[Traumatic diaphragmatic hernia: a vital need for an early diagnosis]. / Hernia diafragmática traumática: necesidad vital de un diagnóstico precoz.

INTRODUCTION: Traumatic diaphragmatic hernia (HDT) is exceptional in children. Its diagnosis is usually delayed for appearing in the context of severe polytrauma. The aim is to analyze our series in relation to the severity scores. PATIENTS AND METHODS: Five patients with HDT are presented. Age, biomechanics, clinical, ISS (injury severity score), ITP (pediatric trauma index), GCS (Glasgow coma scale), RTS (Revised Trauma Score) and treatment were studied. The probability of survival (Ps) was calculated with the TRISS method, Ps = 1/(1 + eb), b = b0 + bl (RTS) + b2 (ISS) + B3 (age). RESULTS: There were two males and three females, mean age was six years old (range = 3-10). Traffic accident was the mechanism of the thoracoabdominal trauma in 80% and one was crushed by garage door. The affected side was right in two cases and left in three. Mean ISS was 41 (range = 32-57), ITP 6 (range = 2-9) and RTS 6.1 (range = 5.1 to 6.9). The main symptom was respiratory. Plain chest radiography was diagnostic in three patients, one by CT scann, and another was a finding at laparotomy. Two had liver herniation, one had tension gastrothorax and two had gastric perforations. All patients underwent surgery through the abdomen. Estimated survival by the TRISS method was respectively 86.6%, 78.2%, 57.2%, 84.7% and 57.1%, while the actual was 100%. One has a severe disability. DISCUSSION: To study the biomechanics and semiology is essential in the early diagnosis of TDH in pediatric polytrauma and suspect it is mandatory prior to realize percutaneous chest procedures. The TRISS method has a great importance to assess the adult polytrauma, but specific scores are needed for children.

[Congenital cystic adenomatoid malformation: prenatal diagnosis, surgical treatment results and long-term follow-up]. / Malformación adenomatoidea quística: diagnóstico prenatal, resultados de la cirugía y seguimiento a largo plazo.

PURPOSE: (PD), possibility of regresion and hidden mortality are open questions in congenital cystic adenomatoid malformation (CCAM) treatment. METHODS: Children with CCAM were reviewed focused on: PD, postnatal diagnosis, clinic, radiology, histology and evolution. RESULTS: Seventeen fetus had PD of CCAM. Five gestations were electively finished (41%) with PD of CCAM previous to 20th week, 3/5 (60%) were type III and 2/5 (40%) type I; 4/5 (80%) presented mediastinal shift and 1/5 (20%) hidrops. Two fetuses (11%) suffered fetal demise in 20th and 32th week; 1 type 1 and 1 type III; 1/2 (50%) presented hidrops and 2/2 (100%) mediastinal shift. Two (12%) died before 24 hours after birth without intervention possibility due to respiratory instability, 1 type II and 1 type III, both with mediastinal shift (100%). In one fetus with a type III malformation the image disappeared completely in 32th week and no intervention was done. Fourteen patients were operated (8 girls and 6 boys); 7/14 (50%) had PD, average diagnosis week was 21.9 (range 19.1-35.5), 5/7 (71%) was type I, 1/7 (14%) type II and 1/7 (14%) type III. None had mediastinal shift or hidrops. Average postnatal diagnosis week was 7 months (range 0.1-29). In 10/14 (71.4%) there were not respiratory difficulty during neonatal period and 3/10 (30%) suffered respiratory infections afterwards. Average week of operation was 8 months (range 0.1-30). PD was according with histology in 6/7 (86%) patients. After an average follow-up period of 4.3 years (range 1-9.5) the only complication is a pectus excavatum. CONCLUSIONS: More than half of patients with PD of CCAM died without intervention. Half of cases of CCAM are diagnosed prenatally. Type of CCAM in PD is according to histology in 86% of the cases. Fetuses with hidrops present a worse prognosis. Surgical timing do not seem to influence on outcome.

Epididymal growth and differentiation are altered in human cryptorchidism.

Despite the knowledge and histological classification of testicular lesions, epididymal lesions associated with cryptorchidism are not well defined and only macroscopic alterations have been reported. We have evaluated the alterations in the growth of both the epithelium and muscular wall of efferent ducts and epididymis in human patients with cryptorchidism from infancy to adulthood. In addition, by cytokeratin immunostaining we have also evaluated the stage of differentiation of each segment along the human postnatal life in these patients. A decrease is shown in the size of efferent and epididymal ducts in cryptorchid children compared with normal, age-matched controls. The height of the epithelium, muscular wall, and lumen of the cryptorchid epididymis were reduced at every age studied. This decrease in all regions was seen even in the testicular quiescent period (1 to 4 years of age). In addition, the cryptorchid epididymis grows more slowly during the transition to the pubertal period. The smaller size of the cryptorchid epididymis in pubertal and adult men compared with that of normal men is due primarily to underdevelopment of the muscular wall and a reduction in epithelial height. The pattern of growth of cryptorchid efferent ducts and ductus epididymides parallels that in normal men, except that development of the lumen and muscular layer in the cauda epididymis region are delayed. Epithelial differentiation, monitored by cytokeratin expression, is minimal in efferent ducts and throughout the epididymis of the cryptorchid male, and this is already seen in children. In conclusion, our immunohistochemical and morphometric results show a reduced development of the human cryptorchid epididymis that is already evident in childhood. They indicate that cryptorchidism is a primary congenital illness of the testis and spermatic ducts, with evident lesions from the first years of life, and suggest that surgical descent would probably not be able to completely reverse these alterations.

Pre- and post-natal growth of the human ductus epididymidis. A morphometric study.

A histometric study of the development of the human epididymis from the fetal period to adulthood has been carried out in males without testicular or related pathology, distributed into the following groups: (I) fetuses (between the 28th and 37th week of pregnancy); (II) newborns (1-30 days of age); (III) infants (2-4 months of age); (IV) infants (5-12 months of age); (V) infants (1-4 years of age); (VI) children (5-14 years [prepubertal]); and (VII) adults (15-60 years of age). For each age group and each epididymal portion (efferent ducts, caput, corpus and cauda epididymidis) the parameters measured were (1) total surface (epithelium + muscular layer + lumen); (2) the surface occupied by the lumen; (3) the surface occupied by the muscular layer; (4) total diameter of the duct; (5) total diameter of the lumen; and (6) the height of the epithelium. The results of the present study revealed that the development of the efferent ducts and ductus epididymidis follows a biphasic pattern. A progressive development occurs from the fetal period to infants 2-4-months of age. However, this development is transient and regresses during infancy (groups IV and V). At childhood (group VI), a definitive development is initiated and completed at puberty (group VII). These changes seem to be related to the androgen-dependence of the epididymis, the different stages of testicular maturation, and the steroidogenic activity of Leydig cells.

Residual cavities after surgery for hepatic hydatid cysts--an ultrasonographic evaluation.

Ultrasonography has made it easier to diagnose precisely hepatic hydatid cysts, but the interpretation of images of residual cavities persisting long after the operation can be difficult. We reviewed the clinical histories of 22 children treated surgically for hepatic hydatid cysts at our hospital (1985-1992) to find clues to the proper attitude toward residual cavities. The children's mean age was 7.4 +/- 2.5 years. Fourteen children had single cysts (11 right and 3 left) and 8 children had multiple cysts, one of them 30 cysts (16 right and 14 left). The mean ultrasonographic diameter of the 44 cysts was 6.1 +/- 3 cm. Cystectomy with partial pericystectomy was performed in every case. Six months after operation, 29 cavities had disappeared, became calcified, or were substituted with fibrous scar tissue. The remaining 15 residual cavities had a mean diameter of 3 +/- 1 cm. The residual cavities exhibited little change at 12 months (2.8 +/- 1 cm), but at 18 months 9 had disappeared, 2 that increased in size and 4 remained the same size. Of these 4 stable lesions, surgery performed in 2 found no cysts and 2 have been followed-up ultrasonographically for 5 years. This short series shows that ultrasonography is useful in the diagnosis and follow-up of residual cavities after surgery for hepatic hydatid cysts. Most residual cavities disappeared by 18 months. In the cavities that persisted, our findings suggest that surgical treatment is justified only when the cyst becomes larger on ultrasonography.

Neural tube defects: an experimental model in the foetal rat.

We report on our experience in the experimental induction of Neural Tube Defects (NTD) in the foetal rat by maternal administration of retinoic acid. The teratogen diluted in olive oil was administered in a single intragastric dose (125 mg/kg body weight) to pregnant rats (n = 31) on the 10th day of gestation. Pure olive oil was given to control rats (n = 9). The foetuses were recovered by caesarian section on the 20th day and prepared for morphological investigation. We have studied 201 experimental and 82 control animals. There were NTD in 36.3% of experimental foetuses and none in the control ones. Sacral dysraphism was the most frequent defect but we also observed Arnold Chiari malformations and crowding of the bony limits by an enlarged neural axis. Other associated malformations found were: craneofacial (78.1%), caudal (80%), anorectal (31.4%), and limb defects (89.5%). This simple and inexpensive model may allow us to gain a better knowledge of the biology in the foetus with NTD.

[Gastroschisis: study of teratogenic factors]. / Gastrosquisis: estudio de factores teratogénicos.

The medical and surgical treatment of gastroschisis has improved in the last decades leading to better survival rates. Since in our institution there were the same cyclic variations in the incidence as in other large series in the literature, we have reviewed the epidemiological factors that can be at the origin of such variations. We studied 20 different variables in our patients in a case-control basis. Only five of them were significantly different between cases and controls. (Birth weight, gestational age, infection, drugs during the first three months of gestation and maternal age). The results point to the role of environmental factors more relevant in the etiology of gastroschisis than genetic ones.

[Extensive aganglionosis. Treatment and long term results]. / Aganglionismos extensos. Tratamiento y resultados a largo plazo.

INTRODUCTION: Extensive aganglionosis (EA) that affects the total colon (including or not part of the small intestine), shows more diagnostic problems and it is associated to higher morbidity and mortality rates than the classic cases of Hirschsprung disease (ED). This study takes into account last years cases and their results in the medium and long term. MATERIAL AND METHODS: Between 1983 and 2000, 232 patients suffering ED have been treated. 15 out of those 232 patients showed EA. We took into consideration the diagnosis, surgical procedures, enterocolitis before and after the treatment, the surgical technique and the complications. We analyze the nutritional state and the long term result according to clinical bowel function scoring system continency Scale, considering the surgical possibilities depending on each case. RESULTS: Two patients died due to septics complications, one of them during the neonatal period and the other one at the age of 3. Two other cases became possible candidates to an intestinal transplantation due to the extension of their disease. Five out of the 11 left patients had more than 30 cm of small intestine involved, and another five had involved less than 30 cm from ileocecal valve. The last case showed a total colonic aganglionosis with associated intestinal neuronal displasia. One case was associated with S. Ondine and another one with a 21 triosomia. Two of the patients were brothers and another patient has got a brother suffering from rectosigmoid HD. The surgical techniques used with 13 were: 8 cases using Lester Martin modification (one of them needed redo procedure because of anastomosis leak and perineal fistula), 4 Swenson procedure and one patient was treated by Ziegler's miectomy with prolongated miotomy. Nine of the patients mentioned before, lead a quite life (five L, Martin, 4 Swenson); 2 patients suffering frequent fecal retention crisis. 5 out of the 11 reviewed cases, show a weight and height p > or = 50, 2 below p50, 2 below p25, and 2 under p3. CONCLUSION: EA represents a small percentage of Hirschsprung disease. Although Martin modification is the most widely employed technique in cases of distal ileal involvement, Swenson procedure has provided good results in the long term follow-up with few complications. Intestinal transplantation may be the only choice for long term survival in patients with near total intestinal aganglionosis. Continence improves in the follow-up but few times is normal. Nutritional state should be-controlled by a specialized team.

[Surgical treatment of differentiated carcinoma of the thyroid. Retrospective study]. / Tratamiento quirúrgico del carcinoma diferenciado de tiroides. Estudio retrospectivo.

This is a review of the surgical treatment in six patients with papillary carcinoma of the thyroid. The mean age at the time of diagnosis was eight years (range four-twelve years). Clinical presentation was: all patients had a palpable thyroid tumor, palpable lymph nodes in four and one with lung metastases. The initial surgical treatment was lobectomy and modified regional lymph nodes resection. Four patients underwent a second operation for multifocal disease, palpable lymph node or thyroid tumor. The interval from initial surgical management to the detection of recurrence ranging from one month to four years. In three patients the remaining thyroid gland was removed. Radioiodine, external irradiation and chemotherapy were given during the postoperative. The median follow-up was eight years (range one-fifteen years). All patients are alive with thyroid hormone therapy by hypothyroidism. There were no hypoparathyroidism or injuries to the recurrent laryngeal nerve. The results of this study suggest that the surgical approach in papillary carcinoma of the thyroid is total thyroidectomy because reoperation were performed in four patients.

[Sclerodermiform linear atrophy caused by triamcinolone]. / Atrofia linear esclerodermiforme por triamcinolona.

A case of linear scleroderma-like atrophy from local injections of triamcinolone acetonide is reported. The clinical picture resembled a true monomelic scleroderma. Spontaneous dis-appearance occurred after a year.

Congruence between clinical and research-based psychiatric assessment in bariatric surgical candidates.

BACKGROUND: Mental health professionals have become increasingly involved in working with bariatric surgical candidates, particularly in performing preoperative psychological evaluations to clear candidates for surgery. The objective of the present study was to examine the concordance of the psychiatric diagnoses obtained during routine clinical evaluation before bariatric surgery and the diagnoses obtained separately at a research facility using the Structured Clinical Interview for DSM (Diagnostic and Statistical Manual of Mental Disorders)-IV axis I disorders. METHODS: The study included 68 consecutively enrolled bariatric surgical candidates who had participated in the Longitudinal Assessment of Bariatric Surgery-3 study. The Structured Clinical Interview for DSM disorders data obtained from the research assessments were compared with the diagnostic data from the routine preoperative psychiatric evaluations. The congruence of the current and lifetime diagnoses was assessed using Cohen's coefficient kappa. RESULTS: Considerable variability was found among the major diagnostic categories, with generally poor agreement found for the current diagnoses. The kappa coefficients tended to be larger for the lifetime diagnoses. The agreement was moderate for any lifetime mood disorder, with a kappa value of 0.45. Regarding any lifetime anxiety, substance use, and eating disorder, the clinical diagnoses rarely concurred with the results from the Structured Clinical Interview for DSM disorders, with a kappa statistic of 0.30, 0.36, and 0.32, respectively. CONCLUSION: The congruence between the diagnoses assigned during the routine clinical psychiatric evaluations and research assessment using the Structured Clinical Interview for DSM disorders was surprisingly low. These conclusions should be considered tentative, given the interval and the possibility of treatment having occurred between the 2 evaluations. Overall, these data raise interesting questions concerning the use of unstructured psychiatric evaluations before bariatric surgery.

[Digestive system duplications]. / Duplicaciones digestivas.

Fifteen digestive duplications, corresponding to fourteen patients, have been surgically treated in "La Paz" Pediatric Hospital between 1966 and 1984. The most common localization (40%) was the large bowel. The first choice treatment was the complete excision of lesions, with led to cure of all patients. Embryologic theories and clinical forms are also reviewed.

[Colonic atresia]. / Atresia cólica.

Nine cases of colonic atresia, treated in the Departament of Pediatric Surgery of "La Paz" Pediatric Hospital, are reported. They account for 11% of all our intestinal atresias. We review the different etiologic and pathologic theories and classificate our group according to the LOUW and HAYS method. In two cases their digestive anomalies and in one renal anomalies were found to be associated mortality was 11%.

[Traumatic diaphragmatic hernia in children]. / Hernia diafragmática traumática en el niño.

We have treated three children with traumatic diaphragmatic hernia appearing after blunt abdominal trauma. The hernia was on the right side in two patients and was accompanied by liver and lung injuries. The most common site of diaphragmatic rupture was the postero-lateral area in both sides. Diagnosis was suspected in all of them with chest radiograph before operative management. The transabdominal approach has proven to be efficacious in repairing the defects and often require emergency care. The diaphragmatic repair was performed using non absorbable interrupted mattress sutures. No prosthetic materials were required.