Infección de herida quirúrgica neonatal: encuesta multicéntrica sobre medidas profilácticas / Neonatal surgical site infection: multicentric survey on prophylactic measures

Objetivos. La infección de herida quirúrgica (IHQ) es una causa frecuente de morbimortalidad en Neonatología. Existen factores de riesgo conocidos: tipo de cirugía (sucia/contaminada/limpia), prematuridad, duración de intervención, hipoalbuminemia, infección previa, ventilación mecánica prolongada y contaminación de vía central. Otros factores perioperatorios no han sido estudiados en neonatos, sí en adultos. Desarrollamos una encuesta sobre las actitudes y las medidas, intraoperatorias y de manejo de herida. Pretendemos dilucidar si existe consenso sobre la profilaxis de IHQ neonatal. Métodos. Encuesta con 22 ítems, basada en la guía de prevención de la IHQ en adultos (Surgical Infection Society, 2008). Cada ítem cuestiona temas sobre hábitos perioperatorios, intra y postoperatorios, relacionados con el manejo de la herida quirúrgica en el neonato, y consta de dos preguntas, según sea cirugía sucia/urgente o limpia/contaminada. Las opciones de respuesta son 4: siempre, con frecuencia, raramente y nunca. Enviamos la encuesta a cirujanos pediátricos españoles mediante correo electrónico en el primer trimestre del 2012. Resultados. Se enviaron 159 encuestas. 51 (32%) respondieron. 69% emplean clorhexidina para preparar campo, 25% usan povidona iodada. Solo el 51% refirió dejar actuar siempre un minuto el antiséptico. 69% nunca usan bisturí eléctrico en piel para ampliar herida. No hubo respuestas unánimes en cuanto al uso de paños adhesivos protectores del campo, la irrigación de planos con suero o antisépticos durante el cierre, el empleo de drenajes, cambio de guantes y/o material al iniciar el cierre (cirugía sucia). El 72% y el 82% nunca emplean cianocrilato como cierre o apósito en neonatos, respectivamente. En cirugía sucia, 43% suturan piel con intradérmica y 49% con puntos sueltos. Conclusiones. La distribución de respuestas refleja la falta de consenso sobre los aspectos de la técnica quirúrgica y el manejo perioperatorio que podrían estar relacionados con la profilaxis de IHQ neonatal

Objectives. Surgical site infection (SSI) has a considerable impact on neonatal morbidity. There are known risk factors such type of surgery (clean/contaminated), prematurity, surgical length, hypoalbuminemia, previous infection, prolonged mechanical ventilation, and so on. Many perioperative factors have not been studied, opposite to adults. We have developed a survey on intraoperative attitudes and measures, as surgical wound management in Neonates among pediatric surgeons, to seek for a wider consense. Methods. Multi-response survey with 22 items, based on the Surgical Infection Society NIH 2008 clinical guideline. Each item poses a question on perioperative attitudes, surgical aspects and wound management. Each question is subdivided in two categories, depending on urgency and type of surgery (clean/contaminated) Results. 159 surveys were sent. Among those, we received back 51 (32%). 69% of the interviewed surgeons use clorhexidin to prepare surgical field, 25% use Iodine solutions. 69% never use diathermy to incise skin. There was no agreement on the use of sterile plastic adhesive drapes, intra-cavity lavage, changing surgical gloves/material, or wound irrigation during closure. 82% never use cyanocrilate dressing. Intracuticular skin suture and simple stitches were used indistinctly. Wound management and dressings were not uniform and depended on each pediatric unit. Conclusions. The survey reflects the lack of consensus regarding prophylactic measures and wound management among pediatric surgeons who care after surgical neonates

[Neonatal surgical site infection: multicentric survey on prophylactic measures]. / Infección de herida quirúrgica neonatal: encuesta multicéntrica sobre medidas profilácticas.

OBJECTIVES: Surgical site infection (SSI) has a considerable impact on neonatal morbidity. There are known risk factors such type of surgery (clean/contaminated), prematurity, surgical length, hypoalbuminemia, previous infection, prolonged mechanical ventilation, and so on. Many perioperative factors have not been studied, opposite to adults. We have developed a survey on intraoperative attitudes and measures, as surgical wound management in Neonates among pediatric surgeons, to seek for a wider consense. METHODS: Multi-response survey with 22 items, based on the Surgical Infection Society NIH 2008 clinical guideline. Each item poses a question on perioperative attitudes, surgical aspects and wound management. Each question is subdivided in two categories, depending on urgency and type of surgery (clean/contaminated). RESULTS: 159 surveys were sent. Among those, we received back 51 (32%). 69% of the interviewed surgeons use clorhexidin to prepare surgical field, 25% use Iodine solutions. 69% never use diathermy to incise skin. There was no agreement on the use of sterile plastic adhesive drapes, intra-cavity lavage, changing surgical gloves/material, or wound irrigation during closure. 82% never use cyanocrilate dressing. Intracuticular skin suture and simple stitches were used indistinctly. Wound management and dressings were not uniform and depended on each pediatric unit. CONCLUSIONS: The survey reflects the lack of consensus regarding prophylactic measures and wound management among pediatric surgeons who care after surgical neonates.

OBJETIVOS: La infección de herida quirúrgica (IHQ) es una causa frecuente de morbimortalidad en Neonatología. Existen factores de riesgo conocidos: tipo de cirugía (sucia/contaminada/limpia), prematuridad, duración de intervención, hipoalbuminemia, infección previa, ventilación mecánica prolongada y contaminación de vía central. Otros factores perioperatorios no han sido estudiados en neonatos, sí en adultos. Desarrollamos una encuesta sobre las actitudes y las medidas, intraoperatorias y de manejo de herida. Pretendemos dilucidar si existe consenso sobre la profilaxis de IHQ neonatal. METODOS: Encuesta con 22 ítems, basada en la guía de prevención de la IHQ en adultos (Surgical Infection Society, 2008). Cada ítem cuestiona temas sobre hábitos perioperatorios, intra y postoperatorios, relacionados con el manejo de la herida quirúrgica en el neonato, y consta de dos preguntas, según sea cirugía sucia/urgente o limpia/contaminada. Las opciones de respuesta son 4: siempre, con frecuencia, raramente y nunca. Enviamos la encuesta a cirujanos pediátricos españoles mediante correo electrónico en el primer trimestre del 2012. RESULTADOS: Se enviaron 159 encuestas. 51 (32%) respondieron. 69% emplean clorhexidina para preparar campo, 25% usan povidona iodada. Solo el 51% refirió dejar actuar siempre un minuto el antiséptico. 69% nunca usan bisturí eléctrico en piel para ampliar herida. No hubo respuestas unánimes en cuanto al uso de paños adhesivos protectores del campo, la irrigación de planos con suero o antisépticos durante el cierre, el empleo de drenajes, cambio de guantes y/o material al iniciar el cierre (cirugía sucia). El 72% y el 82% nunca emplean cianocrilato como cierre o apósito en neonatos, respectivamente. En cirugía sucia, 43% suturan piel con intradérmica y 49% con puntos sueltos. CONCLUSIONES: La distribución de respuestas refleja la falta de consenso sobre los aspectos de la técnica quirúrgica y el manejo perioperatorio que podrían estar relacionados con la profilaxis de IHQ neonatal.

Calidad de vida y resultados a largo plazo en pacientes con enfermedad de Hirschsprung / Quality of life and long term results in Hirschsprung’s disease

Introducción. En este estudio hemos querido comprobar los resultados funcionales a largo plazo de dos técnicas quirúrgicas en la enfermedad de Hirschsprung (Duhamel -D- y De la Torre -dlT-) desde el punto de vista de los pacientes. Métodos. Se seleccionaron los pacientes ≥4 años con EH de segmentocorto intervenidos desde 1996 hasta 2011. Encuestas telefónicas: dos tests validados: el BFS (Bowel Function Score), y el cuestionario GIQLI (Gastrointestinal Quality of Life Index). Se tomaron dos grupos controles pareados por edad para cada grupo (D o dlT). Resultados. De 28 pacientes preseleccionados, 22 (78,6%) contestaron el cuestionario. Edad media: 10 años (rango 4-21). 12 pacientes se habían intervenido mediante técnica de dlT y 10 mediante técnica de D. Los pacientes dlT presentaron fugas más frecuentemente (58,3% vs. 10% p=0,03).Los resultados fueron mejores en el grupo D en los dos cuestionarios: 16 vs.12,8 puntos (BFS, p=0,007) y 74,1 vs. 69,8 (GIQLI, p=0,17). Los resultados en el grupo control fueron mejores en ambos cuestionarios respecto a los pacientes con EH en su conjunto: 17,2 vs. 14,3 (BFS, p<0,001) y 75,9 vs.71,8 (GIQLI, p=0,04). Ambos grupos de pacientes intervenidos presentaban resultados inferiores a su grupo control respectivo. Discusión. Obtuvimos menor puntuación global en pacientes intervenidos de EH respecto a controles sanos. La incontinencia y las fugas tienen más impacto en la calidad de vida que el estreñimiento. Al presentar más frecuentemente fugas, los pacientes del grupo dlT, los resultados en este grupo fueron inferiores. Los pacientes en el grupo dlT eran más jóvenes y sus resultados podrían mejorar con la edad, como se comprueba habitualmente en pacientes con EH operados

Introduction. The most frequent long term side effects of Hirschsprung's disease (HD) surgery are obstructive problems and fecal incontinence. In this study, we analyse long term functional results of the two most used surgical techniques (Duhamel -D- and De la Torre -dlT-) from the patient's point of view, through quality of life and functionality questionnaires. Methods. We selected short segment HD patients (≥4 years) that were operated in our unit from 1996 until 2011. We employed two validated questionnaires: Bowel Function Score (BFS) and Gastrointestinal Quality of Life Index (GIQLI). Both questionnaires were also tested in two control age matched groups, each for every arm (control Dor controldlT). Results. Among 28 preselected patients, 22 (78.6%) answered both questionnaires. Group D (10 patients) showed more constipation: 60%vs. 16,7% (p=0.01). Patients in group dlT (12 patients) showed more leaks: 58,3 vs.10% (p=0,03). Results of both questionnaires were higher (better) in Group D: 16 vs. 12,8 points (BFS, p=0.007) and 74,1 vs. 69,8 (GIQLI, p=0.17). The control group showed an overall better scores than HD patients: 17,2 vs. 14,3 (BFS p=0.001) and 75,9 vs. 71,8 (GIQLI, p=0.04). Separately, both groups of patients showed worse scores when compared with each control group. Discussion. Our results are similar to other studies, where global scores of functional results and quality of life are worse in operated HD patients than in age matched controls. Fecal incontinence has more impact on social scores than constipation. Due to the fact that our dlT patients have more frequently fecal leaks, their scores are worse than in the D group. Nevertheless, patients in dlT group are younger and may improve their results as they get older, as it is often the case in operated HD patients

[Study of bacteriology and resistances in pediatric appendicitis]. / Estudio de la flora patógena y resistencias en apendicitis pediátricas.

UNLABELLED: There is controversy about the convenience of performing a bacteriological peritoneal culture in pediatric appendicitis. We performed a sero-epidemiological survey of the bacteria found in peritoneal swabs from pediatric appendicitis operated in our hospital. METHODS: Ambispective study. Retrospective revision of the bacteriological results from peritoneal swabs performed in pediatric appendicitis from january 2009 to december 2010 (2 years) and prospective study of peritoneal swabs collected between january 2011 and december 2011 (one year). RESULTS: We found 728 pediatric patients (mean age 7.1, range: 2-11 years). Among these, 108 were < 5 years. Cultures were performed in 328 (45.1%). A positive result was found in 155 swabs, (47.3%). Positive cultures were more frequent in patients < 5 years (69.2% vs 40.4%, p < 0.001). The most frequent pathogens were E. coli: 122 specimens, Streptococcus spp (50 swabs), P. aeruginosa: (45) and B.fragilis: (35) Younger age was strongly associated with P. aeruginosa: (30.8% vs 8.4%, p < 0.001. OR: 4.8. IC 95%: 2.3-9.8). So was the detection of E. coli (50% vs 33.2% p = 0.01). 21.3% (26 swabs) of E. coli were resistant to amoxicillin-clavulanic acid. There were 15 (12.3%) multiresistant (ESBL) E. coli. Among the Streptococcus, 32% (16 out of 50) were resistant to clindamicin, and so were 28.6% of the B. fragilis (10 out of 35). DISCUSSION: . The most frequent pathogens were E. coli, Streptococcus spp and P. aeruginosa. P. aeruginosa is five times more frequent in patients < 5 years. Resistance of E. coli to amoxiclavulanate was high: 21.3% of the specimens. We found that 12.3% of the E. coli produced ESBL.

Estudio de la flora patógena y resistencias en apendicitis pediátricas / Study of bacteriology and resistances in pediatric appendicitis

Objetivos. Existe controversia sobre la utilidad del cultivo de líquido peritoneal en las apendicitis pediátricas. Hemos investigado la situación epidemiológica de la fl ora bacteriana en las apendicectomías pediátricas. Material y métodos. Revisión retrospectiva de apendicectomías realizadas en menores de 12 años, en dos años (enero/2009-diciembre/2010) y análisis prospectivo durante un año (enero/2011-diciembre/2011). Resultados. Encontramos 728 pacientes (media 7,1 años, rango 2-11). De ellos, 108 eran <5 años. Se recogió cultivo de líquido perineal en 328 (45,1%). Los cultivos fueron positivos en 155 de esas 328 muestras (47,3%). Fue más frecuente encontrar cultivo positivo en <5 años (69,2% vs. 40,4%, p <0,001. OR: 3,3. IC 95%: 1,8-5,9). Las bacterias más habituales fueron Escherichia coli, con 122 aislamientos, Streptococcus spp (50 aislamientos), P. aeruginosa, (45 aislamientos) y B. fragilis (35). La frecuencia de P. aeruginosa fue cinco veces mayor en el grupo de < 5 años (30,8% vs. 8,4%, p<0,001. OR: 4,8. IC 95%: 2,3-9,8). Asimismo, la presencia de E. coli se duplicó en el grupo de < 5 años (50% vs. 33,2% p = 0,01. OR: 2,01. IC 95%: 1,1-3,4). 26 (21,3%) especímenes de E. coli eran resistentes a amoxicilina-clavulánico. Hubo 15 (12,3%) cepas de E. coli multirresistentes. 16 cepas de Streptococcus (32%) y 10 aislamientos de B. fragilis (28,6%) fueron resistentes a clindamicina. Conclusiones. En < 5 años existe más riesgo de infección por Pseudomonas. Encontramos una alta tasas de resistencia de E. coli a la amoxicilina-clavulánico y 12,3% de E. coli eran multirresistentes

There is controversy about the convenience of performing a bacteriological peritoneal culture in pediatric appendicitis. We performed a sero-epidemiological survey of the bacteria found in peritoneal swabs from pediatric appendicitis operated in our hospital. Methods. Ambispective study. Retrospective revision of the bacteriological results from peritoneal swabs performed in pediatric appendicitis from january 2009 to december 2010 (2 years) and prospective study of peritoneal swabs collected between january 2011 and december 2011 (one year).Results. We found 728 pediatric patients (mean age 7.1, range: 2-11 years). Among these, 108 were <5 years. Cultures were performed in 328 (45.1%). A positive result was found in 155 swabs, (47.3%). Posi-tive cultures were more frequent in patients < 5 years (69.2% vs 40.4%, p <0,001). The most frequent pathogens were E. coli: 122 specimens, Streptococcus spp (50 swabs), P. aeruginosa: (45) and B. fragilis: (35). Younger age was strongly associated with P. aeruginosa: (30.8% vs8.4%, p<0,001. OR: 4.8. IC 95%: 2.3-9.8). So was the detection of E. coli (50% vs 33.2% p=0,01). 21.3% (26 swabs) of E. coli were resistant to amoxicillin-clavulanic acid. There were 15 (12.3%) multiresistant (ESBL) E. coli. Among the Streptococcus, 32% (16 out of 50) were re-sistant to clindamicin, and so were 28.6% of the B. fragilis (10 out of 35). Discussion. The most frequent pathogens were E. coli, Streptococ-cus spp and P. aeruginosa. P. aeruginosa is fi ve times more frequent in patients <5 years. Resistance of E. coli to amoxiclavulanate was high: 21.3% of the specimens. We found that 12.3% of the E. coli produced ESBL

[Quality of life and long term results in Hirschsprung's disease]. / Calidad de vida y resultados a largo plazo en pacientes con enfermedad de Hirschsprung.

INTRODUCTION: The most frequent long term side effects of Hirschsprung's disease (HD) surgery are obstructive problems and fecal incontinence. In this study, we analyse long term functional results of the two most used surgical techniques (Duhamel-D- and De la Torre-dlT-) from the patient's point of view, through quality of life and functionality questionnaires. METHODS: We selected short segment HD patients ≥ 4 years) that were operated in our unit from 1996 until 2011. We employed two validated questionnaires: Bowel Function Score (BFS) and Gastrointestinal Quality of Life Index (GIQLI). Both questionnaires were also tested in two control age matched groups, each for every arm (controlD or control dlT). RESULTS: Among 28 preselected patients, 22 (78.6%) answered both questionnaires. Group D (10 patients) showed more constipation: 60% vs. 16.7% ( p = 0.01). Patients in group dlT (12 patients) showed more leaks: 58.3 vs. 10% (p = 0.03). Results of both questionnaires were higher (better) in Group D: 16 vs. 12.8 points (BFS, p = 0.007) and 74.1 vs. 69.8 (GIQLI, p = 0.17). The control group showed an overall better scores than HD patients: 17.2 vs. 14.3 (BFS p = 0.001) and 75.9 vs. 71.8 (GIQLI, p = 0.04). Separately, both groups of patients showed worse scores when compared with each control group. DISCUSSION: Our results are similar to other studies, where global scores of functional results and quality of life are worse in operated HD patients than in age matched controls. Fecal incontinence has more impact on social scores than constipation. Due to the fact that our dlT patients have more frequently fecal leaks, their scores are worse than in the D group. Nevertheless, patients in dlT group are younger and may improve their results as they get older, as it is often the case in operated HD patients.

Resultados funcionales en pacientes con enfermedad de Hirschsprung intervenidos mediante las técnicas de Duhamel y De la Torre / Functional results of Hirschsprung’s disease patients after Duhamel and De la Torre procedures

Introducción. Los resultados funcionales a largo plazo de las distintas técnicas quirúrgicas en la Enfermedad de Hirschsprung (EH) son variables según las series. Analizamos los resultados funcionales a medio plazo en pacientes con EH intervenidos mediante las técnicas de Duhamel (D) y De la Torre (dlT).Material y métodos. Revisión de historias clínicas y encuestas telefónicas a pacientes con EH intervenidos en los últimos 16 años. Resultados. Se encontraron 38 pacientes, edad media 7,7; rango 1,5-21 años. La media de seguimiento fue de 5,9 años (mediana 5,5; rango 1-16 años). 13,2% presentaron afectación del segmento largo. Se realizaron 17 (44,7%) intervenciones de D, 16 (42,1%) de dLT, 4 (10,5%) intervenciones de Duhamel-Lester-Martin y 1 (2,6%) intervención de Soave. En la última visita o contacto telefónico, 12 (31,6%) presentaban estreñimiento y entre los pacientes ≥4 años (n=33), 11 (33,3%) referían fugas. Diez pacientes (29,4%) presentaron encopresis a lo largo del seguimiento. Los pacientes D presentaron mayores tasas de estreñimiento a los dlT (53,3% vs 20%, p=0,048). Los pacientes intervenidos mediante Duhamel presentaron menos fugas que los de de La Torre, (13,3% vs 46,1% p=0,05). Los pacientes con resecciones muy pequeñas (<10 cm) presentaron más estreñimiento (66,6% vs 17,4%, p=0,007), y menos fugas (12,5% vs 47,3% p=0,08). Todos los grupos presentaron tasas de encopresis similares. Discusión. Ambas técnicas tienen unos resultados a medio plazo similares, si bien en la técnica de Duhamel existe más tendencia al estreñimiento y en la de De la Torre existe más proporción de niños con fugas. Creemos necesario un seguimiento a largo plazo de todos los pacientes con EH (AU)

Introduction. Long term results of different surgical techniques in Hirschsprung´s Disease (HD) are contradictory. There are still no long term large or multicentric reports about functional results of De la Torre technique. We have studied the mid term functional results of the patients operated on Duhamel (D) and De la Torre (dlT) pull-through procedures. Patients and methods. We collected data from medical records and telephone interviews of the HD patients operated in our unit in the last 16 years. Results. 38 patients were found. Ages ranged from 1.5 to 21 years. Mean age was 7.7 years. Median follow up was 5.9 years. 33 (86.8%) had rectosigmoid disease and 5 (13.2%) had long segment disease. D procedure was performed in 17 (44.7%) , Soave in 1 (2.6%) , Duhamel-Lester-Martin in 4 (10.5%) and dlT pull-through in 16 (42%). In the last visit record, 12 (31.6%), had constipation, and fecal leaks were noted in 11 (33.3%) of the 33 patients ≥4 years old.. 10 patients (29.4% of the ≥4 years old group) referred encopresis along the follow-up. Patients from the D group referred higher rates of constipation than those in the dlT group (53.3% vs 20% p=0.048). dlT patients referred more frequency of leaks (46,1% vs 13,3%, p=0,05) Children with very short resections (≤10 cm) were more prone to constipation than children with longer resections (66,6% vs 17.4% p=0.007), and less prone to present leaks (12.5% vs 47.3% p=0.08). Encopresis was similar in all groups. Discussion. Both techniques show similar functional results in the mid term, although children in the D group were more prone to constipation and those in the dlT group presented more fecal leaks. All patients with EH need long follow-ups (AU)

Tratamiento de la hidatidosis hepatopulmonar con cirugía mínimamente invasiva en nuestro hospital. A propósito de 4 casos / Hepatopulmonary hydatidosis treatment through minimally invasive surgery in our hospital: Report of 4 cases

Objetivos. Presentamos nuestra experiencia en el tratamiento quirúrgico mínimamente invasivo de la hidatidosis hepática y pulmonar en los últimos 5 años. Material y Métodos. Revisión retrospectiva de pacientes con quistes hidatídicos hepáticos y pulmonares atendidos en nuestro hospital entre los años 2008-2012 y tratados mediante cirugía mínimamente invasiva Resultados. Se identificaron 4 casos, todos de origen marroquí, la edad media fue de 6,7 años. Un paciente con quiste hepático único y tres con quistes hepatopulmonares. Todos recibieron tratamiento con albendazol previo a la cirugía. Se realizó laparoscopia y/o toracoscopia y en uno de los casos se realizó abordaje transdiafragmático de una lesión hepática posterior inabordable por laparoscopia. La técnica utilizada fue la esterilización del contenido del quiste con suero salino hipertónico, apertura del quiste y extracción de la membrana quística. No realizamos periquistectomía ni capitonaje. La tasa de resolución de las cavidades residuales de los quistes fue del 100% y no ha habido ninguna recidiva como tampoco complicaciones intraoperatorias. Conclusiones. En el niño el tratamiento quirúrgico se puede realizar mediante técnicas endoscópicas con la misma seguridad y eficacia que mediante cirugía abierta. El tratamiento con albendazol previo a la cirugía es útil en la prevención de recidivas y como único tratamiento en lesiones pequeñas. La cirugía ha de ser lo más conservadora de parénquima posible evitándose resecciones innecesarias hepáticas o pulmonares. El tratamiento de la cavidad residual parece ser innecesario. El abordaje transdiafragmático mediante toracoscopia debe considerarse como alternativa en el tratamiento de lesiones hepáticas en segmentos posteriores inabordables con laparoscopia (AU)

Objectives. The aim of this review is to present our experience in minimally invasive surgical procedures as treatment of hepatic and pulmonary hydatidosis in the last five years. Material and Methods. Retrospective review of patients with pulmonary and hepatic hydatid cysts treated in our hospital between 2008-2012 with minimally invasive surgery. Results. We identified 4 cases, all of them Moroccan origin, the mean age was 6.7 years. Only one patient with hepatic cyst and three with hepatopulmonary cysts. All of them were treated with albendazole before surgery. Laparoscopy and / or thoracoscopy was performed and, in one case a transdiaphragmatic approach was used, as a way to reach a posterior hepatic injury unapproachable by laparoscopy. The technique used was the sterilization of the contents of the cyst with hypertonic saline solution, cyst opening and cystic membrane removal. We didn’t do capitonage or pericystectomy. The resolution rate of residual cavities of the cysts was 100% and there was no recurrence or intraoperative complications. Conclusions. In children surgical treatment can be performed using endoscopic techniques with the same safety and efficacy as open surgery. Treatment with albendazole before surgery is helpful in preventing recurrences and as unique treatment in small lesions. Surgery must be as sparing as possible avoiding unnecessary liver or lung resections. Treatment of the residual cavity seems unnecessary. The thoracoscopic transdiaphragmatic approach should be considered as an alternative treatment, for those liver lesions in posterior segments, which are intractable with laparoscopy (AU)

[Preliminary results of a multidisciplinary approach to gastroschisis]. / Resultados iniciales de un protocolo de manejo terapéutico de la gastrosquisis.

INTRODUCTION: In gastroschisis, premature birth may avoid the development of intestinal peel and favour the primary closure. We present the preliminary results obtained after following a multidisciplinary approach to gastroschisis. After prenatal ultrasound diagnosis, preterm caesarean delivery at 34-35 weeks of gestation is programmed. METHODS: Prospective design of a study, where we included all prenatal diagnosed gastrosquisis neonates, from July 2007 to January 2012. RESULTS: We followed 9 infants (3 male). Average weight at birth: 1,927 gr. (+/- 370). Primary closure was successfully accomplished in the first 3 hours of life all cases. We found two cases of slight peel. We found no associated intestinal malformations, except for one small bowel stenosis. No significant neonatal distress respiratory syndrome developed. Mean parenteral nutrition time was 13.9 days (+/- 3.8). 4 neonates developed central line associated infection. No surgical site infection developed. Enteral nutrition was started at day 8th (+/- 2.8). Enteral requirements were fulfilled at day 15th (+/- 3.6). Mean hospital stay was 31 days (+/- 10). Mean follow-up was 30 months. 4 cases developed a small (< 5 mm) umbilical hernia CONCLUSION: Programming premature cesarean section delivery at 34 weeks of gestation was beneficial to the neonates with gastroschisis, yet it avoided peel development, and rendered primary closure without serious difficulties possible. This diminishes hypoperistalsis time and allows rapid instauration of enteral feeding, so hospital stays may be shorter.

[The association of adherence to a Mediterranean diet during early pregnancy and the risk of gastroschisis in the offspring]. / Asociación de la adherencia a la dieta mediterránea al inicio del embarazo y riesgo de gastrosquisis en la descendencia: un estudio de casos-controles.

OBJECTIVES: The aim of this study was to study the association of adherence to the Mediterranean diet in early pregnancy maternal and the offspring's risk of gastroschisis. METHODS: Case-control study. We describe 11 cases of gastroschisis in the region of Murcia from 2007 to 2012 and 34 concurrent controls. At the time of diagnosis each of the cases completed a validated Food Frequency Questionnaire (FFQ) consisting of 98 items on the periconceptional diet. Confounding factors: smoking, exposure to cannabis / marihuana, age of the parents, BMI, income and educational level. We conducted a descriptive and multivariate logistic regression statistical analysis. RESULTS: Mothers of children with gastroschisis were younger (20.8 years, 95% CI 17.3 to 24.2) and their diet consisted of less caloric intake, saturated fat and monounsaturated fats and proteins than controls. The Odds Ratio (OR) in the multivariate model controlling for confounding factors: maternal age (year) 0.70 (95% CI 0.51 to 0.96), monounsaturated fatty acids (oleic acid, g) 0.79 (95% CI 0.65 to 0, 97) and vegetable intake (rations/week) 0.70 (95% CI 0.48 to 1.00). CONCLUSION: A maternal diet rich in oleic acid and vegetable products may prevent vascular risk of onphalomesenteric arteries reducing the risk of gastroschisis.

Resultados iniciales de un protocolo de manejo terapéutico de la gastrosquisis / Preliminary results of a multidisciplinary approach to gastroschisis

Objetivos. En la gastrosquisis, el parto pretérmino podría evitar el fenómeno de peel y favorecer el cierre primario. Presentamos los resultados obtenidos tras la implantación de un protocolo de manejo multidisciplinario de la gastrosquisis en nuestro centro: tras el diagnóstico y seguimiento ecográfico de la malformación se programa la cesárea en la semana 34 de gestación. Material y Métodos. Estudio prospectivo de todos los casos diagnosticados antenatalmente de gastrosquisis desde julio de 2007 hasta enero de 2012. Resultados. Se siguieron 9 niños (3 varones). Peso medio: 1.927 gramos (± 370). La intervención, cierre primario siempre, se realizó en quirófano en las primeras 3 horas de vida. Encontramos 2 casos de peel leve. El defecto fue pequeño en todos. No hubo malformaciones intestinales asociadas, salvo un caso de estenosis en un asa. No hubo enfermedad de membrana hialina ni patología atribuible a prematuridad. Duración media de nutrición parenteral: 13,9 días (± 3,8). 4 casos presentaron bacteriemia asociada a catéter central. No hubo infección de herida quirúrgica. Se inició nutrición enteral al 8º día (media 8,4, rango 4-13). Se logró alimentación enteral completa al 15º día (media 15,6, rango 11-22). Estancia media: 31 días (± 10, rango 20-56). Mediana de seguimiento: 30 meses. 4 casos presentan pequeña debilidad umbilical menor de 0,5 cm. discusión. El adelantamiento del parto a la semana 34 mediante cesárea electiva impide el desarrollo de peel, permite la reintroducción de las asas en la cavidad peritoneal, disminuye el tiempo de hipoperistalsis y permite la instauración precoz de la alimentación enteral con menor estancia hospitalaria (AU)

Introduction. In gastroschisis, premature birth may avoid the development of intestinal peel and favour the primary closure. We present the preliminary results obtained after following a multidisciplinary approach to gastroschisis. After prenatal ultrasound diagnosis, preterm caesarean delivery at 34-35 weeks of gestation is programmed. Methods. Prospective design of a study, where we included all prenatal diagnosed gastrosquisis neonates, from july 2007 to january 2012.Results. We followed 9 infants (3 male). Average weight at birth: 1,927 gr. (± 370). Primary closure was successfully accomplished in the first 3 hours of life all cases. We found two cases of slight peel. We found no associated intestinal malformations, except for one small bowel stenosis. No significant neonatal distress respiratory syndrome developed. Mean parenteral nutrition time was 13.9 days (± 3.8). 4 neonates developed central line associated infection. No surgical site infection developed. Enteral nutrition was started at day 8th (± 2.8). Enteral requirements were fulfilled at day 15th (± 3.6). Mean hospital stay was 31 days (± 10). Mean follow-up was 30 months. 4 cases developed a small (< 5 mm) umbilical hernia Conclusion. Programming premature cesarean section delivery at 34 weeks of gestation was beneficial to the neonates with gastroschisis, yet it avoided peel development, and rendered primary closure without serious difficulties possible. This diminishes hypoperistalsis time and allows rapid instauration of enteral feeding, so hospital stays may be shorter (AU)

[Functional results of Hirschsprung's disease patients after Duhamel and De la Torre procedures]. / Resultados funcionales en pacientes con enfermedad de Hirschsprung intervenidos mediante las técnicas de Duhamel y De la Torre.

INTRODUCTION: Long term results of different surgical techniques in Hirschsprung's Disease (HD) are contradictory. There are still no long term large or multicentric reports about functional results of De la Torre technique. We have studied the mid term functional results of the patients operated on Duhamel (D) and De la Torre (dlT) pull-through procedures. PATIENTS AND METHODS: We collected data from medical records and telephone interviews of the HD patients operated in our unit in the last 16 years. RESULTS: 38 patients were found. Ages ranged from 1.5 to 21 years. Mean age was 7.7 years. Median follow up was 5.9 years. 33 (86.8%) had rectosigmoid disease and 5 (13.2%) had long segment disease. D procedure was performed in 17 (44.7%), Soave in 1 (2.6%), Duhamel-Lester-Martin in 4 (10.5%) and dlT pull-through in 16(42%). In the last visit record, 12 (31.6%), had constipation, and fecal leaks were noted in 11 (33.3%) of the 33 patients > or = 4 years old.. 10 patients (29.4% of the > or = 4 years old group) referred encopresis along the follow-up. Patients from the D group referred higher rates of constipation than those in the dlT group (53.3% vs 20% p=0.048). dlT patients referred more frequency of leaks (46,1% vs 13,3%, p=0,05) Children with very short resections (< or = 10 cm) were more prone to constipation than children with longer resections (66,6% vs 17.4% p=0.007), and less prone to present leaks (12.5% vs 47.3% p=0.08). Encopresis was similar in all groups. DISCUSSION: Both techniques show similar functional results in the mid term, although children in the D group were more prone to constipation and those in the dlT group presented more fecal leaks. All patients with EH need long follow-ups.

[Hepatopulmonary hydatidosis treatment through minimally invasive surgery in our hospital: report of 4 cases]. / Tratamiento de la hidatidosis hepatopulmonar con cirugía mínimamente invasiva en nuestro hospital. A propósito de 4 casos.

OBJECTIVES: The aim of this review is to present our experience in minimally invasive surgical procedures as treatment of hepatic and pulmonary hydatidosis in the last five years. MATERIAL AND METHODS: Retrospective review of patients with pulmonary and hepatic hydatid cysts treated in our hospital between 2008-2012 with minimally invasive surgery. RESULTS: We identified 4 cases, all of them Moroccan origin, the mean age was 6.7 years. Only one patient with hepatic cyst and three with hepatopulmonary cysts. All of them were treated with albendazole before surgery. Laparoscopy and/or thoracoscopy was performed and, in one case a transdiaphragmatic approach was used, as a way to reach a posterior hepatic injury unapproachable by laparoscopy. The technique used was the sterilization of the contents of the cyst with hypertonic saline solution, cyst opening and cystic membrane removal. We didn't do capitonage or pericystectomy. The resolution rate of residual cavities of the cysts was 100% and there was no recurrence or intraoperative complications. CONCLUSIONS: In children surgical treatment can be performed using endoscopic techniques with the same safety and efficacy as open surgery. Treatment with albendazole before surgery is helpful in preventing recurrences and as unique treatment in small lesions. Surgery must be as sparing as possible avoiding unnecessary liver or lung resections. Treatment of the residual cavity seems unnecessary. The thoracoscopic transdiaphragmatic approach should be considered as an alternative treatment, for those liver lesions in posterior segments, which are intractable with laparoscopy.

Actinomicosis: a propósito de 2 casos clínicos / Actinomycosis: presentation of 2 cases

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Stephens-Fowler en 2 tiempos: resultados 14 años después / Stephens-fowler in two times: results 14 years later

El manejo del testículo intraabdominal puede ser difícil, como lo demuestran las múltiples modalidades de evaluación y tratamiento propuestos. Revisamos nuestros resultados tras 14 años de experiencia en el manejo laparoscópico. Material y métodos. Estudio retrospectivo de las laparoscopias realizadas en nuestro servicio por teste no palpable entre los años1996 y 2009. De 174 laparoscopias encontramos 72 testes intraabdominales (5 bilaterales) y realizamos 25 descensos directos (3bilaterales). En 5 casos se realizó Stephens-Fowler en un tiempo. A40 pacientes se les realizó la técnica de Stephens-Fowler en 2 tiempos(2 bilaterales) por no alcanzar el orificio inguinal contralateral. El segundo tiempo en 4 casos se realizó asistido por laparoscopiay, en el resto, vía inguinal exclusivamente. La edad media de la primera intervención fue de 3,7 años y el tiempo medio entre las 2intervenciones fue de 10,9 meses. De los 42 testes descendidos, 22 (..) (AU)

The management of intra-abdominal testis can be challenging, as evidenced by the multiple methods suggested for its assessment and treatment. In this paper, we report our long-term results for our 14-yearsurgical experience with laparoscopic management. Methods. Retrospective study of laparoscopic interventions performed at our department for non palpable testes between 1996and 2009. In 174 procedures, we found 72 intra-abdominal testes (5bilateral) and 25 direct orchiopexies (3 bilateral) were performed. One-stage Fowler-Stephens orchiopexies (FSO) were performed in 5children. 40 boys underwent the two-stage FSO technique (2 bilateral)in those that reached the contralateral inguinal ring. The second stage (..) (AU)

[Stephens-Fowler in two times: results 14 years later]. / Stephens-Fowler en 2 tiempos: resultados 14 años después.

The management of intra-abdominal testis can be challenging, as evidenced by the multiple methods suggested for its assessment and treatment. In this paper, we report our long-term results for our 14-year surgical experience with laparoscopic management. Methods. Retrospective study of laparoscopic interventions performed at our department for nonpalpable testes between 1996 and 2009. In 174 procedures, we found 72 intra-abdominal testes (5 bilateral) and 25 direct orchiopexies (3 bilateral) were performed. One-stage Fowler-Stephens orchiopexies (FSO) were performed in 5 children. 40 boys underwent the two-stage FSO technique (2 bilateral) in those that reached the contralateral inguinal ring. The second stage was performed in 4 cases with a laparoscopic approach, the rest of them underwent an inguinal procedure exclusively. Mean age for the first intervention was 3.7 yrs, and the second stage was performed on average after 10.9 months. Of 42 undescended testes, 22 were on the right side and 20 on the left side. Median followup was 24 months. Results. Of 42 two-stage FSOs performed, 27 surgeries were very successful, with a testis size equivalent to the contralateral mate; 7 had good results, with a smaller testis (volume up to 50% of contralateral); and 7 resulted in atrophic testis. No complications were encountered during surgery. Conclusions. There is no doubt about the usefulness of laparoscopy for intra-abdominal testes with short spermatic vessels, and the two-stage Fowler-Stephens technique should be the procedure of choice given its high success rate.

[Surgical treatment of cholelithiasis in children. Role of cholecystotomy]. / Tratamiento quirúrgico de la colelitiasis en el niño. El papel de la colecistotomía.

Cholelithiasis is a rare pathology in children and with a different etiology, composition and clinic than adult. Cholecystectomy is the standardized treatment. The cholecystectomy is an alternative treatment in childhood. We studied 30 patients, aged between 8 months and 13 years, 15 of them with cholecystectomy and 15 with removal of pigment gallstones. The patients were followed up for 3 months-11 years. Recurrent stone formation was noted in one patient. 14 of the patients were non-symptomatic with normal ecography controls.

[Azygo-portal disconnection with mechanical transection of the esophagus]. / Desconexión ácigo-portal con transección mecánica del esófago.

Many procedures are described to solve the problem of the massive hemorrhages due to esophageal varices in children with Portal Hypertension in which it's not possible to do a porto-systemic shunt by cause of the age. It's possible to treat them by sclerotherapy but in case of massive hemorrhages in which the patient life is at risk we have used the azygo-portal disconnection following the SUGIURA technique making the esophageal transection with autosuture instrument. We believe that this technical simplification account for more instances in which it's indicated. And it could be preferred to other procedures used with the same objective. We have done it in two male patients which came to our Center in several occasions due to massive hemorrhages. In both cases the Portal Hypertension is of extrahepatic cause. Follow up it is been satisfactory in both cases. Being one of them more than 3 1/2 years without hemorrhagic episodes, remaining under clinical and endoscopic controls. We have used in this cases the Proximate ILS of 21 mm. of Ethicon.