCA). METHODS: The case records of all patients diagnosed with biopsy-proven GCA at the Department of Medicine of the Hospital Xeral-Calde (Lugo, Northwest Spain) between 1981 and 2006 were reviewed. RESULTS: During the period of study, 273 Lugo residents were diagnosed with biopsy-proven GCA. The mean age +/- standard deviation at the time of disease diagnosis was 75.1+/-6.8 years (median: 75 years; interquartile range 71-80 years). A longer delay to the diagnosis was observed in patients younger than 70 years of age (13.2+/-12.8 weeks) compared to those 70 years and older (9.4+/-10.2 weeks) (p=0.03). Patients younger than 70 years presented more frequently polymyalgia rheumatica (p=0.02), cerebrovascular accidents (p=0.004), peripheral arteriopathy of recent onset due to large artery stenosis (p=0.03) and high alkaline phosphatase values (p=0.001) than those 70 years and older. Individuals 70-79 years of age at the time of disease diagnosis had ESR values (90.2+/-22.8 mm/1st hour) lower than those observed in patients younger than 70 years (98.3+/-22.2 mm/1st hour) or 80 years and older (99.5+/-20.6 mm/1st hour) (p=0.005). However, no significant differences in the frequency of visual ischemic complications according to the age at the time of disease diagnosis were observed. CONCLUSION: The results from this study display differences in the clinical spectrum of the disease according to the age of disease onset.

[Use of laparoscopy in neonatal pathology: our experience]. / Uso de la laparoscopia en la patología duodenal: nuestra experiencia.

The neonatal duodenal pathology has been diagnosed and treated with open surgery for many years. The use of minimally invasive techniques is widely use today on pediatric surgery, but its use on neonatal pathology poses a challenge. We have conducted a study of the 8 neonatal patients with duodenal obstruction that were operated with a laparoscopy in our hospital between 2001 and 2007. The analyzed parameters were the gender, prenatal diagnostic, type of duodenal malformation, weight at birth, hospitalization stay, start of feeding, complications and follow-up. In our sample (6 girls and 2 boys) the 62.5% of the cases was diagnosed after a prenatal ultrasound scan. The duodenal malformations discovered were 5 atresias, 2 webs and 1 anular pancreas. In all the cases, the feeding started by means of a trans-anastomotic probe 48 hours postoperatives. There were 3 complications: one re-surgery and 2 stenosis of anastomosis. The average hospitalization stay was of 27 days with a mean follow-up of 3 years. We think that laparoscopy is a good method for the treatment of the neonatal duodenal pathology, although the scarce volume of our sample does not allow us to generalize the technique.

[Thoracoscopic lobectomy in patients with congenital cystic adenomatoid malformation]. / Lobectomía toracoscópica en pacientes con malformación adenomatoidea quística.

BACKGROUND: The management of asymptomatic patients with congenital cystic adenomatoid malformation (CCAM) is controversial. This report evaluates the video-assisted thoracoscopic (VAT) lobectomy in children with this malformation, and the different intraoperative complications and their resolution are discussed. METHODS: Six patients with CCAM underwent video-assisted thoracoscopic lobectomy. All the patients were under one year and all of them were asymptomatic at the diagnosis. The procedures were performed with single lung ventilation and the chest was insufflated with a low flow and pressure to complete collapse of the lung. We used 3 or 4 thoracoscopic ports depending on the difficulty of the dissection. A bipolar sealing device was the preferred mode of vessel ligation and bronchi were closed with interrupted sutures. The following features have been taken into account: age at diagnosis, localization, surgical technique, complications, hospital stay, results, and time of follow-up. RESULTS: Four lesions were on the right lower lobe (66.7%) and two (33.3%) in the middle lobe. All the procedures were completed thoracoscopically. Chest tubes were left in all cases. Two patients (33.3%) showed postoperative hemothorax but it didn't need blood transfusion. Mean hospital stay was 6 days. At the moment all the patients are asymptomatic with and the mean time of follow-up has been 2 years and 8 months. CONCLUSIONS: VAT lobectomy avoids the long-term morbidity associated to an open thoracotomy and therefore it is a safe and efficacious technique in asymptomatic children with CCAM. Moreover, a greater number of cases are necessary to validate and to improve the technique.

Uso de la laparoscopia en la patología duodenal: nuestra experiencia / Use of laparoscopy in neonatal pathology: our experience

La patología duodenal neonatal ha sido diagnosticada y tratada concirugía abierta durante muchos años. El uso de técnicas mínimamente invasivas es común hoy en día en la cirugía pediátrica, pero su utilización en neonatos supone un reto. Hemos realizado un estudio de 8 pacientes diagnosticados de obstrucción duodenal congénita que fueron intervenidos por vía laparoscópica en nuestro Hospital entre el 2001 y 2007.Los parámetros analizados fueron el sexo, diagnóstico prenatal, tipo de malformación duodenal, peso medio al nacimiento, tiempo quirúrgico, estancia hospitalaria, inicio de la alimentación, complicaciones y seguimiento. En nuestra muestra (6 niñas y 2 niños) el 62,5% fue diagnosticado tras ecografía prenatal. Las malformaciones duodenales halladas fueron5 atresias, 2 membranas y 1 páncreas anular. En todos ellos se inició la alimentación por sonda transanastomótica a las 48 horas posquirúrgicas. Hubo 3 complicaciones: una reintervención y 2 estenosis de la anastomosis. La estancia media hospitalaria fue de 27 días con un seguimiento medio de 3 años. Pensamos que la laparoscopia es un buen método para tratar la patología duodenal neonatal, aunque el escaso volumen de nuestra serie nos impide generalizar la técnica (AU)

The neonatal duodenal pathology has been diagnosed and treated with open surgery for many years. The use of minimally invasive techniques is widely use today on pediatric surgery, but its use on neonatal pathology poses a challenge. We have conducted a study of the 8 neonatal patients with duodenal obstruction that were operated with a laparoscopy in our hospital between 2001 and 2007. The analyzed parameters were the gender, prenatal diagnostic, type of duodenal malformation, weight at birth, hospitalization stay, start of feeding, complications and follow-up. In our sample (6 girls and 2 boys) the 62.5% of the cases was diagnosed after a prenatal ultrasound scan. The duodenal malformations discovered were 5 atresias, 2 webs and 1 anular pancreas. In all the cases, the feeding started by means of a trans-anastomotic probe 48 hours postoperatives. There were 3 complications: one re-surgery and 2 stenosis of anastomosis. The average hospitalization stay was of 27 days with a mean follow-up of 3 years. We think that laparoscopy is a good method for the treatment of the neonatal duodenal pathology, although the scarce volume of our sample does not allow us to generalize the technique (AU)

Lobectomía toracoscópica en pacientes con malformación adenomatoidea quística / Thoracoscopic lobectomy in patients with congenital cystic adenomatoid malformation

Introducción. El tratamiento de los pacientes asintomáticos con malformación adenomatoidea quística (MAQ) es controvertido. En este trabajo evaluamos la lobectomía por vía toracoscópica en pacientes condicha malformación analizando los diferentes aspectos técnicos, las complicaciones y su resolución. Material y métodos. Hemos intervenido 6 pacientes con diagnóstico de MAQ mediante toracoscopia. Todos los pacientes eran menores de un año y en ningún caso habían presentado síntomas. Se realizó toracoscopia con intubación selectiva y neumotórax controlado a baja presión y bajo flujo. Empleamos 3 ó 4 trócares en función de la dificultad de la disección. Para el control de la vascularización pulmonar utilizamos un sellador térmico y el cierre de los bronquios se realizó mediante sutura intracorpórea. Se han analizado los siguientes parámetros: edad, localización de lesión, técnica quirúrgica, complicaciones postquirúrgicas, estancia hospitalaria, resultado final y tiempo de seguimiento. Resultados. La lesión se localizó en lóbulo inferior derecho en cuatro ocasiones (66,7%) y en lóbulo medio en dos (33,3%) En los seis casos la lobectomía fue completada por vía toracoscópica con éxito. Dos pacientes (33,3%) presentaron hemotórax en el postoperatorio inmediato, que no precisó transfusión ni drenaje. El ingreso medio fue de 6días. Actualmente todos los pacientes están asintomáticos, con un tiempo de seguimiento medio de 2 años y 8 meses. Conclusión. El menor número de complicaciones y efectos secundarios de la lobectomía toracoscópica frente a la toracotomía convencional hacen de esta técnica una opción terapéutica válida y eficaz para el tratamiento de los pacientes asintomáticos con MAQ. No obstante, es necesario un mayor número de casos para validar y perfeccionar completamente la técnica (AU)

Background. The management of asymptomatic patients with congenitalcystic adenomatoid malformation (CCAM) is controversial. This report evaluates the video-assisted thoracoscopic (VAT) lobectomy in children with this malformation, and the different intraoperative complications and their resolution are discussed. Methods. Six patients with CCAM underwent video-assisted thoracoscopic lobectomy. All the patients were under one year and all of them were asymptomatic at the diagnosis. The procedures were performed with single lung ventilation and the chest was insufflated with a low flow and pressure to complete collapse of the lung. We used 3 or 4thoracoscopic ports depending on the difficulty of the dissection. A bipolar sealing device was the preferred mode of vessel ligation and bronchi were closed with interrupted sutures. The following features have been taken into account: age at diagnosis, localization, surgical technique, complications, hospital stay, results, and time of follow-up. Results. Four lesions were on the right lower lobe (66.7%) and two(33.3%) in the middle lobe. All the procedures were completed thoracoscopically. Chest tubes were left in all cases. Two patients (33.3%)showed postoperative hem thorax but it didn´t need blood transfusion. Mean hospital stay was 6 days. At the moment all the patients are asymptomatic with and the mean time of follow-up has been 2 years and 8months.Conclusions. VAT lobectomy avoids the long-term morbidity associated to an open (..) (AU)

Nuestra experiencia en el manejo endourológico de las litiasis en el tracto urinario en la infancia / Minimally invasive endourological management or urinary tract calculi in children

Introducción. La litiasis urinaria es un problema poco frecuente en la infancia. La cirugía endourológica (CEU) juega un papel cada vez más importante en su tratamiento. Mostramos nuestra experiencia en el empleo de este tipo de cirugía. Material y métodos. En el periodo entre 1992- 2006 se ha empleado CEU para el manejo y extracción de urolitiasis en 18 niños (rango de edad: 2 años- 17 años). Hemos realizado un estudio retrospectivo descriptivo, analizando: tamaño de la litiasis, localización, tipo de procedimiento, complicaciones quirúrgicas, recidiva, resultado final y tiempo de seguimiento. Resultados. Se han realizado 21 procedimientos endourológicos: nueve ureterorrenoscopias (43%), 10 extracciones vesicales endoscópicas(47,5%) y dos nefrolitotomías percutáneas (9,5%). El tamaño medio dela litiasis ha sido de 2,75 cm en las litiasis vesicales y de 6,3 mm. en las ureterales. Un paciente presentó un cálculo coraliforme. La localización del cálculo fue: en riñón en 2 ocasiones (9,5%), en uréter proximal en 2 (9,5%), en uréter distal en 7 (33,3%), en vejiga en 9 (43%) y en uretra en una (4,7%). El 55 % de los casos presentaban anomalías urológicas asociadas (6 pacientes con vejiga neurógena, dos con extrofiavesical, uno con ureterocele y uno con megauréter primario. Un paciente con una litiasis vesical y tres con litiasis ureterales (22% de los casos)requirieron cirugía abierta para la extracción del cálculo. El 16,5% delos casos (3 pacientes) presentaron recidiva y precisaron un nuevo procedimiento endoscópico. Actualmente los pacientes se encuentran libres de litiasis en los controles periódicos realizados. El tiempo de seguimiento medio ha sido de 2 años y 6 meses (rango de 1-13 años).Conclusiones. La CEU es una opción terapéutica válida y eficaz para el manejo de cálculos en la vía urinaria del niño. El desarrollo de nuevo instrumental endoscópico para el ámbito pediátrico permitirá ampliarlos criterios de selección de los pacientes (AU)

Background. The urinary tract calculi in children is a very unfrequent problem in the pediatric age group. Endourology plays a major role in pediatric surgery. We reported our experience in endoscopic management of pediatric calculi.Methods. Eighteen children (age range: 2 year- 19 years) underwent endourology procedures for extraction of urinary tract lithiasis in theperiod from 1992 until 2006. We reviewed retrospectively the following features: calculi size, location, procedures, surgical complications, recurrent, results and time of follow-up. Results. Twenty-one endourolgy procedures were performed: nine ureteroscopies(43%), 10 bladder extractions (47.5%) and two percutaneous nephrolithotomies (9.5%). The mean size bladder stone was 2,75cm. and 6,3 mm. in the ureteral stones. A patient had stag horn calculi. The stone was located in distal ureter in 7 occasions (33.3%), in upper ureter in 2 (9.5%), in kidney in 2 (9.5%), in bladder in 9 (43%) and in urethra in one (4.7%). Ten cases (55, 5%) had urology associated anomalies:6 patients neurogenic bladder, two bladder exstrophy, one ureterocele and one diagnosed of primary megaureter. Four patients (22%)underwent open surgery for the extraction of the lithiasis: a patient with a bladder stone and three cases with ureteral calculi. Three patients (16,5%) had recurrence of stones and were successfully treated with endoscopy procedure again. By the moment all the patients are stone-free. The time of follow-up has been 2 years and 6 months (range: 1-13 years).Conclusions. The end urology is a safe and effective therapeutic option for the management of urinary tract calculi in children. With improvements in instrumentation and technology, it will be possible to expand the patients’ selection criterion (AU)

¿Es útil el manejo inicial del megauréter primario con catéteres doble J? / Is effective the initial management of primary nonrefluxing megaureter with double -J stent?

Introducción. El manejo inicial de los pacientes con megauréter primario obstructivo no refluyente y mala función renal o con alto riesgo de deterioro de la función genera controversia. Presentamos nuestra experiencia en el empleo de catéteres doble J en dichos pacientes evaluando su utilidad para disminuir la dilatación ureteral, preservar la función renal o como medida transitoria para un futuro tratamiento quirúrgico. Material y métodos. Desde 1996- 2006 27 pacientes fueron diagnosticados de megauréter primario obstructivo no refluyente (MPONR). Los pacientes se clasificaron en dos grupos según el tratamiento inicial recibido: los que se manejaron de manera expectante y los tratados con catéter doble J durante 6 meses. Se reevaluó a los 12 meses del diagnóstico el primer grupo y a los tres meses de la retirada del catéter el segundo, interviniéndose aquellos pacientes que presentaron una curva de eliminación obstructiva en ese momento. Hemos analizado los siguientes parámetros: edad, sexo, la función renal previa y posterior al tratamiento, la morbilidad asociada a la colocación del catéter, la curva de eliminación renográfica después del manejo inicial, tipo de intervención en los pacientes operados, necesidad de modelaje, resultado final y tiempo de seguimiento. Resultados. Quince casos fueron tratados de manera expectante. A los 12 meses la curva de eliminación continuaba siendo obstructiva en 8 pacientes (53,3%), y en 7 mostraba un patrón no obstructivo(46,7%) La función renal empeoró en dos casos (15,4%), siendo en uno de ellos inferior al 10%. Ocho pacientes fueron intervenidos (53,3%), realizándose 7 ureteroneocistostomías y una nefrectomía. Cuatro casos precisaron modelaje ureteral (57,1%). Doce pacientes fueron manejados inicialmente mediante colocación de catéter doble J. En 5 casos (41,7%) hubo complicaciones asociadas a la colocación del catéter: 2 migraciones proximales, dos migraciones distales y una infección. A los 3 meses de la retirada del catéter 6 pacientes(50%) presentaban una curva de eliminación obstructiva, y el resto un patrón no obstructivo (50%). En uno de los pacientes con la función renal inicial menor del 40%, la función empeoró hasta hacerse menor del 10%. Seis pacientes precisaron tratamiento quirúrgico (50%), una nefrectomía y 5 ureteroneocistostomías, sin precisar en ningún caso modelaje. El tiempo de seguimiento ha sido de 2 años y 7 meses en el primer grupo y de 3 años y 3 meses en el segundo. Conclusiones. La morbilidad asociada a la colocación del catéter doble J y la no mejoría con respecto al grupo manejado de manera expectante hace necesario la creación de criterios más rigurosos para el empleo del catéter doble J como medida transitoria a una futura cirugía en los pacientes con MPONR (AU)

Background. Initial management of patients with primary nonrefluxing megaureter (PNRM) associated with impaired renal function or with high risk rate of decreased kidney function can be a dilemma. We present our experience in the use of double -J stent in these patients to evaluate the role as a method to decompressing the system, to prevent function loss or to temporize surgical treatment. Methods. In the period 1996 - 2006 27 patients were diagnosed of PNRM. The patients classified themselves in two groups according to the initial treatment received: those with conservative management and those managed with double- J stent insertion during 6 months. A complete reassessment was performed after one year from the diagnosis in the first group and three months after stent removal in the second one. Patients underwent uretereral replantation if, at assessment, an obstructed excretion pattern was found on diuretic testing. The following data have been studied in each case: age at diagnosis, sex, renal function previous and after the treatment, morbidity associated to the double-J stent insertion, excretion pattern on diuretic testing after initial management, surgical technique, ureteral tapering, outcome and time of follow-up. Results. 15 cases were managed with conservative conduct. After a 12 month period an obstructed excretion pattern was found on diuretic testing in eight patients (53, 3%), and an unobstructed one in seven (46.7%). The differential function of the affected kidney got worse in two cases (15, 4%), being in one of them less than 10%. Eight patients underwent a surgical intervention (53, 3%), in seven cases was performed ureteral reimplantation and in one case was performed a nefrectomy. Four cases needed ureteral tapering (57, 1%).Twelve patients were selected to undergo double- J stent insertion for al 6-month period. Stent-related complications developed in 5 cases (41, 7%), including upper migration in two cases, distal migration in two and breakthrough infections in one patient. At reassessment three months after stent removal, 6 patients (50%) presented an obstructive pattern and the other cases an unonobstructive pattern (50%). In one of the patients with impaired function, the kidney function got worse until becoming smaller than 10%. Six patients underwent surgical treatment (50%), a nefrectomy and 5 ureteral reimplantation. None case neededureteral tapering. Mean time of follow-up has been 7 months in the first group and 3 years and 3 months in the second one. Conclusions. Double- J stent insertion in patients with PNRM is associated with high morbidity and there weren´t differents in the final outcomes between both groups, therefore it´s necessary to create severe prognosis indicators to use the double-J stent as a method to temporize a surgical treatment (AU)

[The role of tracheobronchial stenting in the management of pediatric airway obstruction]. / El papel de las prótesis traqueobronquiales endoluminales en la patología obstructiva de la vía aérea del niño.

PURPOSE: Tracheobronchial stenting can aid in the management of pediatric airway problems. We reviewed our experience to determine the role of endoscopic airway stents in children. METHODS: Sixteen children (Age range: 10 days- 19 years) underwent 28 tracheobronchial stents in the period 1991-2006. The stent type chosen depended on patient age and location. All procedures were done under general anesthesia with bronchoscopy. The following features have been taken into account: etiology, obstruction diagnosis, stent type, localization,,associated anomalies, complications, results, and time of follow-up. RESULTS: Etiology of the tracheobronchial obstruction included tracheobronchiomalacia in 13 patients (81.3%), tracheal stenosis in 2 (12.5%) and glotic stenosis in one case (6.2%). The stent used were 15 Palmaz (53.5%), 7 Dumon (25%), 4 Montgomey (14.5%), 1 Poliflex (3.5%) and one Dynamic stent (3.5%). More than one stent were undertaken in seven cases (43.7%). 16 patients had tracheal stents, 11 children had bronchial stent and one infant a carinal stent. Five complications are reported (two patients developed granulation tissue, two stents migrated, and a child presented a left lung atelectasis) and five patients died (only one case related to tracheobronchial stenting). Results have been satisfactory in 14 patients (87.5%) and the mean time of follow-up has been two years and ten months (range 2 months- 12 years and 6 months). CONCLUSIONS: The tracheobronchial stenting in children may represent a valid treatment option for many sick children in particular circumstances. The long-term outcome remains uncertain but the medium-term outlook is encouraging.

Resultados iniciales del tatamiento de la hernia inguinal por vía laparoscópica / Laparoscpic inguinal herniorrhaphy in children. First results

Introducción: La herniorrafía inguinal tiene una nueva alternativa, la vía laparoscópica. En este trabajo analizamos los resultados iniciales obtenidos mediante esta técnica en el tratamiento de la hernia inguinal, en nuestro hospital, evaluando las indicaciones y su eficacia. Material y métodos: Estudiamos 150 pacientes con diagnóstico de herniainguinal o crural. La técnica la efectuamos con tres trócares: unoumbilical de 5mm para la óptica y dos de 3 mm situados en ambos flancos. La reparación se realizó con bolsa de tabaco, sutura continua o puntos sueltos, utilizando siempre material irreabsorbible. Resultados: Las indicaciones fueron: hernia inguinal recidivada en el12%, hernia inguinal bilateral en el 28%, asociación de hernia inguinal unilateral y hernia umbilical en el 39%, hernia crural en el 4% y en el16% se reparó la hernia al ser encontrada incidentalmente. En la mayoría de los casos (137) el cierre del anillo inguinal se realizó mediante una sutura en bolsa de tabaco sin sección del peritoneo, en 11 se hizo una sutura continua y en 12 casos se cerró mediante puntos sueltos. No hubo reconversión en ningún caso. Se produjo hematoma por punción de los vasos espermáticos en 6 casos (1,4%). Inicialmente el ingreso fue de 1 a 2 días; actualmente lo hacemos de forma ambulatoria. Hemos tenido 2 casos de recidiva (1%) que fueron tratados por vía laparoscópica. Conclusiones: Aunque el número de pacientes tratados impide sacar unas conclusiones definitivas pensamos que el tratamiento laparoscópico de las hernias inguinocrurales, puede ofrecer ciertas ventajas sobre la vía abierta en casos seleccionados (AU)

Introduction: The inguinal hernia repair in the child has anew alternative, the laparoscopic repair. We study our initial results obtained with this technique. We evaluate the indications and the efficiency. Material and methods: 150 patients have been operated with an initial diagnosis of hernia inguinal or crural. Usually this technique is realized with three ports: we put the umbilical one (5mm) for the scope and two ports (3mm) placed in flanks. The repair was realized in purse string fashion or interrupted or no interrupted suture with non-absorbable suture (polipropylen) 3-4/0.Results: Indications of the herniorraphy were: (12 %) recurrent hernia, bilateral hernia (28 %), association inguinal hernia inguinal and umbilical(39 %), crural hernia (4 %) and in 16 % incidental hernia. Most of them (137) was treated in purse string fashion, (11) non interrupted suture and 12 interrupted suture. No conversion to open was require in any case. Haematoma for puncture of the spermatic vessels was seen in6 cases (1'4 %). Today we do this surgery in ambulatory way. We have had 2 recurrent hernias (1 %) that were treated again laparoscopicaly Conclusions: We can’t extract conclusion from this study because of the number of patients but we think that the laparoscopic treatment of inguinal hernias can offer advantages in selected cases (AU)