Magnetic resonance imaging following the demonstration of a normal common bile duct on ultrasound in children with suspected choledocholithiasis: what is the benefit?

BACKGROUND: The role of MRI in evaluating children with an in situ gallbladder and suspected choledocholithiasis following a negative or inconclusive US is unclear. OBJECTIVE: To determine whether MRI benefits children with suspected choledocholithiasis and a normal common bile duct (CBD) without stones on US. MATERIALS AND METHODS: We conducted a retrospective 10-year review of paired US and MRI (within 10 days) in children 18 years or younger with suspected choledocholithiasis. With MRI as a reference standard, two reviewers independently evaluated the images for CBD diameter, choledocholithiasis, cholelithiasis and pancreatic edema. Serum lipase was recorded. We calculated exact binomial confidence limits for test positive predictive values (PPVs) and negative predictive values (NPVs) using R library epiR. RESULTS: Of 87 patients (46 female, 41 male; mean age 14 years, standard deviation [SD] 4.6 years; mean interval between US and MRI 1.6 days, SD 1.8 days), 55% (48/87) had true-negative US, without CBD dilation/stones confirmed on MRI; 5% (4/87) had false-positive US showing CBD dilatation without stones, not confirmed on MRI; 33% (29/87) had true-positive US, with MRI confirming CBD dilatation; and 7% (6/87) had false-negative US, where MRI revealed CBD stones without dilatation (2 patients) and CBD dilatation with or without stones (4 patients). Patients with false-negative US had persistent or worsening symptoms, pancreatitis or SCD. The overall US false-negative rate was 17% (6/35). Normal-caliber CBD on US without stones had an NPV of 89% (48/54, 95% confidence interval: 0.77-0.96). CONCLUSION: MRI adds little information in children with a sonographically normal CBD except in the setting of pancreatitis or worsening clinical symptoms. Further evaluation is warranted in children with elevated risk of stone disease.

Use of Lumen-apposing Metal Stents for Endoscopic Drainage of Intra-abdominal Fluid Collections in Pediatric Patients.

INTRODUCTION: Intraabdominal fluid collections that previously required surgical intervention can now be drained with less invasive techniques. The use of lumen-apposing metal stents (LAMS) to treat pancreatic pseudocysts and perirectal abscesses has been shown to be a safe and effective technique in adults. We aim to evaluate the indications, outcomes, and complications of the use of LAMS in pediatric patients at our institution. METHODS: A retrospective chart review was performed to study patients up to 18 years of age at the Children's Hospital at Montefiore who underwent drainage of intraabdominal fluid collections with the use of LAMS. The main outcome measures were technical and clinical success and associated adverse events with LAMS placement. RESULTS: Seven patients (2 girls) ranging from 9 to 18 years were identified. Four patients had perirectal abscess postperforated appendicitis and 3 patients had pancreatic pseudocysts. All of the patients had complete resolution of the collections, with no recurrence, and our technical and clinical success rate was 100%. Only 1 patient had mild bleeding after placement that spontaneously resolved. DISCUSSION: Our study demonstrates the efficacy and safety of the use of LAMS for the drainage of intraabdominal fluid collections in pediatric patients, although the number of patients included is limited.

Novel Non-Surgical Interventions for Benign Inflammatory Biliary Strictures in Infants: A Report of Two Cases and Review of Current Pediatric Literature.

Benign biliary strictures are uncommon in children. Classically, these cases are managed surgically, however less invasive approaches with interventional radiology and or endoscopy may have similar results and improved safety profiles While benign biliary strictures have been described in literature on several occasions in young children, (most older than 1 year and once in an infant 3 months of age), all reported cases were managed surgically. We present two cases of benign biliary strictures in infants less than 6 months of age that were managed successfully with novel non-invasive procedures and a review of all current pediatric cases reported in the literature. Furthermore, we describe the use of a Rendezvous procedure, which has not been reported as a treatment approach for benign biliary strictures.

[Nitrogenous content in parenteral nutrition: a four-year experience in a general hospital. Critically-ill patient specificity].

INTRODUCTION: There have been several studies focusing on caloric intake during the last years, while protein content relevance has been underestimated. Some recent evidence has shown that protein deficiency has also an impact on patient outcomes. We have studied the nitrogen (N) content in parenteral nutrition (PN) bags administered to adult patients in a Spanish tertiary level hospital for four years. MATERIAL AND METHODS: Patients who received parenteral nutrition in the general ward and Intensive Care Unit (ICU) were recorded. Caloric and protein content were registered and adjusted to weight and length of stay. Data were compared among three group of patients: those in the general ward, those in the ICU and those requiring renal replacement therapy (RRT). The one-factor analysis of variance (ANOVA) test was used after checking data normality and homoscedasticity. RESULTS: There was an increase in the mean g N/stay year after year (p < 0.01) from 14 to 15.5 g, with a decrease in non-protein caloric content (p < 0.001) from 111.6 to 101.8 kcal/g N. The range was established from 4.1 to 32.6 g. PN diets with ≥ 18 g N% ranged from 12.8% (2010) to 19.6% (2013). There were significant differences among the groups when comparing the variable g N/stay (p < 0.0001): 13.5 general ward vs15.9 ICU patients vs17.6 ICU with RRT, also when referring to adjusted weight. CONCLUSIONS: According to most recent recommendations nitrogen has been provided in higher amounts than previously, especially in critical care patients with RRT.

Nitrogenous content in parenteral nutrition: a four-year experience in a general hospital. Critically-ill patient specificity / Contenido nitrogenado de la nutrición parenteral: un estudio de cuatro años en un hospital general. Especificidad en paciente crítico

Introduction: There have been several studies focusing on caloric intake during the last years, while protein content relevance has been underestimated. Some recent evidence has shown that protein deficiency has also an impact on patient outcomes. We have studied the nitrogen (N) content in parenteral nutrition (PN) bags administered to adult patients in a Spanish tertiary level hospital for four years. Material and methods: Patients who received parenteral nutrition in the general ward and Intensive Care Unit (ICU) were recorded. Caloric and protein content were registered and adjusted to weight and length of stay. Data were compared among three group of patients: those in the general ward, those in the ICU and those requiring renal replacement therapy (RRT). The one-factor analysis of variance (ANOVA) test was used after checking data normality and homoscedasticity Results: There was an increase in the mean g N/stay year after year (p < 0.01) from 14 to 15.5 g, with a decrease in non-protein caloric content (p < 0.001) from 111.6 to 101.8 kcal/g N. The range was established from 4.1 to 32.6 g. PN diets with ≥ 18 g N% ranged from 12.8% (2010) to 19.6% (2013). There were significant differences among the groups when comparing the variable g N/stay (p < 0.0001): 13.5 general ward vs 15.9 ICU patients vs 17.6 ICU with RRT, also when referring to adjusted weight. Conclusions: According to most recent recommendations nitrogen has been provided in higher amounts than previously, especially in critical care patients with RRT (AU)

Introducción: algunos estudios recientes sugieren que se ha dado gran importancia al aporte calórico en la nutrición parenteral (NP) del paciente adulto, infraestimando su contenido proteico. Sin embargo, se ha demostrado su relación con los resultados clínicos. Con este objetivo se ha estudiado el contenido en nitrógeno (N) de las NP administradas en un hospital terciario a lo largo de cuatro años. Material y métodos: se recogieron datos de la NP de pacientes hospitalizados en planta, así como en la Unidad de Cuidados Intensivos (UCI). El peso del paciente, su índice de masa corporal (IMC), el contenido en nitrógeno (total y por peso), el aporte calórico no proteico y la duración de la NP fueron algunas de las variables estudiadas. Se compararon en 2013 los aportes en la planta general, en UCI y en aquellos que recibieron algún tipo de terapia renal sustitutiva (TRS). Se utilizó el análisis de varianza (ANOVA) de un factor, previa comprobación de la normalidad y homocedasticidad. Resultados: se ha observado un aumento progresivo en aporte nitrogenado medio diario cada año (p < 0,01) de 14 a 15,05 g, con descenso del contenido calórico no proteico (p < 0,001) de 111,6 a 101,8 kcal /g N. El rango de N en bolsa fue de 4,1 a 32,6 g. Aumentó el porcentaje de bolsas con ≥ 18 g N (12,8 en 2010 vs. 19,6 en 2013). También hubo diferencias entre grupos de pacientes en g N/estancia (p < 0,0001): 13,5 plantas de hospitalización vs. 15,9 UCI vs. 17,6 UCI con TRS, igualmente si referidos a peso ajustado. Conclusiones: En consonancia con las recomendaciones más recientes, el contenido en nitrógenos ha aumentado con los años, en especial en la NP del paciente crítico, siendo aún mayor en los sometidos a TRS (AU)

Yield of diagnostic tests in obese children with an elevated alanine aminotransferase.

AIM: Nonalcoholic fatty liver disease (NAFLD) is associated with obesity and affects roughly 10% of children. However, NAFLD is often diagnosed by exclusion - that is, obese children with an elevated alanine aminotransferase (ALT) are screened for other liver diseases in the absence of a biopsy. This testing is nonstandardized, and professional society recommendations differ. This study examines the yield of testing for disorders other than NAFLD in this patient population. METHODS: A retrospective study was performed in 120 obese, asymptomatic, noncholestatic children with an ALT ≥40 U/L and additional diagnostic testing. RESULTS: No patients were found to have Wilson's, hepatitis A, hepatitis B, hepatitis C, cytomegalovirus, alpha-1 antitrypsin deficiency, autoimmune hepatitis, celiac disease or Epstein-Barr virus. Only one patient (1/120) was identified with definite disease other than NAFLD, which was muscular dystrophy. The positive predictive value of a screening test was 5%, and the specificity was 97%. Of 70 children with an abdominal ultrasound, no significant abnormalities were identified. CONCLUSION: Extensive testing in asymptomatic, noncholestatic, obese children with an elevated ALT may be of limited diagnostic value and false-positive tests are likely. Large, prospective studies are needed to help focus the work up in this patient population.

Improving Nonattendance at Outpatient Pediatric Endoscopy Unit of a Tertiary Center.

BACKGROUND AND OBJECTIVES: Failure to attend pediatric outpatient endoscopic procedures leads to inefficient use of resources, longer wait-list times, and delay in diagnoses. The causes for pediatric endoscopy nonattendance are not well studied. The aim of the study was to identify factors associated with failure to attend endoscopic procedures and to assess the value of quality improvement (QI) interventions implemented to improve pediatric endoscopy attendance. METHODS: This was a continuous QI project. We collected nonattendance data from November 2011 to November 2013. Information collected included procedure type, age, sex, time on the waiting list, history of previous procedures, and reason for nonattendance. The following QI interventions were implemented sequentially: an appointment reminder letter, a telephone call 1 week before procedure, and creation of an electronic medical note dedicated to endoscopy appointment. Pareto charts and statistical process control charts were used for analysis. RESULTS: From November 2011 to November 2013, we were able to decrease nonattendance from 17% to 11% (P = 0.005). No-show rate was reduced from 5% to 0.9% (P = 0.00001). There was no significant difference between attendees and nonattendees in relation to sex, age, or having a previous procedure. Longer waiting time (33 vs 26 days) was associated with increased risk for nonattendance (P = 0.0007). The most common causes for nonattendance were illness (31.5%), followed by caregiver/patients who no longer wanted the procedure (17.7%), and patients who improved (12.9%). CONCLUSIONS: Applying QI methods and tools improved pediatric endoscopy attendance. Longer wait time for endoscopic procedures is associated with nonattendance. Given the increased pediatric endoscopy demand, strategies should be implemented to reduce wait time for pediatric endoscopy.

Single-center experience with 1-step low-profile percutaneous endoscopic gastrostomy in children.

OBJECTIVES: The 1-step low-profile percutaneous endoscopic gastrostomy (1-step PEG) uses a single procedure that allows immediate use of a low-profile device. The aim of the present study was to provide our experience with this device and to analyze complications and outcomes after the initial placement. METHODS: We performed a retrospective chart review of pediatric patients with 1-step PEG placement done by our pediatric gastroenterologists between 2006 and June 2011. Patients were studied for a minimum period of 6 months. RESULTS: A total of 121 patients were included in our study, with 23% infants. The most common indication for 1-step PEG placement was swallowing dysfunction in children with neurological impairment (49%). Postplacement complications included granulation tissue (52%), cellulitis (23%), leakage (21%), vomiting (17%), tissue breakdown (8%), failed placement (6%), embedded bolster (5%), perforation (0.8%), and bowel obstruction (0.8%). One-step PEG was maintained in 46 patients (38%). In the remaining 75 patients (62%), PEGs were changed to a balloon device in 66 patients and were completely removed in 9 patients. The most common indications for change were damaged PEG (19/75) and issues with size (11/75). The time to change ranged from <1 month to >4 years (14 ± 1.3 months). Sixty-eight percent of 1-step PEG changes/removal was performed with an obturator under brief inhalated anesthesia. CONCLUSIONS: The 1-step PEG has complication rates and outcomes comparable with standard PEGs.

Improving the timeliness of procedures in a pediatric endoscopy suite.

BACKGROUND AND OBJECTIVE: Pediatric endoscopic procedures are essential in the evaluation and treatment of gastrointestinal diseases in children. Although pediatric endoscopists are greatly interested in increasing efficiency and through-put in pediatric endoscopy units, there is scarcely any literature on this critical process. The goal of this study was to improve the timeliness of pediatric endoscopy procedures at Children's Hospital at Montefiore. METHODS: In June 2010, a pediatric endoscopy quality improvement initiative was formed at Children's Hospital at Montefiore. We identified patient-, equipment-, and physician-related causes for case delays. Pareto charts, cause and effect diagrams, process flow mapping, and statistical process control charts were used for analysis. RESULTS: From June 2010 to December 2012, we were able to significantly decrease the first case endoscopy delay from an average of 17 to 10 minutes (P < .001), second case delay from 39 to 25 minutes (P = .01), third case delay from 61 to 45 minutes (P = .05), and fourth case delay from 79 to 51 minutes (P = .05). Total delay time decreased from 196 to 131 minutes, resulting in a reduction of 65 minutes (P = .02). From June 2010 to August 2011 (preintervention period), an average of 36% of first endoscopy cases started within 5 minutes, 51% within 10 minutes, and 61% within 15 minutes of the scheduled time. From September 2011 to December 2012 (postintervention period), the percentage of cases starting within 5 minutes, 10 minutes, and 15 minutes increased to 47% (P = .07), 61% (P = .04), and 79% (P = .01), respectively. CONCLUSIONS: Applying quality improvement methods and tools helped improve pediatric endoscopy timeliness and significantly decreased total delays.

[Clinical simulation as a training tool for clinical teams and care change facilitator]. / La simulación clínica: entrenamiento de equipos clínicos y facilitador de cambios asistenciales.

OBJECTIVE: The objective of this article is to describe and show the results of a simulation training interprofesional program to meet a training need of Surgical area professionals in management in cardiovascular surgery emergencies in Valdecilla Hospital. MATERIAL: The activity was aimed to train at the 42 nurses in rotation in the surgical area, nursing assistances, cardiovascular surgeons and anesthetists. For it was made a study of the training needs and were designed clinical simulation escenarios, theoretical sessions as well in workshops usual workplace. RESULTS: The training project was conducted in four phases between May 21 to June 18, 2012, within which were 3 clinical cases for multidisciplinary training in emergency usual CCV. With the full participation of 65 professionals and 17 instructors, after further analysis to cases, results were achieved improved teamwork, and picked up, several changes to be made in the organization of the service. CONCLUSIONS: Clinical simulation mode responds to adult learning, based on their own experience and personal reflection, and all in an environment that does not risk to patients or professionals. It is really helpful and flexible to meet different institutional challenges and where participants highlighted two key aspects in this activity such as the multidisciplinary team where they could train the professional standard and the possibility of analysis and reflection after the event to share experiences and look for areas of improvement among all the clinical team.

La simulación clínica. Entrenamiento de equipos clínicos y facilitador de cambios asistenciales / Clinical simulation as a training tool for clinical teams and care change facilitator

Objetivo. Describir y mostrar los resultados de un programa de formación interprofesional basado en simulación clínica para para dar respuesta a una necesidad formativa de los profesionales del área quirúrgica del Hospital Valdecilla en el manejo de las urgencias vitales en cirugía cardiovascular (CCV). Material. La actividad fue dirigida para entrenar a las 42 enfermeras de turno rotatorio del área quirúrgica junto con personal auxiliar, cirujanos cardiovasculares y anestesistas. Para ello se realizó un estudio de las necesidades formativas y se diseñaron jornadas de entrenamiento mediante simulación clínica, además de sesiones teóricas y talleres in situ en el lugar habitual de trabajo. Resultados. El proyecto formativo se realizó en cuatro fases entre el 21 de mayo al 18 de junio del 2012, dentro de las cuales se efectuaron tres casos clínicos para el entrenamiento multidisciplinar de urgencias habituales en CCV, con la participación total de 65 profesionales y 17 instructores; gracias a los análisis posteriores a los casos, se alcanzaron resultados de mejora del trabajo en equipo y se recogieron diferentes cambios a realizar en la organización clínica del servicio. Conclusiones. La simulación clínica responde al modo de aprendizaje de los adultos, basado en la propia experiencia y la reflexión personal, y todo ello en un entorno que no pone en riesgo a pacientes, ni a profesionales. Es realmente útil y flexible para hacer frente a diferentes retos institucionales; y los participantes resaltaron dos aspectos clave: el caracter multidisciplinar, pudiendo entrenar el equipo habitual de profesionales, y la posibilidad del análisis y reflexión posterior al caso para compartir experiencias y buscar áreas de mejora entre todo el equipo clínico (AU)

Objective: The objective of this article is to describe and show the results of a simulation training interprofesional program to meet a training need of Surgical area professionals in management in cardiovascular surgery emergencies in Valdecilla Hospital. Material: The activity was aimed to train at the 42 nurses in rotation in the surgical area, nursing assistances, cardiovascular surgeons and anesthetists. For it was made a study of the training needs and were designed clinical simulation escenarios, theoretical sessions as well in workshops usual workplace. Results: The training project was conducted in four phases between May 21 to June 18, 2012, within which were 3 clinical cases for multidisciplinary training in emergency usual CCV. With the full participation of 65 professionals and 17 instructors, after further analysis to cases, results were achieved improved teamwork, and picked up, several changes to be made in the organization of the service. Conclusions: Clinical simulation mode responds to adult learning, based on their own experience and personal reflection, and all in an environment that does not risk to patients or professionals. It is really helpful and flexible to meet different institutional challenges and where participants highlighted two key aspects in this activity such as the multidisciplinary team where they could train the professional standard and the possibility of analysis and reflection after the event to share experiences and look for areas of improvement among all the clinical team (AU)

Laparoscopic excision of a gastric diverticulum in a child.

Gastric diverticulum is a rare entity; the patient usually presents with vague abdominal pain, nausea, vomiting, and weight loss. Diverticulectomy is required for patients with intractable symptoms or complications. We report the laparoscopic excision of a gastric diverticulum in a 15-year-old girl who had been symptomatic for 5 years. A five-port technique and a linear cutting and stapling device were used.

La interposición yeyunal a manera de Merendino: a propósito de un caso / Jejunal interposition like Merendino: report of a case

Presentamos un caso clínico de estenosis esofágica benigna por enfermedad úlcero-péptica que fue intervenido mediante una interposición yeyunal a manera de merendino, en el Hospital Central de Valencia. La anastomosis esófago-yeyunal fue realizada mediante una EEA No 28. Resaltamos las ventajas anatómicas y funcionales del uso del yeyuno como órgano de sustitución esofágica. Creemos que el yeyuno en resecciones pequeñas del esófago inferior, es una buena alternativa. Pero reconocemos que el primer órgano de sustitución esofágica es el estómago y en segundo lugar el colon

Análisis de 16 casos de megacolon tóxico tratado mediante ileorrectoanastomosis primaria / Analysis of 16 cases of toxic megacolon treated by primary ileorectal anastomosis

Se analizan los aspectos clínicos, el tratamiento quirúrgico y los resultados de 16 casos consecutivos de Megacolon Tóxico como complicación de la rectocolitis ulcerosa atendidos en la Clínica Quirúrgica de la Universidad de Roma, en el período 1976-1987. La cirugía realizada fue la colectomía total con ileorectoanastomosis en un solo tiempo, sin ileostomía de protección, en 14 pacientes y colectomía con ileostomía terminal e ileorrectoanastomosis diferida, cinco meses más tarde, en 2 pacientes. No tuvimos mortalidad operatoria; las complicaciones inmediatas fueron: dehiscencia parcial de la anastomosis en un caso, proctorragia en tres casos. Las tardías fueron: fistulización y perforación del "cul de sac" ileal, en 2 casos. En un paciente 10 meses más tarde fue necesaria la protectomía por intensa reaguadización de la enfermedad a nivel rectal, sobre la base de los resultados obtenidos, en casos seleccionados proponemos: La colectomía total con ileorrectoanastomosis inmediata como tratamiento de esta grave complicación

Ruptura espontánea del esófago. (Sind. de Boerhaave). Hospital Privado "Centro Médico Guerra Méndez", Valencia / Spontaneous esophageal perforation. (Boerhaave's syndrome). Private Hospital \"Centro Médico Guerra Méndez\"

Presentamos un caso de ruptura esofágico espontánea (SINDROME DE BORHAAVE) diagnósticado y tratado mediante cirugía de derivación y drenaje en el Hospital Privado "Centro Médico Guerra Méndez" en Valencia en el año 1990. Enfatizamos la importancia del diagnóstico y tratamiento precoz en esta entidad. Se analizan los detalles clínicos y terapéuticos resaltantes de esta patología

Tratamiento quirúrgico del megacolon tóxico en la rectocolitis ulcerosa: análisis de 16 pacientes / Surgical treatment of toxic megacolon in ulcerative rectocolitis: analysis of 16 patients

Se analizan los aspectos clínicos, el tratamiento quirúrgico y los resultados de 16 casos consecutivos de Megacolon tóxico como complicación de la rectocolitis ulcerosa, atendidos en la I Clínica Quirúrgica de la Universidad de Roma, en el período 1976-1987. La cirugía realizada fue la colectomía total con ileorecto-anastomosis en un solo tiempo, sin ileostomía de protección, en 14 pacientes y colectomía con ileostomía terminal e ileorectoanastomosis diferida, cinco meses más tarde, en 2 pacientes no tuvimos mortalidad operatoria, las complicaciones inmediatas fueron: dehiscencia parcial de la anastomosis en un caso, proctorragia en tres casos. Las tardías fueron: fistulización y perforación del "cul de sac" ileal, en 2 casos. En un paciente 10 meses más tarde fue necesaria la protectomía por intensa reaquidización de la enfermedad a nivel rectal, sobre la base de los resultados obtenidos, en casos seleccionados proponemos: La colectomía total con ileorectoanastomosis inmediata como tratamiento de esta grave complicación

Diagnóstico y tratamiento del linfoma no Hodgkin primario gasto-intestinal en el Hospital Central de Valencia: a propósito de 9 casos / Treatment and diagnosis of non-Hodgkin lymphoma primarily gastrointestinal tract in the Hospital Central of the Valencia: areport of the 9 cases

Se estudian 9 casos de linfoma no Hodgkin primario del tracto gastrointestinal, registrados en el Hospital Central de Valencia, en el período 1974-1986. De los 9 casos estudiados, 5 correspondieron al sexo femenino y 4 al sexo masculino, siendo el rango de edad entre 13 y 70 años. La presentación más frecuente fue a nivel gástrico (4 casos): siguiéndole el intestino delgado (3casos) y por último el ciego con 2 casos. En el diagnóstico preoperatorio de esta patología juegan un papel fundamental la clínica, la radiología contrastada y los estudios endoscópicos con toma de biopsia. La laparotomía exploradora nos permite determinar el estadio de la enfermedad. En nuestros pacientes el diagnóstico preoperatorio histopatlógico se hizo en apenas una oportunidad. En relación al tratamiento, 8 de nuestros casos fueron sometidos a cirugía, realizándose resecciones, a excepción de uno al cual sólo se le pudo realizar toma de biopsia por la gran extensión del tumor. Posteriormente todos recibieron tratamiento quimioterápico múltiple, y en 3 de ellos radioterapia. En general, el curso de esta patología dependerá del diagnóstico precoz, del tipo histopatológico, estadio de la enfermedad y de la instalación de una terapéutica multimodal efectiva, asociado cirugía, radioterapia y quimioterapia múltiple