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ABSTRACT: Anal prolapse is a common postoperative complication related to anorectal malformations (MAR) surgery, which is sometimes considered to be insignificant and/or not worthy of further intervention. We analysed the causes of this complication and our current surgical protocols.
Since 1995, 26 patients with anal prolapse have been operated secondary to surgical correction of an anorectal pathology. The most common MAR in girls (12) was cloaca (10), and in boys (14) was anorectal atresia with prostate fistula (8). The symptoms were anal pain and bleeding associated with alterations in bowel control alterations. The diagnosis in most patients was made in the first months after surgery, during the period of anal dilatations period. The surgical procedure involves prolapse resection of the prolapse and a new anoplasty. In 18 patients (69%) the prolapse was corrected before the colostomy closure on an outpatient basis. The other 8 patients (31%) underwent prolapse surgery after colostomy closure, requiring hospitalisation.
There were no immediate postoperative complications, improving continence and aesthetic anus appearance. In 4 patients the prolapse recurred, requiring further surgical correction.
Anal prolapse is a possible minor complication after anorectal correction. MAR type, the quality of the perineal musculature and defects in surgical technique are the main factors determining ia prolapse will appearance. The anal prolapse surgery indication has been recently increased (including small unilateral prolapses) as long as they are done before the colostomy closure, due to good aesthetic and functional results, requiring only outpatient surgery.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 07/2012; 25(3):140-4.
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A R Tardáguila,
A Del Cañizo,
M M Santos,
M Fanjul,
C Corona,
M Zornoza,
A Parente,
N Carrera,
C Beléndez, J Cerdá,
J Saavedra,
E Molina,
M A García-Casillas,
D Peláez
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ABSTRACT: Long-term indwelling central venous access devices are frequently used in pediatric patients. Their main complication is infection, that can even mean their removal. We try to identify the risk factors really involved in this complication and in their removal. We have made a retrospective review of 120 oncologic pediatric patients who received a central venous device between 2003 and 2009. We searched for epidemiologic, clinic, microbiologic and surgical risk factors. We made a comparative data analysis among: GROUP A, children who suffered device infection, GROUP B the others. Group A was divided into early infection (first month after implantation)/late infection, removed/not removed. Data were analized with statistical program SPSS. 29 suffered from leukemia, 19 from lymphoma and the main part, 72, from solid tumour. 31% experienced infection (GROUP A), being early in the 36% of them. 16% had to be withdrawn. Data analysis revealed statistical association with the age (p=0.015) and with the reception of chemiotherapic treatment the week before the surgical insertion. The rest of the studied factors did not revealed a real association, but could be guess a relationship among infection and leukemia, subclavian catheters, those patients whose deviced was introduced using a guide over a previous catheter and also transplanted. Related to early infection the only associateon founded was with the subclavian access (p=0.018). In conclusion, in our serie long-term central venous access infection was more frequent in the younger patients and also in those who had received chemotherapy the week before the catheter implantation. The tendency towards infection in leukemia, transplanted and subclavian carriers has to be studied in a prospective way with a larger number of oncologic children.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 10/2011; 24(4):208-13.
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M Zornoza,
D Peláez,
R Romero,
C Corona,
A Tardáguila,
R Rojo,
N Carrera,
A Cañizo,
E Molina,
M A García-Casillas, J Cerdá
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ABSTRACT: Peritoneal drainage is one of the options for treatment in necrotizing enterocolitis (NEC). Currently its role is controversial as an alternative to laparotomy in low birthweight and mortality associated with both procedures is high (35-55%).
We reviewed 30 low-weight premature (< 1000 g) with NEC treated surgically. We evaluate the hemodynamic, respiratory and metabolic status of the patients, as well as multi-organ involvement and the need for inotropic drugs. These data were analyzed previos to surgery and at 6 and 12 hours. We divided the sample into two groups: those who underwent peritoneal drainage (PD) input or laparotomy (LAP).
In the series the average birth weight was 754 +/- 156 g and gestational age was 26.1 +/- 2.1 weeks. We carry on 10 peritoneal drainage and 20 laparotomies. The DP group before the intervention showed increased heart rate, FiO2 and acidosis (p < 0.05). The needs of dopamine were similar in both groups. Following the peritoneal drainage, we found breathing improvement (adequate ventilation and oxygenation, decreased FiO2) and hemodynamic improvement (blood pressure maintained, reduced heart rate, reduced requirements for dopamine) at 6 and 12 h. DP was not the definitive treatment in any of the patiens, and all survivors (80%) of this group required further laparotomy. 62% of them died. Overall mortality was 47% (70% DP and 35% LAP, p = 0.07).
Peritoneal drainage allowed the stabilization of low-weight premature in critical condition. The hemodynamic and respiratory stabilization was transient and did not prevent the definitive surgical treatment, although it improved the conditions for doing so. In our series, the peritoneal drainage did not improve long-term survival, questioning its role as an alternative to surgery for NEC.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 08/2011; 24(3):146-50.
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A Parente,
A Cañizo,
A Huerga,
A Laín,
M Fanjul,
N Carrera,
C Corona,
M Fariñas,
C Menéndez, J Cerdá,
E Molina,
J Vázquez
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ABSTRACT: The neonatal intensive care unit (NICU) is used in many centres as operating room in order to avoid the co-morbidities that there produces the movement of critical patients. The motive of this work is to analyze the advantages and disadvantages of this type of surgical interventions.
Between January, 2004 and December, 2007 405 newborns were operated in the NICU. The most frequent surgical realized interventions were: deferred closing breastbone (172), placement of ECMO (42), ligation of patent ductus arteriosus (45), laparotomies for necrotising enterocolitis (27), repair of congenital diaphragmatic hernia (20), plicate of diaphragms (5) and closing of gastroschisis (4). We realize a retrospective study of a group of 40 patients operated by diaphragmatic hernia and necrotising enterocolitis in the UCIN (group A) and compare them with a group of patients operated in the operating room with the same pathology (group B). We study 22 variables preoperatory, intraoperatory and postoperatory. For the statistical analysis T-student and Chi-square was in use, being considered to be statistically significant p < 0.05.
The average ages of the patients to the intervention were 11.1 +/- 8 days being the predominant sex the masculine one (60 %). The age gestational and the average weight for the group A was 31.9 +/- 5.7 weeks and 1,735 +/- 123 grams being for the group B of 34 +/- 3.5 weeks and 2,037 +/- 728 grams respectively (p = N.S.). 89.3% of the patients of the group A was with intubation orotracheal before the surgery, being 57.2% for the group B. The needs of high frequency ventilation and vasoactives drugs were higher for the group A (p < 0.01) and the operative time was similar in both groups (81 +/- 34 vs. 98 +/- 33 minutes). We find a difference of corporal temperature pre-post surgery of 0.60 +/- 0.48 degrees C for the group A and 2.18 +/- 0.93 degrees C in the B (p < 0.01). We don't estimate differences as for episodes of infection of wound, intraabdominal infection or need of reintervention. The survival of the patients was discreetly higher for the group operated in the operating room (82.3%) with regard to the group operated in the NICU (60%) without statistically significant differences existed.
In our experience the NICU is a suitable place to realize surgical interventions in critical patients. The higher mortality for the group controlled in the UCIN explains for a major instability preoperatory. The maintenance of the corporal temperature avoiding the hypothermia it's one of the decisive factors to diminish the morbi-mortality.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 05/2009; 22(2):61-4.
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ABSTRACT: Imperforate anus without fistula is an uncommon anorectal malformation, in association to Down syndrome in 50% of cases. This anomaly is described as a lack of annus, with a blind rectal pouch, located about 2 cm above perineal skin, and sharing a common wall with the urethra or vagina. The aim of this work is to present our experience in this condition and to determine the differences between the diagnosis, treatment and long-term outcome of these patients in relation to other forms of anorectal malformation.
We reviewed the medical records of 12 patients treated in our department from 1998 to 2008. Eight were boys and 4 girls. Eleven of these patients had significant associated congenital diseases: Down syndrome (6), cardiovascular anomalies (6), urinary tract malformations (5), esophageal atresia (1). In all cases neonatal colostomy was performed, being 7 months (range between 1 and 19 months) the average age of the definitive surgery through posterior sagital approach. In one case a laparotomy was performed. The distance from the rectal pouch to the skin ranged from 1 to 5 cm, founding a very dilatated rectum in 4 patients.
The postoperative outcome was favorable. Four patients required removal of a small anal prolapse. All patients older than 2 years (7) have urinary continence, while 5 of them have a significant constipation, resistant to treatment with diet and laxatives, requiring medical management with enemas.
Our study confirms the high incidence of Down syndrome in patients with imperforate anus without fistula, and shows a higher incidence of other congenital comobidities. A colostrogram prior to definitive repair seems to be mandatory taking into account the intraopetative findings (height and diameter of rectal pouch). The incidence of anal prolapse is very high and may be related to the hypotonia present in patients with Down syndrome. Since the constipation is very severe in these patients, it should be controlled early in the follow up.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 02/2009; 22(1):45-8.
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A Cañizo,
M Fanjul, J Cerdá,
J Menárguez,
A Parente,
A Laín,
N Carrera,
M D Rodríguez-Arnao,
A Rodríguez-Sánchez,
J R Polo,
J Vázquez
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ABSTRACT: To emphasize the importance of genetic studies in family members and early prophylactic thyroidectomy in oncogene mutation carriers in the management of familiar medullary thyroid carcinoma.
A retrospective review of families with familiar medullary thyroid carcinoma treated at our center in the last 7 years was performed. We identified a total of 7 families who has isolated prevalences with thyroid malignancies. Forty members of the 7 families were screened for gene RET mutations. Prophylactic total thyroidectomy was performed in every RET mutation gene carriers.
In all families the index case were patients with medullary thyroid carcinoma presenting at a mean age of 37.25 years (range 23-42). The RET oncogen mutation was in codon 634 in exon 11 (multiple endocrine neoplasia type 2A) in all these patients. Fourteen gene carriers were identified with a mean age of 20 years (range 7-37), eleven of whom had medullary thyroid carcinoma at the time of surgery. Five of the gene carriers were children, with a mean age of 11 years (range 7-16), four of whom had microcarcinoma and one had metastatic carcinoma at the time of surgery. After surgery no hypoparathyroidism or recurrent nerve paralysis were documented. No pediatric patient has presented with phaeochromocytoma or hypoparathyroidism to date Four of the five children have normal calcitonin levels (< 2 pg/ml) and they are free of disease. The one who presented metastatic carcinoma has recurrent disease and is awaiting surgical treatment.
Genetic studies of family members related to patients with familiar medullary thyroid carcinoma and RET mutations is indispensable. The RET mutation in codon 634 exon 11 was found to be the most frequent association. Prophylactic thyroidectomy is the only curative treatment and has minimal complications when performed by expert surgeons. Early thyroidectomy is recommended since distant metastatic spread can occur at early age.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 04/2008; 21(2):100-3.
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ABSTRACT: The absence or hipoplasia vaginal can turn out to be isolated, associated with ambiguous genitalia, or as anatomical variant in a syndrome of sewer. The fundamental aim in the creation of a new vagina is: to obtain a good aesthetic result, to fulfil functional criteria (elasticity, sensibility, physiological inclination) and to improve the quality of life of the patients avoiding the use of molds and minimizing the morbidity of the zones donors. In this work let's sense beforehand our experience in the accomplishment of neovaginas with intestine.
We analyze the clinical record of 13 patients treated surgically in the last ten years. We differentiate two groups according to the age, the diagnosis and the type of surgery: a) the first group of 8 patients present syndrome of insensibility to the androgens (4), syndrome of Rokitansky (2), extrofia of sewer (1) and mixed gonadal disgenesia (1). This group of patients were controlled in the adolescence by an average of age of 19 years (11-35 years), they fulfilling a neovagina with sigma; b) the second group of 5 patients with sewer (3), extrofia of sewer (1) and congenital suprarrenal hiperplasia (1). This group was controlled prematurely by a middle ages of one year (4 months-3 years). The intestinal segment used as neovagina was sigma (2), ileon (2) and rectum (1), and was performed during the surgical correction of her congenital malformation.
Two patients have presented intestinal obstruction in the postoperatory immediate one. Four patients have needed removal of a small vaginal prolapse, and three have needed vaginal transitory expansions for introit stenosis. The long-term evolution has been favorable with an excellent aesthetic aspect. Four patients recount sexual fully satisfactory relations.
We believe that the neovagina with sigma is at present the best option in patients with absence or hipoplasia vaginal. The advantages are the possibility of precocious and one time correction, a neovagina of dimensions and oiling adapted without need of expansions or molds, an aesthetic excellent aspect, and sexual satisfactory sexual relations.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 02/2008; 21(1):37-42.
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A Laín, J Cerdá,
A Cañizo,
A Parente,
M Fanjul,
E Molina,
R Romero,
M A García-Casillas,
J Matute,
D Peláez,
J Vázquez
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ABSTRACT: Oesophageal Stricture (ES) is one of the most frequent complications of oesophageal atresia repair surgery. The treatment consists of dilatation of the stricture. Mostly more than one procedure is necessary for its correction.
Present our experience in balloon dilatation in the treatment of ES post-correction of oesophageal atresia.
A retrospective study of 34 children diagnosed and treated of oesophageal atresia was done. In all cases the surgical repair included a termino-terminal oesophageal anastomosis. Prevalence of ES (requiring dilatation), number of necessary dilatations, time between the correcting atresia surgery and the first dilatation, time between the first and the last dilatation and complications were analyzed. Dilatations were done under direct radioscopic control with general anesthesia using balloons of 6 to 20 mm diameter. Afterwards esophageal lumen was checked by oral endoscopy.
Thirty-four patients were studied (19 male, 16 female) with a medium weight of 2474 g (rango 1800 to 3300 g). Twenty-nine patients had a type III oesophageal atresia (Vogt classification) which was corrected in their first 24-48 hours of life, five patients had a type I oesophageal atresia and repair surgery was done with a medium age of five months. All patients received medical treatment for the gastroesophageal reflux and 11 patients needed a surgical antireflux surgery. Sixty-eight endoscopic procedures were done. Seventy-nine % of the children required some endoscopic dilatation (27 patients) and received an average of 2.5 dilatations (1 to 8 dilatations): 55.5% between 1 and 2 dilatations, 37% between 3 and 4, and 7.5% more than 5. The first dilatation took place in the average of 49.4 days post-correction surgery (15 days to 1 year). The medium time interval between the first dilatation and the last one was 131 days, although in more than 50% of the cases it did not reach 2 months. Only 2 oesophageal perforations were observed (2.3% of the dilatations), one of which had a favourable outcome with conservative management and the second one required surgery. All patients except for one are alive at this time and in more than 90% of the cases they have a complete and normal oral intake.
Es requiring dilatations after oesophageal atresia repair are a frequent problem, appearing generally in an early period. Balloon dilatation under radioscopic control is an efficient and safe procedure for its treatment. Usually more than 1 dilatation is needed being the time period between two dilatations small. We think that associated medical antirreflux treatment is necessary in all cases, but only in specific cases surgical management of the gastroesophageal reflux.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 11/2007; 20(4):203-8.
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A Parente,
A Cañizo,
A Laín,
O Sánchez, J Cerdá,
E Molina,
M A García-Casillas,
R Romero,
J A Matute,
B Bernardo,
M Sánchez-Luna,
J Vázquez
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ABSTRACT: To determine if the needs of cardiopulmonary support of neonates with congenital diaphragmatic hernia (CDH) they can be indicators for the election of the most suitable moment to the surgery.
We treated 16 consecutive neonates with congenital diaphragmatic hernia (CDH) from 2004 to 2005. Mean birth weight was 2900.63 +/- 531.51 g. Patients was divided in 2 groups. Group A: newborns without adrenaline nor noradrenaline like vasoactive drugs and conventional respiratory assistant; the surgery was performed during the first 48 hours of life. Group B: newborns with adrenaline or noradrenaline like vasoactive drugs, high-frequency oscillatory ventilation or extracorporeal membrane oxygenation; surgery was delayed (10.66 +/- 8.26 days).
Four neonates died during the first 24 hours of life without surgical treatment not fulfilling criteria of support ECMO. Five patients were operated during the first 48 hours, fulfilling all of them the clinical criteria of the group A. Mortality does not exist in this group. Seven patients were operated late fulfilling the criteria of the group B. They all needed VAFO. Two patients of this group needed support ECMO. The survival rate in this group was 83.3%.
In our opinion, the patients with CDH that need initially high cardiopulmonary support, VAFO and/or ECMO would be necessary a time of wait to realize the surgery. In those patients who don't need this level of treatment the delay would not justify itself in the surgical intervention.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 11/2006; 19(4):232-5.
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ABSTRACT: Cloaca is a defect in which the rectum, the vagina and the uretra are fused in a single common channel. Cloaca is the most complex anorectal malformation. The surgical management depends on the length of the common channel and the associated defects.
Since 1993 we have treated 9 cases of cloacas. The average age at surgery was 12 months. Five patients had associated vertebral defects, six had urological defects and six had vaginal defects. All patients were approached posterior sagitally; 4 of them also required a laparotomy.
Five patients underwent a total urogenital mobilization. In the four patients requiring laparotomy we performed vaginal switch in 1, and vaginal replacement in 3 (2 with ileum and 1 with colon). Six patients are older than four and have fecal continence. Three of them are continent of urine, and 1 remains dry with intermittent catheterization. Two patients remain derivated (ureterostomy, vesicostomy).
Surgical repair should be completed early, and it should include cystoscopy, posterior sagital approach, and laparotomy depending on the complexity of the defect. Cloaca is a challenge for the surgeon because of the wide spectrum of anatomic defects and the need to apply different surgical techniques in order to achieve good functional and cosmetic results.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 08/2006; 19(3):140-3.
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A Cañizo,
A Parente,
J A Navascués,
J Soleto, J Cerdá,
E Teigell,
C Merello,
A Carrillo,
J R Fuentes,
J I Mantilla,
C Bañuelos,
R Romero,
A Villa,
O Riquelme,
J L González,
J Vázquez
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ABSTRACT: At 07:39 on 11 March 2004 terrorist bomb explosions ocurred in 4 trains in Madrid killing 177 people instantly and 14 more later in the hospital. This report describes the organization, clinical management and patterns of injuries in casualties who were taken to our chil-patients were taken to the Gregorio Marañon hospital and 12 to the children's one. The mean age was 16 years (14-21), Two of them were critically ill and needed intensive care (ITP 5). Tympanic perforations occurred in 81% victims with moderate to severe trauma, shrapnel wounds in 36% and eye lesions in 27%. Among critically ill patients blast lung injury, cranial and abdominal trauma were the most important lesions. Training in AITP courses and hospital logistics were essential in clinical management of these casualties.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 08/2006; 19(3):156-9.
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A Parente,
J A Navascués,
E Hernández,
O Sánchez-París,
A Cañizo, J Cerdá,
E Molina,
E De Tomás,
J C De Agustín,
J A Matute,
J Vázquez
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ABSTRACT: Analysis of main factors of spinal cord and vertebral column injuries in our environment.
We reviewed the data collected from the patients (n = 2640) admitted to our hospital because of trauma and included in our Registry from January 1995 to April 2002. Among this group, 86 patients (3.3%) had spinal cord and vertebral column injuries and were included in the study.
Group gender distribution was 45 males and 41 females. In our group, 71 patients suffered vertebral fractures, 3 of them with spinal cord injuries (4.2%), 13 patients with vertebral subluxation, 11 of them between C1-C2, and 2 patients with spinal cord injury without radiographic abnormality. Only 71 patients, 4.9% of the total of the patients who were admitted with any type of fracture (n=1457), suffered vertebral fractures. These patients suffered 130 vertebral fractures, 35 of them (49.3%) suffered multiple fractures. Thoracic vertebrae were the most frequently affected (n=82, 63%). The most frequent localization was T4 toT8 (n=50, 38.5% and T11 to L2 (n=41, 31.5%). Age ranged between 12 and 15 years (n=35, 49.3%), with only 5 patients under 6 years. 90.9% of the patients with lumbar fractures were older than 8 years and 76.9% of the patients with cervical fractures were over 8 years. Motor vehicle accident was the most common cause in our series (n=20, 23.3%). 81% of these patients did not use safety belt. Ten children with cervical injuries were seen by medical staff at the prehospital stage, and only 4 of them arrived to Hospital with cervical collar. There were thirty five patients with thoracic or lumbar injuries but only 27 of them were transferred to our Institution by ambulance. Surgery was required in 2 patients, both of them with unstable fractures. Mean hospital stay was 17,1 days (range 2-37 days).
Group gender distribution is similar between males and females and the incidence in our series is higher than other series of the literature. Thoracic injuries are the most frequent. It is necessary to improve prehospital management of these patients and to increase the use of safety belt. Spine injury incidence increased with age.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 08/2005; 18(3):132-5.
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R Luque Mialdea,
R Martín-Crespo,
E Hemández, J Cerdá,
M García-Casillas,
O Sánchez,
A Cañizo,
J Cebrian,
T López Gil,
T Blanco,
L Morales,
A Fernández,
A Luque de Pablos,
C Carrero,
L Moreno
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ABSTRACT: To prove that the nephrectomy, in spite of being a major surgery, requires less than 48 hours stay hospital if it is performed by retro peritoneal approach. Consequently this procedure can be carry out in a short hospital stay.
From 1995, we have treat 40 patients by retroperitoneoscopic nephrectomy, 46 nephrectomies in total, being bilateral in 6 patients because of terminal renal failure (TRF), who do not take part in that study. The average age was 4.8 years range old (with a rank between 6 months and 13 years old), in relation with sex, male (n=16) and female (n=18). As for the side of the nephrectomy, it was the right in 20 cases and left in 14. Those pathologies, which indicated the nephrectomy because of kidney's functional annulations, were: obstructive hydronephrosis (n=2); obstructive megaureter (n=1); kidney destroyed by reflux (n=8); multicystic displasia (n=11); involution multicystic diyplasia (n=12).
In all the cases, the nephrectomy was pure retroperitoneal approach. The average time of surgical duration was of 92 minutes (with a range between 60-240 minutes). It was reconversion in 1 case (4.5%) by peritoneal micro perforation (n=1). We underline absence of inherent complications to retroperitoneoscopy, intraoperative and postoperative procedures. As secondary complications to the access surgical procedure were 2 wall relaxations because of incisional injury and one serum collection of the first port site. The bleeding during the operative act was imperceptible, less than 20 cc. Drainages were not left in the operative bed. The average stay has been reduced to 27 hours, without being counted the 6 cases of TRF. In the last 18 cases the hospitality discharge was made in the first 24 h postoperative. The analgesic established by protocol was analgesic of infiltration of ports site with 1% bupivacaine and one dose of paracetamol/ibuprofen, given 12h after the intervention and repeated after hospitality discharge. Essumpcion of their day home-life and school- was earlier in 100% of cases. We underline the absence of secondary complications to pain (breathing) neither to immobilization.
The retroperitoneoscopic nephectomy is a clearly established indication and of required fulfilment in paediatric age. It is the suitable surgical boarding to perform a nephrectomy because of its reliability, reproductibile and safety. Media hospital stayis lesser when the nephrectomy was performed by retro peritoneal approach than conventional surgery. Consequently this procedure can be carry out in a short hospital stay.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 08/2005; 18(3):136-41.
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R M Romero,
M A García-Casillas,
J A Matute,
G Barrientos,
E Zamora,
A Megías, J Cerdá,
R Sánchez,
M L Franco,
E Molina,
J A Vázquez
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ABSTRACT: Peritoneal drainage (PD) has been proposed as a temporizing procedure for perforated necrotizing enterocolitis (NEC) in very low birth weight neonates. This operation was designed for patients considered too unstable to undergo laparotomy (LAP). Since the introduction of PD some investigators have suggested that it may serve as a definitive therapy. The aim of our study is to determine the efficacy of PD for the stabilization of patients with complicated NEC and its utility as a definitive surgical treatment.
We review the clinical records from all the patients treated in our unit because of NEC that required surgical therapy. We analyze the mean blood pressure, cardiac and respiratory rate, inspired oxygen concentration, mean airway pressure, diuresis, and arterial blood gases measured 6 and 12 hours after the initial surgical treatment. We divide patients in two different groups according to the initial surgical procedure, peritoneal drainage (PD) or laparotomy group (LAP). Data is shown as media +/- standard deviation, statistical analyses were performed using analysis of variance (ANOVA) for repeated measures and Mann-Withney test.
From January 1997 to January 2001 we treated 13 patients with necrotizing enterocolitis that required surgical treatment. Among this group 6 patients were managed initially with PD and 7 with LAP. The gestational age media was 29.07 +/- 3.81 weeks and the birth weight mean 1199.76 +/- 521 gr., without any significant differences between the two groups DP and LAP. All patients improved haemodynamically and respiratory 6 and 12 hours after the surgical treatment. Nevertheless, the mean blood pressure improved even more in the DP group (p<0.005). The DP group showed an improvement in all parameters 6 hours after the drainage was placed, but this effect wasn't maintained for the next 12 hours onwards. From the 12 hours after PD all patients suffered a steady worsening that required further surgical procedures. The overall mortality was 3 patients (23%), without differences between the two groups. The surgical techniques performed (bowel resection, diversion) were similar for both groups.
DP allows the stabilization for very critically ill patients with complicated NEC. However, this stabilization is temporary. This improvement lasts for a few hours providing a better status for the definitive surgical treatment for the perforated NEC. In our experience DP could not be considered as a definitive surgical treatment.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 04/2005; 18(2):88-92.
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J A Navascués,
J Matute,
J Soleto,
M A García Casillas,
E Hernández,
O Sánchez-París,
E Molina,
E De Tomás, J Cerdá,
R Romero,
J C De Agustín,
F Aguilar,
J Vázquez
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ABSTRACT: To analyse the characteristics of the infant population suffering trauma in our setting. To evaluate the importance of the different aetiological mechanisms. To study the pre- and intra-hospital management of these children. To describe the relative significance of the different lesions. To establish the magnitude of paediatric trauma as a social problem in terms of morbidity and mortality.
From January 1995 to April 2002, a total of 2633 children admitted to our Centre (Hospital Universitario Gregorio Maranon) after suffering some type of injury were included in our Trauma Register. 108 variables have been analysed, including the identification of the patient, type, site and mechanism of the accident, pre-hospital care, transport, complete evaluation on admission, indices of injury severity, diagnostic tests, lesions, treatments performed and morbidity and mortality.
The accidents were more frequent in boys than in girls (68.5 % versus 31.5 %). The predominant age group was the 12 - 15 year old group (36.8 %). There was a higher frequency of accidents in the street (37.2 %) than at home (19.4 %) or at school (13.8 %). The most frequent mechanism was a fall (35.6 %), followed by road traffic accidents (23.7 %). On admission, 14.7 % of the children had a Paediatric Trauma Score (P.T.S.) < or = 8 (n = 388). 3.8 % were considered severe multiple trauma patients, presenting an Injury Severity Score (I.S.S.) > or = 15 (n = 101). 4.2 % of the children required intensive care. The most frequent lesions were those of the locomotor system (58.1 %) and head injuries (34.9 %). Some type of surgical or orthopaedic procedure was performed under general anaesthesia in 1522 patients (57.8 %). The mean length of stay was 4.4 days (range 1 - 214 days). Sequelae of some form were detected in 36.4 % of the patients over 3 years of age. The total mortality was 0.5 % (n = 13), being 12.8 % in the group of patients with an I.S.S. > or = 15.
Analysis of the data in our Registry has helped us to define the characteristics of the paediatric trauma population in our setting, to monitor the management of trauma in the different care levels and to develop prevention programmes. It has also enabled us to compare the results with those of other centres in terms of morbidity and mortality with the aim of identifying and correcting any possible deficiencies in the care system.
European Journal of Pediatric Surgery 02/2005; 15(1):30-7. · 0.81 Impact Factor
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ABSTRACT: Necrotizing tracheobronchitis has been described as a complication of mechanical ventilation of newborns with respiratory failure. Neonates with necrotizing tracheobronchitis present a diverse clinical spectrum from asymptomatic disease to severe airway obstruction that causes 45% of mortality. The objective of our study is to analyze our experience in the management of these patients.
In the last three years we have treated eight patients with necrotizing tracheobronchitis The mean age was 0.84 +/- 0.95 months, gestational age of 37.43 +/- 2.3 weeks. The mean weight was 3.07 +/- 1.04 kg. Five patients had a congenital heat disease (62.5%) and three have a respiratory failure (37.5%). We have analyzed the contributing factors, symptoms, diagnosis, treatment and results.
All patients presented episodes of shock with treatment of drugs. Five patients have conventional ventilation (62.5%) while three have high frequency oscillatory ventilation (37.5%). There were not significant differences in the ventilator parameters of both groups (PMA, PIP, PEEP). Three patients were supported by ECMO when they developed necrotizing tracheobronchitis. The treatment was bronchoscopic removal of necrotic tissue. There was not any complication after the procedure. A patient suffered a stenosis in the left main bronchus. Three patients have died during follow-up for different causes. The time of pursuit is of 10.33 +/- 7.61 months.
Necrotizing tracheobronchitis may be increasing in the Neonatal Intensive Care Units, due to a bigger survival of patient with serious respiratory failure and shock. Hypotension and shock seems to be a major contributing factor in the development of this lesion. Bronchoscopy is necessary for treatment and survival of the patients.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 05/2004; 17(2):93-7.
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J A Navascués,
J Soleto,
R Romero,
M A García Casillas,
E Hernández,
O Sánchez-París,
E Molina,
E de Tomás, J Cerdá,
J C de Agustín,
J Matute,
F Aguilar,
J Vázquez
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ABSTRACT: In 1997 we developed the "Pediatric Trauma Life Support Course"applied to every one who provide care for the pediatric trauma patient. Since November 1997 until December 2000, 14 courses were imparted inside of the "Comunidad de Madrid" with total number of 289 students. Thirty-eight students have been people who worked in the prehospital area inside of our Community. The aim of this paper is to determinate the possible impact of these Courses in the prehospital management of the pediatric trauma patient.
We reviewed the Pediatric Trauma Registry inputs of our hospital since January 1995 until December 2000. A total number of 2166 patients required admission in our hospital after the injuries. 495 patients which moved to our Institution by medical people and a special transport (ambulance/medical van) were enrolled. The patients were classified into two groups. In the first group were included the children admitted between 1995 to 1997 (group 1, n = 232), before we had applied our Courses and in the second group, the patients admitted between 1998 to 2000 (group II, n = 263), after The Pediatric Trauma Life Support Course was conducted. Both groups seems to be equal if we compare the age, sex and severity of the injuries. We analysed the infant orotracheal intubation in a coma patient, gastric intubation in the several trauma patient, vascular access and apply a semirigid cervical collar into a head injury. If we think that the application of these manouvers will be a good quality index of the management of these patients in the prehospital area, we compare the index of application of these variables according to the years before and after the Courses were imparted. For this pourpose we used the X2 test shows significant differences within both groups if p < 0.05.
All paramethers analyzed were better in group II than in group I (p < 0.05).
The results of this paper shows that the use of this program for the management of the pediatric trauma patient is going well and the assessment is doing better than few years before.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 01/2004; 17(1):28-32.
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ABSTRACT: The vestibular fistula is the anorectal malformation more frequent in females. In this congenital anomaly the anus is located in the vaginal vestibule, having the rectum a common wall with the vagina. With the posterior sagittal approach described by Alberto Peña it changes the treatment of this anorectal malformation, contributing to the possibility of an aesthetic and functional improvement. From 1996 we have operated on 6 girls with ages included between 6 and 22 years (mean of 11 years) that presented a vestibular fistula. Five cases had been operated on in the neonatal period of vestibular fistula carrying out "cut-back", and a case had been operated on for cloaca syndrome. It was carried out in all of them, posterior sagittal approach disecting the rectum, separating it from the vagina and placing it in the sphincter. In a case a colostomy was carried out and in the other five were carried out intestinal cleaning, maintaining absolute diet and postoperative total parenteral nutrition. The evolution has been favorable in all the cases. the functionality of the neo-anus in terms of continence is absolutely normal, presenting an excellent aesthetic aspect. We believe that the posterior sagittal approach is suitable as surgical treatment of the vestibular fistula. The aesthetic improvement and the satisfaction of our patients motivates us to the realization of this technique that also allows us to correct in only one surgical act associated vaginal malformations.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 11/2002; 15(4):140-4.
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ABSTRACT: Advances in obstetric practice have decreased birth traumas in the last years, although they are still an important chapter in neonatal age. Between 1993-1998 a total of 21,375 stillborns were registered with a total of 309 birth injuries in 303 neonates (1.44%). The diagnoses were: 2 liver subcapsular hematomas, 105 cephalohematomas, 16 parietal fractures, 11 subdural hemorrhages, 107 clavicular fractures, 10 miscellaneous fractures, 8 soft tissue injuries, 25 facial nerve injuries and 25 braquial palsy. About relation between type of labor and birth trauma was found that clavicular fracture and cephalic vaginal delivery were associated in 50% of the cases, cephalohematoma and forceps in 51%, braquial palsy and vaginal delivery in 44% and forceps in 36%. High weight at birth was another risk factor for entities such as clavicular fracture and braquial palsy. We conclude that birth trauma is a pathology with a relevant incidence and their epidemiology factor had to be known.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 11/2000; 13(4):150-2.
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ABSTRACT: The urogenital sinus is an embriological anomaly which consists on a common channel from the urethra and vagina. The major incidence is produced in the congenital adrenal hyperplasia's context. In certain occasions it can be associated to an imperforate anus, then the malformation is called a cloacal defect. There are multiple surgical techniques to correct this malformation and different therapeutical approaches (without surgery, surgery at one or various times, early or delayed surgery) being the newest one the total urogenital mobilization. The purpose of this work is to reflect our experience with this technique. We present seven girls with urogenital sinus (3 with congenital adrenal hyperplasia, 2 with a cloacal defect, and the other 2 associated to ambiguous genitalia). Five patients were operated in the first year of life. The outcome has been favorable, and the cosmetic and functional results have been very good. The surgical technique consists on posterior sagittal incision, it can be done transanorectal if necessary, the urethrovaginal union is achieved and both structures are mobilized together, connecting them to the perineum, as a single unit. We believe that the total urogenital mobilization is actually the surgical technique to be chosen in every of urogenital sinus, for being easier, allowing early realization (girls under 1 year old), correcting simultaneously other anomalies, reducing the complications (urethrovaginal fistula, vaginal structure, or acquired vaginal atresia); and the result is excellent.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 05/2000; 13(2):54-7.
