Sutureless inguinal hernia repair with creation of a peritoneal lesion in children: a novel laparoscopic technique with a low recurrence rate.

BACKGROUND: Hernia repair represents about 25% of all pediatric surgeries. Repair can be done using an open or laparoscopic technique. The open approach has a reported recurrence rate of 1.2% but requires an additional incision to repair for a contralateral hernia. With the laparoscopic approach, no additional incision is needed but the recurrence rate has been reported to be as high as 4%. The objective of this study was to assess the safety and efficacy of a novel sutureless laparoscopic inguinal hernia repair that has the advantages of both approaches. METHODS: Since April 2014 up to March 2017, 26 children (12 girls and 14 boys) aged 3 months to 13 years underwent sutureless laparoscopic inguinal hernia repair. The peritoneum around the internal inguinal ring was severed and folded into the inguinal canal. Regeneration of the peritoneum around the inguinal ring creates a scar that effectively closes the internal orifice. RESULTS: No recurrences or complications were observed in any of the 26 cases after a follow-up of 1-35 months (median, 14 months). CONCLUSIONS: Sutureless laparoscopic inguinal hernia repair provides a new option for the management of patients with a pediatric inguinal hernia. The procedure does not require advanced laparoscopic skills, is easily reproducible, and is safe. THERAPEUTIC STUDY: Level of Evidence IV.

The amniotic band syndrome in the rat is associated with the activation of transforming growth factor-ß.

Amniocentesis in rats is associated with different malformations, such as cleft palate and limb deformation, resembling the human congenital amniotic band syndrome (ABS). Despite many human cases reported in the literature, little is known about the mechanisms involved in ABS. This study addressed if the activation of the transforming growth factor-ß1 (TGF-ß1) pathway is, in part, associated with amniotic band formation and growth restriction induced in rats by amniocentesis, as by a previously published model. For this purpose, quantification of TGF-ß1, α-smooth muscle actin, and collagen type I mRNA and protein levels were determined by quantitative PCR and Western blot analysis, respectively, in the fetus, its amniotic membrane, and the uterus of experimental and control rats. We found that TGF-ß1 mRNA levels are increased in the fetus and the amniotic membrane at 6 hours, whereas α-smooth muscle actin, phosphorylated Smad3, and collagen type I increased at 48 hours, suggesting that a fibrotic response is induced after the amniotic sac puncture. Furthermore, fetuses had hemorrhages, syndactyly, and amputation of limbs, similar to human ABS.

Changes in blood parameters in rhesus monkeys (Macaca mulatta) during the first trimester of gestation.

BACKGROUND: Regarding the good practice in the laboratory work, it is essential to have a broad spectrum of biochemical and hematological references in pregnant females to determine the health status of the colony. OBJECTIVE: To establish reference values to reveal changes in hematology and blood chemistry in pregnant rhesus monkeys (Macaca mulatta) in their first trimester of pregnancy. METHODS: Twenty-eight females in reproductive stage were used, divided into two groups: 14 pregnant macaques in their first trimester and 14 non-pregnant used as the control group. Blood samples were collected for the hematological test and blood chemistry. RESULTS: The results showed significant difference in the blood chemistry for the following parameters: glucose, total bilirubin, and total protein. The hematological evaluation revealed significant difference in leukocytes and neutrophils. CONCLUSIONS: These findings offer a reference range and provide a basis for improvement in techniques and refinement of clinical processes in these specimens.

Preliminary studies of neurosensory and cardiopulmonary health compromise in captive- bred Rhesus macaques (Macaca mulatta) suffering scoliosis.

BACKGROUND: It has been widely documented that quadrupedal animals rarely display natural spontaneous scoliotic rachis deviations of the spinal column. The objective was to determine spinal deformities developed by geriatric monkeys of the Macaca mulatta species, by radiographical and tomographical studies of the vertebral column correlating morphological changes with altered physiological parameters and electrical neurosensorial conductivity of somatosensory-evoked potentials (SEPs). MATERIALS AND METHODS: A cohort of six geriatric monkeys was used: three non-scoliotic subjects and three monkeys with naturally acquired true scoliosis. RESULTS: Radiographic and tomographic studies depicted a thoracic curvature displaying a left-sided thoracic vertebral rotation. The evaluation of physiological parameters demonstrated significant differences in the respiratory rate, as it was observed for the diastolic blood pressures, which showed a decrease in the monkeys with scoliosis compared with healthy monkeys. Regarding the SEPs studies, the non-parametric test for independent samples Mann-Whitney U test displayed a significant difference observed at the left and right thoracic derivative in P1; while regarding the study of upper limbs, a significant difference was seen at the Erb's point derivative, left afferency in P1, showing in all the derivatives an increase in latency in monkeys with scoliosis versus monkeys in the control group. CONCLUSIONS: This study has demonstrated that quadrupedal animals can develop true scoliosis showing an analogous way to that occurring in humans.

Postsurgical intestinal occlusion ileum-ileum double intussusception in eleven-month girl.

BACKGROUND: Postoperative intussusception is an unusual complication in children; the incidence is 0.01-0.25%. CLINICAL CASE: Female of 11 months who underwent colostomy, 48 h later presents abdominal pain, vomiting gastrobiliar and abdominal distension. A laparotomy was performed, finding a double ileo-ileal invagination 60 cm from the ileocecal valve. DISCUSSION: The postoperative intestinal invaginations are extremely rare and most of them occur within the first 7 days. The etiology of postoperative intussusception is unknown. CONCLUSIONS: Postoperative children with intestinal occlusion, intussusception should be suspected and an immediate laparotomy should be performed.

ANTECEDENTES: La invaginación posoperatoria es una complicación inusual en niños. Su incidencia es del 0.01-0.25%. CASO CLÍNICO: Niña de 11 meses a quien se realizó colostomía y 48 horas después presentó dolor abdominal, vómito gastrobiliar y distensión abdominal. Se realizó laparotomía y se encontró una doble invaginación íleo-ileal a 60 cm de la válvula ileocecal. DISCUSIÓN: Las invaginaciones intestinales posoperatorias son extremadamente raras y la mayoría se presentan dentro de los primeros 7 días. La etiología de la invaginación posoperatoria es desconocida. CONCLUSIONES: En niños operados con oclusión intestinal debe sospecharse invaginación intestinal y realizar una laparotomía inmediata.

[Divertículo de Meckel con tejido pancreático ectópico en un niño de 12 años con invaginación intestinal. Reporte de caso y revisión de la literatura]. / Meckel diverticulum with ectopic pancreatic tissue in a 12-year-old boy with intestinal invagination. Case report and review of the literature.

INTRODUCCIÓN: El divertículo de Meckel es un remanente del conducto onfalomesentérico y su prevalencia es del 2%. CASO CLÍNICO: Niño de 12 años con dolor abdominal, acompañado de evacuaciones mucosanguinolentas y hematemesis, con masa en cuadrante inferior derecho. En la laparotomía quirúrgica se encontró invaginación, y se realizó desinvaginación y resección del divertículo de Meckel. CONCLUSIÓN: La asociación de divertículo de Meckel con tejido pancreático heterotópico en niños es poco frecuente. Clínicamente, su principal manifestación es la invaginación intestinal en la literatura revisada, y el ultrasonido constituye el mejor estudio para el diagnóstico de invaginación intestinal, no así para el divertículo de Meckel o el tejido pancreático heterotópico, en los que la tomografía sería una opción. INTRODUCTION: Meckel's diverticulum is a remnant of the omphalomesenteric duct and its prevalence is 2%. CLINICAL CASE: A 12-year-old male with abdominal pain, accompanied by muco-sanguineous evacuations and hematemesis, with right lower quadrant mass. In the laparotomy, invasion was found; intussusception reduction and resection of the Meckel's diverticulum was performed. CONCLUSION: The association of Meckel's diverticulum with heterotopic pancreatic tissue in children is rare, its main manifestation is intussusception and ultrasound is an option for diagnosis.

[Development of an animal model of myelomeningocele and options for prenatal treatment in Macaca mulatta]. / Desarrollo de un modelo animal de mielomeningocele y opciones de tratamiento prenatal en Macaca mulatta.

BACKGROUND: Myelomeningocele is the most common congenital malformation of the central nervous system, with a reported incidence of 4.4-4.6 cases/10,000 live births in the U.S. Experimental studies demonstrated that the neurological deficit is not a cause for a primary defect in neurulation but is probably due to the progressive mechanical and chemical damage of amniotic liquid into the nerve tissue, which remained without protection during gestation. We undertook this study to develop an animal model in myelomeningocele in Macaca mulatta and compare the results of prenatal management between the colocations of an impermeable silicone mesh and closed with skin. METHODS: A total of nine macaques were surgically intervened, randomly assigned between 12 and 14 weeks of gestation. A laminectomy was carried out in a fetus with bone marrow exposure. The defect was closed with skin or mesh. Three fetuses were left completely exposed. Descriptive statistics were done by ANOVA. RESULTS: Of the four surviving fetuses (44%), none presented complications in mobility in the somatosensory evoked potential, hydrocephalus, or in sphincter control. Only one fetus developed bony deformities. The majority of time of the surgical procedure was due to the use of mesh and the least amount of time was involved in skin closing (p<0.005). CONCLUSIONS: Macaca mulatta is an appropriate model for reproducing myelomeningocele and to evaluate the different options for prenatal management. Colocation of an impermeable silicone mesh is feasible, protecting the spine from amniotic liquid, with results similar to skin closure.

[Congenital anomaly band, a rare cause of intestinal obstruction in children. Case report]. / Banda congénita anómala una patología rara de obstrucción intestinal en niños. Caso clínico.

BACKGROUND: Intestinal obstruction in children may be congenital, acquired, intrinsic or extrinsic. Most intestinal obstructions in children are the result of postoperative adhesions. Those caused by anomalous congenital band are extremely rare. CLINICAL CASE: Patient of a 1-year-old male, with no previous history of abdominal surgery or trauma. He suffered with vomiting of bile content and loss of appetite at home three days before admission. On physical examination, he was irritable, with abdominal distention, absence of peristalsis and abdominal tenderness, with no signs of peritoneal irritation being found. The blood count reported leucocytosis and the x-rays show dilated small bowel loops, fluid levels and absence of air in rectal ampulla. An open laparotomy was subsequently performed, and the intraoperative findings were consistent with a congenital band extending from the anti-mesenteric wall of the jejunum to the root of mesentery, compressing the ileum at 50cm from the ileocecal valve, causing ischaemia. The band was ligated and divided, with an uneventful postoperative course. He was discharged 4 days later without complications. CONCLUSIONS: The anomalous congenital band is not associated with abdominal problems, such as remnants of previous laparotomies or embryological structures, such as vitelline vessels or omphalomesenteric yolk duct. These bands seem to have a congenital origin and cause bowel obstruction by trapping between the band and the mesentery. The diagnosis of anomalous congenital band is extremely difficult and no imaging study is useful for the diagnosis, and only exploratory laparotomy or laparoscopy is useful for diagnosis and treatment of this problem.

[Jejunal intussusceptions as a lead point ectopic pancreatic tissue in a 1-year-old male. Case report]. / Invaginación yeyuno-yeyunal secundaria a tejido pancreático ectópico en un lactante de un año de edad. Reporte de caso.

BACKGROUND: intussusception is the most common cause of acute bowel obstruction in infants and young children. Incidence has been reported as 1.5 to 4 cases per 1,000 live births. Most intussusceptions are ileocecocolic; jejunal intussusceptions in children is extremely rare. CLINICAL CASE: a 1-year-old male was admitted to the emergency department with diarrheal evacuations, without mucus or blood, crying and irritable. Previously he had melaena in one occasion. The abdomen was found soft and depressible and low pain. He was treated with ceftriaxone, omeprazole and metoclopramide. Two days after admission he had melaena and rectal bleeding. Plain abdominal radiography showed air fluid levels. Abdominal surgery was performed finding jejunal intussusceptions which were reduced. Demonstrable lesion as a lead point was a small tumor that was removed. The pathologist's report showed pancreatic islets cells. CONCLUSIONS: jejunal intussusceptions in children are extremely rare and occur at any age. Main symptoms are intermittent abdominal pain and vomiting. Ultrasonography is the study of choice. Often a lesion is demonstrable as a lead point for the intussusceptions and therefore requires open or laparoscopic surgery. In this case, it was unusual to have the presence of ectopic pancreatic tissue as a lead point.

Cecum duplication in a 14-year-old female. Case report.

BACKGROUND: Duplications of the alimentary tract are a group of rare malformations occurring in about 1/5,000 live births. These may be either spherical or tubular and may communicate with the intestinal tract. Duplications of the cecum are very uncommon. CLINICAL CASE: A 14-year-old female was admitted to the emergency department with a 1-day history of abdominal pain, vomiting, constipation and abdominal distension. Abdominal examination revealed distension and tenderness around the umbilicus. Plain abdominal radiography showed dilated colon. The patient underwent surgical management with diagnosis of sigmoid volvulus. Laparotomy revealed spherical duplication from the cecum. Hemicolectomy was done and alimentary continuity was restored by end-to-end anastomosis. Pathological report was a spherical communicated duplication from the cecum (22 × 32 cm). CONCLUSIONS: Duplication of the cecum is extremely rare and is seen in 0.4% of duplications of the alimentary tract. The majority of cases (85%) are diagnosed before age 2 years. It is rare at 14 years of age. Diagnosis is difficult and volvulus, intussusception or appendicitis should be considered in the differential diagnosis. Ultrasonography and tomography are the imaging studies of choice. Plain abdominal x-ray is not specific. Resection of the duplication with restoration of alimentary continuity is the treatment of choice.

Latencies obtained of the somatosensory evoked potentials of the median and tibial nerve in rhesus monkey undergoing intrauterine laminectomy to simulate myelomeningocele.

BACKGROUND: Somatosensory evoked potentials (SSEP) have been described as excellent indicators of the degree of medullar injury in degenerative and metabolic diseases of the central nervous system (CNS). The prevalence of neural tube defects (NTD) is 6 cases/10,000 live newborns worldwide. It is thought that genetic as well as environmental factors contribute to the etiology of NTD. The objective of this study was to analyze and compare the latencies obtained by means of SSEP in a clinically healthy monkey vs. rhesus monkeys with intrauterine surgery in order to simulate surgically the neural tube defect (myelomengocele) by performing an intrauterine laminectomy and in which later the defect was corrected. METHODS: This study was performed using three non-human primates of the Macaca mulatta species. There were practice intrauterine surgeries in two monkeys to simulate the neurological defect produced by myelomeningocele, using the third monkey as control. For statistical methodology four monkeys were used. They were born by natural birth without any surgical manipulation. With the cesarean-obtained products, stimulation was performed of the tibial and median nerve. RESULTS: We observed that the hind limbs were the most affected, in particular, the left afferent of the monkey. The spinal cord was exposed to amniotic fluid, and there were no significant differences in the forelimbs. CONCLUSIONS: The use of SSEP provides valuable information regarding preservation of sensorial functions in a variety of experimental neurological abnormalities.

Congenital stenosis of the colon with foreign bodies. Case report.

BACKGROUND: Colonic stenosis is rarely seen in pediatric practice. Its incidence has been reported as 1/40,000 births. Ascending and transverse colon are the most common sites affected. Symptoms may be present at birth. CLINICAL CASE: We present the case of a 2 year, 11 month old male. Since birth, the patient had symptoms of constipation, abdominal pain and abdominal distension. X-ray of the abdomen showed a dilated colon and foreign bodies on the right side. Barium enema was normal. The stenotic segment was resected. Foreign bodies were removed and alimentary continuity was restored by end-to-end anastomosis. The pathologist found a 5-cm lumen at the stenosis. Histological ganglion cells were present throughout the specimen. The patient evolved favorably postoperatively and was discharged 1 week after surgery. The patient has been in good health for 2 years. CONCLUSIONS: Colonic stenosis is uncommon. Abu-Judeh reported on one case and a review of the literature revealed eight cases of congenital colonic stenosis since 1941. Symptoms are abdominal distension, vomiting and constipation with symptom remission, making diagnosis difficult. This is the first report involving foreign bodies. Barium enema and colonoscopy are necessary for diagnosis. Resection of the stenotic segment with end-to-end anastomosis or colostomy is the treatment of choice. Laparoscopy is an alternative procedure.

Effective analgesic between acetominophen + B vitamins vs. acetominophen in pediatric ambulatory surgery.

BACKGROUND: analgesics in pediatric ambulatory surgery must be safe and effective. Acetominophen is safe with moderate efficacy; therefore, we searched for other drugs. In preclinical trials, improved efficacy was reported with the combination of acetaminophen + B vitamins. The aim of this study was to determine the analgesic efficacy of acetaminophen + B vitamins in pediatric ambulatory surgery. METHODS: we conducted a clinical, comparative, randomized, double-blind study. We included 56 patients who were divided into four groups of 14 patients for each surgery (circumcision, tonsillectomy, inguinal hernioraphy, orchiopexy). Half of the patients received acetaminophen + B vitamins, and the remaining patients received acetaminophen alone. Variables were drugs, visual analogue scale and time of discharge. χ(2), Student t-test and analysis of variance (ANOVA) were used for statistical analysis. RESULTS: in children who received acetaminophen + B vitamins during the immediate postoperative period, 58% had a pain score <2 and 89% were discharged with a pain score %lt;1. Both schedules were effective and safe but acetaminophen + B vitamins showed a better pain score. CONCLUSIONS: the adjuvant effect of B vitamins was demonstrated with a better pain score in the immediate postoperative period and at the time of discharge.

Subhepatic appendicitis with subdiaphragmatic abscess in a pediatric patient without intestinal malrotation: case report.

BACKGROUND: Acute subhepatic appendicitis in children is an uncommon presentation. It is usually associated with intestinal malrotation. When these conditions are met, accurate diagnosis and early management decisions are delayed. CLINICAL CASE: We present the case of a 10-year-old male who had diarrhea without mucus or blood for 5 days. He was treated with antibiotics. Afterwards, he presented with vomiting, abdominal pain, and fever. Physical examination of the abdomen demonstrated a soft and depressible mass and pain in the lower right abdomen. Abdominal ultrasound and tomography reported image of subdiaphragmatic abscess. Percutaneous puncture and drainage were performed without results. Exploratory laparotomy was then performed, revealing a subhepatic perforation of the appendix. The patient evolved with abdominal sepsis and septic shock, resulting in a new surgical intervention for drainage of serohematic fluid. The patient improved and was discharged on day 40. DISCUSSION: It is very important to consider the position of the anatomic appendix during appendicitis because it contributes to the various clinical symptoms, of which 30% are atypical. Diagnosis is masked, leading to complications such as perforations and/or abscesses that extend the hospital stay. CONCLUSIONS: Acute subhepatic appendicitis in children is an uncommon presentation. It is usually associated with intestinal malrotation. Delay in treatment due to atypical symptoms caused by the abnormal position of the appendix conditioned complications that implied a prolonged hospital stay, with the risk of increasing morbidity and mortality of the patient.

Anesthetic management in intrauterine surgery to evaluate an experimental model of myelomeningocele in non human primates (Macaca mulatta).

PURPOSE: Evaluate the anesthetic management in intrauterine surgery to induce myelomeningocele in non human primates Macaca mulatta. METHODS: A total of nine fetuses had intrauterine surgery; laminectomy was performed on them in L5 and L6. The studied variables were: maternal death, fetus death, cardiac frequency, respiratory frequency, arterial pressure, temperature, and oxygen saturation. RESULTS: No maternal or fetal deaths occurred; the only variable that was reported below the normal ranges was temperature. CONCLUSION: No maternal or fetal deaths occurred; the only variable that was reported below the normal ranges was temperature.

Radiographic incidence of spinal osteopathologies in captive rhesus monkeys (Macaca mulatta).

Degenerative spinal disease is a leading cause of chronic disability both in humans and animals. Although widely seen as a normal occurrence of aging, degenerative spinal disease can be caused by various genetic, iatrogenic, inflammatory, and congenital factors. The objective of this study was to characterize the degenerative spine-related diseases and the age at onset in a random subpopulation of 20 captive rhesus monkeys (Macaca mulatta; male, 13; female, 7; age: range, 4 to 27 y; median, 18.5 y). Spinal radiographic evaluation (left lateral, right lateral, and ventrodorsal views) of the spinal column (C1 to S1) was performed, and spinal degenerative disease was scored. The incidence of osteopathology was higher in the 14- to 18-y-old group, but incidence did not differ according to sex. In the studied population, degenerative changes were present in monkeys as young as 9 y of age.

Estenosis congénita de colon con retención de cuerpos extraños: informe de un caso / Congenital stenosis of the colon with foreign bodies: case report

Introducción: La estenosis del colon es rara, con una incidencia de uno entre 40 mil nacimientos. El colon ascendente y transverso son los más afectados. Las manifestaciones clínicas pueden aparecer desde el nacimiento. Caso clínico: Niño de dos años 11 meses de edad, con cuadros periódicos de estreñimiento, dolor tipo cólico y distensión abdominal. La radiografía simple de abdomen mostró dilatación de asas y cuerpos extraños. El colon por enema fue normal. Por laparotomía exploradora se identificó estenosis en el colon transverso. Se practicó resección, extracción de cuerpos extraños y anastomosis término-terminal. El examen histopatológico mostró estenosis con lumen de 0.5 cm; las células ganglionares estuvieron presentes entre las capas musculares. A dos años de la cirugía, el paciente se encontraba asintomático. Conclusiones: La estenosis congénita de colon es poco frecuente. Abdu-Judeh informa un caso y refiere ocho descritos desde 1941. Las manifestaciones clínicas son estreñimiento, vómito y distensión abdominal, sin embargo, los pacientes pueden permanecer asintomáticos por periodos variables, lo que dificulta y retrasa el diagnóstico. No existe informe previo acerca de la retención de cuerpos extraños. El colon por enema y la colonoscopia son necesarios para el diagnóstico oportuno. El tratamiento electivo es la resección quirúrgica con anastomosis primaria o colostomía; una opción es la cirugía laparoscópica.

BACKGROUND: Colonic stenosis is rarely seen in pediatric practice. Its incidence has been reported as 1/40,000 births. Ascending and transverse colon are the most common sites affected. Symptoms may be present at birth. CLINICAL CASE: We present the case of a 2 year, 11 month old male. Since birth, the patient had symptoms of constipation, abdominal pain and abdominal distension. X-ray of the abdomen showed a dilated colon and foreign bodies on the right side. Barium enema was normal. The stenotic segment was resected. Foreign bodies were removed and alimentary continuity was restored by end-to-end anastomosis. The pathologist found a 5-cm lumen at the stenosis. Histological ganglion cells were present throughout the specimen. The patient evolved favorably postoperatively and was discharged 1 week after surgery. The patient has been in good health for 2 years. CONCLUSIONS: Colonic stenosis is uncommon. Abu-Judeh reported on one case and a review of the literature revealed eight cases of congenital colonic stenosis since 1941. Symptoms are abdominal distension, vomiting and constipation with symptom remission, making diagnosis difficult. This is the first report involving foreign bodies. Barium enema and colonoscopy are necessary for diagnosis. Resection of the stenotic segment with end-to-end anastomosis or colostomy is the treatment of choice. Laparoscopy is an alternative procedure.

Anesthetic management in intrauterine surgery to evaluate an experimental model of myelomeningocele in non human primates (Macaca mulatta) / Anestesia em cirurgia intra-uterina para avaliar um modelo experimental de mielomeningocele em primatas não humanos (Macaca mulatta)

PURPOSE: Evaluate the anesthetic management in intrauterine surgery to induce myelomeningocele in non human primates Macaca mulatta. METHODS: A total of nine fetuses had intrauterine surgery; laminectomy was performed on them in L5 and L6. The studied variables were: maternal death, fetus death, cardiac frequency, respiratory frequency, arterial pressure, temperature, and oxygen saturation. RESULTS: No maternal or fetal deaths occurred; the only variable that was reported below the normal ranges was temperature. CONCLUSION: No maternal or fetal deaths occurred; the only variable that was reported below the normal ranges was temperature.

OBJETIVO: Avaliar o manejo anestésico em cirurgia intra-uterina para induzir mielomeningocelo em primatas não humanos, Macaca mulatta. MÉTODOS: Operaram-se um total de nove fetos in útero que foram submetidos à laminectomia em L5 e L6. As variáveis a estudar foram mortes maternas ou fetais, freqüência cardíaca e respiratória, pressão arterial, temperatura e saturação de oxigênio. RESULTADOS: Não se apresentaram mortes maternas ou fetais, a temperatura se manteve abaixo dos 36°C, não tendo repercussões no bem-estar dos macacos. CONCLUSÃO: Não ocorreu nenhum óbito materno ou fetal, sendo que a única variável abaixo do normal foi a temperatura.

Apendicitis subhepática con absceso subdiafragmático en paciente pediátrico sin malrotación intestinal: informe de un caso / Subhepatic appendicitis with subdiaphragmatic abscess in a pediatric patient without intestinal malrotation: case report

Introducción: Los cuadros de apendicitis aguda subhepática en niños son raros y no siempre se acompañan de malrotación intestinal, lo que dificulta el diagnóstico y manejo temprano. Caso clínico: Niño de 10 años de edad, con padecimiento de cinco días de evolución caracterizado por evacuaciones diarreicas, tratado con antibióticos. Posteriormente presentó vómito, dolor abdominal tipo cólico y fiebre de 39 °C. El abdomen se encontró blando y depresible, con escaso dolor en flanco derecho. El ultrasonido y la tomografía mostraron imagen compatible con absceso subdiafragmático. Se manejó con drenaje externo. Al no obtener respuesta se realizó laparotomía exploradora, encontrando apéndice inflamada, de 10 cm de longitud, en posición ascendente sobre la corredera parietocólica derecha y perforación del extremo distal a nivel subhepático. El paciente evolucionó con sepsis abdominal y choque séptico, requiriendo nueva intervención quirúrgica para drenaje de líquido serohemático. A los 40 días el paciente fue dado de alta. Conclusiones: La consideración anatómica del apéndice es importante, por las múltiples presentaciones clínicas, de las cuales 30 % son atípicas y el diagnóstico se enmascara ocasionando complicaciones como perforación y abscesos. Los casos de apendicitis aguda de localización subhepática son raros y por lo general se asocian a malrotación del intestino. El retraso del tratamiento relacionado con el cuadro atípico, ocasionado por la posición poco habitual del apéndice, implica estancia hospitalaria más prolongada y riesgo de incrementar la morbilidad y mortalidad.

BACKGROUND: Acute subhepatic appendicitis in children is an uncommon presentation. It is usually associated with intestinal malrotation. When these conditions are met, accurate diagnosis and early management decisions are delayed. CLINICAL CASE: We present the case of a 10-year-old male who had diarrhea without mucus or blood for 5 days. He was treated with antibiotics. Afterwards, he presented with vomiting, abdominal pain, and fever. Physical examination of the abdomen demonstrated a soft and depressible mass and pain in the lower right abdomen. Abdominal ultrasound and tomography reported image of subdiaphragmatic abscess. Percutaneous puncture and drainage were performed without results. Exploratory laparotomy was then performed, revealing a subhepatic perforation of the appendix. The patient evolved with abdominal sepsis and septic shock, resulting in a new surgical intervention for drainage of serohematic fluid. The patient improved and was discharged on day 40. DISCUSSION: It is very important to consider the position of the anatomic appendix during appendicitis because it contributes to the various clinical symptoms, of which 30% are atypical. Diagnosis is masked, leading to complications such as perforations and/or abscesses that extend the hospital stay. CONCLUSIONS: Acute subhepatic appendicitis in children is an uncommon presentation. It is usually associated with intestinal malrotation. Delay in treatment due to atypical symptoms caused by the abnormal position of the appendix conditioned complications that implied a prolonged hospital stay, with the risk of increasing morbidity and mortality of the patient.

Duplicación vésico-génito-rectal asociada a otras malformaciones congénitas mayores / Urinary bladder, genital, and rectal duplications associated with gastrointestinal and respiratory malformations

Introducción. Se reporta el caso de una niña con múltiples malformaciones congénitas mayores a nivel genitourinario, de tubo digestivo y pulmonar que requirió tratamiento quirúrgico con buenos resultados.Caso clínico. La paciente nació de término, con antecedente de ingestión materna de difenilhidantoína y alfametildopa durante el embarazo, con malformaciones varias en las que destacaban: genitales externos ambiguos, duplicación de vejiga, vagina y recto, ano imperforado, complejo malformativo de cloaca, secuestro pulmonar apical derecho con fístula a esófago. El tratamiento fue mediante cirugías correctivas en diferentes tiempos con buenos resultados, actualmente la paciente tiene un buen funcionamiento de los órganos reparados. Conclusión. La asociación de malformaciones congénitas mayores en diferentes órganos es poco frecuente. En este caso la reparación quirúrgica de cada una de ellas fue satisfactoria.