[Transanal irrigations in patients with constipation and fecal incontinence: results, indications and follow up in our center]. / Irrigación transanal en pacientes con estreñimiento e incontinencia orgánica refractaria. Resultados, indicaciones y seguimiento en nuestro centro.

AIM OF THE STUDY: To present our results with transanal irrigation (TAI) for management of fecal incontinence and fecal constipation without response to other treatments. METHODS: Retrospective study of patients with fecal constipation and/or fecal incontinence treated with TAI between 2013 and 2017. A Rintala questionnaire(1) was carried out comparing pre and post-treatment results. This study was approved by the ethical committee. MAIN RESULTS: Twenty-five patients were included with a median age of 13 years old (range 6-44 years). Nineteen patients had spinal pathology (76%), four colorectal surgery (16%) and two functional constipation (8%). They presented fecal incontinence in 20% of cases, 12% of fecal constipation and 68% both conditions. After a mean follow-up of 1.5 years (1 month-4 years), 52% of the patients abandoned the treatment. The mean Rintala score was 6.8±4 before treatment, and after, resulted to 11.42±2.75 (p=0.001). The main complications throughout the treatment were pain (68%) and balloon leaks (28%). The patients declared as cause of treatment cessation: reduced mobility (15%), fear or misinformation (32%) and pain (76%). All patients with reduced mobility (n=3) left treatment, versus 45% (n=12) of the patients that had full mobility (p=0.17, OR 8.3 [IC95% 0.3-38]). Complementary treatments such as laxatives, enemas or digital extraction were abandoned in 55% of the patients. CONCLUSIONS: Using TAI seems to improve quality of life in patients with fecal constipation and fecal incontinence refractory compared to other treatments. Our abandonment rate was higher than expected, so we believe it is necessary to create a support group to improve follow-ups.

OBJETIVOS: Presentar nuestros resultados con el uso del irrigador transanal (IT) en el manejo intestinal de pacientes con incontinencia fecal o estreñimiento sin respuesta a otros tratamientos. METODOS: Estudio retrospectivo de pacientes con estreñimiento y/o incontinencia fecal refractaria tratados con IT (2013-2017) con el sistema Peristeen® (Coloplast). Se realizó cuestionario Rintala(1), comparando resultados pre y postratamiento. La realización del estudio fue aprobada por el comité de investigación clínica. RESULTADOS: Fueron incluidos en el estudio veinticinco pacientes, mediana de edad 13 años (6-44 años), cuatro no localizables. Diecinueve presentaban patología medular (76%), cuatro cirugías colorrectales (16%) y dos estreñimiento funcional (8%). El 20% aquejaba incontinencia, 12% estreñimiento y 68% ambas condiciones. Tras una mediana de seguimiento de 1,5 años (1 mes-4 años), el 52% abandonó el tratamiento. La puntuación media pretratamiento fue 6,8±4, frente a 11,42±2,75 tras su empleo (p=0,001), disminuyendo el número de escapes con repercusión positiva en actividades diarias. Las complicaciones principales fueron dolor (68%) y expulsión del balón (28%). Refirieron como causa de abandono: dificultad de uso por movilidad reducida (15%), miedo o desinformación (32%) y dolor (76%). El 100% de pacientes con movilidad reducida (n=3) abandonó el tratamiento, frente al 45% (n=12) en el resto (p=0,17, OR 8.3 [IC95% 0,3-38]). El 55% de los pacientes dejaron de utilizar laxantes, enemas o extracción digital. CONCLUSIONES: El uso de IT parece mejorar la calidad de vida en pacientes con estreñimiento e incontinencia de causa orgánica refractaria. La tasa de abandono fue mayor de la esperada, por lo que creemos necesaria la creación de un grupo de apoyo que mejore el seguimiento.

[Prevention of the wound infection: little changes, huge results]. / Resultados de la modificación de la actitud ante la asepsia en cirugía neonatal: pequeños cambios, grandes resultados.

INTRODUCTION: Neonatal surgical wound infection occurs in almost 50% of neonatal procedures. It increases the rates of morbimortality in neonatal units. There is no guidelines about prevention of wound infection in neonatal surgery. We present our results after changing our behaviour in neonatal surgery. MATERIALS AND METHODS: Comparative study between 2 groups. In order to decrease wound infection at the end of the procedure gloves, covertures and surgical instruments were changed and saline and antiseptic solutions were used during laparotomy closing. Group P included procedures with these recommendations and Group NP without them. Age, weight, surgery, infection, length of stay, and mortality were analized between groups through a logistic regression model. RESULTS: Group P included 55 procedures in 32 patients, median weight 1,300 g (1,000-2,100), 19 median days of life (6-40), 5 postoperative wound problems (9%). Group NP included 26 procedures in 14 neonates, median weight 1,700 g (700-2,500), 20 median days of life (3-33), 14 wound problems (53.8%). We decrease the wound problems in our patients in 44.8% (p < 0.0001). Additionally, the protection provided by our recommendations was maintained after adjustment by weight, age and type of pathology (0.07) p= 0.000. CONCLUSIONS: Simple changes in during the procedures in neonatal surgery can reduce the appearance of wound infection and morbidity.

OBJETIVOS: La infección de herida quirúrgica neonatal tiene una incidencia de hasta el 50% y produce un aumento de morbimortalidad. No existen recomendaciones preventivas consensuadas en la literatura. Presentamos los resultados tras la implantación de un protocolo creado en nuestro Servicio para cierre de laparotomía en cirugía neonatal contaminada y sucia. MATERIAL Y METODOS: Estudio ambispectivo de las laparotomías neonatales realizadas durante 32 meses comparando los resultados con un grupo de pacientes intervenidos durante un período previo similar. El protocolo incluye cambio de guantes, de campo y material quirúrgico, lavado por planos con antiséptico y sutura antibacteriana en el cierre. Se analizan edad, peso, tipo de intervención, infección, estancia hospitalaria y mortalidad y se compara con un grupo similar de pacientes intervenidos de forma previa a la creación del protocolo (NP) y se analiza la influencia del protocolo en la aparición de infección mediante regresión logística. RESULTADOS: El grupo P incluye 55 laparotomías en 32 neonatos con mediana de peso 1.300 g (1.000-2.100), mediana de edad 19 días (6-40) con 3 infecciones de herida (2 cultivos positivos) y 2 dehiscencias leves (9%). El grupo NP incluyó 26 intervenciones en 14 neonatos, mediana de peso 1.700 g (700-2.500), mediana de edad 20 días (3-33), 14 infecciones (53,8%), 8 cultivos positivos y 2 muertes. Se redujo un 44,8% la aparición de infección (p < 0,0001) y el efecto protector del protocolo se mantuvo después del ajuste por peso, edad y tipo de patología (0,07) p= 0,000. CONCLUSIONES: La sencilla modificación de la asepsia y técnica de cierre ha contribuido a disminuir considerablemente la tasa de infección y morbimortalidad en nuestros pacientes y consideramos que es necesario hacer conciencia de ello.

[Management protocol in gastroschisis]. / Protocolo de manejo en las gastrosquisis.

AIM: There are two classical managements in gastroschisis: primary or delayed closure. From 2007 on, a multidisciplinary approach protocol based in preterm caesarean delivery at 34-35th gestational age (in order to minimize peel injury) plus primary closure is followed in our institution. Prior to this, term delivery, either by caesarean section or not, was the rule. METHODS: Retrospective study of gastroschisis's patients before (1978-2006) and after (2007-2016) protocol approval. Complex gastroschisis frequency, peel's presence, primary or delayed closure, complications, re-interventions, neonatal intensive care unit (NICU) length of stay, age at onset of enteral nutrition, total parenteral nutrition's length and length of stay were compared. MAIN RESULTS: Study groups: before (12 patients) and after (13 newborns) the protocol implantation (pre/post). Nine complex gastroschisis were observed in the pre-protocol period, compared to one in the post-protocol era (p= 0.001). The re-interventions also decreased: 58.33% in the pre-protocol vs. 15.38% in the post-protocol group (p= 0.025). Complications rate were 66.67% before protocol vs. 23.07% after protocol (p= 0.028). NICU length of stay decreased from 40 ± 32 to 17 ± 12 days (p= 0.025). Parenteral total nutrition length was 61 ± 36 in the pre-protocol vs. 15 ± 6 in the port-protocol eras, respectively (p= 0.043). The age at onset of enteral nutrition was 34 ± 26 vs. 9 ± 5 days (p= 0.004) and hospitalization length was 98 ± 81 days pre vs. 35 ± 15 days post protocol implantation (p= 0.011). CONCLUSIONS: The protocol implantation has allowed primary closure, decreased hospitalization; reduced complications and mortality rate as well.

OBJETIVOS: Clásicamente existen dos manejos de las gastrosquisis: cierre directo o diferido. Nosotros apostamos por el cierre directo aplicando un protocolo de actuación en el que se programa cesárea a las 34-35 semanas de gestación para minimizar el "peel". MATERIAL Y METODO: Estudio retrospectivo de los pacientes con gastrosquisis en los períodos pre (1978-2006) y post (2007-2016) implantación del protocolo, comparando frecuencia de gastrosquisis complejas, la presencia o ausencia de peel, cierre directo o diferido, complicaciones, reintervenciones, días de ingreso en unidad de cuidados intensivos, edad al inicio de nutrición enteral, nutrición parenteral total y días de hospitalización. RESULTADOS: Grupo de estudio: previo (12) y posterior (13) al protocolo (previo/post). La frecuencia de gastrosquisis complejas en el período previo fue de 9 neonatos, en el período post solo 1 (p= 0,001). El número de reintervenciones fue de 58,33% previo vs. 15,38% post (p= 0,025). Las complicaciones postoperatorias fueron 66,67% previo frente a 23,07% post (p= 0,028) y existió una disminución de los días de estancia en la unidad de cuidados intensivos de 40 ± 32 vs. 17 ± 12 (p= 0,025) y de los días de nutrición parenteral (61 ± 36 frente a 15 ± 6; p= 0,043). La edad al inicio de la nutrición enteral fue de 34 ± 26 vs. 9 ± 5 días (p= 0,004) y los días de hospitalización fueron de 98 ± 81 días previo frente a 35 ± 15 días post protocolo (p= 0,011). CONCLUSIONES: La implantación del protocolo ha permitido el cierre directo, la disminución de la estancia hospitalaria, de las complicaciones y de la mortalidad.

Quistes mesentéricos en la edad pediátrica: ¿qué son en realidad? / Mesenteric cysts in children

OBJETIVOS: Los quistes mesentéricos (QM) son tumores quísticos benignos, integrados en el tejido del mesenterio o del epiplón. Hemos revisado los casos de QM no enterógeno. MATERIAL Y MÉTODOS: Revisión de historias clínicas y biopsias de los casos intervenidos de QM en el periodo 2002-2012. RESULTADOS: Encontramos a 7 pacientes, edad media de 5,3 a˜nos (rango 3-11). El diagnóstico fue ecográfico en todos, salvo en uno. Todos presentaron dolor abdominal; 5 (71,4%) vómitos; 4 (57%) distensión abdominal; 3 (42,8%) fiebre; ninguno presentó obstrucción abdominal completa, aunque 2 pacientes (28,6%) presentaron suboclusión. El quiste fue pediculado o sésil en todos menos en uno, que englobaba raíz de mesocolon y retroperitoneo. La histología de todos ellos reveló malformación linfática. No hubo recurrencias. CONCLUSIONES: Los quistes mesentéricos en niños son en su mayoría malformaciones linfáticas del mesenterio, con clínica muy variada. En el 50-60% están integrados en el mesenterio y requieren resección del asa afectada y anastomosis

OBJECTIVES: Mesenteric cysts (MC) are benign cystic tumors that grow within mesentery or omentum tissue. We have reviewed the cases of MC reported and operated on in our centre. MATERIAL AND METHODS: Retrospective review of clinical records of MC cases during the period 2002-2012 RESULTS: A total of 7 patients were found. Mean age was 5.3 years (range 3-11). Abdominal ultrasound was the diagnostic tool in all cases, except for one, which was diagnosed during laparotomy. All presented abdominal pain, 5 (71.4%) vomiting, 4 (57%) gross abdominal distension, 3 (42.8%) fever, and none presented complete abdominal obstruction, although 2 patients (28.6%) had slight sub-occlusion symptoms. All MC were pedicled or sesil, except for our last case, which extended into the retroperitoneum. All specimens were reported as Limphatic Malformation. None recurred. CONCLUSIONS: MC in children are mostly Lymphatic Malformations of mesentery or omentum origin, and clinical presentation varies from chronic abdominal pain to sudden-onset peritonitis or volvulus. About 50-60% require intestinal resection and anastomosis

[Mesenteric cysts in children]. / Quistes mesentéricos en la edad pediátrica: ¿qué son en realidad?

OBJECTIVES: Mesenteric cysts (MC) are benign cystic tumors that grow within mesentery or omentum tissue. We have reviewed the cases of MC reported and operated on in our centre. MATERIAL AND METHODS: Retrospective review of clinical records of MC cases during the period 2002-2012 RESULTS: A total of 7 patients were found. Mean age was 5.3 years (range 3-11). Abdominal ultrasound was the diagnostic tool in all cases, except for one, which was diagnosed during laparotomy. All presented abdominal pain, 5 (71.4%) vomiting, 4 (57%) gross abdominal distension, 3 (42.8%) fever, and none presented complete abdominal obstruction, although 2 patients (28.6%) had slight sub-occlusion symptoms. All MC were pedicled or sesil, except for our last case, which extended into the retroperitoneum. All specimens were reported as Limphatic Malformation. None recurred. CONCLUSIONS: MC in children are mostly Lymphatic Malformations of mesentery or omentum origin, and clinical presentation varies from chronic abdominal pain to sudden-onset peritonitis or volvulus. About 50-60% require intestinal resection and anastomosis.

[Neonatal surgical site infection: multicentric survey on prophylactic measures]. / Infección de herida quirúrgica neonatal: encuesta multicéntrica sobre medidas profilácticas.

OBJECTIVES: Surgical site infection (SSI) has a considerable impact on neonatal morbidity. There are known risk factors such type of surgery (clean/contaminated), prematurity, surgical length, hypoalbuminemia, previous infection, prolonged mechanical ventilation, and so on. Many perioperative factors have not been studied, opposite to adults. We have developed a survey on intraoperative attitudes and measures, as surgical wound management in Neonates among pediatric surgeons, to seek for a wider consense. METHODS: Multi-response survey with 22 items, based on the Surgical Infection Society NIH 2008 clinical guideline. Each item poses a question on perioperative attitudes, surgical aspects and wound management. Each question is subdivided in two categories, depending on urgency and type of surgery (clean/contaminated). RESULTS: 159 surveys were sent. Among those, we received back 51 (32%). 69% of the interviewed surgeons use clorhexidin to prepare surgical field, 25% use Iodine solutions. 69% never use diathermy to incise skin. There was no agreement on the use of sterile plastic adhesive drapes, intra-cavity lavage, changing surgical gloves/material, or wound irrigation during closure. 82% never use cyanocrilate dressing. Intracuticular skin suture and simple stitches were used indistinctly. Wound management and dressings were not uniform and depended on each pediatric unit. CONCLUSIONS: The survey reflects the lack of consensus regarding prophylactic measures and wound management among pediatric surgeons who care after surgical neonates.

OBJETIVOS: La infección de herida quirúrgica (IHQ) es una causa frecuente de morbimortalidad en Neonatología. Existen factores de riesgo conocidos: tipo de cirugía (sucia/contaminada/limpia), prematuridad, duración de intervención, hipoalbuminemia, infección previa, ventilación mecánica prolongada y contaminación de vía central. Otros factores perioperatorios no han sido estudiados en neonatos, sí en adultos. Desarrollamos una encuesta sobre las actitudes y las medidas, intraoperatorias y de manejo de herida. Pretendemos dilucidar si existe consenso sobre la profilaxis de IHQ neonatal. METODOS: Encuesta con 22 ítems, basada en la guía de prevención de la IHQ en adultos (Surgical Infection Society, 2008). Cada ítem cuestiona temas sobre hábitos perioperatorios, intra y postoperatorios, relacionados con el manejo de la herida quirúrgica en el neonato, y consta de dos preguntas, según sea cirugía sucia/urgente o limpia/contaminada. Las opciones de respuesta son 4: siempre, con frecuencia, raramente y nunca. Enviamos la encuesta a cirujanos pediátricos españoles mediante correo electrónico en el primer trimestre del 2012. RESULTADOS: Se enviaron 159 encuestas. 51 (32%) respondieron. 69% emplean clorhexidina para preparar campo, 25% usan povidona iodada. Solo el 51% refirió dejar actuar siempre un minuto el antiséptico. 69% nunca usan bisturí eléctrico en piel para ampliar herida. No hubo respuestas unánimes en cuanto al uso de paños adhesivos protectores del campo, la irrigación de planos con suero o antisépticos durante el cierre, el empleo de drenajes, cambio de guantes y/o material al iniciar el cierre (cirugía sucia). El 72% y el 82% nunca emplean cianocrilato como cierre o apósito en neonatos, respectivamente. En cirugía sucia, 43% suturan piel con intradérmica y 49% con puntos sueltos. CONCLUSIONES: La distribución de respuestas refleja la falta de consenso sobre los aspectos de la técnica quirúrgica y el manejo perioperatorio que podrían estar relacionados con la profilaxis de IHQ neonatal.

[Gallbladder motility and long term results in cholecystolithotomy]. / Estudio de la función vesicular y resultados a largo plazo de la colecistolitotomía.

INTRODUCTION: Gallstone removal preserving the gallbladder is a therapeutic option in cholelithiasis. Our group has made use of this technique for twenty-five years in pediatric patients. The purpose of this review was to study gallstone recurrence and gallbladder motility. MATERIALS AND METHODS: Patients who had gallstones removed with this technique from 1989 until 2013 were contacted and asked about digestive or other health problems. A sonographic assessment was made in order to look for gallstone recurrence and to measure gallbladder volumes and contraction after fasting and after consuming a fatty meal. RESULTS: All patients are asymptomatic except a girl who suffered colic pain and who had a gallstone recurrence. The median of volume after fasting was 18.37 cc and after consuming the meal 7.16 cc. The median of gallbladder contraction was 57.63%. CONCLUSIONS: A gallstone relapse was identified (10%). Long-term follow up showed an excellent gallbladder function and contraction (greater than 30%) without other recurrences. Based on our experience, in patients properly selected cholecistolithotomy is an interesting option in children.

[Quality of life and long term results in Hirschsprung's disease]. / Calidad de vida y resultados a largo plazo en pacientes con enfermedad de Hirschsprung.

INTRODUCTION: The most frequent long term side effects of Hirschsprung's disease (HD) surgery are obstructive problems and fecal incontinence. In this study, we analyse long term functional results of the two most used surgical techniques (Duhamel-D- and De la Torre-dlT-) from the patient's point of view, through quality of life and functionality questionnaires. METHODS: We selected short segment HD patients ≥ 4 years) that were operated in our unit from 1996 until 2011. We employed two validated questionnaires: Bowel Function Score (BFS) and Gastrointestinal Quality of Life Index (GIQLI). Both questionnaires were also tested in two control age matched groups, each for every arm (controlD or control dlT). RESULTS: Among 28 preselected patients, 22 (78.6%) answered both questionnaires. Group D (10 patients) showed more constipation: 60% vs. 16.7% ( p = 0.01). Patients in group dlT (12 patients) showed more leaks: 58.3 vs. 10% (p = 0.03). Results of both questionnaires were higher (better) in Group D: 16 vs. 12.8 points (BFS, p = 0.007) and 74.1 vs. 69.8 (GIQLI, p = 0.17). The control group showed an overall better scores than HD patients: 17.2 vs. 14.3 (BFS p = 0.001) and 75.9 vs. 71.8 (GIQLI, p = 0.04). Separately, both groups of patients showed worse scores when compared with each control group. DISCUSSION: Our results are similar to other studies, where global scores of functional results and quality of life are worse in operated HD patients than in age matched controls. Fecal incontinence has more impact on social scores than constipation. Due to the fact that our dlT patients have more frequently fecal leaks, their scores are worse than in the D group. Nevertheless, patients in dlT group are younger and may improve their results as they get older, as it is often the case in operated HD patients.

Tratamiento de la hidatidosis hepatopulmonar con cirugía mínimamente invasiva en nuestro hospital. A propósito de 4 casos / Hepatopulmonary hydatidosis treatment through minimally invasive surgery in our hospital: Report of 4 cases

Objetivos. Presentamos nuestra experiencia en el tratamiento quirúrgico mínimamente invasivo de la hidatidosis hepática y pulmonar en los últimos 5 años. Material y Métodos. Revisión retrospectiva de pacientes con quistes hidatídicos hepáticos y pulmonares atendidos en nuestro hospital entre los años 2008-2012 y tratados mediante cirugía mínimamente invasiva Resultados. Se identificaron 4 casos, todos de origen marroquí, la edad media fue de 6,7 años. Un paciente con quiste hepático único y tres con quistes hepatopulmonares. Todos recibieron tratamiento con albendazol previo a la cirugía. Se realizó laparoscopia y/o toracoscopia y en uno de los casos se realizó abordaje transdiafragmático de una lesión hepática posterior inabordable por laparoscopia. La técnica utilizada fue la esterilización del contenido del quiste con suero salino hipertónico, apertura del quiste y extracción de la membrana quística. No realizamos periquistectomía ni capitonaje. La tasa de resolución de las cavidades residuales de los quistes fue del 100% y no ha habido ninguna recidiva como tampoco complicaciones intraoperatorias. Conclusiones. En el niño el tratamiento quirúrgico se puede realizar mediante técnicas endoscópicas con la misma seguridad y eficacia que mediante cirugía abierta. El tratamiento con albendazol previo a la cirugía es útil en la prevención de recidivas y como único tratamiento en lesiones pequeñas. La cirugía ha de ser lo más conservadora de parénquima posible evitándose resecciones innecesarias hepáticas o pulmonares. El tratamiento de la cavidad residual parece ser innecesario. El abordaje transdiafragmático mediante toracoscopia debe considerarse como alternativa en el tratamiento de lesiones hepáticas en segmentos posteriores inabordables con laparoscopia (AU)

Objectives. The aim of this review is to present our experience in minimally invasive surgical procedures as treatment of hepatic and pulmonary hydatidosis in the last five years. Material and Methods. Retrospective review of patients with pulmonary and hepatic hydatid cysts treated in our hospital between 2008-2012 with minimally invasive surgery. Results. We identified 4 cases, all of them Moroccan origin, the mean age was 6.7 years. Only one patient with hepatic cyst and three with hepatopulmonary cysts. All of them were treated with albendazole before surgery. Laparoscopy and / or thoracoscopy was performed and, in one case a transdiaphragmatic approach was used, as a way to reach a posterior hepatic injury unapproachable by laparoscopy. The technique used was the sterilization of the contents of the cyst with hypertonic saline solution, cyst opening and cystic membrane removal. We didn’t do capitonage or pericystectomy. The resolution rate of residual cavities of the cysts was 100% and there was no recurrence or intraoperative complications. Conclusions. In children surgical treatment can be performed using endoscopic techniques with the same safety and efficacy as open surgery. Treatment with albendazole before surgery is helpful in preventing recurrences and as unique treatment in small lesions. Surgery must be as sparing as possible avoiding unnecessary liver or lung resections. Treatment of the residual cavity seems unnecessary. The thoracoscopic transdiaphragmatic approach should be considered as an alternative treatment, for those liver lesions in posterior segments, which are intractable with laparoscopy (AU)

[Preliminary results of a multidisciplinary approach to gastroschisis]. / Resultados iniciales de un protocolo de manejo terapéutico de la gastrosquisis.

INTRODUCTION: In gastroschisis, premature birth may avoid the development of intestinal peel and favour the primary closure. We present the preliminary results obtained after following a multidisciplinary approach to gastroschisis. After prenatal ultrasound diagnosis, preterm caesarean delivery at 34-35 weeks of gestation is programmed. METHODS: Prospective design of a study, where we included all prenatal diagnosed gastrosquisis neonates, from July 2007 to January 2012. RESULTS: We followed 9 infants (3 male). Average weight at birth: 1,927 gr. (+/- 370). Primary closure was successfully accomplished in the first 3 hours of life all cases. We found two cases of slight peel. We found no associated intestinal malformations, except for one small bowel stenosis. No significant neonatal distress respiratory syndrome developed. Mean parenteral nutrition time was 13.9 days (+/- 3.8). 4 neonates developed central line associated infection. No surgical site infection developed. Enteral nutrition was started at day 8th (+/- 2.8). Enteral requirements were fulfilled at day 15th (+/- 3.6). Mean hospital stay was 31 days (+/- 10). Mean follow-up was 30 months. 4 cases developed a small (< 5 mm) umbilical hernia CONCLUSION: Programming premature cesarean section delivery at 34 weeks of gestation was beneficial to the neonates with gastroschisis, yet it avoided peel development, and rendered primary closure without serious difficulties possible. This diminishes hypoperistalsis time and allows rapid instauration of enteral feeding, so hospital stays may be shorter.

Resultados iniciales de un protocolo de manejo terapéutico de la gastrosquisis / Preliminary results of a multidisciplinary approach to gastroschisis

Objetivos. En la gastrosquisis, el parto pretérmino podría evitar el fenómeno de peel y favorecer el cierre primario. Presentamos los resultados obtenidos tras la implantación de un protocolo de manejo multidisciplinario de la gastrosquisis en nuestro centro: tras el diagnóstico y seguimiento ecográfico de la malformación se programa la cesárea en la semana 34 de gestación. Material y Métodos. Estudio prospectivo de todos los casos diagnosticados antenatalmente de gastrosquisis desde julio de 2007 hasta enero de 2012. Resultados. Se siguieron 9 niños (3 varones). Peso medio: 1.927 gramos (± 370). La intervención, cierre primario siempre, se realizó en quirófano en las primeras 3 horas de vida. Encontramos 2 casos de peel leve. El defecto fue pequeño en todos. No hubo malformaciones intestinales asociadas, salvo un caso de estenosis en un asa. No hubo enfermedad de membrana hialina ni patología atribuible a prematuridad. Duración media de nutrición parenteral: 13,9 días (± 3,8). 4 casos presentaron bacteriemia asociada a catéter central. No hubo infección de herida quirúrgica. Se inició nutrición enteral al 8º día (media 8,4, rango 4-13). Se logró alimentación enteral completa al 15º día (media 15,6, rango 11-22). Estancia media: 31 días (± 10, rango 20-56). Mediana de seguimiento: 30 meses. 4 casos presentan pequeña debilidad umbilical menor de 0,5 cm. discusión. El adelantamiento del parto a la semana 34 mediante cesárea electiva impide el desarrollo de peel, permite la reintroducción de las asas en la cavidad peritoneal, disminuye el tiempo de hipoperistalsis y permite la instauración precoz de la alimentación enteral con menor estancia hospitalaria (AU)

Introduction. In gastroschisis, premature birth may avoid the development of intestinal peel and favour the primary closure. We present the preliminary results obtained after following a multidisciplinary approach to gastroschisis. After prenatal ultrasound diagnosis, preterm caesarean delivery at 34-35 weeks of gestation is programmed. Methods. Prospective design of a study, where we included all prenatal diagnosed gastrosquisis neonates, from july 2007 to january 2012.Results. We followed 9 infants (3 male). Average weight at birth: 1,927 gr. (± 370). Primary closure was successfully accomplished in the first 3 hours of life all cases. We found two cases of slight peel. We found no associated intestinal malformations, except for one small bowel stenosis. No significant neonatal distress respiratory syndrome developed. Mean parenteral nutrition time was 13.9 days (± 3.8). 4 neonates developed central line associated infection. No surgical site infection developed. Enteral nutrition was started at day 8th (± 2.8). Enteral requirements were fulfilled at day 15th (± 3.6). Mean hospital stay was 31 days (± 10). Mean follow-up was 30 months. 4 cases developed a small (< 5 mm) umbilical hernia Conclusion. Programming premature cesarean section delivery at 34 weeks of gestation was beneficial to the neonates with gastroschisis, yet it avoided peel development, and rendered primary closure without serious difficulties possible. This diminishes hypoperistalsis time and allows rapid instauration of enteral feeding, so hospital stays may be shorter (AU)

[Functional results of Hirschsprung's disease patients after Duhamel and De la Torre procedures]. / Resultados funcionales en pacientes con enfermedad de Hirschsprung intervenidos mediante las técnicas de Duhamel y De la Torre.

INTRODUCTION: Long term results of different surgical techniques in Hirschsprung's Disease (HD) are contradictory. There are still no long term large or multicentric reports about functional results of De la Torre technique. We have studied the mid term functional results of the patients operated on Duhamel (D) and De la Torre (dlT) pull-through procedures. PATIENTS AND METHODS: We collected data from medical records and telephone interviews of the HD patients operated in our unit in the last 16 years. RESULTS: 38 patients were found. Ages ranged from 1.5 to 21 years. Mean age was 7.7 years. Median follow up was 5.9 years. 33 (86.8%) had rectosigmoid disease and 5 (13.2%) had long segment disease. D procedure was performed in 17 (44.7%), Soave in 1 (2.6%), Duhamel-Lester-Martin in 4 (10.5%) and dlT pull-through in 16(42%). In the last visit record, 12 (31.6%), had constipation, and fecal leaks were noted in 11 (33.3%) of the 33 patients > or = 4 years old.. 10 patients (29.4% of the > or = 4 years old group) referred encopresis along the follow-up. Patients from the D group referred higher rates of constipation than those in the dlT group (53.3% vs 20% p=0.048). dlT patients referred more frequency of leaks (46,1% vs 13,3%, p=0,05) Children with very short resections (< or = 10 cm) were more prone to constipation than children with longer resections (66,6% vs 17.4% p=0.007), and less prone to present leaks (12.5% vs 47.3% p=0.08). Encopresis was similar in all groups. DISCUSSION: Both techniques show similar functional results in the mid term, although children in the D group were more prone to constipation and those in the dlT group presented more fecal leaks. All patients with EH need long follow-ups.

[Hepatopulmonary hydatidosis treatment through minimally invasive surgery in our hospital: report of 4 cases]. / Tratamiento de la hidatidosis hepatopulmonar con cirugía mínimamente invasiva en nuestro hospital. A propósito de 4 casos.

OBJECTIVES: The aim of this review is to present our experience in minimally invasive surgical procedures as treatment of hepatic and pulmonary hydatidosis in the last five years. MATERIAL AND METHODS: Retrospective review of patients with pulmonary and hepatic hydatid cysts treated in our hospital between 2008-2012 with minimally invasive surgery. RESULTS: We identified 4 cases, all of them Moroccan origin, the mean age was 6.7 years. Only one patient with hepatic cyst and three with hepatopulmonary cysts. All of them were treated with albendazole before surgery. Laparoscopy and/or thoracoscopy was performed and, in one case a transdiaphragmatic approach was used, as a way to reach a posterior hepatic injury unapproachable by laparoscopy. The technique used was the sterilization of the contents of the cyst with hypertonic saline solution, cyst opening and cystic membrane removal. We didn't do capitonage or pericystectomy. The resolution rate of residual cavities of the cysts was 100% and there was no recurrence or intraoperative complications. CONCLUSIONS: In children surgical treatment can be performed using endoscopic techniques with the same safety and efficacy as open surgery. Treatment with albendazole before surgery is helpful in preventing recurrences and as unique treatment in small lesions. Surgery must be as sparing as possible avoiding unnecessary liver or lung resections. Treatment of the residual cavity seems unnecessary. The thoracoscopic transdiaphragmatic approach should be considered as an alternative treatment, for those liver lesions in posterior segments, which are intractable with laparoscopy.

Stephens-Fowler en 2 tiempos: resultados 14 años después / Stephens-fowler in two times: results 14 years later

El manejo del testículo intraabdominal puede ser difícil, como lo demuestran las múltiples modalidades de evaluación y tratamiento propuestos. Revisamos nuestros resultados tras 14 años de experiencia en el manejo laparoscópico. Material y métodos. Estudio retrospectivo de las laparoscopias realizadas en nuestro servicio por teste no palpable entre los años1996 y 2009. De 174 laparoscopias encontramos 72 testes intraabdominales (5 bilaterales) y realizamos 25 descensos directos (3bilaterales). En 5 casos se realizó Stephens-Fowler en un tiempo. A40 pacientes se les realizó la técnica de Stephens-Fowler en 2 tiempos(2 bilaterales) por no alcanzar el orificio inguinal contralateral. El segundo tiempo en 4 casos se realizó asistido por laparoscopiay, en el resto, vía inguinal exclusivamente. La edad media de la primera intervención fue de 3,7 años y el tiempo medio entre las 2intervenciones fue de 10,9 meses. De los 42 testes descendidos, 22 (..) (AU)

The management of intra-abdominal testis can be challenging, as evidenced by the multiple methods suggested for its assessment and treatment. In this paper, we report our long-term results for our 14-yearsurgical experience with laparoscopic management. Methods. Retrospective study of laparoscopic interventions performed at our department for non palpable testes between 1996and 2009. In 174 procedures, we found 72 intra-abdominal testes (5bilateral) and 25 direct orchiopexies (3 bilateral) were performed. One-stage Fowler-Stephens orchiopexies (FSO) were performed in 5children. 40 boys underwent the two-stage FSO technique (2 bilateral)in those that reached the contralateral inguinal ring. The second stage (..) (AU)

[Stephens-Fowler in two times: results 14 years later]. / Stephens-Fowler en 2 tiempos: resultados 14 años después.

The management of intra-abdominal testis can be challenging, as evidenced by the multiple methods suggested for its assessment and treatment. In this paper, we report our long-term results for our 14-year surgical experience with laparoscopic management. Methods. Retrospective study of laparoscopic interventions performed at our department for nonpalpable testes between 1996 and 2009. In 174 procedures, we found 72 intra-abdominal testes (5 bilateral) and 25 direct orchiopexies (3 bilateral) were performed. One-stage Fowler-Stephens orchiopexies (FSO) were performed in 5 children. 40 boys underwent the two-stage FSO technique (2 bilateral) in those that reached the contralateral inguinal ring. The second stage was performed in 4 cases with a laparoscopic approach, the rest of them underwent an inguinal procedure exclusively. Mean age for the first intervention was 3.7 yrs, and the second stage was performed on average after 10.9 months. Of 42 undescended testes, 22 were on the right side and 20 on the left side. Median followup was 24 months. Results. Of 42 two-stage FSOs performed, 27 surgeries were very successful, with a testis size equivalent to the contralateral mate; 7 had good results, with a smaller testis (volume up to 50% of contralateral); and 7 resulted in atrophic testis. No complications were encountered during surgery. Conclusions. There is no doubt about the usefulness of laparoscopy for intra-abdominal testes with short spermatic vessels, and the two-stage Fowler-Stephens technique should be the procedure of choice given its high success rate.

Evaluación del efecto de la actuación de los payasos de hospital sobre la ansiedad, en los niños sometidos a una intervención quirúrgica / Evaluation of the effect of hospital clown´s performance about anxiety in children subjected to surgical intervention

Introducción. Ser hospitalizado es un acontecimiento altamente angustioso para los niños. Actualmente un recurso usado en España y otros países para reducir la ansiedad de los niños en el contexto sanitario son los payasos de hospital. Estudiamos el efecto de los payasos de hospital sobre la ansiedad en los niños que van a ser operados. Método. Reclutamos a 60 niños de entre 6 y 10 años de edad, que iban a ser sometidos a una cirugía electiva. 30 niños tendrían payasos antes de la cirugía (grupo de casos) y 30 no los tendrían (grupo control).En el grupo de casos, 2 payasos actuaron para los niños. Medimos la ansiedad con distintas escalas (STAIC, CCPH, escala de caras), después de la actuación y hasta 7 días después de la cirugía. Resultados. Los resultados muestran que ambos grupos tienen una tendencia a incrementar la ansiedad, pero los niños del grupo de casos mostraron menos incremento en la puntuación de ansiedad. El grupo control mostró que los niños están más alterados a los siete días del alta. Conclusiones. Los niños que reciben la atención de los payasos tienen tendencia a estar menos estresados y con menos miedo que los otros, medido por el STAIC y la escala de caras, y estos resultados se mantienen siete días después del alta (AU)

Objective. To be hospitalized is a highly distressing event for children. At present, a resort used in Spain and other countries to reduce children’s anxiety in the health context are hospital’s clown. We studied the effect of the hospital’s clowns about the anxiety in children that going to be operated. Methods. We recruited 60 children aged 6 to 10 years scheduled to undergo elective surgery. 30 children would have clowns before the surgery (case group) and 30 would not have them (control group).In the case group, two clowns performed for children. We measured the anxiety with several scales (STAIC, CCPH, faces scale), after the performance and until 7 days after the surgery. Results. The outcomes show both groups a tendency to increase anxiety but the children of the case group showed less increase at the anxiety’s score. In the control group is showed that the children are more alterated at seven days from the discharge. Conclusions. Children that receive the clown’s care, have tendency to be less distressing and with less fear that another ones, measurement by STAIC and faces scale, and these results are maintained seven days after the discharge (AU)