Lavados colónicos anterógrados para el estreñimiento refractario en niños sin encefalopatía / Antegrade colonic enemas for intractable constipation in non-mentally retarded children

Revisión retrospectiva de las cecostomías realizadas para lavados anterógrados colónicos. Doce apendicocecostomías desde enero de 2002 a febrero de 2008, 9 apendicostomías en pacientes con mielomeningocele y 3 cecostomías en niños con estreñimiento crónico no orgánico sin encefalopatía ni retraso mental. De los 9 primeros pacientes, de entre 3 y 13 años, 8 tuvieron muy buena evolución y uno requirió retirada por mal empleo familiar. A un niño de 7 años, por lo demás sano, con estreñimiento crónico desde los 10 meses, pese a laxantes múltiples (varias tandas de desimpactación y dilatación anal bajo anestesia), con estudio morfofuncional normal, se le realizó, hace 5 años, cecostomía; persistió cierta tendencia a impactación pero con buena calidad de vida. Otro niño, previamente sano, de 12 años de edad, presentaba incontinencia fecal diaria asociada a estreñimiento desde los 3 años, con manometría anorrectal normal y biopsia con leve displasia neuronal; se le realizó cecostomía hace 3 años, con mejoría evidente y menor trastorno emocional secundario. El último caso de cecostomía tenía 8 años, con cuadro similar al anterior y se realizó procedimiento endoscópico con botón de Chait, con lo que mejoró francamente el cuadro. La progresión del estreñimiento rebelde a edad adulta tiene un impacto negativo en la adaptación social y el estado emocional del paciente, y puede alterar la vida familiar. Los lavados anterógrados colónicos proporcionan independencia y mejoran la calidad de vida. Se necesitan realizar en más pacientes para poder establecer verdaderos datos de efectividad (AU)

A descriptive review of 12 patients who underwent appendicocecostomy or caecostomy for antegrade colonic lavage from January 2002 to February 2008. There were 9 appendicocecostomies performed patients from 3 to 13 years suffering from myelomeningocele, of which 8 of them had a very good outcome, with one case with drawn due to poor use by the family. Three caecostomies were performed in non-mentally retarded constipated children. One was an otherwise healthy 7 year-old boy with hards tools since he was 10 months old, in spite of multiple laxative treatments, with normal morphology and function. He had a percutaneous caecostomy five years ago, with some improvement and a good quality of life, but still some occasional partial impactions. Another healthy 12 year-old boy with daily constipation associated faecal incontinence since he was 3 years old (normal manometry and rectal biopsy with signs of mild neuronal dysplasia)had a percutaneous caecostomy performed three years ago, with improvement in the faecal incontinence and better psychological out come. The last caecostomy patient was an 8 year-old boy, with a similar clinical history and good progress in last three years after placing a Chait’s button using an endoscopic procedure. Stubborn constipation continuing in to adult life has a negative impact on the social and emotional adaptation of the paediatric patient, affecting family interactions. Antegrade colonic lavage allows independence and improves the quality of life in patients affected by recurrent faecal impactions. This technique needs to be performed on more patients to find out its true effectiveness (AU)

[Antegrade colonic enemas for intractable constipation in non-mentally retarded children]. / Lavados colónicos anterógrados para el estreñimiento refractario en niños sin encefalopatía.

A descriptive review of 12 patients who underwent appendicocecostomy or caecostomy for antegrade colonic lavage from January 2002 to February 2008. There were 9 appendicocecostomies performed patients from 3 to 13 years suffering from myelomeningocele, of which 8 of them had a very good outcome, with one case withdrawn due to poor use by the family. Three caecostomies were performed in non-mentally retarded constipated children. One was an otherwise healthy 7 year-old boy with hard stools since he was 10 months old, in spite of multiple laxative treatments, with normal morphology and function. He had a percutaneous caecostomy five years ago, with some improvement and a good quality of life, but still some occasional partial impactions. Another healthy 12 year-old boy with daily constipation associated faecal incontinence since he was 3 years old (normal manometry and rectal biopsy with signs of mild neuronal dysplasia) had a percutaneous caecostomy performed three years ago, with improvement in the faecal incontinence and better psychological outcome. The last caecostomy patient was an 8-year-old boy, with a similar clinical history and good progress in last three years after placing a Chait's button using an endoscopic procedure. Stubborn constipation continuing into adult life has a negative impact on the social and emotional adaptation of the paediatric patient, affecting family interactions. Antegrade colonic lavage allows independence and improves the quality of life in patients affected by recurrent faecal impactions. This technique needs to be performed on more patients to find out its true effectiveness.

[Abdominal lesions associated to safety belt mark]. / Lesiones abdominales asociadas a marca por cinturón de seguridad.

INTRODUCTION: Motor vehicle crashes cause 28% of morbidity and mortality in children. A proper medical evaluation of the polytraumatized patient is essential to reduce these numbers. The aim of our study is to correlate clinical and radiological signs in patients with seat belt mark, to establish an early diagnosis of internal injuries. MATERIALS AND METHODS: From 1998 to 2007 we treated 8 cases of polytraumatized patients (5 boys and 3 girls) with abdominal bruises (seat belt mark) after suffering a traffic accident. The mean age was 8.37 years (range: 4-11). 100% of the patients suffered a frontal collision of their vehicle. In 2 cases the position of the lap belt was inadequate. The trauma team made the initial attention of all patients in the Emergency room, with a complete physical examination and they requested: abdominal X-ray, ultrasound and computed tomography (CT-scan). RESULTS: The main clinical signs found in our patients were: one case of hemodynamic instability, hypovolemic shock and abdominal distension; 2 cases of diffuse abdominal pain and signs of peritoneal irritation; 4 cases of non-specific diffuse abdominal pain and one patient in coma with Glasgow 8. The radiological signs found were: abdominal free fluid (detected in 100% of the CT-scan and only in 75% of ultrasound studies), thickening and enhancement of small bowel (62.5%), mesenteric infiltration (87.5 %) and pneumoperitoneum (37.5%). The surgical findings were: seven cases (87.5%) of an intestinal bursting perforation and one case of vascular injury of the medium colic vein. The diagnosis of intestinal perforation was late established in five patients, and they underwent treatment between 5 and 19 days after the accident. CONCLUSIONS: All our patients (100%) with a seat belt mark presented abdominal injuries. The treatment is frequently delayed due to the difficulty in establishing the diagnosis. The finding of cutaneous ecchymosis caused by the lap belt must be a warning sign to suspect abdominal injuries. The CT scan is the most effective imaging technique to study patients with seat belt mark.

Lesiones abdominales asociadas a marca por cinturón de seguridad / Abdominal lesions associated to safety belt mark

Introducción. Los accidentes de tráfico son causa del 28% de morbimortalidad en la edad pediátrica. Una correcta evaluación médica del politraumatizado es imprescindible para la reducción de estas cifras. El objetivo de nuestro trabajo es correlacionar en pacientes con lesiones cutáneas postraumáticas por cinturón de seguridad, los signos clínicos y radiológicos para establecer un diagnóstico precoz de lesiones internas. Material y métodos. Desde 1998 hasta 2007 hemos tratado a 8pacientes (5 niños y 3 niñas) politraumatizados con marca por cinturón de seguridad tras accidente de tráfico. La edad media fue de 8,37 años(rango: 4-11). El 100% de los pacientes sufrieron una colisión frontal de su vehículo. Se constató que en 2 casos la posición del cinturón era inadecuada. A todos los pacientes se les realizó la atención inicial al politraumatizado, con una exploración física completa y se solicitaron exploraciones complementarias: radiografía simple, ecografía y tomografía computarizada (TC) abdominal. Resultados. La clínica principal que presentaron los pacientes fue: un caso de inestabilidad hemodinámica, shock hipovolémico y distensión abdominal; 2 casos con dolor abdominal difuso y signos de (..) (AU)

Introduction. Motor vehicle crashes cause 28% of morbidity and mortality in children. A proper medical evaluation of the polytraumatized patient is essential to reduce these numbers. The aim of our study is to correlate clinical and radiological signs in patients with seat beltmark, to establish an early diagnosis of internal injuries. Materials and methods. From 1998 to 2007 we treated 8 cases of polytraumatized patients (5 boys and 3 girls) with abdominal bruises(seat belt mark) after suffering a traffic accident. The mean age was 8.37years (range: 4-11). 100% of the patients suffered a frontal collision of their vehicle. In 2 cases the position of the lap belt was inadequate. The trauma team made the initial attention of all patients in the Emergency room, with a complete physical examination and they requested: abdominal X- ray, ultrasound and computed tomography (CT-scan). Results. The main clinical signs found in our patients were: one case of hemodynamic instability, hypovolemic shock and abdominal distension; 2 cases of diffuse abdominal pain and signs of peritoneal irritation; 4 cases of non-specific diffuse abdominal pain and one patient (..) (AU)

[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.

[Puberal gynaecomastia. Review of nine cases]. / Ginecomastia puberal. Revisión de nueve casos.

Gynaecomastia is more frequent during the adolescence. In this paper, a retrospective study of nine cases diagnosed and treated on a period of six years is presented. The reports of nine patients are reviewed. The mean age at diagnosis was 10.4 years (range 9-12). In all cases a bilateral mammary hypertrophy was detected, symmetrical in 6 cases (67%) and asymmetric in 3 (33%). After a mean follow-up period of 24 months, surgical treatment was indicated: a subtotal subcutaneous mastectomy was performed in all nine cases. Only two patients developed early complications: one wound infection and one haematoma. The long-term plastic results were satisfactory after a mean follow-up postoperative period of 11 months. The general management of this kind of pathologic process is presented. In the authors experience the elective surgical procedure is the subtotal subcutaneous mastectomy as simple procedure with a very short morbidity and excellent plastic results.

Ginecomastia puberal. Revisión de nueve casos / Puberal Gynaecomastia: our experience

La ginecomastia presenta mayor incidencia en la adolescencia. Se realiza un estudio retrospectivo de los casos diagnosticados y tratados quirúrgicamente en nuestro hospital en los últimos seis años. Se revisan nueve pacientes, con una edad media de 10,4 años (rango 9-12), en el momento de inicio de la ginecomastia. En todos los casos se observó una afectación mamaria bilateral, que fue simétrica en seis pacientes (67 por ciento) y asimétrica en tres (33 por ciento). Tras un período de evolución medio de 24 meses, todos fueron tratados quirúrgicamente (mastectomía subcutánea subtotal). Dos pacientes desarrollaron complicaciones en el postoperatorio inmediato (infección de la herida y hematoma), no observándose ninguna a largo plazo, tras un período de seguimiento medio de 11 meses. No fueron necesarias reintervenciones, siendo excelentes los resultados estéticos en todos los pacientes. Se expone una sistemática de manejo integral de esta patología, cuyo tratamiento quirúrgico de elección es la mastectomía subcutánea subtotal, por ser una técnica sencilla, con mínima morbilidad postoperatoria y excelentes resultados estéticos (AU)

[Indications of transduodenal papillotomy for choledochal cyst]. / Indicaciones de la papilotomía transduodenal en el tratamiento del quiste de colédoco.

UNLABELLED: The Choledochal Cyst is a dilatation of the biliary tract whose etiology is still under debate. OBJECTIVE: This paper analyzes the cases of our group an contributes on the indications of transduodenal papilotomy in the surgical treatment of this process. MATERIAL AND METHODS: Seven cases diagnosed as choledochal cysts are presented with mean age between 3 and 10 years (5 females and 2 males). Six cases were presented with abdominal pain, four with jaundice, three presented with biliary stones and one cases was a casual discovery during an US examination. In all cases US and magnetic resonance cholangiopancreatography (MRCP) were performed as preoperative work-up. In one case an endoscopic retrograde cholangiopancreatography (ERCP) was made. In all cases intraoperative cholangiography was carried out. The surgical treatment was quistectomy and hepatico yeyunostomy Roux-Y in four cases; in one of them a transduodenal papilotomy was added. Cholecystectomy and transduodenal papilotomy was made in three cases, two of them presented choledocholithiasys. RESULTS: All patients are symptoms free after a mean follow up period of 2 years and 3 months (range: 1 year and 6 months to 4 years and 10 months). In one case persists dilated choledochal distal stump on MRCP.

Indicaciones de la papilotomía transduodenal en el tratamiento del quiste de colédoco / Indications of transduodenal papilotomy for choledochal cyst

El Quiste de Colédoco es una dilatación de la vía biliar cuya etiología sigue sujeta a debate. Objetivos: Análisis de la casuística del Servicio y aportación de las indicaciones de la papilotomía transduodenal en el tratamiento quirúrgica de esta patología. Material y métodos: Se presentan siete casos diagnosticados de quiste de colédoco con una edad entre 3 y 10 años ( 5 hembras y 2 varones). Seis casos presentaron dolor abdominal, cuatro ictericia, tres eran portadores de litiasis biliar y un caso fue un hallazgo casual en el curso de una exploración ecográfica. En todos ellos se realizó ecografia y colangio-pancreato-resonancia magnética (CPRM) preoperatorias. En un caso se realizó una colangio-pancreatografía retrógrada endoscópica (CPRE). En todos se realizó colangiografía intraoperatoria. El tratamiento quirúrgico realizado fue Quistectomia y hepático- yeyunostomía en Y de Roux en cuatro casos. En uno de ellos se añadió una papilotomía transduodenal. En tres casos se efectuó colecistectomía y papilotomía transduodenal. Dos de estos pacientes presentaban coledocolitiasis. Resultados: Todos los pacientes están asintomáticos tras un periodo de seguimiento medio de 2 años y 3 meses (rango: laño y 6 meses a 4 años y 10 meses). En un caso se aprecia en la CPRM postoperatoria la existencia de un muñón residual del colédoco distal con ectasia. (AU)

[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.

Ureteral triplication and duplicated opposite kidney with refluxing ureterocele.

A case is reported of ureteral triplication with ectopia of two of the ureters and contralateral duplication with a ureterocele. This patient is the youngest that we have found reported with this type of anomaly and the only one presenting with abdominal distention and an intact but refluxing ureterocele.

[Venous aneurysms of the neck in childhood (author's transl)]. / Aneurismas fusiformes venosos cervicales en la infancia.

Three children with four fusiform venous aneurysms in the neck are described. A correct referral clinical diagnosis had not been established in any of these children. The diagnosis should be made generally on the basis of the physical examination, including the test of the "digital pressure", which is particularly useful to rule out a laringocele. Three of the aneurysms have been treated by surgical removal. Histological examination showed microscopic changes which were related to the time elapsed since the mass was first noticed. Areas of thinning out and sclerosis of the venous wall were evident in one case. The patient with the remaining aneurysm is being followed closely.

[Intestinal recirculation in the management of experimental short bowel syndrome (author's transl)]. / Recirculación intestinal como tratamiento del síndrome de intestino corto experimental

A short bowel syndrome was produced in 33 mongrel puppies less than one month of age, by resecting 80% of the small bowel. An end-to-end anastomosis was performed in 14 dogs (Group A). Sixteen dogs were reanastomosed by performing an isoperistaltic circular intestinal loop, modified from Tanner and Mackby (Group B). Three dogs had a circular loop performed using Mackby method, but this technique was abandoned because of intraluminal stasis. Long term survival on 18 dogs was 12,5% for Group A and 57% for Group B. Weight gain on the survivors was over 25% higher in Group B. Intestinal transit time was abnormally short only in Group A. The loop procedure seems worthy of further clinical trial.