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Objectives: Orchiectomy is the most widely used surgical technique in testicular tumors (TT). However, according to tumor size, tumor markers, and histology, tumorectomy can be considered as the technique of choice, since these tumors are mostly benign. We present our experience with conservative surgery., Material and Methods: A retrospective study of 21 TT cases in 19 patients under 14 years of age treated in our healthcare facility from 1998 to 2018 was carried out. The following variables were analyzed: age, laterality, histological type, evolution, presence or absence of recurrence, and ultrasound and analytical follow-up. The therapeutic attitude used was reviewed while assessing the possibility of testicular preservation in selected patients., Results: Conservative surgery was performed in 9 TT cases in 7 patients (2 bilateral cases). Mean age was 6 years (0-13 years). 86% of cases started as an asymptomatic scrotal mass. No significant differences were found in terms of laterality. Tumor markers were negative before and after surgery, except in an infant with high alpha-fetoprotein, which was normalized in the postoperative period. The histological study diagnosed 7 stromal TTs (three Leydig cell stromal TTs, one bilateral Sertoli cell stromal TT, one hamartoma, and one fibroma) and 2 germ cell TTs (bilateral epidermoid cyst). Evolution was favorable in all cases, without clinical or ultrasound recurrence., Conclusions: Conservative surgery of the testicular parenchyma using tumorectomy can be the first therapeutic option in benign tumors and in selected patients with bilateral tumor, since it allows future hormonal and reproductive function to be preserved.

Introduction and Objectives: Ovarian tumours are rare in childhood, and account for 1-5% of all tumours. The aim of this study is to determine the epidemiological features, histological subtypes, and therapeutic management of ovarian solid ovarian tumours of the paediatric population of the province of Cordoba, in Spain., Material and Methods: A retrospective, descriptive, observational and institutional study was conducted in which a review was made of the clinical histories of patients younger than 14years-old diagnosed with ovarian tumours, excluding secondary tumours in a University Hospital between 1994 and 2017. A review was carried out on the age, clinical presentation, laterality, diagnostic methodology, treatment, histopathology, and evolution of these tumours., Results: A total of 37 ovarian tumours were reviewed in 31 patients, 6 of them being bilateral. The mean age was 10.3 (0-14) years, with 58% presenting as a palpable mass. There was no predominance of laterality. The tumour markers were negative. Conservative surgery was performed in 29.7% and adnexectomy in 70.3%. Only one case required post-operative adjuvant chemotherapy treatment (stageI immature teratoma with peritoneal gliomatosis). The histological study shows a predominance of germ cell tumours (65%) against those of epithelial lineage (22%). There were 3 stromal tumours that corresponded to fibroma (Gorlin syndrome), and bilateral gonadoblastoma associated with Frasier syndrome. The most frequent type of tumour was mature cystic teratoma (35.1%). There were no complications in the follow-up., Conclusions: Given that most childhood ovarian tumours are benign, conservative surgery is considered as the first choice, being even more important in bilateral tumours. If there is a family history, it is essential to carry out molecular genetic studies, to rule out associated syndromes., (Copyright © 2020 Asociación Española de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.)

Aim: To present our experience in pediatric patients with testicular torsion (TT) treated by manual detorsion (MD)., Patients and Methods: Retrospective analysis of patients treated by MD in a 10-year period in a single center. Description of symptoms, detorsion technique, follow-up and complications., Results: 76 patients diagnosed with TT were studied in a 10-year period. 16 patients were treated by MD. Mean age was 12 years (Range: 10-13 years) and time from onset of pain was 5.25 hours (±4,2). Left testicle was affected in 75% (n=12). Detorsion maneuver was performed by a pediatric surgeon at the radiology room, in counter-clockwise direction in the right testicle and clockwise direction in the left testicle in all cases. The success was defined as the relief of pain, normal physical examination and was confirmed by Doppler ultrasound performed immediately after MD. MD was effective in 75% (n=12) and orchiopexy was performed under elective conditions at median time of 2 weeks (0-5 weeks). MD was unsuccessful in 3 patients and emergency orchiopexy was performed with no testicular loss. 1 patient had a second MD maneuver for incomplete detorsion. No short or long term complication nor testicular atrophy was observed., Conclusion: MD and elective orchiopexy seems to be an efficient and reliable procedure in the treatment of TT in children. Further studies may be necessary to establish its safety and indications.

Objectives: The management of advanced necrotizing enterocolitis (NEC) in preterm birth with low weight remains controversial. The aim of this study consists in the analysis of the results of treatment in these patients, as well as the evaluation of the role of peritoneal drainage as a definitive therapeutic option., Methods: Observational and descriptive study of 31 patients under 1,500 g of weight with advanced NEC, whom have had surgery in our center in the last 15 years. They were classified in two groups: G1 (n = 21) <1,000 g and G2 (n = 10) 1,000-1,500 g., Results: Average weight in G1 patients was 791.7 ± 137.5 g and 1,280.7 ± 207.9 g in G2 patients (p <0.01). Average gestational age was 26 ± 1 weeks in G1 patients and 30 ± 2 weeks in G2 patients (p <0.01). Mean time to the start of the advanced NEC was 9,4 ± 4.4 days in G1 patients and 16.7 ± 13.5 days in G2 patients (p = 0.031). In group G1, 95.2% of the patients were treated throughout peritoneal drainage, and 4,8% (n = 1) with laparotomy. In G2, 60% (n = 6) of the patients were treated throughout peritoneal drainage, and 40% (n = 4) with laparotomy (p = 0.027). The peritoneal drainage was a definitive treatment in 84.2% (16/20) of the G1 patients, with a survival rate of 56.3% (n = 9); G2 patients had a definitive treatment in 50% of the patients (3/6), with a survival rate of 66.7% (n = 2) (p = 0.261). In G1 patients, 50% (2/4) of the drains which required subsequently laparotomy, died 0% (0/3) in G2 patients., Conclusions: Peritoneal drainage is primarily a valid therapeutic option in extremely premature infants and can be used as definitive treatment.

Aim: Neonatal tumours represents less than 2% of all childhood cancers. The biological behaviour of this tumours will differ in older children. The tumours's biological differences and the immature physiological characteristics of newborns represent a great therapeutically challenge making newborns vulnerable. The aim of this study is to describe the clinical characteristics, associated malformations, diagnostic methods, treatment and the outcomes of neonatal tumours., Methods: Retrospective review of patients ≤ 28 days-old with diagnosis of neonatal tumour between 2000-2016. Statistical analysis of clinical characteristics, histology, diagnostic methods, treatment and morbimortality., Results: A total of 26 tumours were diagnosed in newborns with a mean age of 4.85 ± 8.9 days and 69.2% of boys. Prenatal diagnosis was achieved in 38.5% (n = 10) and 38.5% (n = 10) in the first week of age. Associated malformations were found in 30.6% (n = 8). The most frequent tumours were hepatic hemangioma 23.1% (n = 6), neuroblastoma 15.4% (n = 4) and sacrococcygeal teratoma 11.5% (n = 3). Medical treatment was indicated in 7.7% (n = 5), surgical 57.7% (n = 15) and observation 30.8% (n = 7). Global mortality was 19.23% (n = 5) of which 42.9% (n = 3/7) were perioperatively., Conclusions: The management of neonatal tumours require a multidisciplinary approach to minimize the consequences and assure the best outcome. Global mortality is low and depends primarily of the physiologic and association of other malformations of the newborn.

Objective: Intestinal atresia (IA) is the most common obstructive congenital malformation in the gastrointestinal tract. The aim is to describe the morbidity and mortality of AI in our series., Methods: Retrospective study in infants with AI who underwent surgery in our hospital in the past 15 years. Descriptive analysis was performed by collecting clinical and epidemiological variables. Qualitative and quantitative statistical analysis were performed., Results: A total of 32 patients, 40.6% (13) women and 59.4% (19) males, maternal age 31 ± 5 years. Prenatal care in 96.8% (30) and prenatal diagnosis in 68.8% (22). Gestational age 35 ± 3 (SG 25-41), birth weight 2,506 ± 516 g (920-3,470 g). 53% (17/32) were localized in duodenum (65% extrinsic, 35% type I); 37.5% (12/32) jejunoileal (16.6% type I, 25% type II, 16.6% type IIIa, 16.6% type IIIb and 25% type IV); 6.5% (2/32) were colonic and 3% (1/32) pyloric. In 65.6% (21/32) it was associated with other congenital malformation. 81.3% (26) were operated within the first 48 hours of life. 15.6% (5/32) required enterostomy. 21.8% (7/32) had complications requiring reoperation in 71% (5/7) with 1 case of short bowel syndrome. Median time to enteral nutrition onset was 10 days (IQR 7-15), higher in patients with ileal atresia. Hospital stay was 33 days (interquartile range 23-66 days) and overall mortality of 9.3%., Conclusion: In our series the congenital malformations associated with intestinal atresia were determinant in the prognosis and mortality of these patients.

Aim: Balanitis xerotica obliterans (BXO) is a disease of the skin and mucosa of male genitals of unknown etiology that may affect children of any age. It has a low incidence (9-19%) and in adults is considered a potential premalignant lesion. The aim of our study is to establish the incidence of BXO in our center and to determine its correlation between the clinical and immunohistochemical (IHC) findings., Methods: Prospective cohort including all children < 14 years with foreskin pathology that required a circumcision between 2014-2016. Statistical analysis of the clinical characteristics, histological and IHC findings searching for inflammatory response, premalignant lesions and microbiological findings., Results: A total of 176 boys with phimosis had circumcision with a mean age of 7 ± 3 years (Range 2-14). Presurgical diagnosis of BXO was suspected in 28.4% (n= 50) whereas the AP confirmed a total of 29.5% (n= 53) with a very good interobserver concordance (kappa= 0.81: p< 0.01). Previous treatment with corticoids in BXO was found in 63.5% (n= 33/52). Meatal stenosis was found in 7.69% (n= 4/52) requiring meatal/urethral dilations. Patients with BXO had a T-Lymphocytes CD3+ mediated inflammatory response with a positive correlation between tumor suppressing protein (p53) expression and chronic inflammation., Conclusions: BXO is a chronic inflammatory disease mediated by T-lymphocytes with an incidence greater than previously reported. Surgeons' criterion has a very good concordance with the AP findings. The elevation of p53 in children with BXO may indicate a plausible malignant potential that may require a surgical treatment (circumcision) and an adequate follow-up.

Objectives: To assess the accuracy of prenatal ultrasound diagnosis and to analyze the protocol applied for congenital defects (CD) in our environment., Methods: Descriptive study of prenatally diagnosed CD in our area between 2004-2013. Includes: total births, fetal medicine referrals (number of consultations, ultrasound, invasive techniques) anatomical and chromosomal abnormalities, confirmed diagnoses, necropsies performed, false diagnoses, absence of prenatal diagnoses, and number and reasons for abortions (VIEs)., Results: Mean annual births were 3,646 ± 1,299, with a mean prenatal ultrasound of 2,144 ± 307 and 512 ± 74 invasive techniques per year. The annual average of prenatal chromosomopathies diagnosed were 26 ± 8 and 140 ± 14 anatomical abnormalities, which represents a 36.44% from all of the prenatal ultrasound performed. These include: neurological, cardiac and nephron-urological anatomic anomalies. Pre and post-natal correlation was observed in 95.6% of the DCs detected. Most common causes of abortion were chromosomal abnormalities, heart and neurological diseases., Conclusions: Due to the variety of CD that cause VIEs, a highly specialized multidisciplinary approach is recommended to ensure optimal information for parents.

Objectives: Testicular (TT) and paratesticular (PT) tumors account for 1-2%of all infant solid tumors. Due to the increased frequency of benign tumors, conservative management is recommended. Our experience and the therapeutic approach adopted considering testis-sparing surgery, was reviewed., Methods: A retrospective observational study concerning testicular and paratesticular tumors in our hospital between 1998 and 2016, was performed. Age, side, symptoms, imaging, treatment methods, histological findings and evolution were reviewed., Results: Nineteen cases of TT and PT were reviewed in 17 patients. A painless scrotal mass was found in most cases as the initial presentation (79%). Tumor markers were normal in all cases. Similar distribution between germ cell and stromal testicular tumors was found Nevertheless, benign and malignant PT proportion was similar. Testis preserving surgery was performed in 58% of TT and in 57% of PT., Conclusions: Due to the high incidence of the benign histological findings, testicular sparing surgery should be considered as a first therapeutic option, especially in those cases with normal tumor markers.

Introduction: Circumcision is a frequent and common surgical procedure in children; nevertheless it is not completely hassle-free. Post circumcision ischemic complications are even rare and they are generally due to administration of local vasoconstrictor anesthetics. There are few cases reported in the literature. We report the management and treatment of post- circumcision penile ischemia (PCI)., Case Report: A 10 years old patient who underwent circumcision and a dorsal penile nerve block DPNB presents signs of penile ischemia two hours after surgery without any other symptoms. Ultrasonography shows weak flow of the penile artery, with progressive worsening. 24 hours later we start treatment with pentoxifylline (PTX) that is maintained for 6 days, topical testosterone and a caudal blocking (for 48 hours). The patient evolved favorably within a few hours and there was complete resolution in 6 days., Discussion: We analyze 9 cases of pediatric patients which were described in the literature. 7 cases (77.7 %) received DPNB. The PCI is an unusual complication of circumcision, and DPNB seems to be the most frequent cause. Several therapeutic options are available for its management, but none is protocolised.

Objectives: Currently the management of appendicular mass remains controversial. Many authors advocate conservative management followed by delayed appendectomy, whereas others favour inmediate appendectomy. The aim of our study is to compare both treatments., Methods: A descriptive and observational study over 46 patients treated for appendiceal mass at our center in the last ten years was performed. Patients were categorized as group 1, early surgical intervention (54.3%) and group 2, conservative management and interval appendectomy (45.7%), with a mean interval of 5.3 ± 1.5 months., Results: Mean age was 9.2 ± 3.8 years in group 1 and 3.7 ± 3 years in group 2 (p<0.001). Median delay between the first symptoms and diagnosis was 4 ± 2.2 days in group 1 and 7.9 ± 4.2 days in group 2 (p<0.001). Antibiotics were administered before diagnosis in 24% of patients in group 1 and 42.9% in group 2 (p = 0.297). Ultrasound was performed in all patients, while 19.6% of patients requiered TAC for definitive diagnosis. Median hospital stay was 7.9 ± 2.9 days in group 1 and 8.3 ± 2.2 days in group 2 (p = 0.441). Complicactions were found in 64% of patients (group 1) and 23% of patients (group 2) (p = 0.015). Three patients from group 2 requiered readmission because of recurrent abdominal pain, but just one requiered early surgery., Conclusion: Conservative management of appendicular mass has a lower complication rate compared to the initial surgical management.

Objectives: In 2014 our department starts to apply the PatientSafety Strategic in Pediatric Surgery. Our aim is to describe the results obtained., Methods: For the measurement of adverse events (AE) we used a modification of the Global Trigger Tool of the Institute for Healthcare Improvement. Population analysed: patients undergoing surgery with hospitalization. On a monthly basis, audits of the medical records of 12 patients discharged in the prior week of the assessment were performed. The evaluation team was composed by experienced pediatric surgeon, two staff nurses, and a doctor and nurse from the Quality Department., Results: 95 clinical records and a total of 406 days of hospital stay were reviewed. 31 patients (32.6%) experienced one or more AE. Total AE: 43. The AE/1000 patients/day ratio: 105.9. The most common AE were: vomiting, itching and pain. 28 EA were considerd mild and 3 moderate in severity, according to the classification of the National Coordinating Council for Medication Error Reporting and Prevention. No EA were considered serious or critical., Conclusions: The analysis of prevalence through regular assessments of medical records is an easy method to obtain information about the frequency of occurrence, exact understanding of the AE types and the implementation of corrective measures. The main limitation of this method is that it can miss some of the serious EA and miss the records and analysis of sentinel events that may occur in the period between assessments.

A report on two homozygous twin girls affected by X linked hypophosphataemic rickets. They were examined due to short stature and genu varum of both tibias. They were treated with calcitriol and Joulie's solution, whereon it was observed that serum parathyroid hormone and phosphaturia decreased while phosphataemia increased. They underwent a tibial osteotomy (by means of the insertion of Kirchner needles) at 7.7 years of age for correction of genu varum and a normal consolidation was reached 1 month later. Nonetheless, height was percentile <1 after menarche, so both sisters asked for bone lengthening. Because of this, at 15 years of age femoral distraction was performed, but no bone callus was observed 14 months later. Consequently, they were treated with subcutaneous growth hormone, showing bone callus at 6 months. Finally, the external fixators were removed due to ossification in the lengthened segments., (2014 BMJ Publishing Group Ltd.)

Objective: Acute appendicitis is the most common emergency surgical pathology in childhood and there is no consensus on its management. Fast-track treatment, based on optimizing perioperative care has reduced morbidity and mortality of surgical pathologies, including simple acute appendicitis. The aim of our study was to assess the effects of a fast-track protocol in complicated acute appendicitis., Methods: Ambispective cohort study. Historical unexposed cohort: children with complicated appendicitis and appendectomy in our hospital during 2008-2009. Exposed cohort: children operated in 2010-2011 and who performed protocol. The protocol treatment was done after a literature review, adapting the principles of fast-track to a potentially severe urgent disease: early mobilization, limited drainage-tubes and short antibiotic regimens Taking hospital stay as the resulting variable, the calculated sample size for alpha = 0.05 and power = 90% was 54, being X1 = 7 +/- 3DS and X2=5., Results: We included 151 patients, historical cohort 81 and current cohort 70, which excluded 31 children who did not meet protocol because of surgeon choice. Both groups showed homogeneity due to the absence of differences in sex, age, weight, type of appendicitis (gangrenous, perforated, generalized peritonitis) or surgical approach. The average stay decreased 2.71 days (p <0.001) due to the protocol, without any complication increase (abscess, postoperative ileus, readmission)., Conclusions: Complicated appendicitis in children is common and potentially serious, and optimization of treatment should be a primary goal of our practice. Application of a fast-track protocol can provide clinical and economic benefits, although this requires an appropriate multidisciplinary management.

Unlabelled: The infantile myofibromatosis is a rare pathology usually affecting children under 2 years. More than half are congenital, located in head and neck in a 30% of the cases. Myofibroma is a benign mesenchymal tumor that appear an isolated lesion or multiple, with or without visceral involvement. Case 1: A newborn girl that presents lump in scalp suspected of encefalocele. Ultrasound and RM: solid and heterogeneous mass 4 x 2 cm with increased peripheral vascularisation. Case 2: A 7-month-old baby boy with lump in right occipital zone detected at 4 months. Ultrasound and RM: injury 1 x 1.5 cm in head esplenio muscle suggestive of hemangioma., Results: After surgical total resection, the histological study and immunohistochemical identified the lesion as myofibroma. The evaluation of disease dissemination was normal and the recovery of the patients was favorable. The differential diagnosis of myofibroma must be carried out with other mesenchymal tumors and with non neoplastic injuries characteristics of the region affects. The visceral location and multiple forms worsen the prognosis, so is important do an exhaustive study. Treatment is conservative surgery, but if there is no risk to the child, the possibility of spontaneous regression makes the abstention therapeutic a correct alternative.

Pollicization is a single-stage neurovascular pedicle transfer of the index digit to function as a thumb. The objective of this study is to investigate the results of index finger pollicization for correction of congenital deficiency of the first ray in pediatric hand. We have done 6 pollicizations of index fingers in 6 hands (there were 2 right hands, 2 left hands, and 1 bilaterally) in 5 patients (4 boys and 1 girl) who had absent or nonfunctioning thumbs (type III-V of Blauth's classification). Associated anomalies where numerous and included radial club hand, mirror hand and cardiovascular and urologic anomalies. The average time of Kirschner wire extraction was 32 days (30 to 36 days) and to beginning the hand rehabilitation at 5 degrees to 10 degrees day. The average age at pollicization was 5.5 years (range 2 to 8 years), and follow-up averaged 8 years (5 to 11 years). The cosmetic and functional results were excellent, with manual dexterity of prehension and opposition. Pollicization in children can be performed at least 2 years of age, to due of minor risk of neurovascular lesion but without delayed the cortical representation of the pollicized finger.

In extreme cases of tissue defects, wound coverage after excision may be problematic because of the limited existence of donor sites. An option for temporary wound coverage used in the management after early scar release is a dermal substitute: Integral artificial skin. The biosinthetic material consists of un upper silicone film and a lower layer of porous cross-linked bovine collagen and chondroitin-6-sulfate as a template for dermal regeneration after staged tangencial necrectomy. In the third and fourth weeks following application the silicone layer was easily removed and the newly formed neodermis covered with widely unmeshed thin split thickness autograft. We report 6 patients with tissue defects with open fractures in three cases, one hemorrhagic necrosis of the skin by meningococcemia who requiring amputations of all four extremities and two traumatic necrosis. Other patient has a retractil scar. All were treated with Integral and epidermical autograft. The good results with Integral regarding recovery may affect initial treatment and reconstruction planning after extensive wound injuries with tissue defects to obtain immediate wound closure.

Objective: To observe the usefulness of several procedures for draining pneumothorax in an animal model and to identify the best pleural drainage system with minimal impairment of respiratory function., Method: Thirty-four New Zealand white rabbits weighting 1687 +/- 78 g and aged a mean 59 days were randomly placed in groups as follows. Unilateral pneumothorax was induced in the first problem group (P1) rabbits (n = 10) by thoracostomy, with pleural drainage. In the second problem group (P2) of rabbits (n = 10), bilateral pneumothorax was similarly induced by thoracostomy with pleural drainage. The control groups underwent unilateral (C1; n = 7) and bilateral (C2; n = 7) thoracostomy and drainage. Every 7 minutes the chest tube was connected successfully in each animal to an underwater seal with a dead-space volume of 35.58 ml (neonatal Bülau unit) or to a 3,940 ml system (chest drainage unit) and to pleural aspirations of -5 and -20 cmH2O. We analyzed mortality, fluctuations of the hydrostatic column of the underwater seal, heart rate (HR), respiratory rate (RR), PaCO2, SaO2, pH and arterial blood gas measures., Results: Intraoperative mortality was significantly higher (particularly in the P2 group) when connection was to a large volume system without aspiration. Recovery after pneumothorax was more satisfactory with aspiration of -5 and -20 cmH2O., Conclusions: The results suggest that a pleural drainage unit with a large dead space between the pleural cavity and the underwater seal is a frequent cause of respiratory failure or insufficiency. We believe that when an underwater seal without pleural suction is applied, the Bülau unit should be used with the smallest possible volume.