Application of botulinum toxin in the repair of a complex ventral hernia. / Aplicación de toxina botulínica en la reparación de una hernia ventral compleja.

INTRODUCTION: Preoperative application of botulinum toxin type A has demonstrated to be safe and effective in the closure of complex ventral hernias in adults. However, its use in pediatrics has been little documented. CASE REPORT: We present the case of a 22-month-old girl with a complex abdominal wall ventral hernia secondary to multiple neonatal laparotomies. In a first procedure, botulinum toxin was administered using an intramuscular approach at six sites of the muscle layers surrounding the defect, under general anesthesia and ultrasound control. 4 weeks later, an open hernia repair was conducted, without complications. DISCUSSION: Botulinum toxin at low doses could facilitate the surgical treatment of complex ventral incisional hernias in children. Even though it is important to adjust dosage and anatomical reference points according to hernia type and patient age and weight, further studies are required to optimize these variables.

INTRODUCCION: La aplicación preoperatoria de toxina botulínica A ha demostrado ser segura y efectiva en el cierre de hernias ventrales complejas en adultos. Sin embargo, se ha documentado poco su uso en pediatría. CASO CLINICO: Se presenta el caso de una niña de 22 meses con una hernia de pared abdominal ventral compleja secundaria a múltiples laparotomías neonatales. En una primera intervención se administró por vía intramuscular toxina botulínica en seis puntos de las capas musculares alrededor del defecto bajo anestesia general y control ecográfico. Cuatro semanas después, se realizó una reparación abierta de la hernia, sin complicaciones. COMENTARIOS: La toxina botulínica a dosis bajas podría facilitar el tratamiento quirúrgico de hernias incisionales ventrales complejas en niños. Es importante ajustar la dosis y los puntos de referencia anatómicos según el tipo de hernia, la edad y el peso del paciente, aunque se requieren más estudios para optimizar estas variables.

[Safety and efficacy of a therapeutic exercise program in young adults with repaired congenital diaphragmatic hernia]. / Seguridad y eficacia de un programa de ejercicio terapéutico en jóvenes intervenidos de hernia diafragmática congénita.

INTRODUCTION AND OBJECTIVE: Patients with congenital diaphragmatic hernia (CDH) can have up to 40 times more frequency of muskuloskeletal deformities and decreased perception of physical activity tan their pairs. The objective of this study is to evaluate the safety and efficacy of an individualized exercise program in late adolescents and young adults with repaired CDH, as well as a description of their basal status. MATERIAL AND METHODS: Non randomized prospective trial of 13 patients with repaired CDH between 1997-2005. An initial physical exploration and a pre-post assessment of bioimpedance (BIA), dynamometry, maximal inspiratory and expiratory pressure (MIP/MEP), 6-minute walk test (6MWT), physical activity level (IPAQ) and quality of life (QoL) was made. The training program last for 4 weeks. For the statistical analysis, the Student's t test for paired samples and Wilcoxon test were used. RESULTS: 77% (n=10) were male with a mean age of 19.23±2.13 years. In baseline BIA, 62% (n=8) had truncal sarcopenia that improved in -0.43±0.58, and P=.016. MIP, MEP, 6MWT and QoL tests increased by -7.27±8.26 cmH2O, P=.008; -11.91±10.20 cmH2O, P=.002; -70.63±17.88 m, P=.001; -42,19±26.79, P=.00 respectively. The IPAQ did not change significantly (P=0.86), however the time dedicated to muscle strengthening increased. No adverse effects were reported. CONCLUSIONS: A personalized rehabilitation program is safe and could improve the respiratory muscle strength and truncal sarcopenia as well as the submaximal effort capacity in late adolescents and young adults with repaired CDH.

Impacto del confinamiento en el patrón epidemiológico del traumatismo pediátrico / Impact of confinement on the epidemiologic pattern of pediatric trauma

Introducción: El trauma es unas de las causas principales de morbilidad y mortalidad en la infancia. El aislamiento de la población durante la pandemia de 2020 provocó cambios en la frecuencia y gravedad de los traumatismos pediátricos, debido a las modificaciones y restricciones en la dinámica social, el miedo al contagio y la reorganización de la atención sanitaria. Objetivos. Analizar el efecto que tiene el confinamiento de la población infantil en los patrones epidemiológicos y la asistencia sanitaria de urgencias a los traumatismos pediátricos, tomando como referencia un hospital de tercer nivel. Material y métodos. Estudio retrospectivo, comparativo y descriptivo. Análisis de los pacientes atendidos por traumatismo a cualquier nivel en el Servicio de Urgencias de un hospital de tercer nivel, durante los primeros quince días de confinamiento (marzo 2020), comparándolo con el mismo periodo prepandemia. Resultados. Del total de 388 pacientes, 40 fueron atendidos durante el confinamiento (88,5% menos que el mismo periodo del año anterior). La media de edad del grupo prepandemia fue significativamente superior. La gravedad, medida con el Índice de Trauma Pediátrico (ITP), fue mayor en pacientes del grupo confinamiento. El lugar más frecuente de lesión durante la pandemia fue en el domicilio, con un aumento de lesiones de localización facial. Conclusiones. Durante el aislamiento poblacional en la pandemia por SARS-CoV-2 se produjo una disminución en la demanda de la atención de traumas pediátricos en Urgencias, objetivándose un aumento en la gravedad de los niños atendidos. El confinamiento de la población produjo cambios en los patrones de lesión, así como en la localización de las lesiones más frecuentes.(AU)

Introduction: Trauma is among the leading causes of morbidity and mortality in childhood. The isolation of the population during the 2020 pandemic caused changes in the frequency and severity of pediatric trauma, due to modifications and restrictions in social dynamics, fear of contagion and reorganization of health care. Objectives. To analyze the impact of the confinement of the pediatric population on epidemiological patterns and emergency health care for pediatric trauma, taking a tertiary level hospital as a reference. Material and methods. Retrospective, comparative and descriptive study. Analysis of patients treated for trauma at any level in the Emergency Department of a tertiary hospital, during the first fifteen days of confinement (March 2020), compared with the same pre-pandemic period. Results. Of the total of 388 patients, 40 were seen during confinement (88.5% less than the same period of the previous year). The mean age of the pre-pandemic group was significantly higher. The severity in patients in the confinement group was higher than in pre-pandemic patients. The most frequent site of injury during confinement was at home, with an increase in facial injuries. Conclusions. During the SARS-CoV-2 pandemic, there was a decrease in the demand for pediatric trauma emergency care, with an increase in the severity of the children seen. There were changes in injury patterns, as well as in the location of the most frequent lesions.(AU)

Quality of life in adolescents who underwent congenital diaphragmatic hernia surgical repair. / Calidad de vida en adolescentes intervenidos de hernia diafragmática congénita.

OBJECTIVE: The advances made in the surgical and postnatal treatment of congenital diaphragmatic hernia (CDH) have considerably improved patient survival, but morbidity remains significant. The objective of this study was to analyze the effect these sequels have on the health-related quality of life (HRQL) of adolescents and young adults who have survived CDH, and to compare it with that of the general population. MATERIALS AND METHODS: A transversal descriptive study of patients diagnosed with CDH in our institution from 1997 to 2004 was carried out. Survival, location, hernia size, herniated organs, need for extracorporeal membrane oxygenation, and mechanical ventilation time were analyzed. In addition, a comparative study of the current HRQL of survivors was conducted using the SF-36 survey (36-Item Health Survey Short Form), which assessed physical function, physical role, body pain, general health, vitality, social function, emotional role, and mental health. Data of 24 healthy adolescents was used as a control group. RESULTS: Of the 29 survivors (70.7%), 21 were successfully contacted, and 16 responded to the survey. They all claimed their overall quality of life was good or very good. The group of adolescents who underwent CDH surgical repair had better results in the vitality (p= 0.001) and mental health (p<0.05) areas, but the overall HRQL score and the remaining health areas were similar. No significant differences were found regarding diaphragmatic size or need for ECMO. CONCLUSION: According to adolescent survivors who underwent CDH surgical repair, their quality of life is similar to that of other individuals of their age. Our results are encouraging and may prove useful for future parents of CDH patients.

OBJETIVO: Los avances en el tratamiento quirúrgico y posnatal han mejorado significativamente la supervivencia de pacientes con hernia diafragmática congénita (HDC). La morbilidad asociada sigue siendo significativa. El objetivo del estudio es evaluar efecto de estas secuelas sobre la calidad de vida relacionada con la salud (CVRS) de adolescentes y adultos jóvenes supervivientes de HDC y compararla con la población general. MATERIAL Y METODOS: Estudio descriptivo transversal de pacientes diagnosticados de HDC entre 1997 y 2004. Supervivencia, localización, tamaño de la hernia, órganos herniados, necesidad de oxigenación por membrana extracorpórea, tiempo de ventilación mecánica. Estudio comparativo de CVRS actual de pacientes supervivientes mediante la encuesta SF-36 (36-Item Health Survey Short Form): función física, rol físico, dolor corporal, salud general, vitalidad, función social, rol emocional, salud mental. Utilizamos datos de 24 adolescentes sanos como grupo control. RESULTADOS: De los 29 supervivientes (70,7%), fueron localizados 21 y contestaron la encuesta 16, que consideraron tener una calidad de vida global buena o muy buena. El grupo de adolescentes intervenidos tuvieron mejores resultados en las esferas de vitalidad (p = 0,001) y salud mental (p<0,05), pero la puntuación de la CVRS global y el resto de dimensiones de salud fueron similares. No se objetivaron diferencias significativas en relación con el tamaño diafragmático ni la necesidad de ECMO. CONCLUSIONES: Los adolescentes supervivientes intervenidos de HDC consideran tener una calidad de vida similar a jóvenes de su misma edad. Los resultados de nuestro estudio son alentadores y permiten un mejor asesoramiento para futuros pacientes con HDC.

Calidad de vida en adolescentes intervenidos de herniadiafragmática congénita / Quality of life in adolescents who underwent congenital diaphragmatic hernia surgical repair

Objetivo: Los avances en el tratamiento quirúrgico y posnatal hanmejorado significativamente la supervivencia de pacientes con herniadiafragmática congénita (HDC). La morbilidad asociada sigue siendosignificativa. El objetivo del estudio es evaluar el efecto de estas se-cuelas sobre la calidad de vida relacionada con la salud (CVRS) deadolescentes y adultos jóvenes supervivientes de HDC y compararlacon la población general. Material y métodos: Estudio descriptivo transversal de pacientesdiagnosticados de HDC entre 1997 y 2004. Supervivencia, localiza-ción, tamaño de la hernia, órganos herniados, necesidad de oxigenaciónpor membrana extracorpórea, tiempo de ventilación mecánica. Estudio comparativo de CVRS actual de pacientes supervivientes mediante laencuesta SF-36 (36-Item Health Survey Short Form): función física,rol físico, dolor corporal, salud general, vitalidad, función social, rolemocional, salud mental. Utilizamos datos de 24 adolescentes sanoscomo grupo control. Resultados: De los 29 supervivientes (70,7%), fueron localizados21 y contestaron la encuesta 16, que consideraron tener una calidad devida global buena o muy buena. El grupo de adolescentes intervenidostuvieron mejores resultados en las esferas de vitalidad (p = 0,001) ysalud mental (p < 0,05), pero la puntuación de la CVRS global y elresto de dimensiones de salud fueron similares. No se objetivaron diferencias significativas en relación con el tamaño diafragmático ni lanecesidad de ECMO. Conclusiones: Los adolescentes supervivientes intervenidos deHDC consideran tener una calidad de vida similar a jóvenes de su mis-ma edad. Los resultados de nuestro estudio son alentadores y permitenun mejor asesoramiento para futuros pacientes con HDC.(AU)

Objective: The advances made in the surgical and postnataltreatment of congenital diaphragmatic hernia (CDH) have consid-erably improved patient survival, but morbidity remains significant.The objective of this study was to analyze the effect these sequelshave on the health-related quality of life (HRQL) of adolescents andyoung adults who have survived CDH, and to compare it with thatof the general population. Materials and methods: A transversal descriptive study of pa-tients diagnosed with CDH in our institution from 1997 to 2004 wascarried out. Survival, location, hernia size, herniated organs, need forextracorporeal membrane oxygenation, and mechanical ventilationtime were analyzed. In addition, a comparative study of the currentHRQL of survivors was conducted using the SF-36 survey (36-Item Health Survey Short Form), which assessed physical function,physical role, body pain, general health, vitality, social function,emotional role, and mental health. Data of 24 healthy adolescentswas used as a control group. Results: Of the 29 survivors (70.7%), 21 were successfullycontacted, and 16 responded to the survey. They all claimed theiroverall quality of life was good or very good. The group of ado-lescents who underwent CDH surgical repair had better results inthe vitality (p= 0.001) and mental health (p< 0.05) areas, but theoverall HRQL score and the remaining health areas were similar.No significant differences were found regarding diaphragmatic sizeor need for ECMO. Conclusions: According to adolescent survivors who underwentCDH surgical repair, their quality of life is similar to that of otherindividuals of their age. Our results are encouraging and may proveuseful for future parents of CDH patients.(AU)

Re-interventions following appendectomy in children: a multicenter study. / Reintervenciones tras apendicectomía en niños. Estudio multicéntrico.

INTRODUCTION: Acute appendicitis is the most frequent cause of acute abdomen in children. The objective of this study was to analyze the causes, approach, and results of complications requiring surgery following appendectomy. MATERIAL AND METHODS: A retrospective study of the appendectomies conducted in three third-level institutions from 2015 to 2019 was carried out. Complications, causes, and number of re-interventions, time from one surgery to another, surgical technique used, operative findings at baseline appendectomy according to the American Association for the Surgery of Trauma (AAST) classification, and hospital stay were collected. RESULTS: 3,698 appendicitis cases underwent surgery, 76.7% of which laparoscopically, with 37.2% being advanced (grades II-V of the AAST classification). Mean operating time was 50.4 minutes (49.8 ± 20.1 for laparoscopy vs. 49.9 ± 20.1 for open surgery, p > 0.05), and longer in patients requiring re-intervention (68.6 ± 27.2 vs. 49.1 ± 19.3, p < 0.001). 76 re-interventions (2.05%) were carried out. The causes included postoperative infection (n = 46), intestinal obstruction (n = 20), dehiscence (n = 4), and others (n = 6). Re-intervention risk was not impacted by the baseline approach used (open surgery or laparoscopy, OR: 1.044, 95% CI: 0.57-1.9), but it was by appendicitis progression (7.8% advanced vs. 0.7% incipient, OR: 12.52, 95% CI: 6.18-25.3). There was a tendency to use the same approach both at baseline appendectomy and re-intervention. This occurred in 72.2% of laparoscopic appendectomies, and in 67.7% of open appendectomies. The minimally invasive approach (50/76) was more frequent than the open one (27 laparoscopies and 23 ultrasound-guided drainages vs. 26 open surgeries) (p < 0.05). 55% of obstruction patients underwent re-intervention through open surgery (p > 0.05). CONCLUSION: Re-intervention rate was higher in advanced appendicitis cases. In this series, the minimally invasive approach (laparoscopic or ultrasound-guided drainage) was the technique of choice for re-interventions.

INTRODUCCION: La apendicitis aguda es la causa más frecuente de abdomen agudo en niños. El objetivo de este trabajo es estudiar las causas, abordaje y resultados de las complicaciones que requieren intervención quirúrgica después de la apendicectomía. MATERIAL Y METODOS: Estudio retrospectivo de las apendicectomías realizadas en 3 centros de tercer nivel entre 2015-2019. Se recogieron las complicaciones, causas y número de reintervenciones, intervalo entre ambas cirugías, técnica empleada, hallazgos operatorios según la Clasificación de la American Association for the Surgery of Trauma (AAST) en la apendicectomía inicial y tiempo de ingreso. RESULTADOS: Se intervinieron 3.698 apendicitis, un 76,7% por vía laparoscópica, encontrando un 37,2% evolucionadas (grado II-V de la clasificación AAST). El tiempo medio quirúrgico fue de 50,4 minutos (laparoscopia 49,8 ± 20,1 vs. laparotomía 49,9 ± 20,1, p > 0,05), superior en aquellos pacientes que requirieron reintervención (68,6 ± 27,2 vs. 49,1 ± 19,3, p < 0,001). Se realizaron 76 reintervenciones (2,05%). Las causas fueron: infección postoperatoria (n = 46), obstrucción intestinal (n = 20), dehiscencia (n = 4) y otras (n = 6). El abordaje inicial no influyó en el riesgo de reintervención (laparotomía o laparoscopia, OR 1,044, IC 95% 0,57-1,9), pero sí el grado de evolución de la apendicitis (7,8% evolucionadas vs. 0,7% incipientes, OR 12,52, IC 95% 6,18-25,3). Hubo una tendencia a reintervenir por el mismo abordaje que la apendicectomía, esto ocurrió en un 72,2% de las apendicectomías laparoscópicas y en un 67,7% de las apendicectomías abiertas. El abordaje mínimamente invasivo (50/76) fue más frecuente que la laparotomía (27 laparoscopias y 23 drenajes ecoguiados frente a 26 laparotomías) (p < 0,05). El 55% de los pacientes obstruidos se reintervinieron por vía abierta (p > 0,05). CONCLUSION: El índice de reintervención fue superior en las apendicitis evolucionadas. En esta serie, el abordaje mínimamente invasivo (laparoscópico o drenaje ecoguiado) fue la técnica de elección en las reintervenciones.

Reintervenciones tras apendicectomía en niños. Estudio multicéntrico / Re-interventions following appendectomy in children: a multicenter study

Introducción: La apendicitis aguda es la causa más frecuente deabdomen agudo en niños. El objetivo de este trabajo es estudiar lascausas, abordaje y resultados de las complicaciones que requieren in-tervención quirúrgica después de la apendicectomía.Material y métodos: Estudio retrospectivo de las apendicectomíasrealizadas en 3 centros de tercer nivel entre 2015-2019. Se recogieronlas complicaciones, causas y número de reintervenciones, intervalo entreambas cirugías, técnica empleada, hallazgos operatorios según la Clasi-ficación de la American Association for the Surgery of Trauma (AAST)en la apendicectomía inicial y tiempo de ingreso.Resultados: Se intervinieron 3.698 apendicitis, un 76,7% por víalaparoscópica, encontrando un 37,2% evolucionadas (grado II-V de laclasificación AAST). El tiempo medio quirúrgico fue de 50,4 minutos(laparoscopia 49,8 ± 20,1 vs. laparotomía 49,9 ± 20,1, p > 0,05), superioren aquellos pacientes que requirieron reintervención (68,6 ± 27,2 vs.49,1 ± 19,3, p < 0,001).Se realizaron 76 reintervenciones (2,05%). Las causas fueron: infec-ción postoperatoria (n = 46), obstrucción intestinal (n = 20), dehiscencia(n = 4) y otras (n = 6). El abordaje inicial no influyó en el riesgo dereintervención (laparotomía o laparoscopia, OR 1,044, IC 95% 0,57-1,9),pero sí el grado de evolución de la apendicitis (7,8% evolucionadas vs.0,7% incipientes, OR 12,52, IC 95% 6,18-25,3).Hubo una tendencia a reintervenir por el mismo abordaje que laapendicectomía, esto ocurrió en un 72,2% de las apendicectomías lapa-roscópicas y en un 67,7% de las apendicectomías abiertas. El abordajemínimamente invasivo (50/76) fue más frecuente que la laparotomía(27 laparoscopias y 23 drenajes ecoguiados frente a 26 laparotomías)(p < 0,05). El 55% de los pacientes obstruidos se reintervinieron porvía abierta (p > 0,05).

Introduction: Acute appendicitis is the most frequent cause ofacute abdomen in children. The objective of this study was to analyzethe causes, approach, and results of complications requiring surgeryfollowing appendectomy.Materials and methods: A retrospective study of the appendecto-mies conducted in three third-level institutions from 2015 to 2019 wascarried out. Complications, causes, and number of re-interventions, timefrom one surgery to another, surgical technique used, operative findingsat baseline appendectomy according to the American Association forthe Surgery of Trauma (AAST) classification, and hospital stay werecollected.Results: 3,698 appendicitis cases underwent surgery, 76.7%of which laparoscopically, with 37.2% being advanced (grades II-Vof the AAST classification). Mean operating time was 50.4 min-utes (49.8 ± 20.1 for laparoscopy vs. 49.9 ± 20.1 for open surgery,p > 0.05), and longer in patients requiring re-intervention (68.6 ± 27.2vs. 49.1 ± 19.3, p < 0.001).76 re-interventions (2.05%) were carried out. The causes includedpostoperative infection (n = 46), intestinal obstruction (n = 20), dehis-cence (n = 4), and others (n = 6). Re-intervention risk was not impactedby the baseline approach used (open surgery or laparoscopy, OR: 1.044,95% CI: 0.57-1.9), but it was by appendicitis progression (7.8% ad-vanced vs. 0.7% incipient, OR: 12.52, 95% CI: 6.18-25.3).There was a tendency to use the same approach both at baseline ap-pendectomy and re-intervention. This occurred in 72.2% of laparoscopicappendectomies, and in 67.7% of open appendectomies. The minimallyinvasive approach (50/76) was more frequent than the open one (27laparoscopies and 23 ultrasound-guided drainages vs. 26 open surger-ies) (p < 0.05). 55% of obstruction patients underwent re-interventionthrough open surgery (p > 0.05).

Telorragia: revisión de la literatura a propósito de dos casos / Telorrhagia: literature review on two cases

La telorragia es infrecuente en la edad pediátrica y un signo de alarma en la edad adulta. Estos pacientes se remiten a la consulta de Cirugía para valorar intervenciones agresivas por la amenaza de la malignidad. Sin embargo, su principal etiología es la ectasia ductal mamaria, un proceso benigno y autorresolutivo. Se presentan dos pacientes varones de 4 y 5 meses con telorragia. Una vez realizadas la exploración, la ecografía y la citología, se descartó un proceso maligno y se resolvió con manejo conservador en un periodo de 12 meses. A continuación, se realiza una revisión de la literatura incluyendo los pacientes pediátricos (0-16 años) con telorragia monosintomática. Encontramos un total de 59 casos publicados. Es más frecuente en varones (1,5:1) y el 74% de los casos ocurren en el primer año de vida. En los estudios revisados se realizan diversas pruebas complementarias (cultivo, citología, analítica hormonal) pero solo parece aportar información de utilidad la ecografía, que se encuentra alterada en un 69,2% de los pacientes. El abordaje terapéutico clásico ha sido la resección quirúrgica de la glándula mamaria, pero en la literatura más reciente se ha demostrado que, ya que se trata de una patología limitada en el tiempo, el manejo conservador es el más adecuado. Se reserva la cirugía para los casos con diagnóstico dudoso o persistentes. La recidiva es infrecuente (9,8%). Conclusiones: pese a ser un síntoma alarmante, la telorragia en lactantes debe de manejarse de forma conservadora evitando las intervenciones quirúrgicas agresivas, que podrían condicionar secuelas posteriores (AU)

Nipple discharge in children is uncommon, whereas it is considered a warning sign in adulthood. Hence these patients are referred to the Paediatric Surgeon to assess whether it is necessary to perform aggressive procedures to avoid the risk of malignancy. However, the most common ethology is ductal ectasia, a benign and self-limited process.We present two cases of a 4 and 5-month-old male patients with bloody nipple discharge. Once malignancy was ruled out by physical examination, ultrasound and cytology, a conservative approach was adopted and the symptoms disappeared over a period of 12 months. Then we conducted a systematic review including pediatric patients (0-16 years) with monosymptomatic bloody nipple discharge.We found a total of 59 cases published. It is more prevalent in male patients (1,5:1) and 74% present before the age of 12 months. In the articles reviewed several tests are mentioned (secretion culture, cytology, hormonal blood test) but only ultrasound provided useful information, showing altered results in 69.2% of the patients. The classical therapeutic approach was breast surgical resection but in more recent reports ductal ectasia has been shown to be a self-limited pathology. Therefore, conservative treatment is now advocated while surgery is reserved for persistent symptoms or cases where there is a diagnostic doubt. Relapse is infrequent (9.8%).Conclusions: despite of being a disturbing sign, bloody nipple discharge in infants should be managed conservatively, avoiding aggressive surgical procedures that might cause permanent consequences. (AU)

Laparoscopic learning curves. / Curvas de aprendizaje en laparoscopia.

OBJECTIVES: Laparoscopic learning curves are slow, and there are no uniform surgical skill acquisition models. Therefore, our objective was to assess a laparoscopic skill learning program in individuals without any surgical experience, analyzing the learning curve by means of a certified custom-made simulator, and evaluating whether previous surgical experience had an impact on the learning curve. MATERIAL AND METHODS: A certified custom-made simulator and laparoscopic instruments were used to assess 20 university students who performed 10 repetitions of 3 exercises of growing difficulty (eye-hand coordination, hand-hand coordination, and cutting). Three parameters were analyzed: total time with each hand, total mistakes with each hand, and three items of the OSATS technical skill scale. The two first exercises were compared with a group of 14 experienced surgeons. Statistical analysis using repeated-measures Anova and Student's t-test was carried out (p < 0.05). RESULTS: Significant time improvement with each repetition was demonstrated in the three exercises. Curve stabilization was faster in surgeons (2-4 repetitions) than in students (8-9). Time reduction was noted in the first and second exercises in both groups, with 44.08% and 33.1% shorter times, respectively. CONCLUSIONS: Individuals without surgical experience acquired basic laparoscopic skills using a custom-made simulator, which allows simple surgical techniques to be carried out in an inexpensive, accessible fashion. Previous surgical experience was associated with a shorter learning curve. The custom-made simulator allowed individuals with and without surgical experience to be distinguished from each other.

OBJETIVOS: La curva de aprendizaje en cirugía laparoscópica es lenta y no existen modelos uniformes de adquisición de habilidades quirúrgicas. Tratamos de establecer la idoneidad de un programa de aprendizaje de habilidades laparoscópicas en sujetos sin experiencia quirúrgica, analizando la curva de aprendizaje utilizando un simulador artesanal homologado. Comprobar si la experiencia quirúrgica previa modifica la curva de aprendizaje. MATERIAL Y METODOS: Se empleó un simulador artesanal validado e instrumental laparoscópico para evaluar a 20 estudiantes universitarios que realizaron 10 repeticiones de tres ejercicios de dificultad creciente (coordinación ojo-mano, coordinación mano-mano y corte). Se evaluaron tres parámetros: tiempo total y con cada mano, errores totales y con cada mano y tres ítems de habilidad técnica OSATS. Comparación de los dos primeros ejercicios con un grupo de 14 cirujanos con experiencia. Análisis estadístico mediante Anova para medidas repetidas y t de Student (p < 0,05). RESULTADOS: Se demostró la mejoría significativa del tiempo con cada repetición en los tres ejercicios. La estabilización de la curva fue más precoz entre los cirujanos (2-4 repeticiones) que los estudiantes (8-9). Se comprobó la reducción del tiempo invertido para el primer y segundo ejercicio en ambos grupos, que en los estudiantes fue del 44,08% y 33,1% respectivamente. CONCLUSIONES: Individuos sin experiencia quirúrgica desarrollan habilidades laparoscópicas básicas utilizando un simulador artesanal, que permite practicar técnicas quirúrgicas sencillas de forma barata y accesible. La experiencia quirúrgica previa se asocia con el acortamiento de la curva de aprendizaje. El simulador artesanal permite discriminar entre sujetos con y sin experiencia quirúrgica.

Curvas de aprendizaje en laparoscopia / Laparoscopic learning curves

OBJETIVOS: La curva de aprendizaje en cirugía laparoscópica es lenta y no existen modelos uniformes de adquisición de habilidades quirúrgicas. Tratamos de establecer la idoneidad de un programa de aprendizaje de habilidades laparoscópicas en sujetos sin experiencia quirúrgica, analizando la curva de aprendizaje utilizando un simulador artesanal homologado. Comprobar si la experiencia quirúrgica previa modifica la curva de aprendizaje. MATERIAL Y MÉTODOS: Se empleó un simulador artesanal validado e instrumental laparoscópico para evaluar a 20 estudiantes universitarios que realizaron 10 repeticiones de tres ejercicios de dificultad creciente (coordinación ojo-mano, coordinación mano-mano y corte). Se evaluaron tres parámetros: tiempo total y con cada mano, errores totales y con cada mano y tres ítems de habilidad técnica OSATS. Comparación de los dos primeros ejercicios con un grupo de 14 cirujanos con experiencia. Análisis estadístico mediante Anova para medidas repetidas y t de Student (p < 0,05). RESULTADOS: Se demostró la mejoría significativa del tiempo con cada repetición en los tres ejercicios. La estabilización de la curva fue más precoz entre los cirujanos (2-4 repeticiones) que los estudiantes (8-9). Se comprobó la reducción del tiempo invertido para el primer y segundo ejercicio en ambos grupos, que en los estudiantes fue del 44,08% y 33,1% respectivamente. CONCLUSIONES: Individuos sin experiencia quirúrgica desarrollan habilidades laparoscópicas básicas utilizando un simulador artesanal, que permite practicar técnicas quirúrgicas sencillas de forma barata y accesible. La experiencia quirúrgica previa se asocia con el acortamiento de la curva de aprendizaje. El simulador artesanal permite discriminar entre sujetos con y sin experiencia quirúrgica

OBJECTIVES: Laparoscopic learning curves are slow, and there are no uniform surgical skill acquisition models. Therefore, our objective was to assess a laparoscopic skill learning program in individuals without any surgical experience, analyzing the learning curve by means of a certified custom-made simulator, and evaluating whether previous surgical experience had an impact on the learning curve. MATERIALS AND METHODS: A certified custom-made simulator and laparoscopic instruments were used to assess 20 university students who performed 10 repetitions of 3 exercises of growing difficulty (eye-hand coordination, hand-hand coordination, and cutting). Three parameters were analyzed: total time with each hand, total mistakes with each hand, and three items of the OSATS technical skill scale. The two first exercises were compared with a group of 14 experienced surgeons. Statistical analysis using repeated-measures Anova and Student's t-test was carried out (p < 0.05). RESULTS: Significant time improvement with each repetition was demonstrated in the three exercises. Curve stabilization was faster in surgeons (2-4 repetitions) than in students (8-9). Time reduction was noted in the first and second exercises in both groups, with 44.08% and 33.1% shorter times, respectively. CONCLUSIONS: Individuals without surgical experience acquired basic laparoscopic skills using a custom-made simulator, which allows simple surgical techniques to be carried out in an inexpensive, accessible fashion. Previous surgical experience was associated with a shorter learning curve. The custom-made simulator allowed individuals with and without surgical experience to be distinguished from each other

Actualización de la anemia y la deficiencia de hierro en la EPOC / Update of anemia and iron deficiency in COPD

La anemia más frecuente en los pacientes con enfermedad pulmonar obstructiva crónica (EPOC) es la de trastornos crónicos, cuya prevalencia oscila entre el 5 y el 33% de los casos. Su presencia tiene un impacto pronóstico, ya que puede empeorar el grado de disnea y la tolerancia al ejercicio en estos enfermos. Debido a que en la EPOC hay un estado de inflamación crónica, el diagnóstico de anemia y deficiencia de hierro en presencia de esta enfermedad es complejo. En cuanto al tratamiento, no existen actualmente estudios con evidencia suficiente para realizar indicaciones al respecto. No obstante, dado que el mecanismo fisiopatológico es similar, las recomendaciones pueden ser similares a las que se establecen para la insuficiencia cardiaca

The most frequent anemia in patients with chronic obstructive pulmonary disease (COPD) is that of chronic disorders, whose prevalence ranges from 5% to 33% of cases. Its presence has a prognostic impact, since it can worsen the degree of dyspnea and exercise tolerance in these patients. Because there is a state of chronic inflammation in COPD, the diagnosis of anemia and iron deficiency in the presence of this disease is complex. Regarding treatment, there are currently no studies with sufficient evidence to make indications in this regard. However, since the pathophysiological mechanism is similar, the recommendations may be similar to those established for heart failure

Diels-Alder functionalized carbon nanotubes for bone tissue engineering: in vitro/in vivo biocompatibility and biodegradability.

The risk-benefit balance for carbon nanotubes (CNTs) dictates their clinical fate. To take a step forward at this crossroad it is compulsory to modulate the CNT in vivo biocompatibility and biodegradability via e.g. chemical functionalization. CNT membranes were functionalised combining a Diels-Alder cycloaddition reaction to generate cyclohexene (-C6H10) followed by a mild oxidisation to yield carboxylic acid groups (-COOH). In vitro proliferation and osteogenic differentiation of human osteoblastic cells were maximized on functionalized CNT membranes (p,f-CNTs). The in vivo subcutaneously implanted materials showed a higher biological reactivity, thus inducing a slighter intense inflammatory response compared to non-functionalized CNT membranes (p-CNTs), but still showing a reduced cytotoxicity profile. Moreover, the in vivo biodegradation of CNTs was superior for p,f-CNT membranes, likely mediated by the oxidation-induced myeloperoxidase (MPO) in neutrophil and macrophage inflammatory milieus. This proves the biodegradability faculty of functionalized CNTs, which potentially avoids long-term tissue accumulation and triggering of acute toxicity. On the whole, the proposed Diels-Alder functionalization accounts for the improved CNT biological response in terms of the biocompatibility and biodegradability profiles. Therefore, CNTs can be considered for use in bone tissue engineering without notable toxicological threats.

Microscopic visualization of intravasal spermatozoa is positively associated with patency after bilateral microsurgical vasovasostomy.

We evaluated pre-operative and intraoperative factors associated with successful patency following bilateral microsurgical vasovasostomy (VV). We retrospectively reviewed the charts of 1331 men who underwent bilateral VV by two surgeons between 2006 and 2013. Vasal fluid was examined intraoperatively for gross quality (i.e., clear or opaque and creamy/thick) and for the presence of spermatozoa on microscopy (i.e., whole spermatozoa, sperm fragments, or azoospermia). Post-operative patency was assessed by semen analysis or patient report of conception. Perioperative factors were explored using descriptive statistics and examined in logistic regression models for associations with post-operative patency. The median age at VV was 39 years [interquartile range (IQR): 35-44] and the median obstructive interval (OI) was 7 years (IQR: 4-11). Overall, 1307 patients achieved post-operative patency (98%) while 24 remained obstructed (2%). Among those who became patent, 410 reported conception. After adjustment for potential confounders, only microscopic examination of the intravasal fluid for the presence of spermatozoa (bilateral or unilateral whole spermatozoa vs. sperm parts/azoospermia) at the time of VV was significantly associated with post-operative patency with an odds ratio (OR) of 14.2 (95% CI: 5.8-34.9; p = <1 × 10(-8) ). Identification of bilateral or unilateral sperm fragments vs. azoospermia was also associated with increased odds of post-operative patency with an OR of 3.5 (95% CI: 0.9-13.6; p = 0.08). There was no statistically significant association between age at VV, OI, presence of granuloma, gross fluid quality, or surgeon and post-operative patency after controlling for potential confounders. Identification of whole spermatozoa in the vasal fluid at the time of VV was positively associated with post-operative patency. Our findings stress the need for intraoperative microscopy to aid in post-operative patient counseling.

Stiff diamond/buckypaper carbon hybrids.

Given the specific properties of each carbon allotrope such as high electrical/thermal conductivity of multiwall carbon nanotubes (MWCNT) and extreme hardness and high inertness of nanocrystalline diamond (NCD), the integration of both carbon phases is highly desirable. Therefore, in the present work, buckypapers were produced from MWCNT suspensions and were used as free-standing substrates to be coated with NCD by microwave plasma chemical vapor deposition (MPCVD). The integration of both allotropes was successfully achieved, the CNTs being preserved after diamond growth as confirmed by µ-Raman spectroscopy and scanning electron microscopy (SEM). Additionally, a good linkage was observed, the CNTs remaining embedded within the NCD matrix, thus reinforcing the interface of the resulting hybrid structure. This was corroborated by bending tests in a modified nanohardness tester. The increase of the Young's modulus from 0.3 to 300 GPa after NCD growth enables the use of this material in a wide range of applications including microelectromechanical systems (MEMS). Additionally, a highly anisotropic electrical resistivity behavior was confirmed: low in-plane values were found for the CNT layer (1.39 × 10(-2) Ω.cm), while high transverse ones were measured for both the NCD coated and uncoated CNT buckypapers (8.13 × 10(5) and 6.18 × 10(2) Ω.cm, respectively).

Colecistectomía laparoscópica en niños y adultos: lo que podemos aprender / Laparoscopic cholecystectomy: what we can learn about

Objetivos. La colecistectomía laparoscópica (CL) es un procedimiento muy habitual en adultos, pero no es tan frecuente en la edad pediátrica. Nos preguntamos si existen diferencias entre ambas poblaciones en cuanto a morbilidad y evolución postoperatoria. Material y métodos. Revisión retrospectiva de 39 casos consecutivos que precisaron CL en nuestro Servicio entre 2003-2013 y de una muestra similar de casos intervenidos en el Servicio de Cirugía General del mismo centro en pacientes entre 18 y 40 años. Resultados. 39 niños y 40 adultos cumplieron criterios para incluirse en el estudio. La indicación más frecuente fue la colelitiasis en ambos grupos. El tiempo quirúrgico medio fue significativamente mayor en los niños (niños: 127 min, adultos: 70 min, p< 0,01) pero no encontramos diferencias significativas en la tasa de reconversión o la incidencia de complicaciones (niños: 7.7%, adultos 15%). En cuanto a los factores preoperatorios, solo el sexo masculino se relacionó con mayor incidencia de complicaciones (p 0,037). Por otra parte descubrimos que, en ausencia de complicaciones, la estancia postoperatoria (niños: 2,1 días, adultos: 0,5 días), y el tiempo hasta tolerancia oral (niños: 21 h, adultos: 8 h) fueron significativamente mayores en niños (p< 0,01). Conclusiones. 1) La CL en niños es un procedimiento seguro que no presenta más morbimortalidad que en adultos, a pesar de un mayor tiempo quirúrgico. 2) Creemos que el tiempo de ingreso más prolongado se debe en parte a una falta de confianza con la técnica y que la tendencia en el futuro debe encaminarse a fomentar un inicio temprano de la tolerancia y un alta precoz (AU)

Background. Laparoscopic cholecystectomy (LC) is a very usual procedure within adult population, but not as frequent in childhood. The aim of this study was to assess the outcome of LC in children compared with those performed in adulthood. Materials and methods. We reviewed 39 consecutive patients who underwent LC between 2003 and 2013 at our Department and a similar sample of patients from 18 to 40 years of age from the General Surgery Department. Results. 39 children and 40 adults fulfilled criteria to be included in the study. The most frequent indication was cholelithiasis in both groups. The mean operating time was significantly higher among children (127 min, adults 71 min, p< 0.01) but we didn’t find differences neither in conversion nor in complication rates (children 5% and 7.7%, adults 2.5% and 15% respectively). In regard to preoperative factors, only male gender was correlated to a higher complication rate (p 0.037). On the other hand we found out that, in absence of complications, both the average length of stay (children 2.1 days, adults 0.5 days) and mean time to first feeding (children 21 hours, adults 8 hours) were significantly higher among children (p< 0.01). Conclusions. 1) LC in childhood is a safe procedure that does not imply more morbidity than the same intervention in adults, even though a more prolonged operating time. 2) We believe that our longer hospital stay is due to certain lack of confidence with the technique and, in the future, the trend should be bent on encouraging a shorter time to first feeding and an earlier discharge (AU)