Utilización de tubo de Kehr en anastomosis intestinales complejas / Using Kehr's tube in complex anastomoses

Objetivo. Presentar una nueva técnica utilizando el tubo de Kehr (TK) en las anastomosis intestinales complejas.material y métodos. Estudio retrospectivo descriptivo de 8 pacientes, intervenidos desde 2007 hasta 2011, con anastomosis intestinal tutorizada por un TK. 7 pacientes fueron operados por atresia intestinal (5 yeyunales, 1 ileal y 1 duodenal) y 1 caso por estenosis yeyunal asociada a gastrosquisis. 4 casos (50%) fueron pacientes que habían sido intervenidos previamente, y en los que existieron complicaciones con la primera cirugía. técnica quirúrgica: consiste en introducir un TK por el asa dilatada. Un extremo de la "T" del TK se deja, con una ligadura, proximal a la sutura y el otro distal a la misma, actuando como tutor transanastomó-tico. El cabo restante es abocado a la piel y utilizado para alimentación enteral. Las variables estudiadas fueron: inicio de alimentación enteral, tiempo de alimentación a través del TK, de recuperación del tránsito intestinal, tiempo hasta alimentación oral completa y complicaciones. Resultados. No se presentaron complicaciones derivadas de la técnica. La alimentación se inició a través del TK entre 2º-10º día (mediana: 4.5), con una duración de 4-33 días (mediana: 7). Iniciaron tránsito intestinal con deposiciones entre el 2º-7º día (mediana: 3,5). Los pacientes que habían sido intervenidos previamente presentaban signos de colestasis y sepsis, que se solucionaron tras la cirugía. El TK se mantuvo entre 11-51 días (mediana: 22), retirándose sin incidencias. Conclusiones. Este estudio preliminar sugiere que el uso de TK en anastomosis complejas presenta ventajas, como la alimentación enteral precoz y tutorización de la sutura previniendo su acodamiento. Este procedimiento no ha sido reportado en la literatura consultada (AU)

Objective. To present a new technique using the Kehr’s T tube (KT) in complex intestinal anastomoses. materials and methods. Restrospective descriptive analysis of 8 patients intervened from 2007 to 2011. We performed intestinal anastomoses guided by a KT in 7 patients with intestinal atresia (yeyunal n=5, ileal n=1, duodenal n=1), and in 1 patient with yeyunal stenosis associated with gastroschisis. 4 cases (50%) were reoperations because of complications after the first surgery. Surgical technique: the KT is introduced through the dilated proximal bowel. The proximal end of the "T" is tied and the distal one acts as a transanastomotic guide and feeding tube. The long end of the T is externalized through the skin and used for the administration of the enteral nutrition formula. Studied variables were: beginning of enteral feeding, feeding time through the KT, time of intestinal motility recovery, time to complete oral feeding and complications. Results. There were no complications derived from the technique. Feeding was started through the KT between day 2 and 10 (median: 4.5), with a period of 4 to 33 days (median: 7). Patients started intestinal transit between days 2 and 7 (median: 3.5). Reoperated patients showed cholestasis and/or sepsis signs, which were solved with surgery. The KT was left in place between 11-51 days (median: 22), with no complications during or after the removal. Conclusions. The results of this preliminary study suggests that the use of the KT in complex anastomoses as a transanastomotic guide and feeding tube presents advantages, such as early enteral feeding and prevention of leakage and kinking of the intestinal suture. There were no complications derived from the procedure.As far as we know, this technique has not been previously reported in the literature (AU)

Ventajas de la analgesia epidural en cirugía mayor neonatal / Benefits of epidural analgesia in major neonatal Surgery

El objetivo de este trabajo es describir y evaluar las ventajas de la analgesia epidural en cirugía mayor neonatal. Para ello, realizamos un estudio de casos controles emparejado (2:1) de pacientes sometidos a cirugía mayor neonatal (CMN) bajo anestesia general que recibieron analgesia epidural (AE) intra y postoperatoria, y controles con anestesia general convencional. El criterio de emparejamiento fue edad, peso y patología basal. Se administró AE intra y postoperatoria por vía caudal con levobupivacaina mediante catéter epidural colocado con apoyo ecográfico. Se estudiaron el tiempo hasta la extubación, el tiempo de tránsito intestinal (presencia de deposiciones), el tipo de analgesia y las complicaciones. Se estudiaron 11 casos (2 atresias esofágicas, 2 hernias diafragmáticas, 1 enterocolitis necrotizante, 3 atresias intestinales, 2 malformaciones anorrectales y 1 extrofia vesical) y 22 controles. Observamos diferencias estadísticamente significativas en tiempo de extubación (OR 12 IC 95% 1,99-72,35; Chi2 p= 0,004, U Mann Whytney p= 0,013) y del tiempo de tránsito intestinal (U Mann Whitney p< 0,001, Or 100, IC 95% 8,06-1239; Chi2 p< 0,0001). No se observaron complicaciones derivadas de la técnica epidural. Por todo ello, consideramos que la AE intra y postoperatoria ayuda a mejorar el manejo postquirúrgico en neonatos y debe ser de elección en centros en los que esta técnica esté disponible (AU)

The aim of this paper is to describe and evaluate the benefits of epidural anesthesia in major surgery neonatal. We have performed a matched case-control (2:1) study of patients undergoing neonatal major surgery (NMSs) who received intra-and postoperative epidural anesthesia (EA) and controls with conventional general anesthesia. The matching criteria were age, weight and baseline pathology. EA was administered by caudal puncture and epidural catheter placed with ultrasound support. Levobupivacaine was selected as anesthetic drug. The time to extubation, intestinal transit time, type of analgesia and complications were studied. This study is based on 11 cases (2 esophageal atresia, 2 diaphragmatic hernias, 1 necrotizing enterocolitis, 3 intestinal atresia, 2 anorectal malformation and 1 bladder exstrophy) and 22 controls. We observed statistically significant differences in time to extubation (95% CI OR 12 1.99 to 72.35; Chi2 p = 0.004, Mann U Whytney p = 0.013) and intestinal transit time (Mann Whitney U p <0.001, 100 Or , 95% CI 8.06 -1 239; Chi2 p <0.0001). There were no complications from epidural analgesia. Therefore we believe that the intra-and postoperative EA helps improve postoperative management in neonates and should be preferred in centers where this technique is available (AU)

Cuando una peritonitis no parece una peritonitis / When a peritonitis does not seems like a peritonitis

La pancreatitis aguda es una entidad que forma parte del diagnóstico diferencial del abdomen agudo de origen apendicular. Aunque su incidencia es baja, se encuentra en aumento y su correcto diagnóstico evita cirugías innecesarias. El objetivo del trabajo es describir la pancreatitis aguda como diagnóstico diferencial de abdomen agudo de origen apendicular. Se realiza un estudio retrospectivo de los pacientes remitidos para valoración de cirugía pediátrica en la urgencia con sospecha de patología apendicular, que fueron diagnosticados finalmente de pancreatitis aguda desde el año 2010. Se incluyen 5 pacientes. Un paciente fue intervenido y su diagnóstico se realizó en el 5º día postoperatorio. La edad mediana al diagnóstico fue de 5 años (rango de 8 meses a 6 años). La mediana de leucocitos en sangre fue de 16.600 /μL (13.400-31.900 /μL), mediana de neutrofilos 14.432 /μL (11.400-29.348 /μL), mediana PCR 11 mg/L (155-4,6 mg/L), mediana amilasa sérica al diagnóstico 651 U/L (10-1.443 U/L). Todos los casos fueron estudiados con ecografía abdominal y tomografía computarizada o resonancia magnética nuclear. Un caso presentó episodios recurrentes de pancreatitis y como complicación un pseudoquiste y una fístula pancreática, precisando a los 9 meses del inicio del cuadro clínico una derivación cistoentérica en Y de Roux. La mediana global de seguimiento de la serie es de 10 meses, con un rango entre 1 y 22 meses, encontrándose todos los pacientes asintomáticos (AU)

Acute pancreatitis should be considered in the differential diagnosis of acute abdominal pain. Although its incidence is low, it has increased in the last years; therefore, an accurate diagnosis is necessary to avoid inappropriate surgeries. The aim of this study is to describe acute pancreatitis in the context of acute abdominal pain, which suggests appendicitis. We performed a retrospective study of all the patients who were admitted in the emergency department due to suspected appendicitis but were finally diagnosed of acute pancreatitis since 2010. Five patients were included in the investigation. One of them underwent surgery and the diagnosis was made on the 5th postoperative day. Median age at diagnosis was 5 years (range from 8 month to 6 years). Median white blood cell was 16,600 /μL (13,400-31,900 /μL), Median differential count of white blood cell was 14,432 /μL (11,400-29,348 /μL) and Median PCR 11 mg/L (155-4.6 mg/L). Median serum amylase at diagnosis was 651 U/L (10-1,443 U/L). All cases were studied with ultrasound and computerized tomography or nuclear magnetic resonance. One case had recurrent episodes of pancreatitis and was complicated by the development of a pseudocyst and a pancreatic fistula, requiring an Y-en-Roux cysto-enteric anastomosis . The median follow up period was 10 months (range: 1 to 22). All patients are asymptomatic at the moment (AU)

[Using Kehr's tube in complex anastomoses]. / Utilización de tubo de Kehr en anastomosis intestinales complejas.

OBJECTIVE: To present a new technique using the Kehr's T tube (KT) in complex intestinal anastomoses. MATERIALS AND METHODS: Restrospective descriptive analysis of 8 patients intervened from 2007 to 2011. We performed intestinal anastomoses guided by a KT in 7 patients with intestinal atresia (yeyunal n = 5, ileal n = 1, duodenal n = 1), and in 1 patient with yeyunal stenosis associated with gastroschisis. 4 cases (50%) were reoperations because of complications after the first surgery. SURGICAL TECHNIQUE: the KT is introduced through the dilated proximal bowel. The proximal end of the "T" is tied and the distal one acts as a transanastomotic guide and feeding tube. The long end of the T is externalized through the skin and used for the administration of the enteral nutrition formula. Studied variables were: beginning of enteral feeding, feeding time through the KT, time of intestinal motility recovery, time to complete oral feeding and complications. RESULTS: There were no complications derived from the technique. Feeding was started through the KT between day 2 and 10 (median: 4.5), with a period of 4 to 33 days (median: 7). Patients started intestinal transit between days 2 and 7 (median: 3.5). Reoperated patients showed cholestasis and/or sepsis signs, which were solved with surgery. The KT was left in place between 11-51 days (median: 22), with no complications during or after the removal. CONCLUSIONS: The results of this preliminary study suggests that the use of the KT in complex anastomoses as a transanastomotic guide and feeding tube presents advantages, such as early enteral feeding and prevention of leakage and kinking of the intestinal suture. There were no complications derived from the procedure. As far as we know, this technique has not been previously reported in the literature.

[Benefits of epidural analgesia in major neonatal surgery]. / Ventajas de la analgesia epidural en cirugía mayor neonatal.

The aim of this paper is to describe and evaluate the benefits of epidural anesthesia in major surgery neonatal. We have performed a matched case-control (2:1) study of patients undergoing neonatal major surgery (NMSs) who received intra-and postoperative epidural anesthesia (EA) and controls with conventional general anesthesia. The matching criteria were age, weight and baseline pathology. EA was administered by caudal puncture and epidural catheter placed with ultrasound support. Levobupivacaine was selected as anesthetic drug. The time to extubation, intestinal transit time, type of analgesia and complications were studied. This study is based on 11 cases (2 esophageal atresia, 2 diaphragmatic hernias, 1 necrotizing enterocolitis, 3 intestinal atresia, 2 anorectal malformation and 1 bladder exstrophy) and 22 controls. We observed statistically significant differences in time to extubation (95% CI OR 12 1.99 to 72.35; Chi2 p = 0.004, Mann U Whytney p = 0.013) and intestinal transit time (Mann Whitney U p < 0.001, 100 Or, 95% CI 8.06-1 239; Chi2 p < 0.0001). There were no complications from epidural analgesia. Therefore we believe that the intra-and postoperative EA helps improve postoperative management in neonates and should be preferred in centers where this technique is available.

[When a peritonitis does not seems like a peritonitis]. / Cuando una peritonitis no parece una peritonitis.

Acute pancreatitis should be considered in the differential diagnosis of acute abdominal pain. Although its incidence is low, it has increased in the last years; therefore, an accurate diagnosis is necessary to avoid inappropriate surgeries. The aim of this study is to describe acute pancreatitis in the context of acute abdominal pain, which suggests appendicitis. We performed a retrospective study of all the patients who were admitted in the emergency department due to suspected appendicitis but were finally diagnosed of acute pancreatitis since 2010. Five patients were included in the investigation. One of them underwent surgery and the diagnosis was made on the 5th postoperative day. Median age at diagnosis was 5 years (range from 8 month to 6 years). Median white blood cell was 16,600/microL (13,400-31,900/microL), Median differential count of white blood cell was 14,432/microL (11,400-29,348/microL) and Median PCR 11 mg/L (155-4.6 mg/L). Median serum amylase at diagnosis was 651 U/L (10-1,443 U/L). All cases were studied with ultrasound and computerized tomography or nuclear magnetic resonance. One case had recurrent episodes of pancreatitis and was complicated by the development of a pseudocyst and a pancreatic fistula, requiring an Y-en-Roux cysto-enteric anastomosis. The median follow up period was 10 months (range: 1 to 22). All patients are asymptomatic at the moment.

Relación entre la transfusión de concentrado de hematíes y la gravedad de la enterocolitis necrotizante en prematuros / Relation between packed red blood cell transfusion and severity of necrotizing enterocolitis in premature infants

Objetivo. Se ha propuesto que las transfusiones de concentrado de hematíes (TCH) determinan formas de enterocolitis necrotizante (ECN)más severas. Se pretende investigar si las ECN con antecedente de TCH alcanzan una mayor gravedad. Material y métodos. En un estudio retrospectivo de prematuros con ECN se consideraron dos grupos: con antecedente de TCH (grupoTR) y sin antecedente de TCH (grupo No-TR). Se consideraron como resultados principales la gravedad de la ECN, determinada según el estadio de Bell (EB) mayor durante el transcurso de la enfermedad, si fue necesario realizar tratamiento quirúrgico y la mortalidad. Posteriormente se analizaron por separado aquellos pacientes que habían recibido la TCH en las 48 h previas al inicio de los síntomas. Al comparar los grupos se utilizó la prueba exacta de Fisher o la de Chi cuadrado para elEB, el tratamiento quirúrgico, la mortalidad y las variables cualitativas (..) (AU)

Objective. It has been proposed recently that red blood cell transfusions(RBCT) might increase severity in infants with necrotizing enterocolitis (NEC). We intend to study if patients who have received red blood transfusions before the onset of NEC develop more severe forms of this entity. Methods. A retrospective study was carried out including prematures with NEC. Two groups were considered: with previous RBCT(TR) and without previous RBCT (No-TR). The main outcomes of the study were severity of NEC, according to the Bell stage (BS), surgical treatment and mortality. Patients who were treated with RBCT 48hours prior to the onset of NEC symptoms were analysed separately afterwards. Comparison of groups was made with the Fisher test or the Chi square test for the BS, surgery, mortality and nominal variables; the U Mann-Whitney test was used for numeric variables. Results. Forty-six patients were included for the investigation (28 in TR and 18 in No-TR). In the TR Group 20/28 neonates reached a BS II;8/28 BS III; 10 were operated on and there were 7 deaths. In the No-TR group 14/18 patients were classified as EB II; 4/18 as BS III, 3 patients (AU)

[Relation between packed red blood cell transfusion and severity of necrotizing enterocolitis in premature infants]. / Relación entre la transfusión de concentrado de hematíes y la gravedad de la enterocolitis necrotizante en prematuros.

OBJECTIVE: It has been proposed recently that red blood cell transfusions (RBCT) might increase severity in infants with necrotizing enterocolitis (NEC). We intend to study if patients who have received red blood transfusions before the onset of NEC develop more severe forms of this entity. METHODS: A retrospective study was carried out including prematures with NEC. Two groups were considered: with previous RBCT (TR) and without previous RBCT (No-TR). The main outcomes of the study were severity of NEC, according to the Bell stage (BS), surgical treatment and mortality. Patients who were treated with RBCT 48 hours prior to the onset of NEC symptoms were analysed separately afterwards. Comparison of groups was made with the Fisher test or the Chi square test for the BS, surgery, mortality and nominal variables; the U Mann-Whitney test was used for numeric variables. RESULTS: Forty-six patients were included for the investigation (28 in TR and 18 in No-TR). In the TR Group 20/28 neonates reached a BS II; 8/28 BS III; 10 were operated on and there were 7 deaths. In the No-TR group 14/18 patients were classified as EB II; 4/18 as BS III, 3 patients needed surgery and Idied. No relation was found between RBCT and BS (p = 0.39), RBCT and surgery (RR = 2.7; CI 95%: 0.64-11.97; p = 0.19), or RBCT and mortality (RR = 4.5; CI 95%: 0.6-36.6; p = 0.09). In those patients who received a RBCT 48 hours before the initial symptoms there were 3 EB II and 3 EB III; 4 infants required surgical treatment and there were 2 exitus. Comparing this subgroup and the rest of the sample there were only significant differences in the need of surgical treatment: patients who received a RBCT 48 hours before the onset of NEC were at an increased risk for surgery of 2.6 (CI 95%: 1.2-5.1; p = 0.045) but there were not different when surgical treatment and mortality were considered. CONCLUSIONS: These results do not support clearly the hypothesis that there is a relation between previous treatment with RBCT and the severity of NEC.

[Biloma as a complication after closed abdominal trauma. Review of the literature after bile leaks]. / Biloma como complicación tras traumatismo abdominal cerrado. Revisión de la literatura relativa a fugas biliares.

Bile leaks are a rare complication secondary to closed liver trauma. The diagnosis is usually late, which increases the morbidity and hospital stay. We report a case of biloma secondary to severe liver injury, including a description of the diagnosis and management. We also describe the different types of bile leaks, the techniques of early diagnosis and various treatment modalities existing for this type of injury.

Tiroidectomía profiláctica en el síndrome de neoplasia endocrina múltiple / Prophylactic thyroidectomy in multiple endocrine neoplasia syndrome

La neoplasia endocrina múltiple (MEN) 2A se caracteriza por la asociación de carcinoma medular de tiroides (CMT), feocromocitomae hiperparatiroidismo, ser hereditaria y tener una transferencia autosómica dominante. La identificación del protooncogen RET en 1993 ha cambiado el pronóstico de esta enfermedad. El objetivo del presente trabajo es realizar un estudio retrospectivo de los pacientes diagnosticados de síndrome MEN2a en nuestro centro en los últimos 7 años para establecer la edad más apropiada para la cirugía. Presentamos 10 casos diagnosticados de MEN2a entre 1,5 y 11años; estos se han intervenido con una edad media a la cirugía de 6,4años.En el preoperatorio se realiza ecografía cervical, determinación decalcitonina, catecolaminas y metanefrinas en orina. El tratamiento quirúrgico consiste en todos los casos en tiroidectomía total y en casos seleccionados (mayores de 5 años) vaciamiento (..) (AU)

Multiple endocrine neoplasia (MEN) 2a consists on medullary thyroid carcinoma, pheochromocytoma and hyperparathyroidism. The identification of the RET proto-oncogene in 1993 has changed the prognosis of the disease. We have retrospectively studied the patients diagnosed of MEN 2a in our centre for the last 7 years in order to establish the most adequate age to undergo surgery. We present ten patients diagnosed with MEN 2a, whose ages ranged from 1’5 to 11 years old. Mean age at time of operation: 6,4 years An ultrasound study, calcitonin determinations and cathecholamines and urinary metanephrine levels were obtained before surgery. The surgical treatment is based on total total thyroidectomy, inselected cases lymph node resection in the central zone lf the neck. The most frequent RET mutation is the one affecting codon 634(exon 10), which was found in children. Both of them had an alterationin codon 611 (exon11). No complications appeared after surgery and hospital discharge took place in the 2nd-4th day after surgery. Pathological findings were medullary thyroid microcarcinoma (..) (AU)

Biloma como complicación tras traumatismo abdominal cerrado. Revisión de la literatura relativa a fugas biliares / Biloma as a complication after closed abdominal trauma. Review of the literature after bile leaks

Las fugas biliares son una complicación rara secundaria al traumatismo hepático cerrado. El diagnóstico de esta entidad es, por lo general, tardío, lo que incrementa la morbilidad y la estancia hospitalaria. Apropósito de un caso diagnosticado en nuestro centro de biloma secundario a traumatismo hepático severo, hacemos una descripción del mismo incluido diagnóstico y medidas de tratamiento. Se describen a continuación los distintos tipos de fugas biliares, las técnicas de diagnóstico precoz y las diversas modalidades de tratamiento existentes para este tipo de lesiones (AU)

Bile leaks are a rare complication secondary to closed liver trauma. The diagnosis is usually late, which increases the morbidity and hospital stay. We report a case of biloma secondary to severe liver injury, including a description of the diagnosis and management. We also describe the different types of bile leaks, the techniques of early diagnosis and various treatment modalities existing for this type of injury (AU)

[Short term evaluation of transanal pull-through with automatic suture]. / Valoración a corto plazo del descenso transanal con sutura automática.

For the last ten years many centres have adopted transanal pull-through (TP) as the first choice technique for the treatment of Hirschsprung's Disease (HD) affected children. We present our experience, based on the endorectal pull-through with autosuture, which has not been reported up to now. According to our HD management programme, TP with autosuture should be performed in rectosigmoid forms of HD which are easily handled with outpatient care. Seven patients with HD whose ages ranged from 5-months-old to 5-years-old underwent EP with autosuture. We present the short term results of the evolution of our patients. Firstly, a laparoscopic procedure is carried out in order to obtain a biopsy from the transition zone. The second stage consists of the TP following the De La Torre technique, modified by the 21 mm circular autosuture. No new surgical operation was necessary. Passage of stools started between the second and fourth postoperative day. The most frequent complication was abdominal distention, found in an 85.7% of patients and resolved before being discharged. Hospital discharge took place between the fourth and the tenth postoperative day. Oral feeding was started in the 2nd-7th postoperative day. Medium term outcomes show a single case of complications: a patient Developer a skin stricture due to the low suture, which has been treated conservatively with rectal dilatations. Patients older than three (42.8%) are continent, although one presents occasional fecal soiling. The rest of the children present normal stools for their age. Automatic suture involves several advantages such as celerity and safety. We ought to point out that this method should not be used in children under 5 months because the autosuture size does not allow to do so.

Valoración a corto plazo del descenso transanal con sutura automática / Short term evaluation of transanal pull-through with automatic suture

En los últimos 10 años el descenso transanal (DT) se ha popularizado en muchos centros como técnica de elección para el tratamiento de la enfermedad de Hirschsprung (EH). Presentamos nuestra experiencia de DT con autosutura, inédita en la literatura. En nuestro programa de tratamiento de la EH aplicamos el DT para las formas de afectación recto-sigmoidea de fácil manejo ambulatorio. Hemos practicado un estudio retrospectivo de la evolución de 7pacientes con edades comprendidas entre 5 meses y 5 años a los que se les ha realizado un descenso transanal con autosutura en los dos últimos años. Nuestra técnica se desarrolla en dos pasos. En un primer tiempo practicamos una biopsia laparoscópica, en el segundo tiempo se realiza un descenso endorrectal según la técnica de De La Torre, modificado con autosutura circular de 21mm. En ningún caso se han precisado reintervenciones. Nuestros pacientes empezaron a realizar deposiciones entre el 2º y 4º día postoperatorio (DPO). La complicación más frecuente fue distensión abdominal en (..)

For the last ten years many centres have adopted transanal pull-through(TP) as the first choice technique for the treatment of Hirschsprung’s Disease (HD) affected children. We present our experience, based on the endorectal pull-through with autosuture, which has not been reported up to now. According to our HD management programme, TP with autosuture should be performed in rectosigmoid forms of HD which are easily handled with outpatient care. Seven patients with HD whose ages ranged from 5 months old to 5 years old underwent EP with autosuture. We present the short term results of the evolution of our patients. Firstly,a laparoscopic procedure is carried out in order to obtain a biopsy from the transition zone. The second stage consists of the TP following the De La Torre technique, modified by the 21 mm circular autosuture. No new surgical operation was necessary. Passage of stools started between the second and fourth postoperative day. The most frequent complication was abdominal distention, found in an 85.7% of patients and resolved before being discharged. Hospital discharge took place (..) (AU)

[Prophylactic thyroidectomy in multiple endocrine neoplasia syndrome]. / Tiroidectomía profiláctica en el síndrome de neoplasia endocrina múltiple.

Multiple endocrine neoplasia (MEN) 2a consists on medullary thyroid carcinoma, pheochromocytoma and hyperparathyroidism. The identification of the RET proto-oncogene in 1993 has changed the prognosis of the disease. We have retrospectively studied the patients diagnosed of MEN 2a in our centre for the last 7 years in order to establish the most adequate age to undergo surgery. We present ten patients diagnosed with MEN 2a, whose ages ranged from 1.5 to 11 years old. Mean age at time of operation: 6,4 years An ultrasound study, calcitonin determinations and cathecholamines and urinary metanephrine levels were obtained before surgery. The surgical treatment is based on total total thyroidectomy, in selected cases lymph node resection in the central zone lf the neck. The most frequent RET mutation is the one affecting codon 634 (exon 10), which was found in children. Both of them had an alteration in codon 611 (exon11). No complications appeared after surgery and hospital discharge took place in the 2nd-4th day after surgery. Pathological findings were medullary thyroid microcarcinoma (MTMC) in 3 out of 10 patients, calcitonin preoperative tests were high in one of them. No tumoral cells were found in the lymph nodes. During the follow up period, 9 out of 10 from the operated patients, maintained normal calcitonin, CEA, PTH, calcium, cathecholamines and urinary metanephrine levels. Since there are 3 cases of MTC in patients between 3 and 6 years old, and diagnostic test data are not conclusive, we thoroughly recommend prophyilactic thyroidectomy at early ages, from 3 to 4 years old.

[Endoscopic treatment of recurrent tracheoesophageal fistula]. / Tratamiento endoscópico de la fístula traqueoesofágica recurrente.

UNLABELLED: Repermeabilization of the tracheoesophageal fistula (RTE) is one of the major complications of the esophageal atresia with tracheal fistula. We present the long term results of our technique based on broncoscopic treatment with fibrin glue and diathermia. MATERIAL AND METHODS: A retrospective study of 10 children with RTE treated from 1993 to 2006, their ages ranging from 14 days-old to 4 years-old; there were 4 patients from other hospitals. One of the patients involved had a superior congenital fistula that had not been noticed during open surgery. Broncoscopic procedure was performed using rigid instrumentation. The fistula was sealed with fibrin glue; the last seven patients in the series received previous diathermia with an uretheral catheter. Clinical and radiological follow up took place in all children. Endoscopic evaluation was performed in 6 of them. Follow-up time vary from 1 to 13 years and the number of sessions was limited to 3 per patient. RESULTS: Closure of the fistula was confirmed in 9 cases (90%) who required a whole number of 15 sessions (Mean: 1.5). The group who received diathermia needed 9 sessions (Mean: 1.2). There were no major complications. DISCUSSION: Surgery reparation of RTE is often related to serious complications. Therefore, many groups have tried to develop several broncoscopic techniques using different materials. Scientific reviews have not pointed out a definitive option since they involve isolated patients with no long term evolution. Taking this report into account we believe that the application of diathermia and fibrin glue ought to be considered the first choice treatment for the RTE.

Tratamiento endoscópico de la fístula traqueoesofágica recurrente / Endoscopic treatment of recurrent tracheoesophageal fistula

Una de las complicaciones más graves del tratamiento de la Atresia de Esófago (AE) con fístula traqueal, es la repermeabilización (RTE)de la misma. Presentamos los resultados a largo plazo de nuestra técnica de tratamiento broncoscópico con Adhesivo de Fibrina y Diatermia. Material y Métodos. Se presenta un estudio retrospectivo de 10pacientes con RTE tratados entre 1993 y 2006, en enfermos de 14 días a 2 años, cuatro de ellos de otros centros Un paciente asoció una fístula congénita superior, desapercibida en la intervención abierta. Se utilizó un procedimiento broncoscópico, utilizando instrumentación rígida. La fístula fue sellada con Adhesivo de Fibrina y en los últimos 7 se asoció al procedimiento Diatermia previa, con un catéter ureteral. En todos los casos se realizó seguimiento clínico y radiológico. Controlendoscópico en 6. El seguimiento incluye de 1 a 13 años y número de sesiones se limitó a 3 por paciente. Resultados. Es evidenció cierre de la fístula en 9 casos (90%), que precisaron un total de 15 sesiones (Media: 1,5). El grupo de asociación con Diatermia 70% necesitó 9 (Media: 1,2) No se presentaron complicacionesgraves. Conclusiones. La reparación quirúrgica de RTE comporta a menudo serias complicaciones, por lo algunos grupos han intentado desarrollar diferentes técnicas broncoscópicas, con diferentes materiales. La revisión de la literatura no aporta una opción concluyente, pues son pacientes aislados sin evolución a largo plazo. A la vista del presente estudio opinamos que la aplicación de Diatermia y Adhesivo de Fibrina debe considerarse en el tratamiento de la RTE, como opción de inicio (AU)

Repermeabilization of the tracheoesophageal fistula (RTE) is one of the major complications of the esophageal atresia with tracheal fistula. We present the long term results of our technique based on broncoscopictreatment with fibrin glue and diathermia. Material and methods: A retrospective study of 10 children with RTE treated from 1993 to 2006, their ages ranging from 14 days-old to4 years-old; there were 4 patients from other hospitals. One of the patients involved had a superior congenital fistula that had not been noticed during open surgery. Broncoscopic procedure was performed using rigid instrumentation. The fistula was sealed with fibrin glue ; the last seven patients in the series received previous diathermia with an uretheral catheter. Clinical and radiological follow up took place in all children. Endoscopic evaluation was performed in 6 of them. Follow-uptime vary from 1 to 13 years and the number of sessions was limited to3 per patient. Results: Closure of the fistula was confirmed in 9 cases (90%) who required a whole number of 15 sessions (Mean: 1.5). The group who received diathermia needed 9 sessions (Mean: 1.2). There were no majorcomplications. Discussion: Surgery reparation of RTE is often related to serious complications. Therefore, many groups have tried to develop several broncoscopic techniques using different materials. Scientific reviews have not pointed out a definitive option since they involve isolated patients with no long term evolution. Taking this report into account we believe that the application of diathermia and fibrin glue ought to be considered the first choice treatment for the RTE (AU)

Disfagia / Dysphagia

La Disfagia se define como la dificultad para deglutircorrectamente, a diferencia de la odinofagia,que implica la presencia de dolor con la ingesta.Ambos síntomas pueden coexistir en algunas condicionesclínicas. Describimos los mecanismos decontrol de la deglución y el papel del esfínter esofágicosuperior e inferior. Se revisan todas las causasde disfagia en niños, así como la sintomatología,.En cuanto a la etiología se dividen: mecánicas yneuromusculares, haciendo un especial hincapié enla achalasia, la esclerodermia y causas iatrogénicas.Revisamos los medios diagnósticos y terapéuticos

Dysphagia is defined as the difficulty in movingfood or liquid from mouth to stomach. Dysphagiamay be associated with pain while swallowing, ornot being able to swallow at all. Key anatomic andphysiologic features that play an important role innormal and abnormal swallowing in children aredescribed. Highlighted topics include the neurologicafferent and efferent control mechanisms, and theupper and lower esophageal sphincters.All the causes of dysphagia in children are revised,as well as the clinical presentation. Aetiology isdivided in mechanical and neuromuscular origin,with special reference to achalasia, esclerodermiaand iatrogenic cause. We revised the diagnostic andtherapeutic approaches

Urgent distal splenorenal shunt in low-body weight patients.

The authors report two patients with extrahepatic portal hypertension and repeated massive bleeding from esophageal varices who underwent urgent distal splenorenal shunting (DSRS) after having proved refractory to medical treatment, endoscopic sclerotherapy, and ligation of esophageal varices. Their ages and weights were 18 months/10 kg, and 11 months/6.4 kg, respectively. The splenic veins were 6 and 4 mm in diameter. During follow-up of 4 and 3 years, respectively, the shunts have remained patent in both patients as demonstrated by Doppler Ultrasound. Gastrointestinal hemorrhage has not recurred, splenomegaly regressed, and platelet and white blood cell counts increased gradually. Neither patient developed a significant encephalopathy, and liver function tests showed no significant changes throughout the observed period. The authors considered the shunting feasible despite the relatively narrow splenic veins. In both patients the anatomic position of the splenic vein--more caudal to the posterior wall of the pancreas--facilitated its isolation. In the smaller infant, the inferior mesenteric vein was sutured to gain a satisfactory segment of splenic vein. The successful use of a DSRS to control actively bleeding varices in a child weighing 6.4 kg has not been previously reported.

Spontaneous biliary perforation and necrotizing enterocolitis.

A case of spontaneous bile-duct perforation in a 5-month-old boy with a history of necrotizing enterocolitis in his 1st week of life is reported. To our knowledge, this is the second case reported with such an antecedent, supporting a vascular etiology for some cases of spontaneous biliary perforation.

[Laparoscopic transsection of Ladd's bands: a new indication for therapeutic laparoscopy in neonates]. / Sección laparoscópica de bandas de Ladd: una nueva indicación para la laparoscopia terapéutica en neonatos.

Within the last ten years and by the introduction of some new instruments, laparoscopy is a safe and effective method that has been further extended in children. We report our experience in the treatment of laparoscopy on a seven day old newborn affected by malrotation with an intermittent duodenal obstruction. The treatment consisted of a duodenal liberation after the section was easily performed in congenital Ladd's bands. The spiral twists of the small intestine found in the upper gastrointestinal series, disappeared in a new study done after surgery. We consider this operation as a new indication for an operative laparoscopy. It allows a good visualization of this congenital abnormality, and it is easy to perform with a significantly reduced operative trauma.