Comparación de dos técnicas de sección vascular en lavaricocelectomía laparoscópica. Estudio prospectivo / Comparing two vascular division techniques in laparoscopic varicocelectomy. A prospective study

Introducción: El varicocele es la dilatación anormal del plexopampiniforme. Puede afectar al 15-20% de los varones preadolescentes-adultos. La importancia de su diagnóstico radica en que puede inducirhipotrofia testicular y problemas de fertilidad en la etapa adulta. El objetivo de este estudio es evaluar si existe mayor índice de complicaciones,incluyendo la recurrencia del varicocele, dependiendo de la técnica deoclusión vascular utilizada: clip y sección o sellador vascular, en latécnica de Palomo laparoscópico en nuestro centro.Material y métodos: Estudio longitudinal prospectivo que se realizade 2017 a 2021. Se crean dos grupos terapéuticos según el método deoclusión vascular utilizada durante la varicocelectomía laparoscópica:clip y sección o sellador vascular. Los pacientes son incluidos en ungrupo mediante asignación sistemática consecutiva alternante. Se realizael análisis de las variables: edad, grado de varicocele según la clasifica-ción de Dubin-Amelar, complicaciones postquirúrgicas, seguimiento yrecurrencia del varicocele, según el método empleado.Resultados: Se intervinieron un total de 37 niños, con edad mediade 12 años (10-15 años) y una media de seguimiento de 12 meses. En20 pacientes (54,1%), se utilizó clip y sección, y en los 17 restantes(45,9%), sellador vascular. El 24,3% presentaba varicocele Grado IIsintomático y el 75,7%, Grado III. El 32,4% de los niños presentó algunacomplicación postquirúrgica durante el seguimiento. El 29,7% de lospacientes presentó hidrocele tras la intervención, perteneciendo 8 niñosal grupo de sellado y 3 niños al de clipaje. El 13,5% de estos precisóreintervención por este motivo. Ningún paciente presentó recurrenciadel varicocele. Conclusiones: La técnica de Palomo laparoscópica es una técnicasegura y efectiva que presenta buenos resultados en pacientes pediátricos...(AU)

Introduction: Varicocele is the abnormal dilatation of the pampiniform plexus. It occurs in 15-20% of pre-adolescent/adult males.Varicocele diagnosis is important since it can induce testicular hyper-trophy and fertility issues in adulthood. The objective of this studywas to assess whether complications, including varicocele recurrence,depend on the vascular occlusion technique used –clipping + divisionvs. vascular sealer–in the laparoscopic Palomo technique used inour institution. Materials and methods: A longitudinal, prospective study wascarried out from 2017 to 2021. Two therapeutic groups were createdaccording to the vascular occlusion method used during laparoscopicvaricocelectomy –clipping + division vs. vascular sealer. Patients wererandomly allocated to the groups in a systematic alternating consecutivemanner. Variables –age, varicocele grade according to the Dubin-Amelarclassification, postoperative complications, follow-up, and varicocelerecurrence– were analyzed according to the method employed.Results: A total of 37 boys, with a mean age of 12 years (10-15years) and a mean follow-up of 12 months, were studied. In 20 patients (54.1%), clipping + division was used, and in the remaining 17(45.9%), the vascular sealer was employed. 24.3% had symptomaticGrade II varicocele and 75.7% had Grade III varicocele. 32.4% of thechildren had postoperative complications during follow-up. 29.7% ofthe patients had hydrocele following surgery –8 boys from the seal-ing group and 3 boys from the clipping group–, with 13.5% requiringre-intervention as a result of this. None of the patients had varicocelerecurrence. Conclusions: The laparoscopic Palomo technique is safe and ef-fective, with good results in pediatric patients and few postoperativecomplications, regardless of the vascular occlusion device used...(AU)

Comparing two vascular division techniques in laparoscopic varicocelectomy. A prospective study. / Comparación de dos técnicas de sección vascular en la varicocelectomía laparoscópica. Estudio prospectivo.

INTRODUCTION: Varicocele is the abnormal dilatation of the pampiniform plexus. It occurs in 15-20% of pre-adolescent/adult males. Varicocele diagnosis is important since it can induce testicular hypertrophy and fertility issues in adulthood. The objective of this study was to assess whether complications, including varicocele recurrence, depend on the vascular occlusion technique used -clipping + division vs. vascular sealer- in the laparoscopic Palomo technique used in our institution. MATERIALS AND METHODS: A longitudinal, prospective study was carried out from 2017 to 2021. Two therapeutic groups were created according to the vascular occlusion method used during laparoscopic varicocelectomy -clipping + division vs. vascular sealer. Patients were randomly allocated to the groups in a systematic alternating consecutive manner. Variables -age, varicocele grade according to the Dubin-Amelar classification, postoperative complications, follow-up, and varicocele recurrence- were analyzed according to the method employed. RESULTS: A total of 37 boys, with a mean age of 12 years (10-15 years) and a mean follow-up of 12 months, were studied. In 20 patients (54.1%), clipping + division was used, and in the remaining 17 (45.9%), the vascular sealer was employed. 24.3% had symptomatic Grade II varicocele and 75.7% had Grade III varicocele. 32.4% of the children had postoperative complications during follow-up. 29.7% of the patients had hydrocele following surgery -8 boys from the sealing group and 3 boys from the clipping group-, with 13.5% requiring re-intervention as a result of this. None of the patients had varicocele recurrence. CONCLUSIONS: The laparoscopic Palomo technique is safe and effective, with good results in pediatric patients and few postoperative complications, regardless of the vascular occlusion device used. In our study, no statistically significant differences regarding the use of clipping or vascular sealer in this laparoscopic technique were found. However, further studies with a larger sample size are required to find potential differences.

INTRODUCCION: El varicocele es la dilatación anormal del plexo pampiniforme. Puede afectar al 15-20% de los varones preadolescentes-adultos. La importancia de su diagnóstico radica en que puede inducir hipotrofia testicular y problemas de fertilidad en la etapa adulta. El objetivo de este estudio es evaluar si existe mayor índice de complicaciones, incluyendo la recurrencia del varicocele, dependiendo de la técnica de oclusión vascular utilizada: clip y sección o sellador vascular, en la técnica de Palomo laparoscópico en nuestro centro. MATERIAL Y METODOS: Estudio longitudinal prospectivo que se realiza de 2017 a 2021. Se crean dos grupos terapéuticos según el método de oclusión vascular utilizada durante la varicocelectomía laparoscópica: clip y sección o sellador vascular. Los pacientes son incluidos en un grupo mediante asignación sistemática consecutiva alternante. Se realiza el análisis de las variables: edad, grado de varicocele según la clasificación de Dubin-Amelar, complicaciones postquirúrgicas, seguimiento y recurrencia del varicocele, según el método empleado. RESULTADOS: Se intervinieron un total de 37 niños, con edad media de 12 años (10-15 años) y una media de seguimiento de 12 meses. En 20 pacientes (54,1%), se utilizó clip y sección, y en los 17 restantes (45,9%), sellador vascular. El 24,3% presentaba varicocele Grado II sintomático y el 75,7%, Grado III. El 32,4% de los niños presentó alguna complicación postquirúrgica durante el seguimiento. El 29,7% de los pacientes presentó hidrocele tras la intervención, perteneciendo 8 niños al grupo de sellado y 3 niños al de clipaje. El 13,5% de estos precisó reintervención por este motivo. Ningún paciente presentó recurrencia del varicocele. CONCLUSIONES: La técnica de Palomo laparoscópica es una técnica segura y efectiva que presenta buenos resultados en pacientes pediátricos, ya que presenta pocas complicaciones postquirúrgicas, independientemente del dispositivo de oclusión vascular que se utilice. En nuestro estudio, no se ha demostrado que existan diferencias estadísticamente significativas en cuanto al uso de clip o sellador vascular en esta técnica laparoscópica. No obstante, es preciso realizar más estudios con mayor tamaño muestral para hallar posibles diferencias.

Clavien-Dindo classification: a tool to assess complications following surgical treatment in children with acute appendicitis. / Clasificación de Clavien-Dindo. Herramienta para evaluar las complicaciones tras el tratamiento quirúrgico en niños con apendicitis aguda.

INTRODUCTION: In pediatrics, there are few standard criteria to classify and consolidate postoperative complications, particularly in appendectomy, where according to the literature, complications range from 5% to 30%. METHODS: A cross-sectional, observational, retrospective study of patients undergoing surgery as a result of suspected acute appendicitis (AA) from December 2018 to January 2020 was carried out. Complications were grouped and consolidated according to the Clavien-Dindo (CD) classification. Postoperative complications and factors involved were analyzed by conducting a bivariate and multivariate statistical study using SPSS statistical software, version 25. RESULTS: A total of 124 patients were studied. Mean age was 9 years (3-14 years). 62% were boys, and 38% were girls. All patients underwent appendectomy - 80.6% through laparotomy, and 19.4% through laparoscopy. 20% of patients had postoperative complications, which were grouped according to the CD classification (p = 0.002). Most complications were included in the CD I group (64%). Collections treated with antibiotic therapy were included in the CD II group (28%). Intra-abdominal collections requiring re-intervention for drainage purposes were included in the CD IIIb group (8%). The main factors driving complications were complicated AA (81% gangrenous and perforated) (p < 0.001) and progression time (80% > 24 h of progression) (p = 0.036), which increased mean hospital stay by 7 ± 4 days (p = 0.016). 137 ± 37 CRP levels were associated with plastron identification (p < 0.001), whereas 109 ± 19 CRP levels were associated with peritonitis (p < 0.001). CONCLUSIONS: The Clavien-Dindo classification allows post-appendectomy complications in pediatric surgery to be classified using a common language, by associating complication grade with treatment complexity.

INTRODUCCION: En pediatría hay pocos criterios estándares para clasificar y unificar las complicaciones postquirúrgicas y en particular en la apendicectomía, donde, según la literatura, las complicaciones varían de un 5-30%. METODOS: Realizamos un estudio retrospectivo, observacional tipo transversal de los pacientes intervenidos por sospecha de apendicitis aguda (AA) durante diciembre 2018 a enero 2020. Las complicaciones fueron agrupadas y unificadas según la clasificación de Clavien-Dindo (CD). Se analizan las complicaciones postoperatorias y factores implicados, aplicando estudio estadístico bivariante y multivariante según el programa estadístico SPSS versión 25. RESULTADOS: Un total de 124 pacientes incluidos. Edad media 9 años (3-14 años). 62% niños, 38% niñas. A todos se les realizó apendicectomía, el 80,6% apendicectomía abierta, 19,4% por laparoscopia. El 20% presentó algún tipo de complicación en el postoperatorio y fueron agrupadas según la clasificación de CD (p = 0,002). En CD I (64%) se incluyen la mayoría de las complicaciones, En el grupo CD II (28%) colecciones tratadas con antibioticoterapia. En el grupo CD IIIb (8%), colección intraabdominal que requirió reintervención para su drenaje. Los principales factores implicados en la aparición de complicaciones fueron: AA complicadas (81% gangrenosas y perforadas) (p < 0,001), tiempo de evolución (80% > 24 h de evolución) (p = 0,036) que incrementó la estancia media 7 ± 4 días (p = 0,016). El valor de proteína C reactiva (PCR) (137 ± 37) se relacionó con la identificación de plastrón (p < 0,001), y el valor de PCR (109 ± 19) con peritonitis (p < 0,001). CONCLUSIONES: La clasificación de Clavien-Dindo permite utilizar un lenguaje común para clasificar las complicaciones postapendicectomía en cirugía pediátrica, expresando el grado de estas según complejidad del tratamiento utilizado para su resolución.

[Clinical characteristics and complications in patients with OHVIRA (obstructed hemivagina and ipsilateral renal anomaly) syndrome. Our experience]. / Síndrome de OHVIRA: características clínicas y complicaciones, nuestra experiencia.

INTRODUCTION: Obstructed Hemivagina and Ipsilateral Renal Agenesis (OHVIRA) syndrome is a rare variant of Müllerian anomalies. Delay in diagnosis and treatment can produce serious complications in patient's life and fertility. The aim of this study is to present our experience in clinical presentation, diagnosis and complications of patients with OHVIRA syndrome in a 20-year period. PATIENTS AND METHODS: Retrospective analysis of 9 women under 25 years old with OHVIRA syndrome between 1997 and 2017. Analysis included clinical characteristics, demographic, diagnostic methods, follow-up, treatment and complications. RESULTS: A total of 9 patients were studied, 5 diagnosed in prepuberal age and 4 postpuberal. 55% had prenatal diagnosis of renal agenesis and in 3 was incidentally diagnosed. Follow up period for single kidney to diagnosis was 3.6 years (range: 0-13,4 years). Right side was affected in 55%. Symptoms were dysmenorrea (44%), recurrent abdominal pain (22%), urinary dysfunction (22%). Complications were present in postpuberal patients and included hydrometrocolpos (22%) and pyocolpos (11%) requiring septostomy or septum resection. Surgical removal of the septum was performed in 44%). Prepuberal patients were asymptomatic. CONCLUSIONS: OHVIRA syndrome is a rare anomaly in the development of Müllerian ducts with variable clinical presentation. High suspect in patients with single kidney is necessary to avoid potential complications by providing surgical treatment.

INTRODUCCION: El síndrome de OHVIRA (SO) es una rara y compleja variante de las anomalías de los conductos de Müller caracterizado por hemivagina obstruida, útero didelfo y anomalía renal ipsilateral. Su diagnostico prepuberal es raro y el retraso en su diagnóstico y tratamiento compromete la vida y fertilidad de la paciente. MATERIAL Y METODOS: Análisis retrospectivo de las historias clínicas de las pacientes diagnosticadas en nuestro centro en un período de tiempo de 20 años. Los datos se recogen en un protocolo que incluye: características clínicas, diagnóstico, tratamiento y complicaciones. RESULTADOS: Nueve pacientes en total, 55% diagnosticadas en edad prepuberal y 45% postmenarquia. En el 55% se realizó diagnóstico prenatal de malformación renal. En el 33% antecedentes familiares de primer grado de enfermedades nefrourológicas. La media de seguimiento por riñón único, previo al diagnóstico, fue de 3,6 años (rango 0-13,4 años). En el 55% de los casos el lado afecto fue el derecho. Los síntomas fueron ginecológicos en el 44%, miccionales en el 22% y dolor abdominal recurrente en el 22%. Presentaron complicaciones en el 33%, correspondiendo a hidrometrocolpos (22%) y piocolpos (11%). Se realizó septostomía y resección del tabique vaginal como tratamiento en el 44%, todas en edad postpuberal. Las pacientes prepuberales continúan en seguimiento con actitud conservadora y están asintomáticas. CONCLUSIONES: El SO es una rara anomalía del desarrollo de los conductos müllerianos de presentación clínica variable. El alto índice de sospecha y el diagnóstico precoz en niñas con anomalías renales, facilita el tratamiento quirúrgico antes de la presentación de complicaciones.

[Manual detorsion and elective orchiopexy as an alternative treatment for acute testicular torsion in children]. / Detorsión manual y cirugía diferida en la torsión testicular aguda.

AIM: To present our experience in pediatric patients with testicular torsion (TT) treated by manual detorsion (MD). PATIENTS AND METHODS: Retrospective analysis of patients treated by MD in a 10-year period in a single center. Description of symptoms, detorsion technique, follow-up and complications. RESULTS: 76 patients diagnosed with TT were studied in a 10-year period. 16 patients were treated by MD. Mean age was 12 years (Range: 10-13 years) and time from onset of pain was 5.25 hours (±4,2). Left testicle was affected in 75% (n=12). Detorsion maneuver was performed by a pediatric surgeon at the radiology room, in counter-clockwise direction in the right testicle and clockwise direction in the left testicle in all cases. The success was defined as the relief of pain, normal physical examination and was confirmed by Doppler ultrasound performed immediately after MD. MD was effective in 75% (n=12) and orchiopexy was performed under elective conditions at median time of 2 weeks (0-5 weeks). MD was unsuccessful in 3 patients and emergency orchiopexy was performed with no testicular loss. 1 patient had a second MD maneuver for incomplete detorsion. No short or long term complication nor testicular atrophy was observed. CONCLUSION: MD and elective orchiopexy seems to be an efficient and reliable procedure in the treatment of TT in children. Further studies may be necessary to establish its safety and indications.

OBJETIVO: Presentar nuestra experiencia, protocolo e indicaciones de la detorsión testicular manual (DM) como tratamiento en la torsión testicular (TT). MATERIAL Y METODOS: Estudio retrospectivo de pacientes con TT tratados mediante DM en los últimos 10 años. Analizamos tiempo de evolución, técnica de detorsión, evolución y complicaciones. RESULTADOS: 76 pacientes diagnosticados de TT en los últimos 10 años, de los cuales 21% (n=16) fueron tratados mediante DM. Edad media de 12 años (rango: 10-13 años) y duración del comienzo del dolor de 5,25 horas (± 4,2 horas), mayor frecuencia en el testículo izquierdo (75%, n=12). La técnica de DM se realizó ecoguiada, en dirección horaria y antihoraria en el lado derecho e izquierdo, respectivamente. El éxito se definió como el alivio inmediato de los síntomas, hallazgos normales en el examen físico y comprobación de la recuperación del flujo mediante ecografía tras la maniobra de detorsión. Fue efectiva en el 75% (n=12), siendo dados de alta a las 24 horas, tras realizar nueva ecografía de control y comprobar normalidad en el flujo. Orquidopexia vía escrotal diferida a las 2 semanas (rango: 0-5,4 semanas). En tres pacientes (18,8%) se realizó cirugía urgente por insuficiente recuperación del flujo y en otro paciente (6,2%) fue necesario realizar una segunda maniobra de detorsión. No hubo complicaciones tras DM a corto/largo plazo, ningún caso de atrofia testicular. CONCLUSIONES: La DM ecoguiada y orquidopexia diferida es una opción terapéutica en pacientes con TT de corta evolución. Es necesario series más amplias y realizar estudios prospectivos para establecer su seguridad y eficacia.

[Peritoneal drainage as definitive treatment in necrotizing enterocolitis of preterm infants with low weight]. / Drenaje peritoneal como tratamiento definitivo en la enterocolitis necrotizante de prematuros de bajo peso.

OBJECTIVES: The management of advanced necrotizing enterocolitis (NEC) in preterm birth with low weight remains controversial. The aim of this study consists in the analysis of the results of treatment in these patients, as well as the evaluation of the role of peritoneal drainage as a definitive therapeutic option. METHODS: Observational and descriptive study of 31 patients under 1,500 g of weight with advanced NEC, whom have had surgery in our center in the last 15 years. They were classified in two groups: G1 (n = 21) <1,000 g and G2 (n = 10) 1,000-1,500 g. RESULTS: Average weight in G1 patients was 791.7 ± 137.5 g and 1,280.7 ± 207.9 g in G2 patients (p <0.01). Average gestational age was 26 ± 1 weeks in G1 patients and 30 ± 2 weeks in G2 patients (p <0.01). Mean time to the start of the advanced NEC was 9,4 ± 4.4 days in G1 patients and 16.7 ± 13.5 days in G2 patients (p = 0.031). In group G1, 95.2% of the patients were treated throughout peritoneal drainage, and 4,8% (n = 1) with laparotomy. In G2, 60% (n = 6) of the patients were treated throughout peritoneal drainage, and 40% (n = 4) with laparotomy (p = 0.027). The peritoneal drainage was a definitive treatment in 84.2% (16/20) of the G1 patients, with a survival rate of 56.3% (n = 9); G2 patients had a definitive treatment in 50% of the patients (3/6), with a survival rate of 66.7% (n = 2) (p = 0.261). In G1 patients, 50% (2/4) of the drains which required subsequently laparotomy, died 0% (0/3) in G2 patients. CONCLUSIONS: Peritoneal drainage is primarily a valid therapeutic option in extremely premature infants and can be used as definitive treatment.

OBJETIVO: El manejo de la enterocolitis necrotizante (ECN) avanzada en prematuros de bajo peso continúa siendo controvertido. El objetivo de este estudio es analizar los resultados del tratamiento en estos pacientes, así como valorar el papel del drenaje peritoneal como opción terapéutica definitiva. MATERIAL Y METODOS: Estudio observacional y descriptivo de 31 pacientes menores de 1.500 g de peso, intervenidos en nuestro centro, con ECN avanzada en los últimos 15 años. Se clasificaron en dos grupos en función del peso: G1 <1.000 g (n = 21) y G2 1.000-1.500 g (n = 10). RESULTADOS: El peso medio en los pacientes del G1 fue de 791,7 ± 137,5 g y de 1.280,7 ± 207,9 g en el G2 (p <0,01). La edad gestacional media de 26 ± 1 semanas en el G1 y de 30 ± 2 semanas en el G2 (p <0,01). El tiempo medio hasta el comienzo del cuadro de ECN avanzada fue de 9,4 ± 4,4 días en el G1 y de 16,7 ± 13,5 días en el G2 (p = 0,031). En el G1 el 95,2% (n = 20) de los pacientes se trataron mediante drenaje peritoneal y el 4,8% (n = 1) mediante laparotomía; en el G2 el 60% (n = 6) se trataron con drenaje peritoneal y el 40% (n = 4) mediante laparotomía (p = 0,027). El drenaje peritoneal fue el tratamiento definitivo en el 84,2% (16/20) del G1, con una supervivencia del 56,3% (n = 9); en el G2 el 50% (3/6), con una supervivencia del 66,7% (n = 2) (p = 0,261). En el G1 fallecieron el 50% (2/4) de pacientes que tras el drenaje precisaron posteriormente laparotomía, mientras que en el G2 no falleció ningún paciente (0/3). CONCLUSION: El drenaje peritoneal es una opción terapéutica válida fundamentalmente en prematuros extremos y puede ser empleado como tratamiento definitivo.

[Retrospective analysis of morbidity and mortality of intestinal atresias in newborns]. / Análisis retrospectivo de la morbilidad y mortalidad de las atresias intestinales diagnosticadas en el periodo neonatal.

OBJECTIVE: Intestinal atresia (IA) is the most common obstructive congenital malformation in the gastrointestinal tract. The aim is to describe the morbidity and mortality of AI in our series. METHODS: Retrospective study in infants with AI who underwent surgery in our hospital in the past 15 years. Descriptive analysis was performed by collecting clinical and epidemiological variables. Qualitative and quantitative statistical analysis were performed. RESULTS: A total of 32 patients, 40.6% (13) women and 59.4% (19) males, maternal age 31 ± 5 years. Prenatal care in 96.8% (30) and prenatal diagnosis in 68.8% (22). Gestational age 35 ± 3 (SG 25-41), birth weight 2,506 ± 516 g (920-3,470 g). 53% (17/32) were localized in duodenum (65% extrinsic, 35% type I); 37.5% (12/32) jejunoileal (16.6% type I, 25% type II, 16.6% type IIIa, 16.6% type IIIb and 25% type IV); 6.5% (2/32) were colonic and 3% (1/32) pyloric. In 65.6% (21/32) it was associated with other congenital malformation. 81.3% (26) were operated within the first 48 hours of life. 15.6% (5/32) required enterostomy. 21.8% (7/32) had complications requiring reoperation in 71% (5/7) with 1 case of short bowel syndrome. Median time to enteral nutrition onset was 10 days (IQR 7-15), higher in patients with ileal atresia. Hospital stay was 33 days (interquartile range 23-66 days) and overall mortality of 9.3%. CONCLUSION: In our series the congenital malformations associated with intestinal atresia were determinant in the prognosis and mortality of these patients.

OBJETIVOS: La atresia intestinal es la malformación congénita obstructiva del tubo digestivo más frecuente. Nuestro objetivo es describir la morbilidad y mortalidad de las atresias intestinales en nuestro medio. MATERIAL Y METODOS: Estudio retrospectivo de neonatos con atresia intestinal intervenidos en nuestro centro en los últimos 15 años. Se realiza un análisis descriptivo de variables clínicas y epidemiológicas. RESULTADOS: Un total de 32 pacientes, 40,6% (13) mujeres y 59,4% (19) varones, edad materna de 31 ± 5 años, controles prenatales en el 96,8% (30) y diagnóstico prenatal en 68,8% (22). Edad gestacional de 35 ± 3 (25-41 SG), peso al nacer 2.506 ± 516 g (920-3.470 g). El 53% (17/32) de localización duodenal (65% extrínseca y 35% tipo I); el 37,5% (12/32) yeyunoileal (16,6% tipo I, 25% tipo II, 16,6% tipo IIIa, 16,6% tipo IIIb y 25% tipo IV); el 6,5% (2/32) colónica y 3% (1/32) pilórica. El 65,6% (21/32) asociaba otra malformación congénita. El 81,3% (26) fueron intervenidos en las primeras 48 horas de vida, precisando derivación intestinal un 15,6% (5/32). El 21,8% (7/32) presentaron complicaciones, de los cuales el 71% (5/7) requirieron reintervención, con un caso de intestino corto. El tiempo medio de inicio de nutrición enteral fue 10 días (RIQ 7-15), mayor en los pacientes con atresia ileal; la estancia hospitalaria fue de 33 días (RIQ 23-66 días) y la mortalidad general, del 9,3%. CONCLUSIONES: Las malformaciones congénitas asociadas en pacientes con atresia intestinal son un factor determinante en el pronóstico y mortalidad de los mismos.

[Management and description of neonatal tumours in a surgical oncology unit]. / Tumores neonatales: experiencia en una Unidad de Cirugía Oncológica.

AIM: Neonatal tumours represents less than 2% of all childhood cancers. The biological behaviour of this tumours will differ in older children. The tumours's biological differences and the immature physiological characteristics of newborns represent a great therapeutically challenge making newborns vulnerable. The aim of this study is to describe the clinical characteristics, associated malformations, diagnostic methods, treatment and the outcomes of neonatal tumours. METHODS: Retrospective review of patients ≤ 28 days-old with diagnosis of neonatal tumour between 2000-2016. Statistical analysis of clinical characteristics, histology, diagnostic methods, treatment and morbimortality. RESULTS: A total of 26 tumours were diagnosed in newborns with a mean age of 4.85 ± 8.9 days and 69.2% of boys. Prenatal diagnosis was achieved in 38.5% (n = 10) and 38.5% (n = 10) in the first week of age. Associated malformations were found in 30.6% (n = 8). The most frequent tumours were hepatic hemangioma 23.1% (n = 6), neuroblastoma 15.4% (n = 4) and sacrococcygeal teratoma 11.5% (n = 3). Medical treatment was indicated in 7.7% (n = 5), surgical 57.7% (n = 15) and observation 30.8% (n = 7). Global mortality was 19.23% (n = 5) of which 42.9% (n = 3/7) were perioperatively. CONCLUSIONS: The management of neonatal tumours require a multidisciplinary approach to minimize the consequences and assure the best outcome. Global mortality is low and depends primarily of the physiologic and association of other malformations of the newborn.

OBJETIVO: Los tumores neonatales representan menos del 2% de los tumores pediátricos, sin embargo, el comportamiento biológico difiere de los desarrollados en otros grupos de edad. Estas características, junto a la inmadurez neonatal, dificultan el tratamiento, convirtiéndolos en un grupo muy vulnerable. El objetivo de este estudio es describir las características clínicas, anomalías asociadas, diagnóstico y repercusión del tratamiento de los tumores neonatales. MATERIAL: Estudio retrospectivo de pacientes ≤ 28 días diagnosticados de tumor neonatal entre 2000-2016. Se realizó análisis estadístico de las principales características clínicas, histológicas, métodos diagnósticos, tratamientos establecidos y morbimortalidad. RESULTADOS: Se diagnosticaron 26 recién nacidos con tumores. El 69,2% varones, con edad media al diagnóstico de 4,85 ± 8,9 días. El diagnóstico fue prenatal en 38,5% (n = 10) y 38,5% (n = 10) en la primera semana de vida. El 30,6% (n = 8) asoció otra malformación. Los tumores más frecuentes fueron los hemangiomas hepáticos, 23,1% (n = 6), neuroblastoma, 15,4% (n = 4) y teratoma sacrococcígeo, 11,5% (n = 3). Se realizó tratamiento médico en 7,7% (n = 5), quirúrgico en 57,7% (n = 15) y conservador en 30,8% (n = 7). La mortalidad global fue del 19,23% (n = 5), de los cuales 42,9% (n = 3/7) casos ocurrieron durante el periodo perioperatorio. CONCLUSIONES: El manejo de los tumores neonatales requiere un equipo multidisciplinar para minimizar las secuelas y garantizar el mejor resultado. El manejo conservador es una opción terapéutica válida en determinados tipos de tumores. La mortalidad global es baja y depende principalmente de las características fisiológicas del neonato y de sus malformaciones asociadas.

[Conservative or early surgical management of appendiceal mass. Does it affect the appearance of complications?] / Tratamiento quirúrgico o conservador del plastrón apendicular. ¿Influye en la aparición de complicaciones?

OBJECTIVES: Currently the management of appendicular mass remains controversial. Many authors advocate conservative management followed by delayed appendectomy, whereas others favour inmediate appendectomy. The aim of our study is to compare both treatments. METHODS: A descriptive and observational study over 46 patients treated for appendiceal mass at our center in the last ten years was performed. Patients were categorized as group 1, early surgical intervention (54.3%) and group 2, conservative management and interval appendectomy (45.7%), with a mean interval of 5.3 ± 1.5 months. RESULTS: Mean age was 9.2 ± 3.8 years in group 1 and 3.7 ± 3 years in group 2 (p<0.001). Median delay between the first symptoms and diagnosis was 4 ± 2.2 days in group 1 and 7.9 ± 4.2 days in group 2 (p<0.001). Antibiotics were administered before diagnosis in 24% of patients in group 1 and 42.9% in group 2 (p = 0.297). Ultrasound was performed in all patients, while 19.6% of patients requiered TAC for definitive diagnosis. Median hospital stay was 7.9 ± 2.9 days in group 1 and 8.3 ± 2.2 days in group 2 (p = 0.441). Complicactions were found in 64% of patients (group 1) and 23% of patients (group 2) (p = 0.015). Three patients from group 2 requiered readmission because of recurrent abdominal pain, but just one requiered early surgery. CONCLUSION: Conservative management of appendicular mass has a lower complication rate compared to the initial surgical management.

OBJETIVO: Actualmente el manejo del plastrón apendicular sigue siendo controvertido. Muchos autores defienden el tratamiento conservador y posterior apendicectomía programada, frente a otros que defienden la intervención quirúrgica en fase aguda. Nuestro objetivo es comparar ambos tratamientos. MATERIAL Y METODOS: Estudio observacional descriptivo de 46 pacientes tratados por presentar plastrón apendicular en nuestro centro en los últimos diez años. El 54,3% de los pacientes (n = 25) (G1) fueron tratados quirúrgicamente en la presentación del cuadro agudo, mientras que el 45,7% (n = 21) (G2) se trataron de forma conservadora con posterior apendicectomía, con un intervalo medio de 5,3 ± 1,5 meses. RESULTADOS: La edad media de presentación fue de 9,2 ± 3,8 años en el G1 y de 3,7 ± 3 en el G2 (p<0,001). El tiempo medio hasta el diagnóstico fue de 4 ± 2,2 días en el G1 y de 7,9 ± 4,2 en el G2 (p<0,001). El 24% de los pacientes habían recibido tratamiento antibiótico previo al diagnóstico en el G1 y el 42.9% en el G2 (p = 0,297). La TAC fue necesaria para el diagnóstico en el 19.6% del total, en el resto, la ecografía fue suficiente. La estancia hospitalaria media fue de 7,9 ± 2,9 días en el G1, frente a 8,3 ± 2,2 días en el G2 (p = 0,441). El porcentaje de complicaciones en el G1 fue del 64% frente al 23,8% en el G2 (p = 0,015). Tres pacientes del G2 reingresaron de urgencias por dolor abdominal, precisando uno de ellos cirugía antes de la fecha programada. CONCLUSIONES: El manejo conservador del plastrón apendicular presenta una menor tasa de complicaciones respecto al manejo quirúrgico inicial.

[Implementation of a Plan of Patient Safety in Service of Pediatric Surgery. First results]. / Implementación de un Plan de Seguridad del Paciente en un Servicio de Cirugía Pediátrica. Primeros resultados.

OBJECTIVES: In 2014 our department starts to apply the PatientSafety Strategic in Pediatric Surgery. Our aim is to describe the results obtained. METHODS: For the measurement of adverse events (AE) we used a modification of the Global Trigger Tool of the Institute for Healthcare Improvement. Population analysed: patients undergoing surgery with hospitalization. On a monthly basis, audits of the medical records of 12 patients discharged in the prior week of the assessment were performed. The evaluation team was composed by experienced pediatric surgeon, two staff nurses, and a doctor and nurse from the Quality Department. RESULTS: 95 clinical records and a total of 406 days of hospital stay were reviewed. 31 patients (32.6%) experienced one or more AE. Total AE: 43. The AE/1000 patients/day ratio: 105.9. The most common AE were: vomiting, itching and pain. 28 EA were considerd mild and 3 moderate in severity, according to the classification of the National Coordinating Council for Medication Error Reporting and Prevention. No EA were considered serious or critical. CONCLUSIONS: The analysis of prevalence through regular assessments of medical records is an easy method to obtain information about the frequency of occurrence, exact understanding of the AE types and the implementation of corrective measures. The main limitation of this method is that it can miss some of the serious EA and miss the records and analysis of sentinel events that may occur in the period between assessments.

OBJETIVOS: Durante el año 2014 se aplica el Plan de Seguridad del Paciente en un Servicio de Cirugía Pediátrica, elaborado previamente por nuestro Servicio. Se describen los resultados. MATERIAL Y METODOS: El método empleado para la medición de eventos adversos (EAs) es una modificación del Global Trigger Tool del Institute for Health care Improvement. Población analizada: pacientes intervenidos quirúrgicamente con hospitalización. Con una periodicidad mensual, se realizaron 12 auditorias de las historias clínicas correspondientes a los pacientes dados de alta en la semana anterior al día de la evaluación. El equipo evaluador estaba compuesto por: un cirujano pediátrico experto, dos enfermeras de planta más un médico y una enfermera del Servicio de Calidad. RESULTADOS: Se revisaron 95 historias y 406 días de estancia. 31 pacientes (32,6%) sufrieron uno o más eventos adversos. Total EAs: 43. Número EAs/1.000 pacientes/día: 105,9. Los 3 EA más frecuentes fueron: vómitos, prurito y dolor. 28 EAs fueron de gravedad leve y 3 moderada, según la clasificación del National Coordinating Council for Medication Error Reporting and Prevention. Ningún EA fue grave o crítico. CONCLUSIONES: La determinación de la prevalencia mediante evaluaciones regulares de historias clínicas es un método que permite obtener información de forma fácil sobre la frecuencia de aparición, el conocimiento exacto de los tipos de EAs y la aplicación de medidas correctoras. Este método tiene como limitación principal la posible falta de recogida EAs graves así como registro y análisis de eventos centinelas que pueden ocurrir en el periodo entre evaluaciones.

[Achalasia in children and adolescents, a therapeutic challenge]. / La acalasia en la infancia y la adolescencia, un reto terapéutico.

INTRODUCTION: Treatment of achalasia in children is in permanent discussion. It is a rare disorder without cure, which makes its management challenging. METHODS: Retrospective review of patients under 18 years old treated for achalasia in our Hospital between 2000 and 2012, by either pneumatic dilatation (PD) or Heller myotomy (HM). RESULTS: Thirteen children were treated during this time. Mean age was 12 years (4-18), interval time between the onset of symptoms and diagnosis was 15 months (2-48) and mean follow-up was 66,8 months (4-144). Dysphagia and vomits were the main symptoms (61%). A single PD was performed in 5 patients; four were the oldest children of the series (16-18). Three girls remain asymptomatic and 2 boys suffer from moderate dysphagia. Six patients required multiple PD and, after a mean of 3 dilatations, HM was needed in all of them. The last 2 children of the series received surgery as the first treatment. In total, eight patients underwent HM and fundoplication, with 6 laparoscopic procedures. Two boys suffer from low-moderate dysphagia, but additional treatments have not been required. The mean of total hospital stay was 12,7 days (2-45) for PD and 9 days (3-30) for HM. Two patients were reoperated because of oesophagic perforation, one after PD and one after open HM. CONCLUSION: Although PD and HM could be complementary, laparoscopic Heller myotomy should be considered the first therapeutic option, specially in young boys.

[Ovarian torsion. long-term follow-up of the black-bluish ovary after laparoscopic detorsion]. / Torsión ovárica. Evolución del ovario necrótico tras detorsión laparoscópica.

INTRODUCTION: Ovarian torsion presents low incidence in children and unspecific clinical presentation, therefore the diagnostic delay is rather common. Traditionally, necrotic appearance has been synonymous of oophorectomy, however the current trend defends ovary preservation. We present our experience in conservative management of ovarian torsion. METHODS: A retrospective review was made of patients between May 2010 and May 2013. Seven girls were operated by laparoscopy because of ultrasound and clinical suspicion of ovarian torsion. The diagnosis was confirmed in six patients, finding an enlarged, friable and black-bluish ovary. Detorsion and adnexal sparing were performed in all cases, despite the gross appearance. RESULTS: The mean age was 8.5 years (3-12), the time interval between the onset of symptoms to surgery was 6.5 days (1-15) and postoperative stay was 2.6 days (2-3). In 4 cases the damaged ovary was right, and the average size was 5.8 cm. Tumor markers were normal. During the first 6 months the follow-up ultrasound showed good results. However, the long-term outcome evidenced one involved ovary atrophied and two oophorectomies due to recurrent adnexal torsion and ovarian mass consistent with teratoma. CONCLUSIONS: Laparoscopic conservative management with untwisting the ovary, allows that macroscopically nonviable ovaries could be recovered. However, an exhaustive and long-term follow-up is required to confirm the outcome.

[Design of a plan for patient safety in pediatric surgery service]. / Elaboración de un plan de seguridad del paciente en un Servicio de Cirugía Pediátrica.

INTRODUCTION: Patient safety is a key priority in quality management for healthcare services providers. Every patient is entitled to receive safe and effective healthcare. AIMS: The aim of this study was to design a patient safety plan for a Paediatric Surgery Department. METHODS: We carried out a literature review and we established a work group that included healthcare professionals from the Paediatric Surgery Department and the Quality and Medical Records Department. The group identified potential adverse events, failures and causes and established a rating using Failure Mode Effects Analysis. Potential risks were mapped out and a plan was designed establishing actions to reduce risks. We designated leaders to ensure the effective implementation of the plan. RESULTS: A total of 58 adverse events were identified in the Paediatric Surgery Department. We detected 128 failures that were produced by 211 different causes. The group developed a proposal with 424 specific measures to carry out preventive and/or remedial actions that were then narrowed down to 322. The group designed a plan to apply the programme, which is currently being implemented. CONCLUSIONS: The methodology used enabled obtaining key information for improvement of patient safety and developing preventive and/or remedial actions. These measures are applicable in practice, as they were designed using proposals and agreements with professionals that take active part in the care of children with surgical conditions.

[Testicular cancer and cryptorchidism: myth or reality]. / Cáncer testicular y criptorquidia. Mito o realidad.

OBJECTIVE: To evaluate the previous history of cryptorchidism in patients with testicular cancer. MATERIALS AND METHODS: We carried out a study using 175 patients diagnosed with testicular cancer, in our hospital, from 1999 to 2010. We analyzed the previous history of cryptorchidism and its characteristics, testicular placing, histology and intervention age. RESULTS: 5 out of the 175 patients (2,8%) with testicular neoplasm presented a history of cryptorchidism, The average age was 31 years old, an orchidopexy was only carried out in 2 patients. The histology was different depending on the treatment chosen to battle cryptorchidism and in 2 cases it developed in the adjoining testicle. The average ratio was of 1,9. CONCLUSIONS: Our results reflect that the association of cryptorchidism with testicular neoplasm is in fact lower than in the past. A good and proper handling of cryptorchidism can prevent it from turning malignant, presenting these patients similar incidences to the rest of the population.

[Appendectomy and Crohn's disease]. / Apendicectomía y enfermedad de Crohn.

UNLABELLED: We analyzed the relationship between Crohn's disease and appendectomy in paediatric age. METHOD AND MATERIAL: We studied the patients diagnosed with Crohn's disease and appendectomy (under 20) between 1999 and 2011. We retrieved their previous medical histories and carried out an histological re evaluation of those appendix. RESULTS: 11 patients out of 137 (8,02%) had an appendectomy before the development of Crohn's disease. An average age in which the appendectomy took place and the development of Crohn's disease was diagnosed 14 (5-20 years), having 90% of the patients diagnosed in the early post-surgical stages. A patient did not develop any symptoms until a year later. There were no more appendectomies carried out in comparison with the adult population. The initial anatomopathologic diagnosis and the histological re evaluation agreed in just one case, compatible with Crohn's disease. CONCLUSION: The majority of appendectomies carried out in paediatric patients that later develop Crohn's disease are realized by a bias diagnosis of acute appendicitis and the relation between the two of them can be explained as the not yet developed Crohn's disease at the moment of the appendectomy. Appendectomies at a paediatric age are not associated with a potential development of Crohn's disease. There is no evidence of histological changes compatible with Crohn's disease in the first episode.

[Open surgery, laparoscopic Palomo varicocelectomy and embolization in children with varicocele]. / Cirugía abierta, Palomo laparoscópico y embolización en niños con varicocele.

OBJECTIVES: Our aim was to prove the outcomes in varicocele treatment during last 10 years in our institution regarding to the recurrence rate and reactive hydrocele in children and adolescents treated with open technique, laparoscopic approach or embolization. PATIENTS AND METHODS: Medical charts of patients with varicocele younger than 17 years old were reviewed. Age, weight, surgery indications, treatment (open surgery, laparoscopic Palomo varicocelectomy or embolization), location, varicocele grade, hospital stays, recurrence, postoperative hydrocele, genitofemoral nerve damage, infection, bleeding, postoperative incisional hernia and re-do varicocelectomy were collected. RESULTS: From 2000 to 2010, 98 boys with varicocele diagnosis were treated in our institution. Mean age of patients was 12 years. The varicocele location in all cases was on the left side. Grade III varicocele was found in 94 boys and grade II in 4 patients. Indications for surgery were high grade in 81, chronic pain in 16 and testicular hypotrophy in 1. Treatment approach was as follows: 12 patients underwent open surgery (Palomo or Ivanissevich technique), 32 underwent embolization and laparoscopic Palomo varicocelectomy was performed in 54. We found a global recurrence rate of 14.3% and an overall postoperative hydrocele of 24.5% Recurrence rate was higher in the embolization group than the open surgery and laparoscopic group. Three patients presented intraoperative bleeding in the laparoscopic group and there was one conversion to open surgery. CONCLUSIONS: Our retrospective review proves that laparoscopic Palomo varicocelectomy is a safe and efficient approach to treat varicocele in pediatric population, because of its low recurrence rate without any major adverse outcome. Due to our high secondary hydrocele formation, lymphatic sparing laparoscopic procedure should be taken into account in order to decrease this complication.

[Acute pancreatitis in children]. / Pancreatitis aguda en la infancia.

INTRODUCTION: Lately, there has been an increase in incidence of acute pancreatitis in childhood. Fortunately, 80% of cases are mild and do not require surgical approach. Several etiologic factors have been implicated, such as infections, trauma, congenital anomalies, drugs, biliary diseases. The aim of this study was to assess etiology, clinical features and outcomes of children with acute pancreatitis treated at our center. MATERIALS AND METHODS: A retrospective chart review of our cases of acute pancreatitis in patients younger than 16 years old was performed. RESULTS: 24 cases of acute pancreatitis were found from 1998 to 2010. Mean age was 8.75 years. There were 7 boys and 17 girls. The main clinical manifestations were abdominal pain, vomiting and abdominal distention. Mean amylase level was 1565 UI/L. There was one patient with normal serum amylase levels. Serum lipase was required in two patients (239 UI/L and 5,980 UI/L). Ultrasound showed pancreatic lesion in 79.2% of cases. Severe pancreatitis was presented in two cases, due to renal failure and pancreatic necrosis. Surgery was performed in 6 cases (3 cholecystectomies, 1 choledocal cyst resection, 1 percutaneous pseudocyst drainage and 1 necrosectomy) Pancreatic complications were found in 20.8% of cases (4 pseudocysts y 1 pancretic necrosis) Several causes were found: idiophatic, secondary to ERCP, congenital anomalies, drugs, infections, biliary disease and trauma. Mean hospital stay was 25.65 days. There were no deaths due to acute pancreatitis. CONCLUSIONS: There are several causes of acute pancreatitis in children. Some cases may present normoamilasemia, situation, in which serum lipase and clinical and radiological criteria are pivotal. Prospective studies evaluating etiological factors and incidence are required.

Cirugía abierta, Palomo laparoscópico y embolización en niños con varicocele / Open surgery, laparoscopic Palomo varicocelectomy and embolization in children with varicocele

Objetivos. El objetivo del presente estudio es examinar los resultados en el tratamiento del varicocele en nuestro hospital durante los últimos 10 años, valorando la de tasa de recurrencia y de hidrocele reactivo en los niños y adolescentes tratados mediante cirugía abierta, embolización o varicocelectomía laparoscópica. Pacientes y métodos. Se revisaron las historias clínicas de los pacientes menores de 17 años intervenidos de varicocelectomía. Las variables recogidas fueron peso, edad, localización, grado de varicocele, indicación de cirugía, tratamiento, estancia hospitalaria, recurrencia, hidrocele postoperatorio, lesión de nervio genitofemoral, infección, sangrado, hernia incisional y necesidad de nueva varicocelectomía. Resultados. 98 pacientes con diagnóstico de varicocele fueron tratados en nuestra institución entre los años 2000 a 2010. La edad media fue de 12 años. Todos los casos fueron de localización izquierda. 94 pacientes tenían varicocele grado III y 4 varicocele grado II. Las indicaciones de cirugía fueron varicocele de alto grado (grado III) en 81 pacientes, dolor crónico en 16 e hipotrofia testicular en 1. Se realizó cirugía abierta en 12 pacientes, embolización en 32 casos y varicocelectomía laparoscópica en 54 pacientes. La tasa global de recurrencia fue de 14,3% y el porcentaje de hidrocele reactivo fue del 24,5% La tasa de recurrencia fue mayor en el grupo tratado con embolización, que en el de cirugía abierta y en el de laparoscopia. En el grupo de tratamiento laparoscópico, tres pacientes presentaron sangrado postquirúrgico y hubo una conversión a cirugía abierta. Conclusiones. Nuestra revisión retrospectiva indica que la varicocelectomía laparoscópica es un tratamiento seguro y eficaz en el manejo del varicocele en los (..) (AU)

Objectives. Our aim was to prove the outcomes in varicocele treatment during last 10 years in our institution regarding to the recurrence rate and reactive hydrocele in children and adolescents treated with open technique, laparoscopic approach or embolization. Patients and Methods. Medical charts of patients with varicocele younger than 17 years old were reviewed. Age, weight, surgery indications, treatment (open surgery, laparoscopic Palomo varicocelectomy or embolization), location, varicocele grade, hospital stays, recurrence, postoperative hydrocele, genitofemoral nerve damage, infection, bleeding, postoperative incisional hernia and re-do varicocelectomy were collected. Results. From 2000 to 2010, 98 boys with varicocele diagnosis were treated in our institution. Mean age of patients was 12 years. The varicocele location in all cases was on the left side. Grade III varicocele was found in 94 boys and grade II in 4 patients. Indications for surgery were high grade in 81, chronic pain in 16 and testicular hypotrophy in 1. Treatment approach was as follows: 12 patients underwent open surgery (Palomo or Ivanissevich technique), 32 underwent embolization and laparoscopic Palomo varicocelectomy was performed in 54. We found a global recurrence rate of 14.3% and an overall postoperative hydrocele of 24.5% Recurrence rate was higher in the embolization group than the open surgery and laparoscopic group. Three patients presented intraoperative bleeding in the laparoscopic group and there was one conversion to open surgery. Conclusions. Our retrospective review proves that laparoscopic Palomo varicocelectomy is a safe and efficient approach to treat varicocele in pediatric population, because of its low recurrence rate without any major adverse outcome. Due to our high secondary hydrocele formation, lymphatic sparing laparoscopic procedure should be taken into account in order to decrease this complication (AU)

[Evaluation of quality of life in patients operated on for gastroesophageal reflux in the pediatric age]. / Valoración de la calidad de vida en los pacientes intervenidos por reflujo gastroesofágico en la edad pediátrica.

AIM: To assess the quality of life and symptoms of GER patients who underwent laparoscopy in our hospital before and after surgery. MATERIAL AND METHODS: We collect data from patients operated laparoscopically for gastroesophageal reflux disease (GER) in our center before and after surgery in 3 items: nutritional studies, diagnostic methods, interviews with the families of patients about symptoms (preferably differing in digestive or respiratory symptoms) and quality of life; also, determined the age, gender, personal history and surgical technique of patients. RESULTS: 30 patients have been operated for GER, 22 men and 8 women, 11 months to 14 years (median age 5 years) of whom 12 (40%) had some degree of encephalopathy. The most common surgical technique used is Nissen (73% cases). Most patients had significant alterations in their daily activities before surgery. The most common symptom was gastrointestinal (70% cases), although all showed improvement, families of children with respiratory symptoms related predominantly greater reduction in the clinic after surgical correction. All improved in its growth curve. CONCLUSIONS: Surgery for GER patients have a significant improvement in their quality of life, not only by the reduction of their symptoms but also in enhancing from the nutritional status. Patients with respiratory symptoms have a higher satisfaction with surgical treatment than those with gastrointestinal clinical.