Analysis of a clinical guideline for treatment and early discharge in complicated acute appendicitis. / Análisis de una guía clínica para el tratamiento y alta precoz en apendicitis aguda complicada.

OBJECTIVE: The objective of this study was to assess the results of a clinical guideline for the treatment and early discharge of patients with complicated acute appendicitis in terms of infectious complications and hospital stay. MATERIALS AND METHODS: A guideline for appendicitis treatment according to severity was created. Complicated appendicitis cases were treated with ceftriaxone-metronidazole for 48h, with discharge being approved if certain clinical and blood test criteria were met. A retrospective analytical study comparing the incidence of postoperative intra-abdominal abscess (IAA) and surgical site infection (SSI) in patients under 14 years of age to whom the new guideline was applied (Group A) vs. the historical cohort (Group B, treated with gentamicin-metronidazole for 5 days) was carried out. A prospective cohort study to assess which antibiotic therapy (amoxicillin-clavulanic acid or cefuroxime-metronidazole) proved more effective in patients meeting early discharge criteria was also conducted. RESULTS: 205 patients under 14 years of age were included in Group A, whereas 109 patients were included in Group B. IAA was present in 14.3% of patients from Group A vs. 13.8% from Group B (p= 0.83), while SSI was present in 1.9% of patients from Group A vs. 8.25% from Group B (p= 0.008). Early discharge criteria were met by 62.7% of patients from Group A. Median hospital stay decreased from 6 to 3 days. At discharge, 57% of patients received amoxicillin-clavulanic acid, whereas 43% received cefuroxime-metronidazole, with no differences being found in terms of SSI (p= 0.24) or IAA (p= 0.12). CONCLUSIONS: Early discharge reduces hospital stay without increasing the risk of postoperative infectious complications. Amoxicillin-clavulanic acid is a safe option for at-home oral antibiotic therapy.

OBJETIVO: El objetivo de este estudio es evaluar los resultados en términos de complicaciones infecciosas y estancia hospitalaria de la instauración de una guía clínica para el tratamiento y alta precoz en pacientes con apendicitis aguda complicada. MATERIAL Y METODOS: Se elaboró una guía para el tratamiento de las apendicitis en función de su grado de severidad. Las complicadas se trataron con ceftriaxona-metronidazol durante 48 h, siendo alta si cumplen ciertos criterios clínicos y analíticos. Se realizó un estudio analítico retrospectivo comparando la incidencia de abscesos intraabdominales postquirúrgicos (AIA) e infección del sitio quirúrgico (ISQ) en pacientes menores de 14 años sometidos a la nueva guía (Grupo A), respecto a una cohorte histórica (Grupo B), en la que la pauta de tratamiento era gentamicina-metronidazol 5 días. Además, se realizó un estudio de cohortes prospectivas para evaluar qué antibioterapia (amocilina-clavulánico o cefuroxima-metronidazol) es más eficaz en los pacientes que cumplen criterios de alta precoz. RESULTADOS: Se incluyeron 205 pacientes menores de 14 años en el Grupo A y 109 en el Grupo B. Presentaron AIA un 14,3% en el grupo A, frente al 13,8% en el B (p=  0,83); e ISQ un 1,9% y un 8,25% respectivamente (p=  0,008). Cumplieron criterios de alta precoz el 62,7% de los pacientes del Grupo A. La mediana de estancia disminuyó a de 6 a 3 días. Al alta, el 57% recibieron amoxicilina-clavulánico y el 43% cefuroxima-metronidazol, sin hallarse diferencias en términos de ISQ (p=  0,24) ni de AIA (p=  0,12). CONCLUSIONES: El alta precoz disminuye la estancia hospitalaria sin aumentar el riesgo de complicaciones infecciosas postquirúrgicas. La amoxicilina-clavulánico es una opción segura para la antibioterapia oral domiciliaria.

Different Clinical Features of Acral Abortive Hemangiomas.

Some infantile hemangiomas called in literature "minimal or arrested growth hemangiomas" or "abortive hemangiomas" are present at birth and have a proliferative component equaling less than 25% of its total surface area. Often, they are mistaken for vascular malformation. We present five patients (three girls and two boys) with abortive hemangiomas diagnosed between January 2010 and December 2015 localized in acral part of the extremities. They were congenital lesions resembling precursor of hemangiomas but did not show proliferation phase. Immunohistochemical Glut-1 was performed in all of them as a way to confirm the abortive hemangioma diagnosis. The most common appearance was a reticulated erythematous patch with multiple fine telangiectasias on the surface. We remark that one of them presented a segmental patch with two different morphologies and evolutions. The proximal part showed pebbled patches of bright-red hemangioma and presented proliferation and the distal part with a reticulated network-like telangiectasia morphology remained unchanged. We detected lower half of the body preference and dorsal region involvement preference without ventral involvement. The ulceration occurred in three patients with two different degrees of severity.

[Uroflowmetric review of pediatric distal urethroplasty]. / Revisión uroflujométrica de pacientes intervenidos de hipospadias distales.

INTRODUCTION: Urethral stricture is the most common complication in hypospadias surgery. The monitoring of operated patients allows rapid detection of this complication and the uroflowmetry is the main diagnostic method. OBJECTIVES: To study of functional results in patients who underwent distal urethroplasty, using uroflowmetry. PATIENTS AND METHODS: A retrospective chart review was conducted of 81 patients who underwent distal hypospadias repair (7 coronal, 51 subcoronal and 23 distal penile shaft) and a postoperatory uroflowmetric study. The patients were divided into two groups, in each type of hypospadias, according to the presence or absence of stenotic complications (0 coronal, 10 subcoronal and 5 distal penile shaft). The functional effects in both groups were studied. RESULTS: All patients with stenotic complications showed maximum flow rates and mean flow rates below 15 and 20 percentiles respectively and a plateauing layout of the urinary flow curve. The treatment of these conditions resulted in the normalization of the maximum flow values ​​(in 100% of the subcoronal and 100% of the distal penile shaft hypospadias), as well as in the mean flow values ​​(in 88% of the subcoronal and 75% of the distal penile shaft hypospadias). The curve also adapted a bell-shaped in 100% of the H. coronal and 50% of the H. distal penile shaft. The uroflowmetry presented a spontaneous improvement in all patients without stenotic complications but with low flows in their first uroflowmetric. CONCLUSIONS: Uroflowmetry is an objective method for the evaluation of hypospadias surgery, being easy to perform, noninvasive and reliable. Obstructed uroflow patterns point to the presence of a stenotic complication.

INTRODUCCION: La estenosis uretral es la complicación más frecuente de la cirugía del hipospadias. El seguimiento de los pacientes intervenidos permite su rápida detección, siendo la uroflujometría su principal método diagnóstico. OBJETIVOS: Estudiar la repercusión funcional, mediante la uroflujometría, en pacientes intervenidos de hipospadias distal. MATERIALES Y METODOS: Se presenta un estudio descriptivo, retrospectivo, en el que se revisaron las historias clínicas de 81 pacientes intervenidos de hipospadias distal (7 balánicos, 51 balanopeneanos y 23 peneanos anteriores) y a los que les realizaron estudios uroflujométricos. En cada tipo de hipospadias, se dividieron los pacientes en dos grupos según la presencia de complicaciones estenóticas (0 balánicos, 10 balanopeneanos y 5 peneanos anteriores) o la ausencia de estas y se estudiaron las repercusiones funcionales en ambos grupos. RESULTADOS: Todos aquellos pacientes con complicaciones estenóticas presentaron flujos máximos y medios por debajo de los percentiles 15 y 20 respectivamente, así como un trazado de la curva anormal. El tratamiento de estas complicaciones estenóticas se tradujeron en una normalización tanto en los valores de flujo máximo (en el 100% de los hipospadias balanopeneanos y en el 100% de los hipospadias peneanos anteriores), como en los valores de flujo medio (en el 88% de los hipospadias balanopeneanos y el 75% de los hipospadias peneanos anteriores). La curva, además, adaptó un trazado en forma de campana en el 100% de los hipospadias balanopeneanos y el 50% de los hipospadias peneanos anteriores. Se detectó una mejoría uroflujométrica espontánea en aquellos pacientes que, sin complicaciones estenóticas, presentaron en su primer control uroflujométrico flujos bajos. CONCLUSIONES: La uroflujometría es un método objetivo para la evaluación de la cirugía del hipospadias, siendo una técnica fácil, reproducible y no invasiva. Los parámetros uroflujométricos bajos indican la presencia de una complicación estenótica.

[Infantile hypertrofic pyloric stenosis or gastric adenomyoma? Differential diagnosis of gastric outlet obstruction in children]. / ¿Estenosis hipertrófica de píloro o adenomioma pilórico? Diagnóstico diferencial de obstrucción gástrica en niños.

PURPOSE: Gastrointestinal adenomyoma is a rare benign tumor most frequently located in the stomach. The differential diagnosis is wide because of its large clinical spectrum and unspecific radiological findings. Surgical excision is both diagnostic and therapeutic. CASE REPORT: A 49-days old girl presented with nonbilious vomiting of 48 hours of evolution. Infantile hypertrofic pyloric stenosis was suspected. Ultrasound showed a nonobstructive nodular lesion in the anterior pyloric wall. MRI suggested a myofibroblastic tumor. We proceeded to laparotomy and complete resection of the pyloric tumor. Histologic diagnosis was gastric adenomyoma. CONCLUSIONS: Pyloric adenomyoma causes obstructive symptoms similar to other common entities such as hypertrophic pyloric stenosis or cystic duplication. We have to consider this condition in children with digestive symptoms and radiological images of intussusceptions or duplication. Surgical excision is recommended to reach a definitive diagnosis and to avoid a possible malignant degeneration.

INTRODUCCION: El adenomioma gastrointestinal es una tumoración benigna rara cuya localización más frecuente es gástrica. Su diagnóstico diferencial es amplio debido a su gran espectro clínico y baja especificidad radiológica. La escisión quirúrgica es diagnóstico-terapeútica. CASO CLINICO: Niña de 49 días que presenta vómitos no biliosos de 48 horas de evolución. Ante sospecha de estenosis hipertrófica de píloro se solicita ecografía que muestra lesión nodular no obstructiva en pared anterior del píloro. Se realiza RM sugestiva de tumor miofibroblástico. Se procede a laparotomía y resección completa de tumoración pilórica, informada histológicamente como adenomioma gástrico. COMENTARIOS: El adenomioma pilórico produce clínica obstructiva y se confunde con entidades comunes como la estenosis hipertrófica de píloro o la duplicación quística. En un niño con síntomas digestivos e imagen radiológica de invaginación o duplicación, debemos tener en cuenta esta patología. La resección quirúrgica es de elección para un diagnóstico certero y para evitar una posible degeneración maligna.

[Enterocolitis episodes in patients who have previously undergone Hirschsprung disease surgery]. / Episodios de enterocolitis postoperatorios en pacientes intervenidos de enfermedad de Hirschsprung.

OBJECTIVES: To highlight the risk factors for the occurrence of this complication in order to achieve an early diagnosis. METHODS: Retrospective descriptive study in which the medical records of patients diagnosed with enterocolitis and who have previously undergone surgery for Hirschsprung's disease in a tertiary hospital from 1994 to 2013, inclusive (N=29), were reviewed. Epidemiological, surgical and clinical data from two groups of patients: Group A (6 patients with ECPD) and Group B (23 patients without ECPD) were compared. Enterocolitis episode data in the Group A were studied too. RESULTS: The incidence of an episode of ECPD was 20.6% and the incidence of two episodes of ECPD was 33.3%. The onset occurred at 12.17 months (SD 13.04) after pull-through procedure. The incidence was higher in patients operated at a younger age [10 months in Group A [6-16] versus 14 months in the group B (1-153)] and in those patients with the longest segment resected [23.20 cm in group A (DS 10,52) versus 19.20 cm in group B (DS 6.92)]. No patient with a discharge colostomy before pull-through surgery showed this complication. It must be highlighted the highest incidence in patients undergone by Swenson's technique (25%) compared to other surgical techniques (Georgeson (15.80%), Soave (0%)). CONCLUSION: Just the length of the resected segment and the patient's age at the time of the pull-through procedure appear to influence the outcome. It is considered advisable to be extremely vigilant in children operated at an early age and subjected to extensive intestinal resection for an early diagnosis and establishment of a treatment to avoid high morbidity.

OBJETIVOS: Identificar los factores de riesgo de la aparición de esta complicación para conseguir un diagnóstico precoz. MATERIAL Y METODOS: Estudio descriptivo retrospectivo en el que se revisan las historias clínicas de pacientes diagnosticados de enterocolitis e intervenidos previamente de la enfermedad de Hirschsprung en un hospital de tercer nivel desde 1994 hasta el 2013, ambos inclusive (N=29). Se comparan datos epidemiológicos, quirúrgicos y clínicos entre dos grupos de pacientes: grupo A (6 pacientes con enterocolitis postdescenso abdómino-perineal (ECPD) y grupo B (23 pacientes sin ECPD). Se estudian, además, los datos sobre el episodio de ECPD en el grupo A. RESULTADOS: La incidencia de un episodio de ECPD fue de 20,6% y la incidencia de dos episodios de ECPD fue de 33,3%. El inicio del cuadro se produjo a los 12,17 meses (DS 13,04) tras la cirugía. Su incidencia fue más alta en aquellos pacientes intervenidos con menor edad [10 meses en el Grupo A (6-16) frente a 14 meses en el grupo B (1-153)] y con mayor longitud del segmento resecado [23,20 cm del grupo A (DS 10,52) frente a 19,20 cm del grupo B (DS 6,92)]. Ningún paciente portador de una colostomía de descarga previa a la cirugía de descenso presentó esta complicación. Destaca, además, la mayor incidencia en pacientes intervenidos mediante la técnica de Swenson (25%) frente a otras técnicas quirúrgicas [Georgeson (15,80%), Soave (0%)]. CONCLUSION: Solo la longitud del segmento resecado y la edad del paciente en el momento de la cirugía de descenso parecen influir en la evolución de los pacientes. Se considera aconsejable extremar la vigilancia en los niños intervenidos a edades tempranas y sometidos a una resección intestinal amplia para realizar un diagnostico precoz e instaurar un tratamiento precoz que evite su alta morbilidad.

[Abdominal lymphatic malformation (ALM). Our experience]. / Malformación linfática abdominal (MLA). Nuestra experiencia.

INTRODUCTION: Lymphatic malformations are congenital lesions usually placed in the head and neck, the abdominal location is infrequent. OBJECTIVES: Analyze our experience in ALM management. METHOD: Retrospective study of pediatric patients with ALM from 1996 to 2011. It is a descriptive analysis of clinical, diagnostic and therapeutic features. RESULTS: 10 patients with ALM were treated (6 girls: 4 boys), with a median age of 4.03 years (3 days-13 years). Acute abdomen was the most common presenting feature (40%). Ultrasound was carried out in all these cases, completing the study with CT (9 cases), MRI (1) or both (1). Treatment was surgical, excepting one case that presented infection of the ALM. The approach by laparotomy allowed total resection in all cases, involving bowel resection in 6. The mass was located in small bowel mesentery (6), mesocolon (1), liver (1), and in retroperitoneum (1). The final pathologic diagnosis showed an error in diagnostic imaging of 60%.The mean follow-up was 18 months (SD: 12.8), with not recurrences. CONCLUSIONS: ALM often manifests in a non-specific form and it may remain silent. Imaging studies guide the diagnosis, but only the histology provides a definitive result. Total resection is the best option to prevent recurrences and minimize complications.

[Management of pediatric urolithiasis in our center]. / Tratamiento de la urolitiasis pediátrica en nuestro medio.

OBJECTIVES: To determine clinical, epidemiological and therapeutic characteristics of pediatric urolithiasis in our institution. MATERIAL AND METHODS: We reviewed retrospectively patients diagnosed with urolithiasis between 1998 and 2010 in our hospital. RESULTS: A total of 32 patients (19 males and 13 females) with a mean age of 4.5 years (SD 1.9) were studied. 72% had a history of metabolic or nephro-urological malformations. The most common presentation was urinary tract infection (53%) and abdominal pain (21%). The diagnosis was made by ultrasound, with compatible X-ray in 18 cases. The most common location was pyelocalyceal level, affecting the left kidney mostly. A 38% had multiple stones with a size of 11 mm medium (3-30 mm). Ureteroscopy was used 16 times for stones in the bladder and distal ureter, with an effectiveness of 75%, and 2 patients required laparoscopic trocar cystotomy for removal. 8 extracorporeal lithotripsy procedures were performed (25% success) and 8 percutaneous nephrolithotomy procedures (37.5% success). In 3 patients we decided to perform a lumbotomy due to the size of the calculi, and, in 1 patient nephrectomy was necessary due to malfunction. The most common complication was lithiasis recurrence in 10 patients, most with multiple stones or metabolic alterations, and favourable outcome for the rest. CONCLUSIONS: Pediatric urolithiasis is uncommon, showing an increased incidence in patients with a history of metabolic and urologic pathology; it is important to do additional studies. In the last few years, it has been demonstrated that surgical treatment using minimally invasive procedures is effective and safe.

[Prognostic factors in hypertrophic pyloric stenosis]. / Factores pronósticos en la estenosis hipertrófica de píloro.

INTRODUCTION: Although the surgical treatment of hypertrophic pyloric stenosis is well established, its management and main complication after surgery, postoperative vomits, are subject to constant revisions. In this study, we sought a prognostic factor that indicates the occurrence of this complication. METHODS: We analyzed different parameters listed in the medical histories of 169 patients treated at a tertiary hospital between 2000 and 2009, both inclusive, ruling out those who suffered some type of complication (n = 17) and those who followed a different pattern of reintroduction of feeding (n = 43). RESULTS: The decrease in the time interval between surgery and the first shot does not influence the outcome of patients. However, we found a negative correlation between the chlorine level in blood measured by the number of postoperative vomits. The time required to reach a correct tolerance, influenced by the degree of metabolic disorder, does influence both the number of vomits and the time required to achieve a proper tolerance. Other parameters analyzed, such as surgical time and ultrasound measurements of the pyloric olive, do not seem to influence the postoperative course of patients. CONCLUSION: Just the degree of metabolic disturbance and blood levels of chlorine seem to influence postoperative outcome, detected by the time required to reach a correct tolerance and the number of postoperative vomits.

[Laparoscopic appendectomy with endoloop: results of our experience]. / Apendicectomía laparoscópica con endolazo: resultados de nuestra experiencia.

There are several different techniques for laparoscopic appendectomy (LA), with different material requirements and approach. We present the results from our series, where we employ monopolar hook for mesoappendix dissection and double polyglactin endoloop for ligation of appendicular stump. The appendix is taken out through the Hasson trocar without any contact with abdominal wall, in a completely laparoscopic procedure. We sought to analyze the security of this technique. We reviewed retrospectively every LA for acute appendicitis performed during the last 10 years in our Hospital. We collected data regarding surgical procedure and postoperative outcome, focusing on intraoperative or postoperative complications. A total of hundred and ten (110) LA for acute appendicitis (from simple appendicitis to perforated appendicitis) were performed. Mean operative time was 74.7 minutes (median 70 min, SD 24.43 min, min. 25, max. 130 min). Ten patients (9.09%) had postoperative complications, consisting in intraabdominal abscess in 6 patients (5.4%) and wound infection in 3 patients (2.7%). No major complication was found, as uncontrolled hemorrhage, bowel perforation or stump dehiscence. No patient needed a second surgical procedure in the postoperative time. Laparoscopic appendectomy with polyglactin endoloops is a completely laparoscopic and safe procedure, without any intraoperative complication in our series. Laparoscopic approach with 12 mm Hasson trocar and two 5 mm working trocars allows a nice aesthetic result.