[Probabilistic algorithm for management of suspected foreign body aspiration in children]. / Protocolo probabilístico para el manejo del cuerpo extraño en la vía aérea.

INTRODUCTION: The aim is to create a protocol for the managing of foreign body aspiration in children based on a probability scale. MATERIAL AND METHODS: Retrospective observational study, including patients admitted with suspected foreign body aspiration (FBA) in the last 15 years. The parameters were assessed with a SCORE that included witnessed choking, stridor and wheezing during choking, unilateral reduced air entry and abnormal X-Ray. This scale relates them to a probability of FBA, where a score ≤ 1 is associated with less than 10% and ≥ 4 with more than 50% of FBA. According to the probability, we propose: observation, chest Computed Tomography (CT) or bronchoscopy. Then, we tried to adapt it to our casuistry. RESULTS: A total of 109 children admitted between 2002-2017 were included. The median age was 25 months, a foreign body was found in 88 patients, the most frequent being organic (seeds and nuts). Significant predictors of FBA were unilateral reduced air entry and abnormal X-Ray. In our study, we found the same ascending probability between the scale and the presence of foreign body, except for SCORE 1, which was 57% what we attribute to an information bias. If the foreign body were not nuts, inorganic or bone, its aspiration was very unlikely, that is why we included it in the SCORE with -1. CONCLUSION: The use of the algorithm would imply the performance of 7% more of CT in patients without a FBA, but avoiding an 8.5% of bronchoscopy. Our results present an information bias, characteristic of a retrospective study.

OBJETIVOS: Creación de un protocolo de manejo del cuerpo extraño (CE) en vía aérea (VA) basado en una escala de probabilidad. MATERIAL Y METODOS: Estudio retrospectivo observacional de pacientes con sospecha de aspiración de CE en 15 años. Los parámetros fueron valorados con un SCORE que contempla atragantamiento presenciado, estridor y sibilancias durante el atragantamiento, hipoventilación unilateral y radiografía alterada. Dicha escala los relaciona con una probabilidad de presencia de CE en VA, donde una puntuación ≤ 1 se asocia a menos de un 10% y ≥ 4 a > 50%. Según la probabilidad se plantea: observación, TAC o instrumentación de VA. A continuación se intentó optimizar en función de nuestra casuística. RESULTADOS: Se analizaron 109 pacientes (mediana 25 meses), identificándose CE en 88, principalmente frutos secos. De las variables predictoras solo fueron significativas: la hipoventilación unilateral y la radiografía alterada. En nuestra serie se observó la misma probabilidad ascendente entre la escala y la presencia de CE, excepto en la puntuación de 1 que fue del 57%, lo que atribuimos a un sesgo de información. Si el CE no era fruto seco, material inorgánico o hueso, era muy improbable su aspiración (p= 0) por lo que lo incluimos en el SCORE con un -1. CONCLUSIONES: La aplicación de la escala implicaría la realización de un 7,5% más de TAC en pacientes sin CE pero evitando un 8,5% de instrumentaciones de la VA. Nuestros resultados presentan un sesgo de información, propio de un estudio retrospectivo. Actualmente hemos iniciado la implementación prospectiva.

[Paracentesis as abdominal decompression therapy in neuroblastoma MS with massive hepatomegaly]. / Paracentesis como tratamiento descompresivo abdominal en neuroblastoma MS con hepatomegalia masiva.

Neuroblastoma MS with massive hepatomegaly is a small percentage of cases of neuroblastoma. It is more common in infants less than 4-6 weeks of life, and involves, in contrast to the standard of the NB MS, poor prognosis given the complications that can have. In the case of abdominal compartment syndrome it is recommended a quick start of chemotherapy, associating or not radiation therapy, to try to reduce the size of the liver, and if necessary, decompressive laparotomy. We present the case of a patient with NB MS, massive hepatomegaly and threatening symptoms for life, in which the surgical attitude that got relieve intra-abdominal compression syndrome consisted just in an evacuating paracentesis.

El neuroblastoma MS (o 4S según la nomenclatura clásica) con hepatomegalia masiva supone un mínimo porcentaje de los casos de neuroblastoma. Es más frecuente en lactantes de menos de 4-6 semanas de vida, y conlleva, al contrario que la norma del NB MS, mal pronóstico dadas las complicaciones que puede tener. En caso de síndrome compartimental abdominal se aconseja inicio rápido de tratamiento quimioterápico, asociando o no radioterapia para intentar reducir el tamaño del hígado, y en caso de ser necesario, laparotomía descompresiva. Presentamos el caso de una paciente con NB MS, hepatomegalia masiva y síntomas amenazantes para la vida, en la que la actitud quirúrgica que consiguió aliviar el síndrome de compresión intraabdominal consistió únicamente en paracentesis evacuadora.

Use of internal-external diversion stent in open pyeloplasty in patients under one year of age. / Uso de catéter de derivación interno-externo en la pieloplastia abierta en menores de un año.

INTRODUCTION: There are various alternatives available for renal pelvis drainage following pyeloplasty. One of them is the use of an internal-external diversion stent, which according to our protocol, is knotted 48 hours following surgery, prior to discharge, and removed 7 days later on an outpatient consultation basis, with no sedation or analgesia required. OBJECTIVE: To analyze the results of patients under one year of age who underwent open pyeloplasty associated with an outpatient internal-external diversion stent. MATERIALS AND METHODS: A retrospective, descriptive analysis of 28 patients (31 renal units) undergoing surgery from 2011 to 2021 was carried out. Diagnostic methods, indications, surgical approach, and postoperative progression were assessed. RESULTS: 28 patients (23 male) prenatally diagnosed with hydronephrosis confirmed by ultrasonography and/or renogram underwent pyeloplasty at a median age of 3 months (15 days-11 months). Pyeloplasty was conducted according to the Anderson-Hynes technique or dismembered pyeloplasty in 28 renal units, and according to the Culp-DeWeerd technique or spiral flap in 3. In all cases, an internal-external diversion stent was used according to our protocol. Mean hospital stay was 3.5 days (2-7 days), with a good postoperative progression. 2 patients had complications (urinary infection requiring intravenous antibiotics, and pyonephrosis requiring re-pyeloplasty). CONCLUSIONS: Using an internal-external diversion stent following pyeloplasty in patients under 1 year of age with ureteropelvic junction obstruction is a simple and safe option that allows for early discharge with outpatient management. It also avoids a second general anesthesia for drainage catheter removal purposes.

INTRODUCCION: Existen diversas alternativas para el drenaje de la pelvis renal tras una pieloplastia. Una de ellas es la utilización de un catéter de derivación interno-externo que, según nuestro protocolo, se anuda a las 48 horas posoperatorias previas al alta y se retira a los siete días de forma ambulatoria en consulta, sin necesidad de sedoanalgesia. OBJETIVO: Analizar los resultados de los pacientes menores de un año intervenidos mediante pieloplastia abierta, asociando un catéter de derivación interno-externo de manejo ambulatorio. MATERIAL Y METODOS: Análisis descriptivo retrospectivo de 28 pacientes (31 unidades renales) intervenidos entre los años 2011 y 2021. Se evaluaron métodos diagnósticos, indicaciones, abordaje quirúrgico y evolución posoperatoria. RESULTADOS: Veintiocho pacientes (23 varones) con diagnóstico prenatal de hidronefrosis confirmado con ecografía y/o renograma, fueron intervenidos mediante pieloplastia a una mediana de edad de tres meses (15 días-11 meses). Se realizó pieloplastia según técnica de Anderson-Hynes o pieloplastia desmembrada en 28 unidades renales y según técnica de Culp-DeWeerd o colgajo en espiral en 3. En todos los casos se utilizó un catéter de derivación interno-externo según protocolo. El tiempo medio de ingreso fue 3,5 días (2-7 días) con buena evolución posoperatoria. Dos pacientes presentaron complicaciones (infección urinaria que requirió antibioterapia intravenosa y pionefrosis que requirió repieloplastia). CONCLUSIONES: Asociar un catéter de derivación interno-externo a la pieloplastia en pacientes menores de un año con estenosis de la unión pieloureteral es una opción sencilla y segura que permite un alta precoz con manejo ambulatorio y evita una segunda anestesia general para la retirada del catéter de drenaje.

Common surgical training program: standardization of learning quality. / Programa de formación quirúrgica común: uniformidad en la calidad del aprendizaje.

INTRODUCTION: The various surgical specialties in our center have used the simulation and experimental surgery resources available for their training tasks in minimally invasive surgery (MIS) in an individualized manner. With this learning model, a great dispersion of effort and expense was observed, so it was decided to create a unified program based on the following: shared learning, synergy among specialties, moderation of the economic cost, and rational use of the facilities. OBJECTIVE: To describe and assess our consensually designed training program in order to consolidate a shared learning strategy that will enable our residents to acquire and perfect surgical skills in MIS. MATERIALS AND METHODS: The program consists of various increasingly complex phases implemented on a continuous basis throughout the period of specialized training in the virtual laboratory and experimental operating room. The assessment methods were based on quantifiable criteria: percentage of efficiency and completion time of the "McGill Inanimate System for Training and Evaluation of Laparoscopic Skills" (MISTELS) exercises at the beginning and end of the program. An economic study was also conducted. RESULTS: 20 residents have completed the program. Mean times show a significant reduction in each of the exercises. The efficiency percentages at the end of the program were higher than at the beginning (p < 0.001). The cost of the program represented a saving of 67.89%. CONCLUSION: The new MIS training program improved the quality of learning in a safe environment, establishing common criteria among the different specialties and an improved use of resources.

INTRODUCCION: Las diferentes especialidades quirúrgicas de nuestro centro han usado los recursos de simulación y cirugía experimental para sus tareas de formación en cirugía mínimamente invasiva (CMI) de manera individualizada. Con este modelo de aprendizaje se detectó una gran dispersión de esfuerzos y gasto, por lo que se decidió crear un programa unificado basado en: aprendizaje compartido, sinergia entre especialidades, moderación del coste económico y uso racional de las instalaciones. OBJETIVO: Describir y evaluar nuestro programa de entrenamiento diseñado por consenso de cara a la consolidación de una estrategia de aprendizaje compartido que permita a nuestros residentes adquirir y perfeccionar habilidades quirúrgicas en CMI. MATERIAL Y METODOS: El programa consta de diferentes fases con complejidad creciente desarrolladas durante todo el periodo de formación especializada de forma continuada en laboratorio virtual y quirófano experimental. Los criterios de evaluación se basaron en criterios cuantificables: porcentaje de eficiencia y tiempo de realización de los ejercicios de McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) al inicio y final del programa. Se realizó también el estudio económico. RESULTADOS: Han completado el programa 20 residentes. Los tiempos medios demuestran una reducción significativa en cada uno de los ejercicios. Los porcentajes de eficiencia al final fueron mayores que al inicio del programa (p < 0,001). El coste del programa supuso un ahorro del 67,89%. CONCLUSION: El nuevo programa de entrenamiento en CMI mejoró la calidad de aprendizaje en un entorno seguro, estableciendo criterios comunes entre las diferentes especialidades y un mayor aprovechamiento de los recursos.

[Hydrostatic enema outcome in patients with long history of ileocolic intussusception]. / Resultados del enema hidrostático en pacientes con clínica prolongada de invaginación ileocólica.

PURPOSE: Hydrostatic enema is the gold standard treatment for ileocolic intussusception in stable patients without radiologic complication. There is no consensus about the influence of long history of symptoms in the outcome of this treatment. The aim of this study is to determine whether hydrostatic enema is effective and safe in patients with history of ileocolic intussusception of over 24 hours. MATERIAL AND METHODS: Retrospective review of all patients with ileocolic intussusception admitted to our hospital between 2014 and 2017. We divided the patients in whom enema was attempted on into two groups according to the length of history: over or under 24 hours. Statistical analysis was done by using the Fisher's exact test. RESULTS: In this study period 59 children presented with ileocolic intussusception. Duration of symptoms was variable (range 2 hours-7 days). Of the total of patients, initial hydrostatic enema was attempted on 49, with a success rate of 91.8% (45 patients). In the group of history <24 hours (33 patients, 67.3%) we observed a 93.9% effectiveness and in the group >24 hours (16 patients, 32.7%) effectiveness was 87.5%. Success rate showed no significant difference when comparing both groups (p=0.588). No complications were seen after enema reduction. CONCLUSIONS: The use of hydrostatic enema in patients with long history of intussusception is successful and safe. We consider it to be the first-line treatment in stable patients with no radiologic complication, regardless the duration of symptoms.

OBJETIVOS: El gold standard para el tratamiento de la invaginación ileocólica en el paciente estable sin complicación radiológica es el enema hidrostático. No hay unanimidad sobre si la sintomatología prolongada de invaginación influye en los resultados de dicho tratamiento. El objetivo de este estudio es determinar si el enema hidrostático es efectivo y seguro en pacientes con clínica de invaginación ileocólica mayor de 24 horas. MATERIAL Y METODOS: Estudio retrospectivo de los pacientes diagnosticados de invaginación ileocólica en nuestro hospital entre 2014 y 2017. Hemos dividido en 2 grupos a los pacientes a los que se realizó enema en función del tiempo de clínica, mayor o menor de 24 horas. El análisis estadístico se realizó mediante el test exacto de Fisher. RESULTADOS: En este periodo se atendieron 59 niños con invaginación ileocólica con duración variable de los síntomas (2 horas a 7 días). Del total de pacientes, en 49 se realizó enema hidrostático inicial con una efectividad del 91,8% (45 pacientes). En el grupo de clínica <24 horas (33 pacientes, 67,3%) se objetivó una efectividad del 93,9% y en el grupo de clínica >24 horas (16 pacientes, 32,7%) se objetivó una efectividad del 87,5%. No hubo diferencias significativas al comparar la efectividad entre ambos grupos (p=0,588). En ningún paciente hubo complicaciones tras el enema. CONCLUSIONES: El empleo del enema hidrostático en pacientes con clínica prolongada de invaginación es efectivo y seguro. Consideramos que debería ser la primera herramienta terapéutica en el paciente estable sin complicación radiológica, independientemente del tiempo de evolución.

Octogenarian Donors in Liver Transplantation.

INTRODUCTION: Due to the disparity between the number of patients on the list for liver transplantation and the availability of organs, the use of older donors has become necessary. The aim of this study was to investigate the outcomes of liver transplantation using octogenarian donors. METHODS: From December 2003 to February 2016, 777 liver transplantations were performed at our institution, 33 of them (4.2%) with donors 80 years old and above. Our policy for the acceptance of these donors is based on preoperative liver function tests, donor hemodynamic stability, and intraoperative normal gross aspect. Octogenarian grafts were deliberately not assigned to retransplantations or to recipients with multiple previous surgical procedures or extensive portal thrombosis. RESULTS: Mean donor age was 82.7 ± 2.1 years, with a range between 80 and 88. Only 12.1% suffered hemodynamic instability during the intensive care unit stay. Three donors (9.1%) had a history of diabetes mellitus. The mean Model for End-Stage Liver Disease score among recipients was 14.7 ± 5.6. Mean cold ischemia time was 302 ± 61 minutes. After a median follow-up of 18.5 months (range 7.5 to 47.5), no graft developed primary nonfunction. We observed hepatic artery thrombosis in 1 patient (3%) and biliary complications in 4 patients (12.5%). There was 1 case of ischemic-type biliary lesion, although it was related to hepatic artery thrombosis. Patient survival at 1 and 3 years was 90.3%, whereas graft survival was 92.6% and 86.4%, respectively. CONCLUSIONS: Excellent mid-term results can be obtained after liver transplantation with octogenarian donors with strict donor selection and adequate graft allocation.

Social class, race/ethnicity, and incidence of breast, cervix, colon, lung, and prostate cancer among Asian, Black, Hispanic, and White residents of the San Francisco Bay Area, 1988-92 (United States).

BACKGROUND: To date only eight US studies have simultaneously examined cancer incidence in relation to social class and race/ethnicity; all but one included only black and white Americans. To address gaps in knowledge we thus investigated socioeconomic gradients in cancer incidence among four mutually exclusive US racial/ethnic groups-- Asian and Pacific Islander, black, Hispanic, and white-- for five major cancer sites: breast, cervix, colon, lung, and prostate cancer. METHODS: We generated age-adjusted cancer incidence rates stratified by socioeconomic position using: (a) geocoded cancer registry records, (b) census population counts, and (c) 1990 census block-group socioeconomic measures. Cases (n = 70,899) were diagnosed between 1988 and 1992 and lived in seven counties located in California's San Francisco Bay Area. RESULTS: Incidence rates varied as much if not more by socioeconomic position than by race/ethnicity, and for each site the magnitude - and in some cases direction - of the socioeconomic gradient differed by race/ethnicity and, where applicable, by gender. Breast cancer incidence increased with affluence only among Hispanic women. Incidence of cervical cancer increased with socioeconomic deprivation among all four racial/ethnic groups, with trends strongest among white women. Lung cancer incidence increased with socioeconomic deprivation among all but Hispanics, for whom incidence increased with affluence. Colon and prostate cancer incidence were inconsistently associated with socioeconomic position. CONCLUSIONS: These complex patterns defy easy generalization and illustrate why US cancer data should be stratified by socioeconomic position, along with race/ethnicity and gender, so as to improve cancer surveillance, research, and control.