Academic paediatric surgery and work-life balance: Insights from Mexico.

Academic pediatric surgery in Mexico has many challenges and opportunities. Work life balance, health service delivery and committements to our many students and residents must be tailored to goals and aspirations respecting talent at every opportunity when we encounter it. This article offers a perspective on the landscape and how we can shape the future in our nation to embrace new leadership in academic pediatric surgery.

Assessment of the Mexican Board of Pediatric Surgery Certification System.

OBJECTIVE: To evaluate the quality of the Mexican Board of Pediatric Surgery (MBPS) certifying system, using contemporary international guidelines. DESIGN: Retrospective assessment of evidence collected during the design and implementation processes of 2 consecutive applications of the MBPS certifying examination, using Cizek's checklist for evaluating credential-testing programs. It includes the relevant guidelines from the American Education Research Association, the American Psychological Association, the National Council on Measurement in Education, and the National Commission for Certifying Agencies. Four independent and previously trained raters used the checklist. They underwent a 2-week training using frame-of-reference and performance dimensions methodologies. SETTING: Certification examinations of MBPS. POPULATION: The 2013 and 2014 MBPS certification examinations, with 111 evidence items of the processes, followed for the assessment of 86 examinees. RESULTS: The checklist internal consistency was 0.89. Absolute interrater agreement was 0.34 for the 2013 and 0.66 for the 2014 editions of the examination. The 2013 examination complied with 55 (64%) of the checklist 86 items, in 2014 with 72 (84%). CONCLUSION: In 2014, the certifying system reached a quality of 84%. For optimal fulfillment of its social responsibility, the MBPS is required to maintain its level of quality and attempt to improve its performance.

Transluminal endoscopic electrosurgical incision of fenestrated duodenal membranes.

Duodenal fenestrated membranes are traditionally treated by side-to-side diamond-shaped duodenoduodenostomy, or duodenotomy and resection. We describe an alternative endoscopic approach for its resolution. A flexible panendoscopy reaching the duodenal membrane was performed. A balloon was inserted to dilate its orifice. Traction was applied to the balloon to differentiate the border of the membrane forming the duodenal wall. After visualizing the ampulla, the membrane was incised using a sphincterotome or needle knife on two sites opposite to the bile duct. From May 2001 to August 2007, ten patients with a fenestrated duodenal membrane underwent transluminal endoscopic electrosurgical incision (TEEI). Mean patient age was 3.4 years (range 1 month to 15 years). The endoscopic procedure lasted from 30 to 60 min. Oral intake began 24 h postsurgery in eight patients and at 48 h postsurgery in two patients. Hospital stay lasted for 2-5 days. After 1 year of follow-up, eight patients were asymptomatic and thriving at present, and one had a double membrane, required a second endoscopy with TEEI, and has experienced occasional vomiting. An additional asymptomatic patient was lost after 3 months of follow-up. TEEI of fenestrated duodenal membranes is a feasible and effective procedure in children.

Primary cricotracheal resection with thyrotracheal anastomosis for the treatment of severe subglottic stenosis in children and adolescents.

Severe subglottic stenosis in children is best managed by laryngotracheal reconstruction or cricotracheal resection (CTR). We describe clinical outcomes with CTR and end-to-end anastomosis in pediatric patients with severe subglottic stenosis in a tertiary-care pediatric teaching hospital in Mexico City. We prospectively followed up all consecutive patients younger than 18 years of age with a Myer-Cotton grade 3 or 4 subglottic stenosis who underwent CTR between May 1, 2000, and March 31, 2003. The frequency of each clinical outcome was calculated. Twenty-two patients (16 boys [72.7%] and 6 girls [27.3%]) were included. The mean age at operation was 4.6 years (range, 11 months to 16 years). Eighteen patients (81.8%) required primary CTR, and 4 (18.2%) required extended CTR. Seventeen (77.3%) had grade 3 stenosis, and 5 (22.7%) had grade 4 stenosis. Six (27.3%) had associated clinical conditions, and 3 (13.6%) had associated vocal cord mobility defects. All were tracheostomy-dependent at presentation, and none had undergone previous airway surgery. Ten (45.5%) underwent one-stage surgery, and 12 (54.5%) had a concomitant temporary tracheotomy. No intraoperative complications occurred. Seventeen patients (77.3%) developed postoperative granulation tissue requiring endoscopic resection. The mean follow-up was 1.2 years (range, 2 months to 2.8 years). No deaths occurred. Fifteen children (88.2%) with grade 3 stenosis and 5 (100%) with grade 4 stenosis were decannulated, for an overall decannulation rate of 90.9%. Partial cricoid resection with end-to-end anastomosis has been a feasible procedure with reproducible successful results among our patients. We conclude that CTR performed as a primary procedure is an effective treatment for the management of severe subglottic stenosis in children.

A prospective study of surgical site infections in a pediatric hospital in Mexico City.

BACKGROUND: Pediatric surgical site infection (SSI) rates in the United States range from 2.5% to 4.4%. There is little data regarding their risk factors among children. We quantified SSI rates and identified risk factors of SSI in a tertiary care pediatric teaching hospital in Mexico City. METHODS: All neurosurgical, cardiovascular, and general surgical patients who underwent operation between Aug 1, 1998, and Jan 31, 1999, were followed-up daily during hospitalization. On postoperative day 30, a full review of microbiology reports and medical records was performed. Univariate and multivariate analyses were done to identify risk factors. RESULTS: Four hundred twenty-eight of 530 children completed follow-up. The overall SSI rate was 18.7%. Forty percent of SSI were superficial incisional, 21% were deep incisional, and 39% were organ/space infections. For clean, clean-contaminated, contaminated, and dirty procedures, SSI infection rates were 12.4%, 24.4%, 14.3%, and 32.4%, respectively. Open drains (OR = 2.3; 95% CI = 1.3-4.2; P <.005) and surgery that lasted 90 or more minutes (OR = 2.9; 95% CI = 1.6-5.1; P <.001) were associated with infection. CONCLUSIONS: Our rates are greater than comparable reported data among children. Duration of surgery and use of open drains were associated with SSI.

Diaphragmatic hernia from blunt trauma in children with multiple trauma

Introducción. En niños, la hernia diafragmática traumática (HDT) es una condición poco común pero potencialmente letal. En este estudio, se reporta la experiencia del hospital en el diagnóstico y tratamiento de HDT. Material y métodos. Se efectuó un estudio retrospectivo de los expedientes de los niños con HDT tratados en el hospital de 1971 a 1996. Resultados. Cinco hombres y una mujer, de 4 a 12 años de edad fueron tratados. El mecanismo del trauma incluyó accidentes peatonales, vehiculares, por aplastamiento y por caída. En 4 niños se observó dificultad respiratoria. Las lesiones asociadas incluyeron: fractura de base de cráneo, seudosubluxación cervical de C2 sobre C3, fracturas costales, pélvicas y femorales, lesión hepática, esplénica y cecal y hematoma retroperitoneal. Las radiografías iniciales de tórax fueron diagnósticas en 4 casos. Dos obtuvieron un diagnóstico tardío por radiografía de contraste. Todos los pacientes fueron sometidos a exploración transabdominal, con reducción de las vísceras herniadas y sutura del defecto. Dos requirieron esplenorrafia y resección hepática parcial. El paciente con perforación cecal se suturó y drenó. Todos los pacientes están actualmente sanos. Conclusiones. La HDT fue un hallazgo raro entre los niños tratados en el hospital. Su diagnóstico requirió un alto índice de sospecha y radiografía de contraste en los casos dudosos. El abordaje quirúrgico transabdominal fue útil, tanto para la sutura del defecto, como para el diagnóstico y tratamiento de lesiones ocultas

Diagnóstico ultasonográfico prenatal de defectos congénitos internos de resolución quirúrgica / Antenatal ultrasound diagnosis of internal congenital defects of surgical solution

El objetivo fundamental de este trabajo es conocer el valor predictivo positivo de la ultrasonografía prenatal (USPN) en el diagnóstico de los defectos congénitos internos que ameritan intervención quirúrgica inmediata. El análisis de 18 casos con malformaciones congénitas internas encontradas en un universo de 2 880 USPN efectuadas a las 23, 28 y 35 semanas, representa un 0.62 por ciento del total de pacientes estudiadas. De los 18 casos solamente en 14 recién nacidos se pudo comprobar clínica, radiográfica, ultrasonográfica y quirúrgicamente la malformación diagnosticada por USPN. El valor predictivo positivo de la USPN fue de 77 por ciento