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

Objective: To analyze the accuracy of cell ratios in the diagnosis of pediatric acute appendicitis while introducing a new one -the derived neutrophil-to-lymphocyte ratio (dNLR).

Materials and methods: An observational, retrospective study of patients aged 0-15 years old diagnosed with acute appendicitis (AA) and with non-surgical abdominal pain (AP) treated in our institution from 2021 to 2022 was carried out. The neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), and dNLR were compared between groups.

Results: 98 AA patients (30% of whom were female; age: 10 ± 3.3 years) and 97 AP patients (53% of whom were male; age: 9.3 ± 3.7 years) were included. NLR, MLR, PLR, and dNLR values were higher in AA patients than in AP patients: 9.6 IQR (interquartile range) 9.5 vs. 3.3 IQR 5.3: p< 0.0001; 0.7 IQR 0.6 vs. 0.46 IQR 0.7: p< 0.023; 199.8 IQR 163.9 vs. 134.0 IQR 129.2: p< 0.0001; and 5.29 IQR 3.9 vs. 2.39 IQR 2.7; p< 0.0001, respectively. Sensitivity, specificity, positive-negative predictive value, area under the ROC curve, and dNLR cut-off point for AA diagnosis were 70%, 78%, 77-72%, 0.811, and 3.98, respectively.

Conclusions: Cell ratios are useful and cost-effective inflammatory parameters in the diagnosis of pediatric acute appendicitis. The results of this study suggest dNLR has the greatest clinical accuracy.

Introduction: There are multiple tools available to optimize defecation in patients with anorectal malformation (ARM), such as habits, laxatives, and retrograde or anterograde irrigations, which are usually adapted in a progressive and combined fashion. The objective of this study was to assess the incorporation of transanal irrigation (TAI) to constipation and fecal incontinence treatment in patients with ARM.

Materials and methods: A retrospective study of ARM patients with indication of TAI according to the colorectal pathology unit's intestinal management protocol from 2015 to 2022 was carried out. Following use for over 3 months, patients or their guardians completed a phone survey of our own approved by the ethics committee.

Results: 39 ARM patients participated in the study. Pathologies included 11 rectourethral fistulas, 6 rectovesical fistulas, 16 cloacae, 2 rectovaginal fistulas, 2 perineal fistulas, and 2 vestibular fistulas. 44% of them had a sacral index < 0.4. 62% had constipation, and 38% had incontinence. Thanks to TAI, confidence and safety improved in a very high and a high degree in 89% of the patients, whereas time devoted to intestinal management decreased a lot in 68% of them. 79% reported a 9- and 10-point quality-of-life improvement. 92% rated overall satisfaction with TAI with a score of 8, 9, and 10 - 10 meaning "completely satisfied." 100% recommend TAI.

Conclusion: TAI is a good alternative for the intestinal management of fecal incontinence and constipation.

Introduction: Cutis marmorata telangiectatica congenita (CMTC) is a rare capillary malformation characterized by persistent reticular and violaceous erythema. We present two cases of CMTC.

Clinical observation: The first case involved a 13-month-old male with a reticular violaceous macule on the left gluteal region and a brownish papule with Darier's sign on the inner malleolus of the left foot, which was biopsied, revealing > 15 mast cells per field, leading to a diagnosis of CMTC and solitary cutaneous mastocytoma. The second case involved a newborn with a characteristic CMTC lesion without other malformations at birth, who subsequently developed two cutaneous tumors consistent with infantile hemangiomas during follow-up.

Discussion: CMTC is a benign condition. However, approximately 50% of cases exhibit associated anomalies. When CMTC is suspected, musculoskeletal, ophthalmological, and cutaneous malformations should be ruled out. To the best of our knowledge, this is the first report of CMTC associated with mastocytoma and one of the few cases associated with infantile hemangioma.

Objective: To define the types of overactive bladder (OAB) patient enuresis and study daytime bladder treatment response.

Materials and methods: A prospective, multi-center study of OAB patients with enuresis treated with anticholinergics or neuromodulation over 3 months from 2019 to 2021 was carried out. Variables achieved from the voiding calendar and PLUTSS (Pediatric Lower Urinary Tract Score System), as well as enuresis-related variables, were collected. Two study groups were created -primary enuresis (PE) and secondary enuresis (SE). Partial enuretic response (PER) was defined as a >  50% reduction in baseline enuresis, and complete enuretic response (CER) as a 100% reduction. A multivariate analysis was eventually conducted to detect CER independent predictive factors.

Results: 152 OAB patients were included. 109 of them (71.7%) had enuresis -29 (26.7%) SE and 80 (73.3%) PE. PLUTSS score was higher in PE patients than in SE patients (20.8 vs. 17.2; p= 0.001). PER and CER were significantly higher in the SE group (55.2% vs. 15%; p= 0.000 in PER, and 48.3% vs. 5%; p= 0.000 in CER). In the multivariate analysis, SE patients demonstrated to have a 50-fold increased probability of responding to daytime bladder treatment than PE patients (OR: 49.79; 95%CI: 6.73-36.8).

Conclusions: Most OAB children have PE and not SE, which explains why enuresis does not typically respond to daytime bladder treatment. Characterizing the type of enuresis in OAB children is important to adequately approach treatment.

Introduction: In spite of being inaccurate in terms of suprahyoid dissection, Sistrunk's procedure is the gold-standard technique in the treatment of thyroglossal cyst. Since it was first described in 2014, the modifications introduced by Koempel have allowed for a more reproducible suprahyoid approach. We present our initial experience with this technique.

Methods: A retrospective study of patients with thyroglossal cyst undergoing Koempel's technique in our institution from 2021 to 2022 was carried out. Demographic, clinical, and histological data was collected.

Results: In the study period, 5 patients -3 girls and 2 boys- underwent surgery. Median age and weight were 5 years (2-6) and 16 kg (14-25), respectively. All patients had suffered from previous infections, with 60% having cutaneous fistulization. In 2 patients, surgery was indicated following Sistrunk's procedure as a result of recurrence. Median operating time was 77 minutes (57-110), with the genioglossal muscle plane being identified in the 5 patients. No immediate complications were recorded, and diagnosis of thyroglossal cyst was histologically confirmed in all cases. One of the formerly recurrent patients had recurrence following surgery, but it was subclinical and incidentally diagnosed at control ultrasonography. The remaining patients had no recurrences after a median 8-month (1-12) follow-up period.

Conclusions: Koempel's technique allows for a safe and reproducible approach of the suprahyoid segment. It is an attractive option in complicated cases as a result of previous infection or recurrence.

Introduction: Intestinal malrotation is a congenital pathology with potentially catastrophic complications, such as volvulus, whose treatment has barely not changed in nearly 100 years (Ladd's procedure). Dr. Abu-Elmagd recently described a new technique that was applied in one of our patients.

Clinical case: 12-year-old boy who had undergone Ladd's procedure as a result of intestinal volvulus secondary to malrotation when he was 2 days old. He had subocclusion and eventually obstruction, with intestinal volvulus compatible imaging. Intraoperative findings: duodenal subocclusion, volvulus and lymphangiectasias. Kareem's procedure: bowel positioning in normal rotation, duodenopexy (duodenal C posterior to the mesenteric vessels), formation of neo-Treitz, and fixation of the cecum, the ascending colon, and the mesenteric root. The patient was discharged on postoperative day 6 and remains asymptomatic after 1 year of follow-up.

Discussion: Kareem's procedure is a safe and effective malrotation repair technique. It can replace Ladd's procedure as it reduces the risk of re-volvulation and improves digestive symptoms.

Introduction: Pediatric Surgery studies in Spanish universities are not regulated, and their situation varies significantly from one region to another.

Materials and methods: A descriptive study by means of a survey directly addressed to the heads of the 47 Spanish healthcare units was carried out.

Results: Only 33 pediatric surgeons currently teach at the university level. Most of them are employed (associate professors) and assigned to non-surgical departments. The degree of teaching accreditation of these professionals is meager.

Conclusion: It is necessary to reflect deeply on the absence of our specialty in universities and, conversely, on the scarce presence of university studies and research in healthcare units.

Objective: The objective of this study was to analyze whether patients undergoing esophageal atresia (EA) surgery benefit from a cross-disciplinary follow-up program, based on current clinical guidelines, implemented in our institution.

Materials and methods: An observational, analytical, retrospective study of patients undergoing EA surgery from 2012 to 2022 was carried out. The results of a joint pediatric surgery and gastroenterology consultation program -which was implemented in 2018 and applies a protocol based on the new ESPGHAN-NASPGHAN guidelines- were analyzed. Patients were divided according to whether they had been treated before or after 2018. Quantitative variables -follow-up losses, anti-reflux treatment initiation and duration, and enteral nutrition initiation- and qualitative variables -prevalence of gastroesophageal reflux, anti-reflux surgery, respiratory infections, anastomotic stenosis, re-fistulizations, dysphagia, impaction episodes, need for gastrostomy, and endoscopic results- were compared.

Results: 38 patients were included. 63.2% had gastroesophageal reflux. 97.4% received anti-reflux treatment in the first year of life, with treatment being subsequently discontinued in 47.4%. Discontinuation time decreased by a mean of 24 months following program implementation (p< 0.05). A 4.6-fold increase in the frequency of pH-metries was noted following program implementation. The protocol standardized endoscopies in asymptomatic patients when they turn 5 and 10 years old. 25 endoscopies with biopsy were carried out after 2018, with histological disorders being detected in 28% of them. The number of follow-up losses significantly decreased following protocol implementation (p< 0.05).

Conclusions: Digestive-surgical cross-disciplinary follow-up of EA patients has a positive impact on patient progression. Applying the guidelines helps optimize treatment and early diagnosis of complications.

Objective: Circumcision is one of the most common surgical procedures in pediatric surgery. Even though manual suture (MANS) is regarded as the gold standard technique, easy-to-use mechanical suture (MECS) devices have been recently developed, with better postoperative results in the adult population. The objective of our study was to compare the operating time and incidence of postoperative complications between both techniques in our environment.

Materials and methods: A retrospective study of patients undergoing circumcision in our institution from October 2021 to December 2022 was carried out. Operating time and complications observed in the first 14 postoperative days (edema, hematoma, dehiscence) were analyzed according to the technique used (MANS vs. MECS) and patient age (< 12 and ≥ 12 years old).

Results: 173 patients (147 MANS, 26 MECS) were included. Mean operating time was significantly lower in MECS patients, both in patients < 12 years old (16 min vs. 10 min, p= 0.002) and in patients ≥ 12 years old (23 min vs. 12 min, p< 0.001). Regarding complications, MECS patients ≥ 12 years old had a lower rate of suture dehiscence (23.5% vs. 0%, p< 0.001), with no significant differences in the younger group.

Conclusions: MECS circumcision is a simple and effective technique involving shorter operating times than MANS circumcision, regardless of age. It has a lower rate of complications in older children (≥ 12 years), which means it stands as a valid alternative to the conventional technique.

Introduction: In spite of the increase in the prevalence of cholelithiasis in the last decades, no recommendations regarding the best treatment of acute calculous cholecystitis (AC) in Pediatrics have been developed.

Clinical case: 4-year-old, 20kg male patient with no significant history referred to our institution as a result of abdominal sepsis. The blood count showed leukocytosis, with normal hemoglobin and bilirubin levels, and a normal liver function. The abdominal ultrasonography revealed cholelithiasis, gallbladder hydrops, and an inflammatory process compatible with appendicular plastron. In the diagnostic laparoscopy, the appendix was macroscopically normal, and acute cholecystitis was observed. Given the patient's situation, and in cooperation with the General Surgery Department, laparoscopic cholecystectomy was carried out. The patient recovered uneventfully on hospitalization day 5 under piperacillin-tazobactam treatment.

Discussion: There are no recommendations regarding AC treatment in children. In septic patients, cooperation between general and pediatric surgeons allows urgent cholecystectomy to be considered as a safe option.