Assessing nitrate groundwater hotspots in Europe reveals an inadequate designation of Nitrate Vulnerable Zones

Monitoring networks show that the European Union Nitrates Directive (ND) has had mixed success in reducing nitrate concentrations in groundwater. By combining machine learning and monitored nitrate concentrations (1992-2019), we estimate the total area of nitrate hotspots in Europe to be 401,000 km2, with 47% occurring outside of Nitrate Vulnerable Zones (NVZs). We also found contrasting increasing or decreasing trends, varying per country and time periods. We estimate that only 5% of the 122,000 km2 of hotspots in 2019 will meet nitrate quality standards by 2040 and that these may be offset by the appearance of new hotspots. Our results reveal that the effectiveness of the ND is limited by both time-lags between the implementation of good practices and pollution reduction and an inadequate designation of NVZs. Substantial improvements in the designation and regulation of NVZs are necessary, as well as in the quality of monitoring stations in terms of spatial density and information available concerning sampling depth, if the objectives of EU legislation to protect groundwater are to be achieved.

[Satisfaction survey of patients with sequels of peripheral facial palsy treated with botulinum toxin A]

INTRODUCTION

Treatment of peripheral facial palsy with botulinum toxin A is safe and effective. Although its beneficial impact on patients' quality of life is known, to date, there have been no studies specifically analysing patients' subjective perceptions.

PATIENTS AND METHOD

We performed a prospective study in a random sample of patients with sequels of peripheral facial palsy treated with botulinum toxin in the Physical Medicine and Rehabilitation Service of our hospital. We created a simple questionnaire to assess both patient satisfaction and subjective perception of improvement after botulinum toxin treatment.

RESULTS

After infiltration, 95% of the patients felt good or very good. More than 80% noted improvement in the sensation of tightness in the cheek and neck. Around 75% of patients perceived an improvement in the range of voluntary movement and approximately 80% reported improvement in synkinesis. Almost all the patients would repeat the treatment, if proposed, and 100% would recommend botulinum toxin infiltration to other patients with facial palsy.

CONCLUSIONS

Patients treated with botulinum toxin experience substantial subjective improvement in the sequels of peripheral facial palsy, both in repose and in the control of synkinesis. Satisfaction was higher than 8/10 in 99% of patients in this study.

Reducing marine eutrophication may require a paradigmatic change

Marine eutrophication in the North-East Atlantic (NEA) strongly relies on nutrient enrichment at the river outlets, which is linked to human activities and land use in the watersheds. The question is whether human society can reduce its nutrient emissions by changing land use without compromising food security. A new version of Riverstrahler model (pyNuts-Riverstrahler) was designed to estimate the point and diffuse nutrient emissions (N, P, Si) to the rivers depending on land use in the watersheds across a large domain (Western Europe agro-food systems, waste water treatment). The loads from the river model have been used as inputs to three marine ecological models (PCOMS, ECO-MARS3D, MIRO&CO) covering together a large part of the NEA from the Iberian shelf to the Southern North Sea. The modelling of the land-ocean continuum allowed quantifying the impact of changes in land use on marine eutrophication. Pristine conditions were tested to scale the current eutrophication with respect to a "natural background" (sensu WFD), i.e. forested watersheds without any anthropogenic impact. Three scenarios representing potential management options were also tested to propose future perspectives in mitigating eutrophication. This study shows that a significant decrease in nitrogen fluxes from land to sea is possible by adapting human activities in the watersheds, preventing part of the eutrophication symptoms in the NEA rivers and adjacent coastal zones. It is also shown that any significant achievement in that direction would very likely require paradigmatic changes at social, economic and agricultural levels. This requires reshaping the connections between crop production and livestock farming, and between agriculture and local human food consumption. It also involves cultural changes such as less waste production and a shift towards lower-impact and healthier diets where half of the animal products consumption is replaced by vegetal proteins consumption, known as a demitarian diet (http://www.nine-esf.org/node/281/index.html).

Lessons from temporal and spatial patterns in global use of N and P fertilizer on cropland

In recent decades farmers in high-income countries and China and India have built up a large reserve of residual soil P in cropland. This reserve can now be used by crops, and in high-income countries the use of mineral P fertilizer has recently been decreasing with even negative soil P budgets in Europe. In contrast to P, much of N surpluses are emitted to the environment via air and water and large quantities of N are transported in aquifers with long travel times (decades and longer). N fertilizer use in high-income countries has not been decreasing in recent years; increasing N use efficiency and utilization of accumulated residual soil P allowed continued increases in crop yields. However, there are ecological risks associated with the legacy of excessive nutrient mobilization in the 1970s and 1980s. Landscapes have a memory for N and P; N concentrations in many rivers do not respond to increased agricultural N use efficiency, and European water quality is threatened by rapidly increasing N:P ratios. Developing countries can avoid such problems by integrated management of N, P and other nutrients accounting for residual soil P, while avoiding legacies associated with the type of past or continuing mismanagement of high-income countries, China and India.

Nitrogen deposition in Spain: modeled patterns and threatened habitats within the Natura 2000 network

The Mediterranean Basin presents an extraordinary biological richness but very little information is available on the threat that air pollution, and in particular reactive nitrogen (N), can pose to biodiversity and ecosystem functioning. This study represents the first approach to assess the risk of N enrichment effects on Spanish ecosystems. The suitability of EMEP and CHIMERE air quality model systems as tools to identify those areas where effects of atmospheric N deposition could be occurring was tested. For this analysis, wet deposition of NO3(-) and NH4(+) estimated with EMEP and CHIMERE model systems were compared with measured data for the period 2005-2008 obtained from different monitoring networks in Spain. Wet N deposition was acceptably predicted by both models, showing better results for oxidized than for reduced nitrogen, particularly when using CHIMERE. Both models estimated higher wet deposition values in northern and northeastern Spain, and decreasing along a NE-SW axis. Total (wet+dry) nitrogen deposition in 2008 reached maxima values of 19.4 and 23.0 kg N ha(-1) year(-1) using EMEP and CHIMERE models respectively. Total N deposition was used to estimate the exceedance of N empirical critical loads in the Natura 2000 network. Grassland habitats proved to be the most threatened group, particularly in the northern alpine area, pointing out that biodiversity conservation in these protected areas could be endangered by N deposition. Other valuable mountain ecosystems can be also threatened, indicating the need to extend atmospheric deposition monitoring networks to higher altitudes in Spain.

Towards a consensus on a hearing preservation classification system

CONCLUSION

The comprehensive Hearing Preservation classification system presented in this paper is suitable for use for all cochlear implant users with measurable pre-operative residual hearing. If adopted as a universal reporting standard, as it was designed to be, it should prove highly beneficial by enabling future studies to quickly and easily compare the results of previous studies and meta-analyze their data.

OBJECTIVES

To develop a comprehensive Hearing Preservation classification system suitable for use for all cochlear implant users with measurable pre-operative residual hearing.

METHODS

The HEARRING group discussed and reviewed a number of different propositions of a HP classification systems and reviewed critical appraisals to develop a qualitative system in accordance with the prerequisites.

RESULTS

The Hearing Preservation Classification System proposed herein fulfills the following necessary criteria: 1) classification is independent from users' initial hearing, 2) it is appropriate for all cochlear implant users with measurable pre-operative residual hearing, 3) it covers the whole range of pure tone average from 0 to 120 dB; 4) it is easy to use and easy to understand.

Tinnitus and quality of life following vestibular schwannoma surgery

OBJECTIVE

This study on patients undergoing surgery for vestibular schwannoma investigated tumour (i) the effect of pre-operative factors on tinnitus, (ii) the effect of translabyrinthine or hearing preservation surgical approaches on tinnitus, and (iii) the effect of postoperative tinnitus status on the patient's quality of life (QOL).

METHODOLOGY

Seventy-nine patients who underwent vestibular schwannoma (VS) excision between 2001 and 2005 were selected. Postoperative tinnitus status was evaluated using a standard questionnaire for tinnitus, and QOL was measured using the Glasgow Benefit Inventory (GBI).

RESULTS

Overall, 58% of patients noted tinnitus before tumour removal. Pre-operative tinnitus was not associated with age, gender, tumour size, or hearing thresholds. The total percentage of patients suffering postoperative tinnitus was 64%. Hearing preservation approaches showed no difference in terms of changes in tinnitus compared to the translabyrinthine approach. Twenty-one patients (30%) reported better QOL, 40 patients (56%) reported worse QOL, and 10 patients (14%) reported the same QOL. A significant association was found between tinnitus worsening as measured by GBI score and QOL.

CONCLUSIONS

Most patients do not report significant changes in their tinnitus status after surgery. Tinnitus evolution is unpredictable and not related to the type of surgical approach. Thus, tinnitus should not be used as a criterion for selecting the surgical approach. Tinnitus worsening appears to influence QOL following surgery for VS.

Quality of life in hearing-impaired children with bilateral hearing devices

OBJECTIVE

To evaluate the quality of life (QOL) of hearing-impaired children fitted with either a cochlear implant and a hearing aid or bilateral hearing aids, and to compare their outcomes with those of normal-hearing peers. We also investigated the impact of demographic, clinical, and audiological results on QOL.

METHODOLOGY

Cross-sectional study using a generic QOL questionnaire. Questionnaires were completed by children and their parents. Eighty-eight children were divided into three groups: bilateral deaf children with a cochlear implant and a contralateral hearing aid (bimodal group), bilateral deaf children with bilateral hearing aids (hearing aid group), and normal-hearing children. The Spanish version of the KINDLr test was used. Responses were correlated with demographic, clinical, and audiological data.

RESULTS

The questionnaires revealed a high health-related QOL with a total self-rating score for the children and a proxy score for the parents of 75 or higher in five out of six domains. No significant difference was found in the QOL among the three groups. Additionally, there was no significant difference between the self-rating and the proxy total scores, and no significant association was found between the QOL and the variables of the study.

CONCLUSION

Our results indicate a high level of QOL in hearing-impaired children and their families following treatment with either bilateral hearing aids or bimodal stimulation. Children and their parents reported a QOL similar to that of normal-hearing children.

[Noninvasive positive pressure ventilation in postoperative period of tracheal surgery]

OBJECTIVES

Reconstructive surgery of the airway often means prolonged periods of intubation during the post-operatory period, increasing the needs for drugs and favoring the appearance of infectious complications. We present an original system of ventilatory support with non-invasive positive pressure ventilation (NIPPV) using in patients subjected to reconstructive surgery of the airway.

PATIENTS AND METHODS

A retrospective study in patients undergoing reconstructive procedures of the airway in the year 2009 was carried out. We exclude those treated endoscopically and those who had vascular rings. The positive pressure mechanism used in the Surgery Critical Care Unit was a design made by the unit based on the circuit devised by Mapleson that provides optimum levels of ventilation without need for connection to a respiratory. We analyze the results, postoperatory intubation time, time dependent on NIPPV and medical treatment received.

RESULTS

A total of 7 patients (1 Female and 6 Males) with median age of 1.6 (0.1-7.5) years were included. The diagnoses were: 4 subglottic stenosis, 2 had tracheal stenosis and 1 subcarinal stenosis with involvement of both principal bronchioles. The techniques used were: laryngotracheoplasty with costal cartilage graft (4), tracheoplasty with costal cartilage (1) and sliding tracheoplasty (2) with bilateral bronchoplasty in one of them. The mean time of nasotracheal intubation was 3 days, and mean time of NIPPV was 2.3. No patient required reintubation and none had infectious complications.

CONCLUSIONS

Ventilatory support by VPPNI allows effective extubation in these patients, it being possible to maintain a safe airway. Infectious complications, frequent in prolonged intubations, were not observed in any of the cases.

Late surgery for spinal deformities in children previously treated for neural tumors

BACKGROUND/AIM

Surgery for neural tumors occasionally involves opening of the neural canal and/or costovertebral resection that may be followed by radiotherapy. Spinal deformities (SD) may occur in these cases. This study investigated the incidence, surgical indications and results of repair of late SD in a large series of patients with neural tumors.

METHODS

A retrospective review of neural tumors treated between 1991 and 2009 at our institution identified children with SD who subsequently required spinal surgery. SD was meaÂ-sured using Cobb's angle. Instrumentation of the spine was indicated in patients with a Cobb's angle of more than 60° or rapidly progressing SD. The operation was adapted to the location, type and degree of SD. Patients were followed up and the remaining deviations were measured annually.

RESULTS

Out of a series of 188 patients with neural tumors, 5 of 173 patients with neuroblastomas/ganglioneuromas (NB/GN) and 3 of 15 patients with PNET/Askin tumors developed SD over time. NB/GN children had intraspinal tumors requiring laminotomy (n=3) or laminectomy (n=2). PNET/Askin tumor patients had undergone largescale rib and partial vertebral body resection and radiotherapy. Scoliosis or kyphosis were located in the thoracic spine in 4, in the thoracolumbar spine in 3 and in the cervicothoracic spine in 1. The median preoperative Cobb's angle was 65° (50°-90°) prior to spinal surgery performed 2.9 (0.4-11) years after tumor removal. 3 growth bars, 2 vertical expandable prosthetic titanium ribs, 1 pediatric ISOLA device and anterior instrumentation were used. Arthrodesis was necessary in 3 patients. Median post-instrumentation deformity after 3.1 (0.2-12.2) years was 40° (20°-50°), giving an improvement of 38.4%.

CONCLUSIONS

With increasing numbers of children surviving cancer, attention must focus on sequelae. A sizeable number of survivors of NB/GN and PNET/Askin tumors develop serious SD requiring surgical correction. Pediatric surgeons, patients and relatives must be aware of these possible sequelae.

[Traumatic diaphragmatic hernia: a vital need for an early diagnosis]

INTRODUCTION

Traumatic diaphragmatic hernia (HDT) is exceptional in children. Its diagnosis is usually delayed for appearing in the context of severe polytrauma. The aim is to analyze our series in relation to the severity scores.

PATIENTS AND METHODS

Five patients with HDT are presented. Age, biomechanics, clinical, ISS (injury severity score), ITP (pediatric trauma index), GCS (Glasgow coma scale), RTS (Revised Trauma Score) and treatment were studied. The probability of survival (Ps) was calculated with the TRISS method, Ps = 1/(1 + eb), b = b0 + bl (RTS) + b2 (ISS) + B3 (age).

RESULTS

There were two males and three females, mean age was six years old (range = 3-10). Traffic accident was the mechanism of the thoracoabdominal trauma in 80% and one was crushed by garage door. The affected side was right in two cases and left in three. Mean ISS was 41 (range = 32-57), ITP 6 (range = 2-9) and RTS 6.1 (range = 5.1 to 6.9). The main symptom was respiratory. Plain chest radiography was diagnostic in three patients, one by CT scann, and another was a finding at laparotomy. Two had liver herniation, one had tension gastrothorax and two had gastric perforations. All patients underwent surgery through the abdomen. Estimated survival by the TRISS method was respectively 86.6%, 78.2%, 57.2%, 84.7% and 57.1%, while the actual was 100%. One has a severe disability.

DISCUSSION

To study the biomechanics and semiology is essential in the early diagnosis of TDH in pediatric polytrauma and suspect it is mandatory prior to realize percutaneous chest procedures. The TRISS method has a great importance to assess the adult polytrauma, but specific scores are needed for children.

[Pneumonectomy in children]

BACKGROUND/AIM

Pneumonectomy is seldom indicated in children and its long-term effects are not well known. The aim of the present study was to examine retrospectively the indications and the long-term sequelae in a relatively large cohort of patients treated at our institution.

MATERIAL AND METHODS

We reviewed the charts of children undergoing pneumonectomy between 1969 and 2009 with particular attention to indications, techniques, complications, survival, pulmonary function and spine deformities

RESULTS

Ten patients (M:F=6/4) aged 102 +/- 66 months underwent pneumonectomy for bronchiectasis (4, one with cystic fibrosis), tumors (4, 1 myofibroblastic inflammatory pseudotumor, 1 bronchial carcinoid, 1 primary pulmonary PNET and 1 massive metastasis of osteosarcoma) and malformations (2, 1 pulmonary sequestration and 1 congenital bilobar emphysema). Overall survival was 90% at 5.6 (0.3-23) years. Patients with bronchiectasis improved markedly except the one with cystic fibrosis who died. All children with tumors cured. Four have some degree of scoliosis which is severe in one with malformative costal fusion. All survivors live unrestristricted normal lives. Postoperative respiratory function is well preserved with FVC of 58% (40-70%), FEV1 of 60% (47-84%) and FEV1/FVC of 92% (87-98%) of the theoretical value for their height and weight.

CONCLUSIONS

Pneumonectomy does not affect by itself to the overall survival, and the respiratory function is good and there is no impairment of the quality of life.

[The risk of necrotizing enterocolitis in newborns with congenital heart disease. a single institution-cohort study]

BACKGROUND/AIM

Necrotizing enterocolitis (NEC) is the most common gastrointestinal surgical disease among neonates. Congenital heart disease (CHD) is also a significant cause of infant morbidity and mortality and it is usually associated with prematurity, low birth weight, pulmonary and gastrointestinal disease, conditions that also account for the development of NEC. Our aim is to analyze the incidence and the risk factors for NEC in neonates with CDH admitted to the Neonatal Intensive Care Unit (NICU) in a 6 years period.

METHODS

All patients admitted in the NICU for any type of CDH from January 2003 to December 2008 comprised the cohort of this study. The primary outcome measure was the development of NEC in any stage. Sixteen independent variables were selected to include those factors previously correlated with NEC. Uni and multivariate statistical analysis were performed with SPSS 15.0 for Windows. Relative Risks (RR) are presented with 95% confidence intervals.

RESULTS

935 out of the 7803 neonates admitted during this period, 935 (11.9%) presented a CHD. Among them, 70 also had NEC (RR 8.4-17.8), 31 requiring surgical treatment (Bell stages III and IV). The risk for NEC was specially increased if CHD needed surgical correction (2.1-5.1) and among babies with very low birth weight (VLBW, <1,500 g) (2-4.8). After multivariate analysis the only independent variables associated with an increased risk of NEC were birth weight less than 1,500 g (2.2-7.4), the need of surgical correction of CHD (2.2-7.1) and a clinical picture of septicaemia (1.1-3.9).

CONCLUSIONS

The incidence of NEC is greater in neonates with CDH than in the normal newborn population. Early recognition of NEC should be warranted among CHD patients, specially in those with VLBW, surgical treatment of CHD and sepsis. In this sub-cohort of patients an increased risk of NEC should be suspected.

[Long-term results in ulcerative colitis treated with proctocolectomy and ileoanostomy in children]

AIM

The treatment of Ulcerative Colitis (UC) unresponsive to current medical treatment involves total proctocolectomy and ileanostomy. The aim of this study was to assess the long term results in such patients.

MATERIAL AND METHODS

We reviewed children treated from 1992 to 2008. The operations, complications and functional outcome were recorded. For those with preserved rectal defecation, continence (Holschneider score) and quality of life (standardized phone questionnaire) were assessed in the long term.

RESULTS

104 patients had Ulcerative Colitis (UC) and 3 undetermined colitis (excluded from the study). 26/104 UC patients (26%) aged 10.7 +/- 4.1 years required 82 operations. Eight had emergency colectomy for toxic megacolon (3, one death) or severe hemorrhage (5). 25 had restorative proctocolectomy and ileoanostomy (RPCIA) without (16) or with (9) J-pouch under protective ileostomy. Complications were frequent (40%). Permanent ileostomy was required in 5 children (20%). Twelve months postoperatively, RPCIA patients had 6.3 +/- 3 stools/day, all were continent during daytime and 25% have nocturnal leaks. Mean Holschneider score (0-12) was 8.8 +/- 2. Quality of life was good in all with normal school (all) or university attendance (7), 4 work and 60% of those older than 18 have sexual partners.

CONCLUSIONS

The nature of UC involves risky and frustrating surgery. However, it may provide a reasonably good quality of life for UC patients after the first year. Pediatric surgeons should be able to provide adequate preoperative counseling to patients and families.

Long-term results of the treatment of total colonic aganglionosis with two different techniques

AIM

Aim of this study was to assess the long-term results of the treatment of total colonic aganglionosis (TCA) with 2 different techniques in terms of growth, continence and quality of life (QOL).

PATIENTS AND METHODS

Forty-one patients treated for TCA between 1972 and 2007 were reviewed retrospectively with special attention paid to the length of aganglionosis, complications, growth, continence and QOL. Until 1992, patients underwent subtotal colonic resection and side-to-side ileosigmoid anastomosis (modified Martin). Since 1992, straight ileo-anal pull-through was preferred. At the end of follow-up (median 18 years, range 1-35), the height and weight, continence and QOL (scoring feeding habits, school/work performance, family life and professional development) were assessed by clinical visit or phone interview.

RESULTS

Twenty-eight patients were male and 13 female. Six had total intestinal aganglionosis and were excluded from this review together with the 2 who died before definitive treatment. The 33/41 persons in whom aganglionosis had involved less than 50 cm above the ileocecal valve and who had been considered suitable for the reestablishment of transanal fecal flow were included. Eighteen children underwent a modified Martin and 15 straight ileo-anal pull-through. Postoperative intestinal obstruction occurred in 4 cases, prolapse and prolonged TPN requirement in 2, and wound disruption and fistula in 1. Thirteen patients (39 %) had postoperative enterocolitis. Two children died after operation (1 wound disruption with sepsis and 1 pneumonia). Out of 31 survivors, 57 % and 53 % were > p50 with regard to height and weight whereas only 15 % and 19 % were <p3 respectively. Only half the patients had more than 3 bowel movements per day and the median Wildhaber continence score (normal = 14) was 11 (range 6-14). Both types of operations resulted in comparable defecation and continence patterns. QOL was rated as good in all cases but one. All patients but 2 attended high school, 8 attend university, 4 are employed and 1 is married and has 2 daughters. Social life is normal except for 1 patient who perceives his disease as a burden.

CONCLUSIONS

Patients with TCA amenable to reestablishment of the transanal fecal flow can have adequate growth, normal feeding, reasonably good continence and satisfactory QOL. However, complications and enterocolitis are frequent. A modified Martin's procedure was performed as well as straight ileo-anal pull-through with little influence on the long-term outcome.

[Morbility and mortality associated with prosthetic patch in congenital diaphragmatic hernia]

AIM

To analyze morbility, mortality and neonatal intensive care management in CDH patients who required a prosthetic patch to close the diaphragmatic defects, and to compare these results with those who were made a primary closure.

MATERIAL AND METHODS

We reviewed the clinical charts of CDH patients managed at our institution between January 1994 and December 2006, including demographic data, clinical management, treatment options, complications and mortality. Appropriate statistical tests were used to evaluate the data: mortality, need of high frequency oscillatory ventilation (HFOV), days of intubation, days of total parenteral nutrition (TPN), days of admission, reherniation, need of Nissen funduplication and intestinal obstruction; a p value less than 0.05 was considered statistically significant.

RESULTS

Eighty-seven CDH patients were reviewed, 68 right, 17 left and 2 bilateral defects. Seventeen died before surgery (19.5%). Among the 70 operated patients, 21 (24.1%) required a prosthetic patch, 18 in the left and 3 in the right side. Overall mortality, need of HFOV, intubation days, need of TPN, days of admission, reherniation rate and need of Nissen funduplication were all significantly worse in the group who required a patch. Rate of intestinal obstruction was similar in both groups.

CONCLUSIONS

Patients who required a prosthetic patch to close the diaphragmatic defect suffered from higher morbidity and presented a higher mortality than those who did not required the patch.

[Reoperations in gastroesophageal reflux disease]

PURPOSE

The purpose was to determinate the indications in which the failure of the surgical treatment of the gastroesophageal reflux disease (GERD) is more frequent and to analyze the results of the reinterventions.

PATIENTS AND METHOD

We made a restrospective review of the patients who underwent reoperation at our Institution during 1992-2006.

RESULTS

19 of 252 Nissen underwent reoperation. In one case was the fourth fundoplication, in another was the third and the second in the rest of them. The reflux was confirmed by upper gastrointestinal contrast study, endoscopy, pH monitoring and, in some cases, manometry. 5 cases have surgical comorbidity (3 Esophageal Atresia (EA), 2 Congenital diaphragmatic hernia (CDH), 4 patients was neurologically impaired, 1 had caustic stenosis (CS), and 9 only symptoms of GERD. 8.7% of the patients with GERD, 5.8% of the neurologically impaired children, 10% of the EA, 20% of the CDH and 50% of the CS underwent redo Nissen. The mean time between first and second fundoplication was 1.6 years (range = 1 m-5.5 y). It was 11.2 in neurologically impaired patients, 5 m in CS, 11.5 m in CDH, 2.4 y in EA and 2.8 y in the rest. In patients with respiratory disease, the mean was 1.1 y and 1.9 y in the rest. The mechanism of failure was herniation of the fundoplication through the hiatus in 8 cases, wrap incompetence in 4 and wrap dehiscence in 2. In 5 patients it couldn't be determined. There were 2 postoperative complications. The mean follow-up was 5.3 years (range = 6-151.5 m). There was no cases of mortality. 17 of the 19 patients (89.4%) are free of symptoms and don't need more treatments. The child with CS continuous periodic esophageal dilatations and 1 of the patients with EA has dysphagia to solid foods.

[Pediatric patient in adult age. Long-terms results of esophageal replacement]

BACKGROUND

Esophagocoloplasty is one of the most used procedures for esophageal replacement in children. Considering high life expectancy in these patients, long-term results must be considered when evaluating this technique. The aim of our study is to evaluate quality of life of adult patients who underwent surgery at pediatric age.

PATIENTS AND METHODS

We report a retrospective study of 99 patients who underwent esophageal replacement in our institution between 1966 and 2006. Eight of them have died and 63 out of the remaining 91 are over 18 years now and represent our study serie. Long-term results and actual situation of those patients, considering psychological, physic and social aspects, were evaluated through clinical review and telephonic interview. Karnofsky index was applied to mesure functional ability from 0-100% (bad, medium, good-excellent) according to the answers the patients gave to our questions. We also recorded their health personal experience and subjective evaluation of their quality of life.

RESULTS

Sixty-three patients were reviewed (43 males and 20 females) with a mean age of 4.3 +/- 3.4 D.S. Mean follow-up time was 29.6 +/-7.7 years. Indications for esophageal replacement were as follows: caustication (n = 32), type III esophageal atresia (n = 15), type I AE (n = 13) and others (n = 3). In 48 patients the graft was placed in retroestenal position and in 15 cases retromediastic location was used. Postoperative period was uneventful in 44% of the patients, being the most frequent early complications in the remaining, cervical leakage and stenosis. Long-term, 56,8% did not have any sequelae, 28.5% required further surgery and the remaining 43.13% presented the following complications: symptomatic graft reflux (22), scoliosis and thoracic asymmetry (12), colonic redundancy or cervical diverticulum (7), food impaction (6) and failure to thrive (5). Only one 38 year old patient does not have intestinal tract continuity nowadays. Thirty-one patients have a Karnofsky index > or = 80-100%, being considered healthy and able to have a normal activity. Eighteen patients are included between 40-80%, being the most frequent limitation the need of medication to avoid reflux, backache and occasional episodes of food impact. Only 2 patients have Karnofsky index inferior to 40%. None of them are under 20%.

CONCLUSIONS

Esophagocoloplasty allows restoration of intestinal tract continuity in almost all cases and the mortality of this procedure has decreased over time. Even though some risks are still remarkable, it offers long-term good results with little repercussion on functional ability in adult age. Most of the patients consider themselves healthy and enjoy an acceptable quality of life.

[Clinical tumoral size dissociation in acoustic neuroma: reality or measure distortion?]

INTRODUCTION

In this study we have analyzed (i) the audiometric frequencies more often affected in acoustic neuroma (AN), (ii) the percentage of patients presenting normal hearing and those with sudden hearing loss, (iii) if there is a correlation between tumor size and hearing loss, and (iv) the relationship between clinical and radiological parameters and audiological data.

METHODS AND MATERIAL

Retrospective study of 81 patients undergoing surgical removal of a sporadic AN.

RESULTS

The highest threshold in the tumor's ear was found at 8000 Hz, and the highest interaural difference at 4000 Hz. The percentage of patients presenting normal hearing and sudden hearing loss was 2.5% and 9%, respectively. No significant association was found between tumor size and hearing loss, preoperative facial palsy or Vth cranial nerve deficit. There was a significant association between the degree of hearing loss and Vth cranial nerve deficit, and between hearing loss and preoperative facial palsy.

CONCLUSIONS

The association between hearing loss and Vth cranial nerve deficit, and between hearing loss and preoperative facial palsy is independent the size of the tumour.

[What can we do when a esophagocoloplasty fails?]

BACKGROUND

Postoperative complications of esophageal replacement are potentially severe, and they can even make impossible the digestive continuity. However, several surgical options have been used for such situations. The aim of the study is to assess the early and late results in patients who have been managed or referred to our department for this problem.

PATIENTS AND METHODS

We reviewed 8 patients operated between 1975 and 2005, four of them were referred from other hospitals. The ranging in age was from 4 months and 23 years at the moment of the first colonic replacement, and who required a second plasty because of intra or postoperative complications. The esophagocoloplasty was retrosternal in 6 cases and transhiatal in 2, with a left colon graft in 6, ileocolonic in I and right colon in the last one. The initial diagnosis was traqueoesophageal fistula in 6 (type III in 3, type I in 2 and IV in 1), caustic injury in 1 and herpetic esophagitis in 1. Complications requiring reoperation were stricture of the cervical esophagococolic anastomosis because of postoperative dehiscence (n=4), perioperative deficient graft vascularisation (n=2), graft necrosis (n= 1) and symptomatic gastric-colic reflux (n=l).

RESULTS

The deficient graft irrigation was detected and managed during the surgical procedure in 2 cases, left colonic graft was remplaced by a gastric tube and the right colon, respectively, with excellent results. Repeated endoscopic dilatations (n=4) as well as surgical revision with resection and reanastomosis of the stenotic segment (n=2), did not suffice in children with severe strictures (100%). A second plasty was tried in 2 patients: a failed microsurgical sigmoid graft in one of them, and a presternal esophagocoloplasty with a left colonic graft in the other one. It was impossible to perform a new plasty in two chidren, because of the severe mediastinal fibrosis. One patient was referred with severe gastro-colic reflux and the cologastric anastomosis and the gastrostomy were refashioned. Another patient with graft necrosis required total resection of the coloplasty and a new esophagostomy and gastrostomy. 50% of the patients recovered digestive continuity, and nowadays three of them eat normally. The fourth one died after several years because of an Guillain Barré syndrome. Four patients are still waiting for future attempts of esophageal substitution.

CONCLUSIONS

There are surgical options to reestablish the digestive continuity whenever the initial esophageal replacement fails. Severe postoperative strictures do not dissapear with endoscopic dilatations or stenotic resection and reanastomosis, but they usually require a new graft in another less injured place. Poor vascularisation of the graft can be prevented, giving the best solution for each patient, and at minimal suspicion of ischemia, consider another plasty or access during the operation.

[Esophageal replacement. 12 years experience]

Esophageal replacement is a surgical procedure rarely indicated in children. It is used in esophageal atresia type I and long-gap atresia when anastomosis is not possible, corrosive strictures and other unusual causes. Type and location of the graft depend on etiology and surgeon preferences. We analyse our results of a large series of esophageal replacement.

METHODS

. We reviewed esophageal replacements carried out in our department between January-1992 and December-2004. We report 29 patients (15 girls and 14 boys) with ages ranging from 2 months until 14 years old (median 24 months). 11 (37.9%) had esophageal atresia type I, 7 (24.1%) long-gap esophageal atresia, 8 (27.5%) caustic esophagitis, 1 herpetic esophagitis, 1 candida esophagitis and 1 esophageal necrosis due to sclerotherapy. Colon was used for substitution in 25 cases (86.2%) and stomach in 4 (13.8%). Graft location was retromediastinal in 25 children (86.2%), retrosternal in 3 and subcutaneous in 1. Native esophagus was removed in all but 2 out of 3 retrosternal cases.

RESULTS

After a follow up between 7 and 145 months (median 76 months) all children have a functional graft. Actually all patients tolerate oral feeding in a satisfactory way, and have had a normal pondostatural growth. Post-operative complications were pyloric obstruction in 3 patients (10.3%), upper anastomosis stricture in 3 (10.3%), 2 (6.9%) surgical wound evisceration, 2 (6.9%) diaphragmatic hernia, 1 (3.4%) retro-mediastinal abscess and 1 (3.4%) colo-gastric emptying difficulties. Also 2 pleural effusions, 1 cervical wound abscess and 1 abdominal wound one. Re-operation was needed in 11 patients (38%) due to these adverse events. Other complications were conservatively solved: 6 (20.7%) salivary fistula, 1 intestinal suboclusion and a dumping syndrome. One girl died due to a mycotic mediastinal abscess with perforation of the aorta 11 days after surgery. Overall survival was 96.5%.

CONCLUSIONS

Esophageal replacement has limited indications. It allow a good functional result, with adequate oral feeding and normal growth. We believe that both colon and stomach have similar outcomes, but gastric pull-up is easier to perform. It is a major surgery whose risk of complications is higher in early post-operative time.

[Results of the treatment of congenital diaphagmatic hernia with conventional terapeutics modalities]

AIM

In this study, we analyze our results in the treatment of congenital diaphragmatic hernia (CDH) using conventional ventilatory therapy without ECMO.

PATIENTS AND METHODS

fifty one CDH patients (27 males and 24 females) treated at our institution between 1997 and 2004 were reviewed. Data referred to obstetrics, prenatal diagnosis, newborn care, type of hernia and surgical treatment were analyzed. We recorded ventilatory treatment modalities and the outcome of the patients. We also compared the survival of our series with those expected using the formula proposed by the CDH study group in 2001. We finally analized separately those patients with early clinical presentation and who fulfilled ECMO criteria. Data from necropsies were also recovered when available.

RESULTS

Prenatal diagnosis was made in 58% of the patients. Fifty nine percent were born by c-section. The diaphragmatic defect was left-sided in 42 patients, right in 8 and bilateral in 1. Ten patients needed a prosthetic patch to close the defect. Eighteen out of the 51 patients (35%) died, 11 of them without surgical treatment. Early presentation of clinical picture was evident in 44 patients; among them 46% required high frequency ventilation and 53% nitric oxide therapy. Medium age at operation was 56+/-49 hours. The 7 children with late clinical presentation are alive. Among the 44 remaining patients, 26 are also alive (59,09%), data similar to those expected by the formula (62.39%, p>0.05). Fifteen patients had oxigenation index (IO) over 40, with a stimated survival rate of 48%, a statistically significant lower rate when compared to patients with IO<40. None of the patients with IO>40 survived; in 4 out of the 7 available necropsy studies, a severe lung hypoplasia was found (index lung weight/body weight <0.006). Among the remaining 27 children with IO<40, 24 (90%) are alive.

CONCLUSIONS

A survival rate over 90% can be achieved by conventional ventilatory measures in patients with IO<40. In our experience, children with IO>40 are rarely candidates to ECMO therapy because of the associated severe lung hypoplasia confirmed by necropsy studies.

Comparison of different mobile telephones in Combi40+ users

CONCLUSION

Telephone usage is a difficult challenge for cochlear implanted patients. A significant number of cochlear implanted patients are able to carry on a land-line or mobile telephone conversation. The telephone model may be a critical factor for telephone performance.

OBJECTIVES

The goals of this study were to evaluate speech discrimination through land-line and mobile telephones in Combi40+ users, and to compare different mobile telephone models to find out which could be more advisable for them.

PATIENTS AND METHODS

Eighteen Combi40+ implantees were tested with CID sentences and bisyllabic words presented through land-line and mobile telephones, in both quiet and noisy environments.

RESULTS

Mean scores for telephonic speech discrimination were over 85% for CID sentences and 28-59% for bisyllabic words. The Siemens M55 was superior to the other mobile telephones tested.

[Hirschsprung disease: lessons learned from the last 100 cases]

We analyize our experience in the management of the last consecutive 100 Hirschsprung's disease (HD) patients divided into two periods: 1992-1997 and 1998-2004, in order to find out differences in morbidity, mortality and outcome between them.

MATERIAL AND METHODS

During this period, 72 males and 28 females were treated. Twelve had family history and five suffered from Down's syndrome. Information about clinical onset, need of stomas, surgical procedures, continence, outcome and mortality was recorded. We compared the results between the two groups with non-parametrics stadistics test.

RESULTS

50% of patients were symptomatic in the newborn period and 25% of them needed some surgical procedures. Seventy four patients suffered from rectosigmoid forms, fourteen colic forms and twelve were total colonic HD (7 with small bowel extension). Hystochemistry was diagnostic in 98%. Nursing was effective in 47 cases. Differences in the need of stomas were found between the two periods: 30% during the first period and 6% during the second one (p<0,05). Twenty percent (20) of the patients suffered from enterocolitis (with no differences between both groups), and 13 of them still had enterocolitis episodes in spite of stomas or pull-through procedures. We performed 49 Swenson, 29 Soave, 14 transanal and 2 Lester-Martin procedures. The median age at definitive operation was smaller in the last period when compared to the first (p< 0.05). We found good results on continence in 86%, with no relation with definitive surgical procedure nor with the period of time studied.

CONCLUSIONS

The younger age at definitive treatment, the performance of stomas and the increase of transanal procedures were the principal differences between the two groups.

Impact of preoperative diagnosis of congenital heart disease on the treatment of esophageal atresia

Congenital heart disease (CHD) has a major impact on the survival of babies with esophageal atresia (EA). The present study assesses whether early diagnosis influences the management strategies in a large series of EA. Cases of EA treated between 1982 and 2002 were retrospectively divided into groups according to the presence or absence of CHD and to whether this was diagnosed or not prior to tracheo-esophageal fistula repair. Patients were also staged according to Spitz's classification in which major congenital heart disease (MCHD) are those associated with cyanosis and/or heart failure requiring surgery. Comparisons between groups of patients were made by standard statistical tests. Among 195 babies with EA (99 boys and 96 girls), 82 (42%) had CHD (31 boys, 39% and 51 girls, 61%, chi2 P < 0.05) and 43 out of these 82 (52%) had MCHD. Six children died without treatment. CHD was diagnosed prenatally in six cases and before EA repair in 26 cases. The diagnoses were missed in 12 instances (in five it was a MCHD). Regardless of preoperative diagnosis of right aortic arch in 3/6 cases, the oesophagus was approached from the right thorax in all cases and only in one of them the operation was not completed due to hemodynamic instability. There were 145/195 (75%) Spitz group I patients; 44/195 (22%) were group II and 6/195 (3%) group III. The mortality was respectively 9.5, 59 and 83%. We lost 15/113 (13%) babies with EA without CHD, 4/39 (10.2%) with EA and CHD and 26/43 (60%) with EA and MCHD. In children with CHD diagnosed prior to the esophageal operation 8/26 (30.7%) died and among those without diagnoses 3/12 (25%) died, (chi2 P > 0.1). 1. CHD was diagnosed after EA repair in one-third of cases. 2. Preoperative diagnosis of CHD changed the operative indication only in one case. 3. Survival after treatment for EA was not influenced by the moment or the accuracy of the diagnosis of CHD in this series. 4. With only a few exceptions, associated CHD should not change the strategies of EA repair.

[Quality of life in cochlear implanted patients]

Several articles show the audiologic benefits of cochlear implants, although it is still necessary to prove their impact on quality of life. In this study, 36 Med-El processor users were included. The Glasgow Benefit Inventory (GBI) was used to measure changes in quality of life, and another questionnaire was used to evaluate the communication abilities. Eighty-six percent of the patients answered our questionnaire. The quality of life improved significantly according to the specific questionnaire. The average total benefit obtained with the GBI was +41, and the average scores related to general, social and physics benefits were +57, +16, and +3, respectively. No significant difference was found between quality of life and other parameters like insertion depth of the array, etiology or duration of the deafness.

[Speech discrimination through telephone in patients implanted with a Combi 40+]

OBJECTIVE

To assess speech discrimination through line and mobile telephone in cochlear implanted patients.

MATERIAL AND METHODS

Eighteen patients implanted with a Combi 40+ went through different speech discrimination tests with a line telephone and three mobile telephones, in quiet and noisy environment.

RESULTS

Mean scores for telephonic speech discrimination were 84-92% using CID sentences, 27-58% using bisyllabic words in quiet environment and 15-41% using bisyllabic words in noisy environment. Among the mobile telephones tested, the Siemens M55 reached the best scores.

CONCLUSIONS

Telephonic speech discrimination is achieved by a significant number of cochlear implanted patients. Certain mobile telephone models appear to be more advisable for these patients.

[Lipoblastoma: the least well known of adipose tumors]

INTRODUCTION

Lipoblastoma is the least known of adipose tumours. It comes from embryonic adipose tissue and though it is histologically benign, it is locally invasive, implying a high risk of relapse if it is incompletely removed. The pediatric surgeon should be familiar with this tumor since it usually appears in children under three.

MATERIAL AND METHODS

A retrospective study of the patients who were operated upon at our institution with a histologic diagnosis of lipoblastoma from 1966 to 2002 taking into account: age, tumor site, cytogenetic studies, first diagnosis, treatment and clinical course.

RESULTS

The diagnosis of lipoblastoma was carried out in six patients (three boys and three girls). All were diagnosed before the first year of life and one was present at birth. In only one case the diagnosis was pre-operative. Two tumors were thoracic, two paravertebral with an intrarachidian component without spinal cord involvement (one of them was associated with myelomeningocele and diatomyelia), two in limbs and one perineal. A girl operated for the first time at four months, was latter operated in four opportunities for a relapse. In the last operation the excision was incomplete due to a subclavian involvement; in the last 15 years no new tumor growth was seen. After a follow-up period of 1 to 25 years in the other six patients no relapse was observed.

CONCLUSIONS

Despite its low frequency, the diagnosis of lipoblastoma must be considered in children with masses in soft tissue, mainly if they are younger then one year. Because the lipoblastoma is locally invasive, this tumor must be treated before it affects viscera. The resection must be complete, avoiding the risk of relapse, although radical mutilating surgery is not recommended.

[Midgut malrotation risk in abdominal wall defect]

BACKGROUND

Midgut malrotation has a low incidence (0.5-1% at necropsies) and it is a rare symptomatic condition. Nevertheless it is often associated to clinical situations with a high morbility and mortality and it could complicate them. Our aim is to study the patients treated for abdominal wall defects and who have suffered complications due to non-treated malrotation at first surgery.

METHODS

We retrospectively studied the charts of patients diagnosed of abdominal wall defects in our hospital from 1993 to 2002. We reviewed the initial treatment, the associated morbility and any new surgical treatment needed.

RESULTS

During this 10-year period, 110 abdominal wall defects were managed: 56 congenital diaphragmatic hernias, 30 onphaloceles and 14 gastroschisis; overall 79 of these 100 patients survived and were included in this study. Eleven patients had symptoms due to bowel malrotation during the follow-up period. In 1 case the clinical picture had an acute onset as a volvulus that required extensive gut resection; another patient presented as a persistent gastrocutaneous fistula after removal of a gastrostomy tube; in the remaining 9, symptoms were always of classical intestinal obstruction. The malrotation was never treated during the initial surgical procedure for abdominal wall defect; later on, Ladd procedure was always the definitive treatment.

CONCLUSIONS

Due to local conditions during first abdominal wall surgery that limit the evaluation of the malrotation, we must think about it when we find obstructive symptoms any time during life.

[Aggressive conservative treatment remains the best option for oesophageal perforation in children]

Oesophageal perforation (OP) requires prompt and vigorous treatment. In contrast with adult patients in whom surgical closure of perforation is preferred, non-operative treatment has been the usual approach in children. The present report aims at assessing whether this strategy stands the passage of time. We studied retrospectively the charts of patients treated at our institution for OP between 1991 and 2001. Between these years, we treated 19 episodes of OP in 17 patients aged 5.3 +/- 0,94 years. In 9 cases (4 lye burns, 3 oesophageal atresias, 1 bullous epidermolysis and 1 mucocutaneous candidiasis) OP occurred during dilatation of strictures. Foreign body extraction was the cause in 3 cases, and blunt trauma and sclerosis of varices were the causes in 2 cases each. The last child had multiple gastrointestinal perforation during treatment for leukaemia. Subcutaneous emphysema was seen in 7 instances, pneumomediastinum/pneumothorax in 14, pleural effusion in 9, dyspnoea in 9, severe thoracic pain in 1 and pericardial effusion in 1. The diagnosis was intraoperative in only 2 children but the symptoms and imaging signs prompted vigorous treatment within the first 24 hours in 15 instances. One or more pleural tubes were inserted in 11 cases and pericardial drainage was required once. Perforations closed without direct surgery in 18/19 episodes (16/17 children). Five gastrotomies and 2 jejunostomies were performed and several major abdominal operations were necessary to repair concurrent lesions in a child who sustained severe blunt abdominal trauma and in the one with leukaemic perforations. All these patients survive and all recovered oesophageal function although 2 with intractable lye structures ultimately required oesophageal replacement 6 and 10 months after OP. The only patient in whom direct approach for esophageal necrosis after variceal endosclerosis was unavoidable lost her organ and had a replacement after a successful porto-systemic shunt.

CONCLUSIONS

Prompt and aggressive non-operative approach of oesophageal perforations in children allows survival and conservation of the organ and its function in most cases and should remain the first therapeutic choice at this age.

Diagnóstico del schwannoma intracraneal del nervio facial. factores clínicos, radiológicos y valor de la inmunohistoquímica

OBJECTIVE

To analyze the clinical, radiological, and pathological features which may be useful to differentiate intracranial schwannomas of the facial nerve from vestibular schwannomas.

MATERIAL AND METHODS

A retrospective study of 91 patients undergoing surgery with a clinical suspicion of vestibular schwannoma is presented. Clinical and radiological features are analyzed. Immunohistochemistry for neurofilaments was performed in selected cases of unilateral vestibular schwannomas, bilateral vestibular schwannomas, and facial nerve schwannomas.

RESULTS

Facial function was normal in 83% of patients with vestibular schwannoma. Both patients with facial schwannomas had preoperative House-Brackmann grade II facial function. MRI showed no main differences between facial and vestibular schwannomas. A positive immunostaining was found in unilateral vestibular schwannomas, bilateral vestibular schwannomas, and facial nerve schwannomas.

CONCLUSION

There are no specific clinical, radiological, or pathological factors to accurately differentiate schwannomas of the facial nerve from vestibular schwannomas.

[Early esophageal replacement in patients with esophageal atresia]

INTRODUCTION

When primary anastomosis is not feasible in esophageal atresia esophageal replacement is one of the possible options. We report our experience with this approach in patients with long-gap esophageal atresia.

MATERIALS AND METHODS

From 1991 to 2002 we treated 50 children with esophageal atresia. Nine required esophageal replacement because of long-gaps. Six were boys and three girls. Six had isolated atresia, and three had regular atresia with TEF. Associated malformations in 8 patients were: cardiovascular (2), anorectal (2), urogenital (5), intestinal duplication (1), and costovertebral (1). The weight at birth ranged from 1.2 to 3.95 kg (median 2.3). Patients with type I atresia had immediate gastrostomy accompanied by esophagostomy in one. Esophageal anastomosis was impossible or failed in 3 patients with type III EA, who had fistula ligation and esophagostomy. Esophageal replacement was performed at a median age of 4.95 months (range 2.3 to 18), with a median weight of 5.33 (range 2.89 to 11.5 kg.). We used gastric pull-up in 2 cases and colonic transposition in 7 with isoperistaltic left transverse colon in retromediastinal-transhiatal (6) or restrosternal (1) position. Two patients had extramucosal piloromyotomy and 4 had piloroplasty.

RESULTS

All patients survive and have functional grafts. Postoperative complications were: pneumonia (1), wound dehiscence with evisceration (2) and salivary fístula (2) which closed spontaneously. In the long range, one patient was operated three times for hernia through the enlarged hiatus, one had one episode of intestinal subobstruction successfully managed with nasogastric aspiration and another one had dumping syndrome for several months. After a median follow-up of 3.15 years (range 1.6 to 6.9) all patients eat normal diets per os.

CONCLUSIONS

Esophageal replacement for the treatment of infants with long-gap EA has been in our hands as good as any other option with 100% survival and good functional results. The operation can be safely performed in the first months provided that associated malformations are under control. However, like other options, this approach is not devoid of complications.

Aggressive conservative treatment of esophageal perforations in children

BACKGROUND/PURPOSE

In contrast with adult patients in whom surgical closure of the defect is preferred, nonoperative treatment has been the usual approach for esophageal perforation (EP) in children. This report aims to assess whether this strategy stands the passage of time.

METHODS

We reviewed retrospectively the charts of 17 patients aged 5.3 +/- 0.9 years (mean +/- SD) treated at our institution for EP between 1991 and 2001.

RESULTS

Nineteen episodes of EP were caused by stricture dilation in 9 cases, foreign body extraction in 3, and blunt trauma and sclerosis of varices in 2 cases each. The remaining child had multiple gastrointestinal perforations in the course of chemotherapy for leukemia. Vigorous treatment, consisting of nasopharyngeal aspiration, wide spectrum antibiotics, prompt drainage of effusions and either parenteral or infraesophageal nutritition, was implemented immediately after diagnosis. Perforations were closed without direct surgery in 18 of 19 episodes (16 of 17 children). One or more pleural drains were inserted in 12 cases, and pericardial drainage was required once. Seven gastrostomies, 2 jejunostomies, and one esophagostomy were performed. Several major abdominal operations were necessary to repair concomitant lesions in a child who sustained severe blunt abdominal trauma and in the patient with leukemic perforations. All patients survived, and all recovered esophageal function. However, 2 with intractable lye strictures ultimately required esophageal replacement. The only patient in whom a direct approach for esophageal necrosis due to variceal endosclerosis was unavoidable, lost her organ and had a retrosternal colonic interposition after a successful portosystemic shunt. Excluding patients with other concomitant lesions and the patient who underwent surgery, median length of stay was 11 days (range, 6 to 47).

CONCLUSIONS

Prompt and aggressive nonoperative treatment of esophageal perforations in children allows survival with conservation of the organ in most cases and remains, in the authors' hands, the first therapeutic choice at this age.

The contribution of modern imaging to planning separation strategies in conjoined twins

BACKGROUND/AIM

An accurate knowledge of the often complex and unexpected anatomy of conjoined twins is required in order to devise appropriate surgical strategies for separation. The recent progress of imaging techniques prompts an assessment of their contribution to planning separation strategies.

MATERIAL AND METHODS

From 1990, we treated 8 consecutive sets of conjoined twins: 1 acardiac-acephalus, 1 epigastric heteropagus, 2 omphalopagus, 2 omphalothoracopagus, 1 ischiopagus tetrapus and 1 parapagus tripus. The first two sets were separated straightforwardly after birth and were excluded. Ultrasonographic and plain and contrast X-ray studies were used in all the remaining sets, angiography in 5, CT in 4, and MRI in 4. Helical CT and magnetic resonance angiography (MRA) were used in 3 sets.

RESULTS

Two sets of omphalopagus twins and one of omphalothoracopagus twins were separated after birth due to brain damage of one twin, cloacal exstrophy and large arterial shunting, respectively. They were assessed using barium studies (3 sets), IVP (3), angiography (2), CT (2) and MRI (1). Three of six babies survived after separation. In the second set of omphalothoracopagus ecocardiography and MRA revealed that the extent of cardiovascular sharing precluded separation. In the remaining two sets of twins respectively ischiopagus and parapagus, the extent of organ sharing was depicted using three-dimensional helical CT and MRI; the four babies are alive after separation.

CONCLUSIONS

Conventional imaging contributes only modestly to separation planning. In contrast, advanced imaging techniques are amazingly efficient in depicting complex fusions that have to be accurately recognised when planning realistic separation strategies.

[Extensive aganglionosis. Treatment and long term results]

INTRODUCTION

Extensive aganglionosis (EA) that affects the total colon (including or not part of the small intestine), shows more diagnostic problems and it is associated to higher morbidity and mortality rates than the classic cases of Hirschsprung disease (ED). This study takes into account last years cases and their results in the medium and long term.

MATERIAL AND METHODS

Between 1983 and 2000, 232 patients suffering ED have been treated. 15 out of those 232 patients showed EA. We took into consideration the diagnosis, surgical procedures, enterocolitis before and after the treatment, the surgical technique and the complications. We analyze the nutritional state and the long term result according to clinical bowel function scoring system continency Scale, considering the surgical possibilities depending on each case.

RESULTS

Two patients died due to septics complications, one of them during the neonatal period and the other one at the age of 3. Two other cases became possible candidates to an intestinal transplantation due to the extension of their disease. Five out of the 11 left patients had more than 30 cm of small intestine involved, and another five had involved less than 30 cm from ileocecal valve. The last case showed a total colonic aganglionosis with associated intestinal neuronal displasia. One case was associated with S. Ondine and another one with a 21 triosomia. Two of the patients were brothers and another patient has got a brother suffering from rectosigmoid HD. The surgical techniques used with 13 were: 8 cases using Lester Martin modification (one of them needed redo procedure because of anastomosis leak and perineal fistula), 4 Swenson procedure and one patient was treated by Ziegler's miectomy with prolongated miotomy. Nine of the patients mentioned before, lead a quite life (five L, Martin, 4 Swenson); 2 patients suffering frequent fecal retention crisis. 5 out of the 11 reviewed cases, show a weight and height p > or = 50, 2 below p50, 2 below p25, and 2 under p3.

CONCLUSION

EA represents a small percentage of Hirschsprung disease. Although Martin modification is the most widely employed technique in cases of distal ileal involvement, Swenson procedure has provided good results in the long term follow-up with few complications. Intestinal transplantation may be the only choice for long term survival in patients with near total intestinal aganglionosis. Continence improves in the follow-up but few times is normal. Nutritional state should be-controlled by a specialized team.

[Cervical recurrence in the pathologically negative neck (pNO): finding a needle in a haystack]

Recurrence in the pathologically negative neck (pN0) is one of the most striking events occurring in head and neck tumors. It is not even mentioned in many neck dissection studies. The presence of micrometastases has been suggested as an explanation for this event. In accordance to a recent study performed in our institution, we bring up this controversial issue. A definitive explanation for recurrence in the pN0 has not yet been proposed.

[Is hearing preservation feasible with the retrosigmoid approach?]

The main advantages of the retrosigmoid approach are fast and good visualization of the brainstem structures and the possibility to remove tumors of all sizes. Hearing preservation, although possible, is not always achieved. The aim of this study is to present our experience with the retrosigmoid approach for acoustic neuroma resection, emphasizing our hearing results. The notes of 56 cases of acoustic neuroma removed through a the retrosigmoid approach were reviewed. Tumor size ranged from 8 to 50 mm (mean 24 mm). Considering patients with preoperative serviceable hearing, postoperative serviceable and measurable hearing was achieved in 13.3% and 26.7% of cases respectively. No tumor recurrence occurred in our series. The retrosigmoid approach is a reliable surgical procedure for most vestibular schwannoma. However, hearing preservation results may be unsatisfactory and show wide differences depending on selection criteria and the hearing terminology used. Concerns about hearing preservation should not be the deciding factor for using this approach.

T3 glottic cancer: oncologic results and prognostic factors

OBJECTIVES

To analyze oncologic results, prognostic factors, and consideration of transglottic tumors as a separate entity in 73 patients with T3 glottic carcinoma treated by surgery +/- radiation therapy at La Paz University Hospital from 1984 to 1994.

METHODS

Sixty-four patients underwent a total laryngectomy; neck dissection was performed in 50 patients; 29 patients received postoperative radiotherapy.

RESULTS

The 5-year overall survival, cause-specific survival, and relapse-free survival rates were 58.1%, 66.8%, and 63.7%. Univariate analysis revealed prognostic significance for age, dyspnea, initial tracheostomy, and pathologic lymph node status. No difference was found when comparing survival and relapse rates between transglottic and glottic tumors.

CONCLUSION

Surgery provides acceptable rates of cancer control and survival for patients with T3 glottic carcinoma. Older patients, patients with positive neck nodes, and those presenting with dyspnea have worse prognosis. The term transglottic is merely descriptive and has little impact on prognosis.

p53 expression in locally advanced pharyngeal squamous cell carcinoma

BACKGROUND

Prognosis for advanced head and neck squamous cell carcinoma remains poor despite advances in treatment, although a small number of patients may benefit from induction therapy leading to increased local control. Mutations of the p53 gene, which are present in a considerable percentage of head and neck squamous cell carcinomas, have been associated with poor response to chemotherapy. The role of p53 protein overexpression (which is associated with p53 gene mutations) in predicting the response to chemotherapeutic agents and survival rates is not clear.

OBJECTIVE

To determine the association of p53 expression with chemotherapy response rates and disease-free survival rates in 62 patients with locally advanced pharyngeal cancer treated with induction cisplatin-5-fluorouracil chemotherapy between 1983 and 1995.

DESIGN

Historical cohort. Archival tissue from biopsies done before chemotherapy was immunohistochemically stained for the p53 tumor suppressor gene (clone D0-7; DAKO Corp, Glostrup, Denmark).

RESULTS

Positive staining for p53 occurred in 45 (73%) of 62 cases, with the percentage of reactive cells ranging from 35% to 98%. Chemotherapy response rates were higher in the p53-negative group (15/17 [88%]) compared with the p53-positive group (27/45 [60%]) (P =.07). The risk of recurrence was lower in the p53-negative group compared with the p53-positive group at 2, 3, and 5 years after treatment (P = .03, P = .01, and P = .007, respectively). The median relapse-free survival rates of patients in the p53-negative group was 16 months, whereas those with p53 protein expression demonstrated a median relapse-free survival time of 9 months (P = .07). In multivariate analyses, the only independent factor of relapse-free survival rates was age older than 70 years.

CONCLUSION

The present study shows a trend favoring p53 overexpression as a predictive and prognostic factor in locally advanced pharyngeal cancer treated with induction chemotherapy.

[Detection of p53 protein in advanced head and neck cancer]

P53 protein expression, synonymous to p53 gene mutation, is a common event in head and neck squamous cell carcinoma (HNSCC). However, the correlation between p53 expression and clinico-pathologic parameters remains unclear. Primary tumors for analysis were obtained from 99 patients with HNSCC. The expression of p53 was analyzed with monoclonal D07 antibody (Dako Corp., Glostrup, Denmark). Seventy five percent of 79 valid cases expressed the protein. A correlation was found between alcohol intake and p53 expression. None of the other clinico-pathologic factors were associated to p53 expression. Our results suggest that p53 may be involved in the development of HNSCC. However its clinical significance is still not completely understood.

Intestinal lengthening and growth hormone in extreme short bowel syndrome: a case report

Recombinant growth hormone (GH) has been used successfully to promote mucosal intestinal adaptation in adults with short bowel syndrome. Here the authors report the case of an infant with extreme short bowel syndrome successfully treated with intestinal lengthening and GH. The patient was born with intestinal atresia leaving only 12 cm of jejunum and 2 cm of ileum with ileocecal valve. A Bianchi procedure extended the length to 25 cm, but 6 months later she still received 50% of her nutritional requirements by parenteral route. A 4-week course of 0.5 U/kg of GH dramatically changed the situation allowing weaning of total parenteral nutrition (TPN) 2 weeks after the end of the treatment with striking nutritional improvement, decrease in the number of stools from 7 to 2 per day, and no secondary effects. The authors believe that GH deserves clinical trial in cases of extreme short bowel.

[Tissue adhesives in closing of fistulas after surgery of esophageal atresia]

AIMS

Recurrent tracheoesophageal fistula is a severe postoperative complication after esophageal atresia repair. Endoscopic obliteration with tissue adhesives has been used as an alternative to reoperation. The aim of this study is to review our experience with such procedure.

MATERIAL AND METHODS

The medical records of 415 esophageal atresia patients were retrospectively reviewed in order to analyze the incidence of complications and the outcome of patients in whom tissue adhesives were used to close a recurrent tracheoesophageal fistula.

RESULTS

334 patients underwent an esophageal anastomosis and fistula closure or fistula division alone, 41 (12.3%) of them had recurrent tracheoesophageal fistula. In eight of these patients and one having an H type tracheoesophageal fistula, endoscopic obliteration using tissue adhesives was attempted. None of these nine children cured after this procedure and all required an open procedure for their recurrent tracheoesophageal fistula.

CONCLUSIONS

Contrary to some published cases, we have not succeeded with endoscopic obliteration of recurrent tracheoesophageal fistula using tissue adhesives; therefore, we do not recommend this treatment.

Immunoreactivity in granular cell tumours of the larynx

OBJECTIVE

To elucidate histogenesis and behaviour of laryngeal granular cell tumours (GCT) and to determine the role of p53 protein expression in these lesions.

METHODS

The clinical, pathological and immunohistochemical findings of three cases of laryngeal GCTs are described.

RESULTS

All tumours were surgically excised and appeared histologically benign. Pseudoepitheliomatous hyperplasia, mitosis and nuclear pleomorphism were not found in any of the three cases. All lesions were negative for keratin 8, desmin and actin. Only one case stained for collagen IV. Positive staining was found for S-100 protein and CD68 in all tumours. Ki-67 and Bcl-2 staining was confined to occasional cells. p53 reactivity was seen in all tumours; positivity ranged from 35 to 42%. The three patients have remained free of disease without complications up to 10 years after treatment.

CONCLUSION

Immunohistochemical findings support benign behaviour and a Schwann cell origin for laryngeal GCT. The expression of p53 by granular cells is unclear but appears to be unrelated to behaviour.

[Respiratory malformations associated with esophageal atresia]

AIMS

Since trachea, lungs and esophagus develop from foregut and esophageal atresia is a defect of its normal division, we examined the occurrence of respiratory malformations in a large clinical series of esophageal atresia.

MATERIALS AND METHODS

The records of 415 patients born with esophageal atresia between 1965 and 1996 and 129 autopsies of the same patients were retrospectively reviewed. The presence of other associated anomalies was carefully studied and noted.

RESULTS

Of 415 patients with esophageal atresia, 25 (6%) had one or more associated respiratory malformations. Only 8 patients (2.8%) having bronchopulmonary malformations were diagnosed clinically (8/286) while 17 (13.2%) were diagnosed at autopsy (17/129). The most frequent malformations were: lung segmentation defects (n = 14), pulmonary hypoplasia (n = 9) and tracheomalacia (n = 4). Eighty percent of esophageal atresia patients had another associated malformations specially of the cardiovascular system.

CONCLUSIONS

Esophageal atresia patients have a high incidence of associated bronchopulmonary malformations that are frequently not diagnosed.

[Acute suppurative thyroiditis secondary to fistula of the pyriform sinus]

Acute suppurative thyroiditis is very rare and often related to congenital abnormalities of the branchial pouches or immunodeficiency. A case of acute thyroiditis due to fistula of the left pyriform sinus in a young man with no relevant history is reported. We review the embryology, diagnosis, and treatment of this rare entity.

Synchronous glottic granular cell tumor and subglottic spindle cell carcinoma

We report the clinicopathologic findings in a case of coexistent glottic granular cell tumor and subglottic spindle cell carcinoma. There is no evidence in this case that suggests malignant transition of the granular cell tumor to malignant tumor. To our knowledge, this is the first report of synchronous granular cell tumor and subglottic spindle cell carcinoma.

[Multiple symmetrical lipomatosis. Report of a case and literature review]

A case of benign, symmetrical lipomatosis is presented. The clinical aspects of this entity are discussed and points of interest in the head and neck are noted.