The swallowing disorder is an impediment to feed the patient. The percutaneous endoscopic gastrostomy (PEG) offers importants advantages over nasogastric tube feeding in patients who need long-term ...enteral nutrition with difficulty to swallow and to failure to thrive.
We have achieved 40 PEG in our department over the past 10 years. We registered date of the age, weight, indications, types of PEG, the time to first change, evolution of weight and percentiles and the complications.
The average age of our patients was 5 years, 30% under 1 year. We used mostly tubes between 9 and 15 Fr and increasing the size according to nutritional needs. The average weight at the time of PEG placement was 13 kg. The main indications were the impossibility to swallow and failure to thrive and the principal diagnosis was the encephalopathy in 45% of cases. The surgical technique was successful in 100%. Of the complications, only two patients required surgery, a gastrocolic fistula and a laparotomy about broken tube of gastrostomy that has been caught in the cecum. In our series we reported 11 cases of mortality from causes unrelated to the gastrotmy.
The PEG is a good alternative to nasogastric tube in patients with swallowing disorders or failure to thrive in chronic diseases, even in children under one year. The early placement of the PEG support the growth development in these patients with chronic disease who require enteral nutrition for long periods. Probably, the time of placement should be more precocious in chronic patients as well tolerated and may have a long life with a good care.
To present our experience with severe pediatric trauma. The pediatric trauma is the leading cause of death in children under 2 years.
We achieved a retrospective study from 78 pediatric patients ...admitted to the Intensive Care Unit (UCI) for multiple trauma between 2000 and 2008. Age, sex, season, location, mechanism, Glasgow and ITP, type of injuries, complications, days of hospitalization and deaths were reviewed. It was performed descriptive and analytical study using the SPSS 15.0 and chi square and Pearson correlation were applied.
The mean age of patients was of 8.5 +/- 4.2 years with 70% boys. Most accidents occurred in summer (37%) and the most common site was the road (47%). There was 15% of mortality, which the 75% occurred in the first 24 hours. There is an association between abdominal trauma and type of mechanism (p < 0.05). The most common mechanism was the traffic accident (45%) followed by a direct hit. Both ITP as Glasgow score were associated significantly with mortality and complications and with the hospital stay in the UCI there was a weak association but significant and negative (p < 0.05).
Mortality is higher than other series but it may be because that these series include minor injuries. The fall down is the most frequent in pediatric emergencies but it was the mechanism that involves less admission to the UCI. Both ITP as Glasgow score are good indicators of severity and if their values decrease, the hospital stay in UCI and the mortality increase.
Describir la clínica, radiología, diagnóstico y tratamiento en los niños afectados por un brote de tuberculosis en una guardería de Zaragoza.
El caso índice fue una cuidadora que fue diagnosticada ...tardíamente de tuberculosis activa. Se realizó Mantoux a todos los niños, a los positivos se hizo radiografía de tórax. En aquéllos con radiografía patológica se procedió al diagnóstico microbiológico.
De todos los niños de la guardería, 11 presentaron un Mantoux positivo. La radiografía fue patológica en 10. De ellos, 7 (70 %) estaban sintomáticos. Las imágenes radiológicas mostraban en 9 (90 %) casos una condensación parenquimatosa y en 5 (50 %) una adenopatía parahiliar. Tres niños (30 %) presentaron atelectasia lobular y precisaron broncoscopia y administración posterior de corticoides. La baciloscopia fue positiva solamente en un niño, el cultivo en siete y la detección de muestra directa para el complejo tuberculosis en otros siete. Únicamente en un niño toda la investigación fue negativa.
El diagnóstico de tuberculosis en la infancia es difícil, y a veces debe hacerse en base a unos criterios clínicos, radiológicos y epidemiológicos en niños con Mantoux positivo. Los test de detección de muestra directa para el complejo tuberculosis tienen una sensibilidad muy alta y proporcionan resultados muy rápidos. La aparición de brotes epidémicos continúa siendo un hecho frecuente en nuestro medio. El estudio de contactos en los mismos presenta un elevado rendimiento en el control de los brotes.
To describe the clinical and radiological features, diagnosis, and treatment of an epidemic outbreak of tuberculosis in a daycare centre in Zaragoza.
The index case was a teaching assistant with a late diagnosis of bacilliferous tuberculosis. Mantoux testing was carried out in all children. In those with a positive Mantoux test, a chest X-ray was performed. Children with an abnormal chest X-ray underwent microbiological investigations.
Among all the children in the daycare center, the Mantoux test was positive in 11 children. Chest X-ray was abnormal in 10 children. Of these, seven (70 %) were symptomatic. Chest X-ray showed dense opacification in nine children (90 %) and mediastinal lymph adenopathy in five (50 %). Three children (30 %) had lobar atelectasis requiring bronchoscopy and subsequent steroid therapy. Bacilloscopy was positive in only one child. Gastric juice culture was positive in seven children and the amplified
Mycobacterium tuberculosis direct test was positive in a further seven. All microbiological investigations were negative in only one child.
Establishing a definitive diagnosis of tuberculosis in children remains difficult and frequently relies on a constellation of clinical findings, radiology and epidemiology in children with a positive Mantoux test. The amplified
Mycobacterium tuberculosis direct test has high sensitivity and provides fast results. Epidemic outbreaks continue to be frequent in Spain. Study of contacts shows high efficiency in controlling outbreaks.
The masses that we can be found at interlabial in a girl are a extensive spectrum of heterogenous lesions and often there is a confusion in diagnosis, management and prognosis.
We present 5 cases of ...interlabial masses, prolapsed urethra, two paraurethral Skene cysts, botryoid sarcoma and fibroepithelial polyp, and its clinical of debut.
A prolapsed urethra is presented in a 4-year-old black girl with vaginal bleeding from edamatous periurethral mass. The paraurethral cyst is a yellowish cystic mass displacing the urethral meatus in two newborn girls. The fibroepithelial polyp is presented in a newborn girl as polipoid and wartlike tumor and not bleeding injury in the introitus. The botryoid sarcoma appears in a 1-year-old girl with ulcerated polypoid mass of 2 cm from vagina. All cases were treated with surgery except the paraurethral cyst that drained spontaneously and the rhabdomyosarcoma was also treated with chemotherapy.
There must be a good clinical examinations about interlabial masses distinguishing genital or urological origin. The surgery is indicated mainly to reject malignancy because the presentation of sarcoma and polyp could be similar. The prognosis of rhabdomyosarcoma vaginal is good with surgery and chemotherapy. The prolapsed urethra is more common in prepubertal black girls and it is important to exclude sexual abuse. The management of paraurethral cyst is controversial but some authors are advised first observation because they may regress.
Pancreatic pseudocyst: less is more Delgado Alvira, R; Elías Pollina, J; Calleja Aguayo, E ...
Cirugía pediátrica
22, Številka:
2
Journal Article
Pancreatic pseudocysts (PQP) are rare in childhood and management tends to be individualized and controversial, and it is a challenge for the pediatric surgeon. The aim of this study is to determine ...the best management strategies in each patient.
Retrospective review of children admitted to our institution with the diagnosis of PQP and review of literature between 1990 and 2007.
We report two children with postraumatic PQP that respond to non-operative management and 284 cases that were reported in literature (76% after blunt abdominal trauma). 26% of these patients had complete resolution of PQP with conservative management and the others patients required surgical intervention: external percutaneous drainage (18.6%), non-percutanueous external drainage drenaje (3.87%), cystogastrostomy (28.87%), cystojejunostomy o pancreaticojejunostomy (9.5%), endoscopic drainage (9.5%) or distal pancreatectomy (3.5%).
The choice of treatment depends on the surgeon's experience and management of the endoscopic techniques, as well as the availability of interventionist radiology. Asymptomatic PQP in children does no require any specific intervention other than expectant management, especially in patients with trauma-induced PQP. Children with persistent clinical symptoms or those who developed complications may require further intervention.
The incidence of gallstones in childhood is 0.15%-0.22%. Frequency has increased in recent years due to a real increase or to a better diagnosis by ultrasound. The aim of our study is determinate the ...best treatment for every patient.
A retrospective study of 71 children with cholelithiasis admitted to our hospital in the last 20 years.
The male to female ratio was 43:28. Seventeen patients present predisposing factors that might be related to the formation of gallstones. This disease was a casual event in half the cases. In 24 patients the diagnosis was made during a study for inspecific abdominal pain and 14 children showed typical symptoms. Only one patient suffer from acute cholecystitis. In 21 cases we find a single stone and in the other cases there were a lot of stones. The gallstones disappeared spontaneously in two patients. Nine children received treatment with ursodeoxycholic acid, but this treatment was ineffective in 8 of them. 27 patients were operated: Six laparoscopic cholecystectomy, 9 open cholecystectomy, 9 cholecystolithotomy and 3 cholecystectomy with splenectomy.
We recommend periodic checks with ultrasound and conservative management is suggested in asymptomatic children. Operative intervention is recommended for symptomatic patients. The surgical treatment of choice in our centre for patients with solitary gallstones and without inflammatory changes in the gallbladder is cholecystolithotomy. We didn't find reappearence of gallbladder after cholecystolithotomy. Laparoscopic cholecystectomy is the best treatment for children with non working gallbladder, "porcelain gallbladder" and in patients with haematologic disease and gallstones.
Pediatric endoscopy: state of the art Pollina, J Elías; Ibarz, J A Esteban; Martínez-Pardo, N González ...
Cirugía pediátrica
20, Številka:
1
Journal Article
Our society has shown always a great concern with the limits of our speciality. However, we have never approached the issue of pediatric endoscopy. For this reason, we have decided to carry our a ...survey to assess the present situation of endoscopy among surgeon pediatricians.
Twenty-four hospitals whose services include pediatric surgery were sent a survey centred on the following items: name of hospital, number of beds, in pediatrics, number of surgical interventions per year (which enabled us to classify the services in four groups, depending on their surgical volume), which unit is in charge of esophagus-gastroscopy, colonoscopy, esophageal dilatation, percutaneous endoscopic gastrostomy (PEG), endoscopic retrograde colangio-pancreatography (ERCP), rigid and flexible bronchoscopy, and number of such examinations per year.
We received twenty-two answers to the survey (91,88%). The upper endoscopies are carried out in 47,43% of the cases by Pediatric Surgery, (ten units carry out the 100% of the endoscopies in their hospital). All but two ERCP are carry out by the unit of adult gastroenterology, whereas esophageal dilatation and PEG are carry out in 89.33% of cases by Pediatric Surgery. Rigid bronchoscopy is performed by Pediatric Surgery in fifteen units, while flexible bronchoscopy is performed by Pediatric Surgery, Otorhinolaryngology, Pneumology and Pediatrics.
The high degree of response proved the concern with strengthening certain techniques in the field of Pediatric Surgery. Esophageal dilatations and PEG are techniques in the hands of pediatric surgeons, while ERCP is in the hands of adult endoscopists. The units that offer flexible bronchoscopy carry out many more examinations. It would be necessary to reach a consensus regarding various issues related to these examinations, ranging from who is qualified to carry them out to their legal assistance.
Foreign body aspiration in children Ibarz, J A Esteban; Samitier, A Sáinz; Alvira, R Delgado ...
Cirugía pediátrica
20, Številka:
1
Journal Article
The aim to this study is evaluate the history, symptoms, radiographic and endoscopic findings in 420 children who were admitted for suspected foreign body aspiration in our hospital between 1972 and ...2005. In 13 children we didn't find foreign body and in 16 children the foreign bodies were lodged in larynx. The mean age was 33 months. The medical history, phisical exploration, auscultation and radiological findings were positive in 91,4%, 78,3%, 91,6% and 81%. The frecuency or foreign body aspiration is undervaluate and sometimes is excluded as diagnosis. Only 218 (51,9%) patients went to the hospital in the first 24 hours, although 87,8% of patients presented symptoms and 75,4% presented severe symptoms. Moreover the removed foreign bodies and suspected foreign bodies are the same in 82,95%. We think that bronchoscopy should by performed in all children who have had a choking episode.
Infantile hypertrophic pyloric stenosis (IHPS) consists of hypertrophy of the muscular layer of the pylorus. Its etiology is still unknown. In the last years only few jobs that studied the ...extracellular matrix (ECM) in the muscular layer in the IHPS have been reported. Our aim was to investigate the expression of two ECM molecules: chondroitin-sulfate proteoglycan (CSPG) and fibronectin (FN), and fibroblasts.
Full-thickness muscle biopsy specimens were obtained from 33 IHPS patients at pyloromyotomy and 12 controls. Indirect immunohistochemistry was performed using CSPG, FN and fibroblasts monoclonal antibodies. The results were showed by a semiquantitative scale as follows: strong (++), moderate (+), weak (+/-), and absent (-).
We demonstrated that the CSPG immunoreactivity was localized in the connective tissue septa and the expression of FN molecules in the pericellular space. Both molecules were significantly the increased in the muscle layer of the pylorus with IHPS in relation to control pylorus. We also demonstrated a marked increased expression in the number of fibroblasts in the muscle layer of the pylorus with IHPS. Even-though the most striking increase was localized in the septa, we also observed great number of fibroblasts amongst the smooth muscle cells.
We suggest that IHPS is characterized, not only by the muscle layer hypertrophy, but also by the increase of several ECM molecules, such as CSPG and FN. We also think that the increase of fibroblast could explain the higher expression of both ECM molecules in the muscle layer of pylorus in IHPS.
The major advances in neonatal intensive care have made less useful the Waterston's criteria for esophageal atresia (EA) and/or tracheoesophageal fistula (TEF), and other prognostic classifications ...have been reported. The aim of this study was to determine the influence of various parameters on the outcome of EA-TEF.
We reviewed 97 cases admitted in our hospital for 29 years. We divided the cases in two groups in relation to the improvement of our neonatal unit care during the years: 1st. 1971-1982 (n = 46); 2nd. 1983-1999 (n = 51). chi 2 squared test and logistic regression analysis of the influence of several parameters before surgical treatment (Waterston's and Spitz's birth weight groups, pneumonia, ventilator dependence, severity of associated anomalies and cardiac malformations) on mortality was performed.
The survival rate increased since 1983, reaching 86.2% in the last 10 years, although the number of neonates with birth weight < 1500 g has increased. Association with a major anomaly increased the mortality significantly in the 2nd. group only (45.5% major vs 7.1% minor and 8.3% none). The cardiac malformations were the most common, not only before 1983 (26.8%), but also since then (31.3%). When the neonate associated a major cardiac malformation the mortality was significantly higher in the 2nd. group (71.4%). The mortality, when pneumonia was present, was significantly higher before 1983 only (75% vs 32.4%), whereas the mortality was significantly increased by the need of ventilator in the 2nd. group only (85.7% vs 9.1%). Before 1983, the best prognostic parameters were the pneumonia and the severity of associated anomalies, whereas only the ventilator dependence was selected between 1983 and 1999.
The EA-TEF mortality has decreased in the last years. The associated cardiac malformation is the most common. We think that the ventilator dependence is the most reliable prognostic risk factor, showing a poor physiologic status of the neonate.
