RESUMO
OBJECTIVE: To describe a basic training program in microsurgery and to analyze the learning curve through the process, including improvement in operating times and functional outcome. MATERIALS AND METHODS: Our learning program included basic, transitional, and experimental models. The experimental model included tail vein cannulation, intestinal resection and anastomosis, dissection, division and anastomosis of the cava and aorta. Wistar rats (66.7% male; 406.9 ± 38.9 grams) were used. The program adhered to the 3R principle and obtained animal welfare committee approval. RESULTS: Mean tail vein cannulation time was 2.4 ± 1.2 minutes. Mean intestinal resection and jejunocolic anastomosis time was 14.8 ± 2.7 minutes and 10.4 ± 3 minutes, respectively. All anastomoses were functionally valid. Mean vessel dissection time was 22.9 ± 7.7 minutes, aortic artery anastomosis was 17.2 ± 7.1 minutes, and vena cava anastomosis was 25.9 ± 7.3 minutes. 66.7% of vena cava anastomoses were functionally valid vs. 88.9% for the aorta. The time required for all procedures decreased after the third attempt, except for vena cava anastomoses, which remained similar in all 9 procedures. CONCLUSIONS: Our model demonstrated that the procedures were suitable for trainer progression in terms of surgical time and functional outcome. Microsurgical training would benefit from standardized programs to optimize results.
OBJETIVO: Describimos un programa de formación básica en microcirugía y analizamos la curva de aprendizaje a través del proceso, incluyendo la mejora en los tiempos operatorios y en el resultado funcional del procedimiento. MATERIAL Y METODOS: Nuestro programa de aprendizaje incluye modelos básicos, de transición y experimentales. Dentro del modelo experimental se incluyeron: canulación de la vena de la cola, resección y anastomosis intestinal, disección, sección y anastomosis de la cava y la aorta. Se emplearon ratas Wistar (66,7% machos; 406,9 ± 38,9 gramos), el programa se adhirió al principio de las 3R y obtuvo la aprobación del comité de bienestar animal. RESULTADOS: El tiempo medio de canulación de la vena de la cola fue de 2.4 ± 1,2 minutos. El tiempo medio de resección intestinal y anastomosis yeyunocólica de 14.8 ± 2,7 minutos y 10.4 ± 3 minutos, respectivamente. Todas las anastomosis fueron funcionalmente válidas. El tiempo medio de la disección de vasos fue de 22,9 ± 7,7 minutos, la anastomosis de la arteria aorta de 17,2 ± 7,1 minutos, mientras que la anastomosis de la vena cava fue de 25,9 ± 7,3 minutos. El 66,7% de las anastomosis de la vena cava fueron funcionalmente válidas en comparación con el 88,9% de la aorta. El tiempo requerido para todos los procedimientos disminuyó después del tercer intento, excepto para las anastomosis de vena cava, que se mantuvo similar en los 9 procedimientos. CONCLUSIONES: Nuestro modelo demostró que los procedimientos eran adecuados para la progresión del entrenador en términos de tiempo quirúrgico y resultado funcional. La formación microquirúrgica se beneficiaría de programas estandarizados para optimizar los resultados.
Assuntos
Microcirurgia , Cirurgiões , Ratos , Animais , Masculino , Humanos , Feminino , Microcirurgia/métodos , Ratos Wistar , Procedimentos Cirúrgicos Vasculares/educação , Anastomose Cirúrgica/métodosRESUMO
INTRODUCTION: Suprahepatic and inferior vena cava (IVC) pseudoaneurysms are rare in children. Most cases in adults are treated surgically due to the high risk of rupture. CASE REPORT: Seven-year-old girl referred for a thoracic-abdominal trauma of unknown origin. Hemodynamically stable, with a hemoglobin level of 9.1 g/dl. An emergency CT scan was performed, showing a pseudoaneurysm at the confluence of the IVC with the middle and left suprahepatic veins, with active bleeding contained by the hepatic capsule. Given the hemodynamic stability and surgical risk, conservative treatment was decided upon. CT-scan at 24 hours showed cessation of bleeding. A control CT-scan was performed one month, three months, one year, and one and a half years later, showing the lesion had disappeared. DISCUSSION: Conservative treatment of suprahepatic vein pseudoaneurysm/ICV is feasible in the case of hemodynamic stability provided that strict clinical and radiological surveillance is maintained.
INTRODUCCION: Los pseudoaneurismas suprahepáticos y de la vena cava inferior (VCI) son excepcionales en niños. La mayoría de casos en adultos se manejan quirúrgicamente debido al alto riesgo de rotura. CASO CLINICO: Niña de siete años remitida por traumatismo tóraco-abdominal no presenciado. Hemodinámicamente estable, con hemoglobina de 9,1 g/dL. Se realiza un TC urgente, objetivándose un pseudoaneurisma en la confluencia de la VCI con las suprahepáticas media e izquierda, con sangrado activo contenido por la cápsula hepática. Dada la estabilidad hemodinámica y el riesgo quirúrgico, se optó por un manejo conservador. En el TC a las veinticuatro horas se observó cese del sangrado. Se realizó un TC de control al mes, tres meses, un año y año y medio, con desaparición de la lesión. COMENTARIOS: El manejo conservador del pseudoaneurisma de las venas suprahepáticas/VCI es factible en caso de estabilidad hemodinámica siempre que se mantenga una vigilancia clínica y radiológica estrechas.
Assuntos
Falso Aneurisma , Adulto , Feminino , Humanos , Criança , Tratamento Conservador , Veia Cava Inferior/patologia , Fígado , Tomografia Computadorizada por Raios XRESUMO
We describe the unusual case of a female patient with a history of two mature teratomas non-correlated in terms of location and occurrence. A 12-year-old girl presented at our consultation as a result of a growing tumor in the hypogastric region, with no further clinical signs. She had undergone surgery neonatally due to a mature cystic sacrococcygeal teratoma, which was fully removed. No clinical sequelae were noted and no additional treatment was required over a 10-year follow-up. Radiological examination showed a large 20 × 12 × 18 cm cystic mass extending from the pelvic region to the lower hemiabdomen, associated with two similar small formations adjacent to the right ovary. Tumor markers were negative, and a laparoscopic right salpingoophorectomy was carried out, with an excellent postoperative progression. Pathological examination revealed it was, again, a mature cystic teratoma. The genetic study ruled out causation in this respect.
Describimos el inusual caso de una paciente con antecedente de dos teratomas maduros no relacionados en cuanto a su localización y debut. Una niña de 12 años consultó por la aparición de una tumoración en la región hipogástrica de crecimiento progresivo sin otra clínica asociada. Había sido intervenida por un teratoma quístico maduro sacrococcígeo en el periodo neonatal con su extirpación completa y, ausencia secuelas clínicas y tratamiento adicional durante diez años de seguimiento posterior. Los exámenes radiológicos mostraron una gran masa quística de 20 × 12 × 18 cm que se extendía entre la región pélvica y el hemiabdomen inferior, acompañada por otras dos pequeñas formaciones similares adyacentes al ovario derecho. Los marcadores tumorales resultaron negativos y se llevó a cabo una salpingooforectomía derecha laparoscópica con una excelente evolución postoperatoria. El examen histopatológico, de nuevo, informó la lesión como teratoma quístico maduro. El estudio genético descartó una posible causalidad en este ámbito.
Assuntos
Cisto Dermoide , Teratoma , Humanos , Criança , Feminino , Teratoma/cirurgia , Teratoma/patologia , Radiografia , Região Sacrococcígea/patologia , Progressão da DoençaRESUMO
INTRODUCTION: Subglottic cyst is a rare cause of airway obstruction, and there is a lack of evidence about the best treatment in the literature. This report describes our experience with endoscopic removal. MATERIAL AND METHODS: A retrospective study of all patients undergoing endoscopic removal of subglottic cyst at our healthcare facility between 2014 and 2019 was performed. Clinic and demographic data regarding gestational age, intubation, comorbidities, surgical procedures, first symptoms, endoscopic findings, treatment, and follow-up were collected. RESULTS: Four patients were identified. Two out of four (50%) were preterm, and all patients were intubated during their neonatal period. Median age and weight at diagnosis were 6.5 months (6-8) and 5.9 kg (3.6-7). Median time between last intubation and diagnosis was 119.5 days (71-171). Biphasic stridor and progressive respiratory distress were the most common clinical symptoms. Airway obstruction of at least 50% was found during upper airway endoscopy in all patients. Endoscopic removal was performed as a first-line treatment in 3 patients, and as a second-line treatment in 1 patient. Median intubation time after treatment and hospital stay were 13.5 hours (0-48) and 7 days (6-9). All four patients are free of disease, with a median follow-up of 17.5 months (6-42). CONCLUSION: Subglottic cyst is a rare cause of post-extubation stridor. Endoscopic removal seems to be a feasible and effective treatment with a low recurrence rate.
INTRODUCCION: Los quistes ductales subglóticos adquiridos (QDSA) son una causa rara de obstrucción de la vía aérea, sin consenso en la literatura en cuanto al tratamiento más eficaz. Presentamos nuestra experiencia en el tratamiento de los QDSA. MATERIAL Y METODOS: Estudio retrospectivo de los pacientes tratados en nuestro centro por QDSA en los últimos 5 años. Se recogieron los antecedentes de intubación, la clínica presentada, el tratamiento realizado, la evolución postquirúrgica, el seguimiento en consulta y los controles endoscópicos. RESULTADOS: Se identificaron 4 pacientes, con unas medianas de edad y peso de 6,5 meses (6-8) y 5,9 kg (3,6-7), respectivamente. Todos presentaron antecedentes de intubación por intervenciones quirúrgicas, siendo prematuros 2 de ellos. La mediana entre la última intubación y el diagnóstico fue de 119,5 días (71-171). La clínica consistió en estridor bifásico con mejoría postural presentando una ocupación de la luz traqueal de más del 50% en la endoscopia diagnóstica. Se realizó escisión endoscópica (EE) al diagnóstico en 3 de los pacientes y como técnica de rescate en el cuarto por recidiva tras tratamiento con drenaje y dilatación con balón. La mediana de tiempo de intubación postquirúrgico fue de 13,5 horas (0-48) y la estancia hospitalaria de 7 días (6-9). Tras un seguimiento mediano de 17,5 meses (6-42) no se ha presentado ninguna recidiva. CONCLUSION: Los QDSA son una causa poco frecuente de estridor post-extubación. La EE permite un tratamiento eficaz con baja tasa de recidiva.
Assuntos
Obstrução das Vias Respiratórias/cirurgia , Cistos/cirurgia , Endoscopia/métodos , Doenças da Laringe/cirurgia , Obstrução das Vias Respiratórias/etiologia , Cistos/diagnóstico , Feminino , Seguimentos , Humanos , Lactente , Intubação Intratraqueal , Doenças da Laringe/diagnóstico , Masculino , Sons Respiratórios/etiologia , Estudos RetrospectivosRESUMO
The low prevalence of European paediatric transplanted patients and scarcity of resources and expertise led to the need for a multidisciplinary network able to improve the quality of life of paediatric patients and families requiring a solid organ or haematopoietic stem cell transplantation. The European Reference Network (ERN) TransplantChild is one of the 24 ERNs established in a European legal framework to improve the care of patients with rare diseases. ERN TransplantChild is the only ERN focused on both solid organ and haematopoietic stem cell paediatric transplantation, based on the understanding of paediatric transplantation as a complex and highly specialised process where specific complications appear regardless the organ involved, thus linking the skills and knowledge of different organ disciplines. Gathering European centres of expertise in paediatric transplantation will give access to a correct and timely diagnosis, share expertise and knowledge and collect a critical mass of patients and data that increases the speed and value of clinical research outcomes. Therefore, the ERN TransplantChild aims for a paediatric Pan-European, Pan-transplant approach.
Assuntos
Transplante de Células-Tronco Hematopoéticas/métodos , Transplante de Órgãos/métodos , Europa (Continente) , Geografia , Humanos , Modelos Teóricos , Qualidade de Vida , Procedimentos Cirúrgicos OperatóriosRESUMO
AIM OF THE STUDY: Recommendation of early pulmonary resection in asymptomatic congenital pulmonary airway malformations (CPAMs) is based on the presumed compensatory lung growth during the first months of life. Our aim is to analyze the long-term pulmonary function after lobectomy before and after one year of age using spirometry. METHODS: We performed a retrospective review of children who underwent pulmonary lobectomy for CPAM between 2001 and 2016. Patients who were old enough (>5 years) to carry out a spirometry were included in the study and were divided into 2 groups (surgery before or after 12 months of age). Pulmonary function testing values were considered normal if they were >80% of predicted. MAIN RESULTS: Forty-seven patients underwent pulmonary lobectomy for CPAM, 23 of them met the inclusion criteria and prospectively performed a spirometry. Among them, 7 had surgery before and 16 after one year of age (0.1 vs. 2); being both groups comparable in terms of sex, type of CPAM and surgical approach. Time from surgery until pulmonary function testing was longer in patients who had surgery before one year of age (9.1 vs. 4.6 years, p = 0.003). After correcting results by time from surgery until spirometry, a better FEV1/FVC was found in patients who had surgery after one year of age (90% vs. 77%, p = 0.043). CONCLUSION: Although spirometry may be influenced by many other variables, these preliminary results do not support the current recommendation of performing early lobectomy in CPAMs. Further studies are required in order to resolve the best age to perform pulmonary lobectomy.
INTRODUCCION/OBJETIVO: La resección temprana de las malformaciones pulmonares asintomáticas ofrece el beneficio teórico de optimizar el crecimiento pulmonar compensatorio durante la infancia. El objetivo de este estudio es determinar si la lobectomía antes del año de vida se asocia con mejor función pulmonar a largo plazo. MATERIALES Y METODOS: Revisión de pacientes en los que se realizó lobectomía pulmonar desde 2001, incluyendo los que tenían edad suficiente para realizar una espirometría (>5 años). Fueron divididos en dos grupos: lobectomía antes o después de 12 meses de vida. Los parámetros espirométricos se consideraron normales cuando eran mayores del 80% esperado. RESULTADOS: Veintitrés de los 47 pacientes intervenidos cumplieron los criterios de inclusión. Siete fueron intervenidos antes (0,1 ± 0,4 años) y 16 después del año de vida (2 ± 3,6 años), siendo ambos grupos comparables en sexo, tipo de malformación y abordaje quirúrgico. El tiempo de seguimiento desde la cirugía hasta que se realizó la espirometría fue mayor en los pacientes intervenidos antes del año de vida (9,1 vs. 4,6 años, p = 0,003). Tras corregir los resultados por el tiempo de seguimiento, se objetivó un mejor cociente FEV1/FVC en los pacientes intervenidos después del año de vida (90% vs. 77%, p = 0,043). CONCLUSION: Aunque la espirometría puede estar influenciada por otras variables, los datos de nuestro estudio no apoyan la recomendación actual de realizar resección temprana en las malformaciones pulmonares congénitas asintomáticas. Se necesitan estudios prospectivos con mayor número de pacientes para determinar la mejor edad para realizar la lobectomía.
Assuntos
Malformação Adenomatoide Cística Congênita do Pulmão/cirurgia , Pneumonectomia/métodos , Espirometria/métodos , Fatores Etários , Pré-Escolar , Malformação Adenomatoide Cística Congênita do Pulmão/fisiopatologia , Feminino , Volume Expiratório Forçado , Humanos , Lactente , Masculino , Testes de Função Respiratória , Estudos Retrospectivos , Fatores de Tempo , Capacidade VitalRESUMO
INTRODUCTION: Foreign body aspiration (FBA) is a potentially life-threatening event, and is the leading cause of death in children after road traffic injuries. If suspected, a prompt exploration of the airway should be performed. We present our experience in FBA treatment in the last 10 years. MATERIAL AND METHODS: A retrospective study of patients admitted in our center with suspected FBA between 2005 and 2015 was performed. Clinical history, physical findings, radiologic imaging, treatment and evolution were assessed. RESULTS: A total of 115 children (70 M/45 F) with a median age of 2 years old (8 months-13 years), presented with a clinical history of FBA. All of them suffered a choking event and the most frequent symptoms were persistent cough (88.3%) and respiratory distress (46.8%). Pathologic physical examination was registered in 75% and an abnormal chest X-ray was seen in 72%. Rigid bronchoscopy (RB) was performed in 100% based on compatible history, regardless of physical and radiologic exams. A foreign body was found during RB in 78 patients (68.1%) and the most frequent were seeds and nuts (63.4%), located mainly in the right bronchus (46.8%). If the criteria for RB had been based on a compatible history along with clinical findings and abnormal chest X-ray, 21 foreign bodies (26.9%) would have been missed, with the subsequent risk of sudden death. All the foreign bodies were removed with success, without any immediate complication during the procedure. CONCLUSION: FBA is a frequent accident among children. The history, clinical findings and imaging cannot always concur. In case of a positive history of FBA an examination of the tracheobronchial tree must be done.
OBJETIVOS: La aspiración de cuerpos extraños (ACE) es una urgencia pediátrica frecuente, descrita como segunda causa de muerte infantil tras los accidentes de tráfico. Presentamos nuestra experiencia en el tratamiento de la ACE en los últimos 10 años. MATERIAL Y METODOS: Estudio retrospectivo de pacientes atendidos por sospecha de ACE entre los años 2005-2015, describiendo historia clínica, sintomatología, pruebas de imagen, procedimiento y evolución. RESULTADOS: Un total de 115 pacientes (70 V/45 M), con una mediana de 2 años (8 meses-13 años), presentaron historia sugestiva de ACE. Los síntomas más frecuentes fueron: tos (88,3%) y dificultad respiratoria (46,8%). El 75% presentaban exploración física patológica y un 72% presentaban alteraciones en la radiografía de tórax. Se realizó broncoscopia rígida (BR) en el 100% de los pacientes con historia compatible, sin importar los resultados de la exploración física o las pruebas de imagen. En 78 pacientes (68,1%) se encontró un cuerpo extraño (CE) durante la BR, siendo los más frecuentes semillas y frutos secos (63,4%); localizándose sobre todo en el bronquio derecho (46,8%). Si el criterio para realizar una BR se hubiese basado en la historia compatible, junto con alteraciones en la exploración física y pruebas de imagen, 21 CE (26,9%) no habrían sido diagnosticados con el consiguiente riesgo de muerte. Todos los CE se extrajeron con éxito, sin ninguna complicación inmediata. CONCLUSIONES: La ACE es frecuente en la infancia. La historia y los hallazgos clínico-radiológicos pueden no concordar, por lo que ante historia sugestiva de ACE es recomendable una exploración de la vía aérea, dado el bajo riesgo que asocia.
Assuntos
Brônquios/diagnóstico por imagem , Broncoscopia/métodos , Corpos Estranhos/terapia , Aspiração Respiratória/terapia , Adolescente , Obstrução das Vias Respiratórias/etiologia , Criança , Pré-Escolar , Tosse/etiologia , Feminino , Corpos Estranhos/complicações , Corpos Estranhos/diagnóstico por imagem , Humanos , Lactente , Masculino , Aspiração Respiratória/diagnóstico por imagem , Estudos RetrospectivosRESUMO
INTRODUCTION: Acquired stenosis of the airway is a common complication after endotracheal intubation. Endoscopic dilation has been accepted as the treatment of choice in cases detected precociously. Our goal is to know the current status of the patients treated in our hospital with endoscopic dilation in the last 10 years. MATERIAL AND METHODS: Retrospective cohort study of patients with subglottic and tracheal acquired stenosis (STAS) early treated endoscopically with balloon dilation at our center in the last 10 years. Bronchoscopy control at 2 weeks, a month, 3 and 6 months post-dilation were performed and later on depending on the symptoms. RESULTS: 32 patient were treated in the period considered. The median age was 4.5 (3-120) months. There were necessary 2.5 (1-5) dilations per patient. All cases were extubated in the operating room or in the following 24 hours. There were no complications during the procedure. Follow-up time was 6 (1-10) years. Only 1 of the 32 patients have had recurrence of stenosis 2 years after, it was secondary to reintubations due to new surgical interventions; which it was dilated successfully. CONCLUSIONS: Early endoscopic dilation in the acquired airway stenosis is a safe and effective long-term procedure. The results support the use of this technique as a treatment of choice in these patients.
INTRODUCCION: La estenosis adquirida de la vía aérea es una complicación frecuente tras la intubación endotraqueal. La dilatación endoscópica ha sido aceptada como tratamiento de elección en los casos detectados de forma precoz. Nuestro objetivo es conocer el estado actual de los pacientes tratados en nuestro centro mediante dilatación endoscópica en los últimos 10 años. MATERIAL Y METODOS: Estudio de cohorte retrospectivo de pacientes con estenosis subglóticas y traqueales adquiridas (ESTA) tratadas endoscópicamente mediante dilatación con balón en nuestro centro en los últimos 10 años. Se realizaron broncoscopias de control a las 2 semanas, al mes, a los 3 y 6 meses postdilatación y posteriormente en función de la clínica. RESULTADOS: Se trataron 32 pacientes de ESTA de reciente aparición en dicho periodo. La mediana de edad fue de 4,5 (3-120) meses. Fueron necesarias 2,5 (1-5) dilataciones por paciente. Todos los pacientes fueron extubados en quirófano o en las 24 horas siguientes al procedimiento. No hubo complicaciones durante los procedimientos ni durante el postoperatorio. El tiempo de seguimiento fue de 6 (1-10) años. Solo 1 de los 32 pacientes presentó recidiva de la estenosis 2 años después que fue secundaria a reintubaciones por nuevas intervenciones quirúrgicas; la cual se dilató nuevamente. CONCLUSIONES: La dilatación endoscópica precoz en las estenosis adquiridas de la vía aérea es un procedimiento seguro y eficaz a largo plazo. Los resultados avalan el uso de esta técnica como tratamiento de elección en estos pacientes.
Assuntos
Broncoscopia/métodos , Endoscopia/métodos , Laringoestenose/terapia , Estenose Traqueal/terapia , Criança , Pré-Escolar , Estudos de Coortes , Dilatação/métodos , Endoscopia/efeitos adversos , Feminino , Seguimentos , Humanos , Lactente , Intubação Intratraqueal/efeitos adversos , Laringoestenose/etiologia , Masculino , Estudos Retrospectivos , Fatores de Tempo , Estenose Traqueal/etiologia , Resultado do TratamentoRESUMO
INTRODUCTION/AIM OF THE STUDY: In patients with PE, cardiovascular alterations ensue as a result of the mediastinum compression caused by sternum impingement and is responsible of many of the symptoms. Anatomical and functional assessment is of the utmost importance for a comprehensive understanding of the disease and an adequate treatment plan. Our aim was to describe the use of magnetic resonance image (MRI) in the study of PE and whether it is comparable to imaging techniques. PATIENTS AND METHODS: A retrospective study of the first 10 patients in which an MRI was performed as part of PE assessment within august 2015-2016. PE indexes were evaluated: Haller, correction, asymmetry, as well as sternal rotation. An analysis of right ventricular function was carried out comparing echocardiogram and MRI. RESULTS: MRI scan on 10 patients showed the following findings: Haller index: inspiration: 3.75 (3.5-7.3) and expiration 4,9 (3.9-10.8), correction index of 24% (5-37%) and a sternal rotation of 12º (0-31º). The cardiovascular study showed a median ejection fraction of the right ventricle (EFRV) of 50% (38-64%), with 9 of the 10 patients under the normal value of 61% (54-71%). Echocardiographic findings underestimated functional alterations in all of the patients. CONCLUSION: This initial study suggests that the use of MRI as a test of choice in the evaluation of PE subject to surgical correction is feasible. Absence of radiation offers the capacity of a complete and dynamic anatomical as well as cardiovascular study.
INTRODUCCION/OBJETIVOS: Las alteraciones cardiovasculares provocadas por la impronta del esternón en el mediastino causan muchos de los síntomas que presentan los pacientes con pectus excavatum (PE). Su estudio anatómico y funcional es fundamental para el entendimiento de la enfermedad y para la elección del tratamiento adecuado. Nuestro objetivo es describir el uso de la resonancia magnética (RM) en el estudio de los pacientes con PE, y si esta prueba es equiparable o superior a otras técnicas de imagen. PACIENTES Y METODOS: Evaluación retrospectiva de los resultados de las primeras 10 RM indicadas en pacientes con PE en el período de octubre 2015-2016. Se analizaron los índices de PE: Haller, corrección, asimetría, así como el grado de rotación esternal. Además se realizó un análisis de la función ventricular derecha mediante ecocardiografía y RM. RESULTADOS: Los 10 pacientes evaluados con RM presentaron: índice de Haller en inspiración de 3,75 (3,5-7,3) y en espiración de 4,9 (3,9-10,8), índice de corrección 24% (5-37%) y rotación esternal 12º (0º-31º). Del estudio cardiovascular destaca una fracción de eyección del ventrículo derecho (FEVD) del 50% (38-64%), con 9 de los pacientes por debajo del valor normal 61% (54-71%). La ecocardiografía infraestimó la alteración funcional en la mayoría de casos, al calificarla de normal en el 100%. CONCLUSION: Este estudio inicial sugiere que el uso de la RM como prueba de elección en la evaluación del PE susceptible de corrección quirúrgica es factible. La ausencia de radicación ofrece la capacidad de un estudio tanto anatómico como cardiovascular completo y dinámico.
Assuntos
Ecocardiografia/métodos , Tórax em Funil/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Função Ventricular Direita/fisiologia , Adolescente , Criança , Feminino , Tórax em Funil/complicações , Humanos , Masculino , Estudos RetrospectivosRESUMO
BACKGROUND: Extrahepatic portal vein obstruction (EPVO) is the principal cause of portal hypertension in children. The objective of this study was to analyze the capacity of the surgical technique that creates a mesoportal shunt to treat changes caused by EPVO. METHODS: Retrospective review of patients with idiopathic EPVO who underwent a mesoportal shunt and analysis of the changes in the number of leucocytes, platelets, prothrombin time and spleen size one year after the surgery. RESULTS: Twelve patients underwent surgery, out of which 10 had prior leukopenia, 11 thrombopenia, 9 longer prothrombin times and all had hypersplenism. One patient suffered a postoperative shunt thrombosis, was reoperated and underwent a change in the operative technique. The remaining patients (92%) have functioning shunts 4.3 ± 2.5 years after surgery, and none have suffered any episode of gastrointestinal bleeding. One year after surgery, there were significant changes in the number of platelets, prothrombin time and spleen size, with no significant changes in the number of leukocytes. However, the number of patients who went from a leukopenic to a normal state was significant, as happened with changes in prothrombin time. CONCLUSIONS: Mesoportal Rex shunt improves some of the disorders caused by portal hypertension in children suffering EPVO, with a high rate of surgical success. This technique should be of first choice in these patients.
OBJETIVOS: La trombosis portal extrahepática (TPEH) es la causa más frecuente de hipertensión portal en el niño. El objetivo de este estudio es analizar la utilidad de la técnica quirúrgica que crea un shunt mesoportal para mejorar o revertir las alteraciones causadas por la TPEH. MATERIAL Y METODOS: Revisión retrospectiva de los pacientes con TPEH idiopática sometidos al shunt mesoportal y análisis de los cambios en la cifra de leucocitos, plaquetas, tiempo de protrombina y tamaño del bazo al año de la cirugía. RESULTADOS: De los 12 pacientes intervenidos, 10 tenían leucopenia, 11 plaquetopenia, 9 un tiempo de protrombina alargado y todos presentaban hiperesplenismo. Una paciente sufrió una trombosis postoperatoria del shunt por la que fue reoperada con cambio de la técnica quirúrgica. El resto de pacientes (92%) tienen un shunt funcionante con un seguimiento 4,3 ± 2,5 años y no han sufrido ningún sangrado gastrointestinal. Al año de la cirugía, observamos cambios significativos en el número total de plaquetas, tiempo de protrombina y tamaño del bazo, no siendo estos cambios significativos para la cifra de leucocitos. Sin embargo, el número de pacientes que pasó de estar leucopénico a tener cifras normales de leucocitos, sí fue significativo, hecho que también ocurrió en el caso de las alteraciones en el tiempo de protrombina. CONCLUSIONES: El shunt mesoportal de Rex mejora de manera efectiva las alteraciones asociadas a la hipertensión portal por TPEH, con una alta tasa de éxito, por lo que debería ser la técnica de elección en estos pacientes.
Assuntos
Hipertensão Portal/cirurgia , Veia Porta/fisiopatologia , Derivação Portossistêmica Cirúrgica/métodos , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Hipertensão Portal/etiologia , Masculino , Veia Porta/cirurgia , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
AIM: In patients with a choledochal cyst, the malformation and subsequent biliodigestive reconstruction lead to a non-physiological state in the digestive tract and biliary excretion that could affect the child's growth. The effect of this malformation and its surgical treatment are reviewed here in a large patient cohort. MATERIAL AND METHODS: Retrospective review of patients undergoing surgery for choledochal cyst in the last 20 years. Nutrition and liver function parameters, weight and height data were collected from medical records. Patients presenting other serious diseases affecting growth were excluded. RESULTS: From 1994-2014 forty-five patients were diagnosed for choledochal cyst (75% female). All underwent cyst resection followed by Roux-en-Y hepaticojejunostomy. Eight patients were excluded for comorbidities and 37 selected for the study, with a median age at diagnosis and surgery of 16 (0-120) and 24 (1-149) months, respectively. The median follow-up was 76 (1-215) months. At diagnosis, 10.8% of patients had low weight, which was entirely resolved within 6 months after surgery (p< 0.05). CONCLUSIONS: The choledochal cyst induces a situation of moderate malnutrition in around 10% of the patients. Surgical correction quickly reverses this situation, despite the decreased absorption surface and deviation of biliary secretion to the jejunum instead of the duodenum.
OBJETIVO: En pacientes con quiste de colédoco, la malformación primaria y reconstrucción biliodigestiva posterior condicionan una situación no fisiológica del tracto digestivo y de la excreción biliar que, en niños, pueden teóricamente alterar el patrón de crecimiento. Revisamos en una amplia cohorte de pacientes el efecto de esta malformación y de su tratamiento quirúrgico sobre dicho patrón. MATERIAL Y METODO: Revisión retrospectiva de pacientes intervenidos por quiste de colédoco en los últimos 20 años, recogiéndose parámetros nutricionales y de función hepática, peso y talla a través de las historias clínicas. Se excluyeron pacientes con otras patologías graves donde el crecimiento haya podido verse afectado secundariamente. RESULTADOS: De 1994 a 2014 se diagnosticaron 45 pacientes con quiste de colédoco (75% niñas). En todos se realizó una hepaticoyeyunostomía en Y de Roux. Fueron excluidos 8 pacientes por pluripatología y seleccionados 37 para el estudio, con una mediana de edad al diagnóstico e intervención de 16 (0-120) y 24 (1-149) meses respectivamente. El seguimiento fue de 76 (1-215) meses. El 10,8% de pacientes presentaba bajo peso al diagnóstico, situación que desapareció totalmente a los 6 meses del tratamiento quirúrgico (p< 0,05). CONCLUSIONES: El quiste de colédoco supone en algo más de un 10% de los pacientes una situación de desnutrición moderada. La corrección quirúrgica, a pesar de condicionar una disminución de la superficie de absorción y una separación de la secreción biliar, revierte en poco tiempo dicha situación.
Assuntos
Transtornos da Nutrição Infantil/etiologia , Cisto do Colédoco/complicações , Anastomose em-Y de Roux/métodos , Ductos Biliares Extra-Hepáticos/cirurgia , Criança , Transtornos da Nutrição Infantil/cirurgia , Cisto do Colédoco/cirurgia , Feminino , Humanos , Jejuno/cirurgia , Masculino , Estudos Retrospectivos , Resultado do TratamentoRESUMO
AIM OF THE STUDY: Optimal surgical treatment of patients with gastroschisis remains controversial. Recent studies suggest better outcomes with secondary closure techniques (surgical or preformed silo). The purpose of the study is to identify differences in outcome of infants treated with traditional primary closure (PC) versus surgical silo (SS). PATIENTS AND METHODS: Retrospective study of patients primarily treated of gastroschisis between 2004 and 2014. Patients were divided in PC and SS according to abdominal wall closure. Non-parametric statistical analysis was used with p< 0.05 regarded as significant. RESULTS: Twenty-seven patients were included (14M/13F). Primary closure was performed on 17 and 10 underwent surgical silo placement with a median of 6 (5-26) days till secondary closure. Prenatal diagnosis was available in most patients (74%) by the 20th week of gestation. There were no significant differences regarding sex, gestational age or birthweight between groups. Fewer ventilation days were required in PC group compared to SS (4 vs 13, p< 0,05), however, there was no difference in type of ventilation or oxygen needs. Sedation and parenteral nutrition requirements were also lower in PC patients 4 vs 10 and 12 vs 20 days respectively (p< 0,05). Post-operative complications (5vs6) and median length of stay (36vs43 days) were also similar in PC and SS patients. One patient ultimately died due to catheter-related sepsis. Mean length of stay in hospital was 42 days (20-195). CONCLUSION: Patients with gastroschisis who underwent primary closure showed shorter ventilator support and PN dependency than those treated with surgical silo. However, SS is as safe and effective technique as PC and led to similar outcome regarding digestive autonomy and hospital length of stay.
INTRODUCCION/OBJETTIVO: El tratamiento óptimo de la gastrosquisis es controvertido. Algunos autores sugieren mejores resultados del cierre diferido (CD) frente al cierre primario (CP). El propósito del estudio es comparar las necesidades de ventilación mecánica y sedación, así como los aspectos nutricionales y resultados a medio plazo entre el CP y CD. PACIENTES Y METODOS: Estudio retrospectivo de pacientes con gastrosquisis entre 2004 y 2014. Se dividieron en CP y CD según el cierre de pared abdominal. RESULTADOS: Se incluyeron 27 pacientes (14V,13M). En 74% se realizó el diagnóstico prenatal antes de las 20 semanas de gestación. La edad gestacional y peso al nacimiento fueron 36 (31-39) semanas y 2.200 (1.680-3.150) gramos, respectivamente. Se realizó CP en 17 (63%) y a los 6 (5-26) días, un CD en 10 (37%). El grupo con CP precisó menos días de ventilación mecánica que el CD (4 vs 13, p< 0,05), sin diferencias en el tipo de soporte ni requerimiento de oxígeno. La necesidad de sedación y de nutrición parenteral (NP) fueron también menores en el grupo de CP 4 vs 10 y 12 vs 20 días, respectivamente, p< 0,05, pero sin diferencias para alcanzar la autonomía digestiva. Once (41%) presentaron complicaciones postoperatorias, distribuidas por igual en ambos grupos. Un paciente del grupo CD falleció por sepsis asociada a catéter central. La estancia mediana hospitalaria fue de 42 días (20-195). CONCLUSION: Los pacientes con CP de gastrosquisis requirieron menos soporte ventilatorio, sedación y NP exclusiva. Sin embargo, nuestra experiencia demuestra que el CD es una técnica segura que presenta resultados similares al CP en cuanto a estancia hospitalaria y autonomía digestiva.
Assuntos
Gastrosquise/cirurgia , Nutrição Parenteral/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Feminino , Humanos , Lactente , Tempo de Internação , Masculino , Complicações Pós-Operatórias , Estudos Retrospectivos , Resultado do TratamentoRESUMO
UNLABELLED: INTRODUCION AND AIM: The enterostomy used in the treatment of Necrotizing Enterocolitis (NEC) causes many complications before and after its closure. The aim of this study was to examine the complications of closure aiming at determining the best timing for this operation. PATIENTS AND METHOD: Retrospective review patients (p) below 1500 g with NEC in whom the enterostomy was closed in the last seven years. P were divided into two groups: PC (planned closure after uncomplicated postoperative period) and CC (advanced closure due to stomal--excessive looses--or to parenteral nutrition complications--septicemia, liver dysfunction-). We compared the age at closure, time of enterostomy, weight gain and complications. RESULTS: Out of a total of 25 p requiring surgical treatment for NEC, 16 from the PC group and 9 from the CC group were included. The mean age at the moment of the closure were, respectively, 129 + 65 vs. 204 +/- 121 days (p < 0.05). Weight at closure was 2665 +/- 841 vs. 4665 +/- 2076 g (p < 0.05); the mean time with the enterostomy was 105 +/- 64 vs. 187 +/- 116 d (p < 0.05), and the weight gain was 1779 +/- 859 vs. 3693 +/- 2155 g (p < 0.05). After stomal closure, 7/16 p of the CC group (43%) and 2/9 of the PC group (22%) required reoperation due to severe complications (ns). In 4 of them, three of the CC group and one of the PC group, a new enterostomy was performed. CONCLUSIONS: In p with enterostomy-related complications, closure has often to be advanced and it is performed in deficient nutritional conditions. Severe complications after enterostomy closure required reoperation in 43% of the CC group and in 22% of the PC group. Although there was no statistically significant difference, the trend indicates an augmented risk in CC group. The timing for enterostomy closure should be chosen individually. At the time of indicating the closure, the high risk of complications, should be taken into account particularly in preterms with enterostomy-related problems.
Assuntos
Técnicas de Fechamento de Ferimentos Abdominais/normas , Enterocolite Necrosante/cirurgia , Enterostomia/normas , Humanos , Recém-Nascido , Estudos Retrospectivos , Fatores de TempoRESUMO
The most recent outcomes on bowel transplantation (BT), with a survival rate immediately after transplant higher than 80% and a great rate of survivors achieving complete digestive autonomy and able to carry out activities according to their age allow for considering BT as the first choice therapy in patients with irreversible intestinal failure in whom poor prognosis with parenteral nutrition is foreseen. Parenteral nutrition-associated liver damage is the most frequent indication for BT, especially in children that are more susceptible than adults to develop this complication. Other accepted indications for BT are irreversible intestinal failure in association with loss of deep venous accesses, life-threatening severe infections associated with the use of central catheters, and those cases of intestinal failure usually leading to early death, such as ultra-short bowel syndromes, refractory diarrheas, and intestinal failure associated to high morbidity and poor quality of life. BT is performed in human clinical practice under three technical modalities: isolated bowel transplant, combined liver-bowel transplant, and multi-visceral transplantation. Currently, refinements of original techniques including reduction of liver and/or intestinal grafts, grafts from living donors, etc., allow for overcoming the different needs as well as increasing the likelihood of having access to transplantation, which is a desirable goal specially in very young or very low-weighted children candidate to liver-bowel transplant. One of the most interesting issues in BT programs is having given access to the Intestinal Rehabilitation Units, which comprise the three therapeutic modalities by means of a multidisciplinary team: nutritional support, pharmacotherapy, and surgery. These Units optimize the outcomes, minimize costs, and allow for offering a management adapted to individual needs.
Assuntos
Intestino Delgado/transplante , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Procedimentos Cirúrgicos do Sistema Digestório/reabilitação , Humanos , Resultado do TratamentoRESUMO
AIM: Bacterial translocation (BT) can be demonstrated by blood and lymph node cultures and also by polymerase chain reaction (PCR) detection of DNA of enteric bacteria. Aiming at investigating BT after gastrointestinal operations we assessed it on two endpoints after ischemia-reperfusion (IR) or sham operation (SO). METHODS: 2 groups of 200-g Brown Norway male rats were treated as follows: SO animals ( n=12) had laparotomy alone and IR animals ( n=12) had successively 15 min clamping of the portal vein and the mesenteric artery. Half the animals in each group were killed on postoperative (p.o.) day 2 the other half on p.o. day 7. Under sterile conditions regional lymph nodes and vena cava and portal vein blood samples were recovered and cultured for aerobes and anaerobes. Escherichia coli beta-galactosidase DNA was assessed in blood samples by PCR. The findings in the two groups were compared by means of chi(2) tests. RESULTS: Post-hepatic (peripheral blood) BT was detected by cultures of gram-negative bacteria in 16% and 0% of SO and IR animals, respectively, on p.o. day 2 and in 16% and 50% on p.o. day 7. These differences were not significant (ns). E. coli DNA was found in one SO rat. Pre-hepatic BT (portal blood and/or lymph nodes) of gram-negative bacteria was found in 16% and 33%, respectively, on day 2 and in 16% and 16% on day 7 (ns). However, if gram-positive cultures were taken into account, the figures were 66% and 66% on day 2 and 66% and 83% on day 7 (ns). No anaerobes could be cultured. CONCLUSIONS: (1) BT is frequent in surgically manipulated animals. (2) To limit the assessment of BT to Enterobacteriaceae is probably misleading, since consistent amounts of gram-positive bacteria are found in the pre-hepatic territory. (3) PCR tests limited to E. coli DNA alone are likely incomplete. (4) Short periods of vascular clamping do not increase BT on the two endpoints selected in comparison with SO animals.