[PEG versus LAP: towards a safer technique for long-term enteral nutrition]

OBJECTIVE

To compare the outcomes and complications between laparoscopic gastrostomies (LG) and percutaneous endoscopic gastrostomies (PEG).

METHODS

Retrospective review of 79 patients who had their gastrostomies inserted in our hospital (2010-2017). We compared surgical techniques, minor and major complications.

RESULTS

A total of 24 LG (14 males) and 55 PEG (29 males) were performed. The mean age was 4.77 [0.15-15.56] years for LG and 5.37 [0.12-16.58] years for PEG. The median time of presentation of complications was 59 [2-975] days. No statistical differences were found in minor complications between both techniques; however, minor complications were more frequent in LG (54.16% in LG versus 34.55% in PEG), mainly, overgranulation and peristomal leakage. A statistically significant association was found between patients with oncological comorbidity and minor complications (p<0.05).A statistically significant association was found between major complications and PEG (4.17% in LG versus 21.82% in PEG), p=0.045. The major complications were one tube dislodgement in the LG group, and 9 Buried-Bumper syndrome, one colon interposition without perforation, one colon perforation, one omentum interposition, two tube dislodgements and one small bowel perforation in PEG group.

CONCLUSIONS

Given the statistically significant association between major complications and the PEG group, being the higher frequency and severity of these complications with this technique evident; we consider the LG a safer technique. However, studies with larger number of patients and multicentric are necessary.

[Is there an ideal patient for transumbilical laparoscopic assisted appendectomy?]

OBJECTIVES

To identify the factors that lead to postoperative morbidity in acute appendicitis patients treated using a TULAA (Transumbilical laparoscopic assisted appendectomy) approach.

MATERIAL AND METHODS

Retrospective review of patients treated through a TULAA approach between 2007 and 2014. Data concerning the location of the appendix, need for conversion, appendiceal abscess or perforation, surgical time and other complications were collected. Student's T test and Chi-squared test were used for statistical analysis.

RESULTS

A total of 111 appendectomies underwent TULAA. The average operating time was 79 minutes (45-150). Nonperforated appendicitis was found in 90% of patients with 10% having perforated appendicitis or appendiceal abscess. In 35,13% of cases, additional trocars were used, usually when the appendix was in a retrocecal position (89,5%). When the appendix was found in a pelvic or ileal position, a need for extra trocars decreased to 25.9% (p< 0.05). The surgery was converted to open surgery in 6,3% of the cases. The appendix in a retrocecal position had a conversion rate of 20,8% compared to 2,3% of cases with an appendix in a pelvic location (p< 0.05). A total of 3,6% reported postoperative wound infection, possibly caused by perforation of the appendix during extraction (p< 0.05). All the perforated appendixes were considered complicated appendixes.

CONCLUSIONS

The retrocecal location of the appendix is associated with the need to install additional trocars or conversion to open surgery. The TULAA approach is ideal for patients with nonperforated acute appendicitis in a pelvic or ileal location.

[Functional outcomes in postsurgery for Hirschsprung´s disease]

OBJECTIVE

To analyze functional outcomes of patients operated for Hirschsprung's disease (HD).

METHODS AND MATERIAL

Retrospective study of patients with HD (2000-2014). We analyzed surgical technique, age at diagnostic and treatment, amount of resected bowel, complications and their influence on functional outcomes.

RESULTS

Of the 44 diagnosed with HD, 37 were operated in our center. Men 29 (78.4%). With associated pathology 7 (18.9%), and 5 (13.5%) made their debut with enterocolitis. Diagnostic average age 1.04 (0.0 to 7.1 years) and operation average age 1.4 (0.3 to 9.3 years). We did transanal endorectal pull-through (TERPT) in 17 (45.9%) patients and transabdominal approach (TAB) in 20 (54.1%). Received postoperative dilations 8 (21.6%) patients. Functional outcomes were evaluated at an average age of 9.6 (4.7-15.7years) incontinence/soiling were found in 6/28 (21.4%) and constipation in 5/28 (17.9%). The highest rate of incontinence/ soiling was present in 41.7 % TERPT vs. 6.2% TAB (p= 0,036). However, the average age at follow-up in patients with incontinence/soiling was 5.9 ± 1.3 years old, less than the 10,6 ± 3.2 years in the ones without incontinence/soiling (p< 0,001). We found that the 5 cases of constipation arose in patients with TAB (p= 0, 044), and likewise all were operated under 1 year of age.

CONCLUSION

Despite the well known benefits of the TERPT over the TAB, we found a greater degree of incontinence/soiling in the TERPT, which could be explained by a less follow up, since incontinence/soiling improves with age. On the other hand there is a higher rate of constipation in the TAB that lasts in time.

[Analysis of hypertrophic pyloric stenosis: size does matter]

OBJECTIVES

To analyze the correlation between pyloric size and evolution of patients surgically treated for infantile hypertrophic pyloric stenosis (IHPS).

PATIENTS AND METHODS

We realized a retrospective study of 109 patients undergoing IHPS in 5 years. We analyzed by χ2 test if a correlation between evolution time, age and postoperative vomiting and gastroesophageal reflux disease (GERD), and pyloric muscle thickness (group A > 4.5 mm and group B ≤ 4.5 mm) and pyloric channel length (group A ≥ 20 mm and group B < 20 mm) exists.

RESULTS

There is a statistically significant correlation between longer evolution history (>48 h) and pyloric length ≥ 20 mm and between age (> 30 days) and muscle thickness > 4.5 mm (p= 0.022 and p= 0.009, respectively). Also, 38.5% of 109 patients had postoperative emesis 2 days after surgery and 13.8% had GERD for a median time of 8.27 months (1-12 months), showing that there is a statistically significant correlation (p= 0.007) between pyloric channel length ≥ 20 mm and postoperative emesis. It was not observed correlation between pyloric thickness and length and GERD.

CONCLUSIONS

It has been observed that there is correlation between pyloric length ≥ 20 mm and postoperative emesis. However, it has not been observed regarding the pyloric muscle thickness. A longer preoperative evolution and age > 30 days are correlated to channel length ≥ 20 mm and muscle thickness > 4.5 mm, respectively.

[The diagnosis of pilomatrixoma in children is not as easy as it may seem. A review of 126 cases]

OBJECTIVE

To describe our experience with pilomatrixomas, clinical presentation, clinical accuracy, associated diseases, and surgical treatment.

METHODS

A retrospective review of patients with a pathology report of an excised pilomatrixoma between 2011 and 2014. Data regarding gender, age of intervention, number of masses, size, location, and preoperative clinical diagnosis, pathology report, recurrences, and associated diseases were collected. Statistical analysis was performed using EPIinfo 7.1.5.

RESULTS

A total of 151 tumors in 138 patients were removed, 25 were excluded for having a clinical diagnosis of pilomatrixoma without confirmation of the pathology report. The remaining 126 cases have an average age of 8.26 years (range 1-14 years) and 50.72% are males. The tumors were located above the umbilicus in 97% of the cases, with a higher concentration of 50.72% in the head and neck. The clinical diagnosis corresponds with the pathology report in 69.05% of cases. Out of these confirmed cases the most frequent differential diagnosis is cystic lesion (11.90%) and dermoid cyst (10.22%). There were no cases of malignant degeneration. The average diameter is 1.13 cm, there were no recurrences, but there were 11 cases of a new lesion in a different location. There is no statistical association with other pathologies. The most frequent diseases found were obesity (3.62%) and attention deficit syndrome (3.62%).

CONCLUSION

The pilomatrixoma is a tumor that appears predominantly in the head and neck, and has a difficult clinical diagnosis. Complete removal is curative, although it does not prevent the appearance of new lesions.

[Intestinal stomas. Are they as simple as they seem?]

OBJECTIVES

To examine the morbidity and mortality of the formation and closure of enterostomies.

METHODS

Retrospective study between 2000-2014 of patients younger than 14 years old who underwent an enterostomy. We evaluated: surgical technique, underlying pathology, general and stoma complications, sex, age and weight at the time of formation. At the closure we evaluated: surgical technique, age, weight, hemoglobin, hematocrit and albumin, as well as complications.

RESULTS

We performed 120 enterostomies in 114 patients: 69 (57.5%) colostomies, 43 (35.8%) ileostomies and 8 (6.7%) yeyunostomy. The most frequent causes were: anorectal malformation (45/69), necrotizing enterocolitis (24/43) and intestinal atresia (4/8) respectively. 39 (32.5%) complications related to the stoma (colostomy 21, Ileostomy 15, Yeyunostomy 3; p= 0.845), 11 (9.2%) required surgery (colostomy 8, Ileostomy 2, Yeyunostomy 1; p= 0.439), and 17 (14.2%) general complications (colostomy 9, Ileostomy 7, Yeyunostomy 1; p= 0.884). We found a higher rate of complications requiring surgery in loop enterostomy 8/38 (21.1%), separated 3/54 (5.3%) or double-barrel 0/25 (p= 0.007). We closed 96 (80%), presenting complications in 14; yeyunostomy 4/6 (66.7%), colostomies 5/59 (8.5%), ileostomies 5/31 (16.1%) (p= 0.001). Hematocrit and hemoglobin below age average, and albumin under normal values are associated with complications when closing enterostomies (p< 0.05). Six patients (25%) who didn't went to closure died as a result of the underlying pathology and 5 (20.8%) of other causes.

CONCLUSION

The formation and closing of enterostomies remains a procedure with a high rate of complications. However, there are no clear risk factors, excepting the use of loop enterostomy and lower albumin, hemoglobin or hematocrit at the time of closure.

[Clinical assessment of fecal incontinence in patients with anorectal malformation surgery]

BACKGROUND/PURPOSE

To review our management of anorectal malformations (ARM) and to compare two quantitative scales for clinical assessment of fecal incontinence.

MATERIAL AND METHODS

We reviewed all patients with ARM surgery who are currently 3 to 15 years old. Several variables were collected and fecal incontinence was evaluated using two scales: the Holschneider scale and one used previously in our Service, both were filled out through clinical interview.

RESULTS

48 patients were studied, 29 males and 19 females. According to the Peña's classification, 81% had good prognosis indicators (group A) and 19% had bad prognosis indicators (group B). Posterior sagittal anorectoplasty (PSARP) was performed in 32 patients, PSARP and abdominal approach in 3, abdomino-perineal pullthrough in 2, and a "Cut-back" anoplasty in 14 patients. There were not statistical significative differences in average age of continence between both groups. We found no significative differences on the average score of fecal incontinence between both groups using our scale (17.57/20 in group A vs 14/20 in group B; p= 0.05) but it was significantly lower in group B using the Holschneider scale (12.39/14 in group A vs 10.43/14; p= 0.04). Constipation was detected in 16 patients, half of whom had overflow pseudoincontinence.

CONCLUSIONS

Our scale penalizes constipation, for this reason the average score of group A was lower and we didn't find differences with respect to group B, contrary to what it happened using Holschneider's scale, so we believe our scale could be more precise to evaluate fecal incontinence of these patients.

[Puberal gynecomastia: a comparison between the inferior periareolar approach and the concentric circle technique]

BACKGROUND/PURPOSE

The main reason to indicate the surgical treatment in pubertal gynecomastia is the psychological effect on the adolescent. The aim of this paper is to describe our experience in the surgical treatment of this condition, comparing the results obtained depending on the type of approach used.

MATERIAL AND METHODS

In our department, the approach for the subtotal mastectomy depends mainly on the gynecomastia grade. We use an inferior periareolar incision in grades I and II, and a concentric circle technique in grade III of Simon's classification. A retrospective review was conducted to identify all adolescent patients that underwent to gynecomastia surgical treatment between 2007 and 2012. We compared the results obtained in each incision group by parametric statistical tests,

RESULTS

A total of 29 mastectomies were performed in 15 patients. The mean age of surgery was 13.75 +/- 1.06 years ([11-15] years). The presentation in all cases consisted in a progressive increase in size of the mammary gland, without associated symptoms. In half of patients there was a history of obesity or overweight. We performed the concentric circle technique in 5 patients (CCT-group) and inferior periareolar incision in 10 (IPI-group). There was a higher incidence of pathologic scarring in the CCT-group, and this difference was statistically significant (p = 0.007). No recurrences were observed after a mean follow-up of 15.86 +/- 19.47 months ([3-60) months).

CONCLUSIONS

Long term results were satisfactory in both groups. Despite of the higher incidence of hypertrophic and keloid scars observed in concentric circle technique, it remains aesthetically advantageous in cases of gynecomastia with extra skin.

[What can we do to improve our management of intestinal atresia?]

OBJECTIVE

To review our management of intestinal atresia (AI).

MATERIAL AND METHODS

A retrospective review of patientes with AI, from 1995 to 2011.

RESULTS

AI was identified in 41 patients, 29,2% had maternal polyhydramnios and 48,7% were diagnosed prenatally. Four of them had Down Syndrome and 18 had cardiopathy. Duodenal atresia-stenosis (AD) was present in 21 patients, that were treated by 19 duodenoduodenostomy, 1 duodenojejunostomy and 1 duodenotomy with duodenal membrane resection. Jejunoileal atresia (AYI) was present in 20 patients and we performed 15 end to end anastomosis, 1 íleo-colic anastomosis, 1 ileostomy, 2 jejunostomies and 1 end to end anastomosis with jejunostomy. Nine AYI were reoperated: 6 bowel obstructions, 1 evisceration and 2 colo-rectal atresia. The average time on parenteral nutrition was 29 days and average hospital stay was 37,3 days. One AD died due to heart disease. In AYI, 2 required transfer to another center due to short bowel.

CONCLUSIONS

Prenatal diagnosis of AI is difficult, especially AYI, which is only prenatally diagnosed in 35% of cases. AD respond better to surgery and rarely require reoperation, but mortality is higher than AYI because 57% suffer from heart disease. Reoperations are frecuent in AYI (45% of our patients), usually due to obstruction, ostomy closure and problems resulting from extensive bowel resections. It's important to keep in mind colorectal atresias, which can not be identified.

[Assessment of nutritional status in esophageal atresia]

OBJECTIVE

The aim of the study was to find out whether patients who underwent esophageal atresia (EA) surgery suffered from nutritional problems, to compare the nutritional status of these patients with a control group, and to determine if there is a relationship between the type of atresia and the nutritional condition.

MATERIAL AND METHODS

We selected 25 patients out of a total of 32 who underwent EA surgery in our hospital from 2000 to 2006. A retrospective was conducted study based on the information obtained from the medical histories. A case-control study was also carried out by selecting a control group from a randomized population.

RESULTS

The analyses performed showed that the mean weight and height Z-score was always negative, but not below -2 SD. There was a significant decrease in the weight Z-score between 3 and 9 months and in the weight/size Z-score between 3 and 24 months. Significant differences in weight and size Z-score were found between cases and controls, but not in skin-fold thickness. Independently of the type of atresia and the presence or not of congenital heart defects, no significant differences were found.

CONCLUSIONS

There are significant differences in the weight and height Z-score between cases and controls. We stress the need to be aware of the nutritional status in order to prevent changes that could lead to a further deterioration of the patient.

[Our experience in the poly-traumatized pediatric patient with criteria for admission to the ICU]

OBJECTIVE

To present our experience with severe pediatric trauma. The pediatric trauma is the leading cause of death in children under 2 years.

METHODS

We achieved a retrospective study from 78 pediatric patients admitted to the Intensive Care Unit (UCI) for multiple trauma between 2000 and 2008. Age, sex, season, location, mechanism, Glasgow and ITP, type of injuries, complications, days of hospitalization and deaths were reviewed. It was performed descriptive and analytical study using the SPSS 15.0 and chi square and Pearson correlation were applied.

OUTCOMES

The mean age of patients was of 8.5 +/- 4.2 years with 70% boys. Most accidents occurred in summer (37%) and the most common site was the road (47%). There was 15% of mortality, which the 75% occurred in the first 24 hours. There is an association between abdominal trauma and type of mechanism (p < 0.05). The most common mechanism was the traffic accident (45%) followed by a direct hit. Both ITP as Glasgow score were associated significantly with mortality and complications and with the hospital stay in the UCI there was a weak association but significant and negative (p < 0.05).

CONCLUSIONS

Mortality is higher than other series but it may be because that these series include minor injuries. The fall down is the most frequent in pediatric emergencies but it was the mechanism that involves less admission to the UCI. Both ITP as Glasgow score are good indicators of severity and if their values decrease, the hospital stay in UCI and the mortality increase.

[The PEG: why wait?]

The swallowing disorder is an impediment to feed the patient. The percutaneous endoscopic gastrostomy (PEG) offers importants advantages over nasogastric tube feeding in patients who need long-term enteral nutrition with difficulty to swallow and to failure to thrive.

METHODS

We have achieved 40 PEG in our department over the past 10 years. We registered date of the age, weight, indications, types of PEG, the time to first change, evolution of weight and percentiles and the complications.

RESULTS

The average age of our patients was 5 years, 30% under 1 year. We used mostly tubes between 9 and 15 Fr and increasing the size according to nutritional needs. The average weight at the time of PEG placement was 13 kg. The main indications were the impossibility to swallow and failure to thrive and the principal diagnosis was the encephalopathy in 45% of cases. The surgical technique was successful in 100%. Of the complications, only two patients required surgery, a gastrocolic fistula and a laparotomy about broken tube of gastrostomy that has been caught in the cecum. In our series we reported 11 cases of mortality from causes unrelated to the gastrotmy.

CONCLUSIONS

The PEG is a good alternative to nasogastric tube in patients with swallowing disorders or failure to thrive in chronic diseases, even in children under one year. The early placement of the PEG support the growth development in these patients with chronic disease who require enteral nutrition for long periods. Probably, the time of placement should be more precocious in chronic patients as well tolerated and may have a long life with a good care.

[Differential diagnosis of the interlabial masses in girls under 5-years-old]

The masses that we can be found at interlabial in a girl are a extensive spectrum of heterogenous lesions and often there is a confusion in diagnosis, management and prognosis.

METHODS

We present 5 cases of interlabial masses, prolapsed urethra, two paraurethral Skene cysts, botryoid sarcoma and fibroepithelial polyp, and its clinical of debut.

RESULTS

A prolapsed urethra is presented in a 4-year-old black girl with vaginal bleeding from edamatous periurethral mass. The paraurethral cyst is a yellowish cystic mass displacing the urethral meatus in two newborn girls. The fibroepithelial polyp is presented in a newborn girl as polipoid and wartlike tumor and not bleeding injury in the introitus. The botryoid sarcoma appears in a 1-year-old girl with ulcerated polypoid mass of 2 cm from vagina. All cases were treated with surgery except the paraurethral cyst that drained spontaneously and the rhabdomyosarcoma was also treated with chemotherapy.

CONCLUSIONS

There must be a good clinical examinations about interlabial masses distinguishing genital or urological origin. The surgery is indicated mainly to reject malignancy because the presentation of sarcoma and polyp could be similar. The prognosis of rhabdomyosarcoma vaginal is good with surgery and chemotherapy. The prolapsed urethra is more common in prepubertal black girls and it is important to exclude sexual abuse. The management of paraurethral cyst is controversial but some authors are advised first observation because they may regress.

[Pancreatic pseudocyst: less is more]

Pancreatic pseudocysts (PQP) are rare in childhood and management tends to be individualized and controversial, and it is a challenge for the pediatric surgeon. The aim of this study is to determine the best management strategies in each patient.

MATERIAL AND METHODS

Retrospective review of children admitted to our institution with the diagnosis of PQP and review of literature between 1990 and 2007.

RESULTS

We report two children with postraumatic PQP that respond to non-operative management and 284 cases that were reported in literature (76% after blunt abdominal trauma). 26% of these patients had complete resolution of PQP with conservative management and the others patients required surgical intervention: external percutaneous drainage (18.6%), non-percutanueous external drainage drenaje (3.87%), cystogastrostomy (28.87%), cystojejunostomy o pancreaticojejunostomy (9.5%), endoscopic drainage (9.5%) or distal pancreatectomy (3.5%).

CONCLUSION

The choice of treatment depends on the surgeon's experience and management of the endoscopic techniques, as well as the availability of interventionist radiology. Asymptomatic PQP in children does no require any specific intervention other than expectant management, especially in patients with trauma-induced PQP. Children with persistent clinical symptoms or those who developed complications may require further intervention.

[Must we change the surgical treatment of gallstones?]

The incidence of gallstones in childhood is 0.15%-0.22%. Frequency has increased in recent years due to a real increase or to a better diagnosis by ultrasound. The aim of our study is determinate the best treatment for every patient.

MATERIALS AND METHODS

A retrospective study of 71 children with cholelithiasis admitted to our hospital in the last 20 years.

RESULTS

The male to female ratio was 43:28. Seventeen patients present predisposing factors that might be related to the formation of gallstones. This disease was a casual event in half the cases. In 24 patients the diagnosis was made during a study for inspecific abdominal pain and 14 children showed typical symptoms. Only one patient suffer from acute cholecystitis. In 21 cases we find a single stone and in the other cases there were a lot of stones. The gallstones disappeared spontaneously in two patients. Nine children received treatment with ursodeoxycholic acid, but this treatment was ineffective in 8 of them. 27 patients were operated: Six laparoscopic cholecystectomy, 9 open cholecystectomy, 9 cholecystolithotomy and 3 cholecystectomy with splenectomy.

CONCLUSIONS

We recommend periodic checks with ultrasound and conservative management is suggested in asymptomatic children. Operative intervention is recommended for symptomatic patients. The surgical treatment of choice in our centre for patients with solitary gallstones and without inflammatory changes in the gallbladder is cholecystolithotomy. We didn't find reappearence of gallbladder after cholecystolithotomy. Laparoscopic cholecystectomy is the best treatment for children with non working gallbladder, "porcelain gallbladder" and in patients with haematologic disease and gallstones.

[Morphologic evaluation of fecal incontinence by magnetic resonance imaging in patients with corrected anal atresia]

PURPOSE

To describe the findings obtained with magnetic resonance imaging (MRI) in patients with ano-rectal atresia, after treatment by posterior sagittal anorectoplasty (PSARP), who have fecal incontinence and to describe its usefulness in the evaluation of causes of incontinence.

SUBJECT AND METHODS

Twelve patients, 9 men and 3 women, with anorectal atresia were examined with 0.5T MRI after performing PSARP for imperforate anus. The study included T1-weighted, T2-weighted and proton-density, axial, sagittal and coronal planes. The location of descended neorectus and the degree of development of pelvic musculature were evaluated.

RESULTS

Normal development of anus levator muscles and sphincterian complex were observed in six patients, with correct situation of neorectus between anus levator muscles and sphincterian complex in five of them and eccentric in the other one. Diverse grades of striate muscular complex underdevelopment were showed in the other six cases, moderate grade in four of them and severe hypoplasia in the other two. Spinal and urogenital congenital anomalies were found in these patients. Sagittal and coronal T1-weighted MR images were the most useful planes in evaluating the relationship between anus levator muscles and sphincterian complex and axial T1-weighted MR images in the evaluation of the level of development of striated muscle complex in the evaluation of patients.

CONCLUSIONS

MRI is useful in the evaluation of patients with fecal incontinence after performing PSARP for anorectal atresia. Unsuitable neorectus position or striated muscle complex hypoplasia are causes of postoperative incontinence in these patients.

[Foreign body aspiration in children]

The aim to this study is evaluate the history, symptoms, radiographic and endoscopic findings in 420 children who were admitted for suspected foreign body aspiration in our hospital between 1972 and 2005. In 13 children we didn't find foreign body and in 16 children the foreign bodies were lodged in larynx. The mean age was 33 months. The medical history, phisical exploration, auscultation and radiological findings were positive in 91,4%, 78,3%, 91,6% and 81%. The frecuency or foreign body aspiration is undervaluate and sometimes is excluded as diagnosis. Only 218 (51,9%) patients went to the hospital in the first 24 hours, although 87,8% of patients presented symptoms and 75,4% presented severe symptoms. Moreover the removed foreign bodies and suspected foreign bodies are the same in 82,95%. We think that bronchoscopy should by performed in all children who have had a choking episode.

[Pediatric endoscopy: state of the art]

INTRODUCTION

Our society has shown always a great concern with the limits of our speciality. However, we have never approached the issue of pediatric endoscopy. For this reason, we have decided to carry our a survey to assess the present situation of endoscopy among surgeon pediatricians.

MATERIAL AND METHODS

Twenty-four hospitals whose services include pediatric surgery were sent a survey centred on the following items: name of hospital, number of beds, in pediatrics, number of surgical interventions per year (which enabled us to classify the services in four groups, depending on their surgical volume), which unit is in charge of esophagus-gastroscopy, colonoscopy, esophageal dilatation, percutaneous endoscopic gastrostomy (PEG), endoscopic retrograde colangio-pancreatography (ERCP), rigid and flexible bronchoscopy, and number of such examinations per year.

RESULTS

We received twenty-two answers to the survey (91,88%). The upper endoscopies are carried out in 47,43% of the cases by Pediatric Surgery, (ten units carry out the 100% of the endoscopies in their hospital). All but two ERCP are carry out by the unit of adult gastroenterology, whereas esophageal dilatation and PEG are carry out in 89.33% of cases by Pediatric Surgery. Rigid bronchoscopy is performed by Pediatric Surgery in fifteen units, while flexible bronchoscopy is performed by Pediatric Surgery, Otorhinolaryngology, Pneumology and Pediatrics.

CONCLUSIONS

The high degree of response proved the concern with strengthening certain techniques in the field of Pediatric Surgery. Esophageal dilatations and PEG are techniques in the hands of pediatric surgeons, while ERCP is in the hands of adult endoscopists. The units that offer flexible bronchoscopy carry out many more examinations. It would be necessary to reach a consensus regarding various issues related to these examinations, ranging from who is qualified to carry them out to their legal assistance.

[Mortality in patients with esophageal atresia: influence of birth weight and cardiac anomaly]

BACKGROUND

Waterston's prognostic classification of esophageal atresia has been used in most hospitals throughout the world. A number of technical advances, mainly in neonatal intensive care units have contributed to a reduction in mortality. Although the Waterston classification continues to be widely used, increased survival in the highest risk groups in this classification has led to new classifications being described in the last few years.

OBJECTIVE

To determine the influence of birth weight and cardiac anomaly on the outcome of patients with esophageal atresia.

MATERIAL AND METHODS

The outcome of 100 infants with esophageal atresia was analyzed. The patients were divided chronologically into two groups according to advances in ICUs and surgical techniques: 45 patients treated in the first period (1971-1982) and 55 in the second (1983-2000). The influence of birth weight in the groups described by Waterston and Spitz and the association with cardiac malformation were compared between both periods.

RESULTS

Mortality in the birth weight groups described by Waterston decreased significantly between periods but this decrease was lower when the birth weight groups at highest risk described by the Spitz (1,500 g) were compared. Survival in patients with esophageal atresia improved from the first period (57.8 %) to the second (80 %) but mortality was still high when an associated major cardiac anomaly was present (80 % vs 75 %).

CONCLUSIONS

Although advances in the medical and surgical management of neonates have rendered birth weight less important to prognosis than previously, mortality continues to be high in patients with very low weight and major cardiac malformation.

[Prognosis assessment of esophageal atresia: our experience of 29 years]

INTRODUCTION

The major advances in neonatal intensive care have made less useful the Waterston's criteria for esophageal atresia (EA) and/or tracheoesophageal fistula (TEF), and other prognostic classifications have been reported. The aim of this study was to determine the influence of various parameters on the outcome of EA-TEF.

MATERIAL AND METHODS

We reviewed 97 cases admitted in our hospital for 29 years. We divided the cases in two groups in relation to the improvement of our neonatal unit care during the years: 1st. 1971-1982 (n = 46); 2nd. 1983-1999 (n = 51). chi 2 squared test and logistic regression analysis of the influence of several parameters before surgical treatment (Waterston's and Spitz's birth weight groups, pneumonia, ventilator dependence, severity of associated anomalies and cardiac malformations) on mortality was performed.

RESULTS

The survival rate increased since 1983, reaching 86.2% in the last 10 years, although the number of neonates with birth weight < 1500 g has increased. Association with a major anomaly increased the mortality significantly in the 2nd. group only (45.5% major vs 7.1% minor and 8.3% none). The cardiac malformations were the most common, not only before 1983 (26.8%), but also since then (31.3%). When the neonate associated a major cardiac malformation the mortality was significantly higher in the 2nd. group (71.4%). The mortality, when pneumonia was present, was significantly higher before 1983 only (75% vs 32.4%), whereas the mortality was significantly increased by the need of ventilator in the 2nd. group only (85.7% vs 9.1%). Before 1983, the best prognostic parameters were the pneumonia and the severity of associated anomalies, whereas only the ventilator dependence was selected between 1983 and 1999.

CONCLUSIONS

The EA-TEF mortality has decreased in the last years. The associated cardiac malformation is the most common. We think that the ventilator dependence is the most reliable prognostic risk factor, showing a poor physiologic status of the neonate.

[Increase of the chondroitin-sulfate proteoglycan, fibronectin and fibroblasts in infantile hypertrophic pyloric stenosis]

INTRODUCTION

Infantile hypertrophic pyloric stenosis (IHPS) consists of hypertrophy of the muscular layer of the pylorus. Its etiology is still unknown. In the last years only few jobs that studied the extracellular matrix (ECM) in the muscular layer in the IHPS have been reported. Our aim was to investigate the expression of two ECM molecules: chondroitin-sulfate proteoglycan (CSPG) and fibronectin (FN), and fibroblasts.

MATERIAL AND METHODS

Full-thickness muscle biopsy specimens were obtained from 33 IHPS patients at pyloromyotomy and 12 controls. Indirect immunohistochemistry was performed using CSPG, FN and fibroblasts monoclonal antibodies. The results were showed by a semiquantitative scale as follows: strong (++), moderate (+), weak (+/-), and absent (-).

RESULTS

We demonstrated that the CSPG immunoreactivity was localized in the connective tissue septa and the expression of FN molecules in the pericellular space. Both molecules were significantly the increased in the muscle layer of the pylorus with IHPS in relation to control pylorus. We also demonstrated a marked increased expression in the number of fibroblasts in the muscle layer of the pylorus with IHPS. Even-though the most striking increase was localized in the septa, we also observed great number of fibroblasts amongst the smooth muscle cells.

CONCLUSIONS

We suggest that IHPS is characterized, not only by the muscle layer hypertrophy, but also by the increase of several ECM molecules, such as CSPG and FN. We also think that the increase of fibroblast could explain the higher expression of both ECM molecules in the muscle layer of pylorus in IHPS.

[Primary torsion of the greater omentum]

OBJECTIVE

Primary torsion of the greater omentum is an infrequent cause of acute abdomen in children. A retrospective review was conducted to establish the prevalence and clinical features of omental torsion as a cause of acute abdominal pain in childhood.

PATIENTS AND METHODS

We reviewed the clinical histories of the children given surgical treatment for torsion of the greater omentum in our hospital in the last 25 years. The following data were studied: age at presentation, sex, predisposing factors, symptomatology, complementary investigations, treatment and evolution.

RESULTS

The male:female ratio among the 15 patients who underwent surgery was 2:1. Symptomology was similar to that of acute appendicitis with certain peculiarities such as a longer period of evolution at the moment of diagnosis, lower temperature and leucocytosis lower than would be expected in appendicitis at the same time of evolution and, in 12 patients, absence of vomiting. After surgical treatment evolution was satisfactory. Torsion was primary in 13 patients, secondary to inguinal hernia in 1 and secondary to cystic lymphangioma of the omentum in 1. The etiology and pathogenesis, as well as the diagnostic and therapeutic problems of this process, are discussed.

CONCLUSIONS

In all the patients with primary torsion the clinical diagnosis was of acute appendicitis. Although primary torsion is classically associated with obesity, only 1 of the 13 patients weighed significantly more than the average for the same age and sex in our region and none of the patients showed a clearly associated anatomic malformation.

[Severe caustic esophagitis in childhood]

OBJECTIVE

A retrospective analysis of patients treated for serious caustic esophagitis in our hospital was performed with the aim of defining epidemiological factors, initial treatment and therapeutic criteria for esophageal stricture with long evolution.

PATIENTS AND METHODS

Thirty-four cases of serious caustic esophagitis treated since 1982 were analyzed surveying epidemiologic, clinical and endoscopy data, as well as initial medical treatment, dilatation session number, treatment period, complications, surgical treatment indications if necessary and actual situation.

RESULTS

Alkaline caustic agents were swallowed in 71% of the cases, with dishwashing detergent being the most frequent (16 patients), Grade II esophagitis was noticed in 13 cases, grade III in 18. Established esophageal stricture was present in 3 patients when admitted. Repeated esophageal dilations were necessary in 13 patients (38%), with between 1 and 21 dilatation sessions needed. Esophageal stricture persistence forced us to perform an esophageal substitution technique by esophagocoloplasty. Resection and enlargement of a short stenotic segment was performed in 1 patient. Long-term evolution in all cases has been satisfactory.

CONCLUSIONS

We consider that adequate treatment of these patients includes conservative corticosteroids, sucralfate and anti-H2 combined with a previous endoscopy evaluation. If evolution turns into stricture, dilatations must be done, sometimes throughout years. If this treatment fails and the injury is extensive, esophagocoloplasty is the surgical technique of choice. Nevertheless, as any accident, the best treatment is good prevention.

[Cystic dilation of the bile duct in childhood]

OBJECTIVES

Common bile duct dilatation (CBDD) represents part of a wide spectrum of pancreaticobiliary disorders, with different etiopathogenic mechanisms. The objective of this study was to compile the cases treated in our service during the last five years.

PATIENTS AND METHODS

Four cases of CBDD (17 months to 10 years of age) are reported. All of them presented abdominal pain and bilious vomiting. One patient previously had pancreatitis. Cholestatic jaundice was associated in only one patient. The diagnosis was made by ultrasound, being confirmed by endoscopic retrograde cholangiopancreatography (ERCP) in three cases and by computed tomography scan (CT) in one case.

RESULTS

Three patients had a single fusiform dilation of the extrahepatic bile duct (type I cyst, Alonso Lej-Todani classification), which were treated by cyst excision and hepaticojejunostomy by using a Roux-en-Y limb. In one patient, the ERCP detected a combined dilatation of the intra- and extrahepatic bile duct (type IV cyst), associated with an anomalous choledochopancreticoductal junction with a distal obstruction of the common bile duct. In the case, the treatment consisted of a transduodenal esfintherotomy.

CONCLUSIONS

Based on our experience and a literature review, an increasing incidence of this pathology is deduce. Therefore, the relevance of ultrasounds and ERCP in the diagnosis and visualization of pancreatobiliary ducts and the choice of treatment, depending on the CBDD, are discussed.

[Dog bites in children. Epidemiologic and clinical study of 144 cases]

We have done a prospective study of 144 cases of dog bites in children between 1 and 13 years of age that were attended at the Emergency Department of the "Miguel Servet" Children's Hospital of Zaragoza over a period of 30 months. The average child is an 8 year old boy who is bitten at 4 p.m. in the lower limbs by a dog belonging to either the family, a neighbor, or to some friends. The dog of unknown breed and the German shepherd are those most frequently involved (39.5% and 22.2%, respectively). There is a low incidence of infection (4.8%). The attacks were provoked by petting in 52.7%; therefore, we recommend not to get close to the animals even if they are known. In our area, 83.3% of the children are correctly vaccinated. Finally, we compare our results with other studies and we suggest that it is of great interest to establish measures in order to reduce the incidence of dog bites.

[Cholelithiasis in childhood. Proposals based on a multicentric study]

Fifty six cases of cholelithiasis in patients aged two months to 15 years (mean age 7.65 years) concerning to 11 hospitals are reviewed. The study protocol followed was the same in all medical records, although own criterions were considered on management performed in each center. From the cases, it follows: 1. Male/female rate is 1/1.5. 2. Symptomatology in infancy is relatively poor and pain localization is not orientative. 3. It was an incidentally finding in 41 per 100 of the cases. 4. Ultrasonography is the best examination procedure rendering diagnosis in the 51 cases it was underwent. 5. Hematologic study was abnormal in six of 46 cases. 6. Medical treatment was not performed in any hospital. 7. Existence of "lithogenic families" seems to be demonstrated. 8. The presence of four patients with Down syndrome in this series must be pointed out. 9. Among total 56 cases, 21 underwent surgical treatment, 29 were conservatively treated, two have died and four patients had spontaneous stone resolution. 10. In the face of these, we propose: A) Surgical treatment in symptomatic cases, porcelain gallbladder and nonfunctionating gallbladder. B) Expectant management and sonographic monitoring in asymptomatic cases. C) Carefully evaluation in patients with predisposing factors and patients with recurrent abdominal pain.

[Beckwith-Wiedemann syndrome: study of eleven cases]

In this paper we report a review of the omphalic pathology that was admitted to our hospital from january 1973 through december 1990. Eleven cases of Beckwith-Wiedemann Syndrome were diagnosed during this period of time. Our eleven cases comply with at least three of the four major criteria (omphalocele, macroglossia, gigantism and neonatal hypoglycemia) and several of the minor criteria. The interest of this paper is based on the rareness of this syndrome and its association in two of our cases with Cacchi-Ricci Syndrome. Moreover, one of these cases later presented with a Wilms' tumor. Finally, we emphasize the importance of an early diagnosis of this syndrome in order to avoid the metabolic disturbances (hypoglycemia), to establish prompt treatment of the serious anomalies (omphalocele) and to control and follow these patients since they have increased risk to develop neoplastic disease.

[Accidents in childhood: apropos of 14,301 cases treated in the course of one year]

The present study aims: to revise all the cases of paediatric accidents attended at a Emergency Service of a tertiary Hospital; to analyze the epidemiological variables; and to try to draw conclusions in view of prevention. In order to achieve that, the 14.301 accidents attended during 1989 have been collected. The relation between little boys and little girls is 58.2:41.8. The average age is 7.12 years, though the mode has been 2 years. A larger number of accidents occur during non holiday. 44.3% of cases are attended between 18 and 23 hours. 89% of the accidents are, first of all, traumatisms and/or wounds; secondly, those which are produced by strange bodies (4.4%). In 51.9% of cases no complementary trial was carried out. Only 2.9% of cases were admitted to hospital, whereas 104% requires observation, and the rest returns home. The variables in the admitted patients are also analyzed, and a brief exposition of results for each of the 6 diagnostic groups is made.

[Results of biofeedback on incontinence caused by anorectal atresia]

Eight patients with anorectal incontinence because of anorectal atresia, aged between seven and seventeen years, following surgical treatment with Romualdi-Soave procedure in seven cases and with PSARP in one case, have received biofeedback training to improve their continence. Clinical evaluation has been performed with a new numeric punctuation method that allows a quantitative and precise appraisal of incontinence (Incontinence Punctuation: IP). From a clinical point of view, biofeedback training has increased 4.16 points IP in patients in whom the method has been effective. It has prolonged the mean duration of voluntary contraction in 5.9 sec. and elevated in 13.6 mm. Hg. the maximal pressure contraction. In two patients, clinical evolution and manometry measurements indicated surgical treatment and PSARP was performed, improving IP in 5.5 points. We considered biofeedback training, when indicated, an adequate and innocuous technique to achieve an important clinical continence improvement in these patients.

[A new clinical evaluation scale for incontinence: its use in anorectal atresias]

We present a clinical scoring system to obtain a quantitative and accurate assessment of anorectal incontinence. We evaluate ten components, each of one is pointed between 0 and two, then overall incontinence punctuation (I.P.) is between 0 and 20. Variables define clinical data relative to patient's intestinal habits and hygienic methods, voluntary control degree of defecation and repercussion of patient's incontinence in social and physical capabilities. Punctuation lower than nine concerns to a poor continence; It is fair between nine and 14 points and 15 or higher punctuation indicates a good continence mechanism. This incontinence punctuation method (I.P.) has been applied to 23 patients, aged between two and 17 years, operated because high imperforate anus by PSARP procedure in 15 cases and by abdomino-perineal pull-through according to Romualdi-Soave technique in eight cases. We found statistic significative difference between the group of patients aged less than 5 years and the group aged between 5 and 10 years. There is not statistic significative differences between the two procedures used in surgical treatment, although I.P. is slightly higher in cases operated by PSARP procedure than in cases treated with Romualdi-Soave technique, when we compare the two groups with similar mean age.

[Analysis of mortality in myelomeningocele]

Authors present a study of 84 patients with myelomeningocele between years 1971 to 1985. They analyze morbimortality related to level and condition of the lesion, Lorber's selection criteria and treatment received. They find better survival in females and in patients in whom surgical closure of the lesion was carried out without variations if one Lorber's criteria is present. The moment of operation did not change survival and was not related with development of hydrocephaly.

[Epididymo-testicular disjunction. Presentation of 23 cases and review of the literature]

Twenty three cases of alterations of the epididymis-testicular union found in 1,000 children with cryptorchism are discussed. Anatomical and pathological findings are described and world literature on the subject is reviewed, finding very scanty references to this problem in spite of the fact that expected incidence of epididymis testicular non-junction is between 1 and 2% of the patients with cryptorchism.

[Ingestion of batteries: treatment with water overload. Review of 175 cases]

The authors have treated 6 cases of childhood ingestion of disk batteries with bowel irrigation by nasogastric sonde. The disk was expeled with faeces in less than 12 hours without complications. The world literature (169 cases) on this subject is reviewed.

[Intestinal invagination: 12 years of experience]

One hundred and forty two cases of intussusception were treated in our hospital since 1970 to 1982. Patients were divided for analysis into two groups, each consisting of 71 consecutively treated patients. In the second group (1977-1982) the hydrostatic pressure reduction was attempted under general anaesthesia an was successful in 50% of the patients. We compare both groups from the point of view of hydrostatic pressure reduction and conclude that anaesthesia significantly reduces the number of surgical procedures in children with intussusception.

[Atresia of the esophagus caused by bands]

Authors report clinical and anatomopathological findings in two cases esophageal atresia. Authors found in one of them an anomalous vessel crossing the atresic cord and gastric epithelium in the lower pouch. Authors try to explain the pathogenesis of this atresia.