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.

Endobronchial tuberculous granuloma in children.

Endobronchial tuberculosis is rare in children, in whom it is usually a complication of primary tuberculosis. Endobronchial involvement may adopt several forms, with granuloma being infrequent. Here we report on 10 cases of endobronchial tuberculous granuloma diagnosed and treated in our Paediatric Surgery Service between 1991 and 2004. In 2 cases the presentation was acute and constituted the first manifestation of TB; the remaining patients were undergoing treatment or had been treated for primary TB, and presented with clinical symptoms or radiological signs that led us to suspect endobronchial involvement. In all cases the granuloma was removed by bronchoscopy. Patients received conventional medical TB treatment, with corticoids for 4 weeks following granuloma removal. The clinical course was favourable in all cases and on follow-up we saw no complications. Endobronchial tuberculous granuloma should be borne in mind in children with symptoms or signs of airway obstruction and especially during the course of tuberculosis treatment.

Enteric duplication cyst resembling umbilical cord cyst.

We report a case of a neonatal male with a prenatal diagnosis of umbilical cord cyst that was finally diagnosed as an ileal duplication cyst after post-natal surgical exploration of the umbilical mass. To our knowledge, a similar case has never been reported previously. Although this form of presentation of enteric duplication cyst is exceptional, it should be taken into consideration when evaluating suspected umbilical cord cysts.

[Supernumerary intrascrotal ectopic spleen: discontinuous splenogonadal fusion]. / Bazo ectópico supernumerario intraescrotal: fusión esplenogonadal discontinua.

Splenogonadal fusion is a rare congenital malformation that results from abnormal connection of splenic tissue with the gonad or the mesonephric structures during embryonic development. It is usually detected in males and is classified into two types, continuous and discontinuous. We present the case of a 3-year-old boy with an asymptomatic scrotal mass that was suspicious for discontinuous splenogonadal fusion on Doppler ultrasonography. The diagnosis was confirmed by surgical excision and histological analysis. Splenogonadal fusion is a benign anomaly that has sometimes led to unnecessary orchidectomy because of suspicion that the mass represented a malignant tumor. Consequently, it is essential to include this malformation in the differential diagnosis of scrotal masses in children.

Uterus didelphys with obstructed hemivagina and multicystic dysplastic kidney.

Müllerian malformations include a broad range of anomalies, resulting from the incomplete formation and/or differentiation of the Müllerian ducts. The uterus didelphys with obstructed hemivagina represents the result of a lateral nonfusion of the Müllerian ducts with asymmetric obstruction, and it is almost always associated with renal agenesis. We report a case of incidental discovery of this anomaly in a 12-year-old girl during a routine renal ultrasound. A right multicystic dysplastic kidney had been detected in the prenatal and neonatal period with no evidence of uterine anomaly. Postnatal ultrasound examinations performed regularly had never detected either right renal tissue or the uterine anomaly before menarche. Hematocolpos after menarche made uterine anomaly detection easier. Magnetic resonance imaging performed to evaluate the uterine malformation detected a dysplastic right kidney. We review the present knowledge and recommendations for the diagnosis and treatment of this anomaly, and we emphasize the use of magnetic resonance imaging not only for the evaluation and classification of Müllerian malformations, but also for the detection of the persistence of renal tissue missed with other studies.

Handlebar hernia in children: two cases and review of the literature.

Localised traumatic abdominal hernias are rare. Most such hernias are due to the direct impact of the handlebars of a bicycle or motorcycle, with 20 cases reported to date in the English language literature, 12 in children. We report two new cases of handlebar hernia, in children aged 6 and 10 years. In both cases, physical examination revealed an area of contusion and bruising in the lower abdomen. However, the muscle defect was detected during the first examination in only one of the patients, and not until several days later in the other patient. Abdominal ultrasonography proved useful for diagnosis in both patients. Early surgical correction is necessary to prevent possible complications. This type of hernia should be borne in mind when evaluating children who have suffered abdominal trauma in a bicycle accident.

Chronic gastric volvulus: is it so rare?

Gastric volvulus has traditionally been considered a rare entity in children, and standard texts on paediatrics typically make scant reference to it. In our experience, however, careful radiographic study of children with digestive symptoms reveals gastric volvulus to be more frequent than is commonly thought. We report 52 cases of this disorder, and discuss its diagnosis and treatment. Material and Methods. We performed a retrospective study of all children treated for chronic gastric volvulus in our department since 1976. Results. All 52 patients (27 boys, 25 girls) were term infants, mean age 2.8 months at diagnosis. The principal symptoms were crying and colic (90 %), vomiting and nausea (67 %). The mean age at onset of symptoms was 1.1 months. Diagnosis was in all cases on the basis of upper intestinal transit studies. The most frequent radiological signs were high greater curvature (87 %) and greater curvature crossing the oesophagus (83 %). Nine of the 52 children underwent primary surgery. The remaining 43 patients underwent conservative (i.e. postural) treatment; 11 of these patients showed no significant improvement and thus underwent surgery. We performed 20 surgical interventions (19 simple anterior gastropexies and one a percutaneous endoscopic gastrostomy). All patients showed good recovery after surgery. Conclusion. Careful examination of patients with vomiting, abdominal distension, gastro-oesophageal reflux, colic, crying, retarded growth, sleep problems, anxiety, and even repeated respiratory infections will reveal chronic gastric volvulus with greater frequency than has traditionally been thought. We believe that this entity is often undetected, and that, as a result, it is often inappropriately treated.