[Morgagni-Larrey anterior diaphragmatic hernias. Review of 13 cases]. / Hernias diafragmáticas anteriores. Revisión de 13 casos.

OBJECTIVE: A review of anterior congenital diaphragmatic hernias (CDH) treated at our center, analysis of our experience and evolution in the surgical technique in pediatric patients over the last 15 years. MATERIAL AND METHODS: A retrospective descriptive study of patients of our center with anterior CDH (Morgagni, Larrey and Morgagni-Larrey) between 2000 and 2015, through a systematic review of clinical records. The studied variables were: age at diagnosis, age at treatment, diagnostic methods, symptoms, surgical technique, evolution, complications and relapses. Posterior CDH (Bochdalek) and patients older than 14 years old were excluded. RESULTS: 13 patients (8 females) with anterior diaphragmatic hernia. Mean age at diagnosis was 29.4 months (range fetal age 4 months-14 years old) and mean age at surgery 18.5 m (range 1 day-14 years). Three left hernias (Larrey hernia) and n= 2central hernias (Morgagni-Larrey). Two patients were diagnosed prenatally, the rest of them were casual diagnoses. Symptoms: n= 6 asymptomatic, n= 4respiratory symptoms, n= 1abdominal pain, n= 1both symptoms and n= 1 hydrops fetalis. In all cases, a chest X-ray was performed, CT in n= 5 cases and US in other n= 5 patients. The surgical approach was laparoscopic in n= 7 (1 conversion due to bleeding), thoracoscopic in n= 1 (requiring conversion to laparotomy due to technical difficulty), thoracotomy in n= 1patients and laparotomy in n= 4. Prosthetic patches were necessary in n= 2 patients. During the follow-up (3.9 years, range: 1-8), there were n= 2 recurrences (laparoscopy and thoracotomy) and n= 1 exitus 2 years after surgery, due to pathology not associated with diaphragmatic hernia. CONCLUSIONS: The minimally invasive approach is considered of choice in the literature. Our group considers that most patients with anterior CDH should be considered for a laparoscopic repair. The laparoscopic approach is easily reproducible and the conversion rate is low when it is performed by expert surgeons. However, the low prevalence of this pathology would require comparative and long-term multicenter studies to obtain statistically significant conclusions.

OBJETIVO: Revisión de las hernias diafragmáticas congénitas (HDC) anteriores intervenidas en nuestro centro, análisis de nuestra experiencia y evolución de la técnica quirúrgica a lo largo de 15 años en el paciente pediátrico. MATERIAL Y METODOS: Estudio descriptivo retrospectivo de pacientes pediátricos intervenidos de HDC anterior (Morgagni, Larrey y Morgagni-Larrey) en nuestro centro entre 2000 y 2015, mediante revisión sistemática de historias clínicas. Variables estudiadas: edad al diagnóstico, edad al tratamiento, pruebas diagnósticas, síntomas, técnica quirúrgica, evolución, complicaciones y recidivas. Fueron excluidas las hernias posteriores (Bochdaleck) y los pacientes mayores de 14 años. RESULTADOS: 13 pacientes (8 mujeres) con hernia diafragmática anterior. Media de edad al diagnóstico: 29,4 meses (rango: 4 meses de edad gestacional-14 años). Media de edad en el momento de la intervención: 18,5 meses (rango: 1 día-14 años). Tres hernias izquierdas (hernia de Larrey) y 2 centrales (Morgagni-Larrey). Dos diagnósticos prenatales, siendo el resto hallazgos casuales. Síntomas: n= 6 asintomáticos, n= 4 síntomas respiratorios, n= 1 dolor abdominal, n= 1 ambos síntomas, n= 1 hidrops fetalis. En todos los casos se realizó radiografía de tórax, en n= 5 casos TAC y en otros n= 5 ecografía. El abordaje quirúrgico fue laparoscópico en n= 7 (1 conversión por hemorragia), toracoscópico en n= 1 casos (precisando conversión a laparotomía por dificultad técnica), toracotomía en n= 1 y laparotomía en n= 4. Fue necesario el uso de parches protésicos en 2 pacientes. Seguimiento: media 3,9 años (rango: 1-8). Dos recidivas (laparoscopia y toracotomía) y n= 1 exitus a los 2 años de la intervención por patología no asociada a la hernia diafragmática. CONCLUSIONES: El abordaje mínimamente invasivo es considerado de elección en la literatura. Nuestro grupo defiende que la mayoría de los pacientes con HDC anterior deben considerarse para una reparación laparoscópica por ser fácilmente reproducible, con una tasa de conversión baja en manos de cirujanos expertos. Sin embargo, la baja prevalencia de esta patología requeriría estudios multicéntricos comparativos y prolongados en el tiempo para obtener conclusiones estadísticamente significativas.

[Analysis of efficacy in diaphragmatic plication with minimally invasive surgery]. / Análisis de efectividad de la plicatura diafragmática mínimamente invasiva.

OBJECTIVE: Diaphragmatic paralysis may result difficulty for respiratory compromise and extubation. We study the effectiveness of diaphragmatic plication held in its two modalities: videothoracoscopy assisted surgery (VATS) and percutaneous with needle. MATERIAL AND METHODS: Retrospective study of diaphragmatic plication performed in our center in the past three years. Review of clinical histories, analyzing the variables: sex and age, etiology and laterality, surgical indications, technique, ventilation support, complications and outcome. Data Analysis with SPSS 18.0. RESULTS: From 2009-2012, 24 diaphragmatic plication were realized (7 left, 13 right, 2 bilateral) in 22 children (15 males). The mean age was 10.4 months (2 to 23.1). In 68.1% paralysis was secondary to thoracic surgery. In 12 patients was performed VATS and in 5 percutaneous with needle. Surgical indications were: respiratory distress (69.1%) with intercurrent processes (pneumonia, bronchiolitis, and atelectasis) and failure of extubation in 27.3%. After diaphragmatic plication in 90.9% respiratory symptoms remitted. Extubation was accomplished in all patients, requiring ventilator support for 12-96 hours. Mean hospital stay was 7.5 days (3 to 13.5). There were no complications derived from surgery. There were two recurrences (9.2%) and only one was reoperated (4.6%). The percutaneous technique decreased the required postoperative analgesia and improved cosmetic outcome in 90.9%. CONCLUSIONS: The diaphragmatic plication by minimally invasive surgery reduces operative morbidity and facilitates extubation of ventilator-dependent patients with diaphragmatic paralysis. The percutaneous technique improves the cosmetic results and reduces pain after surgery, without finding differences with VATS.

Problemática diagnóstica y terapéutica de la patología respiratoria asocial: al síndrome aspirativo recurrente y al reflujo gastroesofágico / Diagnostic and therapeutic problems presented by respiratory disease associated with recurrent aspiration syndrome and gastroesophageal reflux

El síndrome aspirativo recurrente y el reflujo gastroesofágico, asociados o no, son bastante más frecuentes en la edad pediátrica de lo que se cree. Producen patología broncopulmonar crónica o recurrente muy dificil de diagnosticar y de tratar, debido a una presentación clínica muy variable, a la falta de criterios diagnósticos específicos y a la errática respuesta al tratamiento en muchos casos. Es objetivo de esta revisión dar a conocer los mecanismos de producción de enfermedad respiratoria en el reflujo gastroesofágico y la aspiración recurrente, sus manifestaciones clínicas y factores predisponentes, así como clarificar la problemática diagnóstica y realizar una aproximación a las modalidades terapéuticas que se pueden llevar a cabo en estos enfermos. Todo ello genera la necesidad de elaborar un protocolo diagnóstico y terapéutico perfectamente estandarizado que reduzca las importantes secuelas que en muchas ocasiones, producen las microaspiraciones repetidas y / o el reflujo gastroesofágico en el aparato respiratorio, e impida la realización de excesivas pruebas diagnósticas o terapias sin fundamento (AU)

Anillos vasculares con compromiso respiratorio / Vascular rings with respiratory compromise

Los anillos vasculares son una patología poco frecuente, con una sintomatología derivada de la compresión traqueal o esofágica. Los síntomas son poco característicos, por lo que, habitualmente, los pacientes se diagnostican tarde y, con frecuencia, han recibido tratamientos con broncodilatadores y antibióticos o han tenido varios ingresos previos con múltiples diagnósticos. El mejor método diagnóstico para estos pacientes no está bien definido. Clásicamente, se ha considerado para su tratamiento la toracotomía izquierda con división del anillo vascular y liberación de la tráquea y el esófago de sus estructuras vecinas. En los últimos años, se recomiendan la esternotomía media con circulación extracorpórea para el tratamiento quirúrgico de la mayoría de estos pacientes, proporcionando una oxigenación adecuada durante la cirugía, así como una correcta exposición anatómica de la zona. La fibrobroncoscopia intraoperatoria permite, además, una correcta evaluación de la tráquea para establecer el tratamiento combinado más apropiado en cada caso. (AU)

Patología laringotraqueal pediátrica / Pediatric laryngotracheal disorders

Los pacientes con patología laringotraqueal son escasos en número, pero de gran importancia, debido a que generan mucha ansiedad en sus familias y tienen una tasa de morbimortalidad considerable. El presente trabajo analiza este tipo de enfermedad, que se agrupa en tres grandes áreas de estudio: la estenosis subglótica, la traqueobroncomalacia y la estenosis traqueal. (AU)

[Progress in laryngotracheal surgery]. / Avances en cirugía laringotraqueal.

The number of patients with laryngotracheal disorders is small but they have great importance because they produce anxiety in parents and they have a considerable morbi-mortality rate. We present the state of the art in three groups of patients: subglottic stenosis, tracheobroncomalacia and tracheal stenosis.

Avances en cirugía laringotraqueal / Laryngotracheal surgery. State of the art

Los pacientes con patología laringotraqueal son escasos en número pero de gran importancia debido a que generan mucha ansiedad en sus familias y tiene una tasa de morbimortalidad considerable. El presente trabajo expone qué hay de nuevo en este tipo de patología que agrupamos en tres grandes áreas de estudio: la estenosis subglótica, la traqueobroncornalacia y la estenosis traqueal (AU)

[Laryngo-tracheoplasty in the management of infantile laryngeal stenosis]. / Laringotraqueoplastia en el manejo de la estenosis laríngea infantil.

We present the results obtained in our center with laryngo-tracheoplasty for the management of laryngeal stenosis in infants and children. Nineteen patients were treated between 1989 and 1995. Their weights ranged from 1,200 g to 36 kg. Twenty-five operations were performed, not including endoscopic maneuvers. Fifteen patients have been decannulated (79%). Complications were infrequent and resolved satisfactorily. We consider that these surgical procedures should occupy a prominent place in the management of pediatric patients with laryngeal stenosis.

[Use of anterior cricoid split as an effective therapy for neonatal laryngeal stenosis]. / Uso del split cricoideo anterior como terapéutica eficaz en la estenosis laríngea neonatal.

Anterior cricoid split was described in 1980 by COTTON and SEID as an alternative to tracheotomy for managing neonatal laryngeal stenosis. Seven patients managed in our unit using this technique since 1989 were reviewed. Five evolved favorably. Two patients in whom the technique failed underwent successful laryngotracheal reconstruction. Complications were minimal, the most important being persistent tracheocutaneous fistula. The most common complication was accidental postoperative extubation. The success of the technique depends on the availability of a pediatric intensive care unit staffed by experienced personnel and with suitable equipment.

[Testicular tumors in childhood. Review of cases in the course of 13 years]. / Tumores testiculares en la infancia. Revisión de 13 años.

Testicular and paratesticular tumors are rare in childhood, representing 1-2 percent of the solid tumors in the pediatric age. In patients under 14 years, the incidence is 0.5-2/100,000. The evolution differs from that of the adult. Since 1981 to 1994 we have treated 14 cases of testicular and paratesticular tumors. Mean age was 2.54 years, the younger patients presenting germinal tumors. The most frequent tumor was the yolk sac tumor (36%), followed by teratoma mature (29%), and Leydig cell tumor, epidermoid cyst, paratesticular fibrous hamartoma, paratesticular neuroblastoma and paratesticular rabdomyosarcoma (7% each). A testicular mass was present in all cases (100%). Testicular ultrasound was used in 100%. In all the patients with malignant tumors a thoraco-abdominal CT scans was done to rule out extension or the tumor, being negative in all cases. Alphafetoprotein were high in all the cases of yolk sac tumor, being within normal range one month after surgery except in one case. In 11 patients an orquiectomy was done through an inguinal approach, and in three cases a simple tumorectomy without orquiectomy. No lymphadenectomy was done. All the malignants neoplasms were stage I tumors, except one yolk sac tumor stage III. Postop chemotherapy was applied in this one and in the embrionary rabdomyosarcoma. There were no recurrences after a follow-up mean time of 3.98.

[Surgery of ectopic ureterocele in children: strategy based on prenatal function]. / Tratamiento quirúrgico del ureterocele ectópico en la infancia: estrategia basada en la función renal.

From 1981 to 1993, we have treated 31 pediatric patients with ectopic ureterocele (associated to duplex system, intra and extravesicals). Diagnostic work-up included abdominal ultrasound, intravenous urography (IVU), sequence mictional cystouretrography (SM-CU) and diuresis renography (DTPA-DMSA o MAG-3). Patients were divided in two groups: 1. Good renal function in the affected system (5 cases) with 2 endoscopic incision of the ureterocele and 3 without surgical treatment (all intravesical). 2. Almost non-existent ipsilateral renal function (26 cases), treated by heminephrectomy and ureterocelic aspiration, and in the remaining a nephrectomy was done for ipsilateral non-existent renal function. 2 cases treated by endoscopic incision presented vesicoureteral reflux, and 4 cases treated by nephrectomy had a low grade reflux. There is no a definite treatment established. The choice should by made based on renal function. Endoscopic incision is a good choice in obstructed cases with good renal function. In those with no function at all, heminephrectomy with aspiration of the ureterocele will be the best treatment if we consider that almost 50 percent of the patients will need a second surgical procedure.

[Results of the treatment of Hirschsprung's disease using Duhamel technique and mechanical sutures]. / Resultados del tratamiento de la enfermedad de Hirschsprung mediante la tecnica de Duhamel realizada con suturas mecanicas.

The original Duhamel procedure for the treatment of Hirschsprung's disease (HD) has undergone several important modifications over the years. The use of mechanical suture in recent years has added significant advantages to this surgical procedure. Sixteen patients with HD were operated on according to this surgical technique, from 1985 to 1990. We analyse clinical, radiological and surgical aspects. We concentrate on early and late postoperative complications and the results achieved after a maximum follow-up of 4.5 years.

[Congenital esophageal stenosis associated with corneosclera]. / Estenosis esofagica congenita asociada a esclerocornea.

One case of congenital esophageal stenosis due to tracheobronchial remnants and associated with microphthalmos and corneosclera is reported. Diagnostic and therapeutic methods employed are discussed.

[Our experience with the treatment of congenital megacolon using mechanical sutures]. / Nuestra experiencia en el tratamiento del megacolon congénito con sutura mecánica.

The DUHAMEL operation is widely used for the treatment of HIRSCHSPRUNG disease. Recently, technical modifications using stapled instruments have been introduced. The results of 12 patients treated between 1985 and 1989, performing the DUHAMEL procedure are reviewed. We perform with mechanical sutures, both surgical stages, e.g. abdominal and perineal. The technique for the procedure is described. Since we introduce the technique, we have observed several advantages consisting in a shorter surgical time, earlier normal life pattern, less postoperative complications and better results in clinical evolution.

[Instrumental perforation of the esophagus. Importance of diagnosis early in its clinical course]. / Perforación instrumental de esófago. Importancia del diagnóstico precoz en la evolución.

Instrumental esophageal perforation is a serious complication that demands immediate therapy. In a retrospective study we have evaluated the results in seven patients treated for esophageal perforation by means of a conservative treatment without mortality. Instrumental dilatation of corrosive strictures were the most frequent cause of iatrogenic endoscopy. We have observed an esophageal injury associated with a Sengstaken-Blackemore tube placement. Clinical symptoms associated with chest roentgenograms guided to early diagnosis in all cases. Conservative treatment usually consist of a course of antibiotics, pleural drainage, and total parenteral nutrition. Clinical follow-up has been good in the seven patients treated.

[Total colectomy in necrotizing enterocolitis]. / Colectomías totales por enterocolitis necrotizante.

Total colectomy in the neonatal period, after a necrotizing enterocolitis is not infrequent and implies a series of complex attitudes towards a good adaptation of the remaining small bowel. We present 9 cases of total colectomy in children with necrotizing enterocolitis of 11 cases surgically treated out of 57 cases. We describe the different types of surgical procedures used as well as the evolution of each patient.