Abdominal hernia repair using the Rives-Stoppa technique: an abdominal reconstruction. / Eventroplastia abdominal con técnica de Rives-Stoppa: reconstruyendo un abdomen.

INTRODUCTION: Retromuscular mesh hernia repair using Rives-Stoppa technique has demonstrated the best results when it comes to repairing large midline hernias. We present the first pediatric case successfully treated with this technique. CLINICAL CASE: This is the case of a 9-year-old male patient with hernia following urgent midline laparotomy. Basic repair principles included opening of the hernia sac and adhesiolysis, longitudinal incision on the posterior sheath of the rectus muscle and division of the retromuscular space, closure of the posterior sheath, placement of a mesh on this plane in the brand-new retromuscular space, and tension-free closure of the anterior musculo-aponeurotic flap, thus reconstructing the midline. No recurrences have been noted after a 2-year follow-up. DISCUSSION: Rives-Stoppa technique allows for a more anatomical layered reconstruction, which helps restore the anatomical and physiological properties of the abdominal wall. In our view, this could be a useful alternative for pediatric hernia treatment.

INTRODUCCION: La eventroplastia con malla retromuscular de Rives-Stoppa ha demostrado en adultos tener los mejores resultados en la reparación de las grandes eventraciones de la línea media. Presentamos el primer caso pediátrico tratado exitosamente con esta técnica. CASO CLINICO: Varón de 9 años con eventración tras laparotomía media urgente. Los principios básicos de la corrección fueron: apertura del saco herniario y adhesiolisis, incisión longitudinal sobre la vaina posterior del músculo recto y tallado del espacio retromuscular, cierre de la vaina posterior, colocación de una malla sobre este plano alojándola en el espacio retromuscular creado y cierre sin tensión del colgajo musculo-aponeurótico anterior, reconstruyendo así la línea media. No recidiva tras 2 años de seguimiento. COMENTARIOS: La técnica de Rives-Stoppa implica una reconstrucción por planos más anatómica que restaura las propiedades anatomofisiológicas de la pared abdominal. Consideramos que puede ser una alternativa útil en el tratamiento de las eventraciones pediátricas.

[Cranio-facial-cervical and subglottic hemangioma with respiratory symptoms. A therapeutic emergency].

We describe the case of a 41-day-old infant with a left craniofacial cervical and subglottic hemangioma with respira-tory symptoms. Although infantile hemangiomas are occasional benign vascular tumors that appear predominantly on the skin, 1-2% of patients may have airway lesions that can sometimes cause potentially life-threatening respiratory condi-tions. The decision was made to immediately commence treatment with propranolol, without waiting to complete the exten-sion and syndromic diagnoses. There was a positive clinical response and respiratory symptoms dissipated in twelve hours. Early treatment with beta-blockers is essential for children with hemangiomas whose location causes symptoms or significant functional changes: in some cases it may be a matter of urgency.

[Postural deformities of the skull. Advantages of protocolization in its treatment]. / Deformidades craneales posturales. Ventajas de la protocolización en su tratamiento.

INTRODUCTION: Since 2007, we have examined in our medical practice children with cranial deformities. The increasing demand and lack of professionals dedicated to it has forced us to assume the treatment of this disease. We present our experience. MATERIAL AND METHODS: Retrospective study of patients with cranial deformities treated from 2010 to 2015. We collected data as age at the first visit and at discharge, sequential measurements of the skull and cranial index, type of treatment prescribed (postural, orthosis or both) and consultation requested to other specialties. In the first stage (2010-2012), each surgeon prescribed the treatment he considered appropriate. Since November 2012 a protocol has been implemented, it includes guideline sheets for the surgeon and parents with information on postural therapy and graphs to record the measurements. RESULTS: We have treated 261 patients. Two were diagnosed with craniosynostosis. From the rest, only 151 possessed complete quantitative data and were included in the study with 105 men and 46 women and a mean age of 5.8 months (± 1.9 months). There were 23 pure brachycephaly, 126 mixed forms and 2 pure plagiocephaly. A significant disparity between observers' measurements was noticed. All patients underwent a protocolized postural treatment. In 36 patients who did not improve with postural treatment, cranial orthosis was prescribed with good response: 66.8% became mild forms. Those who maintained only postural treatment also improved to milder forms in 64.4%. CONCLUSIONS: The implementation of a protocol has enabled us to unify the care and follow-up of these patients. Cranial measurement techniques should be more precise and reproducible. Good postural treatment and empathy with the family reduce the use of orthosis in carefully selected cases.

INTRODUCCION: Desde 2007 hemos valorado en consulta a niños con deformidades craneales. La creciente demanda y la falta de profesionales dedicados nos obligaron a asumir el tratamiento de esta patología. Presentamos nuestra experiencia. MATERIAL Y METODOS: Estudio descriptivo retrospectivo de los enfermos con deformidades craneales atendidos desde 2010 a 2015. Recopilamos datos sobre edad en la primera visita y al alta, medidas secuenciales del cráneo, tipo de tratamiento prescrito (postural, ortesis o ambos) e interconsulta a otras especialidades. En la primera etapa (2010-2012), cada cirujano prescribía el tratamiento que consideraba oportuno. Desde noviembre de 2012 se implementó un protocolo que incluye una hoja de actuación para el cirujano y otra para los padres con información sobre medidas posturales y gráficas para anotar las mediciones. RESULTADOS: Hemos atendido a 261 pacientes afectos de deformidades craneales. Dos fueron diagnosticados de craneosinostosis. Del resto, solo 151 disponían de datos cuantitativos completos y se incluyeron en el estudio. Fueron 105 varones y 46 mujeres con edad media de 5,8 meses (± 1,9 meses). Veintitrés presentaban una braquicefalia pura, 126 formas mixtas y 2 presentaban plagiocefalia pura. Existía una importante disparidad entre observadores en la toma de medidas. Todos fueron sometidos a un tratamiento postural protocolizado. En 36 enfermos que no mejoraban se pautó ortesis craneal con buena respuesta: 66,8% pasaron a formas más leves. Los que se mantuvieron solo con tratamiento postural también mejoraron evolucionando a formas más leves en el 64,4%. CONCLUSIONES: La introducción de un protocolo asistencial nos ha permitido unificar la atención y el seguimiento de estos enfermos. Las técnicas de medición craneal deben ser más precisas y reproducibles. Un buen tratamiento postural y empatía con la familia reducen la utilización de ortesis a casos muy seleccionados.

[Peripherally inserted central catheters: Savings, comfort, many advantages]. / Catéteres centrales de inserción periférica: un ahorro, una comodidad, muchas ventajas.

INTRODUCTION: Peripherally inserted central catheters are indicated when an intravenous treatment is expected for more than 6 days or less if phlebotoxic medication is used. We report our recent experience. METHODS: Retrospective study from 2014 to 2015 including patients to whom a catheter was placed either, in the operating room after surgery and before awakening the patient, or in the Pediatric ICU by direct or ultrasound guidance venipuncture. We reviewed patient characteristics, underlying disease, line catheterization procedure, type and duration of venous line, intravenous treatment and complications. RESULTS: Sixty-nine catheters of 3, 4 and 5 Fr (1 or 2 lumens) were placed in 66 patients with a median age of 5.71 years (± 4.24). They were mainly Pediatric Surgery patients (n = 19) mostly complicated acute appendicitis (n = 12). Arm veins were catheterized without difficulties except for two accidental arterial punctures. There were no infectious complications but 7 patients presented extravasation (one chylothorax) that forced the removal of the catheters and 3 reported obstruction by parenteral nutrition resolved with heparin irrigation. Two patients died and one was referred to another center with the catheter in use. There were no clinical venous thromboses. The median line duration was 10.6 days (maximum of 62 days). CONCLUSIONS: Peripherally inserted central catheters facilitate the management of patients avoiding repeated peripheral venipunctures. Its placement in the operating room after surgery and before the patient awakes, facilitates line catheterization and reduces complications. That is why we have included it in the therapeutic protocol of selected patients, the use of this type of catheter.

INTRODUCCION: Los catéteres centrales de inserción periférica están indicados cuando se prevé un tratamiento endovenoso durante más de 6 días o menos si se utiliza medicación flebotóxica. Presentamos nuestra experiencia reciente. METODOS: Estudio descriptivo retrospectivo desde 2014 a 2015 incluyendo pacientes a los cuales se les colocó un catéter ya sea en quirófano, tras la cirugía y antes de despertar al enfermo, o en la UCI Pediátrica por venopunción directa o ecoguiada. Revisamos características del paciente, enfermedad de base, procedimiento de canalización, tipo y duración de la vía, tratamiento endovenoso y complicaciones. RESULTADOS: Colocamos 69 catéteres de 3, 4 y 5 Fr (1 o 2 luces) en 66 pacientes con edad media de 5,71 años (± 4,24). Eran mayoritariamente enfermos de Cirugía Pediátrica (n= 19) sobre todo apendicitis agudas complicadas (n=12). Se canalizaron venas del brazo sin dificultades salvo 2 punciones arteriales accidentales. No hubo complicaciones infecciosas, pero sí 7 extravasaciones (un quilotórax) que obligaron a retirar el catéter y 3 obstrucciones por nutrición parenteral resueltas con irrigación de heparina. Dos enfermos fallecieron y uno fue derivado a otro centro con el catéter en uso. No hubo trombosis venosas clínicas. La duración media del acceso fue de 10,6 días (máximo 62 días). CONCLUSIONES: Los catéteres centrales de inserción periférica facilitan el manejo de los pacientes evitando las punciones venosas periféricas repetidas y su colocación en quirófano, tras la cirugía y antes de despertar al enfermo, facilita la canalización y reduce las complicaciones. Es por eso que hemos incluido estos en el protocolo terapéutico de enfermos seleccionados.

[Slipping rib syndrome. An aggressive but effective treatment]. / Síndrome de la costilla deslizante. Tratamiento agresivo pero eficaz.

Slipping rib syndrome (SRS) is an unusual cause of recurrent chest or abdominal pain in children. The diagnosis is elusive, including gastroenterological, cardiac, respiratory, infectious and chest or abdominal muscular pathologies. Two paediatric patients were diagnosed with SRS, both of them were female teenagers with a similar clinical pattern: crippling unilateral chest pain without a traumatic event. On physical examination, all patients had reproducible pain with the "hooking maneuver". Surgical excision of the costal cartilages was done, preserving the perichondrium. No complications were reported. In both cases we achieve an excellent outcome after one and four years of follow-up, resolving the symptoms completely. The surgical excision of the costal cartilages seems to be an aggressive option but with an excellent outcome. A minimum invasive approach could be a better option in the future.

[Effectiveness analysis of a therapeutic strategy for pediatric varicocele. Have we got what we expected?]. / Análisis de efectividad de una estrategia terapéutica en el varicocele pediátrico. ¿Hemos alcanzado nuestros objetivos?

OBJECTIVE: Optimal treatment ot vancocele in adolescents remains a topic of discussion. Strides in interventional radiology and laparoscopy have allowed us to implement a multidisciplinary therapeutic protocol that aims to get best of both. We evaluate our results. METHODS: . Retrospective study of pediatric patients treated for varicocele in our hospital under protocol between 2008 and 2013. Once the therapeutic indication is confirmed, through clinical and Doppler ultrasound examination, patients undergo percutaneous retrograde embolization (PRE). We perform laparoscopic varicocelectomy (LV) when the PRE fails, together with lymphatic preservation using blue patent lymphography prior to surgery. RESULTS: . Fifty-five patients with varicocele were treated at a mean age of 13 years old (range 11-16). PRE was performed in 50 patients (90.9%), with a proportion of remission of 80% by ultrasound study 6 months after PRE. Sixteen patients (29.1%) underwent LV five of whom without prior PRE. Lymphography with patent blue was performed in 13 (23.6%), and single-port surgery in 6 patients. The presence of coils of PRE did not hinder subsequent LV. The remission rate after LV was 100% at 6 months follow up. Two postoperative lymphoceles were recorded, none after patent blue lymphography. CONCLUSIONS: . We found in this therapeutic sequence a safe and efficient alternative, allowing a minimal surgical invasion and reducing the rate of postoperative lymphoceles.