Pediatric thyroidectomy in a "low volume" institution without protocolization: results and future horizons. / Tiroidectomía pediátrica en un centro de "bajo volumen" y sin protocolización: resultados y horizontes.

OBJECTIVE: Pediatric thyroidectomy is an infrequent, complex surgery, with high risk of complications. Complication rates and oncological results of non-protocolized thyroidectomy in a secondary pediatric hospital were compared with those from reference institutions. MATERIALS AND METHODS: A retrospective study of patients under 15 years old undergoing thyroidectomy ± cervical lymphadenectomy by low volume pediatric surgeons (<30 cervical endocrine surgeries annually) in a pediatric hospital from January 2010 to January 2020 was carried out. RESULTS: 11 patients undergoing 12 surgeries (mean age: 9.8 years; 63% female) were analyzed. Thyroid nodules were the main surgical indication (50%), and prevalence of genetic mutations was 45%. 1 patient had transient hypocalcemia, and there were 2 cases of transient recurrent laryngeal nerve neuropraxia (16.6%). No permanent complications were noted. 66.6% of pathological reports showed malignancy. Mean hospital stay was 2.35 days (range: 1.25-5), with an overall complication rate of 25%, similar to that reported by high-volume institutions. After a mean follow-up of 4 years, tumor recurrence has not been observed in any patient. CONCLUSIONS: In our view, an experienced pediatric surgeon specialized in pediatric and neonatal general surgery - even if below the high volume threshold - acquires the skills required in pediatric thyroid surgery without an increase in morbidity and mortality. Perioperative management should be agreed and protocolized by the various specialists involved to improve results.

OBJETIVOS: La tiroidectomía pediátrica es una intervención infrecuente, compleja y con un riesgo elevado de complicaciones. Se evalúa la tasa de complicaciones y resultados oncológicos de la tiroidectomía no protocolizada en un hospital infantil de segundo nivel en comparación con los centros de referencia. MATERIAL Y METODOS: Estudio retrospectivo de los pacientes menores de 15 años sometidos a tiroidectomía ± disección ganglionar cervical por cirujanos pediátricos de bajo volumen (< 30 cirugías endocrinas cervicales/año) entre enero de 2010 y enero de 2020 en un hospital infantil. RESULTADOS: Se analizaron once pacientes sometidos a 12 procedimientos quirúrgicos (edad media 9,8 años, 63% niñas). Los nódulos tiroideos fueron la principal indicación quirúrgica (50%) y la prevalencia de mutaciones genéticas en la serie fue del 45%. Un paciente presentó hipocalcemia transitoria y hubo 2 casos de neuropraxia transitoria del nervio laríngeo recurrente (16,6%). No hubo complicaciones permanentes. El 66,6% de los informes anatomopatológicos mostraron malignidad. La estancia hospitalaria media fue de 2,35 días (rango 1,25-5) con una tasa global de complicaciones del 25%, similar a la reportada por centros de alto volumen. Después de un seguimiento medio de 4 años, ningún paciente ha presentado recidiva tumoral. CONCLUSIONES: Sugerimos que un cirujano infantil con experiencia en cirugía pediátrica general y neonatal, a pesar de no superar el umbral de alto volumen, adquiere las facultades para realizar la cirugía tiroidea pediátrica sin aumento de morbilidad y mortalidad. El manejo perioperatorio debe ser consensuado entre los diversos especialistas involucrados y protocolizado para mejorar los resultados.

Tiroidectomía pediátrica en un centro de “bajo volumen” y sin protocolización: resultados y horizontes / Pediatric thyroidectomy in a “low volume” institution without protocolization: results and future horizons

Objetivos: La tiroidectomía pediátrica es una intervención infre-cuente, compleja y con un riesgo elevado de complicaciones. Se evalúala tasa de complicaciones y resultados oncológicos de la tiroidectomía noprotocolizada en un hospital infantil de segundo nivel en comparacióncon los centros de referencia. Material y métodos: Estudio retrospectivo de los pacientes menoresde 15 años sometidos a tiroidectomía ± disección ganglionar cervical porcirujanos pediátricos de bajo volumen (< 30 cirugías endocrinas cervi-cales/año) entre enero de 2010 y enero de 2020 en un hospital infantil. Resultados: Se analizaron once pacientes sometidos a 12 proce-dimientos quirúrgicos (edad media 9,8 años, 63% niñas). Los nódulostiroideos fueron la principal indicación quirúrgica (50%) y la prevalenciade mutaciones genéticas en la serie fue del 45%. Un paciente presentóhipocalcemia transitoria y hubo 2 casos de neuropraxia transitoria delnervio laríngeo recurrente (16,6%). No hubo complicaciones permanen-tes. El 66,6% de los informes anatomopatológicos mostraron malignidad.La estancia hospitalaria media fue de 2,35 días (rango 1,25-5) con unatasa global de complicaciones del 25%, similar a la reportada por centrosde alto volumen. Después de un seguimiento medio de 4 años, ningúnpaciente ha presentado recidiva tumoral. Conclusiones: Sugerimos que un cirujano infantil con experienciaen cirugía pediátrica general y neonatal, a pesar de no superar el umbralde alto volumen, adquiere las facultades para realizar la cirugía tiroideapediátrica sin aumento de morbilidad y mortalidad. El manejo periopera-torio debe ser consensuado entre los diversos especialistas involucradosy protocolizado para mejorar los resultados.(AU)

Objective: Pediatric thyroidectomy is an infrequent, complex sur-gery, with high risk of complications. Complication rates and oncolog-ical results of non-protocolized thyroidectomy in a secondary pediatrichospital were compared with those from reference institutions. Materials and methods: A retrospective study of patients under15 years old undergoing thyroidectomy ± cervical lymphadenectomyby low volume pediatric surgeons (<30 cervical endocrine surgeriesannually) in a pediatric hospital from January 2010 to January 2020was carried out. Results: 11 patients undergoing 12 surgeries (mean age: 9.8 years;63% female) were analyzed. Thyroid nodules were the main surgical in-dication (50%), and prevalence of genetic mutations was 45%. 1 patienthad transient hypocalcemia, and there were 2 cases of transient recurrentlaryngeal nerve neuropraxia (16.6%). No permanent complications werenoted. 66.6% of pathological reports showed malignancy. Mean hospitalstay was 2.35 days (range: 1.25-5), with an overall complication rateof 25%, similar to that reported by high-volume institutions. After amean follow-up of 4 years, tumor recurrence has not been observedin any patient. Conclusions: In our view, an experienced pediatric surgeon spe-cialized in pediatric and neonatal general surgery – even if below thehigh volume threshold – acquires the skills required in pediatric thyroidsurgery without an increase in morbidity and mortality. Perioperative management should be agreed and protocolized by the various specialistsinvolved to improve results.(AU)

Abdominal hernia repair using the Rives-Stoppa technique: an abdominal reconstruction. / Eventroplastia abdominal con técnica de Rives-Stoppa: reconstruyendo un abdomen.

INTRODUCTION: Retromuscular mesh hernia repair using Rives-Stoppa technique has demonstrated the best results when it comes to repairing large midline hernias. We present the first pediatric case successfully treated with this technique. CLINICAL CASE: This is the case of a 9-year-old male patient with hernia following urgent midline laparotomy. Basic repair principles included opening of the hernia sac and adhesiolysis, longitudinal incision on the posterior sheath of the rectus muscle and division of the retromuscular space, closure of the posterior sheath, placement of a mesh on this plane in the brand-new retromuscular space, and tension-free closure of the anterior musculo-aponeurotic flap, thus reconstructing the midline. No recurrences have been noted after a 2-year follow-up. DISCUSSION: Rives-Stoppa technique allows for a more anatomical layered reconstruction, which helps restore the anatomical and physiological properties of the abdominal wall. In our view, this could be a useful alternative for pediatric hernia treatment.

INTRODUCCION: La eventroplastia con malla retromuscular de Rives-Stoppa ha demostrado en adultos tener los mejores resultados en la reparación de las grandes eventraciones de la línea media. Presentamos el primer caso pediátrico tratado exitosamente con esta técnica. CASO CLINICO: Varón de 9 años con eventración tras laparotomía media urgente. Los principios básicos de la corrección fueron: apertura del saco herniario y adhesiolisis, incisión longitudinal sobre la vaina posterior del músculo recto y tallado del espacio retromuscular, cierre de la vaina posterior, colocación de una malla sobre este plano alojándola en el espacio retromuscular creado y cierre sin tensión del colgajo musculo-aponeurótico anterior, reconstruyendo así la línea media. No recidiva tras 2 años de seguimiento. COMENTARIOS: La técnica de Rives-Stoppa implica una reconstrucción por planos más anatómica que restaura las propiedades anatomofisiológicas de la pared abdominal. Consideramos que puede ser una alternativa útil en el tratamiento de las eventraciones pediátricas.

Eventroplastia abdominal con técnica de Rives-Stoppa: reconstruyendo un abdomen / Abdominal hernia repair using the Rives-Stoppa technique: an abdominal reconstruction

Introducción: La eventroplastia con malla retromuscular de Rives-Stoppa ha demostrado en adultos tener los mejores resultados en lareparación de las grandes eventraciones de la línea media. Presentamosel primer caso pediátrico tratado exitosamente con esta técnica. Caso clínico: Varón de 9 años con eventración tras laparotomíamedia urgente. Los principios básicos de la corrección fueron: aperturadel saco herniario y adhesiolisis, incisión longitudinal sobre la vainaposterior del músculo recto y tallado del espacio retromuscular, cierrede la vaina posterior, colocación de una malla sobre este plano aloján-dola en el espacio retromuscular creado y cierre sin tensión del colgajomusculo-aponeurótico anterior, reconstruyendo así la línea media. Norecidiva tras 2 años de seguimiento. Comentarios: La técnica de Rives-Stoppa implica una reconstruc-ción por planos más anatómica que restaura las propiedades anatomo-fisiológicas de la pared abdominal. Consideramos que puede ser unaalternativa útil en el tratamiento de las eventraciones pediátricas.(AU)

Introduction: Retromuscular mesh hernia repair using Rives-Stoppatechnique has demonstrated the best results when it comes to repairinglarge midline hernias. We present the first pediatric case successfullytreated with this technique. Clinical case: This is the case of a 9-year-old male patient with her-nia following urgent midline laparotomy. Basic repair principles includedopening of the hernia sac and adhesiolysis, longitudinal incision on the posterior sheath of the rectus muscle and division of the retromuscularspace, closure of the posterior sheath, placement of a mesh on this planein the brand-new retromuscular space, and tension-free closure of theanterior musculo-aponeurotic flap, thus reconstructing the midline. Norecurrences have been noted after a 2-year follow-up. Discussion: Rives-Stoppa technique allows for a more anatomicallayered reconstruction, which helps restore the anatomical and physi-ological properties of the abdominal wall. In our view, this could be auseful alternative for pediatric hernia treatment.(AU)

Pilas de botón impactadas en esófago: una emergencia quirúrgica potencialmente fatal en la infancia / Impaction of button batteries in the esophagus: a potentially fatal surgical emergency in infancy

Con la reciente popularización de las pilas de botón, ha aumentado la incidencia de casos de niños que las ingieren. A diferencia de otros cuerpos extraños, es más probable que las pilas de botón desarrollen complicaciones graves debido a la posibilidad de lesionar precozmente los tejidos con los que contactan. Se presenta el caso de un niño de 22 meses de edad que ingirió una pila de botón que quedó impactada en esófago cervical. Su retirada por vía endoscópica fue imposible, precisando esofagotomía abierta para su extracción. En el postoperatorio presentó una fístula esófago-cutánea que cerró espontáneamente, y una estenosis esofágica que se resolvió mediante dilataciones endoscópicas con balón. Analizamos las recomendaciones descritas en la literatura reciente contrastándolas con nuestro protocolo de actuación ante ingesta de cuerpos extraños, y se proponen medidas a la industria electrónica para reducir el riesgo de ingestión de pilas de botón en niños pequeños

With the recent popularization of button batteries, the incidence of cases of children who ingest them has risen. Unlike other foreign bodies, button batteries are more likely to develop severe complications due to the possibility of early injury to the tissues in direct contact with them. We present the case of a 22-month-old boy who ingested a button battery which subsequently became lodged in the cervical esophagus. The endoscopic attempt to remove the battery failed, requiring an open esophagotomy for its extraction. In the postoperative period, he presented an esophagocutaneous fistula that closed spontaneously, and an esophageal stricture that was treated successfully with endoscopic balloon dilations. We reviewed the literature analyzing the recommendations recently outlined and contrasted them with our own protocol for management of ingested foreign bodies. In addition, measures aimed at reducing the risk of button battery ingestion in small children are proposed to the electronics manufacturing industry

[Impaction of button batteries in the esophagus: a potentially fatal surgical emergency in infancy].

With the recent popularization of button batteries, the incidence of cases of children who ingest them has risen. Unlike other foreign bodies, button batteries are more likely to develop severe complications due to the possibility of early injury to the tissues in direct contact with them. We present the case of a 22-month-old boy who ingested a button battery which subsequently became lodged in the cervical esophagus. The endoscopic attempt to remove the battery failed, requiring an open esophagotomy for its extraction. In the postoperative period, he presented an esophagocutaneous fistula that closed spontaneously, and an esophageal stricture that was treated successfully with endoscopic balloon dilations. We reviewed the literature analyzing the recommendations recently outlined and contrasted them with our own protocol for management of ingested foreign bodies. In addition, measures aimed at reducing the risk of button battery ingestion in small children are proposed to the electronics manufacturing industry.

Un lactante con neumatosis intestinal y neumoperitoneo: la difícil decisión de no intervenir / An infant with intestinal pneumatosis and pneumoperitoneum: the difficult decision not to intervene

El neumoperitoneo en niños puede deberse a causas que no requieran cirugía urgente, como maniobras de reanimación cardiopulmonar, patología respiratoria grave o ventilación mecánica. Intervenir en estos casos podría, incluso, empeorar el pronóstico. Presentamos el caso clínico de un lactante varón, exprematuro, con antecedente al nacer de enterocolitis necrotizante y perforación ileal, que precisó laparotomía y resección intestinal en dos ocasiones y que desarrolló un microcolon por desuso secundario. A los seis meses, tras iniciar alimentación oral exclusiva, presentó distensión abdominal con extensa neumatosis intestinal y neumoperitoneo en las radiografías. Su aspecto era bueno con tránsito intestinal conservado y ausencia de peritonitis. El paciente se mantuvo a dieta absoluta con antibioterapia endovenosa, sondaje nasogástrico y nutrición parenteral. La evolución fue favorable, reiniciando la alimentación oral a los siete días del ingreso. La existencia de un neumoperitoneo no siempre obliga a realizar una laparotomía, y la valoración global del enfermo por un equipo multidisciplinar puede evitar tratamientos agresivos innecesarios

Pneumoperitoneum in children may be due to causes that do not require urgent surgery (cardiopulmonary resuscitation manoeuvres, severe respiratory pathology or mechanical ventilation). Surgery in these cases could even worsen the prognosis. We present the case of a male infant, ex-preterm, with a history of necrotizing enterocolitis and ileal perforation at birth, requiring laparotomy and intestinal resection on two occasions and developing a secondary microcolon, due to disuse. At six months, after transitioning to full oral feeding, he presented abdominal distension with extensive intestinal pneumatosis and pneumoperitoneum on radiographs. His general appearance was good with normal intestinal transit and no peritonitis. The patient remained fasting with intravenous antibiotics, nasogastric decompression and parenteral nutrition. The evolution was favourable with oral feeding restarting on the seventh day of admission. The existence of pneumoperitoneum does not always require a laparotomy and global assessment of the patient by an interdisciplinary health team may avoid unnecessary aggressive treatments

[An infant with intestinal pneumatosis and pneumoperitoneum: the difficult decision not to intervene]. / Un lactante con neumatosis intestinal y neumoperitoneo: la difícil decisión de no intervenir.

Pneumoperitoneum in children may be due to causes that do not require urgent surgery (cardiopulmonary resuscitation manoeuvres, severe respiratory pathology or mechanical ventilation). Surgery in these cases could even worsen the prognosis. We present the case of a male infant, ex-preterm, with a history of necrotizing enterocolitis and ileal perforation at birth, requiring laparotomy and intestinal resection on two occasions and developing a secondary microcolon, due to disuse. At six months, after transitioning to full oral feeding, he presented abdominal distension with extensive intestinal pneumatosis and pneumoperitoneum on radiographs. His general appearance was good with normal intestinal transit and no peritonitis. The patient remained fasting with intravenous antibiotics, nasogastric decompression and parenteral nutrition. The evolution was favourable with oral feeding restarting on the seventh day of admission. The existence of pneumoperitoneum does not always require a laparotomy and global assessment of the patient by an interdisciplinary health team may avoid unnecessary aggressive treatments.

Apendicectomía videoasistida transumbilical por puerto único. Qué hemos ganado y qué hemosperdido después de 754 casos / Single port video-assisted transumbilical appendectomy. What have we gained and what have we lost after 754 cases

Introducción. La técnica de elección para la apendicectomía en nuestro servicio es la videoasistida transumbilical por puerto único(AVT). Inicialmente reservada para casos no complicados y paulatinamente en todos. Hemos adquirido gran experiencia y ha llegado el momento de compartirla, evaluar los resultados y plantearnos otras posibilidades. Material y métodos. Trabajo retrospectivo y descriptivo en el que se valoran, mediante análisis estadístico, los cambios sufridos a lo largo de los años de AVT en aspectos como mejoras técnicas, indicaciones, complicaciones, estancias y reingresos. Resultados. Desde septiembre de 2003 hemos realizado 1.022 apendicectomías (61% varones). En 841 casos iniciamos abordaje umbilical, completándose sin problemas en el 89,65%. En 179 pacientes el cirujano optó por una laparotomía directa por apendicitis complicada, obesidado preferencia personal (43 en el primer año y solo 3 en 2011). Noventa y siete enfermos tuvieron complicaciones, de los cuales 15 reingresaron para tratamiento médico y 3 fueron reintervenidos. El ahorro frente a la laparoscopia se estima en 750.000 €.Discusión. La AVT es una técnica sencilla, fácil de aprender, sin complicaciones añadidas, barata y beneficiosa para los pacientes. Sin embargo, al limitarnos a ella hemos perdido oportunidades y habilidades laparoscópicas. Conclusiones. La AVT sigue siendo nuestra preferencia en la apendicectomía, pero cada vez más pacientes seleccionados serán sometidos a laparoscopia convencional (AU)

Introduction. Single-port transumbilical laparoscopically assisted appendectomy (TULAA) has become the preferred method of treating appendicitis in our Department. At first, it was reserved for non complicated cases, and gradually for the rest of them. We have gained experience, and it is time to share it, evaluate the results and raise into new possibilities. Material and Methods. We performed a retrospective statistical analysis of undergone changes over the last years, referring to aspects such as surgical indications, and postoperative complications, hospital stays and re-admissions. Results. From September 2003 to January 2012, a total of 1,022appendectomies were performed. Eight hundred and forty-one children underwent TULAA, 89.65% were completed with no problems. In 179patients, open appendectomy was initially chosen. In those cases, the reasons were complicated appendicitis, obesity or surgeon’s preference(43 in the first year and just 3 in the last one). Ninety seven patients had postoperative complications of any kind, fifteen were readmitted to the hospital and 3 were reoperated because of intestinal obstruction. Medical cost savings were estimated around 750.000 €.Conclusions. We think that TULAA is a simple and easy learning procedure, which does not result in any increase in complications, inexpensive and beneficial for patients. However, along these years, our surgical staff may have lost skills and training opportunities in conventional laparoscopic surgery. So although TULAA is still our preferred method in appendicectomy, selected cases will undergo laparoscopic appendectomy (AU)

Mortalidad y morbilidad de neonatos de muy bajo peso asistidos en el País Vasco y Navarra (2001-2006): estudio de base poblacional / Mortality and morbidity in very low birth weight infants in the Basque Country and Navarra (2001-2006): population-based study

Introducción: Este estudio describe la morbilidad y mortalidad de los recién nacidos de muy bajo peso (RNMBP) asistidos en las unidades neonatales del País Vasco y Navarra entre los años 2001-2006, y evalúa los factores que afectan a la mortalidad. Pacientes y métodos: Estudio descriptivo observacional de una cohorte de 1.318 RNMBP asistidos entre el año 2001 y 2006 en cinco hospitales del País Vasco y Navarra. Se recogieron un total de 37 variables incluidas en la base de datos de EuroNeoNet, que se refieren a factores perinatales de riesgo y protectores, características demográficas, días de ingreso, intervenciones, morbilidades y mortalidad. Resultados: Un 94% de las mujeres embarazadas recibieron cuidados prenatales y un 78,7% administración de esteroides prenatales, en ambos casos hubo un aumento significativo durante el periodo estudiado. El 42% de los embarazos fueron múltiples y en un 63% el parto fue por cesárea. La displasia broncopulmonar disminuyó de manera estadísticamente significativa de un 20 a un 15%. La incidencia de hemorragia intraventricular de grado III o IV fue de 7,5% y de leucomalacia periventricular de un 3,1%. Se diagnosticó infección vertical en un 4% de niños y sepsis o meningitis tardía en 25%, enterocolitis necrotizante en 9% y persistencia del conducto arterioso en el 14% de los niños. El tratamiento con indometacina o ibuprofeno disminuyó significativamente durante el estudio. La tasa bruta de mortalidad neonatal total, tardía y precoz se ha mantenido constante en este periodo de tiempo. La mortalidad neonatal inmediata mostró una tendencia descendente y una diferencia significativa por sexo, siendo esta mayor en los varones. Conclusión: Este estudio de base poblacional aporta información valiosa sobre variables resultado en UCIN y puede ayudar en el planteamiento de intervenciones que mejoren la calidad asistencial y disminuyan la morbilidad y mortalidad en estos neonatos de alto riesgo(AU)

Introduction: This study describes very low birth weight (VLBW) infant morbidity and mortality in Basque Country and Navarra neonatal units between the years 2001-2006, and evaluates the factors that affect the mortality. Patients and methods: A descriptive observational study of a cohort of 1,318 VLBW infants in neonatal units in five Basque Country and Navarra hospitals between 2001 and 2006. A total of 37 variables included in EuroNeoNet database were collected as regards, perinatal risk and protective factors, demographic characteristics, length of stay, interventions, morbidity and mortality. Results: A total of 94% of pregnant women received prenatal care and 78.7% antenatal steroids. In both cases there was a significant increase during the period studied. A total of 42% of pregnancies were multiple and in 63% delivery was by Caesarean section. Bronchopulmonary dysplasia statistically significantly decreased from 20% to 15%. The incidence of intraventricular haemorrhage grade III or IV was 7.5% and for periventricular leukomalacia it was 3.1%. Vertical infection was diagnosed in 4% of infants and sepsis or late meningitis in 25%, necrotizing enterocolitis in 9% and patent ductus arteriosus in 14% of the infants. The prophylactic or therapeutic treatment with indometacin or ibuprofen decreased significantly during the study. The overall rate of total, late and first day neonatal mortality was almost constant during this period of time. Nevertheless, the early neonatal mortality showed a decreasing trend and with a significant difference between sexes, being higher in males. Conclusion: This population-based study provides valuable information on clinical outcomes in NICUs, and may help in planning strategies to improve health care quality, and to reduce the morbidity and mortality in these neonates at high risk(AU)

[Mortality and morbidity in very low birth weight infants in the Basque Country and Navarra (2001-2006): population-based study]. / Mortalidad y morbilidad de neonatos de muy bajo peso asistidos en el País Vasco y Navarra (2001-2006): estudio de base poblacional.

INTRODUCTION: This study describes very low birth weight (VLBW) infant morbidity and mortality in Basque Country and Navarra neonatal units between the years 2001-2006, and evaluates the factors that affect the mortality. PATIENTS AND METHODS: A descriptive observational study of a cohort of 1,318 VLBW infants in neonatal units in five Basque Country and Navarra hospitals between 2001 and 2006. A total of 37 variables included in EuroNeoNet database were collected as regards, perinatal risk and protective factors, demographic characteristics, length of stay, interventions, morbidity and mortality. RESULTS: A total of 94% of pregnant women received prenatal care and 78.7% antenatal steroids. In both cases there was a significant increase during the period studied. A total of 42% of pregnancies were multiple and in 63% delivery was by Caesarean section. Bronchopulmonary dysplasia statistically significantly decreased from 20% to 15%. The incidence of intraventricular haemorrhage grade III or IV was 7.5% and for periventricular leukomalacia it was 3.1%. Vertical infection was diagnosed in 4% of infants and sepsis or late meningitis in 25%, necrotizing enterocolitis in 9% and patent ductus arteriosus in 14% of the infants. The prophylactic or therapeutic treatment with indometacin or ibuprofen decreased significantly during the study. The overall rate of total, late and first day neonatal mortality was almost constant during this period of time. Nevertheless, the early neonatal mortality showed a decreasing trend and with a significant difference between sexes, being higher in males. CONCLUSION: This population-based study provides valuable information on clinical outcomes in NICUs, and may help in planning strategies to improve health care quality, and to reduce the morbidity and mortality in these neonates at high risk.

[Single port video-assisted transumbilical appendectomy. What have we gained and what have we lost after 754 cases]. / Apendicectomía videoasistida transumbilical por puerto único. Qué hemos ganado y qué hemos perdido después de 754 casos.

INTRODUCTION: Single-port transumbilical laparoscopically assisted appendectomy (TULAA) has become the preferred method of treating appendicitis in our Department. At first, it was reserved for noncomplicated cases, and gradually for the rest of them. We have gained experience, and it is time to share it, evaluate the results and raise into new possibilities. MATERIAL AND METHODS: We performed a retrospective statistical analysis of undergone changes over the last years, referring to aspects such as surgical indications, andpostoperative complications, hospital stays and re-admissions. RESULTS: From September 2003 to January 2012, a total of 1,022 appendectomies were performed. Eight hundred and forty-one children underwent TULAA, 89.65% were completed with no problems. In 179 patients, open appendectomy was initially chosen. In those cases, the reasons were complicated appendicitis, obesity or surgeon's preference (43 in the first year and just 3 in the last one). Ninety seven patients had postoperative complications of any kind, fifteen were readmitted to the hospital and 3 were reoperated because of intestinal obstruction. Medical cost savings were estimated around 750.000 Euros. CONCLUSIONS: We think that TULAA is a simple and easy learning procedure, which does not result in any increase in complications, inexpensive and beneficial for patients. However, along these years, our surgical staff may have lost skills and training opportunities in conventional laparoscopic surgery. So although TULAA is still our preferred method in appendicectomy, selected cases will undergo laparoscopic appendectomy.

Tratamiento del niño quemado en Atención Primaria / Treatment of burns in children in Primary Care

Las quemaduras en la infancia, a pesar de las campañas preventivas, continúan siendo un accidente frecuente. Los niños pequeños son la población más afectada. La mayoría no son graves y sólo precisan atención ambulatoria, pero, en ocasiones, pueden producir una importante morbimortalidad. Actualmente continúan siendo la tercera causa de muerte en la infancia. La causa más frecuente suelen ser las escaldaduras y éstas se producen habitualmente en el domicilio y, en muchas ocasiones, en presencia de algún adulto. El manejo inicial correcto y una valoración adecuada de la gravedad son importantes en el pronóstico. La mayoría de las quemaduras son evitables. Divulgar e insistir en las medidas preventivas continúa siendo fundamental para el descenso de este problema. Por su accesibilidad, el pediatra de Atención Primaria debe tener un papel destacado en este objetivo (AU)

In spite of the preventive campaigns, paediatric burns are still a frequent accident. Small children are the most affected population. Although the majority of burns are not serious and only need ambulatory care, a reduced number can produce great morbidity and even mortality. Currently burns continue being the third cause of death in paediatrics. Burns are most frequently caused by hot liquids and they often happened at home in the presence of some adult people. A correct initial management and an adequate appraisal of the severity are very important to set the right treatment needed and to predict the outcome. Almost all burns are avoidable. We have to face the task of spread educational and preventive measures to take out this problem. The paediatrician of Primary Care is, by his own nature, the main actor in this important target (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)

La agenesia aislada del músculo pectoral mayor: ¿patología infradiagnosticada? / Isolated agenesia of the major pectoral muscle: an underdiagnosed pathology?

Se presenta el caso de un enfermo de 9 años remitido por su pediatra por padecer una alteración del contorno axilar. La exploración física sugería la ausencia de músculo pectoral mayor derecho, lo que se demostró con la realización de una tomografía axial computarizada. No existían otras malformaciones ni deficiencias funcionales asociadas y el impacto estético del defecto era leve, por lo que, de momento, no se ha efectuado ninguna intervención terapéutica

One case of a 9-year-old male with agenesia of the pectoral muscle is presented. Was submitted because the axilar contour was asymmetric. Clinical examination suggested absence of the right pectoral muscle. CAT confirmed this issue. No other associated malformations or functional deficiencies were noted. As aesthetic impact was light no surgery has been necessary at this moment

[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)

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)

[Thrombosis of the superior sagittal sinus in a breast fed infant: secondary to prolonged exposure to mesalazine?]. / Trombosis del seno longitudinal superior en un lactante: ¿secundaria a una exposición prolongada a mesalazina?

INTRODUCTION: Mesalazine or 5 aminosalicylic acid (5 ASA) is currently a first choice drug in the treatment of inflammatory bowel disease. It has been shown that it crosses the placenta and is excreted into breast milk in small quantities. CASE REPORT: We present the case of a four month old breast fed infant, with a thrombosis of the superior sagittal sinus secondary to a severe thrombocytosis (1,124,000/mm3). The only interesting antecedent we would draw attention to, is that breast feeding had been suddenly stopped the week before. The mother, suffering Crohn s disease, had been receiving treatment with oral mesalazine throughout her pregnancy and during lactation. CONCLUSIONS: Once other causes of the thrombocytosis had been eliminated, we based our approach on the hypothesis that it was due to prolonged intake of 5 ASA by the mother.

Trombosis del seno longitudinal superior en un lactante: ¿secundaria a una exposición prolongada a mesalazina? / Thrombosis of the superior sagittal sinus in a breast-fed infant: secondary to prolonged exposure to mesalazine?

Introducción. La mesalazina o ácido 5-aminosalicílico (5-ASA) es actualmente un fármaco de primera elección en el tratamiento de la enfermedad inflamatoria intestinal. Se ha demostrado que atraviesa la placenta y que se excreta a la leche materna, aunque en pequeñas cantidades. Caso clínico. Presentamos el caso de una lactante de 4 meses de edad, afectada de una trombosis del seno venoso longitudinal superior, secundaria a una grave trombocitosis (1.124.000/mm3). Destacaremos como único antecedente de interés que la semana anterior se había suprimido bruscamente la lactancia materna. Su madre, afectada de la enfermedad de Crohn, se había tratado con mesalazina oral durante todo el embarazo y el período de lactancia. Conclusiones. Descartadas otras causas de trombocitosis, planteamos la hipótesis de que ésta se deba a la ingesta materna prolongada de 5-ASA (AU)