[Slipping rib syndrome. An aggressive but effective treatment]. / Síndrome de la costilla deslizante. Tratamiento agresivo pero eficaz.

Slipping rib syndrome (SRS) is an unusual cause of recurrent chest or abdominal pain in children. The diagnosis is elusive, including gastroenterological, cardiac, respiratory, infectious and chest or abdominal muscular pathologies. Two paediatric patients were diagnosed with SRS, both of them were female teenagers with a similar clinical pattern: crippling unilateral chest pain without a traumatic event. On physical examination, all patients had reproducible pain with the "hooking maneuver". Surgical excision of the costal cartilages was done, preserving the perichondrium. No complications were reported. In both cases we achieve an excellent outcome after one and four years of follow-up, resolving the symptoms completely. The surgical excision of the costal cartilages seems to be an aggressive option but with an excellent outcome. A minimum invasive approach could be a better option in the future.

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

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

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

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

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

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

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

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

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

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

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

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

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

An intra-thyroid thyroglossal duct cyst.

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

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

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

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

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

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

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

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

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

[Boix Ochoa's antireflux procedure returns patients to normalcy: 24 hour esophageal pH monitoring of 21 cases]. / La plastia de Boix Ochoa reconvierte al enfermo a la normalidad. Estudio pHmétrico de 21 casos.

A great controversy exist concerning the surgical management of gastroesophageal reflux (GER). It is well known that Nissen procedure produces a hypercorrection of the gastroesophageal competency and often a "gas bloat syndrome". On the other hand, the Boix Ochoa's technique is more physiological but corrects GER allowing the persistence of a "radiological" reflux. The aim of the study was to demonstrate the accuracy of this procedure. 287 pediatric patients were studied because of GER and abnormal barium upper gastrointestinal series. 24 hours esophageal pH monitoring was performed in all this patients and in 21 the results were clearly pathological. They were operated on and six months later were new evaluated with upper GI series and continuous 24 hours esophageal pH monitoring. The results were compared with those previous to operation and also with a control group. Statistical great significance was found between presurgical and postsurgical data, what determine the efficacy of the procedure. No statistical significance was found between postsurgical data and the control group, what means that Boix Ochoa's procedure resolve GER without hipercorrection.

[Study of the esophageal function by prolonged intraluminal pH-metry in patients with gastroesophageal reflux and respiratory manifestations]. / Estudio de la funcion esofagica mediante pH-metrica intraluminar prolongada en pacientes afectos de reflujo gastroesofagico y manifestaciones respiratorias.

Gastroesophageal reflux (GER) can be found in a high number of patients with respiratory tract disease (RTD). In the present study a 24 hours esophageal pH monitoring was performed in 55 children. 15 of them were normal controls, 16 patients with GER but normal score, 14 patients with GER and RTD and 9 patients with GER and only digestive symptoms. The number of reflux episodes of more than 5 minutes, the duration of the longest single reflux episode, the percentage of time the esophageal pH was less than 4, the reflux/hour index and the clearance index were measured. Comparing the results of the different groups we found that normal controls and normal vomiting patients were significatively different. Refluxers and refluxers with RTD also were different of asymptomatic controls. The main significative differences founded comparing refluxers and refluxers with RTD were the duration of the longest single reflux, the percentage of time the esophageal pH was less than 4 and the clearance index. All these parameters were longer in the refluxers with RTD. Our conclusion is that esophageal clearance is slower in the group of refluxers with RTD and that this index is helpful to distinguish them from the single refluxers.

[Neonatal appendicitis. Presentation of three cases (author's transl)]. / Apendicitis neonatal. Aportación de tres casos.

Authors present three patients with acute appendicitis developed during the first month of life. Up to 1975 they found only 106 cases described in the Spanish, French and English literature. The rarity of this pathology together with extreme difficulty in clinical and radiological diagnosis, usually produces a delay of treatment with logical increase of mortality. Their three patients were operated through laparotomy and one through right herniography. None of them had intestinal aganglionosis.