["Fast-track" in pediatric urologic surgery: pronenephrectomy]. / Fast-track en urología infantil: nefrectomía en prono ambulatoria.

UNLABELLED: INTRODUCTION AND OBJETIVES: Minimal invasive surgery trends to get prompt recovery in terms of inmediate deambulation and early discharge from hospital, without increasing patient's discomfort neither postoperative complications. This "fast-track" protocol is being progresively introduced in a crescent number of urological procedures. We are evaluating the viability of applying it in retroperitoneoscopic prone- position nephrectomy. METHODS AND MATERIALS: We have performed a retrospective review of the clinical reports of the patients submitted to prone nephrectomy with hospitalization between 2007 and 2011 and we present patients submitted to this procedure in an outpatient basis (less than 8 hours hospital stay) from 2011. We have recorded epidemiological factors, diagnosis, surgical time, first postoperative week analgesic requirements, parents cofort and postoperative complications. RESULTS: All the procedures were performed retroperitoneoscopically in prone position using two trocars. We included 34 nephrectomies with a mean surgical time of 107 minutes. Mean postoperative stay was under 24 hours in 23 patients, two of them were discharged in the first 8 hours after the procedure. Hospital stay over this time was due to concomitant pre-existent pathology in 6 patients and to non urological fever in the remaining 3. Analgesia was excellent in every patient with endovenous non-steroid drugs, registering no pain after administering them orally. There were no complications. CONCLUSIONS: We believe that "fast-track" requirements can be applied to prone-retroperitoneoscopic nephrectomy in pediatric population, as long as they have no associated pathology. In our experience this surgical procedure can be included in day-case surgery, increasing patient's confort and with a positive economical impact.

[Current problems in training of minimally invasive surgery: vision of residents in pediatric surgery]. / Problemas actuales en la formación en cirugía mínimamente invasiva: visión de los residentes de Cirugía pediátrica.

INTRODUCTION: Minimally Invasive Surgery (MIS) is getting more and more important in our specialty. However, the formation of the residents on MIS is, in many cases, irregular. The purpose of this study is to assess the state of training in MIS among the residents of Pediatric Surgery and their potential weaknesses. MATERIAL AND METHODS: An electronic survey was distributed among 71 residents of Pediatric Surgery from 17 national hospitals. RESULTS: The response rate was 70.2%.100% of the residents are interested in a broadening of training activities in MIS. The main areas of interest are gastrointestinal (92%) and thoracic (47%) surgery. Only 57% have access to training facilities and less than half of them attend to courses and conferences. 80% believe that they are not given adequate attention from specialized associations. 52% think they should do rotations at referral centers, 86% that courses and seminars should be enhanced, and 44% that the responsibility of the resident in surgery should be increased. The main defects encountered in their training are scarce volume of patients, lack of financial support and overcoming the learning curve of surgeons in their services. CONCLUSIONS: Despite the advance of the MIS, resident's training in this discipline still has shortcomings, as expressed in their views. Knowledge of the current state of training should be the starting point for designing a training strategy that ensures adequate skills.

Problemas actuales en la formación en cirugía mínimamente invasiva: visión de los residentes de Cirugía Pediátrica / Current problems in training of minimally invasive Surgery: Vision of residents in pediatric surgery

Introducción. La cirugía mínimamente invasiva (CMI) ocupa una parcela cada vez mayor de nuestra especialidad. Sin embargo, la formación de los residentes en CMI es, en muchos casos, irregular. El propósito de este estudio es evaluar el estado de la formación en CMI entre los residentes de Cirugía Pediátrica y sus posibles deficiencias. Material y métodos. Se distribuyó una encuesta electrónica entre 71 residentes de Cirugía Pediátrica de 17 hospitales nacionales. Resultados. La tasa de respuesta fue 70,2%. El 100% de los residentes está interesado en que se potencien actividades formativas en CMI. Las áreas de mayor interés son cirugía digestiva (92%) y torácica (47%). Solo un 57% tiene acceso a medios de entrenamiento y menos de la mitad acuden a cursos y congresos. Un 80% cree que no se les presta adecuada atención desde las asociaciones especializadas. Un 52% cree que se deberían realizar rotaciones en centros de referencia, un 86% que se deberían potenciar cursos y seminarios, y un 44% que se debería aumentar la responsabilidad del residente en las intervenciones quirúrgicas. Los principales defectos que encuentran en su formación son el volumen escaso de pacientes, la falta de ayudas económicas y la superación de la curva de aprendizaje por los adjuntos de su servicio. Conclusiones. A pesar del avance de la CMI, la formación de los residentes en esta disciplina tiene todavía deficiencias, tal como expresan sus opiniones. El conocimiento del estado actual de la formación debería ser el punto de partida para diseñar una estrategia docente que asegure una formación adecuada (AU)

Introduction. Minimally Invasive Surgery (MIS) is getting more and more important in our specialty. However, the formation of the residents on MIS is, in many cases, irregular. The purpose of this study is to assess the state of training in MIS among the residents of Pediatric Surgery and their potential weaknesses. Material and methods. An electronic survey was distributed among 71 residents of Pediatric Surgery from 17 national hospitals. Results. The response rate was 70.2%.100% of the residents are interested in a broadening of training activities in MIS. The main areas of interest are gastrointestinal (92%) and thoracic (47%) surgery. Only 57% have access to training facilities and less than half of them attend to courses and conferences. 80% believe that they are not given adequate attention from specialized associations. 52% think they should do rotations at referral centers, 86% that courses and seminars should be enhanced, and 44% that the responsibility of the resident in surgery should be increased. The main defects encountered in their training are scarce volume of patients, lack of financial support and overcoming the learning curve of surgeons in their services. Conclusions. Despite the advance of the MIS, resident’s training in this discipline still has shortcomings, as expressed in their views. Knowledge of the current state of training should be the starting point for designing a training strategy that ensures adequate skills (AU)

Infección de la herida quirúrgica neonatal: análisis de factores de riesgo / Surgical Wound infections in newborns: analysis of risk factors

La infección de herida quirúrgica (IHQ) en neonatos tiene una elevada incidencia y morbilidad, que prolonga la estancia hospitalaria y empeora el pronóstico. Nuestro objetivo es analizar los factores de riesgo relacionados con la aparición de infección de herida quirúrgica para identificar pacientes susceptibles y los factores modificables sobre los que actuar.material y métodos. Estudio de casos y controles sobre una muestra de 90 intervenciones quirúrgicas realizadas en recién nacidos. Se analizan factores de riesgo pre, intra y postquirúrgicos como posible causa de IHQ. Resultados. Existen diferencias estadísticamente significativas para el desarrollo de IHQ en cirugías contaminadas o sucias, reintervenciones, lavado de cavidad abdominal intraoperatorio, estancia hospitalaria prequirúrgica mayor de 8 días y cierre de la herida con sutura reabsorbible.Asimismo, encontramos una mayor tendencia a la infección en pacientes pretérminos, dependientes de ventilación mecánica, portadores de acceso venoso central y que han presentado una infección previa con cultivo positivo.No hallamos relación entre IHQ y el tiempo quirúrgico, el sangrado durante la cirugía o el antiséptico utilizado.Conclusiones. Los pacientes reintervenidos, en los que se realiza cirugía contaminada o sucia, se emplea material reabsorbible para sutura de la piel y con una estancia hospitalaria prequirúrgica mayor de 8 días son pacientes de alto riesgo para desarrollar IHQ y requerirán un especial cuidado y antibioterapia más agresiva (AU)

The incidence of surgical wound infections in neonates is high and it has an associated morbidity which extends hospital stay and gets a worse prognosis. The purpose of this study is to analyze the risk factors associated with the development of surgical wound infection and to identify susceptible patients with modifiable factors.material and methods. Case-control study of 90 surgical procedures underwent in newborns. We analyze pre-, intra- and postoperative risk factors.main results. There are statically significant differences in terms of wound infection in dirty and contaminated surgery, reoperation, lavage of abdominal cavity, preoperative hospital stay longer than 8 days and wound closure with reabsorbable material.Furthermore, the surgical site infection is more likely in preterms patients, with a previous positive culture infection and the use of invasive devices as mechanical ventilation or central venous access.We found no relationship between wound infection and surgical time, bleeding during surgery and preoperative skin preparation with antiseptics.Conclusions. Reoperative patients, in which dirty and contaminated surgery is performed, absorbable material for skin is used and who have a preoperative hospital stay longer than 8 days, are in risk of developping wound infection and they will require an aggressive antibiotic treatment and special postsurgical care (AU)

Prolapso anal postoperatorio en pacientes con malformaciones anorrectales: 16 años de experiencia / Postoperative anal prolapse in patients with anorectal malformations: 16 years of experience

Introducción. El prolapso anal es una complicación postoperatoria frecuente e infravalorada en las malformaciones anorrectales (MAR). Analizamos las causas de esta complicación y nuestro protocolo quirúrgico actualmaterial y métodos. Desde 1995, han sido intervenidos 26 pacientes con prolapso anal (12 niñas y 14 niños) secundario a corrección quirúrgica de su patología anorrectal. La MAR en estas 12 niñas fue la cloaca (10), y en los 14 niños la MAR más frecuente fue la atresia anorrectal con fístula prostática (8).La clínica fue dolor y sangrado anal, asociado a alteraciones en el control intestinal. El diagnóstico en la mayoría de los pacientes se hizo en los primeros meses tras la cirugía, durante el periodo de dilataciones anales. La técnica quirúrgica consiste en extirpación del prolapso y nueva anoplastia.En 18 pacientes (69%) el prolapso fue intervenido antes del cierre de la colostomía y de forma ambulatoria. En 8 (31%) el prolapso se trató con ingreso hospitalario, una vez que el paciente ya no era portador (..) (AU)

Introduction. Anal prolapse is a common postoperative complication related to anorectal malformations (MAR) surgery, which is sometimes considered to be insignificant and / or not worthy of further intervention. We analysed the causes of this complication and our current surgical protocols.material and methods. Since 1995, 26 patients with anal prolapse have been operated secondary to surgical correction of an anorectal pathology. The most common MAR in girls (12) was cloaca (10), and in boys (14) was anorectal atresia with prostate fistula (8).The symptoms were anal pain and bleeding associated with alterations in bowel control alterations. The diagnosis in most patients was made in the first months after surgery, during the period of anal dilatations period. The surgical procedure involves prolapse resection of the prolapse and a new anoplasty.In 18 patients (69%) the prolapse was corrected before the colostomy closure on an outpatient basis. The other 8 patients (31%) underwent prolapse surgery after colostomy closure, requiring hospitalisation.Results. There were no immediate postoperative complications, improving continence and aesthetic anus appearance. In 4 patients the (..) (AU)

Dilatación con balón de alta presión como tratamiento del ureterocele ortotópico / High-Pressure Balloon Dilatation for Treatment of Orthotopic Ureterocele

Objetivo: La punción o destechamiento endoscópico es el tratamiento más utilizado en la actualidad tanto para los ureteroceles ortotópicos como para los ectópicos. Sin embargo, tiene una elevada incidencia de reflujo vesicoureteral secundario y de procedimientos quirúrgicos posteriores en ambos grupos. Presentamos una nueva técnica de tratamiento de los ureteroceles ortotópicos. Material y métodos: Analizamos 4 pacientes con ureteroceles ortotópicos de edad 9,7±6,2 meses tratados mediante dilatación del meato del ureterocele. Ningún caso presentaba sistemas duplicados ni reflujo vesicoureteral. La indicación fue pionefrosis en 2 niños y empeoramiento progresivo de la hidronefrosis en otros 2. La dilatación fue realizada con balón de alta presión de 5 o 6mm tras tutorizar el ureterocele con guía de 0,014”. Resultados: No hubo complicaciones intraoperatorias ni post-operatorias, siendo el tiempo quirúrgico de 24±9min. Todos los pacientes fueron dados de alta a las 24 h post-operatorias. En todos los niños desapareció la ureterohidronefrosis y permanecen asintomáticos tras 35±22,5 meses de seguimiento. No hubo ningún caso de reflujo vesicoureteral secundario y la gammagrafía renal se mantuvo sin cambios tras el tratamiento. Conclusiones: La dilatación con balón de alta presión del meato del ureterocele en los casos ortotópicos es una técnica rápida, segura y con buenos resultados a largo plazo. No encontramos en nuestra serie ningún caso de reflujo vesicoureteral secundario ni de procedimientos quirúrgicos posteriores, por lo que consideramos que podría ofertar importantes beneficios respecto a la punción en este tipo de pacientes (AU)

Objective: Transurethral puncture or endoscopic unroofing is the best treatment currently used for both orthotopic and ectopic ureteroceles. However, they have a high incidence of secondary vesicoureteral reflux and subsequent procedures in both groups. We present a new technique for treatment of orthotopic ureterocele. Material and methods: We have analyzed 4 patients with orthotopic ureterocele (9.7±6.2 months old) treated by dilatation of the meatus of the ureterocele. No patient had vesicoureteral reflux or duplicate systems. The indication was pyonephrosis in 2 children and progressive worsening of hydronephrosis in 2. Dilatation was performed with 5 or 6mm high-pressure balloon after inserting a stent with guidewire of 0.014” to the ureterocele. Results: There were no intraoperative or postoperative complications, surgical time being 24±9minutes. All patients were discharged at 24 postoperative hours. Ureterohydronephrosis disappeared in all the children and they continue asymptomatic after 35±22.5 months of follow-up. There were no cases of secondary vesicoureteral reflux and renal scan was unchanged after treatment. Conclusions: High pressure balloon dilatation of the meatus in cases of orthotopic ureterocele is a fast, safe and successful surgical technique. We did not find any cases of secondary vesicoureteral reflux or subsequent procedures in our series, so we believe this may offer significant benefits over the transurethral puncture in such patients (AU)

[High-pressure balloon dilatation for treatment of orthotopic ureterocele]. / Dilatación con balón de alta presión como tratamiento del ureterocele ortotópico.

OBJECTIVE: Transurethral puncture or endoscopic unroofing is the best treatment currently used for both orthotopic and ectopic ureteroceles. However, they have a high incidence of secondary vesicoureteral reflux and subsequent procedures in both groups. We present a new technique for treatment of orthotopic ureterocele. MATERIAL AND METHODS: We have analyzed 4 patients with orthotopic ureterocele (9.7 ± 6.2 months old) treated by dilatation of the meatus of the ureterocele. No patient had vesicoureteral reflux or duplicate systems. The indication was pyonephrosis in 2 children and progressive worsening of hydronephrosis in 2. Dilatation was performed with 5 or 6mm high-pressure balloon after inserting a stent with guidewire of 0.014" to the ureterocele. RESULTS: There were no intraoperative or postoperative complications, surgical time being 24 ± 9minutes. All patients were discharged at 24 postoperative hours. Ureterohydronephrosis disappeared in all the children and they continue asymptomatic after 35 ± 22.5 months of follow-up. There were no cases of secondary vesicoureteral reflux and renal scan was unchanged after treatment. CONCLUSIONS: High pressure balloon dilatation of the meatus in cases of orthotopic ureterocele is a fast, safe and successful surgical technique. We did not find any cases of secondary vesicoureteral reflux or subsequent procedures in our series, so we believe this may offer significant benefits over the transurethral puncture in such patients.

[Surgical wound infections in newborns: analysis of risk factors]. / Infección de la herida quirúrgica neonatal: análisis de factores de riesgo.

UNLABELLED: The incidence of surgical wound infections in neonates is high and it has an associated morbidity which extends hospital stay and gets a worse prognosis. The purpose of this study is to analyze the risk factors associated with the development of surgical wound infection and to identify susceptible patients with modifiable factors. MATERIAL AND METHODS: Case-control study of 90 surgical procedures underwent in newborns. We analyze pre-, intra- and postoperative risk factors. MAIN RESULTS: There are statically significant differences in terms of wound infection in dirty and contaminated surgery, reoperation, lavage of abdominal cavity, preoperative hospital stay longer than 8 days and wound closure with reabsorbable material. Furthermore, the surgical site infection is more likely in preterms patients, with a previous positive culture infection and the use of invasive devices as mechanical ventilation or central venous access. We found no relationship between wound infection and surgical time, bleeding during surgery and preoperative skin preparation with antiseptics. CONCLUSIONS: Reoperative patients, in which dirty and contaminated surgery is performed, absorbable material for skin is used and who have a preoperative hospital stay longer than 8 days, are in risk of developping wound infection and they will require an aggressive antibiotic treatment and special postsurgical care.

[Postoperative anal prolapse in patients with anorectal malformations: 16 years of experience]. / Prolapso anal postoperatorio en pacientes con malformaciones anorrectales: 16 años de experiencia.

INTRODUCTION: Anal prolapse is a common postoperative complication related to anorectal malformations (MAR) surgery, which is sometimes considered to be insignificant and/or not worthy of further intervention. We analysed the causes of this complication and our current surgical protocols. MATERIAL AND METHODS: Since 1995, 26 patients with anal prolapse have been operated secondary to surgical correction of an anorectal pathology. The most common MAR in girls (12) was cloaca (10), and in boys (14) was anorectal atresia with prostate fistula (8). The symptoms were anal pain and bleeding associated with alterations in bowel control alterations. The diagnosis in most patients was made in the first months after surgery, during the period of anal dilatations period. The surgical procedure involves prolapse resection of the prolapse and a new anoplasty. In 18 patients (69%) the prolapse was corrected before the colostomy closure on an outpatient basis. The other 8 patients (31%) underwent prolapse surgery after colostomy closure, requiring hospitalisation. RESULTS: There were no immediate postoperative complications, improving continence and aesthetic anus appearance. In 4 patients the prolapse recurred, requiring further surgical correction. CONCLUSIONS: Anal prolapse is a possible minor complication after anorectal correction. MAR type, the quality of the perineal musculature and defects in surgical technique are the main factors determining ia prolapse will appearance. The anal prolapse surgery indication has been recently increased (including small unilateral prolapses) as long as they are done before the colostomy closure, due to good aesthetic and functional results, requiring only outpatient surgery.

Dispositivos intravasculares centrales de inserción subcutánea en el paciente oncológico pediátrico, ¿podemos minimizar su infección? / Subcutaneously inserted central intravascular devices in the pediatric oncology patient: can we minimize their infection

Los dispositivos intravasculares centrales de implantación subcutánea(DICIS) son utilizados frecuentemente en pacientes pediátricos. Su principal complicación es la infección, que puede requerir su retirada. El objetivo de nuestro trabajo es estudiar los factores de riesgo relacionados con su infección y retirada. Estudio retrospectivo de 120 pacientes oncológicos en los que se implantó un DICIS entre los años 2003-2009. Estudiamos factores epidemiológicos, quirúrgicos, clínicos y microbiológicos. Realizamos un análisis comparativo entre: grupo A, pacientes que presentaron infección, grupo B, el resto. El grupo A se dividió en subgrupos: infección precoz(primer mes postimplantación)/tardía, retirados/no retirados. Los datos fueron analizados mediante el programa estadístico SPSS. De 120 niños, 29 sufrían leucemia,19 linfoma y 72 tumor sólido. Un31% presentaron infección (grupo A), siendo precoz en un 36%. Un 16%de los dispositivos infectados requirió retirada. Analizando los factores relacionados con la infección se encontró diferencia estadísticamente significativa en la edad (p=0,015) y en el hecho de recibir quimioterapia previa a la implantación (p=0,034). El resto de parámetros analizados no arrojaron resultados significativos, si bien es cierto que se observó una tendencia a ésta en los pacientes con diagnóstico de leucemia, en los portadores de vía subclavia, en los que el dispositivo se colocó através de una guía sobre una vía central previa y en los trasplantados. En (..) (AU)

Long-term indwelling central venous access devices are frequently used in pediatric patients. Their main complication is infection, that can even mean their removal. We try to identify the risk factors really involved in this complication and in their removal. We have made a retrospective review of 120 oncologic pediatric patients who received a central venous device between 2003 and 2009. We searched for epidemiologic, clinic, microbiologic and surgical risk factors. We made a comparative data analysis among: GROUP A, children who suffered device infection, GROUP B the others. Group A was divided into early infection (first month after implantation) / late infection, removed /not removed. Data were analized with statistical program SPSS.29 suffered from leukemia, 19 from lymphoma and the main part,72, from solid tumour. 31% experienced infection (GROUP A), being early in the 36% of them. 16% had to be withdrawn. Data analysis revealed statistical association with the age (p=0.015) and with the reception of chemiotherapic treatment the week before the surgical insertion. The rest of the studied factors did not revealed a real association, but (..)(AU)

Toxina botulínica en el fracaso del cierre de derivaciones urinarias altas / Botulinum toxin in the failure of high urinary diversion closure

Introducción: El cierre de las derivaciones urinarias realizadas en la edad neonatal tiene un no despreciable porcentaje de fracasos en pacientes con patología vesical. Presentamos el uso de toxina botulínica como alternativa útil y mínimamente invasiva para el tratamiento en estos pacientes. Material y métodos: Presentamos dos pacientes monorrenos con valvas de uretra posterior (VUP) en los que fue necesario realizar ureterostomía por insuficiencia renal severa. En ambos pacientes fracasó el intento posterior de cierre de la derivación. Con 4 y 10 años de edad presentaban vejigas conocidas comúnmente como «vejigas secas», con baja capacidad (20 y 110ml), mala acomodación (1,5 y 3,1ml/ cm H2O) y altas presiones de apertura del detrusor. Se realizó punción en el detrusor de toxina botulínica-A 10 UI/ kg en una y dos ocasiones respectivamente previas al cierre de la derivación. Resultados: En ninguno de los pacientes hubo empeoramiento clínico ni ecográfico tras el cierre de la derivación, permaneciendo la función renal sin cambios respecto a la previa tras uno y 4 años de seguimiento, respectivamente. La videourodinámica al año de la intervención muestra una gran mejoría de la capacidad vesical (451 y 250ml), de la acomodación (20,4 y 81,9ml/ cm H2O) y de la presión de apertura del detrusor. Conclusiones: El cierre de las derivaciones urinarias altas tiene un porcentaje de fracasos elevado en niños con vejigas patológicas con presiones elevadas. La toxina botulínica puede ser útil como tratamiento vesical previo al cierre de la derivación, especialmente en pacientes monorrenos (AU)

Introduction: The closure of urinary diversions performed on newly born infants has a notable failure percentage in patients with bladder disease. We present the use of botulinum toxin as a useful and minimally invasive alternative to treat these patients. Material and methods: We present two patients with a single kidney and with posterior urethral valves (PUV), in whom it was necessary to perform a ureterostomy due to chronic kidney disease. In both patients, the subsequent attempt to close the diversion failed. Aged 4 and 10years respectively, they presented bladders commonly known as “dry bladders”, with a low capacity (20 and 110ml), bad adaptation (1.5 and 3.1ml/ cm H2O) and high opening detrusor pressure. A 10 UI/Kg botulinum toxin A puncture was applied in the detrusor on one and two occasions respectively, prior to the closure of the diversion. Results: Neither of the patients suffered clinical or ecographic worsening after the closure of the diversion and their kidney function continued without change with respect to the first diversion after one and four years of follow-up respectively. One year after the surgical procedure, video urodynamics showed a significant improvement in bladder capacity (451 and 250ml), in adaptation (20.4 and 81.9ml/cmH2O) and in the opening detrusor pressure. Conclusions: The closure of high urinary diversions has a high failure percentage in infants with pathological high-pressure bladders. Botulinum toxin may be useful as bladder treatment prior to closure of the diversion, especially in patients with a single kidney (AU)

Papel del drenaje peritoneal en la enterocolitis necrotizante de prematuros críticos de bajo peso / Role of peritoneal drainage in necrotizing enterocolitis in critical infants with extremely low birth weight

Introducción. El drenaje peritoneal es una de las opciones de tratamiento en la enterocolitis necrotizante (ECN). Actualmente es muy controvertido su papel como alternativa a la laparotomía en neonatos de bajo peso, y la mortalidad asociada a ambos procedimientos es elevada(35-55%).Material y métodos. Revisamos a 30 prematuros de bajo peso extremo (< 1.000 g) con ECN tratados quirúrgicamente. Evaluamosla situación hemodinámica, respiratoria y metabólica de los pacientes, así como la afectación multiorgánica y la necesidad de inotrópicos. Se analizaron los datos previos a la intervención quirúrgica a las 6 y 12horas. Dividimos la muestra en dos grupos: aquellos a los que se realizó drenaje peritoneal (DP) o laparotomía de entrada (LAP).Resultados. En la serie la media de peso al nacimiento fue de 754± 156 g y la edad gestacional de 26,1 ± 2,1 semanas. Se realizaron 10drenajes peritoneales y 20 laparotomías. El grupo DP presentó previamente a la intervención mayor frecuencia cardiaca, FiO2 y acidosis (p< 0,05). Las necesidades de dopamina fueron similares en ambos grupos. Tras la realización del drenaje se (..) (AU)

Introduction. Peritoneal drainage is one of the options for treatment in necrotizing enterocolitis (NEC). Currently its role is controversial asan alternative to laparotomy in low birth weight and mortality associated with both procedures is high (35-55%).Material and methods. We reviewed 30 low-weight premature (<1,000 g) with NEC treated surgically. We evaluate the hemodynamic, respiratory and metabolic status of the patients, as well as multi-organinvolvement and the need for inotropic drugs. These data were analyzed previos to surgery and at 6 and 12 hours. We divided the sample into two groups: those who underwent peritoneal drainage (PD) input orlaparotomy (LAP).Results. In the series the average birth weight was 754 ± 156 g and gestational age was 26.1 ± 2.1 weeks. We carry on 10 peritoneal drainage and 20 laparotomies. The DP group before the intervention showed (..) (AU)

[Botulinum toxin in the failure of high urinary diversion closure]. / Toxina botulínica en el fracaso del cierre de derivaciones urinarias altas.

INTRODUCTION: The closure of urinary diversions performed on newly born infants has a notable failure percentage in patients with bladder disease. We present the use of botulinum toxin as a useful and minimally invasive alternative to treat these patients. MATERIAL AND METHODS: We present two patients with a single kidney and with posterior urethral valves (PUV), in whom it was necessary to perform a ureterostomy due to chronic kidney disease. In both patients, the subsequent attempt to close the diversion failed. Aged 4 and 10 years respectively, they presented bladders commonly known as "dry bladders", with a low capacity (20 and 110 ml), bad adaptation (1.5 and 3.1 ml/ cm H(2)O) and high opening detrusor pressure. A 10 UI/Kg botulinum toxin A puncture was applied in the detrusor on one and two occasions respectively, prior to the closure of the diversion. RESULTS: Neither of the patients suffered clinical or ecographic worsening after the closure of the diversion and their kidney function continued without change with respect to the first diversion after one and four years of follow-up respectively. One year after the surgical procedure, video urodynamics showed a significant improvement in bladder capacity (451 and 250 ml), in adaptation (20.4 and 81.9 ml/ cmH(2)O) and in the opening detrusor pressure. CONCLUSIONS: The closure of high urinary diversions has a high failure percentage in infants with pathological high-pressure bladders. Botulinum toxin may be useful as bladder treatment prior to closure of the diversion, especially in patients with a single kidney.

Fimosis: ¿prepucioplastia o circuncisión? / Phimosis: ¿dorsal slit or circumcision?

Objetivos. La fimosis es una de las patologías más frecuentes en la consulta del cirujano pediátrico. El propósito de este estudio es compararlas dos opciones quirúrgicas más extendidas en nuestro medio: prepucioplastia y circuncisión. Material y métodos. Estudio retrospectivo de 1.698 pacientes tratados quirúrgicamente en nuestro servicio por presentar fimosis desde2003 a 2009. Se analizan edad, tiempo quirúrgico y anestésico, técnicaquirúrgica y complicaciones. Se realiza un estudio transversal descriptivo mediante encuesta telefónica a padres y pacientes mayores de16 años en cuanto a dolor postoperatorio, satisfacción estética y funcional .Se considera estadísticamente significativo p<0,05.Resultados. En un 76,6% de los casos (n=1.300) se realizó prepucioplastiay en el otro 23,4% (n= 398) circuncisión. La media de edad fue de 7,15 y la media de seguimiento 42,3 meses. El tiempo quirúrgico fue significativamente mayor en la circuncisión (p<0,0001). Huboun 3% (n= 51) de reintervenciones, sin diferencias entre los grupos. Tampoco encontramos diferencias estadísticamente significativas en cuanto a la reestenosis postoperatoria, aunque la incidencia de sangradosí fue mayor en la circuncisión (1,7%; p=0,03). No encontramos diferencias significativas en cuanto a la apreciación paterna del dolor postoperatorio o la satisfacción estética y funcional entre las dos técnicasquirúrgicas. Conclusiones. No hallamos diferencias en cuanto a la satisfacción subjetiva entre grupos. Aunque sí existen diferencias a nivel de sangrado postoperatorio, la incidencia global es muy baja. En nuestra experiencia ambas técnicas son válidas y seguras, por lo que la elección debe quedar a criterio del cirujano y de los padres (AU)

Introduction. Phimosis is perhaps one of the most frequent consultation on pediatric surgery clinics throught the world. The aim of this study is to compare the two procedures more frequently performed in our hospital: dorsal slit and circumcision. Patients y methods: Retrospective study of 1698 patients who were admitted for elective surgical treatment of phimosis between 2003 and2009. We analyzed age, surgical and anesthethic times, surgical technique and complications. We also did transversal descriptive study through telephonic survey on parents and patients older than 16 years old. Results: There was 76.6% of dorsal slit (n=1300) and 23.4% (n=398) of circumcisions. Mean age was 7.15 years y mean time of follow up was 42.3 months. Surgical time was significantly higher in circumcision(p<0.0001). There were 3% (n= 51) of reoperations, no differences between groups. We didn’t find differences in postoperative stenosis, but bleeding was more frequent in circumcision group (1.7%;p=0.03). There were no differences on parental appreciation of postoperative pain, or functional and esthetic satisfaction between groups. Conclusions: We didn’t find differences on subjective satisfaction between groups. Even if there are differences n postoperative bleeding, global incidence is very low. In our experience both techniques are validand safe, so surgeon and parents must jointly make the decisión (AU)

[Subcutaneously inserted central intravascular devices in the pediatric oncology patient: can we minimize their infection]. / Dispositivos intravasculares centrales de inserción subcutánea en el paciente oncológico pediátrico, ¿podemos minimizar su infección?

Long-term indwelling central venous access devices are frequently used in pediatric patients. Their main complication is infection, that can even mean their removal. We try to identify the risk factors really involved in this complication and in their removal. We have made a retrospective review of 120 oncologic pediatric patients who received a central venous device between 2003 and 2009. We searched for epidemiologic, clinic, microbiologic and surgical risk factors. We made a comparative data analysis among: GROUP A, children who suffered device infection, GROUP B the others. Group A was divided into early infection (first month after implantation)/late infection, removed/not removed. Data were analized with statistical program SPSS. 29 suffered from leukemia, 19 from lymphoma and the main part, 72, from solid tumour. 31% experienced infection (GROUP A), being early in the 36% of them. 16% had to be withdrawn. Data analysis revealed statistical association with the age (p=0.015) and with the reception of chemiotherapic treatment the week before the surgical insertion. The rest of the studied factors did not revealed a real association, but could be guess a relationship among infection and leukemia, subclavian catheters, those patients whose deviced was introduced using a guide over a previous catheter and also transplanted. Related to early infection the only associateon founded was with the subclavian access (p=0.018). In conclusion, in our serie long-term central venous access infection was more frequent in the younger patients and also in those who had received chemotherapy the week before the catheter implantation. The tendency towards infection in leukemia, transplanted and subclavian carriers has to be studied in a prospective way with a larger number of oncologic children.

[Phimosis: dorsal slit or circumcision?]. / Fimosis: prepucioplastia o circuncisión?

INTRODUCTION: Phimosis is perhaps one of the most frequent consultation on pediatric surgery clinics throught the world. The aim of this study is to compare the two procedures more frequently performed in our hospital: dorsal slit and circumcision. PATIENTS Y METHODS: Retrospective study of 1698 patients who were admitted for elective surgical treatment of phimosis between 2003 and 2009. We analyzed age, surgical and anesthethic times, surgical technique and complications. We also did transversal descriptive study through telephonic survey on parents and patients older than 16 years old. RESULTS: There was 76.6% of dorsal slit (n = 1300) and 23.4% (n= 398) of circumcisions. Mean age was 7.15 years y mean time of follow up was 42.3 months. Surgical time was significantly higher in circumcision (p < 0.0001). There were 3% (n = 51) of reoperations, no differences between groups. We didn't find differences in postoperative stenosis, but bleeding was more frequent in circumcision group (1.7%; p = 0.03). There were no differences on parental appreciation of postoperative pain, or functional and esthetic satisfaction between groups. CONCLUSIONS: We didn't find differences on subjective satisfaction between groups. Even if there are differences n postoperative bleeding, global incidence is very low. In our experience both techniques are valid and safe, so surgeon and parents must jointly make the decision.

[Role of peritoneal drainage in necrotizing enterocolitis in critical infants with extremely low birth weight]. / Papel del drenaje peritoneal en la enterocolitis necrotizante de prematuros críticos de bajo peso.

INTRODUCTION: Peritoneal drainage is one of the options for treatment in necrotizing enterocolitis (NEC). Currently its role is controversial as an alternative to laparotomy in low birthweight and mortality associated with both procedures is high (35-55%). MATERIAL AND METHODS: We reviewed 30 low-weight premature (< 1000 g) with NEC treated surgically. We evaluate the hemodynamic, respiratory and metabolic status of the patients, as well as multi-organ involvement and the need for inotropic drugs. These data were analyzed previos to surgery and at 6 and 12 hours. We divided the sample into two groups: those who underwent peritoneal drainage (PD) input or laparotomy (LAP). RESULTS: In the series the average birth weight was 754 +/- 156 g and gestational age was 26.1 +/- 2.1 weeks. We carry on 10 peritoneal drainage and 20 laparotomies. The DP group before the intervention showed increased heart rate, FiO2 and acidosis (p < 0.05). The needs of dopamine were similar in both groups. Following the peritoneal drainage, we found breathing improvement (adequate ventilation and oxygenation, decreased FiO2) and hemodynamic improvement (blood pressure maintained, reduced heart rate, reduced requirements for dopamine) at 6 and 12 h. DP was not the definitive treatment in any of the patiens, and all survivors (80%) of this group required further laparotomy. 62% of them died. Overall mortality was 47% (70% DP and 35% LAP, p = 0.07). CONCLUSIONS: Peritoneal drainage allowed the stabilization of low-weight premature in critical condition. The hemodynamic and respiratory stabilization was transient and did not prevent the definitive surgical treatment, although it improved the conditions for doing so. In our series, the peritoneal drainage did not improve long-term survival, questioning its role as an alternative to surgery for NEC.

Valoración de los resultados a largo plazo del tratamiento quirúrgico de la hiperhidrosis palmar / Evaluation of the long-term results of surgical treatment of palmar hyperhidrosis

Introducción y objetivos. La hiperhidrosis palmar es una patología relativamente frecuente que fundamentalmente afecta a la calidad de vida del paciente limitando su vida social y laboral. El tratamiento de elección es la simpatectomía toracoscópica, realizada con frecuencia en edad adulta. El objetivo de nuestro estudio es valorar el grado de satisfacción a largo de plazo de los pacientes pediátricos tratados en nuestro centro. Material y métodos. Realizamos un estudio retrospectivo de las historias clínicas de los pacientes controlados y tratados en nuestro centro en los últimos 4 años, valorando la clínica previa a la cirugía, el nivel de la simpatectomía toracoscópica y las complicaciones postoperatorias. Para el estudio de los resultados a largo plazo se realizó una encuesta telefónica a todos los pacientes, centrada en el grado de satisfacción, la eficacia del tratamiento, la sudoración compensatoria y los cambios (..) (AU)

Introduction. Palmar hyperhidrosis (PH) is a relative frequent pathology which basically affects patients´ life quality limiting social and laboral life. The treatment of choice is thoracoscopic sympathectomy, most frequently done during adulthood. The aim of our study was to evaluate the degree of satisfaction of the pediatric patients treated in our centre. Material and methods. We retrospectively reviewed the clinical records of the patients controlled and treated in our centre during the last4 years evaluating the symptoms before surgery, the level of the sympathectomy and postoperative complications. To evaluate the long-term results we developed a telephone questionnaire for all the patients centralized on the grade of satisfaction, the efficiency of the treatment, the compensatory sweating and the observed changes in life quality. The (..) (AU)

Gastrostomía percutánea: ¿cuándo asociar cirugía antirreflujo? / Percutaneous gastrostomy: when should antireflux surgery be associated?

Introducción. La gastrostomía percutánea es un procedimiento ampliamente realizado en niños con dificultad para la deglución o intolerancia a la alimentación oral. A la hora de realizar la indicación, con frecuencia se plantea la necesidad de una cirugía antirreflejo en el mismo procedimiento. El objeto de este estudio es analizar qué factores preoperatorios se relacionan con un riesgo mayor de precisar posteriormente una funduplicatura. Material y métodos. Estudio retrospectivo de casos y controles de67 pacientes a los que se ha realizado gastrostomía endoscópica percutánea (PEG) por nuestro servicio desde 1997 a 2008. Comparamos dos grupos: Grupo A (n=11), pacientes con reflujo grave tras la realización de PEG, que han precisado cirugía antirreflujo; grupo B (n=56), pacientes que permanecen sin reflujo tras la gastrostomía. Analizamos los distintos factores preoperatorios que podrían relacionarse con la aparición de RGE grave postgastrostomía. Resultados. La media de edad en el momento de la realización de la PEG fue de 15,7 meses (rango), y el tiempo medio de seguimiento 3,5 años. Solo la presencia de enfermedad neurológica y pruebas preoperatorias compatibles con RGE se (..) (AU)

Introduction. Percutaneus gastrostomy placement is a procedure widely performed in children with failure to thrive or intolerance to oral feeding. At the moment of making the indication, the need of an antirreflux surgery in the same procedure comes to question. The aim of this study was to analyse which preoperative factors are associated with a higher risk of a posterior fundoplication. Material and Methods. We realized a retrospective review of 67patients divided in 2 groups (cases and controls) in which a percutaneous gastrostomy (PEG) had been made by our service in the period of 1997 (..) (AU)

[Evaluation of the long-term results of surgical treatment of palmar hyperhidrosis]. / Valoración de los resultados a largo plazo del tratamiento quirúrgico de la hiperhidrosis palmar.

INTRODUCTION: Palmar hyperhidrosis (PH) is a relative frequent pathology which basically affects patients' life quality limiting social and laboral life. The treatment of choice is thoracoscopic sympathectomy, most frequently done during adulthood. The aim of our study was to evaluate the degree of satisfaction of the pediatric patients treated in our centre. MATERIAL AND METHODS: We retrospectively reviewed the clinical records of the patients controlled and treated in our centre during the last 4 years evaluating the symptoms before surgery, the level of the sympathectomy and postoperative complications. To evaluate the long-term results we developed a telephone questionnaire for all the patients centralized on the grade of satisfaction, the efficiency of the treatment, the compensatory sweating and the observed changes in life quality. The medium follow-up time was 26.5 months (rango 6 months to 4 years). RESULTS: In total 6 patients were reviewed (4 female, 2 male), medium age 12, 8 years (rango 8 to 18 years). Thoracoscopic sympathectomy was done at the level of T2 or T3 associating T4 in 1 case. We just observed 1 postoperative complication which consisted in a disestesia of the upper extremity and which disappeared spontaneously without sequels. Patients referred total relief of palmar sweating. Only 1 case reported residual sweating unilaterally in the tenar region, but in all of them sweating of feet still persisted (3 of low grade and 3 of moderate grade). In 50% of the cases we observed compensatory sweating localized at the back of moderate grade in 2 patients and at the upper legs of more severe grade in 1 of them. Only this last patient reported that the compensatory sweating affected his everyday life. We also observed that the patients where the sympathectomy had affected more than 1 ganglia (T2+T3; T3+T4; T2+T3+T4) referred a higher grade of compensatory sweating. All the cases reported an important improvement in life quality, in the social as in the formative manner. They were all very satisfied with the results of the surgery and none of them (neither the children nor the parents) regretted the intervention. The cosmetic result of the surgical scars was also satisfactory. CONCLUSIONS: The thoracoscopic sympathectomy is an efficient procedure for the treatment of palmar hyperhidrosis. Despite the compensatory sweating patients usually are very satisfied with the results. Since palmar hyperhidrosis is not a pathology which improves spontaneously and the surgical treatment has minimal complications we do not think that the surgery should be postponed in pediatric patients.