¿Cuándo derivar un paciente al cirujano pediátrico? / When should a patient be referred to the pediatric surgeon?

Introducción. Las derivaciones incorrectas de los pacientes a consulta de cirugía pediátrica tienen como resultado una saturación de estas y malestar en el paciente y personal sanitario, provocando un deterioro en la calidad de atención. Objetivos. 1) Evaluar las derivaciones de pacientes nuevos a consulta de cirugía pediátrica (CCP) desde atención primaria, considerando indicación médica (IM) y calendario quirúrgico (CQ) e identificar los fallos más comunes. 2) Analizar los inconvenientes de una derivación incorrecta tanto para el paciente como para el personal sanitario. 3) Proponer medidas para disminuir los pacientes incorrectamente derivados. Material y Método. Realizamos un estudio observacional retrospectivo de cohortes, revisando historias clínicas de pacientes nuevos atendidos en CCP desde septiembre de 2010 a enero de 2012. Se recogieron variables de edad, domicilio, diagnóstico, indicación médica y centro de derivación. Resultados. Se revisaron 2.430 historias clínicas de pacientes nuevos, encontrándose una derivación incorrecta en un 44,28% (2,37 niños/día). De estos pacientes, el 18,59% de los errores se relacionaban con CQ y el 81,41% con IM. Los errores más comunes relacionados con la IM fueron: fimosis (91,45% n= 113) y criptorquidia (85,29% n= 122);en relación al CQ fueron: hernia umbilical (88,46% n= 21), hipospadias (72,22% n= 31) e hidrocele (70,83% n=12). La media de kilómetros (..) (AU)

Introduction. An incorrect transfer of patients to paediatric surgery clinic results in clinic saturation and both patient and medical staff discomfort. As a consequence the quality of medical care is deteriorated. Aim. 1) To evaluate the transfer of new patients to paediatric surgery clinic from primary paediatric care considering the medical diagnosis and the surgical calendar, looking for the most common mistakes. 2) To analyze the inconvenience of a wrong indication for both our patients and the medical staff. 3) To propose new measures to decrease the rate of patients incorrectly transferred. Material and Method. An observational retrospective study was performed based on medical records of new patients evaluated in paediatricsurgery clinic between september 2010 and january 2012. Age, address, diagnosis, transfer indication and referring centre were collected. Results. Two thousand four hundred thirty medical records were reviewed from new patients finding an incorrect transfer in 44.28% of them (2.37 children/day). From these cases wrong transfer was related to surgical calendar in 18.59% and wrong diagnosis in 81.41% of them. Most common mistakes due to wrong diagnosis were Phimosis (91.45%n= 113) and Cryptorquidism (85.29% n= 122); mistakes related to surgical calendar were Umbilical Hernia (88.46%), Hypospadias (72.22%n= 31) and Hydrocele (70.83% n= 12). Mean distance of transfer for (..) (AU)

Presentación tardía de estenosis hipertrófica de píloro en la infancia: un caso inusual / Delayed presentation of hypertrophic pyloric stenosis in infants: an unusual case

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[When should a patient be referred to the pediatric surgeon?]. / Cuándo derivar un paciente al cirujano pediátrico?

INTRODUCTION: An incorrect transfer of patients to paediatric surgery clinic results in clinic saturation and both patient and medical staff discomfort. As a consequence the quality of medical care is deteriorated. AIM: 1) To evaluate the transfer of new patients to paediatric surgery clinic from primary paediatric care considering the medical diagnosis and the surgical calendar, looking for the most common mistakes. 2) To analyze the inconvenience of a wrong indication for both our patients and the medical staff. 3) To propose new measures to decrease the rate of patients incorrectly transferred. MATERIAL AND METHOD: An observational retrospective study was performed based on medical records of new patients evaluated in paediatric surgery clinic between september 2010 and january 2012. Age, address, diagnosis, transfer indication and referring centre were collected. RESULTS: Two thousand four hundred thirty medical records were reviewed from new patients finding an incorrect transfer in 44.28% of them (2.37 children/day). From these cases wrong transfer was related to surgical calendar in 18.59% and wrong diagnosis in 81.41% of them. Most common mistakes due to wrong diagnosis were Phimosis (91.45% n= 113) and Cryptorquidism (85.29% n = 122); mistakes related to surgical calendar were Umbilical Hernia (88.46%), Hypospadias (72.22% n= 31) and Hydrocele (70.83% n = 12). Mean distance of transfer for patients wrongly referred outside the metropolitan area was 35.92 km (Range: 7.1-129). CONCLUSIONS: We have detected major mistakes in patient transfer from primary paediatric care. The knowledge of surgical calendar and accurate diagnosis should avoid these problems. These mistakes result in deterioration of medical care quality, patient discomfort and clinic saturation. It is necessary to propose and develop measures that improve the knowledge of surgical calendar and to make more accurate surgical diagnosis in primary paediatric care.

[Management of pediatric iatrogenic tracheobronchial lesions in pediatric patients]. / Manejo de las lesiones traqueobronquiales pediátricas iatrogénicas en pacientes pediátricos.

AIM: To present our experience in the management of three cases of tracheobronchial iatrogenic injuries and the literature revision about this pathology. MATERIAL AND METHODS: We present 3 patients treated in our center with tracehobronchial iatrogenic injuries since 2005. RESULTS: Case 1. 8 year old boy who present cervical, mediastinal and facial emphysema after foreign body extraction. After 9 days of conservative management without endotracheal intubation all emphysema remited, and the bronchial injury healed. Case 2. 1 month old toddler who presented after cardiovascular surgery and endotracheal tube extraction dyspnea and hypoxia. Fibrobronchoscopy showed subglotic posterior tracheal disrupture. Fifteen-day endotracheal intubation throughout the injury was enough management on this patient. One month later the tracheal injury was completely healed. Case 3. 5 year old girl with tracheobronchial iatrogenic injury after orotracheal intubation who developed neumothorax and subcutaneous emphysema. After fiteen-day conservative management without intubation the injury healed. CONCLUSION: After iatrogenic tracheobronchial injury suspicion there were confirmed by fibrobronchoscopy. Conservative treatment in this patients was successful. Orotracheal intubation prevented air leaking through the tracheal injury allowing complete healing of the trachea. Bronchial injuries healed without needing intubation or mechanical ventilation. Articles reviewed recommend surgical treatment in those cases who had complete or large airway disrupture or in those who were misdiagnosed.

Manejo de las lesiones traqueobronquiales pediátricasiatrogénicas en pacientes pediátricos / Management of pediatric iatrogenic tracheobronchial lesions in pediatric patients

Objetivos. Presentar nuestra experiencia en tres casos de lesiones traqueobronquiales traumáticas y la revisión de la literatura. Material y método. Presentamos 3 pacientes tratados conservadoramente por lesiones traqueobronquiales traumáticas durante los últimos5 años en nuestro centro. Resultados. Caso 1. Niño de 8 años de edad que, tras extracción de cuerpo extraño en bronquio principal derecho, presenta enfisemafacial, cervical y mediastínico. Tras 9 días de manejo conservador, el enfisema remitió y la lesión bronquial se resolvió espontáneamente. Caso 2. Lactante de 1 mes de vida que en el postoperatorio de trasposición de grandes vasos presenta disnea e hipoxia tras la extracción de tubo endotraqueal. La fibrobroncoscopia mostró ruptura traqueal subglótica posterior. La intubación endotraque al sorteando el defecto durante 15 días permitió la resolución de la lesión. Un mes después latráquea se encontraba íntegra y sin estenosis. Caso 3. Niña de 5 años de edad con ruptura iatrogénica de la tráqueatras intubación orotraqueal que desarrolló neumotórax, neumomediastino y enfisema subcutáneo. Tras 15 días de manejo conservador se observó la cura de la lesión. Conclusiones. Al sospechar las lesiones traqueobronquiales traumáticas, estas fueron confirmadas por fibrobroncoscopia. El tratamiento conservador en estos pacientes fue exitoso. La intubación endotraquealdistal a la lesión traqueal permitió una cura completa del defecto previniendo la fuga de aire a través de éste. La lesión bronquial se resolviós in necesidad de ventilación mecánica. La literatura revisada recomienda el tratamiento quirúrgico en los casos de lesiones completas oextensas de las vías aéreas y en las lesiones con diagnóstico tardío (AU)

Aim. To present our experience in the management of three cases of tracheobronchial iatrogenic injuries and the literature revision about this pathology. Material and methods. We present 3 patients treated in our center with tracehobronchial iatrogenic injuries since 2005.Results. Case 1. 8 year old boy who present cervical, mediastinal and facial emphysema after foreign body extraction. After 9 days of conservative management without endotracheal intubation all emphysemaremited, and the bronchial injury healed. Case 2. 1 month old toddler who presented after cardiovascular surgery and endotracheal tube extraction dyspnea and hypoxia. Fibrobronchoscopy showed subglotic posterior tracheal disrupture. Fifteen-dayendotracheal intubation throughout the injury was enough management on this patient. One month later the tracheal injury was completely healed. Case 3. 5 year old girl with tracheobronchial iatrogenic injury afterorotracheal intubation who developed neumothorax and subcutaneous emphysema. After fiteen-day conservative management without intubation the injury healed. Conclusion. After iatrogenic tracheobronchial injury suspicion there were confirmed by fibro bronchoscopy. Conservative treatment in this patients was successful. Orotracheal intubation prevented air leaking through the tracheal injury allowing complete healing of the trachea. Bronchial injuries healed without needing intubation or mechanical ventilation. Articles reviewed recommend surgical treatment in those cases who had complete or large airway disrupture or in those who were misdiagnosed (AU)

Análisis comparativo entre la técnica de Seldinger vs. disección abierta en la implantación de reservorios intravenosos / Comparative analysis between the seldinger technique vs. open dissection in the implantation of intravenous reservoirs

Objetivo. Analizar ventajas y desventajas de la técnica de Seldinger (TS) frente a la disección abierta (DA) en la implantación de reservorios intravenosos (RIVS), comparando tiempos quirúrgicos y complicaciones. Material y Método. Realizamos un estudio analítico retrospectivo tipo cohortes históricas, comparando nuestra experiencia en la implantación de RIVS por DA y por TS. Analizamos parámetros clínicos, quirúrgicos, destacando el tiempo operatorio y las complicaciones intra/postoperatorias. Resultados. Analizamos 193 RIVS (119 DA, 74 TS) implantados principalmente para quimioterapia (83,41%). El tiempo quirúrgico utilizado en procedimientos únicos fue de 72,85 ± 29,35 minutos para DA frente a 62,83 ± 20,08 minutos el Seldinger (p<0,05). No hubo diferencias operador-dependientes. No se encontraron diferencias estadísticamente significativas entre las poblaciones de las dos cohortes estudiadas ni en el porcentaje de complicaciones. Los RIVS de mayor tamaño presentaron una media mayor de necrosis de piel (p>0,05) en cambio, los de menor tamaño presentaron mayor tasa de infección (16%sobre 7,7% p>0,05). Tanto en la TS (51,67 vs 98,14 min) como en la DA (78,56 vs 123,61 min) el tiempo operatorio fue menor en los accesos venosos izquierdos. (d =171 vs i =19) Tras complicaciones se retiró el RIVS en 121 días de media. Conclusiones. La TS disminuyó la perdida definitiva de los accesos venosos intervenidos, pudiendo reutilizar la misma vena para la colocación de RIVS posteriores. La TS reduce el tiempo quirúrgico, sin incrementarse las complicaciones. El acceso venoso izquierdo no implica mayor tiempo quirúrgico. Las complicaciones podrían estar en relación al tamaño del RIVS (AU)

Objective. To analyze advantages and disadvantages between Seldinger’s technique (ST) and surgical dissection (SD) on intravenous sport-a-caths comparing surgical parameters as time and complications. Material and Method. An analytic retrospective study involving historic cohorts was realized, comparing our surgical experience on port-a-cath implantation with Seldinger technique or surgical dissection. Statistical analysis was made reflecting clinical and surgical parameters, such as surgical time length and intra/postoperative complications. Results. 193 Port-a-caths were analyzed (119 SD, 74 ST), mainly placed for chemotherapy treatment (83.41%). Surgical time length expended at single procedures was 72.85 ± 29.35 minutes for SD and62.83 ± 20.08 minutes for ST (p<0.05). There were none operator dependent differences. Statistically significant differences were not found between the two cohort’s populations, neither at complications percentages. Greater-sized port-a-caths presented a higher average of skin necrosis (p>0.05) however, lower-sized port-a-caths showed a high eraverage of infection (16% upon 7.7% p>0.05). Both ST (51.67 vs.98.14 min) and SD (78.56 vs. 123.61 min) showed lower surgical time length at left venous accesses (d =171 vs. i =19). Average in days for the extraction of port-a-caths with regard to complications was 121 days. Conclusion: Seldinger technique reduced the definitive lost of surgical dissected venous accesses, being possible further utilization of the same vein for subsequent port-a-caths. Seldinger technique reduces surgical time length without increasing complication’s rate. Left venous access does not imply higher surgical time length. Complications maybe related with port-a-cath’s size (AU)

[Comparative analysis between the Seldinger technique vs. open dissection in the implantation of intravenous reservoirs]. / Análisis comparativo entre la técnica de Seldinger vs. disección abierta en la implantación de reservorios intravenosos.

OBJECTIVE: To analyze advantages and disadvantages between Seldinger's technique (ST) and surgical dissection (SD) on intravenous port-a-caths comparing surgical parameters as time and complications. MATERIAL AND METHOD: An analytic retrospective study involving historic cohorts was realized, comparing our surgical experience on port-a-cath implantation with Seldinger technique or surgical dissection. Statistical analysis was made reflecting clinical and surgical parameters, such as surgical time length and intra/postoperative complications. RESULTS: 193 Port-a-caths were analyzed (119 SD, 74 ST), mainly placed for chemotherapy treatment (83.41%). Surgical time length expended at single procedures was 72.85 +/- 29.35 minutes for SD and 62.83 +/- 20.08 minutes for ST (p < 0.05). There were none operator-dependent differences. Statistically significant differences were not found between the two cohort's populations, neither at complications percentages. Greater-sized port-a-caths presented a higher average of skin necrosis (p > 0.05) however, lower-sized port-a-caths showed a higher average of infection (16% upon 7.7% p > 0.05). Both ST (51.67 vs. 98.14 min) and SD (78.56 vs. 123.61 min) showed lower surgical time length at left venous accesses (d = 171 vs. i = 19). Average in days for the extraction of port-a-caths with regard to complications was 121 days. CONCLUSION: Seldinger technique reduced the definitive lost of surgical dissected venous accesses, being possible further utilization of the same vein for subsequent port-a-caths. Seldinger technique reduces surgical time length without increasing complication's rate. Left venous access does not imply higher surgical time length. Complications may be related with port-a-cath's size.