Conformadores nasales en la rinoplastia primaria del paciente fisurado / Nostril reatainers in the primary cleft rhinoplasty

Introducción. Tras la realización de la rinoplastia primaria o secundaria en el paciente fisurado existe una tendencia a la depresión del cartílago alar perdiendo la nueva morfología obtenida. Por este motivo es habitual el empleo de conformadores nasales en el postoperatorio de la rinoplastia de estos pacientes, ya sea ésta abierta o cerrada. Objetivo. Presentamos nuestra experiencia en el uso de conformadores nasales para mantener en posición el cartílago alar tras la rinoplastia del paciente con fisura unilateral o bilateral, evitando así la deformación producida por la retracción cicatricial. Pacientes y métodos. Hemos colocado 18 stents nasales en 18 pacientes con fisura nasolabial intervenidos (4 bilaterales y 14 unilaterales) en el período 2001-2004. Realizamos una comparación fotográfica de la simetría nasal entre los pacientes intervenidos sin stents en un período anterior (1998-2000) y el grupo de estudio. Los conformadores nasales se fijan en su posición tras la rinoplastia mediante suturas reabsorbibles de Monocryl® 4/0. Estas suturas mantienen el stent en su lugar durante unos 20 días después de la intervención. Resultados. El tiempo medio de retención del conformador nasal fue de 3,5 meses (4 semanas a 6 meses). Los métodos empleados para mantener el stent en su lugar tras la absorción de las suturas de fijación fueron diversos y siempre en función de la comodidad de las familias. El estudio comparativo demostró una asimetría relevante de ambas narinas en el 10% de los pacientes con stents frente al 48% de aquellos sin stents (p<0,01). Conclusiones. El empleo de conformadores nasales en el postoperatorio protege la corrección quirúrgica del cartílago evitando la depresión de la narina, así como la aparición de adherencias intranasales precoces. Permite igualmente la realización sin molestias de lavados nasales y pueden mantenerse hasta la cicatrización del cartílago. Su uso implica una colaboración adecuada por parte de la familia (AU)

Introduction. The nasal cleft cartilage tends to depression after primary rhinoplasty. Nasal stents are probe to be useful in the management of these patients in order to maintain the new morphology. Aim. The purpose of this paper is to present our experience with the use of postoperative nasal splinting in the management of cleft lip nasal deformity. Patients and methods. A nostril retainer was placed in 18 cleft patients (4 bilateral, 14 unilateral) during primary repair of the cleft lip nasal deformity from 2001 to 2004. The nasal morphology in the postoperative period was compared with that of 10 control patients who were operated on without nasal stenting in a previous period. Nostril retainers were left in place after the rhinoplasty using 4/0 poliglecaprone absorbable. Those sutures fixed the stent in place during three weeks after surgery. Results. Average follow-up was 18.5 months. Retention of the splint was 3.5 months mean time (range 4 weeks to 6 months). The methods employed for retention were multiple based upon parental preferences. Photogrammetric analysis showed relevant asymmetry of the nostrils in 10% of the splinted group as compared with 48% for controls (p<0.001). Conclusions. The use of nasal stents has been found effective postoperatively after cleft primary rhinoplasty, avoiding relapse of the nasal reconstruction and drop of the nasal ala. Retainers also allows airway patent and avoid surgical adhesions due to nasal secretions and scarring. Parental collaboration is needed (AU)

[Congenital cystic adenomatoid malformation associated with pulmonary sequestration]. / Malformación adenomatoidea quística congénita asociada a secuestro pulmonar. Presentación de dos casos clínicos.

The association of congenital cystic adenomatoid malformation with pulmonary sequestration is infrequent. Has been reported less than 60 cases. We describe two patients with this association. One of this with extralobar pulmonary sequestration, and the other with an intralobar one.

Malformación adenomatoidea quística congénita asociada a secuestro pulmonar. Presentación de dos casos clínicos / Congenital cystic adenomatoid malformation associated with pulmonary sequestration

La asociación de una malformación adenomatoidea quística congénita con un secuestro pulmonar es infrecuente. Han sido descritos en la literatura menos de 60 casos de esta asociación. Presentamos los casos de dos pacientes con esta asociación, uno de ellos con secuestro pulmonar intralobar y el otro extralobar (AU)

The association of congenital cystic adenomatoid malformation with pulmonary sequestration is infrequent. Has been reported less than 60 cases. We describe two patients with this association. One of this with extralobar pulmonary sequestration, and the other with an intralobar one (AU)

[Nostril retainers in the primary cleft rhinoplasty]. / Conformadores nasales en la rinoplastia primaria del paciente fisurado.

INTRODUCTION: The nasal cleft cartilage tends to depression after primary rhinoplasty. Nasal stents are probe to be useful in the management of these patients in order to maintain the new morphology. AIM: The purpose of this paper is to present our experience with the use of postoperative nasal splinting in the management of cleft lip nasal deformity. PATIENTS AND METHODS: A nostril retainer was placed in 18 cleft patients (4 bilateral, 14 unilateral) during primary repair of the cleft lip nasal deformity from 2001 to 2004. The nasal morphology in the postoperative period was compared with that of 10 control patients who were operated on without nasal stenting in a previous period. Nostril retainers were left in place after the rhinoplasty using 4/0 poliglecaprone absorbable. Those sutures fixed the stent in place during three weeks after surgery. Results. Average follow-up was 18.5 months. Retention of the splint was 3.5 months mean time (range 4 weeks to 6 months). The methods employed for retention were multiple based upon parental preferences. Photogrammetric analysis showed relevant asymmetry of the nostrils in 10% of the splinted group as compared with 48% for controls (p<0.001). CONCLUSIONS: The use of nasal stents has been found effective postoperatively after cleft primary rhinoplasty, avoiding relapse of the nasal reconstruction and drop of the nasal ala. Retainers also allows airway patent and avoid surgical adhesions due to nasal secretions and scarring. Parental collaboration is needed.

[New Modern Magpi: meatal advancement and glanuloplasty clinical course]. / New Modern Magpi: evolución del avance meatal con glanduloplastia.

INTRODUCTION: Meatal advancement and glanuloplasty (MAGPI) described by Duckett, has been the most accepted technique for distal hypospadias repair along the last 20 years. Only 50% of the distal variants are amenable to the Magpi; last years several modifications has been reported in order to reach better cosmetic results and to make it available for the most of the distal hypospadias. We report the first 20 cases with some modifications of Magpi. MATERIALS AND METHODS: The basic steps of the technique are: we remove a triangular segment of glanular tissue distal to the meatus. Dissection of the dorsal and lateral urethral sides is made, accomplishing the urethral advancement without any tension. Strips of glandular epithelium are excised on each side, and glans tissue is sutured above the ventral urethral wall. RESULTS: There were 11 coronal, and 9 glanular hypospadias (3 with megameatus). 8 cases showed a slight incurvation that disappeared after releasing any cutaneous chordee. The posoperative follow-up was 35 weeks (R=7-48 weeks). Cosmetic and functional results were excellent, showing a natural circumcized penis. There wasn't any complications as meatal retraction, stenosis or incurvation. There was only a transitional hematoma and a minimal fistula that closed expontanely. CONCLUSIONS: New Modern Magpi adds minimal variations to the original technique, avoiding the cosmetic limitations derived from borderline indications. New Modern Magpi is amenable to near all of glanular hypospadias and most of coronal hypospadias.

[Ultrasound-guided hydrostatic reduction for the treatment of idiopathic intestinal invagination]. / Reducción hidrostática guiada por ecografía para el tratamiento de la invaginación intestinal idiopática.

The more extended conservative treatment in intussusception consists of the accomplishment of fluoroscopy guided neumoenema. The development of the echography has allowed to introduce this as alternative in diagnosis and treatment of intussusception. Our objective is to analyze the therapeutic value of echography during resolution of intussusception with saline solution enema in pediatric patients. Intestinal intussusception was diagnosed in 183 patients by echography during a period of 7 years. Patients are classified in three groups according to treatment by means of opaque enema, radioscopy guided neumoenema or echography guided hydrostatic reduction enema. The results of the three series are analyzed: rate of failure of the procedure, the recurrences or the presence of complications. We exclude n = 18 patients that were operated on directly after the diagnosis. The reduction rate was 81.25% (9/16) with opaque enema; 94.6% (103/110) with neumoenema and 96.4% (27/28) with echography guided saline enema. Complications appeared in n = 2 cases of intestinal perforation, 1 with barium and 1 with air 2. Recurrences were n = 3, n = 2 with neumoenema and n = 1 with echography guided enema. Echography guide saline enema has a high security and effectiveness (96.4%), similar to the other methods, avoiding the exposition to ionic radiation. The technique is safe and it does not increase the rate of recurrences.

[Involvement of betamimetics in increased survival during fetal surgery in sheep]. / Implicación de los betamiméticos en el aumento de la supervivencia tras procedimientos quirúrgicos en el feto del cordero común.

INTRODUCTION: Fetal surgery is a therapeutic reality. Available only in a few centres worldwide. Experimental animal models are needed to continue research in this field. The target problem being the control of preterm labour. OBJECTIVES: To find a tocolytic drug regimen in order to reduce fetal loss. MATERIAL AND METHODS: Pregnant sheep were divided randomly in two groups. At a gestation age of seventy days sheep were operated in order to create a myelomeningocel model in the fetus. Follow-up with weekly amniocentesis guided by ultrasound scan. Group A (n = 6) were treated pre and post-op with indomethacine and with magnesium sulphate during surgery and in the following 24 hours. Group B (n = 8) were treated with diclofenac pre-op, and post-op with ritodrine until the end of pregnancy. RESULTS: Group A we find a survival rate 50% (n = 3) being 87% (n = 7) in group B. Fetal weight being higher in group A. We find an increase heart rate and a weight loss in both the fetus and mother in group B. Urea and creatinine amniotic fluid levels were increase in group B. CONCLUSIONS: The use of ritodrine as a tocolytic agent reduces fetal loss significantly. Ritodrine increases fetal and mother cardiac output causing weight loss.

[Success of endoscopic management in vesicoureteral reflux, conditioned by ureteral dilatation]. / La dilatación ureteral condiciona el éxito del tratamiento endoscópico del R.V.U.

INTRODUCTION: Endoscopic management has become an important alternative in the treatment of vesicoureteral reflux in children. Since 1995 we indicate it in our Hospital in children with grade II VUR (vesicoureteral reflux) after 1 year of medical management, in all children with grade III VUR and in children with grade IV VUR without reflux nephropathy. According to International Classification of reflux (IRSC), grade IV VUR differ to grade III mainly by the blunting of the calyces and the obliteration of sharp angle of the fornices. There may be seen in the high grades of reflux, important differences in the ureteral dilatation. AIM: The aim of this work is to study the influence of ureteral dilatation in the success of endoscopic management VUR. MATERIAL AND METHODS: A number of 245 refluxing renal units (URR) were treated endoscopically in our Hospital from 1995. We review the first 3.5 years (58 patients with 90 RRU). In a double blind study with the voiding cystourethrographies we graduated the ureteral dilatation in slight-normal, moderate and severe. The success rate after the first injection was compared between the 3 grades of ureteral dilatation. RESULTS: 3 patients had grade I VUR, 10 grade II, 54 grade III and 23 grade IV. After double blind study 39 patients had slight-normal ureteral dilatation, 39 moderate and 12 severe. There were statistical differences between the 3 grades of ureteral dilatation when we consider: all the patients, considering only grade III and IV reflux and studying only the patients with grade III reflux. However there wasn't statistical differences between grade III and IV VUR of the International Classification. CONCLUSIONS: The results show that ureteral dilatation is an important prognostical factor of the success rate in the endoscopic management of vesicoureteral reflux in children.

Implicación de los betamiméticos en el aumento de la supervivencia tras procedimientos quirúrgicos en el feto del cordero común / Involvement ofbetamimetics as increase of survival during fetal surgery in sheep

La cirugía fetal es actualmente una realidad terapéutica en algunos centros a nivel mundial. La investigación en este campo obliga a utilizar modelos animales experimentales. El problema principal de estos modelos es el control del trabajo de parto prematuro. Objetivos: Encontrar un régimen tocolítico que minimice las pérdidas fetales tras procedimientos quirúrgicos en el feto de oveja común. Material y métodos: Partiendo de dos grupos de ovejas gestantes elegidas mediante método aleatorio simple, a los 70 días de gestación son intervenidas, realizándose un mielomeningocele quirúrgico en el feto. Durante el postoperatorio se monitorizó los valores bioquímicos de urea y creatinina en líquido amniótico, mediante la realización de una amniocentesis semanal guiada con control ecográfico. El grupo A (n =6) fue tratado preoperatoriamente con indometacina y postoperatoriamente con sulfato de magnésico, que se mantenía durante 24 horas. En el grupo B (n = 8) se utilizó diclofenaco preoperatorio asociado a ritodrina postoperatoria, mantenida hasta la finalización de la gestación. Resultados. En el grupo A encontramos una supervivencia del 50% (n= 3), siendo en el grupo B del 87% (n = 7). El peso comparado de los fetos en ambos grupos fue menor en los tratados con ritodrina, así como también fue menor la ganancia ponderal de las madres de dicho grupo. Encontramos un incremento en la frecuencia cardíaca materna y fetal en el grupo B. Los valores de urea y creatinina en líquido amniótico fueron mayores en el grupo B, aunque no de forma significativa. Conclusión: El uso de ritodrina como agente tocolítico reduce las pérdidas fetales de forma significativa en el modelo de cirugía fetal basado en la oveja común. La ritodrina aumenta el gasto cardíaco materno y fetal ocasionando pérdidas de peso (AU)

La dilatación ureteral condiciona el éxito del tratamiento endoscópico del R. V. U / Success ofendoscopic management in vesicoureteral reflux, condicioned by ureteral dilatation

Introducción: El tratamiento endoscópico del reflujo vésico-ureteral (RVU) se ha convertido en una de sus principales armas terapéuticas. En 1995 se comienza a utilizar en nuestro hospital. Lo indicamos en los RVU de grado II no curados tras 1 año de tratamiento médico, en todos los de grado III y en los de grado IV sin daño renal. Según la Clasificación Internacional del Reflujo (IRSC); los reflujos de grado IV se diferencian de los de grado III básicamente por el abombamiento de los cálices. En cada uno de los grados de RVU se pueden observar distintos grados de dilatación ureteral. Objetivos: Estudiar la relación entre el grado de dilatación ureteral y la curación endoscópica del RVU independientemente de los gradosde reflujo. Material y métodos: De una serie de 245 unidades renales refluyentes (URR) intervenidas endoscópicamente; realizamos una revisión delos primeros 3,5 años (1996-1999). Se estudiaron 58 pacientes, con un total de 90 URR. Se valoraron las cistografías miccionales (CUMS).Mediante un estudio de doble ciego se graduó la dilatación ureteral de todos los pacientes en tres grados: leve-normal, moderada y severa. Se compararon los porcentajes de curación tras la 1ª inyección endoscópica en los tres grados de dilatación ureteral. Resultados: De las 90 URR estudiadas, 3 presentaban RVU de grado (..) (AU)

Sonocistouretrografía con galactosa en el diagnóstico y seguimiento del reflujo vesicoureteral en pacientes pediátricos / Urethrocystosonography for diagnosis and follow-up of vesicoureteric reflux in pediatrics

Introducción y objetivos. Desde finales de los años 80 se comienzan a emplear medios de contraste ecográfico que realcen los ultrasonidos para poder aplicarlos al estudio dinámico de la vía urinaria. Con la galactosa se ha logrado una gran definición en la imagen sonocistográfica, permitiendo porcentajes de sensibilidad iguales o mayores que la cistografía convencional tanto en el screening de malformaciones urológicas como en el control postoperatorio en pacientes urológicos pediátricos. El objetivo mostrar nuestra experiencia en 3 años de utilización de la sonocistouretrografía en el diagnóstico y seguimiento de pacientes pediátricos con patología urológica. Material y métodos. Se evaluaron 442 pacientes con edades entre 1 día y 13 años, 202 varones y 240 hembras. Todos fueron remitidos para descartar patología urológica con el diagnóstico previo de Infección del Tracto Urinario -ITU- (n=152), seguimiento de Reflujo Vesicoureteral -RVU- (n=60), dilatación del tracto urinario (n=86), control postratamiento endoscópico (n=52), control postratamiento quirúrgico (n=53), otros diagnósticos (n=39). En todos los casos se realizó estudio sonográfico dinámico del tracto urinario, incluyendo uretra, tras introducción de contraste con galactosa por sonda urinaria. El diagnóstico de RVU se consideró positivo cuando se detectaron microburbujas en uréter o en sistema pielocalicial, aplicando la clasificación internacional del RVU. Resultados. Se evaluaron 442 pacientes con sonocistouretrografía siendo diagnosticados de RVU 58 casos de los 277 considerados de screening. En el resto de los pacientes (n=165) se indicó la sonocistografía como seguimiento de una patología ya conocida. Como complicaciones destacamos 2 casos de candiduria postexploración en pacientes con mielomeningocele. En otros 6 casos, todos controlados por dilatación renal sin RVU, se detectó galactosa en pelvis renal a los 6 meses de la prueba. En todos los casos pudo realizarse la técnica ecográfica. Conclusiones. Concluimos que en nuestro centro la utilización de la sonocistografía con los medios de contrastes actuales (galactosa), ha pasado a ser un medio de diagnóstico indispensable, con una gran calidad de imagen, una sensibilidad mayor o igual que la alcanzada con la cistografía convencional, evitando los efectos indeseables derivados de la radiación, disminuyendo el número de estudios complementarios a que se somete al paciente y visualizando en el mismo examen la anatomía de las vías urinarias (AU)

Management of massive air leak following intubation injury in a very low birth weight infant.

Perforation of an infant's trachea after orotracheal intubation for general anaesthesia is a rarely described serious complication. This article reports an unusual case of laceration of the trachea in an 8-week-old infant with a history of prolonged neonatal intubation needed to treat hyaline membrane disease. After diagnosis the tracheal injury was managed conservatively. Factors involved in the occurrence of the injury and its management are discussed.

Pneumosinus dilatans of the frontal and ethmoidal sinuses: case report.

Enlargement of paranasal sinuses with air is rare with less than 50 cases reported in the medical literature. This craniofacial malformation was first described by Meyes in 1898 and its aetiology still remains unknown. Local pain, ocular alterations, anosmia, headache and cosmetic disturbances are the most common symptoms. We present a case of pneumosinus dilatans diagnosed in a male, 8 years of age. He presented with left fronto-orbital bossing that enlarged slowly until he was 12 years old, at which point its growth appeared to increase dramatically. Computerized tomography revealed an enlargement of the frontal and ethmoidal sinuses, with marked deformation of the anterior wall and of the roof of the left frontal sinus, as well as the roof of the ethmoid and upper sinus medial orbital wall. The sinus walls were of normal thickness. Access was via a bicoronal incision and osteotomy of the deformed fronto-orbital bossing. Reconstruction was undertaken with a periosteal flap and hydroxyapatite bone cement (Norian) following sinus mucosal stripping and obliteration of the sinus with fat. Six months postoperatively, the patient was without recurrence and had a good cosmetic result.

[Urethrosonocystography with galactose in the diagnosis and follow-up of pediatric patients with vesicoureteral reflux]. / Sonocistouretrografía con galactosa en el diagnóstico y seguimiento del reflujo vesicoureteral en pacientes pediátricos.

INTRODUCTION AND OBJECTIVES: Since early 80's, attempts to detect Vesicoureteric Reflux (VUR) with Ultrasound (US) contrast medium have been made to study the urinary tract during voiding. The galactose-based agents are comparable in the diagnostic range with the standard fluoroscopic cystography, providing high values of sensitivity and specificity. The purpose of our work is to show our experience during last three years with the urethrosonocystography with echo contrast in the diagnosis and follow-up of pediatric patients with urological malformations. PATIENTS AND METHODS: 442 patients were included in our study (aged 1 day to 13 years; 202 males and 240 females). All cases were referred for investigation of VUR based on previous criteria of urinary tract infection, VUR follow-up, dilated urinary tract, post endoscopic treatment, surgical treatment follow-up and others. After transurethral catheterisation the bladder was filled with US galactose-based contrast medium (Levovist). VUR was diagnosed when micro bubbles appeared in ureter or pelvicalyceal system and was graded according to the International Reflux Study Committee. RESULTS: Of the 442 patients evaluated with echo enhanced urethrosonocystography, 227 were screening cases for discard VUR. Of these patients, only 58 were diagnosed as having VUR. In 165 cases the technique was indicated as follow-up. Two patients with spina bifida developed candiduria after the sonographic cystogram. In 6 patients with dilated urinary tract without reflux, galactose was detected in renal pelvis 6 months after the procedure. CONCLUSIONS: In our experience urethrocystosonography with galactose-based US medium agents is a more sensitive method than standard Voiding Cystourethrography (VCUG) for detecting VUR in pediatric patients. US cystography is an attractive technique which involves no ionising radiation and is usually well tolerated by the young. This procedure should be considered as a routine diagnostic work-up for detecting VUR in pediatrics.