Colectomía en pacientes pediátricos con colitis ulcerosa / Colectomy in paediatric patients with ulcerative colitis

Introducción: No son frecuentes los estudios descritos sobre fallo del tratamiento médico en colitis ulcerosa (CU) que conduce a la realización de colectomía. Material y métodos: Estudio retrospectivo desde 1984 hasta 2009 de pacientes diagnosticados de CU, menores de 14 años, sometidos a colectomía por falta de respuesta al tratamiento. Se clasifica en función de la cirugía en colectomía urgente y en electiva. Resultados: Colectomía efectuada en 14 pacientes pediátricos, el 26,9% del total de pacientes diagnosticados de CU. Edad al diagnóstico 7,8±4,0 años, inferior a 10 años en 8 casos y por debajo de 5 años en 5 pacientes. Todos los casos diagnosticados con menos de 5 años fueron colectomizados antes del sexto mes tras el diagnóstico. Se realiza una colectomía electiva en 5/14 y urgente en 9/14. Las complicaciones surgidas se dividen en precoces, por debajo de los 30 días tras colectomía, y tardías, pasado el primer mes. El tratamiento farmacológico en los casos de colectomía urgente abarca metilprednisolona por vía intravenosa (100%), tacrolimus por vía oral (55,5%), ciclosporina por vía oral/intravenoso (33,3%) einfliximab (33,3%). Los casos correspondientes a colectomía electiva corresponden al periodo1985-1998. Conclusiones: La influencia de la edad es determinante en el pronóstico. Todos los menores de5 años diagnosticados de CU terminaron colectomizados. La indicación de colectomía urgente fue realizada tras falta de respuesta al tratamiento con corticoide por vía intravenosa en combinación con potente agente inmunomodulador (tacrolimus, ciclosporina, infliximab). Los casos correspondientes a colectomía electiva sucedieron en el período anterior a 1999, cuando la terapéutica con fármacos de segunda línea era muy infrecuente, con lo que la remisión era excepcional (AU)

Introduction: There are not many studies published in the literature on failure of medical treatment in Ulcerative Colitis (UC) that leads to colectomy. Patients and methods: Retrospective study of patients under 14 years diagnosed with UC from1984 to 2009, who underwent colectomy due to lack of response to medical treatment. They are divided into urgent or elective surgery. Results: Colectomy performed in 14 paediatric patients (26.9% of total UC patients). Age at diagnosis 7.8±4.0 years, 8 of them younger than 10 years and 5 younger than 5 years. All cases diagnosed on patients less than 5 years of age required colectomy in the first 6 months after diagnosis. Elective colectomy was performed on 5/14 and urgent surgery in 9/14. The reported complications were divided into early (first 30 days after colectomy) and late. Pharmacological treatment in cases with urgent colectomy included methylprednisolone (100%), oral tacrolimus (55.5%), oral/intravenous cyclosporine (33.3%) and infliximab (33.3%). Cases of elective colectomy were all in the 1985—1998 period. Conclusions: The influence of age is a key factor for prognosis. All patients less than 5 year old ended up with colectomy. The main indication for urgent surgery was lack of response to treatment with intravenous steroids combined with a potent immunomodulator (tacrolimus, cyclosporine, infliximab). All cases of elective colectomy were performed before 1999, when second line medical treatment was very uncommon, making remission unlikely (AU)

[Colectomy in paediatric patients with ulcerative colitis]. / Colectomía en pacientes pediátricos con colitis ulcerosa.

INTRODUCTION: There are not many studies published in the literature on failure of medical treatment in Ulcerative Colitis (UC) that leads to colectomy. PATIENTS AND METHODS: Retrospective study of patients under 14 years diagnosed with UC from 1984 to 2009, who underwent colectomy due to lack of response to medical treatment. They are divided into urgent or elective surgery. RESULTS: Colectomy performed in 14 paediatric patients (26.9% of total UC patients). Age at diagnosis 7.8±4.0 years, 8 of them younger than 10 years and 5 younger than 5 years. All cases diagnosed on patients less than 5 years of age required colectomy in the first 6 months after diagnosis. Elective colectomy was performed on 5/14 and urgent surgery in 9/14. The reported complications were divided into early (first 30 days after colectomy) and late. Pharmacological treatment in cases with urgent colectomy included methylprednisolone (100%), oral tacrolimus (55.5%), oral/intravenous cyclosporine (33.3%) and infliximab (33.3%). Cases of elective colectomy were all in the 1985-1998 period. CONCLUSIONS: The influence of age is a key factor for prognosis. All patients less than 5 year-old ended up with colectomy. The main indication for urgent surgery was lack of response to treatment with intravenous steroids combined with a potent immunomodulator (tacrolimus, cyclosporine, infliximab). All cases of elective colectomy were performed before 1999, when second line medical treatment was very uncommon, making remission unlikely.

Lavados colónicos anterógrados para el estreñimiento refractario en niños sin encefalopatía / Antegrade colonic enemas for intractable constipation in non-mentally retarded children

Revisión retrospectiva de las cecostomías realizadas para lavados anterógrados colónicos. Doce apendicocecostomías desde enero de 2002 a febrero de 2008, 9 apendicostomías en pacientes con mielomeningocele y 3 cecostomías en niños con estreñimiento crónico no orgánico sin encefalopatía ni retraso mental. De los 9 primeros pacientes, de entre 3 y 13 años, 8 tuvieron muy buena evolución y uno requirió retirada por mal empleo familiar. A un niño de 7 años, por lo demás sano, con estreñimiento crónico desde los 10 meses, pese a laxantes múltiples (varias tandas de desimpactación y dilatación anal bajo anestesia), con estudio morfofuncional normal, se le realizó, hace 5 años, cecostomía; persistió cierta tendencia a impactación pero con buena calidad de vida. Otro niño, previamente sano, de 12 años de edad, presentaba incontinencia fecal diaria asociada a estreñimiento desde los 3 años, con manometría anorrectal normal y biopsia con leve displasia neuronal; se le realizó cecostomía hace 3 años, con mejoría evidente y menor trastorno emocional secundario. El último caso de cecostomía tenía 8 años, con cuadro similar al anterior y se realizó procedimiento endoscópico con botón de Chait, con lo que mejoró francamente el cuadro. La progresión del estreñimiento rebelde a edad adulta tiene un impacto negativo en la adaptación social y el estado emocional del paciente, y puede alterar la vida familiar. Los lavados anterógrados colónicos proporcionan independencia y mejoran la calidad de vida. Se necesitan realizar en más pacientes para poder establecer verdaderos datos de efectividad (AU)

A descriptive review of 12 patients who underwent appendicocecostomy or caecostomy for antegrade colonic lavage from January 2002 to February 2008. There were 9 appendicocecostomies performed patients from 3 to 13 years suffering from myelomeningocele, of which 8 of them had a very good outcome, with one case with drawn due to poor use by the family. Three caecostomies were performed in non-mentally retarded constipated children. One was an otherwise healthy 7 year-old boy with hards tools since he was 10 months old, in spite of multiple laxative treatments, with normal morphology and function. He had a percutaneous caecostomy five years ago, with some improvement and a good quality of life, but still some occasional partial impactions. Another healthy 12 year-old boy with daily constipation associated faecal incontinence since he was 3 years old (normal manometry and rectal biopsy with signs of mild neuronal dysplasia)had a percutaneous caecostomy performed three years ago, with improvement in the faecal incontinence and better psychological out come. The last caecostomy patient was an 8 year-old boy, with a similar clinical history and good progress in last three years after placing a Chait’s button using an endoscopic procedure. Stubborn constipation continuing in to adult life has a negative impact on the social and emotional adaptation of the paediatric patient, affecting family interactions. Antegrade colonic lavage allows independence and improves the quality of life in patients affected by recurrent faecal impactions. This technique needs to be performed on more patients to find out its true effectiveness (AU)

[Antegrade colonic enemas for intractable constipation in non-mentally retarded children]. / Lavados colónicos anterógrados para el estreñimiento refractario en niños sin encefalopatía.

A descriptive review of 12 patients who underwent appendicocecostomy or caecostomy for antegrade colonic lavage from January 2002 to February 2008. There were 9 appendicocecostomies performed patients from 3 to 13 years suffering from myelomeningocele, of which 8 of them had a very good outcome, with one case withdrawn due to poor use by the family. Three caecostomies were performed in non-mentally retarded constipated children. One was an otherwise healthy 7 year-old boy with hard stools since he was 10 months old, in spite of multiple laxative treatments, with normal morphology and function. He had a percutaneous caecostomy five years ago, with some improvement and a good quality of life, but still some occasional partial impactions. Another healthy 12 year-old boy with daily constipation associated faecal incontinence since he was 3 years old (normal manometry and rectal biopsy with signs of mild neuronal dysplasia) had a percutaneous caecostomy performed three years ago, with improvement in the faecal incontinence and better psychological outcome. The last caecostomy patient was an 8-year-old boy, with a similar clinical history and good progress in last three years after placing a Chait's button using an endoscopic procedure. Stubborn constipation continuing into adult life has a negative impact on the social and emotional adaptation of the paediatric patient, affecting family interactions. Antegrade colonic lavage allows independence and improves the quality of life in patients affected by recurrent faecal impactions. This technique needs to be performed on more patients to find out its true effectiveness.

[Abdominal lesions associated to safety belt mark]. / Lesiones abdominales asociadas a marca por cinturón de seguridad.

INTRODUCTION: Motor vehicle crashes cause 28% of morbidity and mortality in children. A proper medical evaluation of the polytraumatized patient is essential to reduce these numbers. The aim of our study is to correlate clinical and radiological signs in patients with seat belt mark, to establish an early diagnosis of internal injuries. MATERIALS AND METHODS: From 1998 to 2007 we treated 8 cases of polytraumatized patients (5 boys and 3 girls) with abdominal bruises (seat belt mark) after suffering a traffic accident. The mean age was 8.37 years (range: 4-11). 100% of the patients suffered a frontal collision of their vehicle. In 2 cases the position of the lap belt was inadequate. The trauma team made the initial attention of all patients in the Emergency room, with a complete physical examination and they requested: abdominal X-ray, ultrasound and computed tomography (CT-scan). RESULTS: The main clinical signs found in our patients were: one case of hemodynamic instability, hypovolemic shock and abdominal distension; 2 cases of diffuse abdominal pain and signs of peritoneal irritation; 4 cases of non-specific diffuse abdominal pain and one patient in coma with Glasgow 8. The radiological signs found were: abdominal free fluid (detected in 100% of the CT-scan and only in 75% of ultrasound studies), thickening and enhancement of small bowel (62.5%), mesenteric infiltration (87.5 %) and pneumoperitoneum (37.5%). The surgical findings were: seven cases (87.5%) of an intestinal bursting perforation and one case of vascular injury of the medium colic vein. The diagnosis of intestinal perforation was late established in five patients, and they underwent treatment between 5 and 19 days after the accident. CONCLUSIONS: All our patients (100%) with a seat belt mark presented abdominal injuries. The treatment is frequently delayed due to the difficulty in establishing the diagnosis. The finding of cutaneous ecchymosis caused by the lap belt must be a warning sign to suspect abdominal injuries. The CT scan is the most effective imaging technique to study patients with seat belt mark.

Lesiones abdominales asociadas a marca por cinturón de seguridad / Abdominal lesions associated to safety belt mark

Introducción. Los accidentes de tráfico son causa del 28% de morbimortalidad en la edad pediátrica. Una correcta evaluación médica del politraumatizado es imprescindible para la reducción de estas cifras. El objetivo de nuestro trabajo es correlacionar en pacientes con lesiones cutáneas postraumáticas por cinturón de seguridad, los signos clínicos y radiológicos para establecer un diagnóstico precoz de lesiones internas. Material y métodos. Desde 1998 hasta 2007 hemos tratado a 8pacientes (5 niños y 3 niñas) politraumatizados con marca por cinturón de seguridad tras accidente de tráfico. La edad media fue de 8,37 años(rango: 4-11). El 100% de los pacientes sufrieron una colisión frontal de su vehículo. Se constató que en 2 casos la posición del cinturón era inadecuada. A todos los pacientes se les realizó la atención inicial al politraumatizado, con una exploración física completa y se solicitaron exploraciones complementarias: radiografía simple, ecografía y tomografía computarizada (TC) abdominal. Resultados. La clínica principal que presentaron los pacientes fue: un caso de inestabilidad hemodinámica, shock hipovolémico y distensión abdominal; 2 casos con dolor abdominal difuso y signos de (..) (AU)

Introduction. Motor vehicle crashes cause 28% of morbidity and mortality in children. A proper medical evaluation of the polytraumatized patient is essential to reduce these numbers. The aim of our study is to correlate clinical and radiological signs in patients with seat beltmark, to establish an early diagnosis of internal injuries. Materials and methods. From 1998 to 2007 we treated 8 cases of polytraumatized patients (5 boys and 3 girls) with abdominal bruises(seat belt mark) after suffering a traffic accident. The mean age was 8.37years (range: 4-11). 100% of the patients suffered a frontal collision of their vehicle. In 2 cases the position of the lap belt was inadequate. The trauma team made the initial attention of all patients in the Emergency room, with a complete physical examination and they requested: abdominal X- ray, ultrasound and computed tomography (CT-scan). Results. The main clinical signs found in our patients were: one case of hemodynamic instability, hypovolemic shock and abdominal distension; 2 cases of diffuse abdominal pain and signs of peritoneal irritation; 4 cases of non-specific diffuse abdominal pain and one patient (..) (AU)

[Indications of transduodenal papillotomy for choledochal cyst]. / Indicaciones de la papilotomía transduodenal en el tratamiento del quiste de colédoco.

UNLABELLED: The Choledochal Cyst is a dilatation of the biliary tract whose etiology is still under debate. OBJECTIVE: This paper analyzes the cases of our group an contributes on the indications of transduodenal papilotomy in the surgical treatment of this process. MATERIAL AND METHODS: Seven cases diagnosed as choledochal cysts are presented with mean age between 3 and 10 years (5 females and 2 males). Six cases were presented with abdominal pain, four with jaundice, three presented with biliary stones and one cases was a casual discovery during an US examination. In all cases US and magnetic resonance cholangiopancreatography (MRCP) were performed as preoperative work-up. In one case an endoscopic retrograde cholangiopancreatography (ERCP) was made. In all cases intraoperative cholangiography was carried out. The surgical treatment was quistectomy and hepatico yeyunostomy Roux-Y in four cases; in one of them a transduodenal papilotomy was added. Cholecystectomy and transduodenal papilotomy was made in three cases, two of them presented choledocholithiasys. RESULTS: All patients are symptoms free after a mean follow up period of 2 years and 3 months (range: 1 year and 6 months to 4 years and 10 months). In one case persists dilated choledochal distal stump on MRCP.

Indicaciones de la papilotomía transduodenal en el tratamiento del quiste de colédoco / Indications of transduodenal papilotomy for choledochal cyst

El Quiste de Colédoco es una dilatación de la vía biliar cuya etiología sigue sujeta a debate. Objetivos: Análisis de la casuística del Servicio y aportación de las indicaciones de la papilotomía transduodenal en el tratamiento quirúrgica de esta patología. Material y métodos: Se presentan siete casos diagnosticados de quiste de colédoco con una edad entre 3 y 10 años ( 5 hembras y 2 varones). Seis casos presentaron dolor abdominal, cuatro ictericia, tres eran portadores de litiasis biliar y un caso fue un hallazgo casual en el curso de una exploración ecográfica. En todos ellos se realizó ecografia y colangio-pancreato-resonancia magnética (CPRM) preoperatorias. En un caso se realizó una colangio-pancreatografía retrógrada endoscópica (CPRE). En todos se realizó colangiografía intraoperatoria. El tratamiento quirúrgico realizado fue Quistectomia y hepático- yeyunostomía en Y de Roux en cuatro casos. En uno de ellos se añadió una papilotomía transduodenal. En tres casos se efectuó colecistectomía y papilotomía transduodenal. Dos de estos pacientes presentaban coledocolitiasis. Resultados: Todos los pacientes están asintomáticos tras un periodo de seguimiento medio de 2 años y 3 meses (rango: laño y 6 meses a 4 años y 10 meses). En un caso se aprecia en la CPRM postoperatoria la existencia de un muñón residual del colédoco distal con ectasia. (AU)

Diagnostic and therapeutic laparoscopy for nonpalpable testis.

BACKGROUND: We evaluated the use of laparoscopy in the management of impalpable testis to determine what advantages it might offer over the open approach. METHODS: Over a 5.5-year period, a total of 46 patients with 53 nonpalpable testes underwent a laparoscopic procedure at our hospital. There were 28 cases of intraabdominal testis (52.83%), 18 cases of the vas and vessels entering the internal ring (33.96%), and seven cases of intraabdominally absent testis (13.20%). We performed a laparoscopic orchiopexy for 24 testes (scrotal in 21 cases and partial to the inguinal canal in three cases) and an orchiectomy for three testes. We encountered inguinal hernia in 14 cases (26.41%). RESULTS: At follow-up, all testes were the same size as at the time of operation and were well positioned in the scrotum, except for four testes that required reoperation due to partial migration at the superficial inguinal ring. The operating time was <1 h in unilateral cases and <2 h for the bilateral cases. All procedures were completed successfully without conversion or complications. CONCLUSIONS: Laparoscopy is the only exploratory procedure that is accurate enough to enable the diagnosis of nonpalpable testis and also allow the surgical treatment to be done in the same setting.

[Laparoscopy in the non-palpable testicles. Is it always necessary?]. / Laparoscopia en testículos no palpables. Es siempre necesaria?

In order to know the role of diagnostic laparoscopy with non palpable testicles (NPT), 15 children with 16 NPT were studied. Middle age was 7 years (R: 2-12). The surgical procedure was: laparoscopy initially and open inguinal surgery (OIS) after that. Six NPT were discovered with laparoscopy (37.5%). With OIS inguinal hernia was present in 4 cases, with testicle into the inguinal sac in 3 cases; 12 cases had not inguinal hernia, and 6 of them showed spermatic vessel and vas deferent without testicle. Orquidopexy of the 6 located testicles and testicular prothesis implantation in the other 10 cases, were performed. Finding of laparoscopy and OIS were perfectly correlated. Laparoscopy made the diagnosis in 7 cases, which the OIS would have been unable to do it (43.7%). In the other 9 cases, the OIS would have been diagnostic enough (56.2%) without laparoscopy. For those results, the authors prefer to begin the surgical procedure with OIS and if the spermatic vessels are no located, then the laparoscopy is done under the same anesthesia.

[Clinical aspects of infantile megaureter]. / Clínica del megauréter infantil.

84 patients with 126 megaureteres, are studied. There are some clinical differences depending on the type of megaureter and the patient's age. The number of asymptomatic cases is increasing due to ultrasonography during fetal and neonatal period. The younger the patient the more unspecific the symptomatology. Fever, anorexia, failure to gain weight and vomits are the most frequent symptoms in babies. In patients over 6 years of age a more specific symptomatology is present, such as dysuria and lumbar pain. Failure to gain weight is more frequent in cases of refluxing megaureter, especially when they are caused by obstructive uropathy, and when they are bilateral. A urological check up is recommended during fetal ultrasonography: in babies with failure to thrive; in all cases of urinary tract infection; and in micturition disorders.

[Venous aneurysms of the neck in childhood (author's transl)]. / Aneurismas fusiformes venosos cervicales en la infancia.

Three children with four fusiform venous aneurysms in the neck are described. A correct referral clinical diagnosis had not been established in any of these children. The diagnosis should be made generally on the basis of the physical examination, including the test of the "digital pressure", which is particularly useful to rule out a laringocele. Three of the aneurysms have been treated by surgical removal. Histological examination showed microscopic changes which were related to the time elapsed since the mass was first noticed. Areas of thinning out and sclerosis of the venous wall were evident in one case. The patient with the remaining aneurysm is being followed closely.