Ambulation after in-utero fetoscopic and open spina bifida repair: predictors for ambulation at 30 months.

OBJECTIVE: Ambulatory outcomes from children who underwent a new minimally invasive fetal spina bifida surgery approach are included in this study for the first time. Identifying cases with better chances of independent ambulation from fetal life can have an important impact on patient counseling. The objectives of this study were: (1) To compare the ambulatory status of a cohort of children who had a prenatal spina bifida repair using two different methods (fetoscopic and open) with a cohort who underwent postnatal repair; and (2) to identify the best predictors for ambulation. METHODS: Retrospective review of a cohort of children who had spina bifida repair from 2011-2023 using prenatal fetoscopic surgery (N=73), prenatal open-hysterotomy surgery (N=37) or postnatal repair (N=51) in a single tertiary hospital. Consecutive sample of cases who underwent a spina bifida repair in utero following MoMs trial criteria and cases who underwent postnatal repair, meeting same criteria, also followed up after birth at the same institution. Motor function (MF) assessment by ultrasound was recorded at initial evaluation (MF1), 6 postoperative weeks or equivalent (MF2) and prior to delivery (MF3). Clinical exams to assess MF at birth and at 12 months were recorded. First sacral myotome (S1) MF was classified as "intact MF". Ambulatory status data at each follow-up visit was collected. The proportion of cases who were able to walk independently were compared between fetoscopic and open prenatal surgeries and between prenatal (by fetoscopic or open surgery) and postnatal spina bifida repair. Logistic regression analyses were performed to identify predictors for independent ambulation. RESULTS: At 30 months, the proportion of independent ambulators was higher in prenatally vs. postnatally repaired cases (51.8% vs.15.7%; p<0.01). No differences in ambulatory outcomes were seen in the comparison between fetoscopic (52%) vs. open (51.3%; p=0.95) prenatal repair. In the prenatal repair group, having an "intact MF" at 12 months [Odds ratio 7.71 (95%CI: 2.77-21.47), p<0.01] and at birth [4.38 (1.53-12.56), p<0.01], predicted significantly being an independent ambulator by 30 months; the anatomical level of lesion below L2 was also predictive for this outcome [3.68(1.33-9.88), p=0.01]. CONCLUSION: Ambulatory status by 30 months can be predicted by observing S1 MF postnatally. Results from this study have implications for parental counseling and planning for supportive therapies. This article is protected by copyright. All rights reserved.

Implication of chromosomal microarray analysis prior to in-utero repair of fetal open neural tube defect.

OBJECTIVE: In-utero repair of open neural tube defects (ONTD) is an accepted treatment option with demonstrated superior outcome for eligible patients. While current guidelines recommend genetic testing by chromosomal microarray analysis (CMA) when a major congenital anomaly is detected prenatally, the requirement for an in-utero repair, based on the Management of Myelomeningocele Study (MOMS) criteria, is a normal karyotype. In this study, we aimed to evaluate if CMA should be recommended as a prerequisite for in-utero ONTD repair. METHODS: This was a retrospective cohort study of pregnancies complicated by ONTD that underwent laparotomy-assisted fetoscopic repair or open-hysterotomy fetal surgery at a single tertiary center between September 2011 and July 2021. All patients met the MOMS eligibility criteria and had a normal karyotype. In a subset of the pregnancies (n = 77), CMA testing was also conducted. We reviewed the CMA results and divided the cohort into two groups according to whether clinically reportable copy-number variants (CNV) were detected (reportable-CNV group) or not (normal-CMA group). Surgical characteristics, complications, and maternal and early neonatal outcomes were compared between the two groups. The primary outcomes were fetal or neonatal death, hydrocephalus, motor function at 12 months of age and walking status at 30 months of age. Standard parametric and non-parametric statistical tests were employed as appropriate. RESULTS: During the study period, 146 fetuses with ONTD were eligible for and underwent in-utero repair. CMA results were available for 77 (52.7%) patients. Of those, 65 (84%) had a normal CMA and 12 (16%) had a reportable CNV, two of which were classified as pathogenic. The first case with a pathogenic CNV was diagnosed with a 749-kb central 22q11.21 deletion spanning low-copy-repeat regions B-D of chromosome 22; the second case was diagnosed with a 1.3-Mb interstitial deletion at 1q21.1q21.2. Maternal demographics, clinical characteristics, operative data and postoperative complications were similar between those with normal CMA results and those with reportable CNVs. There were no significant differences in gestational age at delivery or any obstetric and early neonatal outcome between the study groups. Motor function at birth and at 12 months of age, and walking status at 30 months of age, were similar between the two groups. CONCLUSIONS: Standard diagnostic testing with CMA should be offered when an ONTD is detected prenatally, as this approach has implications for counseling regarding prognosis and recurrence risk. Our results indicate that the presence of a clinically reportable CNV should not a priori affect eligibility for in-utero repair, as overall pregnancy outcome is similar in these cases to that of cases with normal CMA. Nevertheless, significant CMA results will require a case-by-case multidisciplinary discussion to evaluate eligibility. To generalize the conclusion of this single-center series, a larger, multicenter long-term study should be considered. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Association between ambulatory skills and diffusion tensor imaging of corpus callosal white matter in infants with spina bifida.

OBJECTIVES: To assess brain white matter using diffusion tensor imaging (DTI) at 1 year of age in infants diagnosed with open neural tube defect (ONTD) and explore the association of DTI parameters with ambulatory skills at 30 months of age. METHODS: Magnetic resonance imaging (MRI) was performed at an average of 12 months of age and included an echo planar axial DTI sequence with diffusion gradients along 20 non-collinear directions. TORTOISE software was used to correct DTI raw data for motion artifacts, and DtiStudio, DiffeoMap and RoiEditor were used for further postprocessing. DTI data were analyzed in terms of fractional anisotropy (FA), trace, radial diffusivity and axial diffusivity. These parameters reflect the integrity and maturation of white-matter motor pathways. At 30 months of age, ambulation status was evaluated by a developmental pediatrician, and infants were classified as ambulatory if they were able to walk independently with or without orthoses or as non-ambulatory if they could not. Linear mixed-effects method was used to examine the association between study outcomes and study group. Possible confounders were sought, and analyses were adjusted for age at MRI scan and ventricular size by including them in the regression model as covariates. RESULTS: Twenty patients with ONTD were included in this study, including three cases that underwent postnatal repair and 17 cases that underwent prenatal repair. There were five ambulatory and 15 non-ambulatory infants evaluated at a mean age of 31.5 ± 5.7 months. MRI was performed at 50.3 (2-132.4) weeks postpartum. When DTI analysis results were compared between ambulatory and non-ambulatory infants, significant differences were observed in the corpus callosum (CC). Compared with non-ambulatory infants, ambulatory infants had increased FA in the splenium (0.62 (0.48-0.75) vs 0.41 (0.34-0.49); P = 0.01, adjusted P = 0.02), genu (0.64 (0.47-0.80) vs 0.47 (0.35-0.61); P = 0.03, adjusted P = 0.004) and body (0.55 (0.45-0.65) vs 0.40 (0.35-0.46), P = 0.01, adjusted P = 0.01). Reduced trace was observed in the CC of ambulatory children at the level of the splenium (0.0027 (0.0018-0.0037) vs 0.0039 (0.0034-0.0044) mm2 /s; P = 0.04, adjusted P = 0.03) and genu (0.0029 (0.0020-0.0038) vs 0.0039 (0.0033-0.0045) mm2 /s; P = 0.04, adjusted P = 0.01). In addition, radial diffusivity was reduced in the CC of the ambulatory children at the level of the splenium (0.00057 (0.00025-0.00089) vs 0.0010 (0.00084-0.00120) mm2 /s; P = 0.02, adjusted P = 0.02) and the genu (0.00058 (0.00028-0.00088) vs 0.0010 (0.00085-0.00118) mm2 /s; P = 0.02, adjusted P = 0.02). There were no differences in axial diffusivity between ambulatory and non-ambulatory children. CONCLUSION: This study demonstrates a significant association between white matter integrity of connecting fibers of the corpus callosum, as assessed by DTI, and ambulatory skills at 30 months of age in infants with ONTD. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Massive digestive bleeding as a result of gastric heterotopy: a case report. / Sangrado digestivo masivo por heterotopia gástrica. Reporte de un caso.

INTRODUCTION: Gastric heterotopy is a rare entity in the pediatric population. It occurs in the gastrointestinal tract, leading to digestive bleeding. CLINICAL CASE: This is the case of a 10-year-old boy with gastric tissue in the proximal jejunum, which caused two massive digestive bleeding episodes. Diagnostic techniques included endoscopic capsule, enteroscopy, and biopsy. The patient was scheduled for laparotomy and resection. After one year of follow-up, he remained asymptomatic. DISCUSSION: Gastric heterotopy approach represents a diagnostic challenge. Owing to how rare it is, there is no global consensus in terms of treatment. However, surgery is the definitive therapy. In this case, decision was made not to perform intestinal resection and anastomosis, but resection of the compromised intestinal wall. No malignity was reported in the literature reviewed.

INTRODUCCION: La heterotopia gástrica es una entidad infrecuente en la población pediátrica. Se presenta en el tracto gastrointestinal llevando a cuadros clínicos de sangrado digestivo. CASO CLINICO: Se reporta el caso de un escolar de 10 años, el cual presentó tejido gástrico en el yeyuno proximal, originando sangrado digestivo masivo en dos ocasiones. La secuencia de apoyos diagnósticos requirió cápsula endoscópica, enteroscopia y biopsia. Fue llevado a laparotomía y resección de la lesión. En el seguimiento al año se mantuvo asintomático. DISCUSION: Su abordaje genera un reto diagnóstico. Debido a su infrecuente presentación no hay un consenso global para el tratamiento, sin embargo, la intervención quirúrgica es la terapia definitiva. En este caso no se hizo resección intestinal y anastomosis sino resección de la pared intestinal comprometida. No se reportó malignidad en la literatura revisada.

Perinatal risk factors of neurodevelopmental impairment after fetoscopic laser photocoagulation for twin-twin transfusion syndrome: systematic review and meta-analysis.

OBJECTIVE: Monochorionic twins with twin-twin transfusion syndrome (TTTS) treated with fetoscopic laser photocoagulation (FLP) are at increased risk of neurodevelopmental impairment (NDI). This meta-analysis aimed to identify the prevalence of and perinatal risk factors for NDI in TTTS survivors treated with FLP. METHODS: We performed a search in PubMed, EMBASE, Scopus and Web of Science, from inception to 13 February 2021, for studies evaluating perinatal risk factors for NDI in children diagnosed prenatally with TTTS managed by FLP. Data on severity of TTTS at the time of diagnosis, defined according to the Quintero staging system, FLP-related complications and perinatal outcomes were compared between children with a history of TTTS treated with FLP with and those without NDI, which was defined as performance on a cognitive or developmental assessment tool ≥ 2 SD below the mean or a defined motor or sensory disability. A random-effects model was used to pool the mean differences or odds ratios (OR) with the corresponding 95% CIs. Heterogeneity was assessed using the I2 statistic. RESULTS: Nine studies with a total of 1499 TTTS survivors were included. The overall incidence of NDI was 14.0% (95% CI, 9.0-18.0%). The occurrence of NDI in TTTS survivors was associated with later gestational age (GA) at FLP (mean difference, 0.94 weeks (95% CI, 0.50-1.38 weeks); P < 0.0001, I2 = 0%), earlier GA at delivery (mean difference, -1.44 weeks (95% CI, -2.28 to -0.61 weeks); P = 0.0007, I2 = 49%) and lower birth weight (mean difference, -343.26 g (95% CI, -470.59 to -215.92 g); P < 0.00001, I2 = 27%). Evaluation of different GA cut-offs showed that preterm birth before 32 weeks was associated with higher risk for NDI later in childhood (OR, 2.25 (95% CI, 1.02-4.94); P = 0.04, I2 = 35%). No statistically significant difference was found between cases with and those without NDI with respect to Quintero stage of TTTS, recipient or donor status, development of postlaser twin anemia-polycythemia sequence, recurrence of TTTS and incidence of small- for-gestational age or cotwin fetal demise. CONCLUSIONS: TTTS survivors with later GA at the time of FLP, earlier GA at delivery and lower birth weight are at higher risk of developing NDI. No significant association was found between Quintero stage of TTTS and risk of NDI. Our findings may be helpful for parental counseling and highlight the need for future studies to understand better the risk factors for NDI in TTTS survivors. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Prenatal predictors of motor function in children with open spina bifida: a retrospective cohort study.

OBJECTIVE: To identify predictors for intact motor function (MF) at birth and at 12 months of life in babies with prenatally versus postnatally repaired open spina bifida (OSB). DESIGN: Retrospective cohort study. SETTING: Texas Children's Hospital, 2011-2018. POPULATION: Patients who underwent either prenatal or postnatal OSB repair. METHODS: Prenatal MF of the lower extremities was evaluated by ultrasound following a metameric distribution at the time of diagnosis (US1), 6 weeks postoperatively (or 6 weeks after initial evaluation in postnatally repaired cases) (US2) and at the last ultrasound before delivery (US3). At birth and at 12 months, MF was assessed clinically. Intact MF (S1) was defined as the observation of plantar flexion of the ankle. Results from logistic regression analysis are expressed as odds ratios (95% confidence intervals, P values). RESULTS: A total of 127 patients were included: 93 with prenatal repair (51 fetoscopic; 42 open hysterotomy repair) and 34 with postnatal repair. In the prenatal repair group, predictors for intact MF at birth and at 12 months included: absence of clubfeet (OR 11.3, 95% CI 3.2-39.1, P < 0.01; OR 10.8 95% CI 2.4-47.6, P < 0.01); intact MF at US1 (OR 19.7, 95% CI 5.0-76.9, P < 0.01; OR 8.7, 95% CI 2.0-38.7, P < 0.01); intact MF at US2 (OR 22, 95% CI 6.5-74.2, P < 0.01; OR 13.5, 95% 3.0-61.4, P < 0.01); intact MF at US3 (OR 13.7, 95% CI 3.4-55.9, P < 0.01; OR 12.6, 95% CI 2.5-64.3, P < 0.01); and having a flat lesion (OR 11.2, 95% CI 2.4-51.1, P < 0.01; OR 4.1, 95% CI 1.1-16.5, P = 0.04). In the postnatal repair group, the only predictor of intact MF at 12 months was having intact MF at birth (OR 15.2, 95% CI 2.0-113.3, P = 0.03). CONCLUSIONS: The detection of intact MF in utero from mid-gestation to delivery predicts intact MF at birth and at 12 months in babies who undergo prenatal OSB repair. TWEETABLE ABSTRACT: Detection of intact motor function in utero predicts intact motor function at birth and at 1 year in fetuses who undergo prenatal OSB repair.

Impact of the size of the lesion in prenatal neural tube defect repair on imaging, neurosurgical and motor outcomes: a retrospective cohort study.

OBJECTIVES: (1) To compare brain findings between large and non-large neural tube defect (NTD); (2) to evaluate the impact of large lesion on the surgical parameters; (3) to study any associations between the size of the lesions and brain findings 6 weeks postoperatively and neurological short-term outcomes. DESIGN: Retrospective cohort study. SETTING: Texas Children's Hospital, between 2011 and 2018. POPULATION: Patients who underwent prenatal NTD repair. METHODS: Large lesion was defined when the lesion's surface was >75th centile of our cohorts' lesions. MAIN OUTCOME MEASURES: Time of referral: ventriculomegaly and anatomical level of the lesion; surgery: duration and need for relaxing incisions. 6 weeks postoperative: hindbrain herniation (HBH) and ventriculomegaly. After delivery: dehiscence, need for hydrocephalus treatment and motor function. RESULTS: A total of 99 patients were included, 25 of whom presented with large lesions. Type of lesion and ventriculomegaly were comparable between individuals with large and non-large lesions. Individuals with large lesions were associated with increased need for relaxing incisions by 5.4 times (95% CI 1.3-23.2, P = 0.02). Six weeks postoperatively, having a large lesion decreased by ten times the likelihood of having a postoperative reversal of HBH (odds ratio = 0.1, 95% CI 0.1-0.4, P < 0.01). At birth, larger lesions increased the risk for repair dehiscence by 6.1 times (95% CI 1.6-22.5, P < 0.01) and the risk of dehiscence or leakage of cerebrospinal fluid at birth by 5.5 times (95% CI 1.6-18.9, P < 0.01). CONCLUSION: Prenatal repair of patients with large NTD presents a lower proportion of HBH reversal 6 weeks after the surgery, a higher risk of dehiscence and a higher need for postnatal repair. TWEETABLE ABSTRACT: Evaluation of the size of fetal NTD can predict adverse neurological outcomes after prenatal NTD repair.

Longitudinal evaluation of motor function in patients who underwent prenatal or postnatal neural tube defect repair.

OBJECTIVE: To compare the evolution of motor function from mid-gestation to 12 months of age between prenatally and postnatally repaired cases of open neural tube defect (ONTD). METHODS: This was a retrospective cohort study of all fetuses that underwent prenatal (fetoscopic or open hysterotomy) or postnatal ONTD repair at a single institution between November 2011 and December 2018. The anatomical level of the lesion was defined as the upper bony spinal defect at initial magnetic resonance imaging assessment. Prenatal motor function of the lower extremities was evaluated by ultrasound according to the metameric level of the neurological lesion, based on the methodology of Carreras et al. Fetal motor function was assessed at referral, at 6 weeks after surgery in prenatally repaired cases or 6 weeks after referral in postnatally repaired cases (6-week follow-up) and at the last scan before delivery. In addition, motor function was assessed by a detailed neurological examination at birth and 12 months of age. First sacral (S1) neurological level of the lesion was considered as intact motor function. For statistical comparisons, we attributed numerical scores to each neurological level and motor function was expressed as median (range) neurological level. Motor function (as numerical score) and the proportion of cases with intact motor function and with motor function two or more levels better than expected based on the anatomical level of the lesion were compared between the prenatal- and postnatal-repair groups. Fetal motor function was compared to the anatomical level of the lesion at referral and a better motor function was defined when it was two or more levels better than the anatomical level of the lesion. To assess the evolution of motor function, we compared motor function at referral with that at each follow-up assessment using paired t-tests. RESULTS: We included 127 patients with ONTD, of whom 93 underwent prenatal (51 fetoscopic and 42 open hysterotomy) and 34 postnatal repair. At the time of referral, cases in the prenatal- and postnatal-repair groups presented with a similar anatomical level of lesion (L3 (T9-S1) vs L3 (T7-S1); P = 0.52), similar motor function (S1 (L1-S1) vs S1 (L1-S1); P = 0.52) and a similar proportion of cases with intact motor function (81% vs 79%; P = 0.88) and with motor function two or more levels better than expected based on the anatomical level of the lesion (62% vs 74%; P = 0.24). When compared with prenatally repaired cases, postnatally repaired cases showed worse motor function at birth (S1 (L1-S1) vs L4 (L1-S1); P < 0.01) and at 12 months of age (S1 (L1-S1) vs L4 (L1-S1); P < 0.01). In the prenatal-repair group, motor function remained stable from the time of referral to 12 months of age (P = 0.26). Furthermore, the proportion of patients with intact motor function at referral (81% (75/93)) was similar to that at the 6-week follow-up (74% (64/87)), at the last scan before birth (74% (42/57)), at birth (68% (63/93)) and at 12 months of age (67% (39/58)) in the prenatal-repair group. In the postnatal-repair group, worse motor function, starting from the third trimester to 12 months of age, was observed. The proportion of patients with intact motor function at referral (79% (27/34)) was similar to that at 6-week follow-up (80% (12/15); P = 0.92), but was lower at the last assessment before birth (25% (2/8); P < 0.01), at birth (24% (8/34); P < 0.01) and at 12 months of age (28% (7/25); P < 0.01). Similar findings were noted when assessing the evolution of the proportion of cases with motor function two or more levels better than expected based on the anatomical level of the lesion in each group. CONCLUSIONS: Infants with ONTD that underwent postnatal repair had worse motor function at birth and at 12 months of age than at mid-gestation and when compared with infants that underwent prenatal ONTD repair. Prenatal motor function assessment by ultrasound is an adequate tool to identify those infants who should have a good clinical motor function after delivery. Information obtained by fetal motor function assessment can have an important role for patient counseling and case selection for surgery. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Técnica de linfadenectomía y resección del lecho vesicular laparoscópica por cáncer vesícula biliar incidental / Lymphadenectomy technique and laparoscopic vesicular bed resection for incidental gallbladder cancer

Resumen El cáncer de vesícula es infrecuente a nivel mundial, a diferencia de su alta incidencia en Chile. Su pronóstico es malo en general, y dependerá de su forma de presentación, siendo mejor en los casos diagnosticados después de una colecistectomía laparoscópica por patología benigna. La reintervención, que incluye la resección hepática y linfadenectomía, es el pilar de la terapia curativa en esta neoplasia. Presentamos la descripción de la técnica quirúrgica realizada en los pacientes con cáncer de vesícula de diagnóstico incidental, en el Servicio de Cirugía de Clínica Alemana de Santiago y en el Hospital de la Fuerza Aérea de Chile. El abordaje laparoscópico representa una alternativa quirúrgica válida en el tratamiento de pacientes con cáncer de vesícula biliar diagnosticados después de la colecistectomía. La estandarización de la técnica debiera contribuir a su mayor empleo y a la obtención de buenos resultados desde un punto de vista oncológico.

Gallbladder cancer is considered an infrequent disease but in Chile has a higher incidence. Prognostic is considered dismal except in those patients in whom the diagnosis is performed after the cholecystectomy specimen study. Reoperation with gallbladder bed resection and lymphadenectomy is considered the treatment in patients with incidental cases. We show the way this operation is performed in Clinica Alemana of Santiago and in the Air Force Hospital. The laparoscopic approach is an alternative to those patients in whom the diagnosis was done after the cholecystectomy. Laparoscopy allows to accomplish same objectives and to obtain identical results that the open approach. The technical standardization should contribute to spread its employment and to improve the results.

Resección hepática extendida con vena cava inferior por colangiocarcinoma intrahepático: presentación de 2 casos / Extended hepatic resection with inferior cava vein for intrahepatic cholangiocarcinoma: presentation of two cases

Resumen Introducción: El colangiocarcinoma intrahepático (CIH) corresponde al segundo tumor hepático primario y la resección quirúrgica es la única alternativa válida para el tratamiento curativo de esta enfermedad. Reporte de casos: Describimos 2 paciente portadores de CIH con compromiso de vena cava inferior (VCI) que fueron sometidos a resección en Clínica Alemana de Santiago (CAS). Ambas pacientes son de género femenino de 39 y 47 años de edad. Ambas fueron sometidas a resección mayor hepática izquierda, asociada a resección del segmento I y extendida a VCI. La reconstrucción de la VCI fue realizada con parche pericárdico bovino y cierre primario respectivamente. El período desde el posoperatorio hasta el alta, fue de 13 y 23 días respectivamente. Discusión: Aunque la reseccion quirúrgica es la única vía para la curación en el CIH, el compromiso de estructuras vasculares hacen que esto no sea posible. El manejo multidisciplinario asociado a una técnica meticulosa realizada por un equipo quirúrgico experimentado, hacen posible lograr buenos resultados.

Introduction: Intrahepatic cholangiocarcinoma is the second most common primary liver tumor and surgical resection the only valid curative treatment. Case reports: We describe two patients harboring an intrahepatic cholangiocarcinoma with cava vein involvement who underwent resection at Clinica Alemana of Santiago. Both patients were females with ages of 39 and 47 years old. Both patients underwent left liver resection, associated to resection of segment I and of a portion of cava vein. Reconstruction of resected portion of the cava vein was performed by using a pericardium bovine patch and primary closure respectively. Postoperative period was uneventfully being discharged at 13 and 23 days respectively. Discussion: Although surgical resection is the only way to get curativeness, frequent involvement of large vascular structures make treatment unfeasible. A multidisciplinary approach associated with a meticulous technique performed by an experienced surgical team make possible to accomplish the above objective.

Morfometría y variantes anatómicas del tronco celíaco en población mexicana / Morphometry and anatomical variants of the celiac trunk in Mexican population

RESUMEN: Las variantes anatómicas del tronco celíaco (TC) son relevantes en el ámbito quirúrgico e intervencionista. Existen diferentes estudios a nivel mundial que han demostrado las variaciones que puede presentar el TC tanto en longitud como en estructura; dichos estudios han sido realizados predominantemente en población asiática y europea. Por lo anterior, realizamos un estudio que caracterizó esta estructura y que sea referente para la población mexicana. Se analizó una muestra de 50 especímenes cadavéricos humanos embalsamados de origen mexicano. El promedio de longitud del TC a su primera rama fue de 12,44 mm; de su origen a la segunda rama fue de 17,07 mm; y hasta la tercera fue de 19,15 mm. En la muestra de estudio se encontraron variantes en el 20 % de los especímenes, de éstos el 14 % presentaron variantes morfométricas en cuanto a longitud y 6 % en estructura. Respecto a las variantes morfométricas, destacó la presencia de un TC de 3 mm de longitud. En cuanto a las variantes morfológicas dos individuos presentaron un tronco gastro-esplénico con tronco hepato-mesentérico; y el tercero un tronco bifurcado hepato-gástrico con la arteria esplénica naciendo de la arteria hepática común. Éste último no reportado en la literatura.

SUMMARY: Anatomical variants in the celiac trunk (CT) are important in surgical and interventional fields. Studies worldwide have demonstrated length and structure variations in the celiac trunk. These studies have predominantly been carried out in Asian and European population. Therefore, we considered it necessary to realize a study to describe this structure and serve as a reference in the Mexican population. A sample of 50 human cadaveric specimens of Mexican origin was analyzed. The average length of the celiac trunk from its origin to its first branch was 12.44 mm, to the second branch was 17.07 mm, and to the third branch was 19.15 mm. In the studied sample, variants were found in 20 % of the specimens, 14 % of these presented morphometric variations in terms of length, and 6 % in terms of structure. In reference to the morphometric variants, the presence of one 3 mm length CT was noteworthy. Morphological variants were found in two specimens presenting a gastro-splenic trunk with a hepatomesenteric trunk, and a third specimen with hepatogastric bifurcated trunk, with the splenic artery originating from the common hepatic artery was observed. No reports were found in the literature concerning the latter.

[Role of surgery in Saprochaete capitata (S. capitata) sepsis in a patient with acute myeloid leukemia]. / Rol de la cirugía en el manejo de la infección invasora por Saprochaete capitata.

Saprochaete capitata (S. capitata) fungal sepsis is a severe condition with a clinical presentation that is similar to other yeast originated fungal sepsis. It is observed in patients with hematological malignancies such as acute myeloid leukemia and neutropenia. We report a 23 year old male presenting with cough, fever and malaise. A bone marrow biopsy led to the diagnosis of acute myeloid leukemia. During the first cycle of chemotherapy the patient presented fever: blood cultures were positive for Klebsiella pneumoniae. Despite antimicrobial treatment, fever persisted; a computed tomography showed a focal splenic lesion; a left exudative pleural effusion appeared. A Matrix Assisted Laser Desorption Ionization-Time of Flight mass spectrometry identified the presence of S. capitata. After multiple antifungal treatments and pleural cavity cleansing by means of videothoracoscopy and laparoscopic splenectomy, the infection resolved and the patient completed his chemotherapy.

Rol de la cirugía en el manejo de la infección invasora por Saprochaete capitata / Role of surgery in Saprochaete capitata (S. capitata) sepsis in a patient with acute myeloid leukemia

Saprochaete capitata (S. capitata) fungal sepsis is a severe condition with a clinical presentation that is similar to other yeast originated fungal sepsis. It is observed in patients with hematological malignancies such as acute myeloid leukemia and neutropenia. We report a 23 year old male presenting with cough, fever and malaise. A bone marrow biopsy led to the diagnosis of acute myeloid leukemia. During the first cycle of chemotherapy the patient presented fever: blood cultures were positive for Klebsiella pneumoniae. Despite antimicrobial treatment, fever persisted; a computed tomography showed a focal splenic lesion; a left exudative pleural effusion appeared. A Matrix Assisted Laser Desorption Ionization-Time of Flight mass spectrometry identified the presence of S. capitata. After multiple antifungal treatments and pleural cavity cleansing by means of videothoracoscopy and laparoscopic splenectomy, the infection resolved and the patient completed his chemotherapy.

Barriers to the treatment of childhood tuberculous infection and tuberculosis disease: a qualitative study.

SETTING: In 2012, Peru's National TB Program (NTP) reported approximately 2400 incident cases of tuberculosis (TB) disease in children aged <15 years. Peru's TB burden is concentrated in the Lima metropolitan area, particularly in poor districts such as El Agustino and La Victoria, where this study was conducted. OBJECTIVE: To identify barriers to the treatment of childhood tuberculous infection and TB disease in Lima from the perspective of front-line providers and patients' families. DESIGN: We conducted 10 semi-structured focus groups with 53 purposefully sampled primary care providers, community health workers, and parents/guardians of pediatric TB patients. We also completed nine in-depth interviews with National TB Program administrators and pulmonologists specializing in TB. Two authors performed inductive thematic analysis and identified emerging themes. RESULTS: Four main treatment barriers emerged from the data: 1) dosing errors, 2) time- and labor-intensive preparation and administration of medications, 3) provider concern that isoniazid preventive therapy (IPT) generates isoniazid resistance, and 4) poor adherence to IPT. CONCLUSION: Our findings highlight the urgent need for child-friendly formulations, provider and parent/guardian education about IPT, and strategies to promote adherence to IPT, including support and supervision by health workers and/or regimens with fewer doses.

The evaluation of a novel haptic-enabled virtual reality approach for computer-aided cephalometry.

BACKGROUND AND OBJECTIVE: In oral and maxillofacial surgery, conventional radiographic cephalometry is one of the standard auxiliary tools for diagnosis and surgical planning. While contemporary computer-assisted cephalometric systems and methodologies support cephalometric analysis, they tend neither to be practical nor intuitive for practitioners. This is particularly the case for 3D methods since the associated landmarking process is difficult and time consuming. In addition to this, there are no 3D cephalometry norms or standards defined; therefore new landmark selection methods are required which will help facilitate their establishment. This paper presents and evaluates a novel haptic-enabled landmarking approach to overcome some of the difficulties and disadvantages of the current landmarking processes used in 2D and 3D cephalometry. METHOD: In order to evaluate this new system's feasibility and performance, 21 dental surgeons (comprising 7 Novices, 7 Semi-experts and 7 Experts) performed a range of case studies using a haptic-enabled 2D, 2½D and 3D digital cephalometric analyses. RESULTS: The results compared the 2D, 2½D and 3D cephalometric values, errors and standard deviations for each case study and associated group of participants and revealed that 3D cephalometry significantly reduced landmarking errors and variability compared to 2D methods. CONCLUSIONS: Through enhancing the process by providing a sense of touch, the haptic-enabled 3D digital cephalometric approach was found to be feasible and more intuitive than its counterparts as well effective at reducing errors, the variability of the measurements taken and associated task completion times.

Trauma cervical penetrante / Penetrating neck trauma

Aim: The aim of this study is to report the surgical outcomes in a series of patients undergoing to exploratory cervicotomy by penetrating neck trauma (PNT) in emergency department of Barros Luco-Trudeau Hospital (BLTH), between 2003 and 2013, in terms of postoperative morbidity (POM). Matherial and methods: Retrospective case series of patient undergoing exploratory cervicotomy in emergency department of BLTH, between 2003 and 2013. The outcome variable was development of POM. Other variables were age, sex, etiology and kind of injury, hemodynamic status at admission, surgical time, distribution of injuries by anatomic areas, need for re operation and intra and post operative mortality. Descriptive statistics were used. Results: During the study period, 59 exploratory cervicotomies were performed to patients with PNT, with an average age of 32,5 years old. 89,8 percent of patients were male. The POM was 33,4 percent, being the most frequent the neurological ones. The most frequent etiology was the stab with 83 percent. 66 percent of patients were hemodynamically unstable at admission. Mean operative time was 107 minutes. The most injured area was the area II. Conclusion: The PNT is a little prevalent disease. The outcomes of our study are consistent with those reported in the literature.

Objetivo: El objetivo de este estudio es comunicar los resultados quirúrgicos observados en una serie de pacientes sometidos a cervicotomía exploradora por trauma cervical penetrante (TCP) en el Servicio de Urgencias del Hospital Barros Luco-Trudeau (HBLT), entre los años 2003 y 2013, en términos de morbilidad postoperatoria (MPO). Material y método: Serie de casos retrospectiva de pacientes sometidos a cervicotomía exploradora en el servicio de urgencia del HBLT, entre el año 2003 y 2013. La variable resultado fue desarrollo de MPO. Otras variables fueron: edad, sexo, etiología y tipo de lesión, estado hemodinámico al ingreso, tiempo quirúrgico, distribución de la lesión según zona anatómica, necesidad de re operación y mortalidad intra y post operatoria. Se utilizó estadística descriptiva. Resultados: En el período en estudio, se realizaron 59 cervicotomías a pacientes con TCP, con un promedio de edad de 32,5 años, de los cuales el 89,8 por ciento era de sexo masculino. La MPO fue de 33,4 por ciento, siendo las más frecuentes las de tipo neurológico. La etiología más recurrente fue el arma blanca con 83 por ciento. El 66 por ciento de los pacientes se encontraban hemodinámicamente inestables al momento del ingreso. El tiempo quirúrgico promedio fue de 107 min. La zona más lesionada fue la zona II. Conclusión: El TCP es una entidad poco prevalente. Los resultados obtenidos en nuestra serie son coincidentes con lo reportado en la literatura.

Diagnóstico y manejo precoz de la gangrena de fournerr / Early diagnosis and management of fournier´s gangrene

Aim: The aim of this study is to report the results of a series of patients diagnosed with Fournier’s gangrene underwent surgical debridement plus broad-spectrum antibiotics in the emergency department of the Hospital Barros Luco-Trudeau (HBLT) between 2009 and 2013, in terms of mortality associated with the disease. Material and Methods: Between 2009 and 2013, a case series of patients with diagnosis of Fournier’s gangrene treated in the Emergency Department of the Hospital Barros Luco-Trudeau. The outcome variable was mortality attributed to the disease (MAD). Other variables were: age, sex, comorbidities, focus of origin, waiting time for antibiotic treatment and surgery to start, number of surgical debridement and agents isolated from cultures. Descriptive statistics were used, with calculation of measures of central tendency and dispersion. Results: During the study period, 56 patients were identified with diagnosis of Fournier’s gangrene (60.7 percent were male) with a mean age of 52 years (23-75 years old). The MAD was 48.2 percent. The most common comorbidity was diabetes (66.6 percent). The more prevalent focus of origin was anorectal pathology (42.9 percent). The average waiting time from diagnosis to initiation of antibiotic therapy and surgery was 40 minutes (15-80) and 580 minutes (20-4320), respectively. The required surgical debridement average was 4. Isolated on the intraoperative tissue cultures agent was E. coli (51.8 percent). Conclusion: Mortality attributable to Fournier’s gangrene is similar to that observed in the literature.

Objetivo: El objetivo de este estudio es comunicar los resultados observados en una serie de pacientes con diagnóstico de gangrena de Fournier sometidos a aseo quirúrgico con debridamiento más terapia antibiótica de amplio espectro, en el Servicio de Urgencias del Hospital Barros Luco Trudeau (HBLT), entre los años 2009 y 2013, en términos de mortalidad asociada a la enfermedad. Material y Método: Serie de casos de pacientes con diagnóstico de gangrena de Fournier tratados en el Servicio de Urgencias del Hospital Barros Luco-Trudeau entre 2009 y 2013. La variable resultado fue mortalidad atribuida a la enfermedad (MAE). Otras variables de interés fueron: edad, sexo, patologías asociadas, foco de origen, tiempo de espera para el inicio del tratamiento antibiótico y cirugía, número de aseos y agentes aislados en los cultivos. Se utilizó estadística descriptiva, con cálculo de medidas de tendencia central y dispersión. Resultados: En el período en estudio se identificaron 56 pacientes con diagnóstico de Gangrena de Fournier (60,7 por ciento eran masculinos), con un promedio de edad de 52 años (23-75 años). La MAE fue 48,2 por ciento. La patología asociada más frecuente fue la diabetes (66,6 por ciento). El foco de origen más prevalente fue la patología anorrectal (42,9 por ciento). El tiempo promedio de espera desde el diagnóstico hasta el inicio de la terapia antibiótica y la cirugía fue de 40 minutos (15-80) y 580 minutos (20-4320) respectivamente. El promedio de aseos requeridos fue de 4. El agente más aislado en los cultivos de tejido intraoperatorio fue Escherichia coli (51,8 por ciento). Conclusión: La mortalidad atribuible a la Gangrena de Fournier es similar a la observada en la literatura.

Nefrectomía laparoscópica de donante vivo: experiencia de 75 casos consecutivos / Live donor laparoscopic nephrectomy: experience in 75 cases

Background: Live Donor Laparoscopic Nephrectomy (LDLN) has substantial benefits when compared with open nephrectomy such as shorter hospital stay, prompt return to work, less post-operative pain, better cosmetic results, less blood loss and less surgical wound infections. It is the mode of choice for safely harvesting a kidney for organ transplantation. Aim: To describe the surgical results of LDLN in a pioneer renal transplant center in Chile. Material and Methods: Review of clinical records of 75 subjects aged 27 to 60 years (37 males) subjected to a LDLN in a public hospital between 1998 and 2013. Information about clinical and surgical data and perioperative complications was retrieved. Results: No subject died. All kidneys were satisfactorily implanted in their receptors. The mean operative time was 116 minutes. Mean hospital stay was 1.6 days, warm ischemia time was 6.8 minutes, and cold ischemia time was 31.5 minutes. Operative adverse events occurred in 8 percent. The conversion and reoperation rates were 4 and 1.3 percent, respectively. Among receptors, 1.5 percent evolved with Acute Tubular Necrosis and 2.2 percent required graft excision. Conclusions: LDLN is a safe and pioneering surgical technique in Chile. Its results are satisfactory and comparable to those obtained with classic lumbotomy.

Introducción: El trasplante renal es en la actualidad el tratamiento de elección de la Insuficiencia Renal Crónica Terminal. La Nefrectomía Laparoscópica del Donante Vivo (NLDV) tiene ventajas sustanciales en relación a la Nefrectomía Clásica. Entre estas se destacan una menor estancia hospitalaria, pronto regreso a la actividad laboral, disminución del dolor post-operatorio, mejores resultados cosméticos, menor pérdida de volumen sanguíneo y una disminución de infecciones de heridas operatorias, consolidándose como la primera prioridad como forma de obtener un órgano para trasplante renal. El presente trabajo tiene como objetivo mostrar la casuística y complicaciones en el Hospital Barros Luco-Trudeau (HBLT), como centro pionero en NLDV en nuestro país. Material y Método: Estudio retrospectivo de corte transversal. Se realiza una revisión de registros clínicos de 75 NLDV realizadas entre 1998-2013, seleccionando datos demográficos, clínicos y quirúrgicos de donantes y receptores, con un especial énfasis en relación a complicaciones peri-operatorias. Resultados: Sin mortalidad. Todos los riñones fueron implantados satisfactoriamente en sus respectivos receptores. Cirugía con duración promedio de 116 min, estadía hospitalaria promedio de 1,6 días, isquemia caliente promedio de 6,8 min e isquemia fría promedio de 31,5 min. Incidentes operatorios 8 por ciento y 4 por ciento conducentes a conversión. Tasa de reoperación de 1,3 por ciento. En cuanto a receptores, un 1,5 por ciento desarrolla Necrosis Tubular Aguda. 2,2 por ciento requiere transplantectomía. Discusión: La NLDV representa una técnica segura, que ha llegado a constituir el 100 por ciento de las nefrectomías de donantes vivos realizadas durante los últimos tres años. Los resultados son satisfactorios y plenamente comparables a los resultados obtenidos por lumbotomía clásica y de otros centros de alto volumen laparoscópico a nivel internacional.

Programas educativos anti-tabaco y su relación con el hábito de fumar / Anti-smoking education programs and its relationship to smoking habits

Se analizó en exfumadores el efecto de los programas educativos anti-tabaco. Participaron 241 exfumadores, 171 hombres y 70 mujeres, con edad promedio 56,8 años. El motivo por el cual dejaron de fumar definitivamente, el 43% 10 hizo por enfermedad; el 16% porque un familiar y/o amistad muy cercana enfermó; el 15% por pedido de los hijos y/o nietos. El 17%. había seguido algún programa anti-tabaco, pero sin éxito. El 89% aceptó que fumar es dañino para la salud y esta información fue obtenida a través de la televisión (57%), periódicos (43%) y campañas de salud (J 7%). El 78% sabía que el tabaco puede producir cáncer, el 45% 10 relaciona a enfermedades pulmonares, pero menos de la mitad acepto que ellos están expuestos a dichas enfermedades. Los programas educativos no determinaron para que la persona abandone el cigarrillo. Hubo un mayor conocimiento de los peligros del tabaco pero faltó aceptarlo como un riesgo personal.

We analyzed the effect of the antismoking educational programs in ex-smokers. The population was 241 ex-smokers, 171 males and 70 females, mean age 56,8 years. The principal reason 43% ofparticipants quilted smoking permanently dub to illness; while 16% because afamiliar andlor friendship very close got sick, and 15% at the request their children andl or grandchildren The 17%. hadfollowed an tobacco control program, but without success. 89% agreed that smoking is dangerous to health and this information was obtained through television (57%), newspapers (43%) and health campaigns (/7%). 78% know that the tobacco can cause cancer, 45% related to lung diseases, but less than half agreed that they are exposed to such diseases. Educational programs determined no to make that the person quits smoking. There was an increased awareness of the dangers of smoking, but it was necessary accept as a personal risk.