Randomized clinical trial between polyacrylate-polyalcohol copolymer (PPC) and dextranomer-hyaluronic acid copolymer (Dx/HA) as bulking agents for endoscopic treatment of primary vesicoureteral reflux (VUR).

OBJECTIVE: To compare the radiological and clinical outcomes of endoscopic treatment of primary VUR using polyacrylate-polyalcohol copolymer (PPC-Vantris®) or dextranomer-hyaluronic acid copolymer (Dx/HA-Deflux®). MATERIALS AND METHODS: From October 2014 to April 2017, patients with primary VUR grade III to V that needed endoscopic treatment (ET) were eligible for this randomized clinical trial. We excluded toilet-trained patients with lower urinary tract symptoms. Patients were randomized and allocated into two groups: PPC group and Dx/HA group. After endoscopic treatment a voiding cystourethrography (VCUG) was performed at 6 months; if VUR was still present a second ET was performed. Radiological success was considered if postoperative VUR grade was 0 and clinical success rate was considered if no more fUTI appeared during follow-up. RESULTS: Forty-six patients were eligible but 2 did not accept the trial. Forty-four patients with 73 refluxing ureters were included. PPC: 34 refluxing ureters; and Dx/HA: 39 refluxing ureters. Both groups were statistically homogeneous and comparable. Mean follow-up was 27.6 months. Radiological success rate (82.2%) and clinical success rate (92.3%) were similar in both groups (p > 0.05). The volume of bulking agent used in those successfully treated was greater in Dx/HA group (p < 0.05). Distal ureter was excise in all cases of ureteral reimplantation after PPC treatment; however, distal ureter was preserved in all ureters reimplanted after Dx/HA injection. CONCLUSION: PPC and Dx/HA had similar outcomes, but we must warn that ureteral reimplantation after endoscopic treatment with PPC is difficult because of the periureteral fibrosis.

Anal canal duplication and triplication: a rare entity with different presentations.

Anal canal duplication (ACD) is the rarest of gastrointestinal duplications. Few cases have been reported. Most cases present as an opening in the midline, posterior to the normal anus. The aim of our revision is to contribute with eight new cases, some of them with unusual presentations: five presented as the typical form, one with a perianal nodule, and two presented as two separate orifices (anal canal triplication). Complete excision was performed in all patients with no complications. ACD is the most distal and the least frequent digestive duplication. Its treatment should be surgical excision, to avoid complications such as abscess, fistulization, or malignization. Anal canal triplication has never been described before.

[Left cardiac sympathetic denervation in congenital ventricular arrythmias: initial experience]. / Denervación cardiaca simpática izquierda en las arritmias ventriculares congénitas: experiencia inicial.

BACKGROUND: Left cardiac sympathetic denervation (LCSD) has been proposed as a second-line therapy for potentially lethal ventricular arrythmia with no response to the gold standard treatment with beta-blockers. It has been used mainly in channelopathies such as long QT syndrome (LQTS) and polymorphic cathecolaminergic ventricular tachycardia (PCVT). AIM: Analizing our preliminary experience in the treatment of congenital ventricular arrythmia with thoracoscopic LCSD. MATERIAL AND METHODS: We have reviewed the first 5 LCSD performed in the last two years (2011-2013) to 5 female patients with a mean age of 8 years (1 month-15 years). The underlying disease was the LQTS in three and the PCVT in two. RESULTS: Selective contralateral bronchial intubation was used in two cases and double-lumen tube in three. We performed in all cases T1 sympathicolysis, denervation of T2 ganglion and sympathicolysis of T3 and T5 levels. No intraoperatory nor postoperatory complications were observed. In four cases ventricular tachycardia disappeared after the procedure and in one case, although they did not completely disappeared, they could be better controled on medical therapy. Ventricular extrasystoles reappeared 17 months after the procedure in one PCTV case, but disappeared completely after T1-T5 left sympathectomy completion. With a mean follow-up time of 20 months, all patients are sympthom-free and continue on betablocker oral therapy. CONCLUSIONS: Thoracoscopic DCSI is a safe and effective therapy for prevention of severe congenital ventricular arrythmias.

INTRODUCCION: La denervación cardiaca simpática izquierda (DCSI) se ha propuesto como tratamiento de segunda línea de las arritmias ventriculares con potencial riesgo de muerte que no responden al tratamiento farmacológico gold standard con beta bloqueantes. Fundamentalmente se ha utilizado en las canalopatías, que incluyen el síndrome de QT largo congénito (SQTL) y la taquicardia ventricular polimórfica catecolaminérgica (TVPC). OBJERIVO: Analizar nuestra experiencia inicial en el tratamiento de las arritmias ventriculares congénitas mediante DCSI toracoscópica. MATERIAL Y METODOS: Hemos revisado las primeras 5 DCSI realizadas en los últimos dos años (2011-2013) a 5 pacientes femeninas con una edad media de 8 años (1 mes-15 años). La patología de base fue el SQTL en tres casos y la TVPC en dos. Se utilizó una intubación selectiva contralateral en dos casos y una intubación con tubo de doble luz en tres. En todos los casos se realizó simpaticolisis T1, denervación del ganglio T2 y simpaticolisis de los niveles T3 y T5. RESULTADOS: No se registraron complicaciones intra ni postoperatorias. En 4 casos las taquicardias ventriculares desparecieron tras el procedimiento y en un caso, pese a no desaparecer completamente, se controlaron adecuadamente con tratamiento médico. Un caso de TVPC presentó nuevamente salvas de extrasístoles ventriculares (EV) 17 meses después de la simpaticolisis, realizando una simpatectomía T1-T5 con desaparición de las EV. Con un seguimiento medio de 20 meses, todas las pacientes permanecen asintomáticas y reciben tratamiento betabloqueante oral. CONCLUSIONES: La DCSI vía toracoscópica es un tratamiento efectivo y seguro para la prevención de las arritmias ventriculares congénitas graves.

[Management of rectal traumatism in the pediatric age]. / Manejo del traumatismo rectal en la edad pediátrica.

OBJECTIVE: In pediatrics anorectal injuries are not very common and their management classically includes an intestinal derivation. In selected patients and with favourable conditions, there has been an increased interest in repair the injuries without derivation. We present our experience in the management of this pathology, looking through the literature. The aim of the study is to develop some guidelines to follow in these cases. PATIENTS AND METHODS: Retrospective and descriptive study of patients with anorectal injury admitted in our institution between 2005-2011. Data abstraction included patient demographic data, mechanism of injury, associated injuries, time between injury and treatment, methods of diagnosis, treatment, length of stay and resultant complications. RESULTS: 7 patients were reviewed and classified according to the type of the injury in two groups: iatrogenic injuries (all of them with associated malformations) and non-iatrogenic accidental injuries. A CT was performed in 4 cases. None of them was explored with sigmoidoscopy. We performed colostomy without primary repair in four patients, primary injury repair with colostomy in two patients, and one patient underwent primary repair without colostomy. All patients had a long evolution (mean hospital length of stay was 31,4 days) with many dressings and some of them required relaparotomy. Fecal continence and long term results have been, in all of them, satisfactories. CONCLUSIONS: An early and complete diagnosis of anorectal injuries is basic for an appropriate approach to the treatment. Primary repair of injuries without colostomy could be a safe procedure as a first treatment in selected patients: stables, with no contamination and no associated injuries. It is very important to individualize each patient to minimize the morbidity, reduce the hospital length of stay and reach a full continence.

[Anderson-Hynes pyeloplasty in children under 2 years. Is the laparoscopy the technique of choice?]. / Pieloplastia Anderson-Hynes en menores de 2 años. ¿Es la laparoscopia la técnica de elección?

OBJECTIVE: To analyze if the laparoscopic pyeloplasty is as effective as the open procedure in the ureteropelvic junction obstruction in patients under 2 years of age. PATIENTS AND METHODS: Pyeloplasties performed in children under 2 years of age between 2007 and 2010. Weight, pre and postoperative renal pelvis and calices diameter, operating time, hospital stay and complications were analyzed. RESULTS: We found no statistic differences in weight, complications, or pre and postoperative renal pelvis and calices diameter. However, we found differences in hospital stay and operating time (p<0.05). CONCLUSIONS: Laparoscopic pyeloplasty in children under 2 years of age is a good alternative technique for ureteropelvic junction obstruction, although operating time are still long.

Pop-off mechanisms as protective factors against chronic renal disease in children with posterior urethral valves. / Los fenómenos pop-off como factores protectores de enfermedad renal crónica en niños con válvulas de uretra posterior.

OBJECTIVE: To identify whether pop-off mechanisms act as protective factors against chronic or end-stage renal disease in patients with posterior urethral valves. MATERIALS AND METHODS: A retrospective cohort study of patients with posterior urethral valves treated at a tertiary care children's hospital was carried out. Demographic, clinical, analytical, and radiological variables were collected. Considered as pop-off mechanisms were: unilateral high-grade vesicoureteral reflux with ipsilateral renal dysplasia and without involvement of the contralateral kidney, urinoma, prenatal urinary ascites, large bladder diverticulum, and persistent urachus. Multiple logistic regression and multivariate Cox regression were used for statistical analysis. RESULTS: 70 patients undergoing posterior urethral valve surgery in our institution from 2010 to August 2020 were included. 14 (20%) had pop-off mechanisms and 56 (80%) did not. Pop-off mechanisms protected against developing chronic renal disease (0% vs. 27%; p = 0.03) and could protect against the need for renal replacement therapy (0% vs. 9%; p = 0.58). Nadir creatinine values (mg/dl) were predictors for the development of chronic renal disease (0.37 vs. 0.53; p < 0.0001) and the need for renal replacement therapy (0.38 vs. 1.21; p < 0.001). CONCLUSIONS: Pop-off mechanisms act as a protective factor against chronic renal disease in patients with posterior urethral valves. Nadir creatinine is a predictor of chronic renal disease and the need for renal replacement therapy. A larger sample size is needed to determine whether pop-off mechanisms protect against the need for renal replacement therapy.

OBJETIVOS: Identificar si los fenómenos pop-off actúan como factores protectores de enfermedad renal crónica o terminal en pacientes con válvulas de uretra posterior. MATERIAL Y METODOS: Estudio de cohortes retrospectivo de los pacientes con válvulas de uretra posterior tratados en un hospital infantil de tercer nivel. Se recogieron variables demográficas, clínicas, analíticas y radiológicas. Se consideraron fenómenos pop-off: reflujo vesicoureteral de alto grado unilateral con displasia renal ipsilateral y sin afectación del riñón contralateral, urinoma, ascitis urinaria prenatal, divertículo vesical grande y uraco persistente. Para el análisis estadístico se han utilizado regresiones logísticas múltiples y regresión de Cox multivariante. RESULTADOS: Se incluyeron 70 pacientes intervenidos de válvulas de uretra posterior y visitados en nuestro centro desde 2010 hasta agosto de 2020. Catorce (20%) presentaban fenómenos pop-off y 56 (80%) no. Los fenómenos pop-off fueron protectores para el desarrollo de enfermedad renal crónica (0 vs. 27%; p = 0,03) y podrían proteger de la necesidad de terapia renal sustitutiva (0 vs. 9%; p = 0,58). Los valores de creatinina nadir (mg/dl) fueron predictores de desarrollo de enfermedad renal crónica (0,37 vs. 0,53; p < 0,0001) y de necesidad de terapia renal sustitutiva (0,38 vs. 1,21; p < 0,001). CONCLUSIONES: Los fenómenos pop-off actúan como factor protector de enfermedad renal crónica en los pacientes con válvulas de uretra posterior. La creatinina nadir es un factor predictor de enfermedad renal crónica y de necesidad de terapia renal sustitutiva. Se necesita un tamaño de muestra mayor para determinar si los fenómenos pop-off protegen de la necesidad de terapia renal sustitutiva.

Advantages of endoscopic pilonidal sinus treatment. / Ventajas de la cirugía endoscópica para el tratamiento quirúrgico del sinus pilonidal.

INTRODUCTION: Classic treatment of pilonidal sinus is associated with a high rate of complications and a long and painful postoperative period requiring daily wound care, with a decrease in patients' quality of life. The objective of our study was to evaluate the effectiveness and advantages of the endoscopic technique vs. conventional surgery of pilonidal sinus in the pediatric population. METHODS: A quasi-experimental study was carried out in pediatric patients undergoing pilonidal sinus surgery at a single institution in 2019. Excision and healing by secondary intention (EHSI), excision and primary closure (EPC), and Pediatric Endoscopic Pilonidal Sinus Treatment (PEPSiT) were compared. The surgical technique chosen was surgeon-dependent. RESULTS: 49 patients were studied - 14 undergoing PEPSiT, 23 undergoing EHSI, and 12 undergoing EPC. Full healing process was faster in PEPSiT than in EHSI (11 weeks earlier; 95% CI: 6.2-15.9; p < 0.001). Pain on the Visual Analogue Scale (VAS) and need for analgesics were less in the PEPSiT group (p = 0.001). Mean time to return to normal life was shorter with PEPSiT - 78 days earlier than EHSI (95% CI: 42.2-114.9; p < 0.001) and 39 days earlier than EPC (95% CI: -2.5-81.4; p = 0.06). No complications were recorded with PEPSiT, whereas complication rate with EHSI was 69.6%, and complication rate with EPC was 58.3% (p = 0.001). CONCLUSIONS: Endoscopic pilonidal sinus treatment is effective, with a short and painless postoperative period, and easy wound care. It allows for an early return to normal life without restrictions.

INTRODUCCION: Los procedimientos clásicos exeréticos en el tratamiento del sinus pilonidal están relacionados con una alta tasa de complicaciones y conllevan un postoperatorio largo y doloroso, precisando curas tópicas diarias hasta la cicatrización completa, lo que provoca una disminución de la calidad de vida de los pacientes. El objetivo de este trabajo es evaluar la eficacia y las ventajas de la técnica endoscópica frente a la cirugía convencional del sinus pilonidal en población pediátrica. METODOS: Estudio cuasi-experimental en pacientes pediátricos operados de sinus pilonidal durante 2019 en un único centro. Comparamos la exéresis con cicatrización por segunda intención (ESI), exéresis con cierre primario (ECP) y PEPSiT (Pediatric Endoscopic Pilonidal Sinus Treatment). La elección de la técnica fue cirujano-dependiente. RESULTADOS: Se estudiaron 49 pacientes: 14 PEPSiT, 23 ESI y 12 ECP. Se consigue la epitelización completa 11 semanas antes con PEPSiT que con ESI (IC95%: 6,3 a 16,3; p < 0,001). Encontramos menor dolor en escala analógica visual (EVA) con PEPSiT, y paralelamente también necesitaban menos analgésicos (p = 0,001). Con PEPSiT recuperan su vida normal 78 días antes de media que los ESI (IC95%: 42,2 a 114,9; p < 0,001) y 39 días antes que ECP (IC95%: -2,5 a 81,4; p = 0,06). No se registraron complicaciones con PEPSiT frente a un 69,6% con ESI y 58,3% con ECP (p = 0,001). CONCLUSIONES: El tratamiento endoscópico del sinus pilonidal es efectivo, con un postoperatorio corto, indoloro y con fáciles cuidados. Permite la rápida recuperación de la actividad normal sin las restricciones que conlleva la cirugía convencional.

[Thoracoscopic lobectomy: initial experience]. / Lobectomía toracoscópica: experiencia inicial.

AIM: Analizing our preliminary experience in the treatment of pulmonary malformations with thoracoscopic lobectomy. MATERIAL AND METHODS: We have reviewed our first cases of thoracoscopic lobectomy during last year (2008-09). We have performed 6 thoracoscopic lobectomies in 6 male patients with a mean age of 16 months (6 months-4 years). They were 3 lower lobectomies (2 right and one left), 2 right upper lobectomies and one lingular sparing left upper lobectomy. Lung lesion was a congenital cystic adenomatoid malformation in 5 (2 of them asociated with intralobar sequestration) and one lobar emphysema due to bronquial atresia. RESULTS: Selective bronchial intubation was used in 4 cases and and tracheal intubation with bronchial blocker in 2. There were no conversions to open thoracotomy. Mean operative time was 202' (155-250'). There were no intraoperative nor postoperative complications. None of these patients needed blood transfusion. Mean drainage time was 3.5 days (3-4 d) and mean discharge time was 4.8 days (4-7 d). With a mean follow-up time of 5.3 months (2 m-12 m), all of the patients have no symptoms and X-ray are normal. CONCLUSIONS: Thoracoscopic lobectomy is a safe and efective approach to treat congenital pulmonary pathology. The keys to perform it safely are good anesthetic management, adequate instruments for children size, and careful disection of broncovascular structures. Advantages of the minimal access surgery and implementation and miniaturization of the instruments and sealing devices will favor its progressive use.

Our experience with laparoscopic Anderson-Hynes ureteropyeloplasty. / Ureteropieloplastia Anderson-Hynes laparoscópica en niños. Nuestra experiencia.

OBJECTIVE: To analyze whether the application of laparoscopic surgery in the treatment of pyeloureteral junction obstruction (PUJO) has been beneficial for pediatric patients. MATERIALS AND METHODS: Medical records of all patients undergoing PUJO surgery from January 1997 to December 2017 were retrospectively reviewed. Patients with <6-month follow-up and patients undergoing video-assisted surgery were excluded. Open surgery was compared with laparoscopic surgery. The following data were collected: surgical approach, need for and type of urinary diversion, operating time, mean hospital stay, complications, and restenosis rate. Ultrasound and diuretic renogram parameters were also retrieved. RESULTS: 328 Anderson-Hynes pyeloplasties were analyzed, 142 of which had been performed laparoscopically. Overall success rate was 96.6%, and complication rate was 11.9%. No significant differences were noted between open and laparoscopic surgery. In 97.5% of surgeries, urine was diverted using an external nephroureteral catheter, a double J stent, or a Salle stent, with significant differences between open and laparoscopic surgery. Mean operating time was significantly longer in laparoscopic surgery. Mean hospital stay was significantly shorter in the laparoscopic surgery group. CONCLUSION: Surgical approach does not play a role in PUJO surgery success. Therefore, in our view, laparoscopic surgery should be the technique of choice in pediatric patients.

OBJETIVO: Analizar si la aplicación de la cirugía laparoscópica en el tratamiento de la estenosis pieloureteral (EPU) han sido beneficiosos para el paciente pediátrico. MATERIAL Y METODO: Hemos revisado de forma retrospectiva las historias clínicas de todos aquellos pacientes intervenidos de EPU desde enero 1997 hasta diciembre 2017. Se excluyeron las que tuvieron seguimiento menor a 6 meses, y las cirugías videoasistidas. Se han comparado la cirugía abierta con la cirugía laparoscópica. Se han recogido los siguientes datos: abordaje quirúrgico, necesidad y tipo de derivación urinaria, tiempo quirúrgico, estancia media, complicaciones, tasa de reestenosis. Los parámetros ecográficos y del renograma diurético también han sido recogidos. RESULTADOS: Se han analizado 328 pieloplastias, 142 se realizaron laparoscópicamente. La tasa de éxito global ha sido del 96,6%, existiendo un 11,9% de complicaciones; sin existir diferencias significativas entre la cirugía abierta y la laparoscópica. En el 97,5% de las cirugías, la orina se derivó mediante catéter nefroureteral externo, catéter doble J o catéter tipo Salle; existiendo diferencias entre cirugía abierta y laparoscópica. El tiempo quirúrgico medio fue significativamente superior en la cirugía laparoscópica. La estancia media fue menor en el grupo de cirugía laparoscópica de forma significativa. CONCLUSION: La vía de abordaje no es un factor que influya en el éxito de la cirugía de la EPU, por ello pensamos que la cirugía laparoscópica es la técnica de elección en pacientes pediátricos.

[Which surgical technique should we perform for benign renal disease in children?]. / Qué técnica quirúrgica hemos de utilizar en la nefrectomía por patología benigna?.

AIM: The aim of this paper is to analyze our experience in different surgical techniques to perform a nephrectomy for benign renal diseases in children. MATERIAL AND METHODS: From 1993 to 2005 we have performed 98 nephrectomies. We have three groups of patients depending on the surgical technique: open nephrectomy (ON), transperitoneal laparoscopic nephrectomy (TLN) and retroperitoneal laparoscopic nephrectomy (RLN). ON was performed in 36 patients. Mean age was 3.3 years. TLN was performed in 39 patients. Mean age was 4.7 years old. RLN was performed in 23 patients. Mean age was 3.6 years old. Criteria to nephrectomy was a renographic function under 19%. We have compared the three surgical techniques in relation with surgical time and mean hospital stay. RESULTS: Mean operative time was 126.2 minutes in ON, 132.3 minutes in TLN and 134.1 minutes in RLN. Mean stay was 5.02 days in ON, 2.35 days in TLN and 1.86 days in RLN. The median hospital stay of the ON group is significantly longer than that of NLT and NR groups (p < 0.05). However, there are no differences related to surgical time between all the groups. CONCLUSIONS: Nephrectomy may be performed for benign disease in children using less invasive surgical techniques. They are associated with minimal morbidity, minimal postoperative discomfort, improve cosmesis and a shorter hospital stay. However, we haven't found differences between TLN and RLN.

[The role of surgery for lung nodules in pediatric oncology]. / La cirugía de los nódulos pulmonares en oncología pediátrica.

AIM: To evaluate the role of lung nodule surgery in pediatric cancer patients. MATERIALS AND METHODS: The records of all cancer patients (< 18 y) treated at our pediatric institution since 1993 were reviewed. Clinical data, imaging features, surgical attitude, pathology and outcome were analyzed for those patients developing lung nodules on CT scan at any time. RESULTS: Fifty-seven out of 857 (6.6%) cancer patients had lung nodules at one or more times during their disease course, totalling seventy-five episodes. The primary pathological diagnoses include: Osteosarcoma n = 17, Ewing's sarcoma n = 14, Rhabdomyosarcoma n = 5, Germ cell tumor n = 4, other sarcomas n = 4, Wilms' tumor n = 3, Neuroblastoma n = 3, Lymphoma n = 2. Twenty-nine cases had lung nodules at diagnosis; in 20 they were found during therapy; in 29 concomitant with other sites of relapse off therapy; and in 16 patients as an isolated event during follow-up. Fifty-five biopsy procedures were performed through thoracotomy, thoracoscopy or pleural effusion cytology. Metastasic disease was confirmed in 46, whereas in 9 no malignancy was found. Among the nine, five showed either normal lung tissue or scarring after tumor necrosis, and four had other benign diagnoses including: reactive inflammatory cells, pleural lymphangioma, mycobacteria infection and inflammatory pseudotumor. In 39 instances biopsy was not done either because the diagnosis could be made through specific tests, or because the nodules disappeared in a follow-up CT scan within 2 weeks, or because of disease progressing in spite of treatment. In 4 patients surgical removal of lung metastases has afforded cure. CONCLUSIONS: Lung nodule surgery plays a fundamental role in the management of patients with pediatric malignancies: it allows accurate staging, avoiding overtreatment in more than 15% of the cases, and gives a higher chance of cure in some patients.

[Nutritional and surgical management of short bowel syndrome. Our last 6 patients' experience]. / Manejo nutricional y quirúirgico del intestino corto como causa de fracaso intestinal en niños. A propósito de seis pacientes.

BACKGROUND: Children cause of intestinal failure is short-bowel syndrome. It provokes an altered absorption of nutrients and makes patients to be dependent on parenteral nutrition (PN) while they wait or not for an intestinal transplantation, with its side effects. It is crucial to achieve the maximum efficiency of remaining intestine. Many surgical techniques have been led to reduce stasis of dilated small intestine and improve the mucosal surface area for absorption. METHODS: Six patients have presented intestinal failure because of a surgical resection during newborn period. 2 gastroschisis, 2 intestinal atresias (Apple-peel), 1 necrotizing enterocolitis (NEC) and 1 midgut volvulus. 4 preserve ileocecal valve (ICV): 2 Apple-peel, 1 NEC and the midgut volvulus. The shortest length of bowel after resection were 12cm without ICV (gastroschisis) and 18cm with ICV in a preterm newborn of 24 weeks of gestational age (midgut volvulus). Tapering and plication have been done in Apple-peel cases. No complementary surgical techniques have been necessary in NEC and volvulus. Gastroschisis cases had 12 and 40 cm of small bowel without ICV. In the first one, during newborn period an intestinal lengthening according to Bianchi was done, followed by sequential transversal enteroplasty (STEP), partial gastrectomy and plication of 1st and 2nd duodenal portion. In the second, an STEP was done. All patients have received cycled and optimized PN (COPN) in our centre, only one case (gastroschisis) proceeding from another centre had received standard PN and developed a great hepatic affectation. RESULTS: 2 Apple-peel have been adapted to normal enteral nutrition after 3 and 18 months of COPN, such as NEC and volvulus (3-6 months). One gastroschisis (12cm) has a normal hepatic function with free oral nutrition and home COPN at 23 months. The other one (40cm) has COPN and started enteral nutrition 1 month after surgery, although its hepatic function remains altered. CONCLUSIONS: Parenteral nutrition is essential for these patients to survive. We would like to enhance the importance of COPN in order to preserve hepatic function. Surgical procedures aim to avoid stasis and bacterial overgrowth and improve intestinal motility. Different techniques may be used alone or sequentially. The purpose of this management is to achieve nutritional autonomy or increase waiting time before intestinal transplantation.

Routine delayed voiding cystourethography after initial successful endoscopic treatment with Dextranomer/Hialuronic Acid Copolimer (Dx/HA) of vesicoureteral reflux (VUR). Is it necessary? / ¿Es necesario realizar una cistouretrografía miccional seriada (CUMS) tardía tras el tratamiento endoscópico exitoso inicial con copolímero de dextranómreo/ácido hialurónico (Dx/HA) para el reflujo vesicoureteral (RVU)?

INTRODUCTION: Some guidelines recommend an early voiding cystourethrography (VCUG) after endoscopic treatment of vesicoureteral reflux (VUR), but there's no consensus if it's necessary a long-term follow-up in these patients. The aim of our study is analyze if it's necessary a delayed VCUG after initial successful treatment with Dx/HA. MATERIAL AND METHOD: We have reviewed all medical charts of patients that underwent Dx/HA treatment from 2006 to 2010. We have selected patients with initial successful treatment and more than 3 years of radiological and clinical follow-up. We have analyzed late clinical and radiological outcomes. RESULTS: One hundred and sixty children with 228 refluxing ureters underwent Dx/HA endoscopic treatment with a mean follow-up of 52.13 months. Early VCUG was performed in 215 ureters with an initial successful rate of 84.1%. The group of study was 94/215 ureters with more than 3 years of follow-up with a delayed VCUG. VUR was still resolved in 79,8% of the ureters. Clinical success rate was 91.7%. The incidence of febrile urinary tract infection in those patients with cured VUR and those with a relapsed VUR was 8 and 15%, respectively; but there were no significant differences. We have not found any variable related with relapsed VUR except those ureters that initially received 2 injections (P<.05). CONCLUSION: If our objective in the treatment of VUR is to reduce the incidence of febrile urinary tract infection it is not necessary to perform a delayed VCUG even though the long-term radiological outcomes is worse than clinical outcome.

Comparative study between isolated intestinal perforation and necrotizing enterocolitis.

INTRODUCTION: Intestinal perforations in the neonatal period are usually related to necrotizing enterocolitis (NEC) or intestinal occlusion. Intestinal perforation in the absence of these conditions is called isolated perforation (IP). Several risk factors and pathogenic mechanisms have been suggested, and most of them are common to those classically attributed to NEC. AIM: To identify and compare the clinical and pathological features of IP and NEC. MATERIAL AND METHODS: We reviewed all cases of neonatal intestinal perforation and NEC in the last five years. Thirty-three patients were retrospectively classified into Group NEC: 24 cases, and Group IP: 9 cases. We collected multiple data as study variables: 1) General features; 2) Obstetric history; 3) Neonatal treatment; 4) Comorbidity; 5) Perforation features; 6) Treatment and outcome. RESULTS: Comparing the groups, we found statistical significant differences in isolated perforation cases with these risk factors: extreme prematurity, very low birth weight, abruptio placenta, intubation and neonatal mechanical ventilation, umbilical catheterization, precocious sepsis, and indomethacin therapy. A more precocious operation and a good prognosis also reached statistical significance. In the other hand, we found statistically significant differences in NEC with congenital cardiopathy (excluding isolated patent ductus arteriosus), with intestinal pneumatosis, with diffuse bowel involvement and a worse prognosis. Risk factors and pathologic findings seem to support an ischaemic pathogenesis in both diseases.

[Continent urinary diversion: the Mitrofanoff principle]. / Derivación urinaria continente: principio de Mitrofanoff.

INTRODUCTION: Continent urinary diversion (based on Mitrofanoff's principle), despite its complexity, is the gold standard in the treatment of those vesicourethral disfunctions that need clean intermittent catheterization (CIC) to achieve complete vesical voiding, in patients with non easily catheterizable native urethra. AIM: To analize our experience in continent urinary diversion at our centre. PATIENTS AND METHODS: We have reviewed the records of the 14 cases of continent urinary diversion in the last 8 years. They were grouped in order to the underliying condition: 1-Bladder exstrophy group (n=5): Mean age at diversion time was 5.5 years (range 3-7). In all patients the original Mitrofanoff s technique was performed (continent cutaneous appendicovesicostomy). Associated procedures were: ureterovesical reimplantation in all 5 cases; bladder neck reconstruction also in all 5 (3 of them needed vesicourethral transection); and bladder augmentation in two cases, using ileum and sigmoid respectively. 2- Myelomeningocele group (n=9, 10 procedures): Mean age was 11.5 years (range 6-16). Appendicovesicostomy was performed in 7 cases and a reconfigured ileum with the Casale technique was used in 3 cases (primarily in 2 and as an alternative in one). Associated procedures were: ureterovesical reimplantetion in 5 cases and bladder augmentation in 7 (using sigmoid in 4, ileum in 2 and urether in one case). RESULTS: In all patients complete continence was achieved. Complications found were: one appendicostomy prolapse, one appendix necrosis (that was then diverted with Casale's technique), one appendicular conduit stenosis and one case with catheterization difficulties that needed a tappering of the ileum conduit. Nowadays, 13 out of 14 pacients follow the CIC program each 3-4 hours without complication. CONCLUSION: Continent urinary diversion improves autonomy and life quality in those patients that need a definitive urinary diversion and have a long life expectancy. We have used these procedure with good results in patients with severe vesicourethral disfunction (of an intrinsic or neuropathic origin) in which clean intermittent catheterization was not possible through native urethra, or in patients with refractary incontinence in which vesicourethral transection was the only effective treatment.

[Retroperitoneoscopy: minimally invasive renal surgery]. / Retroperitoneoscopia: cirugía renal mínimamente invasiva.

OBJECTIVE: Retroperitoneal laparoscopy is well known as a surgical technique in adult patients. Its use in pediatric surgery is still-recent but, because of the good results, retroperitoncoscopy indications are getting more acceptance and widening indications. The aim of this work is to analyze our initial experience in retroperitoneal laparoscopy procedures in urological diseases at our centre. PATIENTS AND METHODS: From July 2001 to February 2002 retroperitoneal laparoscopy has been used in 6 patients aged 6 months to 14 years. Surgical indications were: pyelolithotomy (lithiasis non-subsidiary to extracorporeal shock wave lithotripsy (n = 1); nephrectomy ofmulticystic dysplastic kidney (n = 4); and nephrectomy of atrophicpelvic kidney (n = 1). RESULTS: Mean operative time in nephrectomy has been 102 minutes, and 230 minutes in conservative surgery. All 5 patients nephrectomized were discharged 24 hours after operation with no postoperatory incidences. The patient operated on for pyelolithiasis (in which a external drainageand a pyelouretheral stent (pig-tail) was placed) remained one week until he could be discharged without drainage. The pig-tail stent was thrown out spontaneously three weeks later through the urethra. Follow up demonstrated no stenosis in this case and no complications in nephrectomy patients. CONCLUSION: Retroperitoneal laparoscopy is effective and safe in renal surgery and surpasses transperitoneal laparoscopy because its safety in reconstructive surgery avoiding urine leakage risk into the abdomen.

[Laparoscopic adrenalectomy]. / Adrenalectomía laparoscópica.

BACKGROUND/PURPOSE: Laparoscopic adrenalectomy is a standard procedure in adult patients. In the pediatric patient the same advantages with regard to traditional surgery have been demonstrated in the treatment of localized adrenal tumours. The aim of this work is to analyze our initial experience in this technique. MATERIAL AND METHODS: We have reviewed our last three adrenalectomy cases. They were two girl and a boy aged 4, 15 and 17 year-old. The etiology was pheochromocytoma in two cases and one ganglioneuroblastoma. In two cases the tumour was right-sided and the other one was in the left adrenal gland. All cases were studied with ultrasound, TC and MRI. Patients with pheochromocytoma were also studied with MIBG-scintigraphy and genetics, hormone and endocrine MEN screening. One patient with pheochromocytoma had von Hippel-Lindau disease. Main size tumour was 40 mm. Preoperative alpha-blockade in pheochromocytoma was done with prazosín and intraoperative with nitroprusside. In lateral decubitus position, through four 10 and 5 mm ports, in two cases adrenalectomy was performed and tumorectomy in one. RESULTS: Main operating time was 120 minutes. There was no operative-related complication. Blood pressure in pheochromocytoma patients was controlled without drugs 36h after surgery. They were discharged between the 2nd and 4th postoperative day. No incidences on follow-up. CONCLUSIONS: Adrenalectomy joins other pediatric procedures affordable with the laparoscopic approach. It minimizes surgical trauma, gland exposure is better, allows a safe and quick resection in adrenal tumours, with a short and suitable postoperative course.

[Transanal endorectal pull-through alone as treatment of Hirschsprung's disease]. / Descenso endorectal transanal exclusivo para el tratamiento de la enfermedad de Hirschsprung.

UNLABELLED: The aim of this work is to present our experience in the treatment of Hirschsprung's disease (HD) with the technique described by De la Torre. MATERIALS AND METHODS: Seven children diagnosed with recto-sigmoid aganglionism have been treated with this surgical technique, to which a few modifications have been done. RESULTS: There were no intra- nor early postoperative complications. Surgical time ranged 150 to 240 minutes (average 198). All children began oral feedings 2 or 3 days postoperatively (average 2.4). Hospital stay averaged 5.2 days. Follow-up ranges from 6 months to 3 years (average 16 months). Two late complications were seen--one anastomotic stricture and one constipation--and successfully treated as out patients. CONCLUSIONS: The transanal only approach carries a rapid recovery. Family satisfaction is high because of the lack of scars. We believe this is the treatment of choice when confronting rectosigmoid aganglionism.

[Evolution of pre and postoperative renographic parameters in pyeloreteral juntion obstruction syndrome]. / Evolución de los parámetros renográficos pre y postoperatorios en la cirugía del sindrome de la unión pieloureteral.

With the objective of observing the modifications that the postoperative Diuretic Renography (DR) curve shows and determining how the quantitative parameters of this exploration (Differential Renal Function (DRF), Peak Time (PT), Half Time (HT), descent of maximum activity at 10 min (DMA10)) can be modified, the records of 50 patients affected by unilateral pyeloureteral junction obstruction and without any other associated pathology treated between 1991 and 2001, were revised. The age of the patients was between 1 month and 12 years (average 2 years 7 months). Of the 50 patients, 31 were male and in 28 of the cases were affected on the left side. Patient selection was random. The preoperative evaluation was made using ultrasound (US), intravenous urography (IU), voiding cystourethrography (VCU), and RD. The RD technique and surgical intervention were standardized and the latter were performed by the same surgeon. Postoperative control was made with US and/or IU and RD between 6 and 18 months following surgery, even though total follow up ranged from 6 months to 10 years (average 38.24 months). In all of the cases the follow up US and/or IU results were satisfactory, even though there was residual pyelic ectasia and absence of tension. The morphology of the preoperative curves was mostly obstructive or partially obstructive without lasix response, the curves became normal in 9 cases and partially obstructive with a good response to lasix in 38. The 3 remaining cases that corresponded to the hypofunctional kidney curve did not change. The DRF did not present major variations. The postoperative PT decreased in 62% of the cases. The HT and DMA10 improved in very few cases. In conclusion, it can be said that in spite of a good surgical outcome, the patterns of the postoperative renographic curve often do not completely normalize, major variations in the postoperative DRF are not expected, and with a diminshed postoperative PT a favorable pyeloplasty outcome can be appreciated. HT and DMA10 indicate improvement when they decrease, but do not indicate that the disease has reappeared when they do not change or increase.

[Mammaplasty in adolescent girls]. / Mastoplastia en la adolescente.

The aim of this work is to analyze the experience in our pediatric center on the surgical management of mammary malformation in teenagers. We have reviewed or mammaplasty cases until 1999 (n = 24). We have divided them in two groups: augmentation (A) and reduction (R) mammaplasty. The analyzed parameters were: ethiology, associated pathology, surgical approach, aesthetic results and complications. Group A (n = 14; 17 implants). The surgical indication was moderate-severe mammary hypoplasia with psychological repercussion. Associated pathology: thoracic malformation (n = 13) and psychiatric pathology (n = 2). The surgical approach was submammary in 6 cases, videoassisted transaxillary in 4 and iterative on thoracic scar in 3. All the implants were located at the subglandular space. No major complications were found and the cosmetic results were good, with only one reoperation because of asymmetry. Group R (n = 10). Surgery was indicated because of bilateral puberal mammary hipertrophy in all cases. Associated pathology: obesity (n = 3), psychiatric and behaviour disorders (n = 3), scoliosis (n = 2), and one case of isosexual precocious puberty. In all cases but one the Strömbeck mammaplasty was performed. We used the Lejour technique in this single case. The cosmetic results were good, except for 2 cases of hypertrophic scar. The only complication was a wound infection that healed well.