Effects of early administration of acetazolamide on the duration of mechanical ventilation in patients with chronic obstructive pulmonary disease or obesity-hypoventilation syndrome with metabolic alkalosis. A randomized trial.

BACKGROUND: Metabolic alkalosis (MA) inhibits respiratory drive and may delay weaning from mechanical ventilation (MV). MA is common in CO2-retainer patients that need MV. Acetazolamide (ACTZ) decreases serum bicarbonate concentration and stimulates respiratory drive. This study evaluated the effects of ACTZ on the duration of MV in patients with MA and COPD or obesity hypoventilation syndrome (OHS) intubated with acute respiratory failure. METHODS: Multicenter, randomized, controlled, double-blind study, with COPD or OHS patients with MV < 72 h and initial bicarbonate >28 mmol/L and pH > 7.35. Test-treatment, ACTZ 500 mg or placebo, was daily administered if pH > 7.35 and bicarbonate >26 mmol/L. Clinical, respiratory and laboratory parameters were recorded. RESULTS: 47 patients (36 men) were randomized. There were no significant differences between groups in comorbidities, baseline characteristics or arterial blood gases at inclusion. The mean difference in the duration of MV between placebo and ACTZ group was 1.3 days (95%CI, -2.1-4.8; p = 0.44). Kaplan-Meier curves showed no differences in the duration of MV (Log-Rank p = 0.41). Between-group comparison of estimated marginal means (CI 95%) during MV were, respectively: PaCO2 55 (51-59) vs 48 (47-50) mm Hg, p = 0.002; bicarbonate concentration 34 (32-35) vs 29 (28-30) mmol/L, p < 0.0001; and minute volume 9.7 (8.9-10.4) vs 10.6 (9.2-12.0) L/min, p = 0.26. There were no severe adverse effects with ACTZ administration. CONCLUSIONS: Among patients with MA and COPD or OHS, early treatment with ACTZ did not shorten significantly the duration of MV compared with placebo. TRIAL REGISTRY: clinical.trials.gov; NCT01499485; URL:.www.clinicaltrials.gov.

14 years of experience with the artificial urinary sphincter in children and adolescents without spina bifida.

PURPOSE: The efficacy of the artificial urinary sphincter to treat sphincteric incontinence in pediatric patients with spina bifida has been clearly reported. The possibility of maintaining spontaneous voiding has usually been the main reason for prosthetic device surgery. We reviewed our experience with the artificial urinary sphincter in patients without spina bifida who had had previous surgery of the bladder neck or proximal urethra. MATERIALS AND METHODS: From 1990 to 2004, 112 children and adolescents underwent implantation of an AMS 800 artificial urinary sphincter. Of the patients 19 males and 4 females (20.5%) between ages 4 and 17 years (mean 8.1) had no spina bifida. Instead there were bladder exstrophy in 12 patients, anorectal malformation with a rectourethral or vesical fistula in 7 and epispadias in 4. A bladder neck cuff between 5.5 and 7.5 cm, and a 61-70 balloon were used in all patients. RESULTS: Only 1 patient was lost to followup. In 22 patients (95.6%) mean followup was 80 months (range 4 to 155). Three sphincters in patients with exstrophy were removed because of erosion and/or infection 5, 49 and 60 months after initial surgery, respectively. A total of 19 sphincters remained in place (86.3% survival rate) with 5 revisions (26.3%) because of the pump (2), the cuff (2) or balloon fluid leakage. In this group 13 patients (68.4%) voided spontaneously and 6 (31.6%) performed clean intermittent catheterization, although 3 also voided spontaneously. Overall continence was good in 87% of patients because 2 were still incontinent at night. CONCLUSIONS: The artificial urinary sphincter is a good long-term solution to urinary incontinence secondary to sphincter incompetence despite multiple previous surgeries of the bladder neck or proximal urethra. Patients with bladder exstrophy and many previous bladder procedures are more exposed to complications such as erosion compared with patients with epispadias or anorectal malformation. The high percent of patients maintaining spontaneous voiding and the good rate of continence are the most important benefits of this type of surgical option for sphincter incompetence.

[Pure gonad dysgenesia or Swyer sindrome. A case report having tumoral development: melanoma]. / Disgenesia gonadal pura o síndrome de Swyer. A propósito de un caso con degeneración tumoral: melanoma.

A 14 year old girl having 10-days lumbar pain, polaquiuria and moderate pain to palpation is reported. Blood and urine analysis were normal. Abdominal ultrasound scan showed cavity free and solid, rounded, heterogeneous, intrapelvic mass compressing bladder and uterus. Magnetic resonance image was performed showing right gonad compromise with extensive liver and sacro-lumbar spine invasion. Tumoral markers were ruled out. During surgery, primary tumor mass localizad in the right gonad was completely excised. Melanotic peritoneal and hepatic disemination were observed. The patient had left streak gonad and infantile uterus (2 x 3 cm). As gonad dysgenesia was suspected, high resolution cromosomic study was performed and resulted in cariotype 46 XY. Microscopy of the resected gonad showed primary gonad melanoma. Chemotherapy was instituted with no tumor response and the patient died two month later.

[Laparoscopic approach for treatement of gastroesophageal reflux in newborns and infants with severe respiratory disorders. When to indicate it?]. / Abordaje laparoscópico para el tratamiento del reflujo gastroesofágico en recién nacidos y lactantes con trastornos respiratorios graves. Cuándo indicarlo?

Gastroesophageal reflux (GER) is a common finding in the newborn period, which is in general well tolerated, and tends to resolve spontaneously at about 18 months of age. However, a small number of children will present important respiratory manifestations (aspiration and apneic episodes), or increase in the manifestations of pre existing conditions (tracheomalacia, laryngomalacia), which can produce life threatning events. Ph monitoring does not completely discard the possibility of GER and the use of prokinetic drugs, in association with other drugs to protect the esophagus do not prevent serious consecuences produced by reflux to the airway. In this report six children with severe airway disease and marked GER, with no response to initial medical treatment required laparoscopic fundoplication. They have all resolved their airway disease, and are currently well. The laparocopic technique for fundoplication of small children seems to be a secure, well tolerated and definitive treatment in the hands of trained surgeons.

[Indirect calorimetry in critical ill patients: validity of measurement for ten minutes]. / Calorimetría indirecta en el enfermo crítico: validez de la medición durante 10 minutos.

GOAL: There are no gold standards on the duration and frequency of the measurement of indirect calorimetry, a fact of importance in daily clinical practice. An assessment of is made of the degree of concordance between energy expenditure at rest (EER) measured over a short interval (10 minutes) versus another prolonged measurement (1 hour). PATIENTS: Sixty critically-ill patients, under sedation and analgesia with connection to mechanical ventilation, were studied. INTERVENTIONS: EER values were determined by means of a metabolic computer analysis (Engström Eliza) at rest. The reproducibility and the degree of concordance were assessed in the measurements made with both periods. RESULTS: The mean values of the EER determinations at 10 and 60 minutes were 1,818 +/- 319 kilocalories/day and 1,815 +/- 318 Kcal/day. The limits of the concordance between both times were -101 and +117 kilocalories/day and the correlation was significant (r = 0.98, p < 0.0001). CONCLUSIONS: In critically-ill patients under sedation and with mechanical ventilation, the measurement of EER may be taken over short periods of time (10 minutes) providing that baseline examination conditions are met, thus giving greater availability of the resources used to study indirect calorimetry.

Shock séptico e insuficiencia suprarrenal relativa / Septic shock and relative adrenal insufficiency

Objetivos. Valorar en un grupo de pacientes con shock séptico si existe relación entre el valor basal de cortisol en suero y su incremento tras la estimulación de la glándula suprarrenal con hormona adrenocorticotropa (ACTH) sintética, y conocer la incidencia de insuficiencia suprarrenal relativa (ISR) y su repercusión sobre la mortalidad. Pacientes y método. Se ha estudiado a 29 pacientes, no consecutivos, con el diagnóstico de shock séptico. Para valorar la funcionalidad del eje hipotalámico-pituitario-suprarrenal se utilizó el test de estimulación corto de la glándula suprarrenal mediante la administración intravenosa de 250 µg de ACTH sintética. Se determinó en suero el cortisol basal y a los 30 y 60 min de la administración de la ACTH. Se consideró como disfunción del eje hipotalámico-pituitario-suprarrenal (HPS) un incremento del cortisol basal igual o inferior a 9 µg/dl a los 30 o 60 min. Resultados. No hubo relación estadísticamente significativa (r2 = 0,10; p = 0,09) entre el valor basal de cortisol en suero y el incremento de cortisol tras la estimulación de la glándula suprarrenal con ACTH sintética. Dieciocho pacientes (62 por ciento) presentaron un incremento del cortisol 9 µg/dl a los 30 y 60 min de la administración de la ACTH sintética. La mortalidad fue más elevada en los pacientes con ISR que en los que no la presentaban (9/18 [50 por ciento] frente a 1/11 [9,1 por ciento]; riesgo relativo: 10; intervalo de confianza (IC) del 95 por ciento: 1,05-95; p = 0,02).Conclusiones. No hemos observado relación entre el valor basal de cortisol y la falta de respuesta al test corto de estimulación de la glándula suprarrenal con ACTH sintética. La incidencia de insuficiencia suprarrenal relativa es elevada en los pacientes en shock séptico y se asocia con una mayor mortalidad (AU)

Cirugía Conservadora en el tratamiento de los tumores benignos / Conservative surgery in the treatment of benign testicular tumors in childhood

El tratamiento clásico de los tumores testiculares ha sido la orquidectomía radical.En los últimos años esta conducta se ha modificado mediante un tratamiento más conservador:la tumorectomía con conservación de parénquima sano.Esta terapeútica está basada en datos preoperatorios,como la ecografía de alta definición,el dosaje negativo de marcadores serológicos y fundamentalmente,en la anatomía patológica intraoperatoria(congelación)dato esencial para decidir una conducta conservadora.En esta revisión presentamos la experiencia de nuestro servicio en 4 niños con tumores testiculares benignos,que fueron tratados con conservación de la gónada

Cirugía Conservadora en el tratamiento de los tumores benignos / Conservative surgery in the treatment of benign testicular tumors in childhood

El tratamiento clásico de los tumores testiculares ha sido la orquidectomía radical.En los últimos años esta conducta se ha modificado mediante un tratamiento más conservador:la tumorectomía con conservación de parénquima sano.Esta terapeútica está basada en datos preoperatorios,como la ecografía de alta definición,el dosaje negativo de marcadores serológicos y fundamentalmente,en la anatomía patológica intraoperatoria(congelación)dato esencial para decidir una conducta conservadora.En esta revisión presentamos la experiencia de nuestro servicio en 4 niños con tumores testiculares benignos,que fueron tratados con conservación de la gónada

Significado del patrón electrocardiográfico de ingreso en el infarto agudo de miocardio tratado con trombólisis / Meaning of initial electrocardiographic pattern in acute myocardial infartion treated with thrombolysis

Fundamento. Estudiar el grado de asociación entre el patrón electrocardiográfico de ingreso en el infarto agudo de miocardio, la falta de eficacia de la trombólisis y el mayor riesgo de disfunción ventricular izquierda. Pacientes y métodos. Se estudiaron retrospectivamente 150 pacientes ingresados de manera consecutiva por infarto de menos de 6 h de evolución, que recibieron tratamiento trombolítico. Los pacientes se agruparon según el patrón electrocardiográfico, definido por la presencia o ausencia de distorsión de la porción terminal del complejo QRS. Se consideraron criterios de reperfusión el pico temprano de CK/CKMB, el descenso del segmento ST mayor del 50 per cent y la negativización de la onda T a las 2 h postrombólisis. Se realizó un análisis estadístico mediante el test de la t de Student para variables cuantitativas y el de la 2 para las cualitativas. Resultados. La edad media de los pacientes, 131 varones y 19 mujeres, fue de 60 años. Un total de 80 infartos fueron de cara inferior y 59 de pared anterior. No existieron diferencias entre los grupos en cuanto a sexo, tipo y tiempo de inicio de la trombólisis, criterios de reperfusión, resultados de la ergometría y la coronariografía, episodios de angina postinfarto o arritmias malignas y fallecimientos. Los pacientes con distorsión final del complejo QRS presentaron infartos de mayor tamaño (CK/CKMB = 3.207[1662]/403 [226] U frente a 2.251[1564]//281[186] U, p = 0,001). Los pacientes con distorsión del complejo QRS presentaron mayor presencia de claves Killip III/IV (OR = 5,44; IC del 95 per cent, 1,01-229,13; p = 0,002) y disfunción ventricular izquierda severa (OR = 3,2; IC del 95 per cent 1,06-9,66; p = 0,003). Conclusión. El patrón electrocardiográfico del ingreso en el infarto agudo de miocardio tratado con trombólisis no se asocia con la respuesta al tratamiento trombolítico, pero sí con el tamaño del infarto y la disfunción ventricular izquierda. (AU)

Sustained ventricular tachycardia as a marker of inadequate myocardial perfusion during the acute phase of myocardial infarction.

BACKGROUND: Sustained ventricular tachycardia (VT) complicating the acute phase of myocardial infarction (AMI) is a quite rare event but with short-term unfavorable prognosis. The clinical characteristics as well as the therapeutic implications have not yet been well defined. HYPOTHESIS: This paper attempts to prove that VT may be considered a marker of inadequate myocardial perfusion after thrombolysis. METHODS: To assess the clinic-electroangiographic characteristics and prognosis of patients with VT occurring within the first 4 days of an AMI, a case-control study was carried out in 23 patients from a total of 1,100 patients (1.9%) hospitalized with AMI between March 1993 and July 1997. These patients were compared with a control group of 131 patients hospitalized consecutively. A statistical analysis was made using the chi-square test, t-test, and logistic regression. RESULTS: There were no differences among groups with regard to age, gender, and area of necrosis. Average time for the onset of VT was 26 h (range 0-92 h). Sixteen patients underwent coronary angiography: 4 patients had left main coronary artery disease, 2 had single-vessel disease, 8 had lesions in two vessels, and 2 had triple-vessel disease. Univariate analysis showed that patients with VT had a higher incidence of creatine phosphokinase (CPK)-MB peak > 300 UI/l (61 vs. 30%; p<0.001), more frequent occurrence of previous AMI (48 vs. 17%; p<0.001), and acute intraventricular conduction disorders (26 vs. 4%; p<0.001). Furthermore, these patients suffered ischemia previous to VT more frequently (65 vs. 11%; p<0.0001), and had a greater mortality rate than that in the control group (35 vs. 4%; p<0.0001). In the multivariant analysis, the variables related to the occurrence of VT were CPK-MB peak > 300 IU/l (OR 5.9; 95% CI 1.6-21), acute intraventricular conduction disorders (OR 9.02; 95% CI 1.7-48), and ischemia immediately prior to VT (odds ratio [OR] 19.64; 95% confidence interval [CI] 5.3-73). CONCLUSIONS: Ventricular tachycardia may be considered a marker of inadequate myocardial perfusion after thrombolysis; therefore, a more aggressive revascularization treatment in these patients would be advisable. The profile of patients with AMI, hospitalized in the coronary care unit, who will likely suffer from VT is previous AMI, CPK-MB peak > 300, acute intraventricular conduction disorders, Killip > I, and ischemia previous to VT.

Sigmoid cystoplasty with argon beam without mucosa.

PURPOSE: Intestinal bladder augmentations have well recognized complications, including mucus production, metabolic abnormalities and perforation. These complications may be avoided if the intestinal mucosa is not incorporated in the urinary tract. We report our experience with sigmoid cystoplasty without mucosa using argon beam, and describe the clinical, urodynamic, ultrasound and pathological results. MATERIALS AND METHODS: We performed sigmoid cystoplasty without mucosa in 26 patients and with argon beam over the mucosa before it was removed in 6 boys and 4 girls with a mean age of 8 years (range 3 to 14). All patients had neurogenic bladder as the initial disease. Indications for augmentation were poor bladder compliance, low bladder capacity, hydronephrosis and urinary incontinence. Mean followup was 18 months (range 8 to 40) and included ultrasound, urodynamic evaluation, renal function and clinical assessment. In all patients intraoperative biopsies were done. In 8 of the 10 patients endoscopic biopsies of the augmented segment were obtained between 6 months and 2 years postoperatively. The operation consisted of the Goodwin technique without mucosa, which was treated with argon beam before it was removed. RESULTS: The 10 patients are dry on intermittent clean catheterization with intervals of greater than 4 hours. There have been no clinical urinary tract infections. Two patients presented with peristaltic contractions and no symptoms. Bladder capacity increased from 80 (range 45 to 200) to 300 (220 to 400) ml., and mean postoperative compliance was 15 ml./cm. H2O (range 9 to 38). There were no significant changes in the urodynamic data between patients treated with sigmoid cystoplasty without mucosa only and with argon beam. Intraoperative biopsies after treatment with argon beam showed damaged mucosa and muscularis mucosa, and intact serosa, muscularis and submucosa layers. On the 8 argon beam postoperative biopsies the sigmoid submucosa was covered with a pseudostratified metaplasia of connective tissue with collagen fibers without scars (trichromic technique). CONCLUSIONS: Sigmoid cystoplasty without mucosa with argon beam is easy to perform. The clinical and urodynamic results have been satisfactory, and use of argon beam prevents postoperative bleeding and residual glands.

Single distal ureter for ureterocystoplasty: a safe first choice tissue for bladder augmentation.

PURPOSE: Recently, the use of ureter for bladder augmentation has gained wide acceptance due to a lower complication rate compared to gastrointestinal segments. Unfortunately, the presence of a severely dilated urinary tract implicates loss of function of a renal unit which is often not demonstrated at diagnosis. Conversely, many patients present with 1 or both ureters mildly dilated because of vesicoureteral reflux or functional obstruction. In these cases the use of a single distal ureter seems to be a good option. We report our experience and long-term followup with this subset of patients. MATERIALS AND METHODS: Between December 1994 and November 1998, 17 females and 5 males 1.5 to 15.7 years old (mean age 7.2) with a low capacity, poorly compliant bladder underwent ureterocystoplasty with a single distal dilated ureter. Diagnosis included myelomeningocele in 13 cases, central neurogenic bladder in 3, neurogenic nonneurogenic bladder in 2, congenital spinal cord injury in 2, sacral agenesis in 1 and giant sacral teratoma in 1. All but 2 patients complained of recurrent febrile urinary tract infections. Variable degrees of hydronephrosis were observed in all patients. Vesicoureteral reflux was detected in 14 patients and was bilateral in 3. Five patients presented with chronic renal failure. Before surgery 19 patients were on clean intermittent catheterization and prophylactic antibiotics. The segments of ureter used for augmentation ranged from 9 to 14 cm. long (mean 11) and from 0.8 to 2.5 cm. in diameter (mean 1.3). The more distal piece of the ureter was kept unopened to preserve vascular supply. Simultaneous procedures included transureteroureterostomy in all 22 patients, appendicovesicostomy in 10, bladder neck continence procedures in 4 and ureteroneocystostomy in 3. Clinical, radiological and urodynamic evaluation was done 6 months postoperatively and yearly thereafter. RESULTS: Followup ranged from 12 to 60 months (mean 22). Of the patients 19 are dry on clean intermittent catheterization at 4-hour intervals and 6 have had 9 symptomatic urinary tract infections. Hydronephrosis resolved in 14 patients, improved in 6 and remained unchanged in 2. On urodynamics median increase in capacity less than 30 cm. pressure was 177% (range 11% to 560%). When comparing capacity less than 30 cm. water to normal expected capacity for age and weight, 50% of the cases reached or exceeded theoretical capacity while the rest reached 63% to 89% (mean 76%). Long-term complications included persistent reflux in 1 case, deterioration of bladder function without clinical impairment in 1 and spontaneous perforation of the ureteral patch in 1 requiring colocystoplasty. CONCLUSIONS: Although increase in bladder capacity is not always optimal with the use of a distal dilated ureter, it is good enough to ensure a good clinical outcome and allow an adequate catheterization interval with a low complication rate in the long term, thus avoiding use of a piece of gut or stomach to perform bladder augmentation in nearly all patients.

Efecto del diámetro interno del tubo endotraqueal sobre el consumo de oxígeno durante la respiración espontánea / Effect of the inner diameter of the endotracheal tube on oxygen consumption during spontaneous respiration

Objetivo. Valorar, en pacientes con respiración espontánea, el efecto de la reducción simulada del diámetro interno del tubo endotraqueal (TET) desde 8 a 7 mm sobre el consumo de oxígeno (V.O2) y la frecuencia respiratoria. Métodos. Durante la desconexión de la ventilación mecánica, en doce pacientes que mantenían una correcta respiración espontánea a través de un TET, medimos el V.O2 y la producción de CO2 (V.CO2) en dos ocasiones, una con un TET de 8 mm de diámetro interno ( ) y otra con un conector de un TET de 6 mm de , que simula la resistencia al flujo de aire de un TET de 7 mm de . Medimos el V.O2 y la V.CO2 con el método del circuito abierto mediante un espirómetro Wright y un analizador de gases IL-1312 (Izasa, España). Se ha utilizado la prueba de la "t" de Student para datos pareados. Se consideró significativo un valor de p < 0,05.Resultados. La reducción del del TET de 8 a 7 mm se acompañó de un incremento en el V.O2 de 8 (DE 13) ml/min (límites de -12 a 27 ml/min, 95 por ciento IC de -1 a 16 ml/min; p = 0,07) y en la V.CO2 de 9 (DE 8) ml/min (límites de -6 a 16 ml/min, 95 por ciento IC de 4 a 14 ml/min; p = 0,002). La frecuencia respiratoria disminuyó de 26 a 25 rpm (p = 0,07). Conclusión. Durante la desconexión de la ventilación mecánica, en pacientes con buena tolerancia a la respiración espontánea en "tubo en T", la reducción del diámetro interno del tubo endotraqueal de 8 a 7 mm no modifica el consumo de O2, ni la frecuencia respiratoria, de forma clínicamente relevante. (AU)

Implicación pronóstica de la sospecha clínica inicial en la disección de aorta torácica. Revisión de los métodos diagnósticos utilizados / Prognostic significance of the initial diagnostic suspicion in cases of thoracic aortic dissection. review of the diagnostic techniques

Objetivo. Analizar la importancia de la sospecha clínica inicial en el diagnóstico de la disección de aorta torácica y la influencia en su pronóstico, revisar los diferentes métodos complementarios utilizados. Material y métodos. Se estudiaron retrospectivamente 33 casos de disección de aorta torácica entre enero de 1993 y junio de 1998, valorándose parámetros clínico-epidemiológicos, diagnósticos de ingreso y pruebas complementarias. Los resultados cualitativos se valoraron mediante 2.Resultados. La sintomatología típica de disección (dolor torácico, abdominal e interescapular) se apreció en 19 (58 por ciento) casos. La sospecha clínica al ingreso se realizó en 9 (27 por ciento) de los pacientes, siendo diagnósticos tardíos/casuales 22 (67 por ciento ) casos. Se realizó el diagnóstico de disección a través de la necropsia en 2 (6 por ciento) ocasiones. Diagnósticos erróneos de ingreso fueron: cardiopatía isquémica en 9 casos; isquemia de miembros inferiores en 3. Se realizó el diagnóstico de cólico hepático, neumonía, gastroenteritis, síncope, cólico nefrítico, aneurisma de aorta abdominal, pancreatitis y dolor osteomuscular respectivamente en un caso. El retraso en el diagnóstico no influyó significativamente en la mortalidad. La prueba diagnóstica que se utiliza en nuestro medio en primer lugar es la tomografía axial computarizada (TAC). La aortografía se utiliza como prueba confirmatoria del diagnóstico. Conclusiones. No se valoran adecuadamente los datos de la clínica inicial. La mortalidad es mayor en el grupo de pacientes en el cual no hay sospecha clínica inicial de disección de aorta (AU)

Obstrucción intestinal en el prematuro de extremado bajo peso / Small bowel obstruction in very low birth weight preterm newborns

Seis prematuros con extremado bajo peso al nacer(PEBP,< 600 g)presentaron un cuadro de obstrucción intestinal seguido de perforación,ninguno evolucionó como una enterocolitis necrotizante (ECN).Los seis fueron operados,cuatro por neumoperotoneo,uno por una masaabdominal palbable y el restante por obstrucción intestinal.Los hallazgos quirúrgicos fueron,en todos los casos,impactación meconial en íleon distal con perforación inmediatamente proximal.Se realizó una resección segmentaria del íleon y una ileostomía.Tres pacientes fallecieron antes de los 45 días postoperatorios y el resto evolucionó favorablemente.La perforación intestinal no relacionada con ECN ocurre con cierta freceuncia en los PEBP.Prevenir la perforación y encontar la causa que la produce,constituyen el mayor desafío en el tratamiento de esta patología

Obstrucción intestinal en el prematuro de extremado bajo peso / Small bowel obstruction in very low birth weight preterm newborns

Seis prematuros con extremado bajo peso al nacer(PEBP,< 600 g)presentaron un cuadro de obstrucción intestinal seguido de perforación,ninguno evolucionó como una enterocolitis necrotizante (ECN).Los seis fueron operados,cuatro por neumoperotoneo,uno por una masaabdominal palbable y el restante por obstrucción intestinal.Los hallazgos quirúrgicos fueron,en todos los casos,impactación meconial en íleon distal con perforación inmediatamente proximal.Se realizó una resección segmentaria del íleon y una ileostomía.Tres pacientes fallecieron antes de los 45 días postoperatorios y el resto evolucionó favorablemente.La perforación intestinal no relacionada con ECN ocurre con cierta freceuncia en los PEBP.Prevenir la perforación y encontar la causa que la produce,constituyen el mayor desafío en el tratamiento de esta patología

Clinical and urodynamic evaluation after ureterocystoplasty with different amounts of tissue.

PURPOSE: Ureter is one of the best tissues for bladder augmentation. The amount of ureteral segment available is extremely variable among patients. We compared results in patients who underwent ureterocystoplasty with 2 ureters, 1 complete ureter or a distal segment only after transureteroureterostomy. MATERIALS AND METHODS: During a 6-year period we performed 32 ureterocystoplasties at 2 pediatric centers in Argentina (16) and Chile (16). Median patient age at surgery was 9 years (range 4 months to 20 years). Clinical presentation included urinary infection, hydronephrosis, incontinence and undiversion. The diagnosis was neurogenic bladder in 20 cases, infravesical obstruction in 7, massive reflux in 3 and ureterocele in 2. All patients had poor bladder compliance and vesicoureteral reflux. We used different options to augment the bladder, including 2 ureters in 5 patients, bilateral nephrectomy in 3, a complete duplex system in 1 and a bilateral partial ureter in 1 (group 1); a complete ureter in 14 (group 2), and a distal segment of ureter with transureteroureterostomy in 13 (group 3). When transureteroureterostomy was performed, a suprapubic tube remained indwelling for 2 weeks and a Double-J stent was placed for 1 month. Median followup was 16 months (range 4 months to 6 years). Clinical and radiological evaluations, including ultrasound, cystography, urodynamics, renal scan and renal function measurement, were done 4 months postoperatively and twice yearly thereafter as needed. RESULTS: We noted no significant difference in bladder capacity when 1 or 2 ureters were used. Median increase in bladder capacity in groups 1 and 2 was 375% (range 80 to 800). All patients who received a complete segment of ureter had clinical improvement, decreased hydronephrosis and resolution of reflux with improved bladder compliance. When a partial segment of ureter was used median capacity increased 230% (range 40 to 400) with clinical improvement in 12 patients (92.3%). Compliance improved, which led to longer intervals between clean intermittent catheterizations. No patient has needed repeat augmentation to date. CONCLUSIONS: There is a difference in median increased bladder capacity when a segment of distal ureter is used to augment the bladder versus 1 or 2 whole ureters. However, the use of distal ureter still represents a safe alternative for augmenting the bladder and simultaneously resolving massive reflux. Ureterocystoplasty is an excellent choice for increasing bladder capacity and improving bladder compliance despite the different amounts of tissue available.

Perforación espontánea de la vía biliar en niños / Spontaneous Perforation of Bile Ducts: Report of two cases

La perforación espontánea de la vía biliar es una entidad poco frecuente y de etiología variable. Se presentan dos pacientes tratadas en el Servicio de cirugía Pediátrica de Hospital Italiano de Buenos Aires. Las manifestaciones clínicas comunes a los dos pacientes fueron: distensión abdominal, ictericia, acolia y ascitis biliosa. La conducta fue inicialmente quirúrgica, realizándose el diagnóstico de certeza mediante una colecistocolangiografía intraoperatoria. El tratamiento fue con drenaje del área colecistocoledociana y derivación de la vía biliar por colecistomía,obteniéndose una recuperación satisfactoria de ambos pacientes