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)

[Dog bites, a current problem in our environment]. / Mordeduras de perro, un problema vigente en nuestro entorno.

AIMS: Dog bites are frequent reason for consultation in pediatrics emergency department. Despite in our environment dog bites are rarely lethal, some of these accidents can have serious aesthetics consequences. The main goal of this article is to analyze dog bites casuistry and their impact in our community. MATERIAL AND METHODS: Retrospective review of patients treated for dog bite in a tertiary pediatric center between 2013-2018. We studied patient's demographic variables, bite localization, dog-patient relationship, antibiotic therapy, need for admission, complications and secondary sequelae. RESULTS: 256 cases were analyzed (average age 6.4 years), 133 boys (51.9%) and 123 girls (48%). In 153 cases, the aggressor dog was from the patient's familiar environment (59.8%). The most frequent location of the wounds was head and neck (94.1%), followed by extremities (4.7%) and genitals (1.6%). In 227 cases (88.7%) antibiotics were administered. Wound infection was the most frequent complication, occurring in 5 patients (2%). 20 patients (7.8%) required hospital admission with a mean stay of 1.6 days. Aesthetic sequelae were described in 10 cases (3.9%), 7 of which required correcting surgery. CONCLUSIONS: Dog bites persist as a frequent reason for medical consultation, most of them are provoked by patient familiar dogs. Wound infection represents the major complication, and the facial aesthetic sequelae are the most frequent indication for surgical intervention. We consider due to the amount of dog bites and their sequelae, the inclusion of preventive measures against these accidents in home prevention guidelines could be useful to reduce the incidence of these injuries.

OBJETIVOS: Las mordeduras de perro son motivo de consulta habitual en urgencias pediátricas. Si bien en nuestro medio raramente son letales, algunas conllevan secuelas estéticas graves. El objetivo del trabajo es analizar la casuística de mordeduras de perro y su repercusión en nuestro entorno. MATERIAL Y METODOS: Revisión retrospectiva de pacientes atendidos por mordedura de perro en un centro pediátrico terciario entre 2013-2018. Estudiamos variables demográficas, localización de mordedura, relación perro-paciente, antibioterapia, necesidad de ingreso, complicaciones y secuelas derivadas. RESULTADOS: Se analizaron 256 casos (edad media 6,4 años), 133 niños (51,9%) y 123 niñas (48%). En 153 casos el perro agresor era del entorno del paciente (59,8%). La localización más frecuente de heridas fue cabeza y cuello (94,1%), seguida de extremidades (4,7%) y genitales (1,6%). En 227 casos (88,7%) se administró antibiótico. La complicación más frecuente fue la infección de herida en 5 pacientes (2%). Precisaron ingreso hospitalario 20 pacientes (7,8%) con estancia media de 1,6 días. Se describieron secuelas estéticas en 10 casos (3,9%), 7 precisaron cirugía correctora. CONCLUSIONES: Las mordeduras de perro persisten como motivo frecuente de consulta, produciéndose mayoritariamente por perros del entorno del paciente. La infección de herida representa la complicación más común, y la secuela estética facial supone la indicación más frecuente de intervención quirúrgica. Consideramos que por la cantidad de mordeduras y sus secuelas, la inclusión de medidas preventivas ante estos accidentes en guías de prevención del hogar, podría ser de utilidad para concienciar a la población y disminuir la incidencia de estas lesiones.

[Should the laparoscopic approach be avoided in a Nissen fundoplication procedure?] / ¿Debe evitarse el abordaje laparoscópico en la cirugía antirreflujo?

OBJECTIVE: A recently published trial concludes that the recurrence of GER by laparoscopic fundoplication (LF) is higher than by open surgery (OF) modifying their informed consent and the surgery approach. Objective: To analyze our results to assess changing clinical practice where the laparoscopy is the approach of choice. MATERIAL AND METHODS: Retrospective study of patients undergoing laparoscopic fundoplication between 2010-2015. The same criteria of the reference clinical trial were applied in the collected data and recurrence criteria. RESULTS: 56 patients were operated. Our patients were comparable on sex and neurological injury to those of the study. Our average follow-up was 2.6 years (0.07-6.3). During the monitoring period there were five recurrences. The relative risk (RR) of failure in the LF group was 4 times higher than ours (RR 4.19; 95% CI, 1.66-10.5). Our survival was 90% per year. Multivariate analysis was performed (Cox regression controlling neurological injury, esophageal atresia and after gastrostomy). Neurological injury (p= 0.01) was the only risk factor for recurrence. CONCLUSION: A clinical trial is not enough to change clinical practice, but it motivates further studies. According to our review, the results suggest no increased risk of recurrence with laparoscopy but long-term monitoring is necessary.

OBJETIVO: Un ensayo publicado recientemente concluye que la recurrencia del reflujo gastroesofágico mediante funduplicatura laparoscópica (FL) es mayor que en cirugía abierta (FA) modificando así su consentimiento informado y la vía de abordaje. Objetivo: analizar nuestros resultados para valorar modificar la práctica clínica donde el abordaje de elección es la laparoscopia. MATERIAL Y METODOS: Estudio retrospectivo de pacientes intervenidos de enfermedad por reflujo gastroesofágico entre el 2010-2015. En la recogida de datos así como en los criterios de recidiva se aplicaron los mismos criterios que los del ensayo clínico de referencia. RESULTADOS: Se intervinieron 56 pacientes. Nuestros pacientes fueron comparables a los del estudio en cuanto al sexo y al daño neurológico. Nuestra media de seguimiento fue 2,6 años (0,07-6,3). Durante este periodo se produjeron cinco recidivas. El riesgo relativo (RR) de fracaso en su grupo de FL multiplica por 4 el nuestro (RR 4,19; IC 95%: 1,66-10,5). Nuestra supervivencia fue del 90% al año. Realizado un análisis multivariante (regresión de Cox controlando daño neurológico, atresia de esófago y gastrostomía previa) solo el daño neurológico (p= 0,01) fue factor de riesgo de recidiva. CONCLUSION: Puesto que un ensayo clínico no es suficiente para modificar la práctica clínica, es necesaria la realización de más estudios. De acuerdo a la revisión realizada, actualmente nuestros resultados no sugieren mayor riesgo de recidiva con laparoscopia pero es necesario un seguimiento a largo plazo.

No es una neumonía, es una hernia diafragmática / It's not pneumonia, it's a diaphragmatic hernia

No disponible

Hipo y estómago horizontalizado como signos de vólvulo gástrico / Hiccups and horizontal stomach: Signs of gastric volvulus

No disponible

Vólvulo intestinal secundario a duplicación yeyunal / Intestinal volvulus due to yeyunal duplication

La duplicación intestinal (DI) es una malformación congénita rara que puede aparecer en todo el tracto digestivo, siendo la localización más frecuente el íleon. Muchas de ellas se diagnostican de forma incidental. Sin embargo, algunos pacientes presentan una combinación de dolor y síntomas obstructivos o complicaciones como obstrucción intestinal (vólvulo, invaginación o compresión extrínseca), hemorragia y/o perforación. Presentamos el caso de una paciente con dolor abdominal intermitente de dos meses de evolución que se asociaba a vómitos. La analítica de sangre fue normal y en las pruebas radiológicas (ecografía y resonancia magnética) se objetivó una imagen quística acompañada de vólvulo intestinal. La paciente fue sometida a una laparotomía en la que se realizó devolvulación y exéresis de los quistes. El dolor abdominal es causa frecuente de consulta. Entre las causas posibles, deben tenerse presentes etiologías no tan frecuentes pero potencialmente graves como las malformaciones digestivas y sus complicaciones

Duplications of the alimentary tract are congenital malformations. The ileum is the most commonly affected organ. A lot of duplications are incidentally diagnosed but most of patients present a combination of pain or complications such as obstructive symptoms, intestinal intussusception, perforation or volvulus. We report the case of a 6-years-old girl, with intermittent abdominal pain and vomits for two months long. Laboratory work was completely normal and in the radiology analysis (abdominal sonography and magnetic resonance) a cystic image with intestinal volvulus was observed. The patient underwent laparotomy, Ladd’s procedure was done and the cyst was resected. In conclusion, if a patient is admitted with abdominal pain and obstructive symptoms, it is important to consider duplication of the alimentary tract as a possible diagnosis

[Endoscopic sclerosis with pneumatic distension for pyriform sinus fistula treatment]. / Esclerosis endoscópica con distensión neumática para el tratamiento de las fístulas del seno piriforme.

Classic treatment for pyriform sinus fistula (PSF) has been surgical excision; however, less invasive therapeutic alternatives whose aim is the obliteration of the sinus have been described subsequently. The authors present a technical modification of endoscopic sclerosis with diathermy (ESD): continuous infusion of air flow through the flexible endoscope was used to distend the pyriform sinus and facilitate recognition of the fistula opening. The sinus obliteration was performed with a wire guide and diathermy. In the last 15 years, 9 patients were diagnosed of suffering from PSF in our institution. Initial treatment was antibiotics therapy associated in some cases to cervical abscess drainage. Fistulectomy was performed in 4 cases and ESD in 4. The ninth patient received both treatments, performing electrocauterization after a surgical recurrence. Three of the patients who underwent surgery relapsed; none treated by ESD did, or had any complications. In our experience, endoscopic sclerosis with pneumatic distension is a simple technique, reproducible, not invasive and very effective; hence we consider it might become a first line therapy for PSF.

Esclerosis endoscópica con distensión neumática para el tratamiento de las fístulas del seno piriforme / Endoscopic sclerosis with pneumatic distension for pyriform snus fistula treatment

El tratamiento clásico de la fístula seno piriforme (FSP) ha sido la exéresis quirúrigca del trayecto fistuloso, sin embargo posteriormente se han desarollado alternativas menos invasivas que tratan de obliterar el seno. Los autores presentan una modificación técnica de la esclerosis endoscópica con diatermia (ED): aplicar un flujo de aire fl ujo de aire continuo a través del endoscopio fl exible que favorece la distensión del seno piriforme y así la visualización del orifi cio de apertura de la fístula. Se utilizó una guía metálica y diatermia para obliterar el trayecto fi stuloso. En los últimos 15 años se diagnosticaron 9 pacientes de FSP en nuestro centro. El tra-tamiento inicial fue antibioterapia, en algunos casos asociada al drenaje del absceso cervical. Se procedió a la fi stulectomía en 4 casos y a la ED en otros 4. El noveno paciente recibió tratamiento mixto, realizando la electrocauterización tras una recidiva quirúrgica. Mientras que tres casos tratados quirúrgicamente recidivaron, ninguno tratado mediante ED lo hizo ni presentó complicaciones. En nuestra experiencia, la es-clerosis endoscópica con distensión neumática es una técnica sencilla, reproducible, poco agresiva y muy efectiva, por lo que creemos que podría convertirse en la terapia de primera elección para esta patología

Classis treatment for pyriform sinus fistula (PSF) has been surgical excision: however, less invasive therapeutic alternatives whose aim is the obliteration of the sinus have been described subsequently. The authors present a technical modification of endoscopic sclerosis with diathermy (ESD): continuous infusion of air fl ow through the fl exible endoscope was used to distend the pyriform sinus and facilitate recognition of the fi stula opening. The sinus obliteration was performed with a wire guide and diathermy. In the last 15 years, 9 patients were diagnosed of suffering from PSF in our institution. Initial treatment was antibiotics therapy associated in some cases to cervical abscess drainage. Fistulectomy was performed in 4 cases and ESD in 4. The ninth patient received both treatments, perform-ing electrocauterization after a surgical recurrence. Three of the patients who underwent surgery relapsed; none treated by ESD did, or had any complications. In our experience, endoscopic sclerosis with pneumatic distension is a simple technique, reproducible, not invasive and very ef-fective; hence we consider it might become a fi rst line therapy for PSF

[Intestinal volvulus due to yeyunal duplication]. / Vólvulo intestinal secundario a duplicación yeyunal.

Duplications of the alimentary tract are congenital malformations. The ileum is the most commonly affected organ. A lot of duplications are incidentally diagnosed but most of patients present a combination of pain or complications such as obstructive symptoms, intestinal intussusception, perforation or volvulus. We report the case of a 6-years-old girl, with intermittent abdominal pain and vomits for two months long. Laboratory work was completely normal and in the radiology analysis (abdominal sonography and magnetic resonance) a cystic image with intestinal volvulus was observed. The patient underwent laparotomy, Ladd's procedure was done and the cyst was resected. In conclusion, if a patient is admitted with abdominal pain and obstructive symptoms, it is important to consider duplication of the alimentary tract as a possible diagnosis.

Biloma como complicación tras traumatismo abdominal cerrado. Revisión de la literatura relativa a fugas biliares / Biloma as a complication after closed abdominal trauma. Review of the literature after bile leaks

Las fugas biliares son una complicación rara secundaria al traumatismo hepático cerrado. El diagnóstico de esta entidad es, por lo general, tardío, lo que incrementa la morbilidad y la estancia hospitalaria. Apropósito de un caso diagnosticado en nuestro centro de biloma secundario a traumatismo hepático severo, hacemos una descripción del mismo incluido diagnóstico y medidas de tratamiento. Se describen a continuación los distintos tipos de fugas biliares, las técnicas de diagnóstico precoz y las diversas modalidades de tratamiento existentes para este tipo de lesiones (AU)

Bile leaks are a rare complication secondary to closed liver trauma. The diagnosis is usually late, which increases the morbidity and hospital stay. We report a case of biloma secondary to severe liver injury, including a description of the diagnosis and management. We also describe the different types of bile leaks, the techniques of early diagnosis and various treatment modalities existing for this type of injury (AU)

[Congenital choledochal cyst and laparoscopic techniques]. / Tratamiento quirúrgico del quiste de colédoco mediante cirugía laparoscópica mínimamente invasiva.

The authors present a 5-year-old girl with a congenital choledochal cyst and repeated cholangitis. On laparoscopy, a type I choledochal cyst of Todani classification was confirmed. The cyst was excised laparoscopically. After exteriorization of the small bowel through the umbilical incision, a Roux-en Y anastomosis was performed. Then the bowel was reintroduced into the abdominal cavity and a laparoscopic end-to-side hepaticojejunostomy was carried out. There were not intra or post operative problems. Oral food intake started at 72 hours and the patient was discharged on day 5 without complications and with excellent cosmetic results. We conclude that laparoscopic techniques are an excellent option for the resection of congenital choledochal cyst and hepaticojejunostomy in children.

Tratamiento quirúrgico del quiste de colédoco mediante cirugía laparoscópica mínimamente invasiva / Congenital choledochal cyst and laparoscopic techniques

Presentamos el caso de una paciente de 5 años con quiste de colédoco y repetidas crisis de colangitis. La colangiografía realizada durante la intervención confirmó la existencia de un quiste tipo I de Todani. La resección del quiste se realizó íntegramente por laparoscopia. El montaje en “Y” de Roux se realizó exteriorizando las asas intestinales a través del puerto umbilical. Tras la reintroducción del montaje en la cavidad abdominal, la anastomosis hepatoentérica (termino- lateral) se realizó mediante técnica laparoscópica. No hubo problemas intraoperatorios y el postoperatorio cursó sin incidencias, iniciándose la alimentación oral a las 72 horas de la intervención con una rápida recuperación postoperatoria que permitió que la paciente fuera dada de alta al 5º día de la intervención. Tras 6 meses de seguimiento postoperatorio, la paciente se encuentra clínicamente asintomática y con excelentes resultados estéticos. Consideramos que la aplicación de las técnicas laparoscópicas es una excelente opción para la resección del quiste de colédoco congénito y la derivación bilioentérica en el paciente pediátrico (AU)

The authors present a 5-year-old girl with a congenital choledochal cyst and repeated cholangitis. On laparoscopy, a type I choledochal cyst of Todani classification was confirmed. The cyst was excised laparoscopically. After exteriorization of the small bowel through the umbilical incision, a Roux-en Y anastomosis was performed. Then the bowel was reintroduced into the abdominal cavity and a laparoscopic end-to-side hepaticojejunostomy was carried out. There were not intra or post operative problems. Oral food intake started at 72 hours and the patient was discharged on day 5 without complications and with excellent cosmetic results. We conclude that laparoscopic techniques are an excellent option for the resection of congenital choledochal cyst and hepaticojejunostomy in children (AU)

[Wandering spleen syndrome in childhood]. / Síndrome del bazo errante en la infancia.

Wandering spleen is a clinical condition in which an absence of ligaments and a long vascular pedicle allows the spleen to move freely in the abdomen. It is a rare entity in children but the exactly incidence is unknown because most of them are asymptomatic. The most common form of presentation is acute, chronic or intermittent abdominal pain caused by spleen torsion. Ultrasonography is the elective diagnostic method, but frequently diagnosis is made after surgery. We report two cases with acute splenic torsion in children and we discuss the clinical presentation, etiology, diagnostic procedures and management. We conclude that splenopexy--if possible--is the treatment of choice in children.

[Vesicostomy in children]. / Vesicostomía en la edad pediátrica.

OBJECTIVES: To evaluate the upper urinary tract morphology and function in children undergoing vesicostomy for different causes. METHODS: We report on 27 children aged 1 month to 12 years who had undergone a Blocksom vesicostomy procedure. Twenty had a neuropathic bladder and 3 had posterior urethral valves. RESULTS: In the 20 children with neuropathic bladder, renal function improved in 95% and the associated vesicoureteral reflux improved in 56%. The morphology of the upper urinary tract returned to normal prior to the definitive operation in all cases. Only one of the patients with posterior urethral valves has preserved satisfactory renal function two years following vesicostomy. The most common complication was prolapse (14.8%). CONCLUSIONS: In our view, vesicostomy is the best urinary diversion procedure in the cases described herein. Vesicostomy closure must be performed following definitive treatment of the underlying condition, except in those cases with neuropathic bladder who require augmentation cystoplasty to keep upper urinary tract pressures low.

[Outcome of hypertrophic pyloric stenosis after pyloromyotomy]. / Evolución de la estenosis hipertrófica de píloro tras la piloromiotomía.

Twenty four patients diagnosed and operated of hypertrophic pyloric stenosis were examined by ultrasonography at diagnostic and sequential after pyloromyotomy. We measured pyloric diameter, thickness and length of the muscle and we calculated the pyloric volume. The overall configuration of the pylorus is more important than specific pyloric dimensions for diagnosis. The pyloric volume is the most discriminating criterion. Sequential sonograms at one and four months showed that all measurements fell to normal levels within four weeks, except pyloric volume.

[Scimitar syndrome: series of 12 cases]. / Síndrome de la cimitarra: serie de 12 casos.

Our experience in 12 cases of pediatric patients with scimitar syndrome is reported. Except for one, all of them presented cardiac or respiratory manifestations. The symptomatology was related to associated defects (3 atrial septal defects and 1 multiple peripheric pulmonary stenosis), degree of pulmonary hypoplasia, size of the right to left shunt and pulmonary hypertension. 3 patients underwent surgical treatment. One of them died during operation and the other two have had a good evolution. Nine patients with later respiratory manifestations have improved their condition progressively without surgical intervention. Therapeutic approach for patients with scimitar syndrome, respiratory manifestations and onset beyond the neonatal period, should be conservative.