Fibrin glue treatment associated or not with diathermy for recurrent tracheoesophageal fistula: our results after more than 20 years' experience. / Tratamiento con adhesivo de fibrina asociado o no a diatermia para las fístulas traqueoesofágicas recurrentes: resultados tras más de 20 años de experiencia.

INTRODUCTION: Recurrent tracheoesophageal fistula (RTEF) is a frequent complication (5-10%) in patients with esophageal atresia (EA). Open RTEF surgery has a high morbidity and mortality, so the endoscopic approach represents a promising alternative. We present the long-term results of fibrin glue (FG) bronchoscopic application in patients with RTEF secondary to EA, which was first used by our team in 1994. MATERIAL AND METHODS: A retrospective review of all patients diagnosed with RTEF following EA repair and treated with FG bronchoscopic application from 1993 to 2019 was carried out. In most cases, diathermy was applied prior to FG sealing. The maximum number of endoscopic sessions was 5. In case of persistent RTEF following the fifth session, open surgery was performed. RESULTS: 14 RTEF patients were treated with FG. In all but the first 3 cases (11 patients, 78.6%), diathermy was applied concomitantly. Mean first treatment day was day 85 of life (range: 14-770). Patients received a mean of 2.1 (1-5) endoscopic sessions. Mean follow-up was 12.1 (10-20) years. Overall success rate was 71.4%, without significant differences according to whether diathermy was concomitantly applied or not (72.7% vs. 66.6%). CONCLUSIONS: Fibrin glue bronchoscopic application associated or not associated with diathermy is an excellent option for RTEF treatment in EA patients. The endoscopic approach should be considered as the first-choice treatment for RTEF.

INTRODUCCION: La fístula traqueoesofágica recurrente (FTER) representa una complicación frecuente (5-10%) en los pacientes con atresia de esófago (AE). La cirugía abierta de FTER implica una alta morbimortalidad, por lo que los abordajes endoscópicos suponen una alternativa prometedora. Presentamos los resultados a largo plazo de la aplicación broncoscópica de adhesivo de fibrina (AF) en pacientes con FTER secundaria a AE, técnica utilizada por primera vez en 1994 por nuestro equipo. METODOS: Revisión retrospectiva de 1993 a 2019, incluyendo a todos los pacientes diagnosticados de FTER tras la reparación de AE, y tratados con aplicación broncoscópica de AF. En la mayoría de los casos se aplicó diatermia previamente al sellado con AF. El número máximo de sesiones endoscópicas se estableció en cinco; en caso de persistir FTER tras la quinta sesión, se procedió a cirugía abierta. RESULTADOS: 14 pacientes con FTER fueron tratados con AF; en todos salvo los primeros 3 casos (11 pacientes, 78,6%) se aplicó diatermia concomitante. El día promedio del primer tratamiento fue el día 85 de vida (14 a 770). Los pacientes recibieron una media de 2,1 (1-5) sesiones endoscópicas. El seguimiento medio fue de 12,1 (10-20) años. El éxito global fue del 71,4%, sin apenas variar con la aplicación o no de diatermia concomitante (72,7% vs. 66,6%). CONCLUSIONES: La aplicación broncoscópica de adhesivo de fibrina asociado o no a diatermia representa una excelente opción para el tratamiento de FTER en pacientes con AE. El abordaje endoscópico debe considerarse como tratamiento de primera elección para FTER.

Tratamiento con adhesivo de fibrina asociado o no a diatermia para las fístulas traqueoesofágicas recurrentes: resultados tras más de 20 años de experiencia / Fibrin glue treatment associated or not with diathermy for recurrent tracheoesophageal fistula: our results after more than 20 years' experience

INTRODUCCIÓN: La fístula traqueoesofágica recurrente (FTER) representa una complicación frecuente (5-10%) en los pacientes con atresia de esófago (AE). La cirugía abierta de FTER implica una alta morbimortalidad, por lo que los abordajes endoscópicos suponen una alternativa prometedora. Presentamos los resultados a largo plazo de la aplicación broncoscópica de adhesivo de fibrina (AF) en pacientes con FTER secundaria a AE, técnica utilizada por primera vez en 1994 por nuestro equipo. MÉTODOS: Revisión retrospectiva de 1993 a 2019, incluyendo a todos los pacientes diagnosticados de FTER tras la reparación de AE y tratados con aplicación broncoscópica de AF. En la mayoría de los casos se aplicó diatermia previamente al sellado con AF. El número máximo de sesiones endoscópicas se estableció en cinco; en caso de persistir FTER tras la quinta sesión, se procedió a cirugía abierta. RESULTADOS: 14 pacientes con FTER fueron tratados con AF; en todos salvo los primeros 3 casos (11 pacientes, 78,6%) se aplicó diatermia concomitante. El día promedio del primer tratamiento fue el día 85 de vida (14 a 770). Los pacientes recibieron una media de 2,1 (1-5) sesiones endoscópicas. El seguimiento medio fue de 12,1 (10-20) años. El éxito global fue del 71,4%, sin apenas variar con la aplicación o no de diatermia concomitante (72,7% vs. 66,6%). CONCLUSIONES: La aplicación broncoscópica de adhesivo de fibrina asociado o no a diatermia representa una excelente opción para el tratamiento de FTER en pacientes con AE. El abordaje endoscópico debe considerarse como tratamiento de primera elección para FTER

INTRODUCTION: Recurrent tracheoesophageal fistula (RTEF) is a frequent complication (5-10%) in patients with esophageal atresia (EA). Open RTEF surgery has a high morbidity and mortality, so the endoscopic approach represents a promising alternative. We present the long-term results of fibrin glue (FG) bronchoscopic application in patients with RTEF secondary to EA, which was first used by our team in 1994. MATERIALS AND METHODS: A retrospective review of all patients diagnosed with RTEF following EA repair and treated with FG bronchoscopic application from 1993 to 2019 was carried out. In most cases, diathermy was applied prior to FG sealing. The maximum number of endoscopic sessions was 5. In case of persistent RTEF following the fifth session, open surgery was performed. RESULTS: 14 RTEF patients were treated with FG. In all but the first 3 cases (11 patients, 78.6%), diathermy was applied concomitantly. Mean first treatment day was day 85 of life (range: 14-770). Patients received a mean of 2.1 (1-5) endoscopic sessions. Mean follow-up was 12.1 (10-20) years. Overall success rate was 71.4%, without significant differences according to whether diathermy was concomitantly applied or not (72.7% vs. 66.6%). CONCLUSIONS: Fibrin glue bronchoscopic application associated or not associated with diathermy is an excellent option for RTEF treatment in EA patients. The endoscopic approach should be considered as the first-choice treatment for RTE

Aspiración de cuerpo extraño, un problema potencialmente letal menospreciado / Foreign body aspiration. An underestimated life-threatening problem

Objetivos: realizar un estudio retrospectivo y analítico de los casos de aspiración de cuerpo extraño de los últimos 12 años, valorando su incidencia, su evolución y su prevención. Material y métodos:se presentan 175 pacientes (112 hombres y 63 mujeres) visitados en nuestro hospital desde enero de 2000 a diciembre de 2012 con sospecha de aspiración de cuerpo extraño (CE). Se analizan los resultados mediante pruebas Ji-cuadrado (χ²) y U-Mann-Whitney (U). Resultados:la media de edad fue de 3,3 años (desviación estándar: 2,1). El tiempo de evolución hasta que acudieron a Urgencias de nuestro centro fue menor de tres días en el 70,3% (123) de los casos. El CE más frecuentemente broncoaspirado fueron los frutos secos (79,3%). El 77,7% de los casos no presentó complicaciones al diagnóstico, el 21,1% presentó neumonía y el 1,1% fue exitus. El análisis estadístico demostró una relación significativa respecto al tiempo de evolución y las complicaciones al diagnóstico (χ²=42,36; p=0,000). Por el contrario, no existió asociación entre el tiempo de evolución y el número de broncoscopias necesarias para la extracción del CE (U=3121,5; p=0,686). En cambio, el tiempo de evolución sí influyó en la duración de la estancia hospitalaria (U=2521,5; p=0,025). Conclusiones: la aspiración de CE es un proceso frecuente y con complicaciones graves. La incidencia no ha disminuido a lo largo de estos últimos años, siendo máxima en el año 2001 (6,34 casos por 100 000 habitantes) y mínima en el 2007 (2,04/100 000 habitantes) (AU)

Purpose: to conduct a retrospective and analytical study of cases of foreign body (FB) aspiration over the last 12 years, assessing their impact, evolution and prevention. Methods: we present 175 patients (112 male and 63 female) admitted to our hospital from January 2000 to December 2012 and diagnosed with clinically suspected foreign body aspiration (FB). The results are analyzed using Chi-square test and Mann-Whitney U test. Results: the mean age was 3.3 years (SD: 2.1). Time delay until consultation to the ER was less than 3 days in 70.3% (123 cases). Nuts were the most frequent FB (79.3%). Complications at diagnosis: none (77.7%), pneumonia (21.1%), exitus (1.1%). We found a significant relationship between time delay until consultation and complications at diagnosis (χ²=42.36; p=0.000), but there was no association between this time interval and the number of bronchoscopies needed for the extraction of the FB (U=3121.5; p=0.686). In contrast, time delay did influence the length of hospital stay (U=2521.5; p=0.025). Conclusion: FB aspiration remains a serious and frequent problem in paediatric patients. The incidence has not declined over recent years, the highest being in 2001 (6.34 per one hundred thousand children under 14 from Castellon and Valencia) and the lowest in 2007 (2.04/100,000) (AU)

[Long gap esophageal atresia: Schärli versus Foker]. / Atresia esofágica long-gap. Schärli versus Foker.

PURPOSE. To submit the short and long term results of long-gap esophageal atresia (EA) with two surgical techniques. METHODS. We carried out a retrospective study of long-gap type EA without fistula (n=8) and with fistula (n=2) over the last 18 years, comparing the outcome of the Schärli technique (1992) with that of the Foker technique (1997). RESULTS. We included 10 patients with long gap EA. Mean birth weight was 2,418 grams. 30% had associated diseases (VACTERL, Down Syndrome, DiGeorge Syndrome). Gastrostomy or jejunostomy was initially placed in 7 patients. Schärli technique was performed in 4 patients (mean age: 3.3 months), and Foker technique in 6 patients (median age: 23.5 days of life). Complications were: a) Schärli: dehiscence (25%), stenosis (75%), one patient died from his heart disease (25%), colonic herniation through diaphragmatic hiatus (25%). The mean number of stricture dilatations was 7 sessions (S.D. 9.2). a) Foker: dehiscence (83.3%), stenosis (83.3%), gastroesophageal reflux (GER) (83.3%), fistula (16.7%). Mean number of dilatations was 13.7 sessions (S.D. 12.8). All patients operated on with Schärli technique (6-18 years, median follow-up 12 years) were asymptomatic at the time of the study, although one of them had grade III esophagitis in the last biopsy. As for the Foker's, 5 had undergone antireflux surgery and only one was asymptomatic. The rest had complications that were still being treated (stenosis and development of fistulae). CONCLUSION. Treatment of long gap EA remains a surgical challenge. In our experience patients developed fewer complications with the Schärli technique. Nevertheless, it is difficult to make a comparison with such a limited number of patients.

Atresia esofágica long-gap. Schärli versus Foker / Long gap esophageal atresia: schärli versus foker

OBJETIVOS: Presentar los resultados a corto y largo plazo de las atresias de esófago (AE) tipo long-gap con dos técnicas quirúrgicas.Material y métodos. Estudio retrospectivo de AE tipo long-gap sin fístula (n= 8) y con fístula (n= 2) de los últimos 18 años. Se compara el resultado de técnica de Schärli (1992) con la técnica de Foker (1997).Resultados.Se incluyeron 10 pacientes con AE tipo long-gap. Peso medio al nacimiento 2.418 gramos. El 30% tenían patologías asociadas (VACTERL, síndrome de Down, síndrome de DiGeorge). Se realizó gastrostomía o yeyunostomía a 7 pacientes inicialmente. Se realizó la técnica de Schärli en 4 pacientes (edad media 3,3 meses) y 6 con técnica de Foker (edad mediana 23,5 días). Las complicaciones fueron:a) Schärli: dehiscencia (25%), estenosis (75%), exitus por cardiopatía (25%), herniación colónica a través del hiato diafragmático (25%). La media de dilataciones fue de 7 sesiones (SD 9,2).b) Foker: dehiscencia (83,3%), estenosis (83,3%), reflujo gastroesofá-gico (RGE) (83,3%), fistulización (16,7%). La media de dilataciones fue de 13,7 sesiones (SD 12,8).Actualmente los enfermos intervenidos con técnica de Schärli (6-18 años, 12 años evolución media) se encuentran asintomáticos, aunque uno de ellos presenta esofagitis grado III en la última biopsia. En los pacientes en los que se realizó la técnica de Foker, 5 de ellos han sido sometidos a cirugía antirreflujo, solamente uno se encuentra asintomá-tico, el resto siguen en tratamiento de sus respectivas complicaciones.Conclusiones. El tratamiento de la AE tipo "long-gap" sigue siendo un desafío quirúrgico. Nuestra experiencia concluye que la técnica de Schärli presenta menor número de complicaciones. Aunque es difícil establecer esta comparación con un número tan limitado de pacientes

PURPOSE: To submit the short and long term results of long-gap esophageal atresia (EA) with two surgical techniques. METHODS: We carried outa retrospective study of long-gap type EA without fistula (n=8) and with fistula (n=2) over the last 18 years, comparing the outcome of the Schärli technique (1992) with that of the Foker technique (1997). RESULTS: We included 10 patients with long gap EA. Mean birth weight was 2,418 grams. 30% had associated diseases (VACTERL, Down Syndrome, DiGeorge Syndrome). Gastrostomy or jejunostomy was initially placed in 7 patients. Schärli technique was performed in 4 patients (mean age: 3.3 months), and Foker technique in 6 patients (median age: 23.5 days of life). Complications were:a) Schärli: dehiscence (25%), stenosis (75%), one patient died from his heart disease (25%), colonic herniation through diaphragmatic hiatus (25%). The mean number of stricture dilatations was 7 sessions (S.D. 9.2) a) Foker: dehiscence (83.3%), stenosis (83.3%), gastroesophageal reflux (GER) (83.3%), fistula (16.7%). Mean number of dilatations was 13.7 sessions (S.D. 12.8).All patients operated on with Schärli technique (6-18 years, me-dian follow-up 12 years) were asymptomatic at the time of the study, although one of them had grade III esophagitis in the last biopsy. As for the Foker's, 5 had undergone antireflux surgery and only one was asymptomatic. The rest had complications that were still being treated (stenosis and development of fistulae). CONCLUSION: Treatment of long gap EA remains a surgical chal-lenge. In our experience patients developed fewer complications with the Schärli technique. Nevertheless, it is difficult to make a comparison with such a limited number of patients

Hematoma intramural duodenal posbiopsia / Post-biopsy intramural duodenal haematoma

No disponible

[Laparoscopic Kasai portoenterostom: present and future of biliary atresia treatment]. / Intervención de Kasai por vía laparoscópica: presente y futuro del tratamiento de la atresia de vías biliares.

INTRODUCTION: Kasai's operation has proved its value in surgical treatment of biliary atresia (BA). Its laparoscopic approach is a new challenge for pediatric surgeons, with all the potential advantages of minimally invasive surgery. The aim of the present study has been to report our experience in laparoscopic management of five patients with biliary atresia. PATIENTS AND METHODS: The average of age of five patients with biliary atresia, three boys and two girls was 58 days (range 40-64). Pre and postoperative management included antibiotic prophylaxis and choleretic treatment. Laparoscopic procedure was accomplished using one umbilical 10-mm trocar and two additional 5-mm trocars. We carried out the same technique in all the patients except in one of them with a total situs inversus and who compelled us to modify the original procedure. RESULTS: All five patients underwent a laparoscopic procedure, conversion was not necessary. The mean surgical time was 3 hours and 40 minutes (range: 5:30 y 3:10). There were not intra operative complications and all of them had a satisfactory recovery, except for the patient with situs inversus, who suffered a small bowel volvulus 9 days after the operation, leading us to perform an extensive bowel resection. All the patients, except this one, showed signs of adequate bile flow, with disappearance of clinical cholestasis. Biochemistry test became normal. CONCLUSIONS: Besides the certain advantages compared with conventional surgical procedures (lower surgical damage, diminished post-operative recovery), laparoscopic management of BA, allows a better exposure of the porta hepatis without hepatic mobilization so it shows similar or better preliminary results than conventional techniques. The advantages of laparoscopic portoenterostomy are yet to be proved whenever liver transplantation is indicated.

Intervención de Kasai por vía laparoscópica: presente y futuro del tratamiento de la atresia de vías biliares / Laparoscopic Kasai portoenterostom: present and future of biliary atresia treatment

Introducción. La operación de Kasai ha demostrado su eficacia en el tratamiento de los pacientes con atresia de vías biliares (AVB).El abordaje laparoscópico de esta técnica es un nuevo desafío al que ahora nos enfrentamos con las potenciales ventajas que la cirugía mínimamente invasiva puede ofrecer a estos pacientes. Esta comunicación tiene por objeto presentar la técnica utilizada y los resultados obtenidos con la operación de Kasai laparoscópica en cinco pacientes afectos de AVB. Material y métodos. A cuatro pacientes consecutivos, tres niños y una niña, de edad media 58 días (rango 40-64),. se les aplicó el protocolo de manejo pre y postoperatorio de la AVB, que incluye profilaxis antibiótica y tratamiento colerético entre otras medidas. El abordaje laparoscópico se realizó mediante tres puertos: uno umbilical de 10 mm y dos de 5 mm, con instrumental de 5 y 3 mm, y se utilizó el mismo procedimiento técnico en todos los casos excepto en un paciente que presentaba sitos inversas completo y que obligó a modificar ligeramente el procedimiento. Resultados. En todos los pacientes se realizó el procedimiento laparoscópicos in necesidad de conversión. El tiempo medio operatorio fue de3 horas y 40 minutos (rango entre 5:30 y 3:10). No se registraron complicaciones intraoperatorias y todos los pacientes evolucionaron satisfactoriamente a excepción del paciente con situs inversus, que sufrió una ovulación de intestino medio al 9º día del postoperatorio que obligó a una amplia resección intestinal. En todos los pacientes, excepto en este último, se consiguió el reestablecimiento del flujo biliar y la desaparición de la colestasis clínica y analítica. Conclusiones. La aplicación de la cirugía mínimamente invasiva en la AVB, además de las indudables ventajas que ofrece frente a la cirugía convencional (menor agresión quirúrgica, mayor rapidez en la recuperación postoperatoria, etc) permite una mejor visión del porta hepatissin necesidad de movilización hepática y ofrece unos resultados preliminares similares o incluso superiores a la cirugía convencional.Queda pendiente demostrar en un futuro si este tipo de cirugía supondrá un beneficio en el caso de necesidad de trasplante hepático (AU)

Introduction. Kasai´s operation has proved its value in surgical treatment of biliary atresia (BA). Its laparoscopic approach is anew challenge for pediatric surgeons, with all the potential advantages of minimally invasive surgery. The aim of the present study has been to report our experience in laparoscopic management of five patients with biliary atresia. Patients and methods. The average of age of five patients with biliary atresia, three boys and two girls was 58 days (range 40-64). Pre and postoperative management included antibiotic prophylaxis and choleretictreatment. Laparoscopic procedure was accomplished using one umbilical10-mm trocar and two additional 5-mm trocars. We carried out the same technique in all the patients except in one of them with a total situsinversus and who compelled us to modify the original procedure. Results. All five patients underwent a laparoscopic procedure, conversion was not necessary. The mean surgical time was 3 hours and 40minutes (range: 5:30 y 3:10). There were not intra operative complications and all of them had a satisfactory recovery, except for the patient with situs inversus, who suffered a small bowel volvulus 9 days after the operation, leading us to perform an extensive bowel resection. All the patients, except this one, showed signs of adequate bile flow, with disappearance of clinical cholestasis. Biochemistry test became normal. Conclusions. Besides the certain advantages compared with conventional surgical procedures (lower surgical damage, diminished post-operative recovery), laparoscopic management of BA, allows a better exposure of the porta hepatis without hepatic mobilization so it shows similar or better preliminary results than conventional techniques. The advantages of laproscopic portoenterostomy are yet to be proved whenever liver transplantation is indicated (AU)

Long-term assessment of the treatment of recurrent tracheoesophageal fistula with fibrin glue associated with diathermy.

PURPOSE: Recurrent tracheoesophageal fistula (RTF) is a serious common complication of the surgical treatment of esophageal atresia. We report the results of our technique of bronchoscopic treatment of RTF with fibrin glue (Tissucol), with a follow-up of over 1 decade. METHODS: A retrospective review between 1993 and 2004 was conducted, including all patients diagnosed with RTF and treated bronchoscopically with Tissucol, with over 1 year of follow-up. The procedure was implemented under general anesthesia using a rigid neonatal bronchoscope. A magnification chamber and previous diathermia using a urethral catheter were used in the latter 4 patients. The fibrin glue was injected through a clear catheter. The number of endoscopic sessions per patient was limited to 3. RESULTS: Seven patients were treated, with evidence of fistular closure in 6 (85%). One patient with satisfactory results, but a follow-up of 4 months, was not included. The age at bronchoscopy ranged from 14 to 20 days (mean, 16.7 days), and a total of 12 sessions were required (mean, 1.7). In the latter 4 patients, diathermia was associated with good results in all and a lower number of sessions (mean, 1.5). All patients were evaluated clinically and radiologically, and a control endoscopy was performed in 4 patients. The follow-up lasted from 2 to 11 years (mean, 7.4 years). CONCLUSIONS: Because we started to use Tissucol (1994), other authors have reported successful isolated cases, but a relatively large series and a long-term follow-up were lacking. We consider that the success of the procedure depends on several technical factors such as an early diagnosis, before epithelium is formed in the fistula, and the use of initial diathermia, associated in the latter 4 patients. The results obtained with 85% success with a follow-up over 1 year show that the fibrin adhesive is the reference substance for the treatment of RTF; we recommend its endoscopic application associated with diathermia as initial measure.

[Choledocal cyst: analysis of 29 cases and review or the literature]. / Nuestra experiencia en el diagnóstico y tratamiento del quiste de colédoco.

UNLABELLED: The aim of the present study has been to systematize the clinical presentation of the entity named choledochal cyst, in relation with its probable etiopathology and the intraoperative findings as well as its evolution after surgery, based on the revision of the literature and of our experience in 29 cases. MATERIAL AND METHODS: 29 cases of cystic dilatation of the biliar duct extra and/or intrahepatic are analyzed. In 4 cases the diagnosis was prenatal and two were excluded of the study after it has been confirmed they suffered biliary atresia type I. In the left 27 cases, 19 variables are analyzed retrospectively, like age, sex, weight, symptoms, ultrasonographic images, etc. Subsequently, intra-operative cholangiographic findings were correlated with the clinic presentation and the evolution of the patients after surgery. RESULTS: Of the 27 cases analyzed 16 (59,25%) were cystic dilatations from which 14 had a neonatal or early clinic presentation (before 2 years), however the fusiform dilatations were presented later on. From the analyzed symptoms, in relation with the age only the pain and the jaundice showed significant differences, being the pain most frequent in later presentation ande the jaundice in the early form. The two cases of type 3 of Todani or choledochocele were of later presentation. An anomaly in the bilionpacreatric junction was detected in 15 patients; the majority had a later presentation, associated to pancreatitis in 4 cases. Primary cyst excision and biliary Roux-en-Y reconstruction was the treatment of election in the majority of cases. In 3 cases we used the appendix to replace the choledocus, but all three cases were reconverted two years later because of permanent elevation of ALT and GGT. CONCLUSIONS: In favour of the literature and of our experience nowadays it would be possible to systematize this malformation and make a division in two groups, depending on the cholangiographic findings and clinical presentation: 1. Cystic dilatations with a clinical neonatal presentation or beneath 2 years. 2. Fusiform dilatations with a later clinical predominance and associated frequently to pancreatitis and anomalous pancreatobiliary junction. Choledochocele is an entity that must be considered not only for its etiology but for its clinical presentation and treatment. Primary cyst excision and biliary Roux-en-Y reconstruction is the treatment of election. Regular long-term review of these patients is mandatory in the surveillance of sub-clinic cholangitis and the risk of possible long-term malignance of this entity.

Nuestra experiencia en el diagnóstico y tratamiento del quiste de colédoco / Choledocal cyst: analysis of 29 cases and review or the literature

El objeto del presente estudio ha sido el sistematizar la forma de presentación clínica de esta entidad relacionándola con su probable etiopatogenia y los hallazgos colangiográficos y su evolución tras la cirugía, basándonos en la revisión de la literatura y en nuestra propia experiencia de 29 pacientes. Material y métodos. Se analizan 29 casos de dilatación quística de la vía biliar extra y/o intrahepática. En 4 casos, el diagnóstico fue prenatal, dos de los cuales se excluyeron del estudio al confirmarse atresia biliar tipo I. En los 27 casos restantes, se analizan retrospectivamente hasta un total de 19 variables, como la edad, sexo, peso, sintomatología, hallazgos ecográficos y colangiográficos, etc. Posteriormente se correlacionan los hallazgos colangiográficos con la presentación clínica y la evolución tras el tratamiento quirúrgico. Resultados. De los 27 casos analizados, 16 (59,25%) fueron formas quísticas de las que 14 tuvieron una presentación clínica neonatal o precoz (antes de los 2 años), mientras que las formas fusiformes se presentaron más tardíamente. De los síntomas analizados, en relación con la edad de presentación tan sólo el dolor y la ictericia mostraron diferencias significativas, siendo el dolor más frecuente en la presentación tardía y la ictericia en la forma precoz. Los dos casos de tipo III de Todani o coledococele fueron de presentación tardía. Se detectó anomalía del conducto biliopancreático en 15 pacientes, la mayoría de los cuales tuvieron una presentación tardía y asociada a pancreatitis en cuatro casos. El tratamiento quirúrgico de elección fue la quistectomía y derivación bilioentérica en Y de Roux. En 3 casos realizamos hepático- porto-apendicostomía, que se reconvirtieron a los dos años de seguimiento debido a episodios de colangitis subclínicas, detectados exclusivamente por una hipertransaminemia x2. Tras la reconversión (..) (AU)

The aim of the present study has been to systematize the clinical presentation of the entity named choledochal cyst, in relation with its probable etiopathology and the intraoperative findings as well as its evolution after surgery, based on the revision of the literature and of our experience in 29 cases. Material and Methods. 29 cases of cystic dilatation of the biliar duct extra and/or intrahepatic are analyzed. In 4 cases the diagnosis was prenatal and two were excluded of the study after it has been confirmed they suffered biliary atresia type I. In the left 27 cases, 19 variables are analyzed retrospectively, like age, sex, weight, symptoms, ultrasonographic images, etc. Subsequently, intra-operative cholangiographic findings were correlated with the clinic presentation and the evolution of the patients after surgery. Results. Of the 27 cases analyzed 16 (59,25%) were cystic dilatations from which 14 had a neonatal or early clinic presentation (before 2 years), however the fusiform dilatations were presented later on. From the analyzed symptoms, in relation with the age only the pain and the jaundice showed significant differences, being the pain most frequent in later presentation ande the jaundice in the early form. The two cases of type 3 of Todani or choledochocele were of later presentation. An anomaly in the bilionpacreatric junction was detected in 15 patients; the majority had a later presentation, associated to pancreatitis in 4 cases. Primary cyst excision and biliary Roux-en-Y reconstruction was the treatment of election in the majority of cases. In 3 cases we used the appendix to replace the choledocus, but all three cases were (..) (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

[Evidence-based medicine in Spanish pediatric surgery reports]. / Nivel de evidencia científica en la cirugía pediátrica española.

INTRODUCTION: Pediatric surgical literature is characterized by a high prevalence of observational studies and a paucity of randomized controlled trial, comparing mainly medical therapies. AIMS: To asses scientific evidence level produced by spanish pediatric surgeons. MATERIAL AND METHODS: Articles reported in Cirugía Pediátrica, surgical reports in Anales Españoles de Pediatría, and reports from spanish authors published in the Journal of Pediatric Surgery, Pediatric Surgery International and European Journal of Pediatric Surgery, from 1997 to 2002. Internal validity was assessed through the critial guides from Sackett, and evidence level was classified through the Oxford Centre for Evidence Based Medicine classification. RESULTS: 94.5% on therapy reports, 61.5% on diagnosis, 83.3% on prognosis and 52.2% on risk factors or etiology, were classified as level 4 (descriptive studies). Only four randomized controlled trials were found, all of them comparing medical therapies (analgesia, antibiotics and surgical stress control). CONCLUSIONS: Our results are similar to those offered by previous reviews, showing up a low level of scientific evidence in most articles. Diffusion of guides on reporting descriptive studies may improve the evidence level of our reports.

Nivel de evidencia científica en la cirugía pediátrica española / Evidence-Based medicine in spanish pediatric surgery reports

Introducción. El cuerpo de la literatura en cirugía pediátrica se caracteriza por un predominio de estudios observacionales y una escasez de ensayos clínicos aleatorizados que estudian principalmente terapias médicas. Objetivo. Evaluar el nivel de evidencia científica producido en nuestro medio. Material y métodos. Artículos publicados en la revista Cirugía Pediátrica, artículos sobre cirugía publicados en Anales Españoles de Pediatría, así como los publicados por autores españoles en Journal of Pediatric Surgery, Pediatric Surgery International y European Journal of Pediatric Surgery en el período entre 1997 y 2002. Se utilizaron las guías de lectura crítica de Sackett para evaluar la validez interna y la clasificación de niveles de evidencia del Centro de Medicina Basada en la Evidencia de la Universidad de Oxford. Resultados. El 94,5% de los artículos sobre terapia, el 61,5% sobre pruebas diagnósticas, el 83,3% sobre pronóstico y el 52,2% sobre factores de riesgo o etiología presentaron un nivel de evidencia 4, equivalente a estudios descriptivos. Se hallaron únicamente 4 ensayos clínicos aleatorizados, todos comparando terapias médicas (antibioterapia, analgesia y control del estrés quirúrgico). Conclusión. Los resultados son similares a los ofrecidos por revisiones sobre revistas anglosajonas, destacando el bajo nivel de evidencia científica de la mayoría de los artículos. La difusión de guías para la comunicación de estudios descriptivos puede mejorar el nivel de evidencia de los mismos (AU)

Introduction. Pediatric surgical literature is characterized by a high prevalence of observational studies and a paucity of randomized controlled trial, comparing mainly medical therapies. Aims. To asses scientific evidence level produced by spanish pediatric surgeons. Material and methods. Articles reported in Cirugía Pediátrica, surgical reports in Anales Españoles de Pediatría, and reports from spanish authors published in the Journal of Pediatric Surgery, Pediatric Surgery International and European Journal of Pediatric Surgery, from 1997 to 2002. Internal validity was assessed through the critial guides from Sackett, and evidence level was classified through the Oxford Centre for Evidence Based Medicine classification. Results. 94.5% on therapy reports, 61.5% on diagnosis, 83.3% on prognosis and 52.2% on risk factors or etiology, were classified as level 4 (descriptive studies). Only four randomized controlled trials were found, all of them comparing medical therapies (analgesia, antibiotics and surgical stress control). Conclusions. Our results are similar to those offered by previous reviews , showing up a low level of scientific evidence in most articles. Diffusion of guides on reporting descriptive studies may improve the evidence level of our reports (AU)

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.

[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.

Rectal drainage: unusual evolution of a psoas abscess.

We report two cases of primary psoas abscess in two patients of 15 months and 4 years of age. As the first case showed the natural history of this process the second one was large enough to produce a huge ureterohydronephrosis and to drain through the rectal wall to the rectum spontaneously, although this natural way did not achieve complete drainage. Both were treated by open drainage and systemic antibiotics with good response. They were discharged at the 7th and 12th postoperative day. 5 months later no complication has come up. Etiological, clinical and therapeutic aspects of this unusual pathology are reviewed.

Long-gap esophageal atresia: reconstruction preserving all portions of the esophagus by Schärli's technique.

For distances of over 4-5 cm, esophageal replacement is almost always necessary in esophageal atresias. We present the technical details and describe our experience with esophageal reconstruction by elongation of the lesser curvature (Schärli's technique) in four cases of very long atresias. A retrosternal transposition was made without a thoracotomy in two children, and an orthotopic mediastinal route through a right thoracotomy was done in two others. There were two main complications: anastomotic leaks in three patients that closed spontaneously, and too-rapid gastric emptying, resulting in dumping symptoms that improved with time and diet. One patient developed an anastomotic stricture that responded to bouginage, while another had temporary feeding problems. Esophageal reconstruction by elongation of the lesser curvature provides a relatively simple method of esophageal replacement in children in that all portions of the esophagus are preserved. We propose this technique for early establishment of esophageal continuity in neonates.

Cantrell's pentalogy. Report of four cases and their management.

Four neonates with the uncommon Cantrell's pentalogy seen in our hospital within a 6-month period without any apparent factor in common are described, with a review of the world literature. The first case was diagnosed prenatally at 15 weeks' gestation, the earliest intrauterine finding in the literature. The occurrence of imperforate anus with the syndrome, observed in one of the cases, has not been previously reported. Two were operated upon and only one of the four survived. This high mortality was confirmed by similar cases reported by other authors.