[Design and validation of a training model on paediatric and neonatal surgery]. / Diseño y validación de un programa formativo en cirugía laparoscópica pediátrica y neonatal.

We present our experience in the design and development of a training program in paediatric and neonatal laparoscopic surgery, and the determination of face validity by the attendants. Data included in the present study was obtained from five consecutive editions of our Neonatal and Paediatric Laparoscopic Surgery Course. Our training model, with a total duration of 21 hours, begins with acquisition of knowledge in ergonomics and instrument concepts, after which the attendants develop basic laparoscopic dexterity through the performance of hands-on physical simulator tasks. During the second and third days of the course, surgeons undertook various surgical techniques hands-on animal model. At the end of the training program, a subjective evaluation questionnaire was handed out to the attendants, in which different didactic and organizational aspects were considered. We obtained a highly positive score on all questions concerning the different topics and techniques included in the training program (> or = 9 points over 10). 78,5% of the 54 attendants was in accordance with the course total duration, whilst 21,5% considered that it should be of longer duration. Regarding abilities' self assessment, 79,1% considered themselves capacitated to perform trained procedures on live patients. The presented training model has obtained a very positive valuation score, leading to an increase in the attendants' self confidence in the application of learned techniques to their clinical practice.

[Results of laparoscopic treatment of complicated appendicitis]. / Resultados del tratamiento laparoscópico en la apendicitis complicada.

Laparoscopic appendectomy in children is a generally accepted procedure for the treatment of non-complicated acute appendicitis. Nevertheless, the role of laparoscopy in complicated cases is controversial. We show our experience with 40 cases of complicated acute appendicitis treated by means laparoscopy between February 2000 and October 2002. In every case we used 3 ports, one umbilical and the other two in both lower quadrants. The appendix was gangrenous in 31 patients and in the other 9 was perforated. Appendectomy was performed in an extracorporeal way in most of the cases. Average surgical time was 71 minutes and mean hospital stay was 8.8 days. Intraoperative complications occurred in 8 cases (20%) and postoperative complications were observed in 9 patients (22.5%). Four patients were reoperated (2 open and 2 laparoscopic) in order to drain two abscesses and treat two obstructions. The results of this serie is compared with another group of 40 complicated appendicitis operated in a classic open way in the same period of time. Postoperative complications were less often in the laparoscopic group. Oral intake, need for analgesia and hospital stay are more favorable in the laparoscopic group.

[Treatment of congenital tracheal stenosis using a slide tracheoplasty]. / Tratamiento de una estenosis traqueal congénita mediante una traqueoplastia deslizada.

Congenital tracheal stenosis (CTS) is a rare malformation that usually require corrective surgery. Resection and tracheal anastomosis is the treatment of choice when the stenosis is short. However, such an approach is not usually viable when the CTS is long, given that anastomotic pressure would be too great. New surgical techniques have allowed this serious airway malformation to be corrected satisfactorily. We report the case of a three-year-old boy with a long CTS (51% of the length of the trachea) treated with a new reconstructive technique called slide tracheoplasty. Outcome was excellent.

[Tracheal stenosis: individualized treatment]. / Estenosis traqueales: tratamiento individualizado.

INTRODUCTION: Stenosing airway disease is unfrequent in the pediatric age group and includes intraluminal obstructions, extrinsic compressions and malacias. OBJECTIVE: To show our experience in the treatment of congenital and acquired tracheal stenosis (CTS and ATS) and suprastomal tracheal collapse (STC). PATIENTS AND METHODS: Since 1990, 24 patients have been evaluated in our Unit: Ten CTS, 5 ATS and 9 STC. We have studied the following parameters: Sex, age at diagnosis, ethiology, type of lesion, associated anomalies, treatment, postoperative intubation, length of hospital stay, number of bronchoscopies, complications and follow-up. RESULTS: 14 girls and 10 boys are included in this survey. Age at diagnosis ranged from 3 days to 12 years and associated anomalies were present in 75% of cases. We have treated 22 of the 24 patients with the following procedures: Costal cartilage tracheoplasty (6 cases), slide tracheoplasty (2), resection and anastomosis (3), anterior cricoid suspension (8), dilation (2) and laser resection (1). We have achieved good results in 17 patients (77%), bad in 4 (18%) and fair in one. CONCLUSIONS: Due to the variety of stenotic lesions, we think that treatment should be tailored to each particular case and performed by a multidisciplinary pediatric team in order to achieve the best results.

[Epidermoid cyst of the mouth floor]. / Quiste epidermoide en el suelo de la boca.

The epidermoid cysts are frequent during childhood, however mouth floor location are very unusual, because of their more difficult diagnosis and therapeutic approach. We present a 5 years old male, symptoms free until a week before, when his parents noticed a well defined mass in the mouth floor. A physical examination leaded to the diagnosis of possible epidermoid cyst. The tumor was excised through an introral approach. A review of different diagnostic means and surgical management are undertaken.

[Thoracoscopic repair of esophageal atresia]. / Tratamiento toracoscópico de la atresia de esófago.

We present the first three cases of esophageal atresia with tracheoesophageal fistula treated with a thoracoscopic approach in our Service. The technique was accomplished through three trocar inserted in the right hemithorax. Carbon dioxide insufflation was required for lung retraction Primary correction was carried out in all the cases without major perioperative complications. The mean surgical time was 240 minutes. One patient had an anastomotic leak, resulting in a complicated postoperative course. The leak healed on conservative treatment. The others two patients were fed at the seventh postoperative day. Mean hospital stay in these cases was 12 days. Although thoracoscopic repair of esophageal atresia with fistula is a currently feasible technique that offers different advantages on the conventional open technique, a greater number of cases is needed in order to advance in the learning curve and determine the exact place that this technique can have in the future treatment of esophageal atresia.

[Jejunal diaphragm. Laparoscopic treatment in newborns]. / Atresia yeyunal membranosa. Tratamiento laparoscopico en periodo neonatal.

Intestinal obstructions in newborns secondary to atresias or membranes have been treated until the current moment through laparotomy and resection with anastomosis. Recently, it has been reported the use of minimally invasive techniques to correct this congenital anomaly. We present a case of jejunal diaphragm treated in our Service. Diagnosis and treatment by mean of endoscopic techniques was achieved in the fourth day of life. Operative time was 180 minutes. Postoperative course was uneventful. Results in terms of function and cosmetic were excellent. Laparoscopic management in selected cases of intestinal atresia has proven to be safe and effective and represents an alternative to neonatal open surgery.

[Treatment of tracheobronchomalacia with expandable metallic stents]. / Tratamiento de la traqueobroncomalacia grave con prótesis traqueobronquiales endoluminales.

Tracheomalacia is an unfrequent disease that causes tracheal collapse during breathing. It is generally associated to esophageal atresia, but cases of primary tracheomalacia and others secondary to extrinsic compression, have also been described. Spontaneous resolution is generally the rule and only a few cases need surgical treatment. When this therapy fails or is not indicated for any reason, endoluminal tracheobronchial stents may be used. We have treated two patients with four expandable metallic stents: one had severe tracheomalacia associated to esophageal atresia and the other tracheobronchomalacia secondary to cardiomegaly. Results have been good in both cases.

[Retrospective analysis of 80 cases of neonatal necrotizing enterocolitis]. / Análisis retrospectivo de 80 casos de enterocolitis necrotizante neonatal.

We present the cases of necrotizing enterocolitis (NEC) treated in our hospital between 1980 and 1994, in order to analyze the risk factors that appear in the disease. We elaborate treatment and follow-up protocols. Prematurity, low birth weight and perinatal stress have a significant influence in NEC. Hemodinamic inestability, bloody stools, abdominal distension with decrease gastric outlet, along with significant radiological evidence in 90 percent of the cases, should rise suspition of NEC. We find fundamental the prevention of the disease in premature newborns with risk factors. Mean gestational age was 33 weeks. Prematurity was found in 87.5 percent of the patients, with a mean birth weight of 1683 g. Symptoms appeared at the age of 14 days. 32 percent of the cases were operated, 13 cases (16%) presenting with pneumoperitoneum, and a Mortality rate 15 percent. We treated 15 patients with colonic stenosis by resection and end-to-end anastomosis, with 6 percent mortality global mortality rate for NEC has been 28 percent.

[Instrumental perforation of the esophagus. Importance of diagnosis early in its clinical course]. / Perforación instrumental de esófago. Importancia del diagnóstico precoz en la evolución.

Instrumental esophageal perforation is a serious complication that demands immediate therapy. In a retrospective study we have evaluated the results in seven patients treated for esophageal perforation by means of a conservative treatment without mortality. Instrumental dilatation of corrosive strictures were the most frequent cause of iatrogenic endoscopy. We have observed an esophageal injury associated with a Sengstaken-Blackemore tube placement. Clinical symptoms associated with chest roentgenograms guided to early diagnosis in all cases. Conservative treatment usually consist of a course of antibiotics, pleural drainage, and total parenteral nutrition. Clinical follow-up has been good in the seven patients treated.

[Analysis of anti-reflux surgery failure]. / Análisis del fracaso de la cirugía antirreflujo.

Recurrent gastroesophageal reflux following fundoplication is a challenging problem, because it is usually refractory to medical treatment and a second, technically difficult, antireflux operation is required. Different factors that may contribute to surgery failure have been identified in children. We present 8 cases who underwent redofundoplication after failed procedures, from a total number of 96 patients operated on due to gastroesophageal reflux. Four patient's had their initial fundoplication performed at our institution. Six patients were neurologically impaired, six had chronic pulmonary disease, and two had esophageal atresia. The main presenting symptoms were recurrent vomiting (n = 8) and aspiration (n = 4). Gastroesophageal reflux was confirmed by barium swallow and endoscopy. Operative findings showed wrap breakdown in two cases, warp breakdown associated with hiatal hernia in five, wrap breakdown associated with paraesophageal hernia in two cases, and paraesophageal hernia with normal wrap in one. A second Nissen procedure were performed in five cases, whereas a Collis-Nissen gastroplasty was realized in three with a short esophagus. Six patients had a successful outcome remaining symptom free, one has severe disphagia, and one has recurrent vomiting. In our experience, patients with recurrent gastroesophageal reflux disease should undergo an antireflux procedure tailored to specific anatomic or functional abnormalities.

[Testicular tumors in childhood. Review of cases in the course of 13 years]. / Tumores testiculares en la infancia. Revisión de 13 años.

Testicular and paratesticular tumors are rare in childhood, representing 1-2 percent of the solid tumors in the pediatric age. In patients under 14 years, the incidence is 0.5-2/100,000. The evolution differs from that of the adult. Since 1981 to 1994 we have treated 14 cases of testicular and paratesticular tumors. Mean age was 2.54 years, the younger patients presenting germinal tumors. The most frequent tumor was the yolk sac tumor (36%), followed by teratoma mature (29%), and Leydig cell tumor, epidermoid cyst, paratesticular fibrous hamartoma, paratesticular neuroblastoma and paratesticular rabdomyosarcoma (7% each). A testicular mass was present in all cases (100%). Testicular ultrasound was used in 100%. In all the patients with malignant tumors a thoraco-abdominal CT scans was done to rule out extension or the tumor, being negative in all cases. Alphafetoprotein were high in all the cases of yolk sac tumor, being within normal range one month after surgery except in one case. In 11 patients an orquiectomy was done through an inguinal approach, and in three cases a simple tumorectomy without orquiectomy. No lymphadenectomy was done. All the malignants neoplasms were stage I tumors, except one yolk sac tumor stage III. Postop chemotherapy was applied in this one and in the embrionary rabdomyosarcoma. There were no recurrences after a follow-up mean time of 3.98.

[Congenital colonic stenosis]. / Estenosis congénita de colon.

The colon is the least common site of congenital intestinal stenosis and atresia and accounts for 5-15 % of all of these abnormalities. We present the case of a 2-month-old boy who presented vomiting, constipation, weakness, and abdominal distension. Contrast enema and colonoscopy revealed an abrupt change in caliber in the sigmoid colon and, after ruling out other disorders, a diagnosis of colonic stenosis was made. Laparoscopy under total anesthesia was performed and a stenotic area in the sigmoid colon and proximal dilatation were identified. A small incision was made and the stenotic segment was removed. Video-assisted resection and end-to-end anastomosis were performed and the child made and uneventful postoperative recovery. Contrast enema after surgery showed good anastomosis and normal bowel diameter. At the age of 18 months the patient is asymptomatic and his stools are normal. With laparoscopy, visualization of the abdominal cavity was magnified and detailed, the affected intestinal segment was easily identified and other diseases were ruled out. Recovery was rapid and the functional and esthetic results were excellent.

[Complete congenital cartilaginous trachea in a girl with Crouzon's syndrome]. / Tráquea cartilaginosa completa congénita en una niña con síndrome de Crouzon.

A tracheostomy was performed in a 4-month-old girl with Crouzon's syndrome because of upper respiratory obstruction. During the procedure the absence of tracheal rings was observed. These findings were confirmed by postoperative bronchoscopy. Subsequent surgical correction of the patient's craniofacial anomalies enabled decannulation when the patient was 10 months old. Complete cartilaginous trachea is very rare and is always associated with craniosynostotic syndromes. Tracheobronchial anomalies should be investigated in patients whose respiratory symptoms are not due to upper airway obstruction.

[Conservative treatment of neonatal ovarian cysts]. / Tratamiento conservador de los quistes ováricos neonatales.

Treatment of choice of ovarian cysts diagnosed in the neonatal period has been until nowadays mainly surgical. Another possibility is a conservative approach, since these cysts have a natural tendency to spontaneous regression. We present 9 cases treated in our hospital in the last 8 years. 6 of them were treated surgically, while in 3 a conservative attitude was used, with sera ultrasound follow-up and disappearance of the cysts in 2 months in 2 cases and in 12 in the other. In cysts smaller than 5 cm we adopt a conservative management, leaving surgery only for those bigger or complicated.

[Cysts of the thyroglossal duct: analysis of diagnostic errors and causes of recurrence]. / Quistes del conducto tirogloso: análisis de los errores en el diagnóstico clínico y de las causas de aparición de recurrencias.

Thyroglossal-duct cysts usually present as an anterior midline neck mass, ranking first in this location in the pediatric age. We have carried out a retrospective revision of 52 pediatric patients with a preoperative diagnosis of thyroglossal-duct cyst. All of them were treated in our surgical unit between 1982 and 1989. The male to female ratio of cases was 34:18 with symptoms appearing at an average age of 4 years. The most frequent clinical presentation was that of a cystic mass without any inflammatory signs (65%), located in the mid-line at the hyoid level (75%). In this paper we analyze the existing possibilities as regards to the clinical presentation, location and characteristics of this type of cervical swellings, as well as the most frequent causes of misdiagnosis. We also make a comparison between the results we have obtained with the different surgical techniques used. We conclude that it is necessary to perform a radical surgical treatment of the thyroglossal-duct remnants, which includes removal of the middle third of the hyoid bone and excision of the thyroglossal duct as far as the foramen cecum.