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CD19-directed immunotherapies have revolutionized the treatment of advanced B-cell acute lymphoblastic leukemia (B-ALL). Despite initial impressive rates of complete remission (CR) many patients ultimately relapse. Patients with B-ALL successfully treated with CD19-directed T cells eventually relapse, which, coupled with the early onset of CD22 expression during B-cell development, suggests that preexisting CD34+CD22+CD19− (pre)-leukemic cells represent an “early progenitor origin-related” mechanism underlying phenotypic escape to CD19-directed immunotherapies. We demonstrate that CD22 expression precedes CD19 expression during B-cell development. CD34+CD19−CD22+ cells are found in diagnostic and relapsed bone marrow samples of ∼70% of patients with B-ALL, and their frequency increases twofold in patients with B-ALL in CR after CD19 CAR T-cell therapy. The median of CD34+CD19−CD22+ cells before treatment was threefold higher in patients in whom B-ALL relapsed after CD19-directed immunotherapy (median follow-up, 24 months). Fluorescence in situ hybridization analysis in flow-sorted cell populations and xenograft modeling revealed that CD34+CD19−CD22+ cells harbor the genetic abnormalities present at diagnosis and initiate leukemogenesis in vivo. Our data suggest that preleukemic CD34+CD19−CD22+ progenitors underlie phenotypic escape after CD19-directed immunotherapies and reinforce ongoing clinical studies aimed at CD19/CD22 dual targeting as a strategy for reducing CD19− relapses. The implementation of CD34/CD19/CD22 immunophenotyping in clinical laboratories for initial diagnosis and subsequent monitoring of patients with B-ALL during CD19-targeted therapy is encouraged., The work in P.M. and C.B.’s Laboratory was supported by the European Research Council (CoG-2014-646903, PoC-2018-811220) and the Spanish Ministry of Economy and Competitiveness (SAF2016-80481R, PID2019-108160RB-I00) (P.M.); the ISCIII (ISCIII/FEDER, PI17/01028 and PI20/00822), the Spanish Association against Cancer (AECC), and the FERO Foundation (C.B.). P.M. and J.M.R. acknowledge the support of ISCIII-RICORS within the Next Generation EU program (Plan de Recuperación, Transformación y Resiliencia). N.E. is supported by Cancer Research UK and a Children and Young People’s Cancer Innovation Award (DRCPGM\100058). A.R. is supported by a Wellcome Trust Clinical Research Career Development Fellowship (216632/Z/19/Z). A.O. was supported by ISCIII (PI19/011183). F.S. was supported by AGAUR/Generalitat de Catalunya (SGR288). The single-cell transcriptomic analysis was supported by MRC Discovery award MRCDA 0816-11 and the MRC WIMM Single Cell Facility and MRC-funded Oxford Consortium for Single-Cell Biology (MR/M00919X/1) provided assistance.

The pandemic caused by the SARS-CoV-2 virus has led to an unprecedented situation, with population lockdowns, congestion of healthcare resources, cancellation of scheduled surgical activity, fear of contagion, and delays in patient care. The objective of this study was to analyze its impact on pediatric surgical activity at a reference healthcare facility.A comparative study of activity in the pediatric surgery environment at a Spanish reference healthcare facility was carried out. It included outpatient consultations, scheduled surgeries, and activity at the emergency department during the lockdown period in Spain (March-May 2020) vs. the same 2019 period. Number of consultations and surgeries, type of surgery performed and/or cancelled, and stage of the pathologies treated were collected.A 98% decrease in scheduled surgeries, an 84% decrease in healthcare burden from the pediatric emergency department, a 55.24% decrease in urgent surgeries, an 82% decrease in outpatient activity at external consultations, and a 94% decrease in inter-hospital referrals, along with a 66% increase in urgent pathology severity, were found.The COVID-19 pandemic cancelled virtually all pediatric surgery activity, which caused treatment delays in severe pathologies and increased morbidity in regular urgent procedures.La pandemia surgida como consecuencia del virus SARS-CoV-2 ha provocado una situación inaudita, el confinamiento de la población, el colapso de los recursos sanitarios, la suspensión de la actividad programada en los servicios quirúrgicos, el miedo al contagio y la demora en la atención de pacientes. El objetivo es analizar el impacto de esta situación en la actividad del Servicio de Cirugía Pediátrica de un centro de referencia.Se ha realizado un estudio comparativo de la actividad realizada en el ámbito de Cirugía Pediátrica de un centro de referencia español, incluyendo consultas ambulatorias, cirugía programada y actividad en urgencias durante el periodo de confinamiento (marzo-mayo 2020) frente al mismo periodo de tiempo en 2019. Se recogen el número de consultas e intervenciones, el tipo de cirugía practicada y/o anulada y el grado de evolución de las patologías atendidas.Se ha registrado un descenso del 98% de las cirugías programadas, del 84% de la presión asistencial desde urgencias pediátricas, un 55,24% menos de cirugías urgentes y un 82% la actividad ambulatoria en Consultas Externas. Se ha registrado un descenso en los traslados interhospitalarios del 94% y un incremento del 66% de la gravedad de la patología urgente.La pandemia por COVID-19 ha supuesto la anulación de la práctica totalidad de la actividad del Servicio de Cirugía Pediátrica, con la consiguiente demora en el tratamiento de patologías graves y un aumento en la morbilidad de procesos urgentes habituales.

Nuss procedure is a safe surgery but not exempt from complications. Clavien-Dindo classification (1992) allows complications of any surgery to be recorded. Our objective was to prove its applicability in the study of Nuss procedure complications.We present a retrospective series of PE patients undergoing surgery from January 2010 to January 2018. Nuss procedure associated morbidity prior to bar removal was studied. Complications were stratified according to Clavien-Dindo classification.A total of 31 patients were included. Mean age was 14.67 years (4-27 years), with a mean Haller index of 6.06 (3.35-14.14) and a mean correction index of 41.2% (16-87%). Clavien-Dindo classification I-IIIb mild complications were recorded in 35.48% of patients. Seroma was found in 4 patients (12%), of whom 1 had superinfection and 1 had wound dehiscence. In 6 patients, bar and/or stabilizer mobilization was noted, and in 1 patient, postoperative acute pulmonary edema (3%) was observed. Of the 11 patients with complications, only 6 required re-intervention -5 as a result of prosthesis mobilization, and 1 as a result of infection not resolved with intravenous antibiotic therapy.Clavien-Dindo classification is being increasingly used as a way of unifying surgical complication criteria by comparing results. Our study demonstrated that such classification is a feasible and reproducible method when it comes to reflecting Nuss procedure morbidity and comparing it with other groups.La intervención de Nuss es una cirugía segura pero no está exenta de complicaciones. La clasificación de Clavien-Dindo (1992) permite registrar complicaciones de cualquier operación. Nuestro objetivo es demostrar la aplicabilidad de dicha clasificación para el estudio de las complicaciones de la cirugía de Nuss.Presentamos una serie retrospectiva de pacientes afectos de PE intervenidos entre enero 2010 y enero 2018 y su morbilidad asociada a la cirugía de Nuss hasta la retirada de la barra. Dichas complicaciones se agruparán mediante la clasificación de Clavien-Dindo.Se recogen un total de 31 pacientes. La media de edad fue 14,67 años (4-27 años), con una media de índices de Haller de 6,06 (3,35-14,14) y una media de índices de corrección de 41,2% (16-87%). Se observaron complicaciones leves I-IIIb de la clasificación de Clavien-Dindo en el 35,48% de los pacientes. Se constató seroma en 4 pacientes (12%), de los cuales 1 presentó sobreinfección y otro, dehiscencia de herida. En 6 pacientes se observó movilización de la barra y/o estabilizador y en 1 paciente, edema agudo de pulmón postoperatorio (3%). De los 11 pacientes que presentaron complicaciones, solo 6 requirieron reintervención: 5 de ellos por movilización de la prótesis y uno por infección no resuelta con antibioterapia endovenosa.La clasificación de Clavien-Dindo se emplea cada vez más como una forma de unificar los criterios de las complicaciones quirúrgicas permitiendo comparar los resultados obtenidos. Comprobamos que es perfectamente factible y reproducible para reflejar la morbilidad del procedimiento quirúrgico de Nuss y poder compararla con otros grupos.

Primary palmar hyperhidrosis is a pathology that begins during childhood and can represent a significant reduction in the quality of life of adolescents. The current treatment of choice is thoracoscopic sympathicolysis. The aim of our study is to evaluate the results of surgery in paediatric patients.Retrospective study of patients with primary palmar or palmo-axillary hyperhidrosis who underwent thoracoscopic sympathicolysis in our hospital during the last 5 years.We operated and included in the study 28 patients, 10 men and 18 women. Mean age was 13.8 (8-18) years. Bilateral thoracoscopic sympatholysis was performed with monopolar cautery, between T2-T4 ribs. Mean operative time was 63 minutes and mean hospitalisation time was 1.1 days. The incidence on intraoperative complications was zero. 2 patients presented postoperative subcutaneous emphysema. There were no other postoperative complications. 1 patient presented partial recurrence. In all the rest, sweating completely disappeared and they were totally satisfied with the surgery (96.42%). Temporary compensatory sweating appeared in 57.14% of the cases, a collateral effect that did not change their level of satisfaction.Palmar hyperhidrosis can be a major problem for socialization and quality of life for the child or adolescent who suffers it. Thoracoscopic sympatholysis in the pediatric patient is an effective treatment, highly resolutive and with low morbidity. Despite compensatory sweating, patients are highly satisfied with the results of surgical treatment.La hiperhidrosis primaria palmar es una patología que comienza ya en la niñez y puede representar una importante reducción de la calidad de vida del adolescente. El tratamiento de elección actual es la simpaticolisis toracoscópica. El objetivo de nuestro estudio es evaluar los resultados de la cirugía en pacientes pediátricos.Hemos estudiado retrospectivamente los pacientes diagnosticados de hiperhidrosis palmar y/o palmoaxilar que han sido tratados en nuestro centro durante los últimos 5 años.En este periodo han sido tratados 28 pacientes (10 varones y 18 mujeres), con una edad media de 13,8 años (8-18 años). La simpaticolisis toracoscópica bilateral se practicó, con monopolar, entre los niveles T2-T4 con un tiempo quirúrgico medio de 63 minutos. La estancia media fue de 1,1 días. No se registraron neumotórax ni otras complicaciones intraoperatorias. Dos casos presentaron enfisema subcutáneo postoperatorio. No hubo otras complicaciones postoperatorias. Excepto un caso de recurrencia parcial, en el resto de pacientes la sudoración desapareció por completo y quedaron totalmente satisfechos con la cirugía (96,42%). Apareció sudoración compensatoria transitoria en el 57,14% de los casos, efecto colateral que no modificó su nivel de satisfacción.La hiperhidrosis palmar puede ser un problema importante para la sociabilización y la calidad de vida del niño o adolescente que la padece. La simpaticolisis toracoscópica en el paciente pediátrico es un tratamiento efectivo, altamente resolutivo y de escasa morbilidad. A pesar de la sudoración compensatoria, los pacientes están altamente satisfechos con los resultados del tratamiento quirúrgico.

To analyze functional outcomes of patients operated for Hirschsprung's disease (HD).Retrospective study of patients with HD (2000-2014). We analyzed surgical technique, age at diagnostic and treatment, amount of resected bowel, complications and their influence on functional outcomes.Of the 44 diagnosed with HD, 37 were operated in our center. Men 29 (78.4%). With associated pathology 7 (18.9%), and 5 (13.5%) made their debut with enterocolitis. Diagnostic average age 1.04 (0.0 to 7.1 years) and operation average age 1.4 (0.3 to 9.3 years). We did transanal endorectal pull-through (TERPT) in 17 (45.9%) patients and transabdominal approach (TAB) in 20 (54.1%). Received postoperative dilations 8 (21.6%) patients. Functional outcomes were evaluated at an average age of 9.6 (4.7-15.7years) incontinence/soiling were found in 6/28 (21.4%) and constipation in 5/28 (17.9%). The highest rate of incontinence/ soiling was present in 41.7 % TERPT vs. 6.2% TAB (p= 0,036). However, the average age at follow-up in patients with incontinence/soiling was 5.9 ± 1.3 years old, less than the 10,6 ± 3.2 years in the ones without incontinence/soiling (p 0,001). We found that the 5 cases of constipation arose in patients with TAB (p= 0, 044), and likewise all were operated under 1 year of age.Despite the well known benefits of the TERPT over the TAB, we found a greater degree of incontinence/soiling in the TERPT, which could be explained by a less follow up, since incontinence/soiling improves with age. On the other hand there is a higher rate of constipation in the TAB that lasts in time.Analizar resultados funcionales de pacientes operados por enfermedad de Hirschsprung (EH).Estudio retrospectivo de pacientes con EH (2000-2014). Se analizó técnica quirúrgica, edad diagnóstica y de tratamiento, cantidad de intestino resecado, complicaciones y su influencia sobre resultados funcionales.De los 44 diagnosticados con EH se operaron en nuestro centro 37. Varones 29 (78,4%). Con patología asociada 7 (18,9%), y 5 (13,5%) debutaron con enterocolitis. Edad media diagnóstica 1,04 (rango: 0,01-7,1 años) y de intervención 1,4 (0,3-9,3 años). A 17 (45,9%) se realizó descenso endorectal trans-anal (DERTA) y a 20 (54,1%) descenso trans-abdominal (DTA). Recibieron dilataciones postquirúrgicas 8 (21,6%). Los resultados funcionales se valoraron a una edad media de 9,6 (4,7-15,7 años) encontrando incontinencia/encopresis en 6/28 (21,4%) y estreñimiento en 5/28 (17,9%). El mayor índice de incontinencia/encopresis se presentó en los DERTA 41,7% vs 6,2% DTA (p= 0,036); sin embargo, la edad media al seguimiento en pacientes con incontinencia/encopresis fue menor 5,9 ± 1,3 años vs 10,6 ± 3,2 años en los que no la presentan (p 0,001). Encontramos que los 5 casos de estreñimiento se presentaron en pacientes con DTA (p= 0,044) y, así mismo, todos operados ≤ 1 año de edad.A pesar de los ya comprobados beneficios del DERTA sobre el DTA, hemos encontrado un mayor grado de incontinencia/encopresis en el DERTA, que podría estar explicado por el menor tiempo de seguimiento, dado que la incontinencia/encopresis mejora con la edad. Por el contrario, hay un mayor índice de estreñimiento en el DTA que se prolonga en el tiempo.

Current knowledge of the evolution of the postcranial skeleton in the genus Homo is hampered by a geographically and chronologically scattered fossil record. Here we present a complete characterization of the postcranium of the middle Pleistocene paleodeme from the Sima de los Huesos (SH) and its paleobiological implications. The SH hominins show the following: (i) wide bodies, a plesiomorphic char- acter in the genus Homo inherited from their early hominin ancestors; (ii) statures that can be found in modern human middle-latitude pop- ulations that first appeared 1.6–1.5 Mya; and (iii) large femoral heads in some individuals, a trait that first appeared during the middle Pleistocene in Africa and Europe. The intrapopulational size variation in SH shows that the level of dimorphism was similar to modern humans (MH), but the SH hominins were less encephalized than Ne- andertals. SH shares many postcranial anatomical features with Ne- andertals. Although most of these features appear to be either plesiomorphic retentions or are of uncertain phylogenetic polarity, a few represent Neandertal apomorphies. Nevertheless, the full suite of Neandertal-derived features is not yet present in the SH popula- tion. The postcranial evidence is consistent with the hypothesis based on the cranial morphology that the SH hominins are a sister group to the later Neandertals. Comparison of the SH postcranial skeleton to other hominins suggests that the evolution of the postcranium oc- curred in a mosaic mode, both at a general and at a detailed level.

The outcome of video-assisted thoracoscopic treatment of spontaneous pneumothorax was analyzed. Eighty-three procedures were performed in 79 patients (58 men, 21 women: mean age 28.3 years, range 16 to 76 years). The reasons for intervention were recurring pneumothorax in 53 patients, contralateral pneumothorax in 10 (one of whom was treated on both sides), bilateral involvement in 3, and persistent air leakage in 13. Seven patients (8.4%) also required open thoracotomy. In 72 (88%) of the remaining 76 procedures, only video thoracoscopy was used. Three patients (3.6%) underwent video-assisted thoracotomy. Mean postoperative hospital stay was 5.1 days (2 to 24 days). No related deaths occurred but surgical complications were reported for 3 (3.9%). Significant postoperative complications developed in 9 cases (11.8%). One patient with prolonged air leakage underwent a second procedure, video-assisted thoracotomy, 12 days after the first intervention. Seventy-one of the 72 patients received follow-up examinations, with a mean follow-up period of 28.1 months (range 54 days to 54 months). Three recurrences (3.9%) were recorded but there were no cases of chronic pain requiring analgesia. We conclude that video thoracoscopy is an effective approach, with the advantage of being minimally invasive. We therefore believe it should be the procedure of choice, once improved morbidity and recurrence rates are observed, as these factors are influenced by the learning curve.

To compare postoperative follow up in patients older and younger than 12 months who underwent surgical treatment of ureteropelvic junction obstruction (UJO).Retrospective study of 77 patients, 78 kidney units, intervened from UJO (2007-2014). We analyzed epidemiological, clinical, echographic, and pre and postoperative renogram variables, outcomes and complications. We divided the patients into 2 groups according to age: group A ≤ 12 months and group B12 months, comparing the results by statistical analysis, considering p0.05 statistically significant.Group A: 38 patients, 26 males (68.4%), one bilateral UJO and 22 rights (57.9%), 36 prenatal diagnoses (92.3%) and mean age of intervention 5.28 months [range 0.24 -11,28]. We performed 9 minilumbotomies, 29 assisted by retroperitoneoscopy (ARP) and 1 pneumatic dilation (PD). Group B: 39 patients, 26 males (66.7%), 10 rights (25.64%), 19 prenatal diagnoses (48.7%) and mean age 6.13 years [range 1.13-14.52]. 15 minilumbotomies, 20 ARP, 3 laparoscopic and 1 PD. Preoperative mean renal function (MRF) of group A: 35.9 ± 13.4 [range 8-57] vs. 39.74 ± 13.91 [range 9-57] in group B (p = 0.347). Postoperative MRF 43.29 ± 18.2 [range 12-100] group A and 39.41 ± 12.89 [range 11-54] group B (p = 0.464). Group A and B: 11 and 8 complications, respectively (p = 0.429). We did not find statistically significant differences in the mean preoperative anteroposterior diameter (DAP) between both groups (p = 0.313). We compared DAP at 3, 6, 12, 24 and 48 postoperative months, observing a greater reduction of DAP from group A compared to B; however, we found only statistically significant differences in DAP at 3 months postoperatively (p = 0.047).Renal DAP is reduced postoperatively more in patients younger than 1 year. Moreover, an improvement of the DRF after pieloplasty can be observed despite not being statistically significant.Comparar la evolución postquirúrgica en pacientes mayores y menores de 12 meses intervenidos de estenosis pieloureteral (EPU).Estudio retrospectivo de 77 pacientes, 78 unidades renales, intervenidos por EPU (2007-2014). Analizamos variables epidemiológicas, clínicas, ecográficas y de renogramas pre y postoperatorios, resultados y complicaciones. Dividimos a los pacientes en 2 grupos según la edad: grupo A ≤ 12 meses y grupo B12 meses, comparando los resultados mediante análisis estadísticos (p0,05 estadísticamente significativo).Grupo A: 38 pacientes, 26 varones (68,4%), una EPU bilateral y 22 derechas (57,9%), 36 diagnósticos prenatales (92,3%) y edad media de intervención 5,28 meses [rango 0,24-11,28]. Realizamos 9 minilumbotomías, 29 asistidas por retroperitoneoscopia (ARP) y una dilatación neumática (DN). Grupo B: 39 pacientes, 26 varones (66,7%), 10 derechas (25,64%), 19 diagnósticos prenatales (48,7%) y edad media 6,13 años [rango 1,13-14,52]. Realizamos 15 minilumbotomías, 20 ARP, 3 laparoscópicas y 1 DN. Función renal diferencial media (FRDM) preoperatoria del grupo A: 35,9 ± 13,4 [rango 8-57] vs. 39,74 ± 13,91 [rango 9-57] grupo B (p = 0,347). FRDM postoperatoria 43,29 ± 18,2 [rango 12-100] grupo A y 39,41 ± 12,89 [rango 11-54] grupo B (p = 0,464). Grupos A y B: 11 y 8 complicaciones, respectivamente (p = 0,429). No encontramos diferencias estadísticamente significativas en la media del diámetro anteroposterior (DAP) de la pelvis preoperatoria entre ambos grupos (p = 0,313). Comparamos los DAP a los 3, 6, 12, 24 y 48 meses postoperatorios, observando una reducción mayor del DAP del grupo A frente al B, sin embargo, solo encontramos diferencias estadísticamente significativas en el DAP a los 3 meses postoperatorios (p = 0,047).El DAP de la pelvis renal se reduce más en los pacientes menores de 1 año a los 3 meses postoperatorios. Además, podemos observar una evidente mejoría de la FRDM tras la pieloplastia a pesar de no encontrar diferencias estadísticamente significativas.

Salivary gland ducts play a relevant role in saliva secretion through transport processes. Na(+)-independent chloride-bicarbonate anion exchangers (AE) may be involved in these processes by generating ion fluxes into the salivary secretion. In Sjögren's syndrome, a disorder with gland dysfunction, there might be an impaired expression of AE proteins. Here we study AE immunoreactivities in human salivary glands, both in health and in Sjögren's syndrome. Immunohistochemistry was carried out on salivary glands from normal subjects and patients with Sjögren's syndrome, using two monoclonal antibodies against AE1 and AE2. Normal salivary glands showed AE2 immunoreactivity, which was restricted to the epithelium of the ducts, with no staining at the acini. A strong positivity was seen in the basolateral portion of the striated ducts, while interlobular duct cells showed a discrete positivity at their apical pole. In salivary glands from most of the patients with Sjögren's syndrome, AE2 immunoreactivity was absent in the ducts as well as in the acini. In both normal and diseased salivary glands, AE1 immunoreactivity was only located at the erythrocyte membrane. The recently reported AE0 was discarded because no AE0 message was found in salivary glands by reverse transcription polymerase chain reaction. In conclusion, AE2 immunoreactivity is observed in the ducts of normal salivary glands, particularly in the striated ducts. AE2 immunoreactivity is virtually absent in salivary glands from patients with Sjögren's syndrome, which may reflect either a loss of AE2 after inflammatory atrophy, or a primary defect occurring in the disease.

Systemic amyloidosis is a disease resulting from extracellular deposition of fibrillar protein in various organs. Main systemic amyloidosis are: primary (AL) and Secondary (AA). The kidney is usually involved, conferring and adverse prognosis. In the last decade there has been a change in the aetiology of AA amyloidosis.To analyse the incidence of AL and AA amyloidosis in our current population as well as the aetiology of AA amyloidosis. To describe clinical outcomes, renal involvement and survival.We performed a descriptive analysis of all cases of amyloidosis diagnosed from 1992 to 2004 in our hospital. Diagnosis was assessed on histological criteria: positivity Congo Red stain. Clinical data, renal involvement, dialysis treatment and survival were analysed.76 cases, 44 women, mean age 70.7 +/- 12. Types: 55 AA (72%), 21 AL (28%) systemic amyloidosis. AA aetiology was: 66% rheumatic disorders, 28% infectious disease, 6% others. Incidence for AL was 4.6 and for AA 12.2 cases/million. Renal involvement was present in 75% at diagnosis (69% Creatinine clearance60 ml/min, 37% urinary protein3 g/24 hours). 21 cases (28%) progressed to renal disease stage V in the 8.1 +/- 9.8 months follow up period, and 14 cases started dialysis treatment (10 HD, 4 CAPD). In 7 cases (33%) dialysis was not indicated due to their poor clinical condition, short life expectancy and bad quality of life. Mean global survival at diagnosis was 55% and 40% at 12 and 24 months (AL 58% and 19%; AA 55% and 44%). Mean survival from the start of dialysis was 30% and 5% at 12 and 24 months.Although amyloidosis has a low incidence in our population, the kidney is usually involved. Rheumatological disorders are the principal aetiology of AA amyloidosis. Long term survival is poor, specially for AL.

To identify the factors that lead to postoperative morbidity in acute appendicitis patients treated using a TULAA (Transumbilical laparoscopic assisted appendectomy) approach.Retrospective review of patients treated through a TULAA approach between 2007 and 2014. Data concerning the location of the appendix, need for conversion, appendiceal abscess or perforation, surgical time and other complications were collected. Student's T test and Chi-squared test were used for statistical analysis.A total of 111 appendectomies underwent TULAA. The average operating time was 79 minutes (45-150). Nonperforated appendicitis was found in 90% of patients with 10% having perforated appendicitis or appendiceal abscess. In 35,13% of cases, additional trocars were used, usually when the appendix was in a retrocecal position (89,5%). When the appendix was found in a pelvic or ileal position, a need for extra trocars decreased to 25.9% (p 0.05). The surgery was converted to open surgery in 6,3% of the cases. The appendix in a retrocecal position had a conversion rate of 20,8% compared to 2,3% of cases with an appendix in a pelvic location (p 0.05). A total of 3,6% reported postoperative wound infection, possibly caused by perforation of the appendix during extraction (p 0.05). All the perforated appendixes were considered complicated appendixes.The retrocecal location of the appendix is associated with the need to install additional trocars or conversion to open surgery. The TULAA approach is ideal for patients with nonperforated acute appendicitis in a pelvic or ileal location.Identificar los factores que influyen en la morbilidad postoperatoria en pacientes intervenidos mediante apendicectomía transumbilical asistida por laparoscopia o TULAA (transumbilical laparoscopic assisted appendectomy).Estudio analítico retrospectivo de pacientes intervenidos mediante TULAA en nuestro centro entre 2007-2014. Se incluyeron las variables: localización del apéndice, reconversiones, tipo de apendicitis, tiempo quirúrgico y complicaciones. Se utilizó t de Student y chi-cuadrado para el análisis estadístico.Se analizaron un total de 111 apendicectomías TULAA. Tiempo quirúrgico medio 79 minutos (45-150). El 90% de pacientes tenían apendicitis simple y 10% apendicitis complicada. En 35,13% casos se utilizaron trócares adicionales, cuando el apéndice se posicionaba de forma atípica ascendió al 89,5% de casos, mientras que cuando el apéndice se encontró en posición típica este dato disminuía al 25,9% (p 0,05). Se reconvirtió en un 6,3% de casos (20,8% apéndice en posición atípica, 2,3% apéndice en posición habitual, pp 0,05). Se encontró un 3,6% de casos con infección de herida quirúrgica explicada por perforación iatrogénica en la maniobra de extracción del apéndice (pp 0,05). Todas las apéndices perforadas en la maniobra de extracción se trataron de apendicitis complicadas.La posición anómala del apéndice se relaciona de forma significativa con la necesidad de colocación de trócares adicionales o reconversión a cirugía abierta. Consideramos la TULAA ideal en los casos de localización anterior del apéndice y en apendicitis no complicadas.

Caudal anesthesia is a safe and effective technique in children. Some surgical procedures, such as abdominal or inguinal surgeries, could be performed avoiding general anesthesia in newborns and babies, reducing the risk of respiratory depression and neurotoxicity. Our objective is to analyze the experience in a tertial referral center.We carried a retrospective study in patients under 1 year of age who underwent abdominal or inguinal procedures under caudal regional anesthesia, between 2016 and 2018. Demographics, diagnosis, comorbidity, surgical procedure, operation time, oral intake, perioperative complications and hospital stay were recorded.We included 87 patients under 1 year of age. In 56 patients (23 males, 33 females) surgery was performed under caudal anesthesia (37 scheduled, 19 urgent). Mean age was 2 months (0-11). Comorbidity: 25 associated prematurity, 3 severe tracheomalacia, 1 apnea and 8 bronchopulmonary dysplasia. Surgical procedures: 34 inguinal hernia repair, 9 incarcerated inguinal hernias, 5 neonatal testicular torsions, 8 pyloromyotomies. Mean operation time was 35 min (15-80) and mean anesthetic time 30 min (20-60). Oral intake started 2 h after surgery in 55 patients. Discharge was given in 24 h (12-36). Complications were not noticed. Any patient needed conversion to general anesthesia.Caudal anesthesia should be the anesthetic technique of choice in newborns and babies who undergo abdominal or inguinal surgeries, especially in those with comorbidity. This procedure could be performed safely, avoiding respiratory or neurological complications, with a fast recovery of patients and short hospital stay.La anestesia caudal es una técnica que permite la realización de diversos procedimientos quirúrgicos en neonatos y lactantes evitando complicaciones respiratorias y neurotoxicidad asociada a la anestesia general, permitiendo un inicio precoz de la ingesta y una menor estancia hospitalaria. Presentamos la experiencia en un centro terciario.Estudio retrospectivo en neonatos y lactantes intervenidos de cirugía abdominal o inguinal (2016-2018) mediante anestesia caudal asociada a sedación. Se recogieron datos epidemiológicos, comorbilidad, procedimientos quirúrgicos, tiempo quirúrgico y anestésico, inicio de ingesta, estancia hospitalaria y complicaciones asociadas a la técnica.Se intervinieron 87 pacientes menores de 1 año en nuestro centro, en 56 (23 varones, 33 mujeres) se realizó cirugía bajo anestesia caudal (37 programadas,19 urgentes), edad media 2 meses (0-11). En 25 se asociaba prematuridad, 3 traqueomalacia severa, un paciente monitorización de apneas y 8 displasia broncopulmonar. Procedimientos: hernia inguinal no complicada (34), hernia inguinal incarcerada (9), torsión testicular (5), piloromiotomía (8). Tiempo medio de cirugía 35 minutos (15-80), tiempo anestésico de 30 min (20-60) y tiempo quirúrgico total 60 min (40-120). La ingesta se inicio a las 2 horas salvo un paciente que precisó antieméticos. El alta hospitalaria se produjo a las 24 horas (12-36). No se registraron complicaciones durante la realización de la anestesia caudal ni necesidad de conversión a anestesia general.Consideramos la anestesia caudal de elección en neonatos y lactantes en determinadas cirugías, con escasa morbilidad asociada. Permite un rápido inicio de la ingesta acortando la estancia hospitalaria y minimiza las complicaciones respiratorias y neurotoxicidad a largo plazo, incluso en pacientes prematuros con comorbilidad grave.

Surgery is considered a stressful experience for children and their families who undergo elective procedures. Different tools have been developed to improve perioperative anxiety. Our objective is to demonstrate if the audiovisual psychoprophylaxis reduces anxiety linked to paediatric surgery.A randomized prospective case-control study was carried out in children aged 4-15 who underwent surgery in a Paediatric Surgery Department. We excluded patients with surgical backgrounds, sever illness or non-elective procedures. Simple randomization was performed and cases watched a video before being admitted, under medical supervision. Trait and state anxiety levels were measured using the STAI-Y2, STAI-Y2, STAI-C tests and VAS in children under 6-years-old, at admission and discharge.100 patients (50 cases/50 controls) were included, mean age at diagnosis was 7.98 and 7.32 respectively. Orchiopexy was the most frequent surgery performed in both groups. Anxiety state levels from parents were lower in the Cases Group (36.06 vs 39.93 p= 0.09 in fathers, 38.78 vs 40.34 p= 0.43 in mothers). At discharge, anxiety levels in children aged 6 were statistically significant among cases (26.84 vs 32.96, p 0.05).The use of audiovisual psychoprophylaxis tools shows a clinically relevant improvement in perioperative anxiety, both in children and their parents. Our results are similar to those reported by other authors supporting these tools as beneficial strategy for the family.La cirugía supone una experiencia traumática tanto para el niño como para su familia. Recientemente se han diseñado estrategias audiovisuales en nuestro Servicio para tratar de disminuir la ansiedad vinculada a la intervención quirúrgica. Nuestro objetivo es analizar si la psicoprofilaxis audiovisual reduce los niveles de ansiedad derivados del evento quirúrgico.Estudio prospectivo aleatorizado en niños intervenidos en el Servicio de Cirugía Pediátrica (4-15 años). Se excluyeron pacientes con antecedentes quirúrgicos, patología grave o procedimientos de Urgencia. La aleatorización en casos-controles fue realizada mediante sistema par-impar. Los casos visualizaron el vídeo antes del ingreso bajo supervisión médica. Se realizó la evaluación de los niveles de ansiedad estado y ansiedad rasgo mediante test autocompletables (STAI-Y1,STAI-Y2,STAI-C, test EVA en 6 años) al ingreso y al alta en ambos grupos.100 pacientes fueron incluidos (50 casos/50 controles) edad media de 7,98 y 7,32 años, respectivamente. La intervención practicada con mayor frecuencia fue la orquidopexia en ambos grupos. Se observaron niveles de ansiedad estado menores en los progenitores de los casos frente a los controles (36,06 vs 39.93 en padres p= 0,09, 38,78 vs 40,34 en madres p= 0,43). Al alta, los niveles de ansiedad fueron menores en niños 6 años (26,84 vs 32,96), siendo esta diferencia estadísticamente significativa (p 0,05).El uso de la psicoprofilaxis prequirúrgica mediante herramientas audiovisuales disminuye la ansiedad de forma clínicamente relevante tanto en los niños como en sus familias de manera sencilla y fácilmente reproducible. Nuestros resultados coinciden con los reportados en la literatura y consideramos esta herramienta beneficiosa para el núcleo familiar.