[Abdominal lymphatic malformation (ALM). Our experience]. / Malformación linfática abdominal (MLA). Nuestra experiencia.

INTRODUCTION: Lymphatic malformations are congenital lesions usually placed in the head and neck, the abdominal location is infrequent. OBJECTIVES: Analyze our experience in ALM management. METHOD: Retrospective study of pediatric patients with ALM from 1996 to 2011. It is a descriptive analysis of clinical, diagnostic and therapeutic features. RESULTS: 10 patients with ALM were treated (6 girls: 4 boys), with a median age of 4.03 years (3 days-13 years). Acute abdomen was the most common presenting feature (40%). Ultrasound was carried out in all these cases, completing the study with CT (9 cases), MRI (1) or both (1). Treatment was surgical, excepting one case that presented infection of the ALM. The approach by laparotomy allowed total resection in all cases, involving bowel resection in 6. The mass was located in small bowel mesentery (6), mesocolon (1), liver (1), and in retroperitoneum (1). The final pathologic diagnosis showed an error in diagnostic imaging of 60%.The mean follow-up was 18 months (SD: 12.8), with not recurrences. CONCLUSIONS: ALM often manifests in a non-specific form and it may remain silent. Imaging studies guide the diagnosis, but only the histology provides a definitive result. Total resection is the best option to prevent recurrences and minimize complications.

[Management of pediatric urolithiasis in our center]. / Tratamiento de la urolitiasis pediátrica en nuestro medio.

OBJECTIVES: To determine clinical, epidemiological and therapeutic characteristics of pediatric urolithiasis in our institution. MATERIAL AND METHODS: We reviewed retrospectively patients diagnosed with urolithiasis between 1998 and 2010 in our hospital. RESULTS: A total of 32 patients (19 males and 13 females) with a mean age of 4.5 years (SD 1.9) were studied. 72% had a history of metabolic or nephro-urological malformations. The most common presentation was urinary tract infection (53%) and abdominal pain (21%). The diagnosis was made by ultrasound, with compatible X-ray in 18 cases. The most common location was pyelocalyceal level, affecting the left kidney mostly. A 38% had multiple stones with a size of 11 mm medium (3-30 mm). Ureteroscopy was used 16 times for stones in the bladder and distal ureter, with an effectiveness of 75%, and 2 patients required laparoscopic trocar cystotomy for removal. 8 extracorporeal lithotripsy procedures were performed (25% success) and 8 percutaneous nephrolithotomy procedures (37.5% success). In 3 patients we decided to perform a lumbotomy due to the size of the calculi, and, in 1 patient nephrectomy was necessary due to malfunction. The most common complication was lithiasis recurrence in 10 patients, most with multiple stones or metabolic alterations, and favourable outcome for the rest. CONCLUSIONS: Pediatric urolithiasis is uncommon, showing an increased incidence in patients with a history of metabolic and urologic pathology; it is important to do additional studies. In the last few years, it has been demonstrated that surgical treatment using minimally invasive procedures is effective and safe.

[Endoscopic treatment of ureterocele in children: is a long term effective technique?]. / Tratamiento endoscópico de los ureteroceles en edad pediátrica, efectivo a largo plazo?

INTRODUCTION: The endoscopic treatment of the ureterocele is a less invasive procedure. Currently, there are only a few published articles regarding the long-term outcomes of this treatment. MATERIAL AND METHODS: We have introduced this technique in our practice since 1995, and have been tracking 15 pediatric patients for long-term evaluation. RESULTS: The average operative age for endoscopic treatment is 19.40 months (1 week-8 years). In 53% of the cases, the diagnosis was made during prenatal screening. In 27% of the cases, the ureterocele was bilateral, and 47% of the patients have a double system. The indication for endoscopic treatment is 66% ureteric obstruction and 34% vesicoureteric reflux. We perform "uncapping" and incision in the two first cases and puncture in the subsequent procedure. The patients were followed for 4 years (7 months-7 years). During this time, two ureteroceles needed a second perforation, out of the seven that continued having reflux, two were treated with quimioprofilaxis and two were treated endoscopically for anti-reflux. Two patients continued to have reflux, and two were diagnosed with renal atrophy and hemiatrophy. DISCUSSION: The endoscopic treatment avoided an open surgical procedure in almost all cases. The need for anti-reflux puncture occurred in 33% of the cases.

Tratamiento endoscópico de los ureteroceles en edad pediátrica, ¿efectivo a largo plazo? / Endoscopic treatment of ureterocele in children: is a long term effective technique?

Introducción. El tratamiento endoscópico del ureterocele supone la forma menos invasiva de intervención. Pocos trabajos hablan de los resultados a largo plazo. Material y método. Desde que en 1995 se introdujo esta técnica en nuestro Servicio se ha aplicado a 15 pacientes, revisando su evolución a largo plazo. Resultados. La media de edad en el momento de la intervención es de 19,40 meses (1 semana-8 años). El diagnóstico fue prenatal en el 53% de los casos. El ureterocele es bilateral en el 27%. El 47% de los niños presentan un doble sistema. La indicación de intervención es la obstrucción ureteral en el 66% y el reflujo vesicoureteral en los demás casos. Se realiza apertura del techo e incisión en los dos primeros casos y perforación en los siguientes. El seguimiento se realiza durante 4 años de media (7 meses-7 años). En este tiempo, dos ureteroceles precisan una segunda perforación y siete presentan reflujo, tratados con quimioprofilaxis en dos y antirreflujo endoscópico en los otros. Dos mantienen reflujo y dos, atrofia y hemiatrofia renal. Discusión. El tratamiento endoscópico del ureterocele evitó la cirugía abierta en prácticamente todos los pacientes, precisando tratamiento antirreflujo en el 33% (AU)

Introduction. The endoscopic treatment of the ureterocele is a less invasive procedure. Currently, there are only a few published articles regarding the long-term outcomes of this treatment. Material and methods. We have introduced this technique in our practice since 1995, and have been tracking 15 pediatric patients for longterm evaluation. Results. The average operative age for endoscopic treatment is 19.40 months (1 week-8 years). In 53% of the cases, the diagnosis was made during prenatal screening. In 27% of the cases, the ureterocele was bilateral, and 47% of the patients have a double system. The indication for endoscopic treatment is 66% ureteric obstruction and 34% vesicoureteric reflux. We perform «uncapping» and incision in the two first cases and puncture in the subsequent procedure. The patients were followed for 4 years (7 months-7 years). During this time, two ureteroceles needed a second perforation, out of the seven that continued having reflux, two were treated with quimioprofilaxis and two were treated endoscopically for anti-reflux. Two patients continued to have reflux, and two were diagnosed with renal atrophy and hemiatrophy. Discussion. The endoscopic treatment avoided an open surgical procedure in almost all cases. The need for anti-reflux puncture occurred in 33% of the cases (AU)

[Retroperitoneoscopic heminephrectomy]. / Heminefrectomía retroperitoneoscópica.

The practice of minimally invasive surgery techniques in the retro-peritoneal space presents additional difficulties. Due to the absence of a real cavity and the presence of a dense fat tissue involving the structures, the need for an artificial space to work in is necessary. We present three cases of the retro-peritoneal superior heminephrectomy present in a 3-months, 6-months and a 6-year old children. In all cases a 1 centimeter port for the optique and two 0.5 centimeter ports for the instruments were situated, and the use of harmonic scalpel was satisfactory to remove renal tissue without bleeding. Drainages were unnecessary and all of the children left the hospital within the first 48 post-operative hours. Since 1994, when Figenhans and Clayman communicated the first laparoscopic nephrectomy in children, the technique has been used generally and their forward advances in conventional surgery are now universally accepted. Furthermore, the practice of polar retro-peritoneoscopic heminephrectomy allowed a very precise renal hiliar dissection and an excellent differentiation of each hemirenal tissue, separating the ill kidney and preserving the maximum function possible for the other half-kidney and the adrenal gland.

Heminefrectomía retroperitoneoscópica / Retroperitoneoscopic heminephrectomy

La práctica de las técnicas de cirugía minimamente invasiva (CMI) en el espacio retroperitoneal, presenta una dificultad adicional debida a la ausencia de una cavidad real y a la presencia de un denso tejido graso que envuelve las estructuras, lo que obliga a la creación artificial de un espacio de trabajo. Se presentan tres casos de heminefrectomía polar superior vía retroperitoneoscópica en pacientes de tres meses, seis meses, y seis años. En todos se colocó un puerto de 1 cm para la óptica y dos de 0,5 cm para el instrumental, la utilización del bisturí ultrasónico resultó de gran utilidad para escindir de forma exangüe el tejido renal. No se precisó el uso de drenajes y todos los pacientes abandonaron el hospital en las primeras 48 horas tras la intervención. Desde que en 1994 Figenhans y Clayman comunicaron la primera nefrectomía laparoscópica en el niño, la técnica se ha ido generalizando y sus ventajas frente a la cirugía convencional son actualmente universalmente aceptadas. Sin embargo, aunque menos difundida, la vía retroperitoneoscópica para la práctica de la heminefrectomía polar permite una disección del hilio renal extremadamente precisa y una excelente diferenciación del parénquima correspondiente a cada hemirriñón, compatibilizando la extirpación del hemirriñón enfermo con la máxima conservación de la función del otro hemirriñón y de la glándula suprarrenal (AU)

The practice of minimally invasive surgery techniques in the retro-peritoneal space presents additional difficulties. Due to the absence of a real cavity and the presence of a dense fat tissue involving the structures, the need for an artificial space to work in is necessary. We present three cases of the retro-peritoneal superior heminephrectomy present in a 3-months, 6-months and a 6-year old children. In all cases a 1 centimeter port for the optique and two 0.5 centimeter ports for the instruments were situated, and the use of harmonic scalpel was satisfactory to remove renal tissue without bleeding. Drainages were unnecessary and all of the children left the hospital within the first 48 post-operative hours. Since 1994, when Figenhans and Clayman communicated the first laparoscopic nephrectomy in children, the technique has been used generally and their forward advances in conventional surgery are now universally accepted. Furthermore, the practice of polar retro-peritoneoscopic heminephrectomy allowed a very precise renal hiliar dissection and an excellent differentiation of each hemirenal tissue, separating the ill kidney and preserving the maximum function possible for the other half-kidney and the adrenal gland (AU)

[Usefulness of video-assisted thoracic surgery techniques in intra-thoracic mass resection in children]. / Utilidad de las técnicas de cirugía torácica vídeo asistida en la extirpación de masas intratorácicas en el niño.

The progressive advances in Minimally Invasive Surgical Procedures, are applied presently to the surgical treatment of intra-thoracic injuries in children by way of Video-Assisted Thoracic Surgery (VATS) techniques. We present the complete findings of two intra-thoracic masses, in an infant and in a school-aged child, with the use of the VATS technique. The operative technique is detailed in each case. We conclude that the lack of invasiveness and cost-efficiency of VATS the technique, constitute it as being the first choice in the treatment of intra-thoracic masses in children.

Ingestión accidental de agua oxigenada en niños / Accidental intake of hydrogen peroxide in children

Introducción. El agua oxigenada es un producto ampliamente utilizado como antiséptico local. En forma hiperosmolar se usa en ganadería como antioxidante de la leche de vaca. Material y métodos. PResentamos un grupo de 10 pacientes pediátricos con el antecedente común de ingestión accidental de agua oxigenada hiperosmolar. Analizamos las características epidemiológicas de la serie, sintomatología presentada y pruebas diagnósticas realizadas, prestando especial atención a los resultados de las esofagogastroscopias. Resultados. Todos los pacientes procedían de un entorno rural relacionado con la ganadería vacuna, lo que explicó el contacto con el producto. La clínica predominante fue digestiva, presentando sólo un paciente clínica respiratoria. Los principales hallazgos endoscópicos fueron gastritis hemorrágica en todos los casos y afectación variable. Todos los pacientes fueron tratados de forma conservadora. En comparación con la literatura revisada, en nuestra serie son infrecuentes las complicaciones extradigestivas. Tanto éstas como las lesiones en la mucosa digestiva son consecuencia de la respuesta inflamatoria y la liberación de radicales libres al reaccionar el agua oxigenada con las catalasas tisulares. Conclusiones. El daño producido por el agua oxigenada depende de la cantidad ingerida y su concentración. Tras su ingestión deberá realizarse una estrecha vigilancia clínica del paciente ante las posibles complicaciones cardiorrespiratorias. Está indicado realizar esofagogastroscopia en las primeras 48 horas si las condiciones clínicas lo permiten (AU)

[Current aspects in the treatment of vesicoureteral reflux. Analysis of our experience]. / Estado actual del tratamiento del reflujo vesicoureteral. Análisis de nuestra casuística.

We have evaluated 465 patients diagnosed as having vesicoureteral reflux between 1975 and 2000 in our Department. Three hundred cases were treated surgically and 165 received submucosal injection of Teflon as endoscopic procedure. Since 1991, when we introduced the endoscopic technique in our Department, 31 patients required open surgery. The work includes the study of the diagnostic procedures performed in the patients, such as ultrasonography, voiding cystouretrography and renal isotopic gammagraphy. We focused on these patients treated endoscopically. The overall success rate was 97.6% with surgical techniques. Reflux was resolved using the endoscopic procedure in 76% after first injection, 93% after second and 96% after third. We conclude that the submucosal injection of Teflon is an appropriate treatment for most cases of vesicoureteral reflux. The non-invasive procedure requirement, lack of adverse effects and minimal morbidity make it an alternative to medical treatment and open surgery. The future is the search for new biocompatible materials with tissue-augmenting properties as Teflon.

Estado actual del tratamiento del reflujo vesicoureteral. análisis de nuestra casuística / 25 Years of experience in the treatment of vesicoureteral reflux

Hemos estudiado 465 pacientes pediátricos diagnosticados de reflujo vesicouretral en nuestro Servicio en el período 1975-2000. Trescientos casos fueron tratados quirúrgicamente y 165 endoscópicamente mediante la inyección submucosa de Teflón. Desde 1991, año en que se introdujo la técnica endoscópica en nuestro Servicio, 31 pacientes necesitaron cirugía abierta. El trabajo incluye el estudio de los procedimientos diagnósticos realizados en los pacientes, como ecografía, cistouretrografía miccional y gammagrafía renal isotópica. Nos hemos centrado en aquellos pacientes tratados endoscópicamente. La tasa de curación fue del 97,6 por ciento con las técnicas quirúrgicas. El reflujo se resolvió mediante inyección de Teflón en el 76 por ciento tras una inyección, 93 por ciento tras dos y el 96 por ciento después de tres inyecciones. Pensamos que la inyección submucosa de Teflón es un tratamiento apropiado para la mayoría de los tipos de reflujo vesicoureteral. La técnica no invasiva, la falta de efectos adversos y la mínima morbilidad la convierten en una alternativa a los tratamientos médico y quirúrgico. El futuro está en la búsqueda de materiales biocompatibles con propiedades mecánicas similares al Teflón (AU)

[Fascia lata transplant from cadaveric donor in the reconstruction of abdominal wall defects in children]. / Injerto de fascia lata de donante cadáver en la reconstrucción de defectos de pared abdominal en niños.

INTRODUCTION: Abdominal wall closure is not possible in large congenital defects, even after extensively stretching in to enlarge its capacity. The skin coverage is usually adequate but the aponeurotic defect has to be closed temporally using synthetic patches. The use of these materials leads to increase complication such as infection, fistula formation and extrusion. In addition a second operation is required to remove the material and to perform a definitive closure. The role of fascia lata in reconstruction of abdominal wall is well established as free grafts, pedicled flaps or free flaps. Bank cadaveric fascia lata is used extensively in neurosurgical, ophtalmological, orthopaedic and urogynecological procedures. This is the first description of the use of cadaveric fascia lata for the closure of large abdominal wall defects. CASE REPORTS: We present two cases of congenital diaphragmatic hernia. The first patient was a newborn who presented the impossibility to close the fascia, that was salvaged by a teflón patch. Five months later the wound opened, leaving the mesh exposed that had to be removed. A cadaveric fascia lata patch was used to cover the defect, closing the skin satisfactorily. The second case was a two days newborn. We performed the diaphragmatic closure, and the aponeurotic defect was closed using cadaveric fascia lata. RESULTS: Cosmetic and functional appearance are satisfactory in both cases and no complications have been seen. CONCLUSION: Fascia lata patches are revascularized in the abdominal wall and incorporates into receptor tissue. They have the following advantages with respect to synthetic materials: First, the risk of complications is lower. Second, their removal is not necessary. Finally, no intraperitoneal adhesions occur. The risks of disease transmission and rejection are minimized by the Centro Comunitario de Transfusiones donor selection and processing of the cadaveric fascia lata.

Injerto de fascia lata de donante cadáver en la reconstrucción de defectos de pared abdominal en niños / The use of cadaveric lata grafts in the reconstruction on abdominal wall defects in children

Introducción. El cierre de la pared abdominal no es posihle en grandes defectos congénitos, incluso tras extensas disecciones que aumenten su capacidad. EI cierre de la piel suele ser adecuado, pero el defecto aponeurótico debe cerrarse temporalmente utilizando parches de material sintética. La infección, fistulizacicín o exteriorización del parche son complicaciones frecuentes derivadas de su uso. Es necesario una segunda intervención para retirar el material extraño y lograr un cierre definitivo, La fascia lata se usa para la reconstrucción abdominal en adultos en forma de injertos libres, colga.jos pediculados o colgajos con microcirugía. La fascia lata de cadáver se usa en diversas especialidades médicas como neurocuirugía, oftalmología, ortopedia y uroginecología. Ésta es la primera descripción de utilización de parches de fascia lata de cadáver para el cierre de defectos abdominales congénitos, Casos clínicos. Presentamos dos pacientes con hernia diafragmatica congénita. En el primer paciente, tras la corrección del defecto diafragmático, fue imposible el cierre del plano aponeurótico de la pared abdominal, por lo que se utilizó un parche de teflón A los cinco meses la herida se abrió produciéndose la exteriorización de la malla. El defecto resultante fue cerrado con ¡,m parche de fascia lata de cadáver. No hubo problemas para cl cierre de piel por encima. El segundo paciente fue un recién nacido de dos días de vida, cuyo defecto diafragmático se cerní sin incidencias pero para el cierre de la aponeurosis fue preciso un parche de fascia lata de cadáver.Resultados. El aspecto estético y funcional en ambos casos es excelente. Ho hemos tenido complicaciones.Conclusión. Los parches de fascia lata de cadáver se revascularizan y se integran en el tejido del receptor. Presentan ciertas ventajas respecto a los parches sintéticos: menor riesgo de complicaciones, no es necesario su retirada y no se han visto adherencias intraperitoneales. El riesgo de Transmisión de enfermedades y de rechazo quedan minimizadas tras una estricta selección de donantes y, el procesamiento tisular que realiza el Centro de Transfusiones (AU)

Ectopia testicular cruzada. Presentación de un caso / Crossed testicular ectopia. A new case

La ectopia testicular cruzada es una rara patología congénita en la cual ambos testículos se localizan en el mismo hemiescroto y que traduce una alteración en el descenso testicular normal. Desde su descripción por Lenhossek en 1886(1) y posteriormente Halstead en 1907(=) han sido descritos hasta la actualidad poco más de 100 casos de esta rara patología. Como teorías etiológicas se han postulado la adhesión de los testículos a estructuras mullerianas, fusión de los conductos de Wolff o la alteración en la implantación del gubernáculo, sin que ninguna de ellas haya sido universalmente aceptada. La presentación clínica habitual es la de una hernia inguinal con testículo contralateral ausente, encontrando ocasionalmente ambos testículos en el lado herniario. Presentamos un nuevo caso de esta patología (AU)

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[Crossed testicular ectopia. Report of a case]. / Ectopia testicular cruzada. Presentación de un caso.

Crossed testicular ectopia is a rare congenital malformation in which both testis are located in the same hemiscrotum, and is related to an anomaly in normal testicular descent. This entity was first described by Lenhossek in 1886 and posteriorly by Halstead in 1907. Since then, there have been described less than a hundred of cases of this rare congenital malformation. Several ethiopathogenic theories have been proposed, including testicular adherence to mullerian structures, fusion of the wolffian ducts or defective gubemacular development, although none of them has been widely accepted. Usually, clinical sign is an inguinal hernia with empty contralateral hemiscrotum, and sometimes both testis in ipsilateral hemiscrotum. A new case of this pathology is presented.