What urethrogram sees and a surgeon does not. / Lo que una uretrografía ve y un cirujano no.

INTRODUCTION: Urethrorrhagia is an infrequent sign in childhood. It should be distinguished from hematuria, since they have a different etiology. CLINICAL CASE: 11-year-old male patient with significant urethrorrhagia. Urinary sediment analysis: red blood cells++. Pelvic ultrasonography: fusiform anechoic image in the corpus spongiosum of the penile root. Retrograde urethrogram: normal anterior urethra, extraluminal contrast passage in the ventral aspect of the bulbar urethra. Cystoscopy: no pathological findings in the urethra or the bladder. Control retrograde urethrogram: cystic dilatation of Cowper's gland duct; Maizels' type 3 perforated syringocele. DISCUSSION: Cowper's syringocele is a rare pathology. It can occur at any stage of childhood in the form of urinary infection, obstructive voiding symptoms, or urethrorrhagia. Urethrogram is key for diagnostic purposes, since most Cowper's syringoceles are detected following urethrogram or cystoscopy. Cases with functional repercussions for the urinary system require surgical treatment. Otherwise, a wait-and-see approach is feasible.

INTRODUCCION: La uretrorragia es un signo infrecuente en la infancia que debe distinguirse de la hematuria dada la diferente etiología de las mismas. CASO CLINICO: Varón de 11 años con uretrorragia franca. Sedimento urinario: hematíes++. Ecografía pélvica: imagen anecoica fusiforme en cuerpo esponjoso de raíz peneana. Uretrografía retrógrada: uretra anterior normal, paso de contraste extraluminal ventral en uretra bulbar. Cistoscopia: sin hallazgos patológicos en uretra ni vejiga. Uretrografía retrógrada de control: dilatación quística del conducto de las glándulas de Cowper; siringocele perforado tipo 3 de Maizels. COMENTARIOS: El siringocele de Cowper es una patología infrecuente que puede debutar en cualquier momento de la infancia como infección urinaria, síntomas miccionales obstructivos o uretrorragia. La uretrografía es fundamental en su diagnóstico ya que la mayoría se objetivan por este medio o cistoscopia. Los casos con repercusión funcional del sistema urinario requieren tratamiento quirúrgico. En caso contrario podrá realizarse actitud expectante.

Lo que una uretrografía ve y un cirujano no / What urethrogram sees and a surgeon does not

Introducción: La uretrorragia es un signo infrecuente en la infancia que debe distinguirse de la hematuria dada la diferente etiología de lasmismas. Caso clínico: Varón de 11 años con uretrorragia franca. Sedimento urinario: hematíes++. Ecografía pélvica: imagen anecoica fusiforme en cuerpo esponjoso de raíz peneana. Uretrografía retrógrada: uretra anterior normal, paso de contraste extraluminal ventral en uretra bulbar.Cistoscopia: sin hallazgos patológicos en uretra ni vejiga. Uretrografíaretrógrada de control: dilatación quística del conducto de las glándulasde Cowper; siringocele perforado tipo 3 de Maizels.Comentarios: El siringocele de Cowper es una patología infrecuente que puede debutar en cualquier momento de la infancia como infección urinaria, síntomas miccionales obstructivos o uretrorragia.La uretrografía es undamental en su diagnóstico ya que la mayoría se objetivan por este medio o cistoscopia. Los casos con repercusión funcional del sistema urinario requieren tratamiento quirúrgico. En caso ontrario podrá realizarse actitud expectante.

Introduction: Urethrorrhagia is an infrequent sign in childhood. It should be distinguished from hematuria, since they have a different etiology.Clinical case: 11-year-old male patient with significant urethror-rhagia. Urinary sediment analysis: red blood cells++. Pelvic ultrasonog-raphy: fusiform anechoic image in the corpus spongiosum of the penileroot. Retrograde urethrogram: normal anterior urethra, extraluminal con-trast passage in the ventral aspect of the bulbar urethra. Cystoscopy: nopathological findings in the urethra or the bladder. Control retrograde urethrogram: cystic dilatation of Cowper’s gland duct; Maizels’ type 3perforated syringocele.Discussion: Cowper’s syringocele is a rare pathology. It can occurat any stage of childhood in the form of urinary infection, obstructivevoiding symptoms, or urethrorrhagia. Urethrogram is key for diagnos-tic purposes, since most Cowper’s syringoceles are detected followingurethrogram or cystoscopy. Cases with functional repercussions for theurinary system require surgical treatment. Otherwise, a wait-and-seeapproach is feasible

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.

[Postural deformities of the skull. Advantages of protocolization in its treatment]. / Deformidades craneales posturales. Ventajas de la protocolización en su tratamiento.

INTRODUCTION: Since 2007, we have examined in our medical practice children with cranial deformities. The increasing demand and lack of professionals dedicated to it has forced us to assume the treatment of this disease. We present our experience. MATERIAL AND METHODS: Retrospective study of patients with cranial deformities treated from 2010 to 2015. We collected data as age at the first visit and at discharge, sequential measurements of the skull and cranial index, type of treatment prescribed (postural, orthosis or both) and consultation requested to other specialties. In the first stage (2010-2012), each surgeon prescribed the treatment he considered appropriate. Since November 2012 a protocol has been implemented, it includes guideline sheets for the surgeon and parents with information on postural therapy and graphs to record the measurements. RESULTS: We have treated 261 patients. Two were diagnosed with craniosynostosis. From the rest, only 151 possessed complete quantitative data and were included in the study with 105 men and 46 women and a mean age of 5.8 months (± 1.9 months). There were 23 pure brachycephaly, 126 mixed forms and 2 pure plagiocephaly. A significant disparity between observers' measurements was noticed. All patients underwent a protocolized postural treatment. In 36 patients who did not improve with postural treatment, cranial orthosis was prescribed with good response: 66.8% became mild forms. Those who maintained only postural treatment also improved to milder forms in 64.4%. CONCLUSIONS: The implementation of a protocol has enabled us to unify the care and follow-up of these patients. Cranial measurement techniques should be more precise and reproducible. Good postural treatment and empathy with the family reduce the use of orthosis in carefully selected cases.

INTRODUCCION: Desde 2007 hemos valorado en consulta a niños con deformidades craneales. La creciente demanda y la falta de profesionales dedicados nos obligaron a asumir el tratamiento de esta patología. Presentamos nuestra experiencia. MATERIAL Y METODOS: Estudio descriptivo retrospectivo de los enfermos con deformidades craneales atendidos desde 2010 a 2015. Recopilamos datos sobre edad en la primera visita y al alta, medidas secuenciales del cráneo, tipo de tratamiento prescrito (postural, ortesis o ambos) e interconsulta a otras especialidades. En la primera etapa (2010-2012), cada cirujano prescribía el tratamiento que consideraba oportuno. Desde noviembre de 2012 se implementó un protocolo que incluye una hoja de actuación para el cirujano y otra para los padres con información sobre medidas posturales y gráficas para anotar las mediciones. RESULTADOS: Hemos atendido a 261 pacientes afectos de deformidades craneales. Dos fueron diagnosticados de craneosinostosis. Del resto, solo 151 disponían de datos cuantitativos completos y se incluyeron en el estudio. Fueron 105 varones y 46 mujeres con edad media de 5,8 meses (± 1,9 meses). Veintitrés presentaban una braquicefalia pura, 126 formas mixtas y 2 presentaban plagiocefalia pura. Existía una importante disparidad entre observadores en la toma de medidas. Todos fueron sometidos a un tratamiento postural protocolizado. En 36 enfermos que no mejoraban se pautó ortesis craneal con buena respuesta: 66,8% pasaron a formas más leves. Los que se mantuvieron solo con tratamiento postural también mejoraron evolucionando a formas más leves en el 64,4%. CONCLUSIONES: La introducción de un protocolo asistencial nos ha permitido unificar la atención y el seguimiento de estos enfermos. Las técnicas de medición craneal deben ser más precisas y reproducibles. Un buen tratamiento postural y empatía con la familia reducen la utilización de ortesis a casos muy seleccionados.

Deformidades craneales posturales. Ventajas de la protocolización en su tratamiento / Postural deformities of the skull. Advantages of protocolization in its treatment

Introducción. Desde 2007 hemos valorado en consulta a niños con deformidades craneales. La creciente demanda y la falta de profesionales dedicados nos obligaron a asumir el tratamiento de esta patología. Presentamos nuestra experiencia. Material y métodos. Estudio descriptivo retrospectivo de los enfermos con deformidades craneales atendidos desde 2010 a 2015. Recopilamos datos sobre edad en la primera visita y al alta, medidas secuenciales del cráneo, tipo de tratamiento prescrito (postural, ortesis o ambos) e interconsulta a otras especialidades. En la primera etapa (2010-2012), cada cirujano prescribía el tratamiento que consideraba oportuno. Desde noviembre de 2012 se implementó un protocolo que incluye una hoja de actuación para el cirujano y otra para los padres con información sobre medidas posturales y gráficas para anotar las mediciones. Resultados. Hemos atendido a 261 pacientes afectos de deformidades craneales. Dos fueron diagnosticados de craneosinostosis. Del resto, solo 151 disponían de datos cuantitativos completos y se incluyeron en el estudio. Fueron 105 varones y 46 mujeres con edad media de 5,8 meses (± 1,9 meses). Veintitrés presentaban una braquicefalia pura, 126 formas mixtas y 2 presentaban plagiocefalia pura. Existía una importante disparidad entre observadores en la toma de medidas. Todos fueron sometidos a un tratamiento postural protocolizado. En 36 enfermos que no mejoraban se pautó ortesis craneal con buena respuesta: 66,8% pasaron a formas más leves. Los que se mantuvieron solo con tratamiento postural también mejoraron evolucionando a formas más leves en el 64,4%. Conclusiones. La introducción de un protocolo asistencial nos ha permitido unificar la atención y el seguimiento de estos enfermos. Las técnicas de medición craneal deben ser más precisas y reproducibles. Un buen tratamiento postural y empatía con la familia reducen la utilización de ortesis a casos muy seleccionados (AU)

Introduction. Since 2007, we have examined in our medical practice children with cranial deformities. The increasing demand and lack of professionals dedicated to it has forced us to assume the treatment of this disease. We present our experience. Material and methods. Retrospective study of patients with cranial deformities treated from 2010 to 2015. We collected data as age at the first visit and at discharge, sequential measurements of the skull and cranial index, type of treatment prescribed (postural, orthosis or both) and consultation requested to other specialties. In the first stage (2010-2012), each surgeon prescribed the treatment he considered appropriate. Since November 2012 a protocol has been implemented, it includes guideline sheets for the surgeon and parents with information on postural therapy and graphs to record the measurements. Results. We have treated 261 patients. Two were diagnosed with craniosynostosis. From the rest, only 151 possessed complete quantitative data and were included in the study with 105 men and 46 women and a mean age of 5.8 months (± 1.9 months). There were 23 pure brachycephaly, 126 mixed forms and 2 pure plagiocephaly. A significant disparity between observers’ measurements was noticed. All patients underwent a protocolized postural treatment. In 36 patients who did not improve with postural treatment, cranial orthosis was prescribed with good response: 66.8% became mild forms. Those who maintained only postural treatment also improved to milder forms in 64.4%. Conclusions. The implementation of a protocol has enabled us to unify the care and follow-up of these patients. Cranial measurement techniques should be more precise and reproducible. Good postural treatment and empathy with the family reduce the use of orthosis in carefully selected cases (AU)

Nutrición parenteral precoz en postoperatorios complejos / Early parenteral nutrition in complex post-operative periods

Objetivo. El estado hipercatabólico proteico en el paciente pediátrico postoperado puede ser minimizado con un tratamiento nutricional eficaz. Realizamos un estudio para evaluar los beneficios de la nutrición parenteral precoz (NPp) valorando su efecto sobre los parámetros nutricionales y su relevancia clínica en postoperatorios quirúrgicos complejos. Material y método. Estudio prospectivo aleatorizado en pacientes sometidos a cirugía abdominal donde se preveía dieta absoluta por un periodo ≥3 días, entre 2012 y 2016. Se realizaron analíticas valorando parámetros nutricionales en las primeras 24 horas y al 5º día postoperatorio. Se crearon 2 grupos, iniciando NPp en grupo A y fluidoterapia estándar en grupo B, tras la extracción de la primera muestra. Resultados. Se incluyeron 44 pacientes, 18 en grupo A y 26 en grupo B. En la primera analítica todos presentaban niveles disminuidos de prealbúmina y proteína fijadora del retinol. Al 5º día, el 55,6% del grupo A normalizaron la prealbúmina frente al 11,5% del B (p: 0,003, FEE = 80%) mientras que la proteína fijadora del retinol se normalizó en el 66,7% y 34,6%, respectivamente (p: 0,07 FEE = 48,4%). Tres pacientes del grupo A (16,7%) presentaron complicaciones infecciosas en el postoperatorio frente a 8 del B (30,8%), diferencia no estadísticamente significativa pero relevante clínicamente (NNT = 7,1), ya que estos últimos mostraban niveles bajos de prealbúmina y mayor estancia hospitalaria. No se detectaron complicaciones relacionadas con la NPp. Conclusión. La administración de NPp en postoperatorios complejos parece ser segura y beneficiosa para la recuperación de los pacientes, siendo la prealbúmina un indicador precoz de buena respuesta nutricional

Objective. The protein hypercatabolic state in critically ill pediatric patients can be minimized by an effective nutrition therapy. We conducted a study to evaluate the benefits of early parenteral nutrition (EPN) assessing its effect on nutritional parameters and clinical relevance after complex surgical procedures. Methods. Prospective randomized study in patients undergoing abdominal surgery in which nothing by mouth is anticipated for a period ≥ 3 days, between 2012 and 2014. Blood tests were performed assessing nutritional parameters in the first 24 hours and the 5th postoperative day. Two groups were created, starting EPN in group A and standard fluid therapy in group B, after the extraction of the first sample. Results: Forty-four patients were included, 18 in group A and 26 in group B. In the first analysis all had decreased levels of prealbumin and retinol-binding protein. On the 5th day, 55,6% of group A normalized prealbumin levels compared to 11,5% of B (p: 0.003, EF = 80%) whereas retinol-binding protein was normalized in 66,7% and 34.6%, respectively (p: 0,07, EF = 48,4%). Three patients in group A (16,7%) had postoperative infectious complications compared to 8 in B (30,8%), difference no statistically significant but clinically relevant (NNT=7,1), since the latter showed low prealbumin levels and longer hospital stay. No complications related to EPN were detected. Conclusion. Administration of EPN in the complex postoperative patients appears to be safe and beneficial for their recovery, being the prealbumin an early indicator of good nutritional response

Catéteres centrales de inserción periférica: un ahorro, una comodidad, muchas ventajas / Peripherally inserted central catheters: Savings, comfort, many advantages

Introducción. Los catéteres centrales de inserción periférica están indicados cuando se prevé un tratamiento endovenoso durante más de 6 días o menos si se utiliza medicación flebotóxica. Presentamos nuestra experiencia reciente. Material y métodos. Estudio descriptivo retrospectivo desde 2014 a 2015 incluyendo pacientes a los cuales se les colocó un catéter ya sea en quirófano, tras la cirugía y antes de despertar al enfermo, o en la UCI Pediátrica por venopunción directa o ecoguiada. Revisamos características del paciente, enfermedad de base, procedimiento de canalización, tipo y duración de la vía, tratamiento endovenoso y complicaciones. Resultados. Colocamos 69 catéteres de 3, 4 y 5 Fr (1 o 2 luces) en 66 pacientes con edad media de 5,71 años (± 4,24). Eran mayoritariamente enfermos de Cirugía Pediátrica (n= 19) sobre todo apendicitis agudas complicadas (n=12). Se canalizaron venas del brazo sin dificultades salvo 2 punciones arteriales accidentales. No hubo complicaciones infecciosas, pero sí 7 extravasaciones (un quilotórax) que obligaron a retirar el catéter y 3 obstrucciones por nutrición parenteral resueltas con irrigación de heparina. Dos enfermos fallecieron y uno fue derivado a otro centro con el catéter en uso. No hubo trombosis venosas clínicas. La duración media del acceso fue de 10,6 días (máximo 62 días). Conclusiones. Los catéteres centrales de inserción periférica facilitan el manejo de los pacientes evitando las punciones venosas periféricas repetidas y su colocación en quirófano, tras la cirugía y antes de despertar al enfermo, facilita la canalización y reduce las complicaciones. Es por eso que hemos incluido estos en el protocolo terapéutico de enfermos seleccionados

Introduction. Peripherally inserted central catheters are indicated when an intravenous treatment is expected for more than 6 days or less if phlebotoxic medication is used. We report our recent experience. Methods. Retrospective study from 2014 to 2015 including patients to whom a catheter was placed either, in the operating room after surgery and before awakening the patient, or in the Pediatric ICU by direct or ultrasound guidance venipuncture. We reviewed patient characteristics, underlying disease, line catheterization procedure, type and duration of venous line, intravenous treatment and complications. Results. Sixty-nine catheters of 3, 4 and 5 Fr (1 or 2 lumens) were placed in 66 patients with a median age of 5.71 years (± 4.24). They were mainly Pediatric Surgery patients (n = 19) mostly complicated acute appendicitis (n = 12). Arm veins were catheterized without difficulties except for two accidental arterial punctures. There were no infectious complications but 7 patients presented extravasation (one chylothorax) that forced the removal of the catheters and 3 reported obstruction by parenteral nutrition resolved with heparin irrigation. Two patients died and one was referred to another center with the catheter in use. There were no clinical venous thromboses. The median line duration was 10.6 days (maximum of 62 days). Conclusions. Peripherally inserted central catheters facilitate the management of patients avoiding repeated peripheral venipunctures. Its placement in the operating room after surgery and before the patient awakes, facilitates line catheterization and reduces complications. That is why we have included it in the therapeutic protocol of selected patients, the use of this type of catheter

[Peripherally inserted central catheters: Savings, comfort, many advantages]. / Catéteres centrales de inserción periférica: un ahorro, una comodidad, muchas ventajas.

INTRODUCTION: Peripherally inserted central catheters are indicated when an intravenous treatment is expected for more than 6 days or less if phlebotoxic medication is used. We report our recent experience. METHODS: Retrospective study from 2014 to 2015 including patients to whom a catheter was placed either, in the operating room after surgery and before awakening the patient, or in the Pediatric ICU by direct or ultrasound guidance venipuncture. We reviewed patient characteristics, underlying disease, line catheterization procedure, type and duration of venous line, intravenous treatment and complications. RESULTS: Sixty-nine catheters of 3, 4 and 5 Fr (1 or 2 lumens) were placed in 66 patients with a median age of 5.71 years (± 4.24). They were mainly Pediatric Surgery patients (n = 19) mostly complicated acute appendicitis (n = 12). Arm veins were catheterized without difficulties except for two accidental arterial punctures. There were no infectious complications but 7 patients presented extravasation (one chylothorax) that forced the removal of the catheters and 3 reported obstruction by parenteral nutrition resolved with heparin irrigation. Two patients died and one was referred to another center with the catheter in use. There were no clinical venous thromboses. The median line duration was 10.6 days (maximum of 62 days). CONCLUSIONS: Peripherally inserted central catheters facilitate the management of patients avoiding repeated peripheral venipunctures. Its placement in the operating room after surgery and before the patient awakes, facilitates line catheterization and reduces complications. That is why we have included it in the therapeutic protocol of selected patients, the use of this type of catheter.

INTRODUCCION: Los catéteres centrales de inserción periférica están indicados cuando se prevé un tratamiento endovenoso durante más de 6 días o menos si se utiliza medicación flebotóxica. Presentamos nuestra experiencia reciente. METODOS: Estudio descriptivo retrospectivo desde 2014 a 2015 incluyendo pacientes a los cuales se les colocó un catéter ya sea en quirófano, tras la cirugía y antes de despertar al enfermo, o en la UCI Pediátrica por venopunción directa o ecoguiada. Revisamos características del paciente, enfermedad de base, procedimiento de canalización, tipo y duración de la vía, tratamiento endovenoso y complicaciones. RESULTADOS: Colocamos 69 catéteres de 3, 4 y 5 Fr (1 o 2 luces) en 66 pacientes con edad media de 5,71 años (± 4,24). Eran mayoritariamente enfermos de Cirugía Pediátrica (n= 19) sobre todo apendicitis agudas complicadas (n=12). Se canalizaron venas del brazo sin dificultades salvo 2 punciones arteriales accidentales. No hubo complicaciones infecciosas, pero sí 7 extravasaciones (un quilotórax) que obligaron a retirar el catéter y 3 obstrucciones por nutrición parenteral resueltas con irrigación de heparina. Dos enfermos fallecieron y uno fue derivado a otro centro con el catéter en uso. No hubo trombosis venosas clínicas. La duración media del acceso fue de 10,6 días (máximo 62 días). CONCLUSIONES: Los catéteres centrales de inserción periférica facilitan el manejo de los pacientes evitando las punciones venosas periféricas repetidas y su colocación en quirófano, tras la cirugía y antes de despertar al enfermo, facilita la canalización y reduce las complicaciones. Es por eso que hemos incluido estos en el protocolo terapéutico de enfermos seleccionados.

[Early parenteral nutrition in complex post-operative periods]. / Nutrición parenteral precoz en postoperatorios complejos.

OBJECTIVE: The protein hypercatabolic state in critically ill pediatric patients can be minimized by an effective nutrition therapy. We conducted a study to evaluate the benefits of early parenteral nutrition (EPN) assessing its effect on nutritional parameters and clinical relevance after complex surgical procedures. METHODS: Prospective randomized study in patients undergoing abdominal surgery in which nothing by mouth is anticipated for a period ≥ 3 days, between 2012 and 2014. Blood tests were performed assessing nutritional parameters in the first 24 hours and the 5th postoperative day. Two groups were created, starting EPN in group A and standard fluid therapy in group B, after the extraction of the first sample. RESULTS: Forty-four patients were included, 18 in group A and 26 in group B. In the first analysis all had decreased levels of prealbumin and retinol-binding protein. On the 5th day, 55,6% of group A normalized prealbumin levels compared to 11,5% of B (p: 0.003, EF = 80%) whereas retinol-binding protein was normalized in 66,7% and 34.6%, respectively (p: 0,07, EF = 48,4%). Three patients in group A (16,7%) had postoperative infectious complications compared to 8 in B (30,8%), difference no statistically significant but clinically relevant (NNT=7,1), since the latter showed low prealbumin levels and longer hospital stay. No complications related to EPN were detected. CONCLUSION: Administration of EPN in the complex postoperative patients appears to be safe and beneficial for their recovery, being the prealbumin an early indicator of good nutritional response.

OBJETIVOS: El estado hipercatabólico proteico en el paciente pediátrico postoperado puede ser minimizado con un tratamiento nutricional eficaz. Realizamos un estudio para evaluar los beneficios de la nutrición parenteral precoz (NPp) valorando su efecto sobre los parámetros nutricionales y su relevancia clínica en postoperatorios quirúrgicos complejos. MATERIAL Y METODO: Estudio prospectivo aleatorizado en pacientes sometidos a cirugía abdominal donde se preveía dieta absoluta por un periodo ≥3 días, entre 2012 y 2016. Se realizaron analíticas valorando parámetros nutricionales en las primeras 24 horas y al 5º día postoperatorio. Se crearon 2 grupos, iniciando NPp en grupo A y fluidoterapia estándar en grupo B, tras la extracción de la primera muestra. RESULTADOS: Se incluyeron 44 pacientes, 18 en grupo A y 26 en grupo B. En la primera analítica todos presentaban niveles disminuidos de prealbúmina y proteína fijadora del retinol. Al 5º día, el 55,6% del grupo A normalizaron la prealbúmina frente al 11,5% del B (p: 0,003, FEE = 80%) mientras que la proteína fijadora del retinol se normalizó en el 66,7% y 34,6%, respectivamente (p: 0,07 FEE = 48,4%). Tres pacientes del grupo A (16,7%) presentaron complicaciones infecciosas en el postoperatorio frente a 8 del B (30,8%), diferencia no estadísticamente significativa pero relevante clínicamente (NNT = 7,1), ya que estos últimos mostraban niveles bajos de prealbúmina y mayor estancia hospitalaria. No se detectaron complicaciones relacionadas con la NPp. CONCLUSION: La administración de NPp en postoperatorios complejos parece ser segura y beneficiosa para la recuperación de los pacientes, siendo la prealbúmina un indicador precoz de buena respuesta nutricional.

[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.

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

El síndrome de la costilla deslizante (SCD) es una entidad infrecuente, que exige un diagnóstico diferencial preciso incluyendo patología digestiva, cardiaca, respiratoria, infecciosa y músculo-esquelética torácica o abdominal. Se presenta el caso de dos niñas, en edad puberal, con dolor torácico incapacitante de varios meses de evolución y sin antecedente traumático. En la exploración existía un punto de dolor a la palpación de la parrilla costal y la 'maniobra del gancho' era dolorosa. Se realizó una resección de los cartílagos costales, respetando el pericondrio. La evolución tras uno y cuatro años de seguimiento, fue satisfactoria sin complicaciones y con resolución inmediata de la sintomatología. La cirugía de resección costal parece una opción muy agresiva, aunque con resultados muy satisfactorios. Un abordaje mínimamente invasivo podría ser mejor opción a considerar en el futuro (AU)

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 (AU)

Análisis de efectividad de una estrategia terapéutica en el varicocele pediátrico. ¿Hemos alcanzado nuestros objetivos? / Effectiveness analysis of a therapeutic strategy for pediatric varicocele. Have we got what we expected?

Objetivo. Los avances en radiología intervencionista y cirugía laparoscópica nos han permitido implantar un protocolo terapéutico del varicocele del adolescente que pretende obtener el máximo rendimiento de ambas opciones. Evaluamos nuestros resultados. Material y métodos. Estudio retrospectivo de los pacientes pediátricos con diagnóstico de varicocele tratados en nuestro hospital según protocolo entre 2008 y 2013. Tras confirmar clínica y ecográficamente la indicación terapéutica, los pacientes son sometidos a embolización percutánea retrógrada (EPR). Realizamos varicocelectomía laparoscópica (VL) cuando la EPR no ha sido resolutiva y desde 2009 asociamos preservación linfática mediante linfografía con azul patente. Resultados. Hemos tratado a 55 pacientes afectos de varicocele. Edad media en el momento del tratamiento: 13 años (rango: 11 -16). Se realizó EPR según protocolo en 50 pacientes (90,9%), de los cuales el 80% presentó remisión del varicocele comprobada en ecografía realizada a los 6 meses del procedimiento. Fueron sometidos a VL 16 pacientes (29,1%), de los cuales 5 no pudieron ser embolizados previamente. Se realizó linfografía con azul patente en 13 (23,6%), y cirugía por puerto único en 6 pacientes. En ningún caso la presencia de coils por EPR previa supuso limitación para la VL posterior. La tasa de remisión tras VL fue del 100% a los 6 meses de seguimiento. Se registraron 2 linfoceles postoperatorios, ninguno tras linfografía previa a la VL. Conclusiones. Teniendo en cuenta nuestros resultados, consideramos que esta secuencia terapéutica es segura, altamente resolutiva, supone una mínima agresión quirúrgica y permite reducir la tasa de linfoceles postoperatorios

Objective. Optimal treatment of varicocele in adolescents remains a topic of discussion. Strides in interventional radiology and laparoscopy have allowed us to implement a multidisciplinary therapeutic protocol that aims to get best of both. We evaluate our results. Methods. Retrospective study of pediatric patients treated for varicocele in our hospital under protocol between 2008 and 2013. Once the therapeutic indication is confirmed, through clinical and Doppler ultrasound examination, patients undergo percutaneous retrograde embolization (PRE). We perform laparoscopic varicocelectomy (LV) when the PRE fails, together with lymphatic preservation using blue patent lymphography prior to surgery. Results. Fifty-five patients with varicocele were treated at a mean age of 13 years old (range 11-16). PRE was performed in 50 patients (90.9%), with a proportion of remission of 80% by ultrasound study 6 months after PRE. Sixteen patients (29.1%) underwent LV, five of whom without prior PRE. Lymphography with patent blue was performed in 13 (23.6%), and single-port surgery in 6 patients. The presence of coils of PRE did not hinder subsequent LV. The remission rate after LV was 100% at 6 months follow up. Two postoperative lymphoceles were recorded, none after patent blue lymphography. Conclusions. We found in this therapeutic sequence a safe and efficient alternative, allowing a minimal surgical invasion and reducing the rate of postoperative lymphoceles

[Effectiveness analysis of a therapeutic strategy for pediatric varicocele. Have we got what we expected?]. / Análisis de efectividad de una estrategia terapéutica en el varicocele pediátrico. ¿Hemos alcanzado nuestros objetivos?

OBJECTIVE: Optimal treatment ot vancocele in adolescents remains a topic of discussion. Strides in interventional radiology and laparoscopy have allowed us to implement a multidisciplinary therapeutic protocol that aims to get best of both. We evaluate our results. METHODS: . Retrospective study of pediatric patients treated for varicocele in our hospital under protocol between 2008 and 2013. Once the therapeutic indication is confirmed, through clinical and Doppler ultrasound examination, patients undergo percutaneous retrograde embolization (PRE). We perform laparoscopic varicocelectomy (LV) when the PRE fails, together with lymphatic preservation using blue patent lymphography prior to surgery. RESULTS: . Fifty-five patients with varicocele were treated at a mean age of 13 years old (range 11-16). PRE was performed in 50 patients (90.9%), with a proportion of remission of 80% by ultrasound study 6 months after PRE. Sixteen patients (29.1%) underwent LV five of whom without prior PRE. Lymphography with patent blue was performed in 13 (23.6%), and single-port surgery in 6 patients. The presence of coils of PRE did not hinder subsequent LV. The remission rate after LV was 100% at 6 months follow up. Two postoperative lymphoceles were recorded, none after patent blue lymphography. CONCLUSIONS: . We found in this therapeutic sequence a safe and efficient alternative, allowing a minimal surgical invasion and reducing the rate of postoperative lymphoceles.

¿Es útil tratar de forma conservadora las apendicitis agudas complicadas en pediatría? / Is useful the conservative treatment in children with complicated appendicitis?

Los autores de este artículo presentan 4 casos de apendicitis aguda complicada, tratados de forma conservadora con antibioterapia intravenosa durante 7 días, y posterior apendicectomía laparoscópica diferida a las 4-6 semanas del comienzo del tratamiento. Los resultados han sido satisfactorios, y la enfermedad se ha resuelto en los 4 casos(AU)

The authors present four patients with complicated appendicitis, which have received conservative treatment with intravenous antibioterapy and an interval appendectomy 4-6 weeks after the beginning of the treatment. The results have been satisfactory(AU)

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)

[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.

¿Estamos tratando bien la enfermedad pilonidal en los niños? Objetivos terapéuticos más allá de prevenir la recidiva / Are we correctly treating pilonidal disease in children? Therapeutic goals beyond preventing recurrence

Introducción. Presentamos un estudio retrospectivo de nuestros pacientes pediátricos afectos de enfermedad pilonidal en los últimos5 años. Pacientes y método. Realizamos una extirpación amplia del tejido pilonidal, sin marcaje con colorantes de los trayectos y un cierre primario sin drenajes. Resultados. Atendimos a 20 adolescentes (15 mujeres y 5 varones)de edades comprendidas entre 12 y 15 años (edad media 13,3 años) e índice de masa corporal comprendido entre 17 y 33 (IMC medio 26,4kg/m2). La estancia media hospitalaria fue de 1,45 días. El 55% recibió antibioterapia preoperatoria con amoxicilina-clavulánico que se prolongó de forma oral durante 7 días. Tuvimos 4 recidivas de la enfermedad (20%) (dos de ellos con doble recidiva) que tratamos con 3 cierres primarios en línea media y tres con puesta a plano. En 2 casos en los que se produjo una dehiscencia parcial de la herida permitimos una cura por segunda intención. En ningún caso se realizaron colgajos o marsupializaciones. En todos ellos el resultado estético obtenido ha sido satisfactorio en nuestra opinión. Conclusiones. Aunque el cierre primario en línea media permite una reincorporación rápida a la actividad normal y el mantenimiento del pliegue interglúteo sin grandes cicatrices (aspectos que no se obtienen con la puesta a plano o el cierre con colgajos), la tasa de reintervenciones es inaceptable. Hemos incluido en nuestro protocolo quirúrgico el marcaje previo de los trayectos fistulosos con agua oxigenada y colorante para reducir las recidivas, junto con el control dietético del posible sobrepeso (AU)

Introduction. We present a retrospective study of our paediatric patients affected by pilonidal disease over the last 5 years. Patients and method. In all cases a broad excision of the pilonidalt issue was made, without colour signing the different incision sites and primary closure of the defect with no drainage. Results. Using this technique we treated 20 adolescents (15girls and 5 boys) of ages between 12 and 15 years (average age13.3 years) and body mass index between 17 and 33 (mean BMI26.4 kg/m2). Mean hospitalisation time was 1.45 days. Preoperative antibiotherapy with Amoxicillin-clavulanic was administered to 55% of patients and continued over the first postoperative week. We had four cases with recurrence of the disease (25%) (two of these with two recurrences), which we treated with three primary closures on the midline and three by flattening the cleft. In 2 cases with dehiscence of the wound we allowed treatment by secondary intention. No flaps or marsupialisation were attempted in any case. In all cases the result was aesthetically satisfactory, with maintenance of the intergluteal fold. Conclusions. In our series we have succeeded in undertaking primary closure of the defect after pilonidal resection without any excessive tension. This treatment enables a rapid return to a normal routine. We considered it important to undertake surgery that maintained the intergluteal fold, especially in patients with a short-term evolution of the disease, reserving flattening the cleft, closure by secondary intention, or primary closure by inserting fl aps only for cases of recurrent disease; those with long-term evolution; or patients with complex lesions prior to surgery. Nutritional support to reduce overweight is very important in many patients (AU)

[Are we correctly treating pilonidal disease in children? therapeutic goals beyond preventing recurrence]. / Estamos tratando bien la enfermedad pilonidal en los niños? Objetivos terapéuticos más allá de prevenir la recidiva.

INTRODUCTION: We present a retrospective study of our paediatric patients affected by pilonidal disease over the last 5 years. PATIENTS AND METHOD: In all cases a broad excision of the pilonidal tissue was made, without colour signing the different incision sites and primary closure of the defect with no drainage. RESULTS: Using this technique we treated 20 adolescents (15 girls and 5 boys) of ages between 12 and 15 years (average age 13.3 years) and body mass index between 17 and 33 (mean BMI 26.4 kg/m2). Mean hospitalisation time was 1.45 days. Preoperative antibiotherapy with Amoxicillin-clavulanic was administered to 55% of patients and continued over the first postoperative week. We had four cases with recurrence of the disease (25%) (two of these with two recurrences), which we treated with three primary closures on the midline and three by flattening the cleft. In 2 cases with dehiscence of the wound we allowed treatment by secondary intention. No flaps or marsupialisation were attempted in any case. In all cases the result was aesthetically satisfactory, with maintenance of the intergluteal fold. CONCLUSIONS: In our series we have succeeded in undertaking primary closure of the defect after pilonidal resection without any excessive tension. This treatment enables a rapid return to a normal routine. We considered it important to undertake surgery that maintained the intergluteal fold, especially in patients with a short-term evolution of the disease, reserving flattening the cleft, closure by secondary intention, or primary closure by inserting flaps only for cases of recurrent disease; those with long-term evolution; or patients with complex lesions prior to surgery. Nutritional support to reduce overweight is very important in many patients.

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

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

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