Análisis del fracaso de la cirugía antirreflujo / Study of fundoplication failure

La reaparición de síntomas de reflujo gastroesofágico (RGE) después de realizarse una funduplicatura es un grave problema, ya que la sintomatología es refractaria al tratamiento médico y es necesario efectuar una segunda operación antirreflujo en condiciones técnicas más difíciles. Se han identificado diferentes factores que contribuyen al fallo de este tipo de intervenciones en el niño. Presentamos ocho pacientes en los cuales realizarnos una segunda técnica antirreflujo después del fallo de la técnica inicial, sobre una serie total de 96 pacientes intervenidos por reflujo gastroesofágico. En cuatro casos la primera intervención fue realizada en nuestro servicio. Seis pacientes tenían lesiones o déficit neurológico, seis padecían patología respiratoria crónica y dos casos presentaban atresia de esófago. Los síntomas principales fueron recurrencia del vómito (n = 8) y aspiración (n = 4). La reaparición del reflujo se confirmó mediante esofagograma y endoscopia. Los hallazgos operatorios fueron: rotura del manguito de la funduplicatura en dos casos, rotura del manguito asociado a hernia hiatal en cinco casos, rotura del manguito asociado a hernia paraesofágica en dos casos y hernia paraesofágica con manguito normal en uno. Se efectuó una segunda funduplicatura de Nissen en cinco pacientes, y en tres niños en los que se consideró que tenían un 'esófago corto', realizamos una gastroplastia de Collis-Nissen. En seis casos la evolución clínica ha sido satisfactoria; un paciente presenta una disfagia severa y otro recurrencia de los vómitos. En nuestra experiencia, los pacientes con enfermedad por reflujo gastroesofágico recurrente, precisan una técnica antirreflujo adaptada de forma específica a sus alteraciones anatómicas o funcionales (AU)

[Analysis of anti-reflux surgery failure]. / Análisis del fracaso de la cirugía antirreflujo.

Recurrent gastroesophageal reflux following fundoplication is a challenging problem, because it is usually refractory to medical treatment and a second, technically difficult, antireflux operation is required. Different factors that may contribute to surgery failure have been identified in children. We present 8 cases who underwent redofundoplication after failed procedures, from a total number of 96 patients operated on due to gastroesophageal reflux. Four patient's had their initial fundoplication performed at our institution. Six patients were neurologically impaired, six had chronic pulmonary disease, and two had esophageal atresia. The main presenting symptoms were recurrent vomiting (n = 8) and aspiration (n = 4). Gastroesophageal reflux was confirmed by barium swallow and endoscopy. Operative findings showed wrap breakdown in two cases, warp breakdown associated with hiatal hernia in five, wrap breakdown associated with paraesophageal hernia in two cases, and paraesophageal hernia with normal wrap in one. A second Nissen procedure were performed in five cases, whereas a Collis-Nissen gastroplasty was realized in three with a short esophagus. Six patients had a successful outcome remaining symptom free, one has severe disphagia, and one has recurrent vomiting. In our experience, patients with recurrent gastroesophageal reflux disease should undergo an antireflux procedure tailored to specific anatomic or functional abnormalities.

[Retrospective analysis of 80 cases of neonatal necrotizing enterocolitis]. / Análisis retrospectivo de 80 casos de enterocolitis necrotizante neonatal.

We present the cases of necrotizing enterocolitis (NEC) treated in our hospital between 1980 and 1994, in order to analyze the risk factors that appear in the disease. We elaborate treatment and follow-up protocols. Prematurity, low birth weight and perinatal stress have a significant influence in NEC. Hemodinamic inestability, bloody stools, abdominal distension with decrease gastric outlet, along with significant radiological evidence in 90 percent of the cases, should rise suspition of NEC. We find fundamental the prevention of the disease in premature newborns with risk factors. Mean gestational age was 33 weeks. Prematurity was found in 87.5 percent of the patients, with a mean birth weight of 1683 g. Symptoms appeared at the age of 14 days. 32 percent of the cases were operated, 13 cases (16%) presenting with pneumoperitoneum, and a Mortality rate 15 percent. We treated 15 patients with colonic stenosis by resection and end-to-end anastomosis, with 6 percent mortality global mortality rate for NEC has been 28 percent.

[Cysts of the thyroglossal duct: analysis of diagnostic errors and causes of recurrence]. / Quistes del conducto tirogloso: análisis de los errores en el diagnóstico clínico y de las causas de aparición de recurrencias.

Thyroglossal-duct cysts usually present as an anterior midline neck mass, ranking first in this location in the pediatric age. We have carried out a retrospective revision of 52 pediatric patients with a preoperative diagnosis of thyroglossal-duct cyst. All of them were treated in our surgical unit between 1982 and 1989. The male to female ratio of cases was 34:18 with symptoms appearing at an average age of 4 years. The most frequent clinical presentation was that of a cystic mass without any inflammatory signs (65%), located in the mid-line at the hyoid level (75%). In this paper we analyze the existing possibilities as regards to the clinical presentation, location and characteristics of this type of cervical swellings, as well as the most frequent causes of misdiagnosis. We also make a comparison between the results we have obtained with the different surgical techniques used. We conclude that it is necessary to perform a radical surgical treatment of the thyroglossal-duct remnants, which includes removal of the middle third of the hyoid bone and excision of the thyroglossal duct as far as the foramen cecum.

[Results of the treatment of Hirschsprung's disease using Duhamel technique and mechanical sutures]. / Resultados del tratamiento de la enfermedad de Hirschsprung mediante la tecnica de Duhamel realizada con suturas mecanicas.

The original Duhamel procedure for the treatment of Hirschsprung's disease (HD) has undergone several important modifications over the years. The use of mechanical suture in recent years has added significant advantages to this surgical procedure. Sixteen patients with HD were operated on according to this surgical technique, from 1985 to 1990. We analyse clinical, radiological and surgical aspects. We concentrate on early and late postoperative complications and the results achieved after a maximum follow-up of 4.5 years.

[Surgical treatment of myasthenia gravis in children using transsternal thymectomy]. / Tratamiento quirúrgico de la miastenia gravis en niños mediante timectomía transesternal.

Myasthenia gravis is an inmunological disease infrecuent during childhood. In recent years, thymectomy has gained increasing acceptance as the most effective treatment for acheiving sustained improvement in patients affected of myasthenia gravis. We report our experience in five children treated by trassternal radical thymectomy in the last five years. This patients were clinically staged following Osserman's classification as stage IIB (three cases) and stage III (two cases). All of them are in complete remission after a mean postoperative period of thirty three months. We add a review of the literature comparing the differents surgical approaches for thymectomy and its results in children.

[Conservative treatment of neonatal ovarian cysts]. / Tratamiento conservador de los quistes ováricos neonatales.

Treatment of choice of ovarian cysts diagnosed in the neonatal period has been until nowadays mainly surgical. Another possibility is a conservative approach, since these cysts have a natural tendency to spontaneous regression. We present 9 cases treated in our hospital in the last 8 years. 6 of them were treated surgically, while in 3 a conservative attitude was used, with sera ultrasound follow-up and disappearance of the cysts in 2 months in 2 cases and in 12 in the other. In cysts smaller than 5 cm we adopt a conservative management, leaving surgery only for those bigger or complicated.

[Our experience with the treatment of congenital megacolon using mechanical sutures]. / Nuestra experiencia en el tratamiento del megacolon congénito con sutura mecánica.

The DUHAMEL operation is widely used for the treatment of HIRSCHSPRUNG disease. Recently, technical modifications using stapled instruments have been introduced. The results of 12 patients treated between 1985 and 1989, performing the DUHAMEL procedure are reviewed. We perform with mechanical sutures, both surgical stages, e.g. abdominal and perineal. The technique for the procedure is described. Since we introduce the technique, we have observed several advantages consisting in a shorter surgical time, earlier normal life pattern, less postoperative complications and better results in clinical evolution.

[Instrumental perforation of the esophagus. Importance of diagnosis early in its clinical course]. / Perforación instrumental de esófago. Importancia del diagnóstico precoz en la evolución.

Instrumental esophageal perforation is a serious complication that demands immediate therapy. In a retrospective study we have evaluated the results in seven patients treated for esophageal perforation by means of a conservative treatment without mortality. Instrumental dilatation of corrosive strictures were the most frequent cause of iatrogenic endoscopy. We have observed an esophageal injury associated with a Sengstaken-Blackemore tube placement. Clinical symptoms associated with chest roentgenograms guided to early diagnosis in all cases. Conservative treatment usually consist of a course of antibiotics, pleural drainage, and total parenteral nutrition. Clinical follow-up has been good in the seven patients treated.

[Total colectomy in necrotizing enterocolitis]. / Colectomías totales por enterocolitis necrotizante.

Total colectomy in the neonatal period, after a necrotizing enterocolitis is not infrequent and implies a series of complex attitudes towards a good adaptation of the remaining small bowel. We present 9 cases of total colectomy in children with necrotizing enterocolitis of 11 cases surgically treated out of 57 cases. We describe the different types of surgical procedures used as well as the evolution of each patient.

[Long-term course of esophageal stenosis treated with pneumatic dilatation. A comparative study versus other methods]. / Evolución a largo plazo de las estenosis de esofágo tratadas con dilataciones neumáticas. Estudio comparativo con otros métodos.

Dilatation of benign esophageal strictures by means of a balloon catheter is a well established procedure in children. In this report a comparison of bouginage and balloon dilatation is made in eight patients treated by both procedures. The lesions treated included two strictures secondary to surgical anastomosis, one restrictive Nissen fundoplicature and five esophageal stenosis following caustic ingestion. These eight patients had a total of 44 bouginage procedures with a mean relapse free period of 80 days. There were two esophageal perforations. The clinical course was unsatisfactory in five cases. Only one patient had good results. In contrast, to date, the 15 balloon dilatations have resulted in a mean relapse free time of 174 days. There were no complications that required treatment. The clinical follow up shows four asymptomatics patients and the other four presenting difficulties to swallow with spontaneous resolution. We have the best results in younger patients with esophageal stenosis secondary to esophageal atresia repair. Balloon dilatation of esophageal stenosis in children is effective and safe, and should be considered before other methods of treatment are used.