La cirugía en la Oncohematología Pediátrica / Surgery in Pediatric Oncohematology

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Escaras tras otoplastia de Mustardé: importancia de las curas y seguimiento postoperatorio de los pacientes / Scarring after mustarde otoplasty: importance of cures and post-operative follow-up of the patients

Introducción. En el protocolo de tratamiento de los pacientes conotoplastias de Mustardé incluimos la colocación de cintas elásticas durante 2 meses (el primer mes debe llevarse permanentemente y el segundo mes solo para dormir) para proteger la corrección obtenida y evitar traumatismos. Material y métodos. Describimos los casos de 3 enfermos sometidos a otoplastia de Mustardé que presentaron escaras en el borde anterior del antehelix, secundarias a compresión del vendaje de sujeción. Resultados. En un enfermo intervenido en la oreja derecha aparecieron escaras en la oreja no intervenida, lo que demuestra que las lesiones fueron secundarias al vendaje y no a la intervención. En dos pacientes, las escaras evolucionaron a la formación de cicatrices nodulares hipertróficas que se corrigieron lentamente con apósitos siliconados, corticoides tópicos y cremas hidratantes en uno y debieron ser resecadas en otro. Conclusiones. Es imprescindible explicar detenidamente a los padres la misión y características de las cintas elásticas, así como revisar frecuentemente su colocación, para evitar una complicación que, sin estropear el resultado final de la otoplastia, reduce la satisfacción del paciente y prolonga el tiempo de recuperación (AU)

Introduction. In the treatment protocol for patients with Mustardéotoplasties we use tennis head sweatbands for 2 months (to be worn all the time in the first month and only at night in the second month) to protect the correction obtained and to avoid traumatisms. Material and methods. We describe the cases of 3 patients who underwent Mustardé otoplasty and presented sloughs in the anterior edge of the ante helix that are secondary to the pressure of the compression bandage. Results. One patient operated for unilateral malformation suffered bilateral scars (in the operated ear and in the healthy one). This prove that the scars are secondary to the dressings not to surgery. In two patients the sloughs evolved into the formation of nodular hypertrophic scars, which were slowly corrected with silicone dressings and externally applied corticosteroids and moisturising creams in one patient and had to be resected in the other. Conclusions. It is important to give a detailed explanation to the parents about the mission and characteristics of the sweatbands, and also about the need to frequently check their correct placing. This isto avoid a complication that, without spoiling the final result of the otoplasty, reduces patient satisfaction and extends the recovery period (AU)

[Scarring after Mustarde otoplasty: importance of cures and post-operative follow-up of the patients]. / Escaras tras otoplastia de Mustardé: importancia de las curas y seguimiento postoperatorio de los pacientes.

INTRODUCTION: In the treatment protocol for patients with Mustardé otoplasties we use tennis head sweatbands for 2 months (to be worn all the time in the first month and only at night in the second month) to protect the correction obtained and to avoid traumatisms. MATERIAL AND METHODS: We describe the cases of 3 patients who underwent Mustardé otoplasty and presented sloughs in the anterior edge of the antehelix that are secondary to the pressure of the compression bandage. RESULTS: One patient operated for unilateral malformation suffered bilateral scars (in the operated ear and in the healthy one). This prove that the scars are secondary to the dressings not to surgery. In two patients the sloughs evolved into the formation of nodular hypertrophic scars, which were slowly corrected with silicone dressings and externally applied corticosteroids and moisturising creams in one patient and had to be resected in the other. CONCLUSIONS: It is important to give a detailed explanation to the parents about the mission and characteristics of the sweatbands, and also about the need to frequently check their correct placing. This is to avoid a complication that, without spoiling the final result of the otoplasty, reduces patient satisfaction and extends the recovery period.

[Correction of recurrent pectus excavatum post-Ravitch with the Nuss technique]. / Corrección de la recidiva del pectus excavatum post-Ravitch con la técnica de Nuss.

INTRODUCTION: For one decade, the minimally invasive technique (MIRPE) of Nuss has been used in our Service as the elective technique for correction of Pectus Excavatum. If recurrences occur in patients that underwent open surgery, a new surgery of the same characteristics entails important technical problems, long surgical times and poor outcome. For this reason, we think that one specific indication for the MIRPE technique may be this type of patients. MATERIAL AND METHODS: Based on our experience with four patients with a recurrence of pectus excavatum after an open surgery "Ravitch type", we illustrate the fundamental aspects for the development of the Nuss technique, adapted to this type of patients. The factors to be consider are: Systematic bilateral thoracoscopy with a suitable position of the two towers to guarantee a good visualisation of the passage of the introducer clamp by the mediastino. Use of thoracoscope with work channel on the right side, that allows the releasing of adherences and with a 5 mm lens on the left side. Use of a large introducer clamp more length for adolescent patients, The rest of the material is the usual one in this protocol surgery. Our patients did not present any remarkable incidences, with very satisfactory results. COMMENTS AND CONCLUSIONS: We found of great importance for the good development of the technique to establish a correct strategy prior to surgery and to dispose a good organisation of the surgery room. The surgery must be carried out in a spacious surgical room, given the great amount of material that is used. It is important to be familiarized with the procedure, because even if performed in a regulated way, variations in the positioning and fixation of the bar are frequently needed.

Corrección de la recidiva del pectus excavatum post-Ravitch con la técnica de Nuss / Correction of recurrent pectus excavatum post-ravitch with the nuss technique

Introducción. Desde hace una década, la técnica mínimamente invasiva (MIRPE) de Nuss es la que empleamos en nuestro servicio para la corrección del pectus excavatum. En los casos de recidiva de pacientes operados por cirugía abierta, una nueva cirugía de las mismas características, conlleva importantes problemas técnicos, mucho tiempo quirúrgico y resultados poco satisfactorios. Es por ello que una de las indicaciones específicas de la MIRPE sea este tipo de pacientes. Material y métodos. Basados en la experiencia de cuatro pacientes con una recurrencia del pectus excavatum después de una cirugía abierta “tipo Ravitch”, comentamos en este trabajo los aspectos fundamentales del desarrollo de la técnica de Nuss, adaptada a este tipo de pacientes. Los factores a tener en cuenta son:- Realización sistemática de una toracoscopia bilateral con una adecuada colocación de las dos torres para garantizar una buena visión (..) (AU)

Introduction. For one decade, the minimally invasive technique(MIRPE) of Nuss has been used in our Service as the elective technique for correction of Pectus Excavatum. If recurrences occur in patients that underwent open surgery, a new surgery of the same characteristics entails important technical problems, long surgical times and poor outcome. For this reason, we think that one specific indication for the MIRPE technique may be this type of patients. Material and methods. Based on our experience with four patient swith a recurrence of pectus excavatum after an open surgery “Ravitchtype”, we illustrate the fundamental aspects for the development of the Nuss technique, adapted to this type of patients. The factors to be consider are:- Systematic bilateral thoracoscopy with a suitable position of the two towers to guarantee a good visualisation of the passage of the (..) (AU)

Apendicectomía con trocar único a través del ombligo: resultados de nuestra serie y aproximación a su coste / Appendectomy with a single trocar through the umbilicus: results of our series and a cost aproximation

Nuestro grupo realiza la apendicectomía a través de una única incisión periumbilical con apoyo de un laparoscopio de doble canal para localizar y exteriorizar el apéndice. Objetivo. Buscamos comprobar si esta técnica aúna las ventajas de la cirugía laparoscópica y de la cirugía abierta, reduciendo costes y sin un mayor número de complicaciones. Material y método. El grupo de estudio lo forman las apendicectomías transumbilicales (AU) por apendicitis aguda no complicada, realizadas en 2004 y 2005, y el grupo de control las apendicectomías abiertas (AA) sobre apendicitis agudas no complicadas realizadas en nuestro servicio en 2002 y 2003 (estas últimas obtenidas de un estudio previo). Registramos los datos quirúrgicos, estancia, complicaciones, dolor postoperatorio y coste aproximado. Resultados. Realizamos un total de 162 AU. Su estancia media fue de 2,84 días frente a 4,83 días de las AA (diferencia significativa). Lasspazio unificatorespazio unificatore complicaciones infecciosas fueron de un 4,29%, frente a un 1,75% de las AA (diferencia no significativa). El dolor postoperatorio y la necesidad de analgesia fue menor en las AU que en las AA (diferencia no significativa). Conclusiones. La técnica descrita es sencilla y aplicada sólo a apendicitis no complicadas, supone un ahorro de unos 90.561,97 €/año comparado con el coste que supondría la apendicectomía laparoscópica, y unos 42.232,37 €/año comparado con la cirugía abierta tradicional. No conlleva una morbilidad significativamente mayor que la apendicectomía abierta (AU)

In our department we perform the appendectomy through a single periumbilical incision. A double channel laparoscope aids to locate and exteriorize the appendix. Objective. We studied this practice to determine if this technique makes it possible to make use of the advantages of laparoscopic surgery and of open surgery, decreasing costs without increasing the rate of complications. Materials and methods. Clinical prospective paper. The study group was made up of transumbilical appendectomies (TA) for acute, uncomplicated appendicitis carried out in 2004 and 2005. The control group consisted of a group of open appendectomies (OA) performed for acute, uncomplicated appendicitis in our department in 2002 and 2003 (from a previous study). Results. Both study groups were comparable. We performed a total of 162 TA due to uncomplicated appendicitis. The mean hospital stay was 2.84 days (versus 4.83 days with OA) (significant difference). Infectious complications presented in 4.29% (versus 1.75% in the OA group) (this difference was not significant). Postoperative pain and need for analgesia were less in the TA group than in the OA (difference did not reach significance). Conclusions. Described technique is easily performed. The savings resulting from the transumbilical technique represent some 90,561.97 € / year compared with the cost that laparoscopic appendectomy would incur, and some 42,232.37 €/ year versus traditional, open surgery. Postoperative complications didn’t increase significantly if compared with open appendectomy (AU)

[Programmed surgery for acute appendicitis]. / Cirugía programada de la apendicitis aguda.

Non-complicated appendicitis surgery is still considered to be an emergency, although it has been observed that a reasonable therapeutic delay (up to 18 hours) does not imply a higher number of complications. In our department, surgery is programmed for those non-complicated appendicitis, thus avoiding duty staff (surgeons, anaesthesiologists, nurses, assistants) to operate during late night. Acute appendicitis records from august 2001 to december 2002 were reviewed. Collected data included: clinical findings, physical examination, ultrasound findings, surgical delay (recorded time from emergency attendance until the end of the surgery) and evolution. A total of 209 patiens (125 males and 84 females) underwent surgery. Mean age was 10.1 years (standard deviation 3.02). A non-complicated appendicitis group (NC) included 171 subjects while the complicated appendicitis group (C) included 38, assessed by means of clinical evaluation plus ultrasonography. Patients in NC group had programmed surgery, with up to 20-hour delay (mean of 7 hours 45 minutes). Mean admission time was 4.87 days with a percentage of infectious complications of 1.73%. Patients in group C underwent surgery as soon as possible. Mean admission time was 9.23 days (p < 0.0001) and percentage of infectious complications of 43.6%. There was no difference between those operated rapidly and those who were delayed. Patiens with non-complicated disease could undergo programmed surgery, without having a higher risk of complicated disease and without disturbing normal department activity.

Cirugía programada de la pendicitis aguda / Programmed surgery for acute appendicitis

El tratamiento quirúrgico de la apendicitis aguda no complicada sigue considerándose una urgencia, aunque está descrito que una demora terapéutica razonable (hasta 18 horas, no supone un aumento de complicaciones). En nuestro Servicio programamos la apendicectomía en los procesos no complicados, evitando que el equipo de guardia (cirujanos, anestesistas, enfermeras y auxiliar localizados) realice cirugías a horas inadecuadas. Estudiamos las historias clínicas de pacientes afectos de apendicitis aguda, entre enero del 2001 y diciembre del 2002, valorando clínica, exploración y hallazgos ecográficos, demora terapéutica (tiempo desde la entrada en urgencias hasta el final de la intervención) y evolución. Recogimos 125 varones y 84 niñas (209 pacientes), de edad media 10,1 y desviación estándar 3,02 años. Mediante la valoración clínica y ecográfica distinguimos un grupo de 171 enfermos con apendicitis no complicadas(grupo NC) y otro de 38 enfermos con procesos complicados(grupo C). Los enfermos del grupo NC fueron intervenidos de forma programada, con demoras de hasta 20 horas (media de 7 horas y 45 minutos). La estancia media de este grupo fue de 4,87 días y el porcentaje de complicaciones infecciosas de 1,73%. Los enfermos del grupo C fueron intervenidos con premura. Su estancia media fue de 9,23 días (p <0,0001) y su porcentaje de complicaciones infecciosas del 43,6%. Dentro del grupo NC no hubo diferencias entre los enfermos intervenidos precozmente y aquellos en los que se demoró la intervención. Los enfermos con apendicitis no complicadas pueden ser intervenidos de forma programada, sin mayor riesgo de complicaciones y sin distorsionar la actividad asistencial del Servicio (AU)

Non-complicated appendicitis surgery is still considered to be an emergency, although it has been observed that a reasonable therapeutic delay (up to 18 hours) does not imply a higher number of complications. In our department, surgery is programmed for those non-complicated appendicitis, thus avoiding duty staff (surgeons, anaesthesiologists, nurses, assistants) to operate during late night. Acute appendicitis records from august 2001 to december 2002 were reviewed. Collected data included: clinical findings, physical examination, ultrasound findings, surgical delay (recorded time from emergency attendance until the end of the surgery) and evolution. A total of 209 patiens (125 males and 84 females) underwent surgery. Mean age was 10.1 years (standard deviation 3.02). A non-complicated appendicitis group (NC) included 171 subjects while the complicated appendicitis group (C) included 38, assessed by means of clinical evaluation plus ultrasonography. Patients in NC group had programmed surgery, with up to 20-hour delay (mean of 7 hours 45 minutes). Mean admission time was 4.87 days with a percentage of infectious complications of 1.73%. Patients in group C underwent surgery as soon as possible. Mean admission time was 9.23 days (p < 0.0001) and percentage of infectious complications of 43.6%. There was no difference between those operated rapidly and those who were delayed. Patiens with non-complicated disease could undergo programmed surgery, without having a higher risk of complicated disease and without disturbing normal department activity Non-complicated appendicitis surgery is still considered to be an emergency, although it has been observed that a reasonable therapeutic delay (up to 18 hours) does not imply a higher number of complications. In our department, surgery is programmed for those non-complicated appendicitis, thus avoiding duty staff (surgeons, anaesthesiologists, nurses, assistants) to operate during late night. Acute appendicitis records from august 2001 to december 2002 were reviewed. Collected data included: clinical findings, physical examination, ultrasound findings, surgical delay (recorded time from emergency attendance until the end of the surgery) and evolution. A total of 209 patiens (125 males and 84 females) underwent surgery. Mean age was 10.1 years (standard deviation 3.02). A non-complicated appendicitis group (NC) included 171 subjects while the complicated appendicitis group (C) included 38, assessed by means of clinical evaluation plus ultrasonography. Patients in NC group had programmed surgery, with up to 20-hour delay (mean of 7 hours 45 minutes).Mean admission time was 4.87 days with a percentage of infectious complications of 1.73%. Patients in group C underwent surgery as soon as possible. Mean admission time was 9.23 days (p < 0.0001)and percentage of infectious complications of 43.6%. There was no difference between those operated rapidly and those who were delayed. Patiens with non-complicated disease could under go programmed surgery, without having a higher risk of complicated disease and without disturbing normal department activity (AU)

An intra-thyroid thyroglossal duct cyst.

Thyroglossal duct cysts can be found in several different locations, although intra-thyroid presentations are rare. We present the case of an 11-year-old patient with a visible neck mass on the right thyroid lobe. On sonogram, it was consistent with a unilocular cyst measuring 2 centimeters in diameter. The cyst did not take up the radioisotope during a gammagram. Fine needle aspiration cytology suggested a diagnosis of thyroglossal duct cyst. At surgery, we found that there were no lesion-dependent thyroglossal tracts; we therefore performed a simple enucleation of the cyst, sparing the rest of the gland. The pathologic examination confirmed that it was an intra-thyroid thyroglossal duct cyst. After 8 months of follow-up, the patient has remained without complications of any kind or recurrence. Only four prior cases of intra-thyroid thyroglossal cysts have been described in the pediatric population. Half of them presented with a typical thyroglossal tract crossing the hyoid and the other half presented an isolated cyst. It is highly unlikely that a cold, cystic, thyroid mass in a child is a thyroglossal duct cyst. Diagnosis is made on the basis of fine needle aspiration cytology and the lesion is treated surgically. A thyroglossal tract must be methodically sought out during intervention, although they frequently do not exist.

[Ultrasonography for surgical pathology discrimination in acute abdominal pain. Prospective study]. / La ecografía en la selección del dolor abdominal quirúrgico urgente. Estudio prospectivo.

Abdominal ultrasonographic study is a part of the acute abdominal pain diagnosis protocol in our hospital. As an internal quality assessment, we performed a six-month prospective study, including those patients who meet one of these requirements: 1st the reason for attendance being non-traumatic abdominal pain 2nd an abdominal ultrasonography achieved at the hospital. Collected data included: demographic characteristics, presenting sign and symptoms, test results, ultrasonography, final diagnosis and treatment. Children attended to the hospital were evaluated through clinical findings to verify concordance between clinical and ultrasound diagnosis, and patients who did not stay at the hospital had telephone follow-up in 2 weeks. A total of 136 patients underwent ultrasonography (7 children did not cooperate and were discarded): 74 females and 55 males with a mean age of 9.52 years. Admission was required in 63 subjects and 66 were sent home after clinical evaluation. Abdominal ultrasonography was performed by the radiologist on duty (occasionally paediatric radiologist). Ultrasound examination, for acute appendicitis, had a sensitivity of 94.8%, specificity of 98.8%, positive predictive value of 97.3% and negative predictive value of 97.8%. Abdominal ultrasonography has showed usefulness for surgical pathology discrimination in acute abdominal pain. When ultrasonography is inconclusive, clinical follow-up and periodical ultrasonography results in a positive change in management and treatment.

Síndrome de Dietl: dolor abdominal recurrente y estenosis pieloureteral intermitente por vaso polar / Dietl's syndrome: recurrent abdominal pain and intermittent ureteropelvic junction stenosis caused by a pole vessel

Introducción: Una de las múltiples causas de dolor abdominal recurrente (DAR) es la hidronefrosis intermitente por vaso polar aberrante o síndrome de Dietl. El objetivo de esta nota clínica es mostrar la importancia de esta enfermedad dentro del diagnóstico diferencial de un DAR de larga evolución, así como su diagnóstico y tratamiento quirúrgico definitivo. Caso clínico: Se trata de un varón de 13 años que acudió a consulta por DAR de 3 años de evolución. Tras el diagnóstico de imagen de hidronefrosis intermitente derecha coincidente con episodios de sobreingestión hídrica, se confirmó el hallazgo tras exploración quirúrgica y se siguió de corrección de la obstrucción mediante pieloplastia. Discusión: La clínica característica de crisis de dolor en un contexto de sobrecarga hídrica debe hacer pensar en un síndrome de Dietl. El diagnóstico se llevará a cabo mediante la conjunción de estudios de ecografía y de urografía excretora tras sobrecarga hídrica. El estudio de la funcionalidad renal se realizará con gammagrafía. Conclusiones: El síndrome de Dietl es una enfermedad importante dentro del diagnóstico del DAR y puede pasar inadvertido de no efectuarse una correcta anamnesis y estudio de imagen coincidente con las crisis de dolor. De la misma manera, su tratamiento será siempre quirúrgico (AU)

Hidronefrosis intermitente de causa vascular. Revisión de nuestra casuística / Vascular-related intermittent hydronephrosis. Review of our reports

Objetivo: El dolor abdominal recurrente debido a una hidronefrosis causada por un vaso polar anómalo que obstruye la unión pieloureteral (estenosis pieloureteral vascular o EPUV), es una enfermedad poco conocida. La dilatación de la pelvis renal oscila desde la normalidad absoluta entre crisis hasta la hidronefrosis masiva. Esto puede conducir a problemas diagnósticos y terapéuticos que comentamos tras el estudio de nuestros pacientes. Material y métodos: Revisamos 30 pacientes intervenidos en los últimos 11 años por estenosis pieloureteral (EPU) y encontramos cinco causadas por un vaso polar. Resultados: Se trata de 3 niñas y 2 niños con edades comprendidas entre los 10 meses y los 11 años (edad media 6 años), que acudieron a la consulta por dolor abdominal recurrente, salvo uno (el paciente de 10 meses), que acudió tras presentar una infección urinaria. En un paciente fue necesario realizar varias ecografías abdominales antes de comprobar la existencia de una hidronefrosis. El ácido dietilentriaminopentacético (DTPA) con sobrecarga hídrica y estímulo diurético fue diagnóstico en todos ellos. Se realizó una pieloplastia de Anderson-Hynes, con tutor ureteral y nefrostomía de descarga. La media de hospitalización fue de 8,8 días y el seguimiento medio postoperatorio, de 3,4 años. No hubo complicaciones postoperatorias, pérdidas significativas de función renal o recaída sintomática tras la cirugía, aunque en 3 pacientes persistió una ectasia piélica residual. Conclusiones: Esta enfermedad puede sospecharse por la historia clínica y debe tenerse en cuenta en cualquier paciente con dolor abdominal recurrente (AU)

Anestesia epidural caudal en la piloromiotomía del lactante: Nuestra experiencia* / Caudal epidural anaesthetic in infants for pyloromyotomy: Our experience

El objetivo de este trabajo es presentar la anestesia epidural caudal como alternativa a la anestesia general convencional con entubación endotraqueal para la cirugía de la estenosis pilórica, aportando como ventajas su relativa sencillez una vez dominada la técnica, un mejor control de la analgesia perioperatoria y postoperatoria sin la necesidad de usar opiáceos, y el evitar la entubación orotraqueal y el manejo ventilatorio. Basándonos en la experiencia con 18 pacientes, presentamos la técnica realizada, los sistemas de monitorización y los resultados obtenidos. Concluímos que esta sistemática es un buen método alternativo a la anestesia general en la corrección quirúrgica de la estenosis de píloro (AU)

[Caudal epidural anesthesia in pyloromyotomy in infants: our experience]. / Anestesia epidural caudal en la piloromiotomía del lactante: nuestra experiencia.

The aim of this work is to introduce an alternative to ordinary anaesthetic with tracheal intubation for the surgery of pyloric stenosis. We argue in favour of this alternative that it can be achieved with relative ease if the technique of caudal epidural is well known, a better control of peri and post-operative analgesia without the need of opiates, and that this technique obviates orotracheal intubation and intermittent positive pressure ventilation. Based on our experience with 18 patients, we introduce the anaesthetic technique, the monitoring systems and the obtained results. Our conclusion is that this technique is a good alternative to general anaesthetic for the surgical treatment of pyloric stenosis.

[Comparison of prosthetic materials for abdominal wall reconstruction. Experimental study]. / Comparación entre materiales protésicos para reconstrucción de la pared abdominal. Estudio experimental.

To repair large abdominal deficiencies, either congenital of acquired, occasionally serious problems show up where obtaining the ideal material is concerned, in those cases where autological tissue in the right size can not be found. In this sense materials like silver, steel and tantalium darning have been used, as well as many other synthetic tissues and non porous materials like silastic. During this same period, prosthesis of reabsorbing materials have been developed and used. We present a experimental work in which we compare four prosthesic materials as there are Marlex, Silastic, polyglycolic acid and lyodura, from the clinical, biological and histopathological point of view, distinguishing the ideal material in definite pathologies.

[Acute perforated sigmoid diverticulitis in childhood]. / Diverticulitis aguda de sigma perforada en la infancia.

Colonic diverticulosis is a pathology of high incidence in normal population during the last decades of life. About 2-5 per 100 of patients admitted because of this disease are below 40 years old, and in this group of patients diverticulitis tends to be very aggressive with a high number of complications. We report a clinical case of acute perforation of sigmoid colon due to diverticulitis in a ten year old child who was treated surgically by means of resection of the sigma and primary end-to-end anastomosis. We did not find in the literature consulted any cases of this illness under twenty years of age.