[Combination of pulsed dye laser and propranolol in the treatment of ulcerated infantile haemangioma]. / Combinación de propranolol oral y láser de colorante pulsado en el tratamiento de los hemangiomas infantiles ulcerados.

INTRODUCTION: Ulceration is the most common complication of infantile haemangioma, with 15.8% of them usually appearing in the proliferative phase. They can be managed in several ways. We present our experience in the treatment of ulcerated haemangioma with the combination of pulsed dye laser and propranolol. MATERIAL AND METHODS: A retrospective observational study was conducted on patients with ulcerated infantile haemangioma treated with pulsed dye laser in association with propranolol. The study included 7 patients, 3 cases in labial area and 4 cases in the nappy area. A review was also performed on a historical cohort of 5 children with ulcerated haemangiomas with the same features, but treated only with propranolol, topical agents and occlusive dressings. RESULTS: The median size of the ulcer was 1.0 cm, and there was a mean time of onset pre-treatment of 2 weeks. Pain and bleeding was present in all patients. After 2 weeks of combined propranolol and laser treatment, all lesions were healed. The pain disappeared after the first laser session. Patients with ulcerative haemangioma in the labial area obtained a better response than patients with haemangioma in the nappy area. The cohort of patients treated with propranolol required a mean healing time of 5.2 weeks, with the addition of an occlusive dressing with ointment. CONCLUSIONS: We believe that our results suggest that combined treatment, laser and propranolol, has synergistic effects that accelerate the healing of ulcerated haemangioma, as observed in our patients. Further studies with larger numbers of patients are needed to confirm this fact.

Tratamiento ortopédico de las malformaciones craneales posturales / Orthopedic treatment of the postural cranial malformations

Introducción: En 1992, la Academia Americana de Pediatría recomendó que los bebés durmieran boca arriba o de lado para reducir el riesgo de síndrome de muerte súbita del lactante. Desde entonces, la incidencia de las malformaciones craneales posturales ha aumentado de forma considerable y, con ello, sus consecuencias estéticas e incluso psicológicas. Gran parte de los niños afectados precisarán tratamiento ortopédico de su deformidad mediante ortesis craneal. Realizamos un estudio sobre la eficacia, las indicaciones y el resultado de dichas ortesis según la experiencia y el protocolo de tratamiento en la unidad de malformaciones craneales de nuestro hospital. Material y métodos: Analizamos los niños tratados por malformaciones craneales posturales durante 5 años. Recogemos los datos clínicos que nos han resultado más importantes para el diagnóstico diferencial con las sinostosis y la necesidad de pruebas complementarias. Valoramos la morfología de la lesión, su gravedad, los factores etiológicos asociados, la edad del niño en el momento del diagnóstico, la duración del tratamiento postural u ortésico y la eficacia de éste según nuestro registro fotográfico, así como la opinión subjetiva de los padres. Realizamos una revisión bibliográfica al respecto (AU)

Resultados: Hemos registrado un total de 105 niños con malformaciones craneales posturales, la gran mayoría con plagiocefalia. Entre los factores asociados podemos indicar que 12 pacientes estuvieron ingresados durante largo tiempo en la unidad de neonatos, 16 con una desproporción materno fetal, 8 niños padecían tortícolis congénita y, curiosamente, 12 niños eran de procedencia china por adopción, 8 con antecedente departo instrumental. La media de edad en el momento del diagnóstico en nuestra consulta fue de 6,3 meses, la misma media de edad en que se indicó una ortesis, ya que en general los pacientes acuden con un diagnóstico demasiado tardío como para poder instaurar el tratamiento postural, y sólo 16 niños acudieron o fueron diagnosticados antes de los 3 meses de edad. La ortesis se mantuvo durante una media de 4,5 meses. El porcentaje de malformación facial apreciable subjetivamente fue del 28%. El porcentaje de niños diagnosticados en nuestra consulta que no precisaron ortesis dentro del mismo tipo de deformidad fue nulo, dado el mencionado diagnóstico tardío. Ninguna malformación postural precisó cirugía. Se realizó una radiografía craneal al 20% de los niños, todas ellas solicitadas por médicos no especialistas. La cuantificación subjetiva de la mejoría fue mayor en los niños diagnosticados precozmente. El tiempo medio de resolución fue de 4,5 meses. Conclusiones: Las malformaciones craneales, dada su elevada incidencia actual, precisan un adecuado conocimiento, protocolo de tratamiento y diagnóstico precoz, ya que éste facilita la probabilidad de éxito con un tratamiento sencillo y corto; provocan una no despreciable incidencia de deformidad facial. El desconocimiento de esta patología conlleva la realización de pruebas complementarias innecesarias (AU)

Introduction: In 1992, the American Academy of Pediatrics (AAP) recommended for babies to sleep face up or sideways to reduce the risk of sudden infant death syndrome, since then, the incidence of cranial malformations has increased considerably and thus its esthetic and psychological consequences. Many affected children require orthopedic treatment of their cranial deformities through an orthosis helmet. We make a study of effectiveness, indications and results of these orthosis according to our experience and our treatment protocol in the unit of cranial malformations of our hospital. Material and methods: We studied children treated for postural cranial malformations during 5 years. We analyze the most important clinical data for differential diagnosis with synostosis and the need of additional studies. We appreciate themorphology of the lesion, severity, the associated etiological factors, child’s age at diagnosis, duration of conservative or orthotic treatment and their effectiveness in our photographic files and in the subjective opinion of the parents. We have made a bibliographic review on this matter (AU)

Results: We have registered a total of 105 children with positional cranial malformations, most of them with morphologically with plagiocephaly. The associated factors were: 12 patients stayed long time in our newborn unit, 16 had maternal fetal disproportion, 8 children suffered from congenital torticollis, oddly 12 children whom were adopted had a Chinese origin, 8 had history of instrumental delivery. The average age of diagnosis in our department was of 6.3 months, same mean age in which an orthosis was indicated, because they generally arrive with a late diagnosis to be able to establish the positional therapy, only 16 children attended or were diagnosed at ages younger than 3 months. The orthosis helmet was kept for an average of 4.5 months. The percentage of subjective facial malformation was of 28%. The number of children diagnosed in our department who did not require helmets within the same type of deformity was of zero because of such a late diagnosis. None of them needed surgery, skull radiography was performed in 20% of the children, all of them requested by a non-specialist doctors. The quantification of subjective improvement was greater in children with an early diagnosis. The mean time of resolution was of 4.5 months. Conclusions: Positional cranial malformations, because of their high incidence require a complete knowledge, treatment protocol and early diagnosis, as this provides higher probability of successful, simple a short treatment. They cause a non negligible incidence of facial deformity. The ignorance of this condition causes the consumption of unnecessary tests (AU)

[Quality of life in children operated on for anal atresia]. / Calidad de vida en los pacientes intervenidos de atresia de ano.

INTRODUCTION: Most children with anorectal malformations have some type of intestinal dysfunction. A correct follow up in this aspect after surgery affects their quality of life. MATERIAL AND METHODS: We gathered a sample of 20 children that were lost in their follow up after posterior sagittal anorectoplasty (PSARP). We got contact with them and they were interviewed and examined in our department. RESULTS: We collected 12 girls and 8 boys. Age range was between 3 and 14 years. 70% had good prognosis for continence (low fistula) and 30% poor prognosis (high fistula). 35% suffered from postoperative complications being the most frequent prolapse especially in high atresias. 85% had good rectal sensitivity, 15% had poor sensitivity that was directly related to incontinence. Anal tone was decreased in our exploration in 35% of patients which was not directly related to their continence. 65% suffered constipation with or without fecaloma. 5% of cases had intestinal hipermotility. The total incidence of fecal loose was 40%. More than a half (62,5%) kept on loosing stool despite treating their constipation or hipermotility, so we consider them true incontinents (no voluntary bowel movements). 67% of children with high fistula were true incontinents, just 7% of those with low fistula. Subjective quality of life in patients with soling was 6.4. In clean patients it was 9.3. Objective quality of life (Score/13) in dirty patients was 6.6. In Clean patients: 11.9. After our bowel management protocol we got 100% of patients clean during school time, thereby improving their quality of life. CONCLUSIONS: Incontinence determines the long-term quality of life in our patients in addition to the psycho-social consequences. They are clearly more frequent in patients with high fistula. Much assume incontinence as an unavoidable part of their disease so do not always demand treatment if they are not followed by a surgeon.

Toracoscopia en niños con empiema pleural en fase II. ¿Lavado y desbridamiento de tabiques de fibrina o decorticación? / Thorascoscopy in children with pleural empyema in 2nd stage, breaking and washing fibrinous loculations or decortication?

Introducción: Ante el aumento de incidencia de derrames pleurales paraneumónicos complicados en niños, ha aumentado considerablemente el número de toracoscopias realizadas, ya sea para el lavado y el desbridamiento de los tabiques de fibrina para liberar el líquido acumulado, o completando la intervención con decorticación completa de la fibrina aún no organizada adherida a la pared pulmonar. Material y métodos: Estudiamos una muestra de 31 niños tratados toracoscópicamente por un derrame pleural complicado en fase II. Estudiamos diversas variables: edad, tiempo de clínica y de tratamiento antibiótico preoperatorios, composición del líquido pleural, germen, opción quirúrgica, tiempo operatorio, días con drenaje pleural mayor de 20 mL/día o fiebre y complicaciones. Resultados: De 31 toracoscopias, el 52% son descorticaciones pulmonares y el 48% desbridamientos y lavados. Mediante el test de la t de Student comprobamos que el tiempo de drenaje pleural en los pacientes con desbridamiento simple es estadísticamente superior, al igual que los días de fiebre (sin diferencias significativas), y se requieren más fibrinolíticos y reintervención. No observamos una mayor incidencia de fuga aérea en la decorticación, aunque sí de íleo paralítico posquirúrgico. Conclusiones: La decorticación pulmonar en los derrames pleurales complicados en fase II conlleva un menor tiempo de drenaje torácico y clínica febril. En manos entrenadas no aumenta el tiempo operatorio ni el número de complicaciones graves (AU)

Introduction: Before the increase of incidence of complicated pleural parapneumonic effusion in children, has increased the number of Video Assisted Thoracoscopy (VATS) considerably. Whether it is for the washing or breaking of the nasal bone fibrin to liberate the accumulated liquid, or complete the intervention with complete decortication of a non-organized fibrin wall attached to the lung. Material and methods: We study a sample of 31 children whounder went VATS for complicated pleural effusion in 2nd stage. We study: age, clinical time and pre-surgical symptoms and antibiotics, composition of the pleural liquid, infectious agent, surgical option, operative time, days with fever and pleural drainage more than 20 cc/day or fever and complications. Results: From 31 VATS, 52 % were pulmonary decortications and 48 % debridement and wash. Using the t-student we get statistically significative difference in time of pleural drainage, longer in patients with simple debridement, as in days with fever, not being this difference significant. There is more need of fibrinolysis and reintervention in this group. We do not see more incidence of air leak in the decortication group, but there is more post surgery paralytic ileus. Conclusions: Lung decortication in pleural complicated effusions2nd stage entails less time with thoracic drainage and fever. In trained hands it does not increase neither the operative time nor the number of serious complications (AU)

[Platelet-rich plasma (platelet gel) in secondary alveoloplasty in cleft patients]. / Plasma enriquecido en plaquetas en la alveoloplastia de pacientes fisurados.

INTRODUCTION: The use of Platelet-rich plasma (platelet gel--PRP--) was introduced in the oral and maxilofacial surgery 10 years ago. Its good results are due to the quickly generation of new bone and the acceleration of the period of surgical scar formation. Its employment in the alveolar reconstruction of the cleft patient is not still consistent and the works published in the literature are infrequent. The objective of this preliminary study is presenting our experience with the use of PRP in the reconstruction of the alveolar congenital defects of cleft patients. PATIENTS AND METHODS: Between July 2002 and January 2004 were operated 14 patients with congenital alveolar cleft carrying out an standard secondary alveoloplasty. In 12 cases was employed cancellous bone of iliac crest and in two cases the donor area was tibial. The laboratory of Hematology of our Hospital prepared the plasma gel rich in platelets by means of a double centrifuge of autologous serum of the patient. After adding calcium a rich gel in platelets in approximate quantities of 1-2 ml was obtained. In this preliminary report we have studied the aspect of the surgical injury the 3er postoperative day, and the first and second weeks after intervention. These results were compared carried out previously with the Standard alveoloplasty without use of the PRP. Likewise we evaluated the bony density by means of intraoral Rx at 3 and 6 months postoperative. RESULTS: The injury of the alveoloplasty healed more quickly in the patients in which plasma enriched gel was employed. The patients referred less pain and edema in the first days of the postoperative period. The alveolar bony regeneration was faster to the 3 months, though the result was similar in the intraoral Rx to the 6 months. The necessary quantities of cancellous bone were smaller in all cases in which the plasma enriched gel was used (30% less). CONCLUSIONS: The use of Platelet-rich plasma (PRP) is a valid protocol for the reconstruction in patients with congenital alveolar clefts. Its low price and morbidity do it recommendable for its employment in cleft patients.

Relevancia del diagnóstico y tratamiento precoz de la otitis media seromucosa en pacientes con fisura palatina / Significance of early diagnosis and treatment of otitis media with effusion in cleft palate pediatric patients

Introducción: La otitis media seromucosa afectaa casi el 95% de los pacientes con fisura palatina. Elresultado de esta lesión es la pérdida auditiva, el retrasoen el lenguaje y el retraso en el desarrollo escolar.La corrección quirúrgica del paladar fisuradono mejora la permeabilidad de la trompa de Eustaquio.Objetivo: Analizar los resultados del drenaje quirúrgicode las otitis medias seromucosas que aparecenen nuestra serie de pacientes afectos de fisuradel paladar.Material y Métodos: Revisamos las historias de72 pacientes fisurados en el período 1998-2004. Delos 72 pacientes pediátricos, sólo 57 fueron adecuadospara el estudio. En todos los pacientes se realizóotoscopia y audiometría para comprobar la movilidadde la membrana timpánica y la pérdida auditiva.El seguimiento se realizó en la consulta de ORLinfantil de forma trimestral durante el primer añoposterior al drenaje y cada 6 meses los 3 años siguientes.El seguimiento medio fue de 22 meses (6meses a 7 años).Resultados: La prevalencia de la otitis media seromucosauni o bilateral de los 57 pacientes estudiadospor otoscopia fue del 84.3%. De los 57 pacientesestudiados, 9 no tuvieron datos de otitis media ysus audiometrías fueron normales (15.7%). Otros 16pacientes fueron tratados médicamente de su otitisserosa debido a la conservada movilidad del tímpanoy no fueron inicialmente candidatos a drenajequirúrgico. En 20 casos se insertaron tubos de ventilacióna la vez que se realizó la palatoplastia mientrasque en 12 casos los tubos se colocaron posteriormenteal cierre del paladar. De los 32 pacientescon miringotomías y tubos de ventilación, 5 casospresentaron otorrea crónica sin pérdida auditiva. En7 de estos niños aparecieron episodios de otitis a lolargo del seguimiento si bien sólo 4 presentaban otitisseromucosa persistente en la última revisión. En5 pacientes fue necesario reinsertar otro tubo porpersistencia de la enfermedad tras la caída del tubooriginal. Pese al tratamiento quirúrgico efectivo, encasi un 15% de los niños de nuestra serie persiste laotitis media seromucosa (5 pacientes).Conclusiones: La miringotomía junto con la colocaciónde tubos transtimpánicos a la vez que lareparación del paladar es la mejor estrategia paraasegurar la mejor audición con la mínima morbilidad.Pese al tratamiento efectivo, en un 15% delos niños fisurados persiste la otitis media seromucosa

Introduction: Otitis media with effusion affects toalmost 95% of the patients with cleft palate. Theconsequences of this pathology are hearing loss, alterationin the language and delay in school development.The surgical correction of the cleft palatedoes not improve the permeability of the Eustachiantube. Aim: to analyze the results of the surgical drainageof Otitis media with effusion that appears in ourserie of patients with cleft palate.Material and Methods: we review the clinical dataof 72 cleft palate patients from 1998 to 2004. Ofthe 72 pediatric patients, only 57 they were adequatefor the study. In all the patients was carried outotoscopy and audiometry to verify the mobility of themembrane and the auditory loss. The monitoringwas carried out in the consultation of ORL during thefirst subsequent year drainage and each 6 monthsthe 3 following years. The mean follow-up was 22months (6 months to 7 years).Results: The prevalence of otitis serosa with effusionwas 84.3%. Of the 57 patients studied, 9 did notthey have data of otitis and their audiometries werenormal (15.7%). Other 16 patients were treated medicallyand they were not initially candidates to surgicaldrainage. In 20 cases ventilation tubes were insertedat the same time that the palatoplasty was carriedout. In 12 cases the grommets were placed afterthe palate surgery. Of the 32 patients with miringotomyand grommets, 5 cases presented chronicotorrea without auditory loss. Recurrent otitis duringfollow-up appeared in 7 of these children. But only 4cases presented otitis with effusion in the last revision.In 5 patients was necessary to insert anothertube by persistence of the effusion after the fall of theoriginal grommet. In 15% of the children of our seriespersists otitis seromucosa with effusion (5 patients).Conclusions: The miringotomy along with theplacement of grommets at the same time of the repairof the palate is the most accurate strategy to assurethe best hearing with the minimum morbidity

Plasma enriquecido en plaquetas en la alveoloplastia de pacientes fisurados / Platelet-rich plasma (platelet gel) in secondary alveoloplasty in cleft patients

Introducción. El uso de plasma autólogo enriquecido en plaquetas (PRP) fue introducido en la cirugía oral y maxilofacial hace unos 10 años. Sus buenos resultados se deben a la rapidez con la que genera nuevo hueso y la aceleración del período de cicatrización quirúrgico. Su empleo en la reconstrucción alveolar del paciente fisurado no es todavía consistente y los trabajos publicados en la literatura son muy escasos. El objetivo de este estudio preliminar es el de presentar nuestra experiencia con la utilización del plasma rico en plaquetas en la reconstrucción de las fisuras alveolares congénitas de pacientes fisurados. Material y métodos. Entre julio de 2002 y enero de 2004 fueron intervenidos 14 pacientes con fisura alveolar congénita realizando una alveoloplastia secundaria estándard. En 12 casos se empleó injerto óseo esponjoso de cresta ilíaca y en dos casos la zona dadora fue tibial. El laboratorio de Hematología de nuestro centro preparó el concentrado plasmático rico en plaquetas mediante un doble centrifugado de suero autólogo del paciente y pipeteado del mismo. Tras añadir gluconato cálcico se obtuvo un gel rico en plaquetas en cantidades aproximadas de 1-2 ml. En este estudio preliminar hemos estudiado el aspecto de la herida quirúrgica el 3er día postoperatorio, y la primera y segunda semanas de la intervención. Se compararon estos resultados con los realizados previamente en la alveoloplastia estándard sin uso del plasma rico en plaquetas. Igualmente se valoró la densidad ósea mediante Rx intraoral a los 3 y 6 meses. Resultados. La herida de la alveoloplastia cicatrizó mucho más rápidamente en los pacientes en los que se empleó plasma (..) (AU)

Introduction. The use of Platelet-rich plasma (platelet gel–PRP-) was introduced in the oral and maxilofacial surgery 10 years ago. Its good results are due to the quickly generation of new bone and the acceleration of the period of surgical scar formation. Its employment in the alveolar reconstruction of the cleft patient is not still consistent and the works published in the literature are infrequent. The objective of this preliminary study is presenting our experience with the use of PRP in the reconstruction of the alveolar congenital defects of cleft patients. Patients and methods. Between July 2002 and January 2004 were operated 14 patients with congenital alveolar cleft carrying out an standard secondary alveoloplasty. In 12 cases was employed cancellous bone of iliac crest and in two cases the donor area was tibial. The laboratory of Hematology of our Hospital prepared the plasma gel rich in platelets by means of a double centrifuge of autologous serum of the patient. After adding calcium a rich gel in platelets in approximate quantities (..) (AU)

Conformadores nasales en la rinoplastia primaria del paciente fisurado / Nostril reatainers in the primary cleft rhinoplasty

Introducción. Tras la realización de la rinoplastia primaria o secundaria en el paciente fisurado existe una tendencia a la depresión del cartílago alar perdiendo la nueva morfología obtenida. Por este motivo es habitual el empleo de conformadores nasales en el postoperatorio de la rinoplastia de estos pacientes, ya sea ésta abierta o cerrada. Objetivo. Presentamos nuestra experiencia en el uso de conformadores nasales para mantener en posición el cartílago alar tras la rinoplastia del paciente con fisura unilateral o bilateral, evitando así la deformación producida por la retracción cicatricial. Pacientes y métodos. Hemos colocado 18 stents nasales en 18 pacientes con fisura nasolabial intervenidos (4 bilaterales y 14 unilaterales) en el período 2001-2004. Realizamos una comparación fotográfica de la simetría nasal entre los pacientes intervenidos sin stents en un período anterior (1998-2000) y el grupo de estudio. Los conformadores nasales se fijan en su posición tras la rinoplastia mediante suturas reabsorbibles de Monocryl® 4/0. Estas suturas mantienen el stent en su lugar durante unos 20 días después de la intervención. Resultados. El tiempo medio de retención del conformador nasal fue de 3,5 meses (4 semanas a 6 meses). Los métodos empleados para mantener el stent en su lugar tras la absorción de las suturas de fijación fueron diversos y siempre en función de la comodidad de las familias. El estudio comparativo demostró una asimetría relevante de ambas narinas en el 10% de los pacientes con stents frente al 48% de aquellos sin stents (p<0,01). Conclusiones. El empleo de conformadores nasales en el postoperatorio protege la corrección quirúrgica del cartílago evitando la depresión de la narina, así como la aparición de adherencias intranasales precoces. Permite igualmente la realización sin molestias de lavados nasales y pueden mantenerse hasta la cicatrización del cartílago. Su uso implica una colaboración adecuada por parte de la familia (AU)

Introduction. The nasal cleft cartilage tends to depression after primary rhinoplasty. Nasal stents are probe to be useful in the management of these patients in order to maintain the new morphology. Aim. The purpose of this paper is to present our experience with the use of postoperative nasal splinting in the management of cleft lip nasal deformity. Patients and methods. A nostril retainer was placed in 18 cleft patients (4 bilateral, 14 unilateral) during primary repair of the cleft lip nasal deformity from 2001 to 2004. The nasal morphology in the postoperative period was compared with that of 10 control patients who were operated on without nasal stenting in a previous period. Nostril retainers were left in place after the rhinoplasty using 4/0 poliglecaprone absorbable. Those sutures fixed the stent in place during three weeks after surgery. Results. Average follow-up was 18.5 months. Retention of the splint was 3.5 months mean time (range 4 weeks to 6 months). The methods employed for retention were multiple based upon parental preferences. Photogrammetric analysis showed relevant asymmetry of the nostrils in 10% of the splinted group as compared with 48% for controls (p<0.001). Conclusions. The use of nasal stents has been found effective postoperatively after cleft primary rhinoplasty, avoiding relapse of the nasal reconstruction and drop of the nasal ala. Retainers also allows airway patent and avoid surgical adhesions due to nasal secretions and scarring. Parental collaboration is needed (AU)

[Nostril retainers in the primary cleft rhinoplasty]. / Conformadores nasales en la rinoplastia primaria del paciente fisurado.

INTRODUCTION: The nasal cleft cartilage tends to depression after primary rhinoplasty. Nasal stents are probe to be useful in the management of these patients in order to maintain the new morphology. AIM: The purpose of this paper is to present our experience with the use of postoperative nasal splinting in the management of cleft lip nasal deformity. PATIENTS AND METHODS: A nostril retainer was placed in 18 cleft patients (4 bilateral, 14 unilateral) during primary repair of the cleft lip nasal deformity from 2001 to 2004. The nasal morphology in the postoperative period was compared with that of 10 control patients who were operated on without nasal stenting in a previous period. Nostril retainers were left in place after the rhinoplasty using 4/0 poliglecaprone absorbable. Those sutures fixed the stent in place during three weeks after surgery. Results. Average follow-up was 18.5 months. Retention of the splint was 3.5 months mean time (range 4 weeks to 6 months). The methods employed for retention were multiple based upon parental preferences. Photogrammetric analysis showed relevant asymmetry of the nostrils in 10% of the splinted group as compared with 48% for controls (p<0.001). CONCLUSIONS: The use of nasal stents has been found effective postoperatively after cleft primary rhinoplasty, avoiding relapse of the nasal reconstruction and drop of the nasal ala. Retainers also allows airway patent and avoid surgical adhesions due to nasal secretions and scarring. Parental collaboration is needed.

[New Modern Magpi: meatal advancement and glanuloplasty clinical course]. / New Modern Magpi: evolución del avance meatal con glanduloplastia.

INTRODUCTION: Meatal advancement and glanuloplasty (MAGPI) described by Duckett, has been the most accepted technique for distal hypospadias repair along the last 20 years. Only 50% of the distal variants are amenable to the Magpi; last years several modifications has been reported in order to reach better cosmetic results and to make it available for the most of the distal hypospadias. We report the first 20 cases with some modifications of Magpi. MATERIALS AND METHODS: The basic steps of the technique are: we remove a triangular segment of glanular tissue distal to the meatus. Dissection of the dorsal and lateral urethral sides is made, accomplishing the urethral advancement without any tension. Strips of glandular epithelium are excised on each side, and glans tissue is sutured above the ventral urethral wall. RESULTS: There were 11 coronal, and 9 glanular hypospadias (3 with megameatus). 8 cases showed a slight incurvation that disappeared after releasing any cutaneous chordee. The posoperative follow-up was 35 weeks (R=7-48 weeks). Cosmetic and functional results were excellent, showing a natural circumcized penis. There wasn't any complications as meatal retraction, stenosis or incurvation. There was only a transitional hematoma and a minimal fistula that closed expontanely. CONCLUSIONS: New Modern Magpi adds minimal variations to the original technique, avoiding the cosmetic limitations derived from borderline indications. New Modern Magpi is amenable to near all of glanular hypospadias and most of coronal hypospadias.

[Ultrasound-guided hydrostatic reduction for the treatment of idiopathic intestinal invagination]. / Reducción hidrostática guiada por ecografía para el tratamiento de la invaginación intestinal idiopática.

The more extended conservative treatment in intussusception consists of the accomplishment of fluoroscopy guided neumoenema. The development of the echography has allowed to introduce this as alternative in diagnosis and treatment of intussusception. Our objective is to analyze the therapeutic value of echography during resolution of intussusception with saline solution enema in pediatric patients. Intestinal intussusception was diagnosed in 183 patients by echography during a period of 7 years. Patients are classified in three groups according to treatment by means of opaque enema, radioscopy guided neumoenema or echography guided hydrostatic reduction enema. The results of the three series are analyzed: rate of failure of the procedure, the recurrences or the presence of complications. We exclude n = 18 patients that were operated on directly after the diagnosis. The reduction rate was 81.25% (9/16) with opaque enema; 94.6% (103/110) with neumoenema and 96.4% (27/28) with echography guided saline enema. Complications appeared in n = 2 cases of intestinal perforation, 1 with barium and 1 with air 2. Recurrences were n = 3, n = 2 with neumoenema and n = 1 with echography guided enema. Echography guide saline enema has a high security and effectiveness (96.4%), similar to the other methods, avoiding the exposition to ionic radiation. The technique is safe and it does not increase the rate of recurrences.

[Involvement of betamimetics in increased survival during fetal surgery in sheep]. / Implicación de los betamiméticos en el aumento de la supervivencia tras procedimientos quirúrgicos en el feto del cordero común.

INTRODUCTION: Fetal surgery is a therapeutic reality. Available only in a few centres worldwide. Experimental animal models are needed to continue research in this field. The target problem being the control of preterm labour. OBJECTIVES: To find a tocolytic drug regimen in order to reduce fetal loss. MATERIAL AND METHODS: Pregnant sheep were divided randomly in two groups. At a gestation age of seventy days sheep were operated in order to create a myelomeningocel model in the fetus. Follow-up with weekly amniocentesis guided by ultrasound scan. Group A (n = 6) were treated pre and post-op with indomethacine and with magnesium sulphate during surgery and in the following 24 hours. Group B (n = 8) were treated with diclofenac pre-op, and post-op with ritodrine until the end of pregnancy. RESULTS: Group A we find a survival rate 50% (n = 3) being 87% (n = 7) in group B. Fetal weight being higher in group A. We find an increase heart rate and a weight loss in both the fetus and mother in group B. Urea and creatinine amniotic fluid levels were increase in group B. CONCLUSIONS: The use of ritodrine as a tocolytic agent reduces fetal loss significantly. Ritodrine increases fetal and mother cardiac output causing weight loss.

[Success of endoscopic management in vesicoureteral reflux, conditioned by ureteral dilatation]. / La dilatación ureteral condiciona el éxito del tratamiento endoscópico del R.V.U.

INTRODUCTION: Endoscopic management has become an important alternative in the treatment of vesicoureteral reflux in children. Since 1995 we indicate it in our Hospital in children with grade II VUR (vesicoureteral reflux) after 1 year of medical management, in all children with grade III VUR and in children with grade IV VUR without reflux nephropathy. According to International Classification of reflux (IRSC), grade IV VUR differ to grade III mainly by the blunting of the calyces and the obliteration of sharp angle of the fornices. There may be seen in the high grades of reflux, important differences in the ureteral dilatation. AIM: The aim of this work is to study the influence of ureteral dilatation in the success of endoscopic management VUR. MATERIAL AND METHODS: A number of 245 refluxing renal units (URR) were treated endoscopically in our Hospital from 1995. We review the first 3.5 years (58 patients with 90 RRU). In a double blind study with the voiding cystourethrographies we graduated the ureteral dilatation in slight-normal, moderate and severe. The success rate after the first injection was compared between the 3 grades of ureteral dilatation. RESULTS: 3 patients had grade I VUR, 10 grade II, 54 grade III and 23 grade IV. After double blind study 39 patients had slight-normal ureteral dilatation, 39 moderate and 12 severe. There were statistical differences between the 3 grades of ureteral dilatation when we consider: all the patients, considering only grade III and IV reflux and studying only the patients with grade III reflux. However there wasn't statistical differences between grade III and IV VUR of the International Classification. CONCLUSIONS: The results show that ureteral dilatation is an important prognostical factor of the success rate in the endoscopic management of vesicoureteral reflux in children.

Implicación de los betamiméticos en el aumento de la supervivencia tras procedimientos quirúrgicos en el feto del cordero común / Involvement ofbetamimetics as increase of survival during fetal surgery in sheep

La cirugía fetal es actualmente una realidad terapéutica en algunos centros a nivel mundial. La investigación en este campo obliga a utilizar modelos animales experimentales. El problema principal de estos modelos es el control del trabajo de parto prematuro. Objetivos: Encontrar un régimen tocolítico que minimice las pérdidas fetales tras procedimientos quirúrgicos en el feto de oveja común. Material y métodos: Partiendo de dos grupos de ovejas gestantes elegidas mediante método aleatorio simple, a los 70 días de gestación son intervenidas, realizándose un mielomeningocele quirúrgico en el feto. Durante el postoperatorio se monitorizó los valores bioquímicos de urea y creatinina en líquido amniótico, mediante la realización de una amniocentesis semanal guiada con control ecográfico. El grupo A (n =6) fue tratado preoperatoriamente con indometacina y postoperatoriamente con sulfato de magnésico, que se mantenía durante 24 horas. En el grupo B (n = 8) se utilizó diclofenaco preoperatorio asociado a ritodrina postoperatoria, mantenida hasta la finalización de la gestación. Resultados. En el grupo A encontramos una supervivencia del 50% (n= 3), siendo en el grupo B del 87% (n = 7). El peso comparado de los fetos en ambos grupos fue menor en los tratados con ritodrina, así como también fue menor la ganancia ponderal de las madres de dicho grupo. Encontramos un incremento en la frecuencia cardíaca materna y fetal en el grupo B. Los valores de urea y creatinina en líquido amniótico fueron mayores en el grupo B, aunque no de forma significativa. Conclusión: El uso de ritodrina como agente tocolítico reduce las pérdidas fetales de forma significativa en el modelo de cirugía fetal basado en la oveja común. La ritodrina aumenta el gasto cardíaco materno y fetal ocasionando pérdidas de peso (AU)

La dilatación ureteral condiciona el éxito del tratamiento endoscópico del R. V. U / Success ofendoscopic management in vesicoureteral reflux, condicioned by ureteral dilatation

Introducción: El tratamiento endoscópico del reflujo vésico-ureteral (RVU) se ha convertido en una de sus principales armas terapéuticas. En 1995 se comienza a utilizar en nuestro hospital. Lo indicamos en los RVU de grado II no curados tras 1 año de tratamiento médico, en todos los de grado III y en los de grado IV sin daño renal. Según la Clasificación Internacional del Reflujo (IRSC); los reflujos de grado IV se diferencian de los de grado III básicamente por el abombamiento de los cálices. En cada uno de los grados de RVU se pueden observar distintos grados de dilatación ureteral. Objetivos: Estudiar la relación entre el grado de dilatación ureteral y la curación endoscópica del RVU independientemente de los gradosde reflujo. Material y métodos: De una serie de 245 unidades renales refluyentes (URR) intervenidas endoscópicamente; realizamos una revisión delos primeros 3,5 años (1996-1999). Se estudiaron 58 pacientes, con un total de 90 URR. Se valoraron las cistografías miccionales (CUMS).Mediante un estudio de doble ciego se graduó la dilatación ureteral de todos los pacientes en tres grados: leve-normal, moderada y severa. Se compararon los porcentajes de curación tras la 1ª inyección endoscópica en los tres grados de dilatación ureteral. Resultados: De las 90 URR estudiadas, 3 presentaban RVU de grado (..) (AU)

Sonocistouretrografía con galactosa en el diagnóstico y seguimiento del reflujo vesicoureteral en pacientes pediátricos / Urethrocystosonography for diagnosis and follow-up of vesicoureteric reflux in pediatrics

Introducción y objetivos. Desde finales de los años 80 se comienzan a emplear medios de contraste ecográfico que realcen los ultrasonidos para poder aplicarlos al estudio dinámico de la vía urinaria. Con la galactosa se ha logrado una gran definición en la imagen sonocistográfica, permitiendo porcentajes de sensibilidad iguales o mayores que la cistografía convencional tanto en el screening de malformaciones urológicas como en el control postoperatorio en pacientes urológicos pediátricos. El objetivo mostrar nuestra experiencia en 3 años de utilización de la sonocistouretrografía en el diagnóstico y seguimiento de pacientes pediátricos con patología urológica. Material y métodos. Se evaluaron 442 pacientes con edades entre 1 día y 13 años, 202 varones y 240 hembras. Todos fueron remitidos para descartar patología urológica con el diagnóstico previo de Infección del Tracto Urinario -ITU- (n=152), seguimiento de Reflujo Vesicoureteral -RVU- (n=60), dilatación del tracto urinario (n=86), control postratamiento endoscópico (n=52), control postratamiento quirúrgico (n=53), otros diagnósticos (n=39). En todos los casos se realizó estudio sonográfico dinámico del tracto urinario, incluyendo uretra, tras introducción de contraste con galactosa por sonda urinaria. El diagnóstico de RVU se consideró positivo cuando se detectaron microburbujas en uréter o en sistema pielocalicial, aplicando la clasificación internacional del RVU. Resultados. Se evaluaron 442 pacientes con sonocistouretrografía siendo diagnosticados de RVU 58 casos de los 277 considerados de screening. En el resto de los pacientes (n=165) se indicó la sonocistografía como seguimiento de una patología ya conocida. Como complicaciones destacamos 2 casos de candiduria postexploración en pacientes con mielomeningocele. En otros 6 casos, todos controlados por dilatación renal sin RVU, se detectó galactosa en pelvis renal a los 6 meses de la prueba. En todos los casos pudo realizarse la técnica ecográfica. Conclusiones. Concluimos que en nuestro centro la utilización de la sonocistografía con los medios de contrastes actuales (galactosa), ha pasado a ser un medio de diagnóstico indispensable, con una gran calidad de imagen, una sensibilidad mayor o igual que la alcanzada con la cistografía convencional, evitando los efectos indeseables derivados de la radiación, disminuyendo el número de estudios complementarios a que se somete al paciente y visualizando en el mismo examen la anatomía de las vías urinarias (AU)

Pneumosinus dilatans of the frontal and ethmoidal sinuses: case report.

Enlargement of paranasal sinuses with air is rare with less than 50 cases reported in the medical literature. This craniofacial malformation was first described by Meyes in 1898 and its aetiology still remains unknown. Local pain, ocular alterations, anosmia, headache and cosmetic disturbances are the most common symptoms. We present a case of pneumosinus dilatans diagnosed in a male, 8 years of age. He presented with left fronto-orbital bossing that enlarged slowly until he was 12 years old, at which point its growth appeared to increase dramatically. Computerized tomography revealed an enlargement of the frontal and ethmoidal sinuses, with marked deformation of the anterior wall and of the roof of the left frontal sinus, as well as the roof of the ethmoid and upper sinus medial orbital wall. The sinus walls were of normal thickness. Access was via a bicoronal incision and osteotomy of the deformed fronto-orbital bossing. Reconstruction was undertaken with a periosteal flap and hydroxyapatite bone cement (Norian) following sinus mucosal stripping and obliteration of the sinus with fat. Six months postoperatively, the patient was without recurrence and had a good cosmetic result.

[Urethrosonocystography with galactose in the diagnosis and follow-up of pediatric patients with vesicoureteral reflux]. / Sonocistouretrografía con galactosa en el diagnóstico y seguimiento del reflujo vesicoureteral en pacientes pediátricos.

INTRODUCTION AND OBJECTIVES: Since early 80's, attempts to detect Vesicoureteric Reflux (VUR) with Ultrasound (US) contrast medium have been made to study the urinary tract during voiding. The galactose-based agents are comparable in the diagnostic range with the standard fluoroscopic cystography, providing high values of sensitivity and specificity. The purpose of our work is to show our experience during last three years with the urethrosonocystography with echo contrast in the diagnosis and follow-up of pediatric patients with urological malformations. PATIENTS AND METHODS: 442 patients were included in our study (aged 1 day to 13 years; 202 males and 240 females). All cases were referred for investigation of VUR based on previous criteria of urinary tract infection, VUR follow-up, dilated urinary tract, post endoscopic treatment, surgical treatment follow-up and others. After transurethral catheterisation the bladder was filled with US galactose-based contrast medium (Levovist). VUR was diagnosed when micro bubbles appeared in ureter or pelvicalyceal system and was graded according to the International Reflux Study Committee. RESULTS: Of the 442 patients evaluated with echo enhanced urethrosonocystography, 227 were screening cases for discard VUR. Of these patients, only 58 were diagnosed as having VUR. In 165 cases the technique was indicated as follow-up. Two patients with spina bifida developed candiduria after the sonographic cystogram. In 6 patients with dilated urinary tract without reflux, galactose was detected in renal pelvis 6 months after the procedure. CONCLUSIONS: In our experience urethrocystosonography with galactose-based US medium agents is a more sensitive method than standard Voiding Cystourethrography (VCUG) for detecting VUR in pediatric patients. US cystography is an attractive technique which involves no ionising radiation and is usually well tolerated by the young. This procedure should be considered as a routine diagnostic work-up for detecting VUR in pediatrics.