[Treatment of the postoperative bowel obstructions in children: laparoscopic vs. open adhesiolysis]. / Tratamiento de las oclusiones postoperatorias en niños: ¿adhesiolisis abierta o laparoscópica?

OBJECTIVE: To compare the results of laparoscopic versus open adhesiolysis in children affected by postoperative bowel obstruction. METHODS: Retrospective study reviewing charts of all patients who were operated on due to postoperative adhesions in our Department. Demographic data, clinical characteristics and postoperative data were collected. RESULTS: During the last 8 years, 37 patients were operated on for postoperative intestinal obstructions. 40.5% were operated by laparoscopy and 59.5% by laparotomy. Mean ages were 6.31 and 4.32 years in laparoscopic and open groups, respectively. There were no differences in days of evolution of the occlusion, neither in their medical history. Patients in laparoscopic group had better outcomes in the need of central lines (15% vs 61.90% p= 0.012), use of parenteral nutrition (38.46% vs 83.33% p= 0.005), beginning of the enteral nutrition (4.04 vs 8.17 days p= 0.004) and hospital stay (7.77 vs 13.05 days p= 0.027). CONCLUSIONS: Open and laparoscopic adhesiolysis are effective to treat adhesive cases. Laparoscopic adhesiolysis has some advantages over open surgery: less need of central lines and parenteral nutrition, earlier start of enteral nutrition, less rate of complications and shorter hospital stay.

OBJETIVO: Comparar los resultados de la adhesiolisis laparoscópica frente a la técnica abierta en niños con oclusiones postoperatorias. METODO: Estudio retrospectivo de los pacientes intervenidos por oclusiones postoperatorias en nuestro centro. Se recogieron variables demográficas, las características clínicas del paciente y del cuadro oclusivo y los resultados postoperatorios. RESULTADOS: En los últimos 8 años, se han realizado 37 intervenciones por oclusiones intestinales postoperatorias: un 40,5% mediante laparoscopia y un 59,5% mediante laparotomía. La media de edad fue 6,31 y 4,32 años para la técnica laparoscópica y abierta, respectivamente. No encontramos diferencias en el tiempo de evolución del cuadro oclusivo, ni en los antecedentes quirúrgicos. Sin embargo, el grupo de adhesiolisis laparoscópica presentó mejores resultados que el de cirugía abierta en: necesidad de vía central (15% frente a 61,90% p= 0,012), uso parenteral (38,46% frente a 83,33% p= 0,005), reinicio de la nutrición enteral (4,04 días frente a 8,17 p= 0,004) y estancia postoperatoria (7,77 frente a 13,05 días p= 0,027). CONCLUSIONES: Ambos abordajes son eficaces para la resolución de la oclusión. La adhesiolisis laparoscópica aporta ventajas frente a la cirugía abierta: menor necesidad de vía central y de nutrición parenteral, reinicio precoz de la nutrición enteral y menor estancia hospitalaria.

[Conservative management of retained central venous catheters]. / Manejo conservador de los catéteres venosos centrales retenidos.

BACKGROUND: Withdrawal of central venous catheters (CVCs) is usually a simple surgical procedure. However, in some cases, the catheter is stuck in the vessel wall and its removal is not possible if more invasive interventions are not performed. MATERIAL AND METHODS: We performed a retrospective study from 2003 to 2011 of patients who were clearing a CVC and the factors that could have intervened in the removal impossibility. We compared the type of catheter, the insertion site, the time between its insertion and removal, the primary diagnosis and the treatment. In addition, a monitoring by clinical and imaging tests has been made in patients with retained CVCs. RESULTS: An amount of 174 interventions were carried out. In 5 cases the CVC could not been removed. These 5 cases were patients diagnosed with ALL B and were treated with identical chemotherapy treatment. In addition, at the time of its retirement, all the patients had the CVC for a period longer than 2 years -29 to 84 months-. In patients with retained fragments, no complication arose from this condition. The mean follow-up period was 36 months -maximum 48 months-. CONCLUSIONS: The potential complications arising from the presence of the retained CVCs fragments include infection, venous thrombosis and catheter migration. Based on our results, we propose that a conservative management might be considered as an option in these patients.

Manejo conservador de los catéteres venosos centrales retenidos / Conservative management of retained central venous catheters

Introducción. La retirada de los catéteres venosos centrales (CVCs) suele ser un procedimiento quirúrgico sencillo. Sin embargo, en algunos casos el catéter se encuentra englobado en la pared del vaso y su extracción no es posible si no se realizan intervenciones más invasivas. Material y métodos. Se ha realizado un estudio retrospectivo desde 2003 a 2011 de los pacientes a los que se les ha retirado un CVC y de los factores que podrían haber intervenido en la imposibilidad de retirada. Se han comparado los tipos de catéter, la zona de inserción, el tiempo transcurrido desde la inserción a la retirada, el diagnóstico principal y el tipo de medicación. Además, se ha realizado un seguimiento clínico y mediante pruebas de imagen en los pacientes con CVCs retenidos. Resultados. Se realizaron 174 intervenciones. En 5 casos no se pudo extraer el CVC. Estos 5 casos fueron pacientes diagnosticados de LLA B y llevaron tratamiento quimioterápico idéntico. Además, en el momento de su retirada, todos llevaban el CVC por un periodo mayor a 2 años (de 29 a 84 meses). En los pacientes con fragmentos retenidos no se produjo ninguna complicación derivada de esta condición. El periodo medio de seguimiento fue de 36 meses (máximo de 48 meses).Conclusiones. Las posibles complicaciones derivadas de la presencia de fragmentos de los CVCs retenidos son la infección, la trombosis venosa y la migración del catéter. En base a nuestros resultados, planteamos que se podría considerar en estos pacientes una actitud expectante y un manejo conservador (AU)

Background. Withdrawal of central venous catheters (CVCs) is usually a simple surgical procedure. However, in some cases, the catheter is stuck in the vessel wall and its removal is not possible if more invasive interventions are not performed. Material and methods. We performed a retrospective study from 2003 to 2011 of patients who were clearing a CVC and the factors that could have intervened in the removal impossibility. We compared the type of catheter, the insertion site, the time between its insertion and removal, the primary diagnosis and the treatment. In addition, a monitoring by clinical and imaging tests has been made in patients with retained CVCs. Results. An amount of 174 interventions were carried out. In 5 cases the CVC could not been removed. These 5 cases were patients diagnosed with ALL B and were treated with identical chemotherapy treatment. In addition, at the time of its retirement, all the patients had the CVC for a period longer than 2 years -29 to 84 months-. In patients with retained fragments, no complication arose from this condition. The mean follow-up period was 36 months -maximum 48 months-.Conclusions. The potential complications arising from the presence of the retained CVCs fragments include infection, venous thrombosis and catheter migration. Based on our results, we propose that a conservative management might be considered as an option in these patients (AU)

Modificaciones de las curvas de glucemia y vaciamiento gástrico de los niños con síndrome dedumping tras cirugía de Nissen laparoscópico / Modifications of the glucose curves and gastric voiding of children with dumping syndrome after laparoscopic nissen surgery

Introducción. Se ha asistido a una importante evolución del tratamiento quirúrgico en los últimos años por la generalización progresiva de la cirugía laparoscópica. Todas las técnicas disponibles pueden hacerse laparoscópicamente con similares resultados a los de la cirugía abierta. En 1978, Villet et al. describieron el síndrome de Dumping (SD) como una complicación frecuente de la fundoplicatura de Nissen. EL SD es un complejo de signos y síntomas que aparecen poco después de la cirugía, incluyendo dolor abdominal, palidez, sudoración, diarrea, náuseas, palidez, incluso pérdida de peso. Los síntomas se pueden diferenciar en dumping precoz, que ocurre entre 30 y 60 minutos después de la comida, y tardío, que ocurre entre 90-240 min. del período postprandial. Material y métodos. Se han estudiado 8 pacientes (3 niños y 5niñas) de edades comprendidas entre 3 y 12 años (media de 9 años) diagnosticados de síndrome de dumping tras la realización de Nissen-Rosseti laparoscópico. A todos ellos se les realizó un estudio de vaciadogástrico por gammagrafía tras administración de un volumen de leche adecuado a su peso marcado con Tc99 DTPA y Test de sobrecarga ora (..) (AU)

Introduction. There has been an important evolution of surgical treatment in recent years due to the progressive generalization of laparoscopic surgery. All of the available techniques can be done laparoscopically with similar results to those of open surgery. In 1978, Villet etal. described the Dumping syndrome (DS) as a frequent complication of Nissen fundoplication. DS is a group of signs and symptoms that appear shortly after surgery, including abdominal pain, paleness, sweating, diarrhea, nausea, even weight loss. These symptoms can be differentiated into early dumping that occurs between 30 to 60 minutes after eating and late dumping that occurs 92-240 minutes after the postprandial period (..) (AU)

[Modifications of the glucose curves and gastric voiding of children with Dumping syndrome after laparoscopic Nissen surgery]. / Modificaciones de las curvas de glucemia y vaciamiento gástrico de los niños con síndrome de dumping tras cirugía de nissen laparoscópico.

INTRODUCTION: There has been an important evolution of surgical treatment in recent years due to the progressive generalization of laparoscopic surgery. All of the available techniques can be done laparoscopically with similar results to those of open surgery. In 1978, Villet et al. described the Dumping syndrome (DS) as a frequent complication of Nissen fundoplication. DS is a group of signs and symptoms that appear shortly after surgery, including abdominal pain, paleness, sweating, diarrhea, nausea, even weight loss. These symptoms can be differentiated into early dumping that occurs between 30 to 60 minutes after eating and late dumping that occurs 92-240 minutes after the postprandial period. MATERIAL AND METHODS: A total of 8 patients (3 boys and 5 girls) have been studied. Their ages ranged from 3 to 12 years (mean 9 years), and they were diagnosed of dumping syndrome after performing the laparoscopic Nissen-Rossetti. All underwent a gastric voiding study by scintigraphy after administration of a volume of milk adjusted to their weight labeled with 99Tc-DTPA and oral glucose overload test with 1.75 g/kg of glucose, determining the baseline glycemia and every 30 minutes post-intake, at 0, 30 and 90 minutes. Insulin was also measured to obtain the glucose/insulin ratio. This study was conducted for all patient diagnosed of dumping syndrome before and after laparoscopic Nissen-Rossetti surgery. RESULTS: The following results were obtained: Glucose Curve: 1. Maximum glycemia. PreNissen. The mean of the maximum glycemia values before surgery was 133.9+/-32.11 mg/dl. Post-Nissen. Mean maximum glycemias after surgery was 208.5 +/- 45.07 mg/dl with a range of 147-276 mg/dl. These differences of maximum glycemia were clearly significant with a p <0.002. Minimum glycemia. The mean value of the minimum glycemias after the surgery, compared with the previous value, did not show significant differences: 62.6+/- 11.51 mg/dl versus 71.8 +/- 28.04 mg/dl. Glucose/insulin ratio. The hyperinsulinism values after the intervention studied by means of the glucose/insulin ratio were abnormal in 70.5% (defined as ratio under 3). The mean value was also characteristic of hyperinsulinism (2.3 +/- 1.62). The mean value of the coefficient prior to the surgery was 4.6 with a deviation of 3.04, the differences not being statistically significant with a p= 0.097. Measurement of gastric voiding: The T1/2 (decay) value in post-Nissen patients was significantly lower than in pre-Nissen patients. The postsurgical mean and standard deviation was 29.74 +/- 7.92 min, while in the presurgical group, the mean and standard deviation was 73.75 +/- 28.34 min with p< 0.011; statistically significant. CONCLUSIONS: From the values obtained, we can state that a significant increase in maximum glycemia has been found in all children after surgery who were diagnosed of dumping syndrome and a significant decrease in the mean time of gastric voiding and therefore an increase in the acceleration of gastric voiding after the performance of the Nissen regarding the previous values. The dumping syndrome is a frequent side effect that we must keep in mind in patients who have been previously operated for anti-reflex surgery, the symptoms being greater in most of the transitory cases. Furthermore, it is important to keep in mind because it has an easy treatment that reverts the symptoms in a short time

[Study of renal function and compensatory changes in children with single kidney]. / Determinación de función renal y cambios compensadores en niños con riñón único.

INTRODUCTION: It has always been thought that a reduction of renal tissue in childhood sometimes causes some irreversible injury in the remnant kidney as the years go by. The aim of this paper is to look over the presence of these changes and identify the risk of nephropaty throughout several parameters. MATERIAL AND METHODS: We reviewed 38 children, 23 males and 15 females, aged between 1 and 15 years, who had lost unilateral renal mass because of congenital or adquired diseases. We made two groups of patients on the basis of having born without any unilateral renal function -group I- or having lost unilateral renal function after the second year of life. We measured: Somatometry, arterial pressure, glomerular filtration, microalbuminuria, renal volume and gammagraphic studies were also made. We also considered the presence of contralateral anomalies. RESULTS: Body weight and height were within normal percentiles. Arterial pressure increased in 5 patients. Seric creatinine was normal, creatinine clearance (Ccr) was higher than normal in all patients of both groups, and urinary excretion of protein was normal. Renal volume of remnant kidney was similar in both groups, and no relation with renal function level was found, but it increased through the years. Isotopic studies showed ectatic drainage in all urinary systems. Contralateral anomalies were seen in 7 patients, and they consisted in hydronephrosis and vesico-ureteral reflux. CONCLUSIONS: Hypertension was not related to the cause of renal absence nor the pathology of remnant kidney. Ccr was higher than normal, showing an hyperfiltration status, not confirmed by the values of isotopic filtrate. Renal volume reached by the single kidney was affected by the time after the renal loss, and apparently has been slowed down in cases with contralateral anomalies.

Determinación de función renal y cambios compensadores en niños con riñón único / Study of renal function and compensatory changes in children with single kidney

Introducción. Se ha considerado siempre que la reducción de la masa renal durante la infancia, causa una serie de cambios funcionales que eventualmente pueden conducir a un daño irreversible en el riñón remanente con el paso de los años. Objetivos. La evidencia de estas lesiones en múltiples publicaciones nos movió a revisar a un grupo de 38 pacientes monorrenos en la edad infantil y a intentar determinar el riesgo de aparición de las mismas a través de parámetros como la función renal, la tensión arterial, la presencia de proteinuria y el volumen renal. Material y métodos. Se estudiaron 38 pacientes, 23 de ellos varones y 15 mujeres, de edades entre 1 y 13 años, que habían sufrido pérdida de masa renal por causas congénitas o adquiridas. Se separaron en dos grupos de enfermos: Grupo I: Ausencia congénita unilateral de riñón funcionante (25 casos). Grupo II: Nefrectomizados por pérdida de un riñón(con función previa normal) después del segundo año de vida (13 casos). Se midió la somatometría, la tensión arterial (TA), el filtrado glomerular (FG), la proteinuria, el volumen renal (VR) y se consideró la presencia de anomalías contralaterales (AC). Resultados. El peso y la talla se encontró en percentiles normales. La TA se encontró elevada en 5 pacientes. La creatinina sérica sólo estaba elevada en 1 paciente con severa afectación del riñón remanente, el aclaramiento de creatinina (Ccr) resultó elevado de forma generalizada y se observó microalbuminuria en 2 pacientes. El volumen renal fue similar en ambos grupos. El estudio isotópico evidenció ectasia sin obstrucción en el 80% de todos los casos y el FG según el método de Inoue (corregido para niños) resultó en ambos grupos dentro de valores normales. Conclusiones. No encontramos diferencias significativas en la función renal entre los dos grupos de pacientes ni tampoco indicios de nefropatía por hiperfiltración. El Ccr evidenció una situación de hiperfiltrado en todos los casos. El filtrado glomerular calculado por estudio isotópico no confirmó estasituación. El volumen renal no se observó relacionado con la edad a la que se produjo la pérdida renal, y sí con el tiempo transcurrido postpérdida. La existencia de anomalías en el riñón contralateral influye en el grado de hipertrofia que desarrolla (AU)

Introduction. It has always been thought that a reduction of renal tissue in childhood sometimes causes some irreversible injury in the remnant kidney as the years go by. The aim of this paper is to look over the presence of these changes and identify the risk of nephropaty throughout several parameters. Material and methods. We reviewed 38 children, 23 males and 15 females, aged between 1 and 15 years, who had lost unilateral renal mass because of congenital or adquired diseases. We made two groups of patients on the basis of having born without any unilateral renal function –group I– or having lost unilateral renal function after the second year of life. We measured: Somatometry, arterial pressure, glomerular filtration, microalbuminuria, renal volume and gammagraphic studies were also made. We also considered the presence of contralateral anomalies. Results. Body weight and height were within normal percentiles. Arterial pressure increased in 5 patients. Seric creatinine was normal, creatinine clearance (Ccr) was higher than normal in all patients of both groups, and urinary excretion of protein was normal. Renal volume of remnant kidney was similar in both groups, and no relation with renal function level was found, but it increased through the years. Isotopic studies showed ectatic drainage in all urinary systems. Contralateral anomalies were seen in 7 patients, and they consisted in hydronephrosis and vesico-ureteral reflux. Conclusions. Hypertension was not related to the cause of renal absence nor the pathology of remnant kidney. Ccr was higher than normal, showing an hyperfiltration status, not confirmed by the values of isotopic filtrate. Renal volume reached by the single kidney was affected by the time after the renal loss, and apparently has been slowed down in cases with contralateral anomalies Introduction. It has always been thought that a reduction of renal tissue in childhood sometimes causes some irreversible injury in the remnant kidney as the years go by. The aim of this paper is to look over the presence of these changes and identify the risk of nephropaty throughout several parameters. Material and methods. We reviewed 38 children, 23 males and 15 females, aged between 1 and 15 years, who had lost unilateral renal mass because of congenital or adquired diseases. We made two groups of patients on the basis of having born without any unilateral renal function –group I– or having lost unilateral renal function after the second year of life. We measured: Somatometry, arterial pressure, glomerular filtration, microalbuminuria, renal volume and gammagraphic studies were also made. We also considered the presence of contralateral anomalies. Results. Body weight and height were within normal percentiles. Arterial pressure increased in 5 patients. Seric creatinine was normal, creatinine clearance (Ccr) was higher than normal in all patients of both groups, and urinary excretion of protein was normal. Renal volume of remnant kidney was similar in both groups, and no relation with renal function level was found, but it increased through the years. Isotopic studies showed ectatic drainage in all urinary systems. Contralateral anomalies were seen in 7 patients, and they consisted in hydronephrosis and vesico-ureteral reflux. Conclusions. Hypertension was not related to the cause of renal absence nor the pathology of remnant kidney. Ccr was higher than normal, showing an hyperfiltration status, not confirmed by the values of isotopic filtrate. Renal volume reached by the single kidney was affected by the time after the renal loss, and apparently has been slowed down in cases with contralateral anomalies (AU)

[Evolution of hypospadias surgery. Comparative study of the various techniques used for 20 years]. / Evolución en la cirugía del hipospadias. Estudio comparativo de las diferentes técnicas empleadas a lo largo de 20 años.

With the purpose of studying the long-term results of the different surgical techniques used for the treatment of hypospadias, we have examined 1186 patients treated in our centre over the last 20 years. To facilitate the comparative study, three well-defined periods have been established: 1974-1981 (165 pts.). Treatment was done in several operative times. Denis Browne and Mathieu's urethroplasties were the techniques more frequently used. Their long-term evolution show keratosis and hairiness of the neourethra, which in 17 patients required a new urethroplasty with vesicle mucosa, as the most serious complication. 1982-1986 (281 pts.). Restoration was done in one single operative time. Magpi, Mathieu and Duckett's techniques were the most frequently used during this period. 1987-1993 (624 pts.). An island flap is added as cutaneous plasty after urethroplasty has been performed. Fistulae were the most frequent complications in all the above time-periods (18, 10 and 7.3%, respectively), followed by stenosis (12, 6.5 and 4.4%) and megaurethra (6.8, 6.7 and 2.9%). The remarkable decrease both in number and seriousness of the complications is due to the island cutaneous flap, hormonal stimulation, use of slow reabsorption materials , silicone probes, silastic foam dressings, caudal anaesthetics and, above all, a better indication for the surgical technique in each case.

[Complications in hypospadias repair: 20 years of experience]. / Complicaciones de los hipospadias y su tratamiento: veinte años de experiencia.

We report a comparative study of the complications in hypospadias repair of 1185 patients treated in our hospital in the last 20 years. They are divided in three well-defined groups: from 1974 to 1981 (265 p.); from 1982 to 1986 (281 p.) and from 1987 to 1993 (624 p.). These were the more frequent complications seen: a) Early as cutaneous necrosis, a severe complication that had an incidence of 3% in the first period. In the second and third period this percentage diminished to 1.9% and 1.1%, respectively. Only one patient developed a total necrosis of the cutaneous island flap that required a new urethroplasty. b) Late: Persistent chordee. It was present in 10% of the children in the first period and it was secondary to an inadequate release of the chordee and cutaneous necrosis. The incidence of the second period was 3.5% and only 2% of patients of the third group suffered it because of a non appropriate selection of the surgical technique. Fistula. It was the most common complication and it was present in 18%, 10% and 7.3% of the patients of each period. We think that the introduction of the cutaneous island flap procedure helped to the improvement in the rate of fistulas. Urethral structure. The incidence was 12% in the first period, 6.5% in the second one and it fall down to 4.4% in the third group due to the triangular flap of the glans. Megaurethra. The incidence was of 6.8% in the first period, 6.5% in the second one and only the 2.9% in the last years.(ABSTRACT TRUNCATED AT 250 WORDS)

[Videothoracoscopy, laparoscopy and minimal-access surgery]. / Videotoracoscopia, laparoscopia y cirugía de mínimo acceso.

Since we start our way in endoscopic surgery, a total of 101 procedures (93 by laparoscopy and 8 by thoracoscopy) have been performed. In two cases (splenectomy, lobectomy) the combination with a minimal enlargement of the wall incision let us remove the entire piece and reduce the operatory time. This is the review of our experience. While the 51.5% of the cases concern to the genitourinary system, the 40.5% of the pathology was digestive and only the 8% was thoracic. The age of the patients ranged between 20 days and 17 years with a clear predominance of the boys. Absence of complications and a high grade of success should do laparoscopy and thoracoscopy frequent surgical procedures in any department of pediatric surgery.

[Posterior urethral valves. Prognostic factors in the clinical course]. / Válvulas de uretra posterior. Factores pronóstico en la evolución.

A retrospective study was conducted in 27 patients with posterior urethral valves that had been treated between 1978 and 1991 in order to determine the prognostic factors of renal function. Patient age ranged from 12 days to 12 years. The mean follow-up was 5 years. Urinary infection was the most common symptom. We used micturating cystography, intravenous urography, US, urodynamics and cystoscopy for the diagnosis. Renal function was evaluated by serum creatinine. All the valves were treated endoscopically by transurethral fulguration. Nineteen patients also underwent ureteral reimplantations. There were 5 nephrectomies and 12 upper tract diversions. There was a strong correlation between serum creatinine at the beginning and after a year and the final renal function (p > 0.001 and p = 0.030, respectively). The correlation between the age and initial serum creatinine was almost significant (p = 0.065). There was no significant correlation between the age at diagnosis, the reflux and the final renal function.

[Fibrin adhesive: a new therapeutic alternative in the treatment of cystic lymphangioma]. / Adhesivo de fibrina: una nueva alternativa terapéutica en el tratamiento del linfangioma quístico.

We present three cases of cystic lymphangioma of the neck, treated with a new therapeutic method which consists of an injection of fibrin adhesive into the lesion following aspiration of the liquid contents of the lymphangioma. Two of the cases had been treated surgically and were faced with the recurrence of the tumor, the aforesaid treatment was applied. In the third case, it was the only therapy applied. We believe that the results obtained were excellent in all three cases.

[Acute intestinal invagination: hydrostatic reduction vs. pneumatic reduction]. / Invaginación intestinal aguda: reducción hidrostática versus reducción neumática.

We report the results of 100 cases of acute intussusception treated by inflation of the colon with air under controlled pressure. We compare this method with the traditional one and we analyse the advantages of each method. Successful reduction was achieved in 76% of the cases of intussusception treated with a barium enema and in 88% of the cases treated with an air enema. Pneumocolon in the treatment of acute intestinal intussusception is an alternative method that is very effective and with additional advantages such as: less radiation, less cost and less morbidity in case of perforation.