Spanish primary care in pediatric trauma (AITP) consensus: An AITP checklist. / Consenso AITP español: Una lista de verificación AITP.

INTRODUCTION: The course in Primary Care in Pediatric Trauma (ATIP in Spanish) has been taught in Spain since 1997, and there are currently 9 accredited training centers. Care of polytraumatized pediatric patients often takes place in an environment conducive to errors resulting from forgetfulness, which is why checklists - mnemonic tools widely used in industry and medicine - are particularly useful to avoid such errors. Although several checklists exist for pediatric trauma care, none have been developed within the setting of our course. MATERIALS AND METHODS: The criteria for being selected as an expert in Primary Care in Pediatric Trauma were agreed upon with the scientific polytrauma committee of the Spanish Pediatric Surgery Society. The items that make up the checklist were obtained from a review of the literature and consultation with selected experts, using the Delphi Technique. RESULTS: 10 experts representing the 9 groups or training centers in Primary Care in Pediatric Trauma were selected, and a 28-item checklist was drawn up in accordance with their design recommendations. CONCLUSIONS: With the consensus of all the groups, a checklist for the treatment of polytraumatized pediatric patients was drawn up using the Delphi Technique, an essential requirement for the dissemination of this checklist, which should be adapted and validated for use in each healthcare center.

INTRODUCCION: El curso de Asistencia Inicial al Trauma Pediátrico se imparte en España desde 1997, existiendo en la actualidad 9 centros formadores acreditados. La asistencia al paciente pediátrico politraumatizado se produce muchas veces en un ambiente proclive al error por olvido, por lo que las listas de verificación, como herramientas mnemotécnicas de amplia difusión en la industria y en medicina, serían especialmente útiles para evitarlos. Aunque existen varias listas de verificación para la asistencia al traumatismo pediátrico, ninguna se ha desarrollado en el entorno de nuestro curso. MATERIAL Y METODOS: Se acordaron los criterios para ser seleccionado como experto en Asistencia Inicial al Trauma Pediátrico con la comisión científica de politrauma de la Sociedad Española de Cirugía Pediátrica. Los ítems para formar la lista de verificación se obtuvieron a partir de una revisión bibliográfica y de la consulta a los expertos seleccionados, empleando un método Delphi. RESULTADOS: Se seleccionaron 10 expertos que representan los 9 grupos o centros formadores en Asistencia Inicial al Trauma Pediátrico y se elaboró una lista de verificación con 28 ítems, siguiendo sus recomendaciones de diseño. CONCLUSIONES: Se diseñó una lista de verificación para el manejo del paciente pediátrico politraumatizado, con el consenso de todos los grupos empleando un método Delphi, requisito fundamental para facilitar la difusión de esta lista. Sería preciso adaptar y validar dicha lista para su uso en cada centro asistencial.

Treatment of pectus excavatum with vacuum bell during puberty. / Tratamiento del pectus excavatum con campana de succión durante la pubertad.

OBJECTIVE: To assess the efficacy of the vacuum bell during puberty, according to the daily hours of use and treatment duration. MATERIALS AND METHODS: A retrospective analysis of patients treated with vacuum bell during puberty in the 2010-2021 period was carried out. Several variables were collected, including baseline and final sinking, repaired sinking expressed in cm and as a percentage from baseline sinking, daily hours of use, treatment duration, and complications. Patients were categorized into groups according to the daily hours of use (≤ 3 hours; 4-5 hours; ≥ 6 hours) and treatment duration (6-12 months; 13-24 months; 25-36 months; > 36 months), and they were statistically analyzed. RESULTS: A total of 50 patients -41 male and 9 female- were studied, with a mean age of 12.5 years (range: 10-14 years). No significant differences among groups were observed in terms of baseline sinking, thoracic index, and final sinking. Repaired sinking did increase with the daily hours of use, with significant differences. Complications were mild. 3 patients withdrew from follow-up, and 5 out of the 25 patients who completed treatment achieved a good repair. CONCLUSIONS: To increase treatment efficacy, the vacuum bell should be used for 6 hours/day during puberty. This method is well-tolerated, causes mild complications, and may be an alternative to surgery in some cases.

OBJETIVO: Evaluar la eficacia de la campana de succión durante la pubertad, según las horas diarias de uso y la duración del tratamiento. MATERIAL Y METODOS: Se evaluaron retrospectivamente los pacientes tratados con campana de succión durante la pubertad en el periodo 2010-2021. Se recogieron diferentes variables, incluyendo el hundimiento inicial y final, el hundimiento corregido expresado en centímetros y en porcentaje con respecto al hundimiento inicial, las horas diarias de uso, la duración del tratamiento y las complicaciones. Se categorizaron los pacientes en grupos según las horas diarias de uso (≤ 3 horas; 4-5 horas; ≥ 6 horas) y la duración del tratamiento (6-12 meses; 13-24 meses; 25-36 meses; > 36 meses), y se analizaron estadísticamente. RESULTADOS: Se estudiaron un total de 50 pacientes; 41 varones y 9 mujeres, con una edad media de 12,5 años (rango 10-14 años). No se observaron diferencias significativas entre los diferentes grupos en relación con el hundimiento inicial, el índice torácico y el hundimiento final. El hundimiento corregido aumentó en relación con las horas diarias de uso, con diferencias significativas. Las complicaciones fueron leves, 3 pacientes abandonaron el seguimiento y 5 pacientes de los 25 que finalizaron el tratamiento, alcanzaron una buena corrección. CONCLUSIONES: Para aumentar la eficacia del tratamiento, el tiempo de uso de la campana de succión durante la pubertad debería alcanzar las 6 horas diarias. Este método es bien tolerado, presenta leves complicaciones y puede ser una alternativa a la cirugía en algunos casos.

Postoperative hyperlipasemia in perforated appendicitis in children. / Hiperlipasemia posoperatoria en apendicitis perforada en niños.

OBJECTIVE: The objective of this study was to assess the hyperlipasemia cases detected in the postoperative period of perforated appendicitis. MATERIALS AND METHODS: A retrospective analysis of the perforated appendicitis cases occurred in our institution over a 7-year period (2013-2019) was carried out. Only cases where preoperative and postoperative serum lipase levels were available were included. The variables collected were statistically assessed by means of a descriptive, univariate analysis. RESULTS: A total of 88 patients were studied. They were divided into 3 groups according to postoperative lipase levels - 57 were allocated to Group 1 (lipase: 70-194.0 U/L, normal range), 20 were allocated to Group 2 (lipase: 195-582 U/L), and 11 were allocated to Group 3 (lipase: > 582 U/L, which triples normal levels). Statistically significant differences were found in the following variables: sex, postoperative abscess, postoperative subocclusion/intestinal occlusion, preoperative lipase levels, days of parenteral nutrition, days of ICU stay, and days of hospital stay. Postoperative lipase had a moderate correlation with preoperative lipase, and none of the cases met acute pancreatitis diagnostic criteria. CONCLUSIONS: Hyperlipasemia in the postoperative period of perforated appendicitis is not associated with developing clinical pancreatitis, but it is associated with worse progression in terms of increased complications, such as subocclusion/intestinal occlusion and intra-abdominal abscess, and longer ICU stay, hospital stay, and parenteral nutrition. There is a moderate correlation between preoperative and postoperative lipase, which means they could both prove useful as prognostic markers.

OBJETIVO: El objetivo del estudio es evaluar los casos de hiperlipasemia detectados en el posoperatorio de la apendicitis perforada. MATERIAL Y METODO: Se evaluaron retrospectivamente los casos de apendicitis perforada en nuestro centro durante 7 años (2013-2019), seleccionando aquellos con mediciones preoperatorias y posoperatorias de lipasa sérica. Las diferentes variables recogidas se analizaron estadísticamente de manera descriptiva y univariante. RESULTADOS: Se estudiaron un total de 88 pacientes que se dividieron en tres grupos según el valor de la lipasa posoperatoria: 57 corresponden al grupo 1 (lipasa 70-194 U/L, rango normal), 20 al grupo 2 (lipasa 195-582 U/L) y 11 al grupo 3 (lipasa > 582 U/L, valor tres veces por encima del normal). Las variables que mostraron diferencias estadísticamente significativas fueron el sexo, el absceso posoperatorio, la suboclusión/oclusión intestinal posoperatoria, la lipasa preoperatoria, los días de nutrición parenteral, los días de ingreso en UCI y los días de estancia hospitalaria. La lipasa posoperatoria mostró una correlación moderada con la lipasa preoperatoria y ningún caso cumplió criterios diagnósticos de pancreatitis aguda. CONCLUSIONES: La hiperlipasemia en el posoperatorio de la apendicitis perforada no se asocia al desarrollo de pancreatitis clínica, pero sí se asocia a una peor evolución en relación con un aumento de complicaciones, como la suboclusión/oclusión intestinal y el absceso intraabdominal, y un mayor número de días de ingreso en UCI, de días de nutrición parenteral y de estancia hospitalaria. Existe una moderada correlación entre la lipasa preoperatoria y posoperatoria, de modo que ambas podrían ser útiles como marcadores pronósticos.

[Appendicitis versus nonspecific acute abdominal pain: diagnostic accuracy of ultrasound]. / Apendicitis versus dolor abdominal agudo inespecífico: rendimiento diagnóstico de la ecografía.

PURPOUSE: The aim of this study is to assess the diagnostic accuracy of ultrasound to differentiate appendicitis from nonspecific acute abdominal pain, that is the most common process requiring differential diagnosis in clinical practice. MATERIAL AND METHODS: Patients admitted for suspicion of appendicitis were prospectively evaluated in our hospital during two years (2013-2014). Cases of nonspecific acute abdominal pain and appendicitis assessed by ultrasound were enrolled in the study. The different variables collected were statistically analyzed by descriptive, univariate and diagnostic accuracy studies. RESULTS: A total of 275 patients were studied, 143 cases of nonspecific acute abdominal pain and 132 cases of appendicitis. Ultrasound sensitivity and specificity to differentiate appendicitis were 94.7% and 87.4% respectively, with a 12.6% rate of false positives and a 5.3% rate of false negatives. The rate of false negatives in perforated group was 17.4% and analysis according to Pediatric Appendicitis Score risk groups showed a 12.2% rate of false positives in low-risk group and a 6.3% rate of false negatives in high-risk group. CONCLUSIONS: The use of ultrasound in low clinical probability cases of appendicitis could rise unnecessary surgery rate, due to the significant number of false positives in this group of patients. In high probability clinical cases, ultrasound does not contribute too much to diagnosis and it could be a confusion factor by the significant number of false negative associated to perforated appendicitis.

OBJETIVO: El objetivo del estudio es evaluar el rendimiento diagnóstico de la ecografía para diferenciar la apendicitis del dolor abdominal agudo inespecífico, principal proceso con el que requiere diagnóstico diferencial en la práctica clínica. MATERIAL Y METODOS: Se evaluaron los pacientes atendidos por sospecha de apendicitis en nuestro centro durante 2 años (2013-2014), incorporando al estudio los casos de dolor abdominal agudo inespecífico y apendicitis en los que se realizó ecografía. Las diferentes variables recogidas se analizaron estadísticamente de manera descriptiva, univariante y con estudios de rendimiento diagnóstico. RESULTADOS: Se estudiaron 275 casos; 143 casos de dolor abdominal agudo inespecífico y 132 casos de apendicitis. La sensibilidad y especificidad de la ecografía para diferenciar apendicitis fue del 94,7% y 87,4%, respectivamente, con un porcentaje de falsos positivos del 12,6% y de falsos negativos del 5,3%. El porcentaje de falsos negativos en el grupo de apendicitis perforada alcanzó el 17,4% y el análisis según los grupos de riesgo establecidos por el Pediatric Appendicitis Score mostró un porcentaje de falsos positivos del 12,2% en el grupo de bajo riesgo y de falsos negativos del 6,3% en el grupo de alto riesgo. CONCLUSIONES: El uso de la ecografía en casos de baja probabilidad clínica de apendicitis podría incrementar la tasa de cirugía innecesaria, debido al significativo número de falsos positivos en este grupo de pacientes. En casos de alta probabilidad clínica de apendicitis, la ecografía aporta poco al diagnóstico, e incluso podría ser un factor de confusión por el significativo número de falsos negativos asociados a la apendicitis perforada.

[Is experimental surgery necessary or essential in the training program of a pediatric surgeon?]. / ¿Es necesaria o imprescindible la cirugía experimental en el programa formativo de un cirujano pediátrico?

Many surgical procedures performed in pediatric surgery have a slow learning curve, the volume of patients and the existence of complex diseases that require extensive training and surgical skill, have taken our service to create a global training program of experimental surgery. This program based on the simulation and training invasive procedures in real anatomical models, aims to educate our residents in a global and efficiently way in order to obtain an improvement of technical training, and increased patient safety result of experience and expertise wined in the experimental animal. This paper presents the main features, objectives and results obtained with this training program and seeks to promote the incorporation of simulation programs in live animal as an essential part of the training of pediatric surgery resident.

[Quality of life in children operated on for anal atresia]. / Calidad de vida en los pacientes intervenidos de atresia de ano.

INTRODUCTION: Most children with anorectal malformations have some type of intestinal dysfunction. A correct follow up in this aspect after surgery affects their quality of life. MATERIAL AND METHODS: We gathered a sample of 20 children that were lost in their follow up after posterior sagittal anorectoplasty (PSARP). We got contact with them and they were interviewed and examined in our department. RESULTS: We collected 12 girls and 8 boys. Age range was between 3 and 14 years. 70% had good prognosis for continence (low fistula) and 30% poor prognosis (high fistula). 35% suffered from postoperative complications being the most frequent prolapse especially in high atresias. 85% had good rectal sensitivity, 15% had poor sensitivity that was directly related to incontinence. Anal tone was decreased in our exploration in 35% of patients which was not directly related to their continence. 65% suffered constipation with or without fecaloma. 5% of cases had intestinal hipermotility. The total incidence of fecal loose was 40%. More than a half (62,5%) kept on loosing stool despite treating their constipation or hipermotility, so we consider them true incontinents (no voluntary bowel movements). 67% of children with high fistula were true incontinents, just 7% of those with low fistula. Subjective quality of life in patients with soling was 6.4. In clean patients it was 9.3. Objective quality of life (Score/13) in dirty patients was 6.6. In Clean patients: 11.9. After our bowel management protocol we got 100% of patients clean during school time, thereby improving their quality of life. CONCLUSIONS: Incontinence determines the long-term quality of life in our patients in addition to the psycho-social consequences. They are clearly more frequent in patients with high fistula. Much assume incontinence as an unavoidable part of their disease so do not always demand treatment if they are not followed by a surgeon.

[Role of alpha antagonists in uncoordinated micturition syndrome in childhood]. / Papel de los alfa-antagonistas en el síndrome de micción no coordinada en la infancia.

INTRODUCTION: Dysfunctional voiding syndrome in children is characterized by a pattern of dysfunctional bladder emptying due to an active contraction of the external sphincter during micturition. Diagnosis is based on electromyographic and flowmetry results. The treatment is focused on relaxing the external sphincter during micturition where biofeedback is the treatment of choice. By the moment there are still centres without this possibility, alpha blockers are an alternative. OBJECTIVE: To determine the efficacy of alpha blockers as an alternative to biofeedback as a therapeutic possibility. MATERIAL AND METHODS: We included a total of 17 children with dysfunctional voiding syndrome and carried out a retrospective study. We registered age, symptoms at diagnosis, presence of associated urologic problems, flowmetry results pre and post-treatment, type of treatment used and its effectiveness comparing patients treated with alpha blockers and those who are starting to deal with biofeedback. RESULTS: There were 12 girls and 5 boys. The mean age at diagnosis was 4.9 years old, 88% of these children related enuresis, diurnal urinary incontinence and urgency, 57% of them had also urinary infections, 63% constipation, 36% had psychosocial problems. Ten patients were treated with alpha-antagonists: 6 with Tamsulosin and 4 with Doxazosin. They followed this treatment an average of 5.8 months, range between 2 and 12 months. Five patients were treated with biofeedback. All cases had an abnormal pelvic electromyography. Patients treated with alpha-blockers achieved a 70% of electromyographic improvement with a 70% of recurrence. In children treated with biofeedback we got improvement in 80% with no recurrence. After alpha blocker therapy, maximum flow rates and average flow values were better but not statistically significant, this difference was significant with biofeedback. A patient treated with Tamsulosin left treatment due to hypotension, 2 patients left Doxazosin because of dizziness. CONCLUSIONS: Alpha-blockers are effective in the treatment of dysfunctional voiding syndrome with a high percentage of recurrence. They can be an alternative to biofeedback but this one is the effective and definitive treatment.

[Non-palpable testes: laparoscopic or inguinal approach?]. / Testes no palpables: abordaje laparoscópico o inguinal?

INTRODUCTION: Twenty per cent of the operated patients suffering from cryptorchidisim show no palpable testis in the physical check-up. The use of a non-palpable testis in the initial stages is considered to be controversial when deciding between a laparascopic or an inguinal approach. Our aim is to compare the results obtained with these two approaches and evaluate which one of them would be the most relevant as an initial option. MATERIALS AND METHODS: We examined the patients who have been subjected to surgical intervention for non-palpable testis in the last three years. We had a sample of 53 patients. Bilateral non-palpable testes were disregarded. In the case of 35 patients the initial approach was through the groins while in 18 of them the approach was laparascopic. Relevant data were recorded, such as the age of the patient, right or left side, surgical findings, need for a laparascopic or groin approach and associated hernia. RESULTS: The average age of the patients at the time of the surgical treatment was 3.7 years R (1-13 years). 42% of the testes were on the right side and 58% on the left. In an initial stage the inguinal approach was used with 35 patients, 2 of these requiring laparascopic exploration due to a non-concluding check-up; it was concluded that they were 2 cases of anorchia. An initial laparoscopic approach was used with 18 patients. Internal vessels in the canal were found which required an inguinal approach. In 12 patients normal or atrophic testes were observed. Testicular descent was achieved through the groin in 10 of them while in the remaining 2 a combined approach was adopted. CONCLUSIONS: 80% of the patients subjected to a first laparoscopic approach needed a groin approach later on. 11% of the patients subjected to a first inguinal approach required laparascopic examination. In view of the results obtained, we conclude that inguinal exploration diminishes the need for second procedures.

[Therapeutic approach of enuresis based on the differentiation of the enuretic syndrome and monosymptomatic enuresis]. / Enfoque terapéutico de la enuresis basándose en la diferenciación del síndrome enurético y la enuresis monosintomática.

INTRODUCTION: Enuresis affects 15% of the children under 5. Possible etiopatogeny explaining the mechanism of production of nocturnal enuresis has been described, resulting in different terapeutical approaches; however, we cannot speak up to now of general guidelines for its treatment. MATERIALS AND METHODS: On the basis of 544 children who were treated in our hospital in the last 12 years, we analysed a sample of 124 patients corresponding to the last two years. We now present the therapeutical protocol used and analyse the results. In the initial therapeutical approach a distinction is made between monosymptomatic enuresis and eneuretic syndrome. RESULTS: We studied a total of 120 patients (89 boys and 31 girls). 63% of them showed monosymptomatic enuresis while 37% suffered from enuretic syndrome. In the case of 15% of them, this was associated with heavy sleep and difficulties to wake up. 92% was the general percentage of recovery. In the patients suffering from nonosymptomatic eneuresis, the problem was solved with desmopressin in 87% of them (demospressin on its own in 65% or in combination with oxibutine in the remaining 35%). In the group of enereutic symdrome, the problem was solved with oxibutine in 71% (on its own in 40% or in combination with desmopressin in 54%. CONCLUSIONS: The treatment and solution of enuresis improve the child's self-esteem and the anxiety caused in the family. A good medical history with a clear distinction between enuretic syndrome and monosyntomatic enuresis leads us to a suitable therapeutical approach for every patient, allowing us to find earlier the right treatment for every individual.