[Treatment of the postoperative bowel obstructions in children: laparoscopic vs. open adhesiolysis]. / Tratamiento de las oclusiones postoperatorias en niños: ¿adhesiolisis abierta o laparoscópica?

OBJECTIVE: To compare the results of laparoscopic versus open adhesiolysis in children affected by postoperative bowel obstruction. METHODS: Retrospective study reviewing charts of all patients who were operated on due to postoperative adhesions in our Department. Demographic data, clinical characteristics and postoperative data were collected. RESULTS: During the last 8 years, 37 patients were operated on for postoperative intestinal obstructions. 40.5% were operated by laparoscopy and 59.5% by laparotomy. Mean ages were 6.31 and 4.32 years in laparoscopic and open groups, respectively. There were no differences in days of evolution of the occlusion, neither in their medical history. Patients in laparoscopic group had better outcomes in the need of central lines (15% vs 61.90% p= 0.012), use of parenteral nutrition (38.46% vs 83.33% p= 0.005), beginning of the enteral nutrition (4.04 vs 8.17 days p= 0.004) and hospital stay (7.77 vs 13.05 days p= 0.027). CONCLUSIONS: Open and laparoscopic adhesiolysis are effective to treat adhesive cases. Laparoscopic adhesiolysis has some advantages over open surgery: less need of central lines and parenteral nutrition, earlier start of enteral nutrition, less rate of complications and shorter hospital stay.

OBJETIVO: Comparar los resultados de la adhesiolisis laparoscópica frente a la técnica abierta en niños con oclusiones postoperatorias. METODO: Estudio retrospectivo de los pacientes intervenidos por oclusiones postoperatorias en nuestro centro. Se recogieron variables demográficas, las características clínicas del paciente y del cuadro oclusivo y los resultados postoperatorios. RESULTADOS: En los últimos 8 años, se han realizado 37 intervenciones por oclusiones intestinales postoperatorias: un 40,5% mediante laparoscopia y un 59,5% mediante laparotomía. La media de edad fue 6,31 y 4,32 años para la técnica laparoscópica y abierta, respectivamente. No encontramos diferencias en el tiempo de evolución del cuadro oclusivo, ni en los antecedentes quirúrgicos. Sin embargo, el grupo de adhesiolisis laparoscópica presentó mejores resultados que el de cirugía abierta en: necesidad de vía central (15% frente a 61,90% p= 0,012), uso parenteral (38,46% frente a 83,33% p= 0,005), reinicio de la nutrición enteral (4,04 días frente a 8,17 p= 0,004) y estancia postoperatoria (7,77 frente a 13,05 días p= 0,027). CONCLUSIONES: Ambos abordajes son eficaces para la resolución de la oclusión. La adhesiolisis laparoscópica aporta ventajas frente a la cirugía abierta: menor necesidad de vía central y de nutrición parenteral, reinicio precoz de la nutrición enteral y menor estancia hospitalaria.

[Conservative management of retained central venous catheters]. / Manejo conservador de los catéteres venosos centrales retenidos.

BACKGROUND: Withdrawal of central venous catheters (CVCs) is usually a simple surgical procedure. However, in some cases, the catheter is stuck in the vessel wall and its removal is not possible if more invasive interventions are not performed. MATERIAL AND METHODS: We performed a retrospective study from 2003 to 2011 of patients who were clearing a CVC and the factors that could have intervened in the removal impossibility. We compared the type of catheter, the insertion site, the time between its insertion and removal, the primary diagnosis and the treatment. In addition, a monitoring by clinical and imaging tests has been made in patients with retained CVCs. RESULTS: An amount of 174 interventions were carried out. In 5 cases the CVC could not been removed. These 5 cases were patients diagnosed with ALL B and were treated with identical chemotherapy treatment. In addition, at the time of its retirement, all the patients had the CVC for a period longer than 2 years -29 to 84 months-. In patients with retained fragments, no complication arose from this condition. The mean follow-up period was 36 months -maximum 48 months-. CONCLUSIONS: The potential complications arising from the presence of the retained CVCs fragments include infection, venous thrombosis and catheter migration. Based on our results, we propose that a conservative management might be considered as an option in these patients.

Have acute appendicitis complications increased in children as a result of SARS-CoV-2? / ¿Han aumentado las complicaciones de las apendicitis agudas en niños por el impacto del SARS-CoV-2?

INTRODUCTION: The impact of the SARS-CoV-2 pandemic on healthcare has already been described, since it has caused an increase in diagnostic delay and morbidity. Our objective was to assess its influence on the development of complications in children with acute appendicitis. MATERIALS AND METHODS: A retrospective cohort study was carried out. It included acute appendicitis patients under 15 years of age treated from January 1, 2019 to December 31, 2020. They were classified according to diagnosis date as before the pandemic (B) (January 2019-February 2020) and during the pandemic (D) (March 2020-December 2020). According to operative findings, they were classified as complicated appendicitis (perforated/abscess/plastron/peritonitis) and non-complicated appendicitis (catarrhal/phlegmonous/gangrenous). Demographic data, progression time, and postoperative complications were analyzed. RESULTS: A total of 309 patients were included, 193 (62.5%) in Group B, and 116 (37.5%) in Group D, with an age of 9.2 ± 0.4 and 9.4 ± 0.6 years, respectively (CI = 95%). Diagnostic time was 1.35 and 1.43 days (p>0.05) in Groups B and D, respectively, with ≥ 3 days representing 15.5% of cases in Group B, and 16.4% of cases in Group D (p = 0.84). The proportion of complicated appendicitis was 23.3% in Group B vs. 21.6% in Group D (p>0.05). Postoperative complications were observed in 11.4% of patients in Group B, and in 13.8% of patients in Group D (p>0.05), with intra-abdominal abscess being the most frequent complication in both groups (54.5% of the total complications in Group B vs. 65.5% in Group D; p>0.05). CONCLUSIONS: The management of acute appendicitis and its complications in pediatric patients has not been impacted by the SARS-CoV-2 pandemic or the safety measures enforced.

INTRODUCCION: Se ha descrito el impacto de la pandemia del SARS-CoV-2 en la atención sanitaria, al suponer un aumento del retraso diagnóstico y morbilidad. Nuestro objetivo es evaluar su influencia en el desarrollo de complicaciones en las apendicitis agudas en niños. METODOLOGIA: Estudio retrospectivo de cohortes, incluyendo los pacientes menores de 15 años tratados por apendicitis aguda desde 01/01/2019 hasta 31/12/2020. Se distribuyeron según su fecha de diagnóstico en: antes de la pandemia (A) (enero/2019-febrero/2020) y durante la pandemia (P) (marzo-diciembre/2020). Según los hallazgos quirúrgicos se clasificaron en: apendicitis complicadas (perforadas/abscesos/plastrones/peritonitis) y no complicadas (catarrales/flemonosas/gangrenosas). Se analizaron datos demográficos, tiempo de evolución y complicaciones postoperatorias. RESULTADOS: Se incluyeron un total de 309 pacientes, 193 pacientes (62,5%) en el grupo A y 116 (37,5%) en el P, con edades de 9,2 ± 0,4 y 9,4 ± 0,6 años respectivamente (IC = 95%). Los días al diagnóstico fueron 1,35 y 1,43 (p>0,05) en A y P respectivamente, siendo ≥ 3 días en 15,5% de A y 16,4% en P (p = 0,84). La proporción de apendicitis complicada fue un 23,3% en A vs. 21,6% en P; con p>0,05. Se observaron complicaciones postoperatorias en 11,4% de A y 13,8% de P (p>0,05), siendo la más frecuente el absceso intraabdominal en ambos grupos (54,5% del total de complicaciones vs 65,5%; en A y P respectivamente; p>0,05). CONCLUSIONES: La atención sanitaria de la apendicitis aguda y sus complicaciones en pacientes pediátricos no se ha visto modificada por la pandemia del SARS-CoV-2 o las medidas de seguridad adoptadas durante la misma.

[Modifications of the glucose curves and gastric voiding of children with Dumping syndrome after laparoscopic Nissen surgery]. / Modificaciones de las curvas de glucemia y vaciamiento gástrico de los niños con síndrome de dumping tras cirugía de nissen laparoscópico.

INTRODUCTION: There has been an important evolution of surgical treatment in recent years due to the progressive generalization of laparoscopic surgery. All of the available techniques can be done laparoscopically with similar results to those of open surgery. In 1978, Villet et al. described the Dumping syndrome (DS) as a frequent complication of Nissen fundoplication. DS is a group of signs and symptoms that appear shortly after surgery, including abdominal pain, paleness, sweating, diarrhea, nausea, even weight loss. These symptoms can be differentiated into early dumping that occurs between 30 to 60 minutes after eating and late dumping that occurs 92-240 minutes after the postprandial period. MATERIAL AND METHODS: A total of 8 patients (3 boys and 5 girls) have been studied. Their ages ranged from 3 to 12 years (mean 9 years), and they were diagnosed of dumping syndrome after performing the laparoscopic Nissen-Rossetti. All underwent a gastric voiding study by scintigraphy after administration of a volume of milk adjusted to their weight labeled with 99Tc-DTPA and oral glucose overload test with 1.75 g/kg of glucose, determining the baseline glycemia and every 30 minutes post-intake, at 0, 30 and 90 minutes. Insulin was also measured to obtain the glucose/insulin ratio. This study was conducted for all patient diagnosed of dumping syndrome before and after laparoscopic Nissen-Rossetti surgery. RESULTS: The following results were obtained: Glucose Curve: 1. Maximum glycemia. PreNissen. The mean of the maximum glycemia values before surgery was 133.9+/-32.11 mg/dl. Post-Nissen. Mean maximum glycemias after surgery was 208.5 +/- 45.07 mg/dl with a range of 147-276 mg/dl. These differences of maximum glycemia were clearly significant with a p <0.002. Minimum glycemia. The mean value of the minimum glycemias after the surgery, compared with the previous value, did not show significant differences: 62.6+/- 11.51 mg/dl versus 71.8 +/- 28.04 mg/dl. Glucose/insulin ratio. The hyperinsulinism values after the intervention studied by means of the glucose/insulin ratio were abnormal in 70.5% (defined as ratio under 3). The mean value was also characteristic of hyperinsulinism (2.3 +/- 1.62). The mean value of the coefficient prior to the surgery was 4.6 with a deviation of 3.04, the differences not being statistically significant with a p= 0.097. Measurement of gastric voiding: The T1/2 (decay) value in post-Nissen patients was significantly lower than in pre-Nissen patients. The postsurgical mean and standard deviation was 29.74 +/- 7.92 min, while in the presurgical group, the mean and standard deviation was 73.75 +/- 28.34 min with p< 0.011; statistically significant. CONCLUSIONS: From the values obtained, we can state that a significant increase in maximum glycemia has been found in all children after surgery who were diagnosed of dumping syndrome and a significant decrease in the mean time of gastric voiding and therefore an increase in the acceleration of gastric voiding after the performance of the Nissen regarding the previous values. The dumping syndrome is a frequent side effect that we must keep in mind in patients who have been previously operated for anti-reflex surgery, the symptoms being greater in most of the transitory cases. Furthermore, it is important to keep in mind because it has an easy treatment that reverts the symptoms in a short time

Diuresis renography in the diagnosis and follow-up of nonobstructive primary megaureter.

Due to the widespread use of obstetrical ultrasonography with concomitant fetal screening, congenital uropathies are usually diagnosed in asymptomatic neonates. The main issue is to distinguish those cases of dilatation which are clearly obstructive and need surgical treatment from those which are within the normal anatomical range. Out of 47 patients with primary megaureter, 23 were nonobstructive and these are the subject of our study. There were 16 males and 7 females. Thirteen were located on the left side, 7 on the right side and 3 were bilateral, adding up to 26 renoureteral units. Prenatal diagnosis was made in 16 cases, the oldest patient diagnosed was 9 years old. All infants were evaluated with ultrasonography, voiding cystourethrography, excretory urography and diuresis renography. The latter has been the most important test inducing us to adopt a conservative attitude. Differential renal function was more than 40% in 24 units and in 2 it was more than 35%. Diuretic renograms were type IIIa (dilated, nonobstructed) in 19 cases and IIIb (dilated, partially obstructed) in 7. There were 2 cases with vesicoureteral reflux in the contralateral system. We performed ultrasonography and diuresis renography during the follow-up. There were 8 cases with type I (normal) renograms and 17 cases with type IIIa. Only one patient developed an obstruction and was operated on. Differential renal function did not deteriorate in any of the cases. Urography was performed in 9 cases during the follow-up. All the patients have remained asymptomatic during the surveillance, except for 2 cases which presented urinary tract infection. BUN, creatinine and other biochemical figures remained within the normal range. The follow-up period of time ranged between 1 and 8 years. We conclude that primary megaureter must be assessed and followed up and that the main test to be used is diuresis renography.

[Surgery of ectopic ureterocele in children: strategy based on prenatal function]. / Tratamiento quirúrgico del ureterocele ectópico en la infancia: estrategia basada en la función renal.

From 1981 to 1993, we have treated 31 pediatric patients with ectopic ureterocele (associated to duplex system, intra and extravesicals). Diagnostic work-up included abdominal ultrasound, intravenous urography (IVU), sequence mictional cystouretrography (SM-CU) and diuresis renography (DTPA-DMSA o MAG-3). Patients were divided in two groups: 1. Good renal function in the affected system (5 cases) with 2 endoscopic incision of the ureterocele and 3 without surgical treatment (all intravesical). 2. Almost non-existent ipsilateral renal function (26 cases), treated by heminephrectomy and ureterocelic aspiration, and in the remaining a nephrectomy was done for ipsilateral non-existent renal function. 2 cases treated by endoscopic incision presented vesicoureteral reflux, and 4 cases treated by nephrectomy had a low grade reflux. There is no a definite treatment established. The choice should by made based on renal function. Endoscopic incision is a good choice in obstructed cases with good renal function. In those with no function at all, heminephrectomy with aspiration of the ureterocele will be the best treatment if we consider that almost 50 percent of the patients will need a second surgical procedure.

[Testicular tumors in childhood. Review of cases in the course of 13 years]. / Tumores testiculares en la infancia. Revisión de 13 años.

Testicular and paratesticular tumors are rare in childhood, representing 1-2 percent of the solid tumors in the pediatric age. In patients under 14 years, the incidence is 0.5-2/100,000. The evolution differs from that of the adult. Since 1981 to 1994 we have treated 14 cases of testicular and paratesticular tumors. Mean age was 2.54 years, the younger patients presenting germinal tumors. The most frequent tumor was the yolk sac tumor (36%), followed by teratoma mature (29%), and Leydig cell tumor, epidermoid cyst, paratesticular fibrous hamartoma, paratesticular neuroblastoma and paratesticular rabdomyosarcoma (7% each). A testicular mass was present in all cases (100%). Testicular ultrasound was used in 100%. In all the patients with malignant tumors a thoraco-abdominal CT scans was done to rule out extension or the tumor, being negative in all cases. Alphafetoprotein were high in all the cases of yolk sac tumor, being within normal range one month after surgery except in one case. In 11 patients an orquiectomy was done through an inguinal approach, and in three cases a simple tumorectomy without orquiectomy. No lymphadenectomy was done. All the malignants neoplasms were stage I tumors, except one yolk sac tumor stage III. Postop chemotherapy was applied in this one and in the embrionary rabdomyosarcoma. There were no recurrences after a follow-up mean time of 3.98.

Low prevalence of complications of delayed herniotomy in the extremely premature infant.

AIM: To study the relationship between the delay of herniotomy in the extremely premature infant and the rate of complications in comparison with full-term children. METHODS: A follow-up study of three groups of neonates operated on for inguinal hernia was performed. The groups were defined as: a) the short-waiting group (SWG): prematures (mean gestational age: 32.56 +/- 0.62; n = 9) operated on within 2 wk of diagnosis (median: 5 d); b) the long-waiting group (LWG): prematures (mean gestational age: 28.38 +/- 1; n = 21) operated on after more than 2 wk (median: 39 d); and c) control group of full-term children (FTG); (mean gestational age: 38.18 +/- 0.29; median of timing: 3 d; n = 11). Several variables (gestational age, weight at birth and at surgery, side of the inguinal herrnia, timing, duration of surgery, type of anaesthesia, length of hospitalization), as well as the occurrence of apnoea, incarceration and testicular atrophy were compared between groups. RESULTS: Timing was the only variable that was different between the LWG and the other two groups (p < 0.001, ANOVA). Seven preoperative episodes of incarceration occurred: one in the SWG, two in the LWG and four in the FTG (p = 0.138, chi2). In the follow-up study two testicular atrophies, related to previous episodes of incarceration, were found: one in the FTG and the other in the SWG (p = 0.221, chi2). CONCLUSION: The deferral of herniotomy in the extremely premature infant, until the child is ready to be discharged from the neonatal unit, does not seem to increase the risk of incarceration episodes or testicular atrophy.