Cirugia pediatrica : organo oficial de la Sociedad Espanola de Cirugia Pediatrica最新文献

Objective: To analyze the experience in the management of myeloid sarcomas at a pediatric oncology referral center.

Material and methods: A descriptive, retrospective study of patients under 18 years of age diagnosed with myeloid sarcoma between 2010 and 2024. Demographic variables, underlying disease, tumor location, tumor size, treatment, and clinical outcome were collected. The analysis was performed using IBM® SPSS Statistics 30.0.

Results: Seventeen myeloid sarcomas were identified in 14 patients, 13 (76.5%) of whom were male. The median age at diagnosis was 4.33 years (range: 1 month-14.5 years). In 10 cases (58.8%), the sarcoma was the first manifestation of an underlying hematologic malignancy. Biopsy was performed in 12 cases (70.6%). The most frequent locations were soft tissues (47.1%) and bone (23.5%). The mean tumor volume was 45.2 cm3. Acute myeloid leukemia was the most common underlying neoplasm (n= 14), followed by B-cell acute lymphoblastic leukemia (n= 3). Eight myeloid sarcomas (47.1%) resolved after a first cycle of chemotherapy, 6 (35.3%) required additional cycles, 2 (11.8%) received local treatment, and in 1 case (5.9%) resolution was not achieved.

Conclusions: Myeloid sarcoma represents an uncommon extramedullary manifestation. Early diagnosis, based on a high index of suspicion and appropriate clinical and radiological characterization, is crucial to establish an effective therapeutic approach and improve prognosis.

Objective: To assess the use of contrast-enhanced ultrasonography in the diagnosis of gastroesophageal reflux and hiatal hernia, avoiding ionizing radiation.

Material and methods: Seven contrast-enhanced esophagogastric ultrasound examinations were performed in children between 5 months and 3 years of age, 5 to evaluate gastroesophageal reflux and hiatal hernia, and 2 for gastroesophageal reflux. An ultrasound machine with specific software for contrast visualization, a multi-frequency probe, and sonographic contrast agent were used. Findings were correlated with upper gastrointestinal series in 4 cases.

Results: Of the 7 patients, 4 were awaiting percutaneous endoscopic gastrostomy (2 with a nasogastric tube and 2 with vomiting, 1 of them also with a nasogastric tube), and the remaining three had undergone surgery: 1 for hypertrophic pyloric stenosis, another for esophageal atresia, both also with vomiting; and the last was a patient with percutaneous endoscopic gastrostomy and suspected gastroesophageal reflux disease. The following were observed: 2 cases without gastroesophageal reflux, 4 with mild reflux on ultrasound (1 while coughing and another while crying) but not on fluoroscopy, and 1 with massive reflux and hiatal hernia. No side effects were reported.

Conclusions: Contrast-enhanced ultrasound allows confirming or ruling out the presence of GER and hiatal hernia. Its great advantage is the absence of ionizing radiation and the possibility of a real-time study, making it easier to detect reflux.

Introduction: Extraction of bars during Minimally Invasive Repair for Pectus Excavatum (MIRPE) is susceptible to complications ranging from mild to severe. Objective: to compare the outcomes following the implementation of a Bar Extraction Safety Protocol (BESP) to determine its effectiveness in reducing complications.

Material and methods: Retrospective comparative cohort study. Inclusion criteria: Patients who underwent bar removal from November 2013 to March 2024, in whom BESP was implemented, compared with a historical cohort operated on previously. Protocol includes: a) Preoperative measures: during implantation, use of smooth bars, a minimum of two bars with lateral stabilizers, sternal elevation; pre-removal: chest X-rays. b) Intraoperative measures: bilateral incisions, bar straightening, and "safety string" maneuver. c) Postoperative measures: 24-hour admission to the pediatric intensive care unit (PICU) and post-removal chest X-ray. Complications were classified using the Clavien-Dindo (C-D) system, focusing on clinically relevant ones (C-D ≥ II). Statistical analysis was performed using the chi-squared test (Stata v16).

Results: Sixty-seven patients were included; 62 were male. Mean age at surgery: 17 years (range 14-24). Thirty patients (43 bars) operated on pre-BESP, 37 (81 bars) post-BESP. Pre-BESP bars were serrated; post-BESP bars were smooth. Bar dwell time was 27 months (IQR 23-33) pre-BESP and 24 months (IQR 23-25) post-BESP. Hospital stay was 1 day in both groups (maximum: 16 vs. 4 days). Clinically relevant complications occurred in 20% of pre-BESP patients and 0% post-BESP (p=0.048).

Conclusions: Implementation of BESP significantly reduced complications after bar removal, improving safety during bar removal in the MIRPE.

Introduction: Teratomas are congenital tumors originating from pluripotent germ cells that contain derivatives of the three germ layers. One of their extragonadal forms is the anterior mediastinum, where they can present atypically.

Clinical case: A 3-year-old female patient was diagnosed with a cystic mediastinal teratoma in the context of pleural effusion due to tumor rupture. With negative tumor markers, surgical resolution was performed, which evidenced a heterogeneous tumor, adhered to adjacent structures, that was completely resected. The histopathology was compatible with a mature teratoma presenting pancreatic tissue, whose enzymatic secretion we assume was responsible for its rupture.

Conclusions: Cystic mediastinal teratomas can rupture and present as pleural effusion. Although this form of presentation is unusual, it is necessary to be aware of it for proper medical and surgical management.

Introduction: Surgical necrotizing enterocolitis (NEC) is associated with high mortality. Bell's criteria may indicate surgery in late stages, leading to worse outcomes. Early identification of surgical candidates is necessary. Objective: To evaluate surgical decision-making strategies in neonates with NEC, comparing Bell's criteria versus the combined use of metabolic disorder components (MD7) and paracentesis.

Material and methods: A randomized controlled clinical trial was conducted in perinatal hospitals (2022-2023), ClinicalTrials.gov identifier: NCT06035848. Preterm neonates with NEC were divided into a control group (CG): surgery determined by Bell's criteria, and an intervention group (IG): surgery indicated by MD7 and positive paracentesis. The primary outcome was mortality. Descriptive and inferential statistics, relative risk (RR), with 95% confidence interval (CI), and a p-value < 0.05 indicating statistical significance were used.

Results: 117 patients participated (CG n = 56, IG n = 61). In surgical NEC, mortality was 32.1% in IG and 64.7% in CG (p = 0.034; RR = 2, 95% CI: 1.1-4.8). In the IG, surgery was performed early, with better outcomes for perforation, intestinal necrosis, and reoperation (p < 0.05). There were no complications derived from paracentesis, and there were 3 non-therapeutic laparotomies in the IG.

Conclusions: The strategy based on MD7 and paracentesis was superior to Bell's criteria for guiding surgical decisions in preterm neonates with NEC, reducing mortality. The main limitation was a small number of non-therapeutic laparotomies, expected due to the greater sensitivity of the strategy.

Introduction: The treatment of choice in pediatrics for solid organ injuries resulting from blunt abdominal trauma is conservative management. However, in Spain, said management has proven to be heterogeneous and inconsistent with recent evidence. The Spanish Society of Pediatric Surgery (SECP) sponsored the development of this consensus document in the year 2024.

Material and methods: After recruiting a group of experts, a bibliographic review was conducted using the systematic reviews from APSA, the ATOMAC group, and contributions from the experts themselves, to draft a series of initial suggestions. The experts, using the Delphi method, scored these (Likert scale) in different voting rounds until statistical stability in the responses was determined (Wilcoxon Test). Consensus was defined as agreement (scores 4-5) exceeding 70%.

Results: Twelve experts from 11 centers were recruited, achieving gender parity. Seventeen suggestions were developed, organized into four key areas: PICU admission, discharge criteria and strict bed rest, analytical/radiological controls, and physical activity restriction. Statistical stability was reached after 2 scoring rounds, achieving consensus on 15 of the 17 suggestions, while it was not achieved regarding hospital discharge criteria and duration of strict bed rest.

Conclusions: Through Delphi methodology, a consensus document on the conservative management of solid organ injuries was developed. Although consensus was not reached on key aspects such as discharge criteria and strict bed rest, this document aims to help homogenize clinical practice.

Introduction: Median arcuate ligament syndrome (MALS) is a rare vascular disorder characterized by compression of the celiac artery by the median arcuate ligament, resulting in variable clinical presentations, including abdominal pain.

Case report: A 16-year-old female patient presented with chronic abdominal pain, recurrent vomiting, and weight loss over seven months. Doppler ultrasound showed increased peak systolic velocity in the celiac artery (331 cm/s) exacerbated during expiration and computed tomography angiography confirmed celiac artery compression with the typical "J-hook" deformity. She underwent successful laparoscopic surgical decompression assisted with indocyanine green fluorescence to confirm adequate perfusion of the celiac territory. Pre and postoperative quality of life was assessed using PedsQL scores, showing significant improvement. After a six-month follow-up, the patient remains asymptomatic.

Conclusion: This case highlights the importance of considering MALS in the differential diagnosis of chronic abdominal pain in adolescents and reinforces the established efficacy and safety of laparoscopic management for MALS.

Introduction: Open inguinal herniorrhaphy is the most widely used inguinal hernia repair treatment in pediatric surgery. Understanding the anatomy of the inguinal canal is essential to conduct this procedure.

Material and methods: A low-cost, easily reproducible model aimed at training residents was designed to simulate open inguinal herniorrhaphy in children. It simulated the presence of inguinal hernia using low-cost materials such as balloons, transparent dressings, materials simulating the cremaster muscle, and cord elements. The model was validated by 4 pediatric surgeons and built by residents, who completed a post-simulation survey using the Likert scale. The survey assessed general aspects such as usefulness, texture, or grade of recommendation for regular training.

Results: The surgical technique was completed step-by-step in the simulation model by a total of 10 pediatric surgery residents from various Spanish hospitals. Scores of 4.5/5 in general aspects, 4/5 in texture, 4.7/5 in usefulness, and 4.6/5 in grade of recommendation were achieved.

Conclusions: We believe this low-cost, easy-to-build model stands as a useful tool both for surgical training and for understanding the anatomy of the inguinal canal in training residents.