Use of Nonvascularized Fascia in Liver Transplantation.

Abdominal wall transplant is developed in the context of intestinal and multivisceral transplant, in which it is often impossible to perform a primary wall closure. Despite the fact that abdominal wall closure is not as consequential in liver transplant, there are circumstances in which it might determine the success of the liver graft, especially in situations that compromise the abdominal cavity and facilitate an abdominal compartment syndrome. CASE 1: A 14-year-old girl suffering from cryptogenic cirrhosis with severe portal hypertension that causes ascites and severe malnutrition. Uneventful liver transplant, with a graft procured from a 14-year-old donor. At the time of wall closure it was decided to implant a nonvascularized fascia graft to supplement the right side of the transverse incision, with a 17 x 7 cm defect. This required reintervention after 4 months for biliary stricture. At that point, the wall graft was almost completely integrated into the native tissue. CASE 2: A 63-year-old man, transplanted for hepatitis C virus+ hepatocellular carcinoma+ nonocclusive portal thrombosis. Thirty-six hours after transplant the patient developed portal thrombosis. Thrombectomy and closure with biological mesh were performed. After 24 hours he was reoperated on for abdominal compartment syndrome and temporary closure with a Bogotá bag. Six days later he underwent omentectomy, intestinal decompression, and left components separation, identifying a 25 x 20 cm defect. For definitive closure, a nonvascularized fascia graft procured from a different donor was used, accomplishing a reduction in intra-abdominal pressure. Nonvascularized fascia transplantation is an interesting alternative in liver transplant recipients with abdominal wall closure difficulties.

Trascendencia de la elección de las tablas de crecimiento en el diagnóstico de sobrepeso y obesidad / Relevance of the choice of growth charts in the diagnosis of overweight and obesity

Objetivos: estimar las diferencias de prevalencias de obesidad y sobrepeso de nuestra población entre las gráficas más utilizadas en nuestro medio. Material y métodos: estudio descriptivo trasversal de base poblacional. Se diagnosticó sobrepeso u obesidad comparando el índice de masa corporal (IMC) de 8905 niños de 6, 10 y 13 años con los puntos de corte establecidos por las siguientes tablas: Fundación Orbegozo 1988, 2004 y 2011 (FO88, FO04 y FO11); International Obesity Task Force 2012 (IOTF12); Organización Mundial de la Salud 2007 (OMS07); y Estudio Transversal Español 2008 (ETE08). Resultados: las tablas ETE08 proporcionaron las prevalencias de obesidad más bajas para todas las edades (2,8%, intervalo de confianza del 95% [IC 95]: 2,3 a 3,4 a los seis años; 2,2% [IC 95: 1,7 a 2,8] a los diez años; y 2,2% [IC 95: 1,6 a 2,8] a los 13 años). Las OMS07 proporcionaron la prevalencia de obesidad más alta a los seis años 10,6% (IC 95: 9,6 a 11,6) y las FO88 para las demás edades: 15,4% (IC 95: 14,1 a 16,6) a los diez años y 12,4% (IC 95: 11 a 13,7) a los 13 años. En cuanto al sobrepeso, las OMS07 presentaron las prevalencias más altas mientras que las FO88 presentaron las más bajas. Conclusiones: Las prevalencias de obesidad y sobrepeso varían de forma importante según las diferentes tablas de crecimiento. Es preciso conocer las tablas que utilizamos para poder contextualizar los resultados. Los datos sobre prevalencia de obesidad y sobrepeso deben ir siempre acompañados de las tablas utilizadas, ya que en caso contrario los valores carecen de sentido (AU)

Objectives: to estimate the differences in prevalence of obesity and overweight in our population using different growth charts. Methods: population based, descriptive, cross-sectional study. Overweight or obesity were diagnosed by comparing the BMI of 8905 children aged 6, 10 and 13 with the cut-off points established by the following charts: Orbegozo Foundation 1988, 2004 and 2011; International Obesity Task Force 2012; WHO 2007; and Spanish cross-sectional study 2008. Results: the Spanish cross-sectional study 2008 chart provided the lowest prevalence for all ages (2.8% [CI 95%: 2.3 to 3.4] at 6 years, 2.2% [CI 95%: 1.7 to 2.8] at 10 years and 2.2% [CI 95%: 1.6 to 2.8] at 13 years). The WHO 2007 chart provided the highest prevalence of obesity at 6 years (10.6% [CI 95%: 9.6 to 11.6]) and the Orbegozo Foundation 1988 chart for other age groups (15.4% [CI 95%: 14.1 to 16.6] at 10 years and 12.4% [CI 95%: 11 to 13.7] at 13 years). Regarding overweight, the results were also discordant. The WHO 2007 chart had the highest prevalence while Orbegozo Foundation 1988 had the lowest. Conclusions: the prevalence of overweight and obesity varies significantly according to the different growth charts. We should know the growth charts we use to contextualize the results. Data on the prevalence of obesity and overweight should always be accompanied by the chart used because otherwise the values are meaningless (AU)

[Anti-NMDA receptor encephalitis in a 3-year-old girl with no associated pathology involving a tumour]. / Encefalitis antirreceptor de NMDA en una nina de 3 anos sin patologia tumoral asociada.

INTRODUCTION: Encephalitis due to NMDA receptors antibodies is a relatively common condition but it was under diagnosed until recently. It courses predictably and similarly in adults and children, although there are some differences, still less its association with tumours. CASE REPORT: A 3 years-old girl who was admitted to our hospital with symptoms compatible with acute encephalitis, so we started treatment with acyclovir. During admission she was alterning periods of poor response to stimuli with periods of agitation, and progressed to complete silence, adding sleep problems. She suffered epileptic seizures, dystonic movements and autonomic disturbances. Cranial MRI showed mild cortical atrophy and EEG generalized slowing of base tracing. Repeated samples of cerebral spinal fluid were normal from cytological and biochemical point of view. In view of the torpid evolution she began methylprednisolone therapy and later inmunoglobulins with no improvement. Upon confirmation of the positivity for NMDA receptors antibodies in cerebral spinal fluid and serum, cyclophosphamide was administered, with gradual improvement of symptoms until full recovery. After ten months of follow-up without treatment she has not presented relapses and has ruled out the presence of tumours. CONCLUSIONS. It is important to recognize encephalitis with behavioural changes and abnormal movements, because early diagnosis and the beginning of appropriate therapy could improve the prognosis.

Anaplastic transformation of an atypical intraventricular meningioma with metastases to the liver: case report.

OBJECTIVE: Malignant intraventricular meningiomas are very rare. To the best of our knowledge, only eleven cases have been reported thus far. Seven of them developed cerebrospinal fluid (CSF) metastases. We present herein the first case of a malignant intraventricular meningioma with extraneural metastases. CLINICAL PRESENTATION: We report a 44 year-old-man with a history of progressive headache and disorientation. Magnetic resonance imaging (MRI) revealed a 5-cm homogeneously-enhancing mass in the right trigone. INTERVENTION: The lesion was totally resected via a parietooccipital transcortical approach. Histological examination demonstrated an atypical meningioma. Thereafter, the tumor recurred twice. At first recurrence, the tumor was completely removed again and external radiotherapy was administered. At surgery at second recurrence, the tumor was more aggressive, invading the brain parenchyma. Histological examination showed anaplastic meningioma. The patient was readmitted to hospital with fever and pain in right hypochondrium. Abdominal ultrasound examination disclosed multiple hypoechoic liver lesions. Biopsy was consistent with liver metastases of a malignant meningioma. The patient died of acute liver failure seven months after initial diagnosis. CONCLUSION: Malignant intraventricular meningiomas are prone to recur and develop metastases, mainly through the CSF. Nevertheless, our case shows that extraneural metastases are also possible. Therefore, when systemic deterioration occurs in a patient with a malignant intraventricular meningioma, metastases to extraneural organs such as the liver must be ruled out.

Anaplastic transformation of an atypical intraventricular meningioma withmetastases to the liver: case report

Objective. Malignant intraventricular meningiomasare very rare. To the best of our knowledge, only elevencases have been reported thus far. Seven of them developedcerebrospinal fluid (CSF) metastases. We presentherein the first case of a malignant intraventricularmeningioma with extraneural metastases.Clinical presentation. We report a 44 year-old-manwith a history of progressive headache and disorientation.Magnetic resonance imaging (MRI) revealed a5-cm homogeneously-enhancing mass in the right trigone.Intervention. The lesion was totally resected via aparietooccipital transcortical approach. Histologicalexamination demonstrated an atypical meningioma.Thereafter, the tumor recurred twice. At first recurrence,the tumor was completely removed again andexternal radiotherapy was administered. At surgeryat second recurrence, the tumor was more aggressive,invading the brain parenchyma. Histological examinationshowed anaplastic meningioma. The patientwas readmitted to hospital with fever and pain in righthypochondrium. Abdominal ultrasound examinationdisclosed multiple hypoechoic liver lesions. Biopsywas consistent with liver metastases of a malignantmeningioma. The patient died of acute liver failureseven months after initial diagnosis.Conclusion. Malignant intraventricular meningiomasare prone to recur and develop metastases, mainlythrough the CSF. Nevertheless, our case shows thatextraneural metastases are also possible. Therefore,when systemic deterioration occurs in a patient with amalignant intraventricular meningioma, metastases toextraneural organs such as the liver must be ruled out (AU)

Objetivos. Los meningiomas malignos intraventricularesson muy infrecuentes. En la bibliografía existentesólo se han descrito once casos hasta ahora. Sietede ellos desarrollaron metástasis a través del líquidocefalorraquídeo (LCR). Presentamos el primer caso deun meningioma maligno intraventricular con metástasisextraneurales.Caso clínico. Paciente varón de 44 años de edad conuna clínica de cefalea progresiva y desorientación. Laresonancia magnética mostraba un proceso expansivointracraneal en el trígono derecho con captación decontraste de forma homogénea.Intervención. Se practicó una resección total de lalesión a través de un acceso transcortical. El análisishistológico mostró un meningioma atípico. A pesarde la resección total, el tumor recidivó otras dosveces. Después de la primera recidiva, el tumor fueextirpado nuevamente y el paciente recibió radioterapiaexterna. En la segunda recidiva, el tumorse comportó de forma más agresiva, invadiendo elparénquima cerebral. El análisis histológico mostrabaun meningioma anaplásico. El paciente fueingresado nuevamente por fiebre y dolor en el hipocondrioderecho. Una ecografía abdominal mostrómúltiples lesiones hipoecogénicas hepáticas. La biopsiade dichas lesiones fue compatible con metástasisdel meningioma maligno. El paciente falleció debidoa una insuficiencia hepática aguda siete meses despuésdel diagnóstico inicial.Conclusiones. Los meningiomas malignos intraventricularestienden a recurrir y producir metástasis,principalmente a través del LCR. Sin embargo,nuestro caso muestra que los meningioma malignosintraventriculares también pueden metastatizar fueradel sistema nervioso central, siendo el primer caso descrito. Por lo tanto, cuando un deterioro sistémicoocurra en un paciente con un meningioma malignointraventricular debería descartarse la posibilidad demetástasis extraneurales como sucedió en este caso (AU)

[Intraoperative neurophysiological monitoring of the spinal cord: our experience]. / Monitorización neurofisiológica intraoperatoria de la médula espinal: nuestra experiencia.

INTRODUCTION: The main objective of intraoperative monitoring of the spinal cord is to detect any neurological damage that may occur (and which would otherwise go unnoticed) while it is still reversible. AIM: To retrospectively evaluate the effectiveness of neurophysiological monitoring in spine and spinal cord surgery since the time such procedures were first implemented within our centre. PATIENTS AND METHODS: The patients were divided into three groups, according to their pathologies. They were clinically evaluated with the McCormick scale before surgery, on discharge from hospital and at six months after the operation. Neurophysiological monitoring was performed with motor evoked potentials, somatosensory potentials and screw stimulation, when appropriate. RESULTS: The sample finally consisted of 49 subjects, with a mean age of 51 +/- 19.4 years. Distribution by groups was 53.1% spinal cord tumours, 22.4% traumatic injuries to the spinal cord and 24.5% bone/disc pathologies. During surgery potentials improved in 4.08% of patients, in 63.26% they remained intact, 20.41% were alerted by the neurophysiologist with intact potentials, 10.2% suffered a transitory decline and in one case there was permanent loss. All the patients who were submitted to a follow-up at six months displayed a clinical status that was the same or better than the one before their operation. CONCLUSIONS: Neurophysiological monitoring is a valuable tool that prevented, in 30.61% of our patients, damage that could otherwise have occurred. From the clinical point of view, its high predictive value is also worth highlighting.

Monitorización neurofisiológica intraoperatoria de la médula espinal: nuestra experiencia / Intraoperative neurophysiological monitoring of the spinal cord: Our experience

Introducción. El principal objetivo de la monitorización intraoperatoria de la médula espinal es la detección decualquier daño neurológico, que de otro modo pudiese pasar inadvertido, durante el período en el que éste es reversible. Objetivo. Evaluar retrospectivamente la efectividad de la monitorización neurofisiológica en la cirugía vertebral y de médula espinal desde su implantación en nuestro centro. Pacientes y métodos. Los pacientes se dividieron en tres grupos según patologías. Se evaluaron clínicamente antes, en el momento del alta y a los seis meses de la cirugía con la escala de McCormick. La monitorización neurofisiológica se realizó con potenciales evocados motores, potenciales somatosensoriales y estimulaciónde tornillos donde procedía. Resultados. El tamaño de la muestra fue de 49 sujetos, con una media de edad de 51 ± 19,4 años. La distribución por grupos fue de un 53,1% de tumores medulares, un 22,4% de traumatismo medular y un 24,5% de patologíaosteodiscal. Durante la cirugía, el 4,08% de los pacientes presentó una mejoría de sus potenciales, el 63,26% los mantuvo intactos, el 20,41% sufrió una alerta por parte del neurofisiólogo con unos potenciales intactos, el 10,2% sufrió una caída transitoria, y en un caso hubo una pérdida permanente. Todos los pacientes seguidos a los seis meses presentaron un estadoclínico igual o mejor al prequirúrgico. Conclusiones. La monitorización neurofisiológica constituye una herramienta de gran valor que evitó, en el 30,61% de nuestros pacientes, daños que de otro modo podrían haberse producido. Debe reseñarse tambiénsu importante valor predictivo desde el punto de vista clínico

Introduction. The main objective of intraoperative monitoring of the spinal cord is to detect any neurological damage that may occur (and which would otherwise go unnoticed) while it is still reversible. Aim. To retrospectively evaluate the effectiveness of neurophysiological monitoring in spine and spinal cord surgery since the time such procedures were firstimplemented within our centre. Patients and methods. The patients were divided into three groups, according to their pathologies. They were clinically evaluated with the McCormick scale before surgery, on discharge from hospital and at sixmonths after the operation. Neurophysiological monitoring was performed with motor evoked potentials, somatosensory potentials and screw stimulation, when appropriate. Results. The sample finally consisted of 49 subjects, with a mean age of 51 ± 19.4 years. Distribution by groups was 53.1% spinal cord tumours, 22.4% traumatic injuries to the spinal cord and 24.5% bone/disc pathologies. During surgery potentials improved in 4.08% of patients, in 63.26% they remained intact, 20.41% were alerted by the neurophysiologist with intact potentials, 10.2% suffered a transitory decline and in one case there was permanent loss. All the patients who were submitted to a follow-up at six months displayed a clinical status that was the same or better than the one before their operation. Conclusions. Neurophysiological monitoring is a valuable tool that prevented, in 30.61% of our patients, damage that could otherwise have occurred. From the clinical point of view, its high predictive value is also worth highlighting

[Bilateral lower limb compartment syndrome after lumbar schwannoma surgery in genupectoral position]. / Síndrome compartimental bilateral en miembros inferiores tras cirugía deschwannoma lumbar en posición genupectoral.

Lower limb compartment syndrome is an unusual complication of the genu-pectoral position in lumbar spine surgery. We report a case of compartment syndrome in a patient who was operated in the genu- pectoral position for lumbar schwannoma resection. Overweigth and long time surgery could be important predisposing factors. Early diagnosis and treatment are mandatory to prevent permanent neurological deficits and other possible complications.

[Severe cerebellar mutism after posterior fossa tumor resection]. / Mutismo cerebeloso grave tras cirugía de un tumor de fosa posterior.

Cerebellar mutism is an infrequent but important complication after posterior fossa surgery in children. Dysarthria, irritability and ataxia are among the signs and symptoms of this disorder, which are usually mild and self-limiting. However, in severe cases, there can be impairment of higher-level cognitive functions, affecting the child's future personal and social relations. This disorder has been described in many other situations and consequently pediatricians should be familiar with its symptoms, physiopathology, diagnosis, degrees of severity, treatment, and prognosis, since a multidisciplinary approach is required. We present the case of a 5-year-old boy who underwent surgery for a low-grade ependymoma in the fourth ventricle; 48 hours after surgical resection, the boy developed irritability, cranial nerve involvement and stereotyped movements in the context of active hydrocephalus. His symptoms progressively improved 6 weeks after the intervention. We review the literature on cerebellar mutism and discuss the physiopathology of this disorder, which seems to confirm that the cerebellum not only acts as a simple coordinator of motor function, but also plays an important role in higher-level cognitive functions, such as language.

Síndrome compartimental bilateral en miembros inferiores tras cirugía de schwannoma lumbar en posición genupectoral / Bilateral lower limb compartment syndrome after lumbar schwannoma surgery in genupectoral position

Los síndromes compartimentales de las extremidades inferiores, son una complicación muy infrecuente de la posición genupectoral en la cirugía de columna lumbar. Presentamos el caso de un paciente con síndrome compartimental bilateral en ambos miembros inferiores, tras ser intervenido de un schwannoma lumbar en posición de genupectoral. El sobrepeso y la larga duración del acto quirúrgico podrían ser factores predisponentes para desarrollar esta patología. El diagnóstico y tratamientos precoces son imprescindibles para evitar déficits neurológicos permanentes y otras posibles complicaciones

Lower limb compartment syndrome is an unusual complication of the genu-pectoral position in lumbarspine surgery. We report a case of compartment syndrome in a patient who was operated in the genu- pectoral position for lumbar schwannoma resection. Overweight and long time surgery could be important predisposing factors. Early diagnosis and treatment are mandatory to prevent permanent neurological deficits and other possible complications

Mutismo cerebeloso grave tras cirugía de un tumor de fosa posterior / Severe cerebellar mutism after posterior fossa tumor resection

El mutismo cerebeloso es una complicación infrecuente pero con gran trascendencia en los niños intervenidos de cirugía de fosa posterior. Disartria, irritabilidad y ataxia, son parte de sus síntomas y signos, que suelen ser leves y autolimitados, pero en algunos casos graves, pueden alterarse funciones cognitivas superiores, pudiendo verse comprometidas las relaciones personales y sociales futuras del niño. Está descrito en otras situaciones, por lo que es importante para el pediatra el conocimiento de sus síntomas, fisiopatología, diagnóstico, grados de severidad y enfoque terapéutico, así como su pronóstico, dado que requiere de un tratamiento multidisciplinario. Presentamos el caso clínico de un niño de 5 años intervenido de un ependimoma de bajo grado localizado en el cuarto ventrículo, que desarrolló 48 h después de la resección quirúrgica, un cuadro consistente en mutismo, irritabilidad, afectación de pares craneales y movimientos estereotipados, en el contexto de una hidrocefalia activa. La clínica del paciente mejoró progresivamente a partir de 1,5 mes tras la intervención. Revisamos la bibliografía existente sobre el mutismo cerebeloso y discutimos su fisiopatología, que parece confirmar que el cerebelo no participa únicamente como un simple coordinador de la función motora, sino que desempeña un papel relevante en funciones cognitivas superiores, como el lenguaje

Cerebellar mutism is an infrequent but important complication after posterior fossa surgery in children. Dysarthria, irritability and ataxia are among the signs and symptoms of this disorder, which are usually mild and self-limiting. However, in severe cases, there can be impairment of higher-level cognitive functions, affecting the child's future personal and social relations. This disorder has been described in many other situations and consequently pediatricians should be familiar with its symptoms, physiopathology, diagnosis, degrees of severity, treatment, and prognosis, since a multidisciplinary approach is required. We present the case of a 5-year-old boy who underwent surgery for a low-grade ependymoma in the fourth ventricle; 48 hours after surgical resection, the boy developed irritability, cranial nerve involvement and stereotyped movements in the context of active hydrocephalus. His symptoms progressively improved 6 weeks after the intervention. We review the literature on cerebellar mutism and discuss the physiopathology of this disorder, which seems to confirm that the cerebellum not only acts as a simple coordinator of motor function, but also plays an important role in higher-level cognitive functions, such as language

[Giant arteriovenous malformation of the scalp. Case report]. / Malformación arteriovenosa gigante de cuero cabelludo: caso clínico.

Arteriovenous malformations (AVM) in the scalp are infrequent vascular lesions. Its clinical presentation varies from annoying and unaesthetic mass of the skin to devastating hemorrhages. Its origin can be congenital or traumatic. The diagnosis of AVM is based on physical examination and confirmed by internal and external carotid angiography. Nowadays the gold standard treatment is the surgical intervention although the endovascular approach is gaining field in order to reduce blood losses as presurgical or like lonely treatment. A 50 year old woman was admitted with a huge mass in scalp, with subcutaneous enlarged vessels and no other symptoms. A head traumatic antecedent had occurred 12 years before. The angiography evidenced a mottled AVM with blood supplies from the external and internal carotid arteries, with meningeal transosseous branches from both ophthalmic arteries. Endovascular treatment could not be performed due to high risk of uni or bilateral amaurosis. Thus, a conventional surgical treatment was done without complications. The treatment of AVM of scalp offers various possibilities but the individualization of each case becomes essential to decide the correct management in order to avoid complications.

Malformación arteriovenosa gigante de cuero cabelludo: caso clínico / Giant arteriovenous malformation of the scalp. Case report

Las malformaciones arteriovenosas (MAV) en el cuero cabelludo son lesiones vasculares muy infrecuentes. Sus síntomas son variados, desde molestas y antiestéticas tumoraciones de la piel, hasta hemorragias que pueden ser devastadoras. Su origen puede ser congénito o traumático. El diagnóstico de las mismas es clínico, mediante la inspección del enfermo, y la angiografía de las carótidas interna y externa confirma el diagnóstico. Las posibilidades terapéuticas son variadas, siendo la extirpación quirúrgica el tratamiento de elección, aunque cada vez se utiliza más el tratamiento endovascular como tratamiento único o prequirúrgico, para disminuir las pérdidas hemáticas. Presentamos el caso de una paciente de 50 años de edad que presentaba una gran tumoración en cuero cabelludo, con dilataciones vasculares muy marcadas y sin otra sintomatología asociada. Describió un antecedente traumático hacía 12 años. La angiografía mostró una MAV abigarrada, con aporte vascular dela carótida externa y también de la interna, a cargo de ramas meníngeas transoseas provenientes de arterias etmoidales y dependientes de ambas arterias oftálmicas. El tratamiento endovascular de los aportes intracraneales no fue posible, debido al alto riesgo de amaurosis uni o bilateral, por lo que la lesión se resecó quirúrgicamente, sin presentarse complicaciones. El tratamiento de las MAV de cuero cabelludo ofrece diversas posibilidades pero se hace imprescindible la individualización de cada caso a la hora de decidir el abordaje correcto para evitar las posibles complicaciones

Arteriovenous malformations (AVM) in the scalp are in frequent vascular lesions. Its clinical presentation varies from annoying and unaesthetic mass of the skin to devastating hemorrhages. Its origin can be congenitalor traumatic. The diagnosis of AVM is based on physical examination and confirmed by internal and external carotid angiography. Nowadays the gold standard treatment is the surgical intervention although the endovascular approach is gaining field in order to reduce blood losses as presurgical or like lonely treatment. A 50 year old woman was admitted with a huge mass in scalp, with subcutaneous enlarged vessels and no other symptoms. A head traumatic antecedent had occurred 12 years before. The angiography evidenced amottled AVM with blood supplies from the external and internal carotid arteries, with meningeal transosseous branches from both ophthalmic arteries. Endovascular treatment could not be performed due to high risk of uni-or bilateral amaurosis. Thus, a conventional surgical treatment was done without complications. The treatment of AVM of scalp offers various possibilities but the individualization of each case becomes essential to decide the correct management in order to avoid complications