Oral tacrolimus for pediatric steroid-resistant ulcerative colitis.

BACKGROUND: Ulcerative colitis (UC) occurring during childhood is generally extensive and is associated with severe flares that may require intravenous steroid treatment. In cases of corticosteroid resistance is necessary to introduce a second-line treatment to avoid or delay surgery. AIMS: To describe the efficacy and safety of oral tacrolimus for the treatment of severe steroid-resistant UC. METHODS: We performed a retrospective study that included all patients under age 18 suffering from severe steroid-resistant UC treated with oral tacrolimus during the period January 1998 to October 2012 and with a follow-up period after treatment of 24 months or more. RESULTS: A total of ten patients were included. The age at baseline was 9.4±4.9 years, and the time from diagnosis was 1.3 months (IQR, 1-5.7). Seven of the patients were in their first flare of disease. All of them received an oral dose of 0.12 mg/kg/day of tacrolimus divided in two doses. Trough plasma levels of tacrolimus were maintained between 4 and 13 ng/ml. Response was seen in 5/10 patients at 12 months, colectomy was eventually performed in 60% of patients during the follow-up period. CONCLUSIONS: Tacrolimus is useful in inducing remission in patients with severe steroid-resistant UC, preventing or delaying colectomy, and allowing the patient and family to prepare for a probable surgery. Tacrolimus may also be used as a treatment bridge for corticosteroid-dependent patients until the new maintenance therapy takes effect.

[Colectomy in paediatric patients with ulcerative colitis]. / Colectomía en pacientes pediátricos con colitis ulcerosa.

INTRODUCTION: There are not many studies published in the literature on failure of medical treatment in Ulcerative Colitis (UC) that leads to colectomy. PATIENTS AND METHODS: Retrospective study of patients under 14 years diagnosed with UC from 1984 to 2009, who underwent colectomy due to lack of response to medical treatment. They are divided into urgent or elective surgery. RESULTS: Colectomy performed in 14 paediatric patients (26.9% of total UC patients). Age at diagnosis 7.8±4.0 years, 8 of them younger than 10 years and 5 younger than 5 years. All cases diagnosed on patients less than 5 years of age required colectomy in the first 6 months after diagnosis. Elective colectomy was performed on 5/14 and urgent surgery in 9/14. The reported complications were divided into early (first 30 days after colectomy) and late. Pharmacological treatment in cases with urgent colectomy included methylprednisolone (100%), oral tacrolimus (55.5%), oral/intravenous cyclosporine (33.3%) and infliximab (33.3%). Cases of elective colectomy were all in the 1985-1998 period. CONCLUSIONS: The influence of age is a key factor for prognosis. All patients less than 5 year-old ended up with colectomy. The main indication for urgent surgery was lack of response to treatment with intravenous steroids combined with a potent immunomodulator (tacrolimus, cyclosporine, infliximab). All cases of elective colectomy were performed before 1999, when second line medical treatment was very uncommon, making remission unlikely.

[Rectosigmoidectomy and end to end coloanal anastomosis with mechanical stapler for treatement of Hirschsprung disease]. / Rectosigomoidectomía y anastomosis término-terminal coloanal con sutura mecánica para el tratamiento de la enfermedad de Hirschsprung.

UNLABELLED: The experience of the Pediatric Surgical Service of the Materno Infantil University Hospital from Málaga on surgical treatment of the Hirschsprung disease by means of a modified technique of Swenson and Rehbein operations is presented. MATERIAL AND METHODS: Between 1992 and 2001 25 patients were operated of a rectosigmoidectomy. Of them, 23 were diagnosed of Hirschsprung's disease, one suffered a rectal angiodisplasia and the other one presented with a rectal stenosis secondary to a previous rectosigmoidectomy. In all of them a transabdominal rectosigmoidectomy with coloanal end to end anastomosis by means of a circular intraluminal stapler was performed. In 10 of them (group A), a modified Rehbein operation with intraabdominal anastomosis was performed. In the remaining 15 patients (group B), a modified Swenson operation with exteriorization of the aganglionic colon through the anus and extrabdominal anastomosis was performed. RESULTS: The postoperative course was evaluated by measuring the postoperative fasting time and the first spontaneous deposition. The medium hospital stay was of 9 days, nevertheless in 16 patients (64%) was lower than 7 days. The postoperative complications are presented. It consists in 1 anastomotic leakage (4%), postoperative enterocolitis 1 case (4%) and transient anastomotic stenosis in 4 patients (16%). All of them were treated with conservative treatment except one case of stenosis which needed a sphincterotomy. CONCLUSIONS: The rectosigmoidectomy and coloanal end to end anastomosis with endoluminal stapler is a safe and easy to do technique to treat the Hirschsprung's disease allowing a deep rectal resection which is very difficult to achieve by manual suture. The anastomosis is located in and extraperitoneal position, with a minimum risk of peritoneal involvement in case of anastomotic leakage. The patients presented a fast recovery, a minimum of complications and good functional result.

Diagnostic and therapeutic laparoscopy for nonpalpable testis.

BACKGROUND: We evaluated the use of laparoscopy in the management of impalpable testis to determine what advantages it might offer over the open approach. METHODS: Over a 5.5-year period, a total of 46 patients with 53 nonpalpable testes underwent a laparoscopic procedure at our hospital. There were 28 cases of intraabdominal testis (52.83%), 18 cases of the vas and vessels entering the internal ring (33.96%), and seven cases of intraabdominally absent testis (13.20%). We performed a laparoscopic orchiopexy for 24 testes (scrotal in 21 cases and partial to the inguinal canal in three cases) and an orchiectomy for three testes. We encountered inguinal hernia in 14 cases (26.41%). RESULTS: At follow-up, all testes were the same size as at the time of operation and were well positioned in the scrotum, except for four testes that required reoperation due to partial migration at the superficial inguinal ring. The operating time was <1 h in unilateral cases and <2 h for the bilateral cases. All procedures were completed successfully without conversion or complications. CONCLUSIONS: Laparoscopy is the only exploratory procedure that is accurate enough to enable the diagnosis of nonpalpable testis and also allow the surgical treatment to be done in the same setting.

[A technic to avoid postoperative intestinal hypodynamia]. / Técnica para evitar la hipodinamia intestinal postoperatoria.

The hypodynamic postoperative ileus in children, has as main cause the circle gastric distension-reflex intestinal ileus, produced by the swallowed air. The gastric emptying system-through a Levin tube from the stomach is not usually sufficient to get off all the swallowed air. Nevertheless, a continuous suction from the lower third of oesophagus, through a double lumen sump tube is twelve times more effective in the getting off de air before it comes into the stomach, without need of a nasogastric tube.

[Pheochromocytomas in children]. / Feocromocitomas en la infancia.

Three cases of pheochromocytoma in children are presented. Diagnosis was made by selective adrenal arteriography, ultrasound examination and catecholamines urinary levels. The surgical treatment consisted in exeresis of the tumor in all cases. In one case familial incidence was found. The postoperative course has been normal in all cases.