[Single port video-assisted transumbilical appendectomy. What have we gained and what have we lost after 754 cases]. / Apendicectomía videoasistida transumbilical por puerto único. Qué hemos ganado y qué hemos perdido después de 754 casos.

INTRODUCTION: Single-port transumbilical laparoscopically assisted appendectomy (TULAA) has become the preferred method of treating appendicitis in our Department. At first, it was reserved for noncomplicated cases, and gradually for the rest of them. We have gained experience, and it is time to share it, evaluate the results and raise into new possibilities. MATERIAL AND METHODS: We performed a retrospective statistical analysis of undergone changes over the last years, referring to aspects such as surgical indications, andpostoperative complications, hospital stays and re-admissions. RESULTS: From September 2003 to January 2012, a total of 1,022 appendectomies were performed. Eight hundred and forty-one children underwent TULAA, 89.65% were completed with no problems. In 179 patients, open appendectomy was initially chosen. In those cases, the reasons were complicated appendicitis, obesity or surgeon's preference (43 in the first year and just 3 in the last one). Ninety seven patients had postoperative complications of any kind, fifteen were readmitted to the hospital and 3 were reoperated because of intestinal obstruction. Medical cost savings were estimated around 750.000 Euros. CONCLUSIONS: We think that TULAA is a simple and easy learning procedure, which does not result in any increase in complications, inexpensive and beneficial for patients. However, along these years, our surgical staff may have lost skills and training opportunities in conventional laparoscopic surgery. So although TULAA is still our preferred method in appendicectomy, selected cases will undergo laparoscopic appendectomy.

Pediatric thyroidectomy in a "low volume" institution without protocolization: results and future horizons. / Tiroidectomía pediátrica en un centro de "bajo volumen" y sin protocolización: resultados y horizontes.

OBJECTIVE: Pediatric thyroidectomy is an infrequent, complex surgery, with high risk of complications. Complication rates and oncological results of non-protocolized thyroidectomy in a secondary pediatric hospital were compared with those from reference institutions. MATERIALS AND METHODS: A retrospective study of patients under 15 years old undergoing thyroidectomy ± cervical lymphadenectomy by low volume pediatric surgeons (<30 cervical endocrine surgeries annually) in a pediatric hospital from January 2010 to January 2020 was carried out. RESULTS: 11 patients undergoing 12 surgeries (mean age: 9.8 years; 63% female) were analyzed. Thyroid nodules were the main surgical indication (50%), and prevalence of genetic mutations was 45%. 1 patient had transient hypocalcemia, and there were 2 cases of transient recurrent laryngeal nerve neuropraxia (16.6%). No permanent complications were noted. 66.6% of pathological reports showed malignancy. Mean hospital stay was 2.35 days (range: 1.25-5), with an overall complication rate of 25%, similar to that reported by high-volume institutions. After a mean follow-up of 4 years, tumor recurrence has not been observed in any patient. CONCLUSIONS: In our view, an experienced pediatric surgeon specialized in pediatric and neonatal general surgery - even if below the high volume threshold - acquires the skills required in pediatric thyroid surgery without an increase in morbidity and mortality. Perioperative management should be agreed and protocolized by the various specialists involved to improve results.

OBJETIVOS: La tiroidectomía pediátrica es una intervención infrecuente, compleja y con un riesgo elevado de complicaciones. Se evalúa la tasa de complicaciones y resultados oncológicos de la tiroidectomía no protocolizada en un hospital infantil de segundo nivel en comparación con los centros de referencia. MATERIAL Y METODOS: Estudio retrospectivo de los pacientes menores de 15 años sometidos a tiroidectomía ± disección ganglionar cervical por cirujanos pediátricos de bajo volumen (< 30 cirugías endocrinas cervicales/año) entre enero de 2010 y enero de 2020 en un hospital infantil. RESULTADOS: Se analizaron once pacientes sometidos a 12 procedimientos quirúrgicos (edad media 9,8 años, 63% niñas). Los nódulos tiroideos fueron la principal indicación quirúrgica (50%) y la prevalencia de mutaciones genéticas en la serie fue del 45%. Un paciente presentó hipocalcemia transitoria y hubo 2 casos de neuropraxia transitoria del nervio laríngeo recurrente (16,6%). No hubo complicaciones permanentes. El 66,6% de los informes anatomopatológicos mostraron malignidad. La estancia hospitalaria media fue de 2,35 días (rango 1,25-5) con una tasa global de complicaciones del 25%, similar a la reportada por centros de alto volumen. Después de un seguimiento medio de 4 años, ningún paciente ha presentado recidiva tumoral. CONCLUSIONES: Sugerimos que un cirujano infantil con experiencia en cirugía pediátrica general y neonatal, a pesar de no superar el umbral de alto volumen, adquiere las facultades para realizar la cirugía tiroidea pediátrica sin aumento de morbilidad y mortalidad. El manejo perioperatorio debe ser consensuado entre los diversos especialistas involucrados y protocolizado para mejorar los resultados.

Abdominal hernia repair using the Rives-Stoppa technique: an abdominal reconstruction. / Eventroplastia abdominal con técnica de Rives-Stoppa: reconstruyendo un abdomen.

INTRODUCTION: Retromuscular mesh hernia repair using Rives-Stoppa technique has demonstrated the best results when it comes to repairing large midline hernias. We present the first pediatric case successfully treated with this technique. CLINICAL CASE: This is the case of a 9-year-old male patient with hernia following urgent midline laparotomy. Basic repair principles included opening of the hernia sac and adhesiolysis, longitudinal incision on the posterior sheath of the rectus muscle and division of the retromuscular space, closure of the posterior sheath, placement of a mesh on this plane in the brand-new retromuscular space, and tension-free closure of the anterior musculo-aponeurotic flap, thus reconstructing the midline. No recurrences have been noted after a 2-year follow-up. DISCUSSION: Rives-Stoppa technique allows for a more anatomical layered reconstruction, which helps restore the anatomical and physiological properties of the abdominal wall. In our view, this could be a useful alternative for pediatric hernia treatment.

INTRODUCCION: La eventroplastia con malla retromuscular de Rives-Stoppa ha demostrado en adultos tener los mejores resultados en la reparación de las grandes eventraciones de la línea media. Presentamos el primer caso pediátrico tratado exitosamente con esta técnica. CASO CLINICO: Varón de 9 años con eventración tras laparotomía media urgente. Los principios básicos de la corrección fueron: apertura del saco herniario y adhesiolisis, incisión longitudinal sobre la vaina posterior del músculo recto y tallado del espacio retromuscular, cierre de la vaina posterior, colocación de una malla sobre este plano alojándola en el espacio retromuscular creado y cierre sin tensión del colgajo musculo-aponeurótico anterior, reconstruyendo así la línea media. No recidiva tras 2 años de seguimiento. COMENTARIOS: La técnica de Rives-Stoppa implica una reconstrucción por planos más anatómica que restaura las propiedades anatomofisiológicas de la pared abdominal. Consideramos que puede ser una alternativa útil en el tratamiento de las eventraciones pediátricas.

[Impaction of button batteries in the esophagus: a potentially fatal surgical emergency in infancy].

With the recent popularization of button batteries, the incidence of cases of children who ingest them has risen. Unlike other foreign bodies, button batteries are more likely to develop severe complications due to the possibility of early injury to the tissues in direct contact with them. We present the case of a 22-month-old boy who ingested a button battery which subsequently became lodged in the cervical esophagus. The endoscopic attempt to remove the battery failed, requiring an open esophagotomy for its extraction. In the postoperative period, he presented an esophagocutaneous fistula that closed spontaneously, and an esophageal stricture that was treated successfully with endoscopic balloon dilations. We reviewed the literature analyzing the recommendations recently outlined and contrasted them with our own protocol for management of ingested foreign bodies. In addition, measures aimed at reducing the risk of button battery ingestion in small children are proposed to the electronics manufacturing industry.

[An infant with intestinal pneumatosis and pneumoperitoneum: the difficult decision not to intervene]. / Un lactante con neumatosis intestinal y neumoperitoneo: la difícil decisión de no intervenir.

Pneumoperitoneum in children may be due to causes that do not require urgent surgery (cardiopulmonary resuscitation manoeuvres, severe respiratory pathology or mechanical ventilation). Surgery in these cases could even worsen the prognosis. We present the case of a male infant, ex-preterm, with a history of necrotizing enterocolitis and ileal perforation at birth, requiring laparotomy and intestinal resection on two occasions and developing a secondary microcolon, due to disuse. At six months, after transitioning to full oral feeding, he presented abdominal distension with extensive intestinal pneumatosis and pneumoperitoneum on radiographs. His general appearance was good with normal intestinal transit and no peritonitis. The patient remained fasting with intravenous antibiotics, nasogastric decompression and parenteral nutrition. The evolution was favourable with oral feeding restarting on the seventh day of admission. The existence of pneumoperitoneum does not always require a laparotomy and global assessment of the patient by an interdisciplinary health team may avoid unnecessary aggressive treatments.

[Programmed surgery for acute appendicitis]. / Cirugía programada de la apendicitis aguda.

Non-complicated appendicitis surgery is still considered to be an emergency, although it has been observed that a reasonable therapeutic delay (up to 18 hours) does not imply a higher number of complications. In our department, surgery is programmed for those non-complicated appendicitis, thus avoiding duty staff (surgeons, anaesthesiologists, nurses, assistants) to operate during late night. Acute appendicitis records from august 2001 to december 2002 were reviewed. Collected data included: clinical findings, physical examination, ultrasound findings, surgical delay (recorded time from emergency attendance until the end of the surgery) and evolution. A total of 209 patiens (125 males and 84 females) underwent surgery. Mean age was 10.1 years (standard deviation 3.02). A non-complicated appendicitis group (NC) included 171 subjects while the complicated appendicitis group (C) included 38, assessed by means of clinical evaluation plus ultrasonography. Patients in NC group had programmed surgery, with up to 20-hour delay (mean of 7 hours 45 minutes). Mean admission time was 4.87 days with a percentage of infectious complications of 1.73%. Patients in group C underwent surgery as soon as possible. Mean admission time was 9.23 days (p < 0.0001) and percentage of infectious complications of 43.6%. There was no difference between those operated rapidly and those who were delayed. Patiens with non-complicated disease could undergo programmed surgery, without having a higher risk of complicated disease and without disturbing normal department activity.

[Thrombosis of the superior sagittal sinus in a breast fed infant: secondary to prolonged exposure to mesalazine?]. / Trombosis del seno longitudinal superior en un lactante: ¿secundaria a una exposición prolongada a mesalazina?

INTRODUCTION: Mesalazine or 5 aminosalicylic acid (5 ASA) is currently a first choice drug in the treatment of inflammatory bowel disease. It has been shown that it crosses the placenta and is excreted into breast milk in small quantities. CASE REPORT: We present the case of a four month old breast fed infant, with a thrombosis of the superior sagittal sinus secondary to a severe thrombocytosis (1,124,000/mm3). The only interesting antecedent we would draw attention to, is that breast feeding had been suddenly stopped the week before. The mother, suffering Crohn s disease, had been receiving treatment with oral mesalazine throughout her pregnancy and during lactation. CONCLUSIONS: Once other causes of the thrombocytosis had been eliminated, we based our approach on the hypothesis that it was due to prolonged intake of 5 ASA by the mother.

[Cortical fracture of the sternum in a child: an infrequent case]. / Fractura cortical de esternón en la infancia: un caso excepcional.

We report the case of a six-year-old girl who suffer an isolated sternal fracture due to hyperflexion of the thorax (while she was playing on a jumping-bed). On clinical examination, only slight tenderness and pain with compression of sternum was found. Chest X-ray demonstrated a fracture of the body of the sternum without other findings. The patient was admitted, observed during 12 hours with ECG monitoring and discharged because no cardiac or pulmonary pathology appeared. We present this case because fracture of the sternum in a child is rare, especially if road-traffic accident with seat belt injury is not implicated as a cause.

[Rupture of a gastrostomy button. Importance of choosing the adequate material]. / Rotura del botón de gastrostomía. Importancia de la elección del material.

PEG is a safe, effective and widely used modality for nutritional andpharmacological enteral support in children. Rupture of the gastrostomy button during replacement is a very infrequent complication that may be avoided by choosing the adequate tube.

[Fluid dynamics in the Port-a-Cath Low Profile: therapeutic uses]. / Dinámica de fluidos en el Port-a-Cath Low Profile: aplicaciones terapéuticas.

The treatment of infection and obstruction in totally implantable central venous access catheters is based on the administration of medication into the system. Injected medication may be diluted in the portal which acts as a dead space in the line. We have studied the dynamic of fluids in the Low Profile Port-a-Cath, and developed an infusion-suction technique with double syringe to achieve high concentrations in the system with minimum repercussion in the vascular space. This procedure can be applied both in the treatment of infection with high-dose local antibiotics and in total or partial obstructions.

[Central venous access by the Seldinger technic in neonatology]. / Accesos venosos centrales por técnica de Seldinger en neonatología.

Eighteen catheterizations were attempted in 17 patients catheters (Arrow 3ChFr and 4ChFr), between january of 1996 and december of 1997. The patients ranged in age from 3 to 148 days (mean of 43.3 and standard deviation of 47.5) and in weight from 1110 to 4000 grams (mean of 3182 grams and standard deviation 767.2 grams). Overall successful catheterization rate was 94.5%. Complications included a pneumothorax that needed pleural drainage, one self-limited femoral artery spasm and one stenosis of femoral vein that did not require any treatment. The mean catheterism time was 6.64 days (deviation of 3.84 days), and the causes of removal were end of treatment in 8 patients, accidental removal in 5, infectious suspicion in 2 and limb edema in 2. Seldinger technique may be a useful approach for central venous catheterization in neonates. Careful catheterization, extensive experience and appropriate selection of material, help to keep the risk of complications low.

[Mortality and morbidity in very low birth weight infants in the Basque Country and Navarra (2001-2006): population-based study]. / Mortalidad y morbilidad de neonatos de muy bajo peso asistidos en el País Vasco y Navarra (2001-2006): estudio de base poblacional.

INTRODUCTION: This study describes very low birth weight (VLBW) infant morbidity and mortality in Basque Country and Navarra neonatal units between the years 2001-2006, and evaluates the factors that affect the mortality. PATIENTS AND METHODS: A descriptive observational study of a cohort of 1,318 VLBW infants in neonatal units in five Basque Country and Navarra hospitals between 2001 and 2006. A total of 37 variables included in EuroNeoNet database were collected as regards, perinatal risk and protective factors, demographic characteristics, length of stay, interventions, morbidity and mortality. RESULTS: A total of 94% of pregnant women received prenatal care and 78.7% antenatal steroids. In both cases there was a significant increase during the period studied. A total of 42% of pregnancies were multiple and in 63% delivery was by Caesarean section. Bronchopulmonary dysplasia statistically significantly decreased from 20% to 15%. The incidence of intraventricular haemorrhage grade III or IV was 7.5% and for periventricular leukomalacia it was 3.1%. Vertical infection was diagnosed in 4% of infants and sepsis or late meningitis in 25%, necrotizing enterocolitis in 9% and patent ductus arteriosus in 14% of the infants. The prophylactic or therapeutic treatment with indometacin or ibuprofen decreased significantly during the study. The overall rate of total, late and first day neonatal mortality was almost constant during this period of time. Nevertheless, the early neonatal mortality showed a decreasing trend and with a significant difference between sexes, being higher in males. CONCLUSION: This population-based study provides valuable information on clinical outcomes in NICUs, and may help in planning strategies to improve health care quality, and to reduce the morbidity and mortality in these neonates at high risk.

A fatal case of congenital disseminated Langerhans cell histiocytosis.

The case of a newborn male infant with congenital Langerhans cell histiocytosis (LCH) is presented. At birth, showed cutaneous lesions (papules and vesicles with a haemorrhagic aspect), mucosal and ganglionic involvement. Biopsy of these lesions led to the diagnosis of LCH. At 24 hours of life the patient began with respiratory, hepatic, hematological and renal dysfunction, and died at 72 hours of life, despite corticoid treatment. LHC with vesicles and a rapid and fatal development, has previously only been described in three patients. The differential diagnosis of a disseminated and hemorrhagic vesicular eruption in a newborn infant is extensive and must include LHC.

Wet umbilicus caused by pancreatic heterotopia in urachal remains.

Drainage from the umbilicus may be due to the presence of structures derived from the vitelline duct or urachus, granulomas, ectopic tissue, or poor hygienic practice. This paper discusses the case of a 6-month-old infant with a wet umbilicus caused by ectopic pancreatic tissue, in urachal remains. No similar cases have been found in the literature.

Pseudosubluxation of C2-C3 in childhood: a frequent clinico-radiological diagnostic error. / Pseudosubluxación C2-C3 en la infancia: un error frecuente de diagnóstico clínico-radiológico.

Although serious cervical injuries in pediatric patients are very infrequent, the may occur occasionally as a result of a strong blow to the head. Clinical records and radiological pictures, and in some cases computer tomography, help to provide the correct diagnosis. During childhood there are several normal radiological variants that may be interpreted as pathological findings, of which pseudosubluxation C2-C3 is the most frequent. We present two such cases and discuss the clinical and radiological criteria for the differential diagnosis between normal variants and injuries to the cervical spine in pediatric patients.