[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.

[Endoscopic treatment of ureterocele in children: is a long term effective technique?]. / Tratamiento endoscópico de los ureteroceles en edad pediátrica, efectivo a largo plazo?

INTRODUCTION: The endoscopic treatment of the ureterocele is a less invasive procedure. Currently, there are only a few published articles regarding the long-term outcomes of this treatment. MATERIAL AND METHODS: We have introduced this technique in our practice since 1995, and have been tracking 15 pediatric patients for long-term evaluation. RESULTS: The average operative age for endoscopic treatment is 19.40 months (1 week-8 years). In 53% of the cases, the diagnosis was made during prenatal screening. In 27% of the cases, the ureterocele was bilateral, and 47% of the patients have a double system. The indication for endoscopic treatment is 66% ureteric obstruction and 34% vesicoureteric reflux. We perform "uncapping" and incision in the two first cases and puncture in the subsequent procedure. The patients were followed for 4 years (7 months-7 years). During this time, two ureteroceles needed a second perforation, out of the seven that continued having reflux, two were treated with quimioprofilaxis and two were treated endoscopically for anti-reflux. Two patients continued to have reflux, and two were diagnosed with renal atrophy and hemiatrophy. DISCUSSION: The endoscopic treatment avoided an open surgical procedure in almost all cases. The need for anti-reflux puncture occurred in 33% of the cases.

[Retroperitoneoscopic heminephrectomy]. / Heminefrectomía retroperitoneoscópica.

The practice of minimally invasive surgery techniques in the retro-peritoneal space presents additional difficulties. Due to the absence of a real cavity and the presence of a dense fat tissue involving the structures, the need for an artificial space to work in is necessary. We present three cases of the retro-peritoneal superior heminephrectomy present in a 3-months, 6-months and a 6-year old children. In all cases a 1 centimeter port for the optique and two 0.5 centimeter ports for the instruments were situated, and the use of harmonic scalpel was satisfactory to remove renal tissue without bleeding. Drainages were unnecessary and all of the children left the hospital within the first 48 post-operative hours. Since 1994, when Figenhans and Clayman communicated the first laparoscopic nephrectomy in children, the technique has been used generally and their forward advances in conventional surgery are now universally accepted. Furthermore, the practice of polar retro-peritoneoscopic heminephrectomy allowed a very precise renal hiliar dissection and an excellent differentiation of each hemirenal tissue, separating the ill kidney and preserving the maximum function possible for the other half-kidney and the adrenal gland.

[Importance of initial management in severe pediatric trauma]. / Importancia de la evaluación inicial en los traumatismos graves en la infancia.

INTRODUCTION: Trauma is the most frequent cause of mortality in childhood and adolescence and causes almost 25% of admissions in Pediatric Intensive Care Units (PICU). We have evaluated the initial assesment of the severely injured children admitted in our PICU (pre-hospital care). MATERIAL AND METHODS: We reviewed the children younger than 16 years admitted in our PICU between January 1996 and December 2002. Prehospital caretakers, transportation after initial evaluation and therapeutic management were analized, using Pediatric Trauma Score (PTS) and Pediatric Risk of Mortality Score (PRISM) as predictors of injury severity and mortality, respectively. RESULTS: We treated 152 traumatized children in this period, 106 males and 46 females, with a mean age of 7.5 +/- 4.3 years. 116 patients received inmediate medical care with a mean PTS significatively greater than non-medical group (12 children). Non-medical caretakers treated 8.1% of severe trauma (PTS<8). Specialized transporter was inadequated in 7.1% of severe traumatized children. Gastric and vesical tube and spinal inmobilization were accomplished in 50%, specially in children with low PTS and high PRISM. We found a great variability in fluid and drugs administration. CONCLUSIONS: Although there has been a good evolution in treatment of pediatric trauma, in order to diminish morbidity and mortality it is necessary to identify and correct deficiencies in management, specially during the "golden hour", and train pre-hospital caretakers in pediatric trauma management.

[Usefulness of video-assisted thoracic surgery techniques in intra-thoracic mass resection in children]. / Utilidad de las técnicas de cirugía torácica vídeo asistida en la extirpación de masas intratorácicas en el niño.

The progressive advances in Minimally Invasive Surgical Procedures, are applied presently to the surgical treatment of intra-thoracic injuries in children by way of Video-Assisted Thoracic Surgery (VATS) techniques. We present the complete findings of two intra-thoracic masses, in an infant and in a school-aged child, with the use of the VATS technique. The operative technique is detailed in each case. We conclude that the lack of invasiveness and cost-efficiency of VATS the technique, constitute it as being the first choice in the treatment of intra-thoracic masses in children.

[Fascia lata transplant from cadaveric donor in the reconstruction of abdominal wall defects in children]. / Injerto de fascia lata de donante cadáver en la reconstrucción de defectos de pared abdominal en niños.

INTRODUCTION: Abdominal wall closure is not possible in large congenital defects, even after extensively stretching in to enlarge its capacity. The skin coverage is usually adequate but the aponeurotic defect has to be closed temporally using synthetic patches. The use of these materials leads to increase complication such as infection, fistula formation and extrusion. In addition a second operation is required to remove the material and to perform a definitive closure. The role of fascia lata in reconstruction of abdominal wall is well established as free grafts, pedicled flaps or free flaps. Bank cadaveric fascia lata is used extensively in neurosurgical, ophtalmological, orthopaedic and urogynecological procedures. This is the first description of the use of cadaveric fascia lata for the closure of large abdominal wall defects. CASE REPORTS: We present two cases of congenital diaphragmatic hernia. The first patient was a newborn who presented the impossibility to close the fascia, that was salvaged by a teflón patch. Five months later the wound opened, leaving the mesh exposed that had to be removed. A cadaveric fascia lata patch was used to cover the defect, closing the skin satisfactorily. The second case was a two days newborn. We performed the diaphragmatic closure, and the aponeurotic defect was closed using cadaveric fascia lata. RESULTS: Cosmetic and functional appearance are satisfactory in both cases and no complications have been seen. CONCLUSION: Fascia lata patches are revascularized in the abdominal wall and incorporates into receptor tissue. They have the following advantages with respect to synthetic materials: First, the risk of complications is lower. Second, their removal is not necessary. Finally, no intraperitoneal adhesions occur. The risks of disease transmission and rejection are minimized by the Centro Comunitario de Transfusiones donor selection and processing of the cadaveric fascia lata.