Nutritional management and clinical outcome of critically ill patients with COVID-19: A retrospective study in a tertiary hospital

BACKGROUND & AIMS

Severe COVID-19 infection is characterized by an inflammatory response and lung injury that can evolve into an acute respiratory distress syndrome that needs support treatment in intensive care unit. Nutritional treatment is an important component of the management of critically ill patients and should be started in the first 48 h of ICU admission to avoid malnutrition. This study describes the characteristics of the patients treated in a tertiary hospital in Madrid during the months of March-May 2020 (first wave), the medical nutrition treatment employed and its influence in the clinical outcome of these patients.

METHODS

This is a retrospective study including COVID-19 patients admitted in ICU that needed medical nutrition treatment (MNT). Collected variables included sex, age, BMI, underlying diseases, time from hospitalisation to ICU admission, type of respiratory support (invasive mechanical ventilation (IMV) or high flow nasal cannula (HFNC) or non-invasive ventilation (non-IMV)), caloric and protein requirements (25 kcal/kg adjusted body weight (ABW), 1.3 g/kg ABW/day), MNT type (enteral nutrition (EN), parenteral nutrition (PN), mixed EN + PN), total calories (including propofol) and proteins administered, percentage of caloric and protein goal in ICU day 4th and 7th, metabolic complications, acute kidney failure (AKF), length of stay (LOS) and mortality. Data are expressed as mean ± SD, median (IQR) or frequencies. Statistical analysis was performed with the IBM SPSS Statistics for Windows, Version 25.0. p < 0.05 were considered statistically significant.

RESULTS

A total of 176 patients were included (72.7% male), 60.1 ± 13.5 years, BMI 29.9 ± 5.4 kg/m². Underlying diseases included 47.4% overweight, 39.8% obesity, 49.1% hypertension, 41.4% dyslipidaemia. 88.6% of patients needed IMV, 89.1% prone position, 2.9% ECMO. Time to ICU admission: 2 (4.75) days. Estimated caloric and protein requirements were 1775 ± 202 kcal and 92.4 ± 10.3 g. Calories and proteins administered at days 4th and 7th were 1425 ± 577 kcal and 66 ± 26 g and 1574 ± 555 and 74 ± 37, respectively. Most of the patients received PN (alone or complementary to EN) to cover nutritional requirements (82.4% at day 4th and 77.9% at day 7th). IVM patients received more calories and proteins during the first week of ICU admission. Complications included 77.8% hyperglycaemia, 13.2% hypoglycaemia, 83.8% hypertriglyceridemia, and 35.1% AKF. ICU LOS was 20.5 (26) days. The mortality rate was 36.4%.

CONCLUSIONS

In our series, the majority of patients reached energy and protein requirements in the first week of ICU admission due to the use of PN (total or complementary to EN). Patients with HFNC or non-IMV may be at risk of malnutrition if total or complementary PN to oral diet/ONS/tube feeding is not used to cover nutritional requirements. Therefore, if EN is not possible or insufficient, PN can be safely used in critically ill patients with COVID-19 with a close monitoring of metabolic complications.

Sex difference in aortic valve fibrosis assessed by contrast-enhanced computed tomography in severe aortic stenosis

Background

Aortic stenosis (AS) is characterized by fibro-calcific remodeling of aortic valve leaflets. Progressive aortic valve calcification (AVC) occurs in both sexes and cardiac computed tomography (CT) is recognized as a high-quality technique for AVC evaluation. To date, sex-specific CT thresholds of AVC have been implemented in clinical practice since it is now recognized that women have less AVC burden than men. In addition, recent evidences indicate that women have more fibrotic remodeling of aortic valve leaflet compared to men.

Purpose

Aortic valve fibrosis (AVF) being a significant contributor to valve gradient, we sought to evaluate the difference in AVF burden between men and women with severe AS using contrast-enhanced CT.

Methods

We included 56 patients matched for age and sex with severe AS. All patients underwent Doppler echocardiography and cardiac CT before intervention. Contrast attenuation values (Hounsfield Units, HU) and contrast-to-noise ratio were measured at the level of the ascending aorta. Total AVF was assessed based on HU ranging between 30 and 350, adjusting the upper threshold by increments of 25 HU in either direction until blood pool was not highlighted. Indexed contrast-enhanced CT calcium volume (iAVC) and fibrosis volume (iAVF) were calculated dividing the volumes by the aortic annular area. Fibro-calcific ratio was calculate dividing iAVF by iAVC volumes.

Results

There was no difference between men and women in major cardiovascular risk factors, valve phenotype (bicuspid vs. tricuspid), nor pharmacological treatment. Men had higher body surface area than women (1.89±0.14 vs. 1.67±0.17 m2, respectively; p&lt;0.001), while women had lower aortic valve area than men (AVA; 0.74±0.2 vs. 0.91±0.2 cm2, respectively; p=0.007) but similar indexed AVA (0.44±0.15 vs. 0.48±0.12 cm2/m2, respectively; p=0.262). Women had significantly lower iAVC compared to men (36 [36–72] vs. 72 [67–123] mm3/cm2, respectively; p=0.03). However, iAVF was significantly higher in women compared to men (83 [78–123] vs. 63 [58–83] mm3/cm2, respectively; p=0.006). Finally, the fibro-calcific ratio, which indicates the predominance of valve fibrosis if &gt;1.0, was significantly higher in women compared to men (2.57 [2.14–7.02] vs. 0.78 [0.84–2.02], respectively; p=0.003).

Conclusions

Our study highlights for the first time a sex difference in the fibrotic content of severe AS evaluated by contrast-enhanced CT. These findings might be valuable to promote further studies on the role of sex-specific tissue composition in AS progression and outcomes.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Fondazione Gigi e Pupa Ferrari ONLUS

[Correction of the complicated pectus excavatum with extracorporeal circulation (ECC) support]

INTRODUCTION

The most serious complication in surgery of the pectus excavatum is the possible cardiac perforation. After its resolution, it is very likely that the relapse of the excavatum will be more severe due to the intense retrosternal fibrosis generated, involving cardiac structures and fixing them to the sternum. Reintervention requires modifications of the usual techniques and special monitoring due to the increased risk of cardiac and large vessel lesions. We present the case of 2 patients with severe pectus excavatum with a previous attempt for correction with cardiac perforation.

CLINICAL CASES

Case 1. A 16 year old male with Haller index 9.9, diagnosed of Ehlers-Danlos syndrome and operated on in neonatal period of cardiac disease, with previous attempt for correction using the Ravitch technique that relapsed and cardiac perforation during it. Case 2. An 11 year old girl, with background of diaphragmatic hernia and cardiac perforation on introducing the Nuss bar at 5 years of age, with Haller index 5.5. Both were operated on under ECC with the collaboration of the Cardiac Surgery Service and cardiac adherences were released after median sternotomy. After it, the Nuss bar was introduced and then sternal closure was performed with reinforced steel wires with titanium plates in the anterior and posterior part.

DISCUSSION

The backgrounds of the cardiac approach complicate the intervention for the correction of the pectus excavatum, with a high risk of cardiac trauma. Counting on the support of the cardiac surgery and the ECC, we achieve an adequate control and prediction of the complications

Association of cutaneous red-to-purple hemangiomas with leptomeningeal hemangiomas. a clinical study of two patients

Cutaneous hemangioma is a benign vascular tumor of infancy with an initial proliferating period that appears between 1 to 2 weeks of life, extends during 18 months to 2 years of life, and then slowly regresses during several years until it disappears completely. They are characterized by endothelial cell proliferation followed by diminishing hyperplasia and progressive fibrosis. Vascular malformations are present at birth, grow commensurately with the child, and are characterized histologically by a normal rate of endothelial cell turnover, flat endothelium, thin (normal) basal membrane and normal mast cells. These cutaneous anomalies are commonly associated with cerebellar malformations, main cerebral arteries anomalies, congenital cardiac anomalies and/or coarctation of the aorta and persistence of embryonic arteries. Cutaneous hemangiomas can be associated with intracranial or extracranial hemangiomas that regress at the same time as the cutaneous hemangiomas. Cutaneous hemangiomas may show different types of color. Cutaneous red-to-purple hemangiomas are uncommon and their bright-red color is evident from the first weeks of life and remains unaltered until the hemangioma disappears. The intracranial angiographic studies in our series of more than 50 cases with facial hemangioma showed that patients with red-to-purple hemangiomas are commonly associated with localized leptomeningeal hemangiomas either in the ipsilateral or contralateral side. These leptomingeal hemangiomas were visualized only by MR enhanced with gadolinium. Involution of the cutaneous and leptomeningeal hemangiomas seems to occur simultaneously as in other types of external and internal hemangiomas.

[Laparoscopic resection of the prostatic utricle in children]

INTRODUCTION

The prostatic utricle is an embryological remnant from Müllerian duct tissue. Most prostatic utricles are asympomatic, but they may manifest as a urinary tract infection or an incontinence.

MATERIAL AND METHOD

Surgery consists in a cysto-urethroscopy and cannulation of the prostatic utricle with a ureteral catheter (Fogarty ner 4) and the cystoscopy left in situ to facilitate identification and mobilization. A 10 mm port through a umbilical incision and two more 5 mm working ports were inserted. After mobilization, the ureteral defect was closed by an absorbable suture and ultrasonic coagulation.

RESULTS

Five boys with symptomatic prostatic utricles underwent surgery at a mean (range) age of 7 (2-11) years. The laparoscopic excision was successful in all but one due to a bleeding. The mean (range) operative duration was 165 (120-240) min.

CONCLUSION

Laparoscopic excision under cystoscopic guidance offers a good surgical view and allowing easy dissection.

[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.

[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.

Non stenotic food impaction due to eosinophilic esophagitis: a potential surgical emergency

AIM

Eosinophilic esophagitis (EoE) is an emergent condition in which a mucosal infiltrate of > 20 eosinophils per high power microscopic field is accompanied by motor disturbances that may cause food impaction in the absence of esophageal stricture. We report a series of such cases to point out the potential involvement of pediatric surgeons in diagnosis and treatment. Furthermore, data on the motor function of the esophagus investigated manometrically is included.

MATERIAL AND METHODS

Thirteen patients with EoE were referred to our emergency room for acute food bolus impaction. Their median age at diagnosis was 12 years (range 7.6-14.4). History of allergy, endoscopy with biopsy and esophageal function (24-h combined ambulatory manometry with simultaneous pH-metry) were investigated.

RESULTS

In 7 patients emergency endoscopic extraction of the impacted bolus was necessary. Allergic tests were positive in eight patients. The pH probe showed gastroesophageal reflux in two cases. Upon endoscopy, typical features of EoE (esophageal trachealization and whitish papular exudates) were found. Ambulatory 24-h manometry revealed abnormal motility of the distal esophagus with strikingly high amplitudes (> 150 mmHg) and long duration (> 7 sec) of the waves, particularly during the night. Six patients responded rapidly to steroids and/or antiallergic treatment. The remaining patients had a good outcome with dietary treatment alone.

CONCLUSIONS

EoE is an emergent condition that may involve the pediatric surgeon in both the diagnosis and treatment. Typical endoscopic findings and biopsy are required for proper diagnosis. Ambulatory manometry reveals a marked propulsive dysfunction that explains impaction. This dysfunction is reversible, since the symptoms usually disappear with steroids or antiallergic treatment.

[Bronchial and appendiceal carcinoid tumors]

BACKGROUND

Carcinoid tumor (CT) is an unusual neoplasm observed in several locations and associated with the production of vasoactive substances and occasionally with carcinoid syndrome (flushing, diarrhea, wheezing).

PATIENTS AND METHODS

A retrospective review of the medial records of all children with a diagnosis of CT treated in our service between 1966 and 2003 was performed.

RESULTS

Ten patients (5 boys and 5 girls with a mean age of 8 years) were diagnosed with CT. Eight had CT of the appendix, of which 4 showed the typical clinical presentation of acute appendicitis. Seven of these tumors were localized at the tip of the appendix and measured 2 cm or less. In one patient, the tumor was located at the cecum and measured 3.5 cm. In this patient, reoperation with ileocecal resection was performed. Two patients (4 and 6 years old) had bronchial CT associated with chronic respiratory manifestations. An accurate diagnosis was made after a 1-year follow-up. Pneumonectomy and tracheobronchial sleeve resection were carried out. None of the patients showed symptoms of carcinoid syndrome. All the patients underwent biochemical and radiological studies and fiberoptic bronchoscopy during follow-up. All the patients are currently disease-free.

CONCLUSIONS

Typical symptoms of acute appendicitis were not observed in half of patients with CT of the appendix. CT associated with carcinoid syndrome is exceptional in pediatric patients. In most CT of the appendix, simple appendicectomy was associated with an excellent prognosis. Diagnosis of bronchial TC tends to be delayed and consequently CT should be considered in the differential diagnosis of children with respiratory symptoms unresponsive to standard medical treatment.

[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.

[Congenital portosystemic shunt. The Abernethy malformation]

BACKGROUND

Congenital portosystemic shunt (CEPS) is a rare condition that was first reported by John Abernethy in 1793. Two types of CEPS are described: type I (side to end anastomosis) or congenital absence of the portal vein, and type II (side to side anastomosis) with portal vein supply partially conserved. Type I CEPS is usually seen in girls and associates multiple malformations as polysplenia, malrotation, and cardiac anomalies. Type II is even rarer with no sex preference and no malformations associated. Hepatic encephalopathy is a common complication of both types in adulthood. Liver transplantation is the only effective treatment for symptomatic type I CEPS. A therapeutic approach for type II could be surgical closure of the shunt.

OBJECTIVE

To analyse our experience in diagnosis and management of portosystemic shunts.

METHODS

We report 4 cases of CEPS (3 type I and 1 type II) diagnosed between January-1997 and March-2005 in our department.

RESULTS

We present 4 patients with ages at diagnosis ranging from 0 to 28 months, 3 type I CEPS (2 boys and 1 girl) and 1 boy type II. The type I girl was prenatally diagnosed at 12 weeks of gestation. Initial clinical signs in type 1 boys were splenomegaly and hypersplenism, both with normal pondo-statural growth. No polysplenia or cardiac anomalies were assessed. One of them presented mild developmental delay, dismorphic features and facial telangiectasias. He had normal coagulation tests with chronic hepatic dysfunction (high transaminases) and regenerative nodular lesions were seen by imaging techniques. The other type I patient had hypoprothrombinemia, tendency to capillary bleeding (haematomas and epistaxis) with preserved liver function. Both patients have developed mild portal hypertension and present steatosis signs at liver biopsy. The type I girl presents a 21 trisomy and associates a cardiac anomaly (interauricular communication). Her hepatic function test are normal but liver calcifications can be seen by ultrasound. Type II child associates hypospadias but he has no clinical sigh or symptom related to the shunt. In our three cases diagnosis was suggested by conventional and Doppler ultrasound and confirmed by angio-resonance imaging. All our patients are included in a meticulous clinical and radiological follow-up with no need of surgical treatment for the shunt until now.

CONCLUSIONS

Although diagnosis of these malformations could be casual we have to think about CEPS in children presenting unspecific liver disease. Magnetic angio-resonance imaging is actually the best diagnosis methods for CEPS. These patients have a high risk for developing hepatic encephalopathy and portal hypertension, so a careful follow-up is required although surgery is not usually needed until adulthood.

[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.

[Cardiac function alterations in pectus excavatum]

BACKGROUND

Cosmetic deformity and psychological repercusion are the main surgical indications in pectus excavatum. However cardiopulmonary function is subclinically abnormal in some patients. The goal of this paper is to demonstrate that heart response during physical activity improves after surgical correction of pectus excavatum.

PATIENTS AND METHODS

Fifty five patients were operated upon for pectus excavatum during the last 10 years at our institution. Baseline ecocardiography and isometric effort test (Handgrip) were preoperatively performed in 15 patients (11 males and 4 females) aged from 6 to 15 years (median 9,63). An increase below 12% in cardiac index was considered as positive. In those patients with positive tests, a new test was made 6 months after surgical correction. Pre and postoperative results were compared using non-parametric tests.

RESULTS

Baseline cardiac index values were normal in all cases (11). Four patients were not included, 2 because of no collaboration (aged 6 and 7 years) and 2 because difficult ecocardiography interpretation (both operated upon for congenital diaphragmatic hernia). Overall, preoperative test was negative in 6 patients and positive in the remaining 5. Postoperative test was made in these 5 patients, and all of them showed an improvement in cardiac index (medium 40,6%, range 25-70) when compared to preoperative values. There was statistically significant association between test values and patient ages.

CONCLUSIONS

Baseline cardiac index values were normal in children with pectus excavatum, albeit 45,5% of them showed a limited response to exercise. Pectus excavatum repair improves these values, so physiopathological indication as well as cosmetic one should be considered specially in children.

[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.

The tumor necrosis factor alpha of the bony fish seabream exhibits the in vivo proinflammatory and proliferative activities of its mammalian counterparts, yet it functions in a species-specific manner

Information on the bioactivities of non-mammalian cytokines is scant due to the lack of the recombinant molecules and specific antibodies. We produced the mature predicted peptide of tumor necrosis factor alpha (TNF alpha) from the bony fish gilthead seabream (Sparus aurata L.) (sbTNF alpha), and its biological role was determined in vitro and in vivo. We first demonstrated by analytical size-exclusion chromatography that sbTNF alpha is an oligomeric protein but the dimer appears to predominate over the trimeric form, in contrast to mammalian TNF alpha. Intraperitoneal injection of native sbTNF alpha resulted in (i) priming of the respiratory burst of the peritoneal exudate and head-kidney (HK) leukocytes, the latter being the bone marrow equivalent in fish; (ii) rapid recruitment of phagocytic granulocytes to the injection site, and (iii) induction of granulopoiesis in the HK. Interestingly, sbTNF alpha was able to induce a strong proliferation of HK cells in vitro, whereas human TNF alpha did not. Conversely, sbTNF alpha was not cytotoxic for murine L929 fibroblasts.

[Paraneoplasic syndrome in inflammatory pseudotumor of the lung]

BACKGROUND

Inflammatory pseudotumor (IPT) is the most frequent pulmonary mass in childhood. It is histologically benign but locally aggressive. Atelectasis and recurrent airway infections are the most frequent presenting findings. We present two children in whom first clinical signs were paraneoplasic syndromes.

MATERIAL AND METHODS

Retrospective study of two cases of IPT treated in our clinic from 1998 to 2002. Age, clinical presentation, preoperative diagnosis, treatment, histological diagnosis and postoperative outcome were reviewed from clinical chart.

RESULTS

Case 1: 7 year old male with incidental diagnosis of superior right lobe IPT in routine study because of diabetes. The mass collapsed superior and median lobar arteries and compressed superior cava vein. Right pneumonectomy was necesary to complete removal of the mass. From immediate postoperatory the child became normoglycemic and is free of insulin. Case 2: 11 year old male with rheumatologic clinic consisting in hypertrophic osteoarthropathy, arthralgy and knees liquid lasting for two years. X-ray examination showed mediastinic mass. He underwent complete removal of a pulmonary mass. Few months after the operation the rheumatologic-like symptoms were resolved.

CONCLUSIONS

IPT can present with paraneoplasic syndromes, although physiopathology is not well understood. In children with recurrent respiratory infections one diagnosis to take in mind is IPT, even more when clinic is associated with symptoms compatible with paraneoplasic syndrome.

[Biliary lithiasis in childhood: therapeutic approaches]

Until recently, biliary lithiasis was considered infrequent in childhood. According to their composition, gallstones can be classified into cholesterol stones and pigment stones. The latter are mainly composed of calcium salts of unconjugated bilirubin and are divided into hard black and soft brown stones. In children, up to 75 % of gallstones are pigment stones. Their etiology is often unknown. Biliary lithiasis in children differs from that in adults and there is very little scientific evidence on the most suitable therapeutic procedures. Symptom-free stones usually have a benign course and do not require medical or surgical treatment. Symptoms are often nonspecific and include dyspepsia and chronic abdominal pain. These symptoms are an indication for ultrasonographic scan to rule out the presence of gallstones. Cholecystectomy is the definitive treatment for gallstones but is not always indicated. Medical treatment with ursodeoxycholic acid is indicated in oligosymptomatic and asymptomatic lithiasis with transparent, soft, cholesterol-rich stones and a functional bladder and in patients with a high surgical risk.

[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.

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.

[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.

Esophageal motor dysfunction persists in children after surgical cure of reflux: an ambulatory manometric study

BACKGROUND/PURPOSE

Esophageal dysmotility shown by perfusion manometry in children with gastroesophageal reflux can be primary or acquired. This study examines by combined ambulatory pH-metry and manometry the nature of motor dysfunction and whether it improves after surgical cure of reflux.

METHODS

Sixteen refluxing children aged 131 +/- 54 months were studied by combined ambulatory pH-metry and manometry before and more than 6 months after successful fundoplication. pH-metric and manometric variables were compared at both time end-points by paired statistical tests accepting a significance level of P less than.05.

RESULTS

Operation cured all patients clinically and pH-metrically, but, in spite of this, only the frequency of motor sequences decreased significantly after the operation from 1 (0.45) to 0.8 (0.6) waves per minute (median [interquartile range]). Wave amplitude and duration were similar in both conditions; the proportion of peristaltic waves was normal and did not change before and after the operation (79.5% [17.25] v 81.4% [21.5]; not significant), whereas the proportions of complete (63.2% [17.5] v 67.8% [19.3]; not significant) and effective (32.4% [31.95] v 27.25% [22.5]; not significant) waves were definitely low and remained so after treatment.

CONCLUSIONS

The esophagus of children with GER has mild disturbances of peristaltic activity with waves often incomplete, weak, and scarcely effective. Dismotility does not improve after successful fundoplication suggesting that it could be a primary phenomenon.

[Laparoscopic surgery in children]

OBJECTIVE

We summarize our experience in laparoscopic surgery between 1992 and 1997 in an attempt to provide the pediatrician with up-dated information regarding the background, technical basis and limitations of this procedure in children.

PATIENTS AND METHODS

For our 315 operations we used conventional endoscopic equipment with miniaturized instruments and regular anesthetic procedures assisted only with on-line capnography and increased tidal volume. Ages ranged between newborn and adolescence and the main indications for surgery were gonadal operations (n = 113), fundoplication (n = 40), cholecystectomy (n = 35), exploration for recurrent abdominal pain (n = 44) and appendectomy (n = 29), but we also performed spleenectomies (n = 7), nephrectomies (n = 6), rectosigmoidectomies (n = 4) and several other procedures.

RESULTS

Complications were scares [4 major (1.2% and 17 minor (5.3%)] and were satisfactorily solved. The conversion to an open operation was felt necessary in only 7 instances (2.2%) and this approach has been fully rewarding in terms of good results, little pain, short hospital stay and rapid recovery.

CONCLUSIONS

Laparoscopic surgery is already a realistic alternative in pediatric medicine and its indications are growing every day as a result of its widespread use. The pediatrician has to be aware of the opportunity, rationale and limits of this approach since he will be increasingly confronted with it.

Functional results of laparoscopic fundoplication in children

BACKGROUND

There is no evidence that the results of laparoscopic fundoplication in children match those of the open procedure. In the current report, pre- and postoperative function of the antireflux barrier is examined in children having laparoscopic fundoplication for gastroesophageal reflux.

METHODS

Twenty-seven patients with gastroesophageal reflux, aged 7.2+/-4.5 years, were operated on for unremitting gastrointestinal symptoms (n = 24), with respiratory tract disease (n = 11), cystic fibrosis (n = 2), or brain damage (n = 11). Gastrostomy was added in 5 cases. Barium contrast study, pH-metering, endoscopic examination, and biopsy were performed before and after a median of 19 months (range, 8 to 46) after operation.

RESULTS

At diagnosis, 15 of 21 patients had esophagitis that was moderate or severe in 11 (1 with Barrett's esophagus). Symptoms disappeared after fundoplication in all but 2 patients, in whom they became milder. The reflux index decreased from 20.2+/-20% to 4.9+/-9% and became normal in all except 4 children (2 with brain damage and 1 with cystic fibrosis). Open repair of the failed wrap was considered necessary in only 1 of them.

CONCLUSIONS

Laparoscopic fundoplication is as effective as the open procedure (14% overall failure rate). However, the failure rate in neurologic patients (18%) suggests that before reaching conclusions on the benefits of this approach, careful long-term assessment of the functional results is necessary.

[Pulmonary granulomatosis caused by lentil aspiration]

Pulmonary nodular granulomatosis caused by aspirated lentils is a rare entity. We report the case of a healthy 8 years-old girl who suffered a choking life-threatening choking event during a meal, with cardiorespiratory arrest. After a delay of one month delay without symptoms, she developed respiratory distress with radiologic changes. Lung biopsy disclosed foreing body granulomas. Steroids were not used because of their uncertain effectiveness in these cases. One year later the patient's progress was satisfactory.

[Partial splenic embolization in the treatment of hypersplenism. Long-term results]

In order to assess long term evolution of partial splenic embolization (PSE), 21 patients with hypersplenism treated by this technique from January 1984 to December 1992 have been reviewed. Between 50 and 90% of the splenic parenchyma was embolized in these patients. The follow-up period ranged between 12 and 103 months (mean = 32 months). Remaining splenic tissue was evaluated through sequential hematologic, ultrasonic and gammagraphic studies. After one year post-embolization white blood cells and platelets showed normal values. Five years later the mean values for these two parameters was lower but within the normal range. The mean reduction of splenic mass as estimated by ultrasound and gamma graphic studies was of 40% at one year and 17% at five years. Our results show that SPE can control hypersplenism, specially during the first years, but there is a tendency to a decrease in the leucocyte and platelet counts after five years. A regeneration of the splenic mass occurs in the long run after embolization. In our patients a relation between splenic regeneration and hypersplenism could not be demonstrated.

[Surgical evaluation of a liver transplant program. Experiences with the first 45 cases]

The cumulative experience in liver transplantation since the introduction of cyclosporine A has confirmed its efficacy in the treatment of diverse liver diseases in children and adults. In the present study we review the surgical aspects of 45 transplants performed in 39 patients (17 children and 22 adults). Immunosuppressive treatment consisted of cyclosporine A, steroids and monoclonal antibodies (OKT3) in rejection unresponsive to steroids. The actuarial survival rate one year after transplantation was 74%. In the course of development of the program, the elective use of veno-venous bypass during the anhepatic phase in adults was confirmed as useful. Among pediatric transplantations there were numerous arterial malformations (31.5%) in donor organs, which, with the malformations associated in receptors, made allograft reconstruction difficult. Our results confirm those reported by other groups, as well as the importance of specialized training for this type of intervention.

[Torsion of the spleen]

Twisting of the spleen on its pedicle, due to the lack of the normal fixation elements, is a rare pathological condition in childhood. The revised literature reports 11 cases under the age of 10 years. We present three new cases treated at the Clínica Infantil "La Paz" (Madrid) during a period of 15 years. Ages of the three patients were 18 months, 15 months and a newborn, operated upon at 10 days. It is important to point out that only two cases of the 11 reported in the literature were younger than 12 months of age. This article also presents the embriological study of this malformation and discusses its clinic, diagnostic and treatment.

[Torsion of the testis in the newborn (author's transl)]

27 cases of torsion of the testis in the newborn among 46 operations for torsion of the spermatic cord in childhood are reported. Usually torsions were extravaginal and orchidectomy for advanced necrosis was necessary in 22 cases. Authors comment on predisposing factors which produce a torsion of the testis in the newborn. The aetiology is unclear. Pathology of the specimens of orchidectomy as well as the final atrophy of several of the conserved testis demonstrate that excision is probably indicated even with an early diagnosis, which is essential.

[Neonatal gastric perforation (author's transl)]

Three cases of neonatal gastric perforation of unknown etiology are presented. All three patients are female, one of them a second twin and two of them less than 2,000 g. in weight. All the patients were born under anoxic deliveries and needed resuscitative treatment. Digestive and respiratory symptoms started in all between the 2nd and the 4th days of life. Diagnosis, clinically suspected, is established radiologically. Perforations were surgically closed in all three patients. Two remain alive.

[Traumatic esophageal pseudodiverticulum (author's transl)]

Hypoharyngeal perforation with production of an esophageal pseudodiverticulum in the newborn is reviewed. Two new cases are reported and the clinical signs, very similar to those of tracheoesophageal fistula with esophageal artresia, commented upon. The radiological findings of the lesion are discussed, and hints on conservative treatment, advanced.