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To assess the precision of the Sickness Certificate (SC) issued for Temporary Unfitness for Work (TUW). To measure the percentage of TUW where the diagnoses in the medical records and in the TUW Sickness Certificate do not coincide. To seek objective criteria to determine TUW.A descriptive, prospective and observational study.Health Centre in an urban area in Vitoria.All the sickness occasioning time off work between May and July, 1991, recorded at the above Health Centre: a sample of 224 TUW.In 11.6% of the TUW the diagnoses did not coincide. The main reasons for the lack of correspondence were: initial ignorance of the diagnosis (34.6%); confidentiality before a third party (25.9%); pretense (14.8%). There was a notable difference between the psychological diagnoses (12) and those found in the official certificate 3 for TUW (p = 0.032). The most common diagnostic group was the locomotive one (29%).There is considerable inexactness in the diagnoses on the official TUW certificate. A lot of time off for psychological reasons is covered up by organic complaints. The locomotive group of complaints is the most commonly found one. We propose that the CIAP classification should be adopted to standardise diagnoses in this area.

A total of 84 radical cystectomies were performed for invasive bladder cancer in 67 men (79.8%) and 17 women (20.2%). The present study investigated the possible sex-dependent differences in the pattern of invasive bladder cancer. More than 40% of the women presented lower urinary tract syndrome alone or with haematuria, giving a clinical picture similar to acute cystitis. This caused an average time-lag in diagnosis of 18.5 months in the women and 8 months in the men. There was a higher frequency of non-transitional cell carcinoma in the women (17.6%) than in the men (2.9%). We found statistically significant differences (p0.005) in tumor grade: 35.2% of the women had low grade tumors, compared to 7.4% of the men. However, no significant differences in staging or survival rate were found when comparing the two sexes. This leads us to believe that bladder cancer is less aggressive in women.

To show the absence of inhibitory reflex of the anus (R.I.A.) by ano-rectal manometry is an important sign in the diagnosis of Hirschsprung's disease. Between 1989 and 1991, a series of 199 patients was studied. The patients were divided into two groups: 0-1 month and 1 month to 50 years. Both groups were subdivided into cases with or without clinical and radiological suspicion of aganglionism. In this series, R.I.A. was absent in 88 patients and present in 111. Histologic study and follow-up confirmed the existence of aganglionism in 86 patients, hyperganglionism in 1, anal stenosis in 8, cystic fibrosis in 4 and 1 coeliac disease; the rest were megarecta to a greater or lesser degree. There was 1 false negative, signifying a percentage of error of 0.5%.

Analysis of results and complications of retrograde rigid ureterorenoscopies (URS) performed in our unit between August 1985 and June 1990. Our series includes 122 URS performed in 106 patients: 68% female and 32% male. A rigid ureteroscopy Storz 11.5 Ch was used. URS indications were: 72% treatment of ureteral lithiasis, 14% diagnosis, 7% treatment of ureteral tumores and 3% other reasons. Treated lithiasis were predominantly located in the pelvic ureter. Overall success in the treatment of lithiasis was 92.86% in "primary" lithiasis, and 71.43% in post-ESWL. URS allowed us to resolve troubles of differential diagnosis in 93.75% of cases. With a complications rate of 19.7%, only 3.28% were considered relevant.

Chronic intestinal pseudo-obstruction is defined as a syndrome related to any process which affects intestinal regulation and propulsion. Its origin may be muscular, neurogenic or hormonal, excluding Hirschsprung's disease or any known mechanical obstruction. Between 1989 and 1991, 11 patients with intestinal pseudo-obstruction were studied at our centre, and included nine hyperganglionisms B, and two hypoganglionisms) and two visceral myopathies (Berdon's syndrome). Diagnosis was established in all cases by histologic study. The techniques of haematoxylin-eosin, acetylcholinesterase, enolase, protein S-100 and Smith were used in neuropathies and haematoxylin-eosin and Masson's trichromic in myopathies. Intestinal motility was studied by ano-rectal and gastrointestinal manometry in seven and three cases respectively. Gastrointestinal manometry and radiology permitted differentiation of localized and diffuse forms of involvement. Medical treatment consisted of total parenteral nutrition when oral feeding was impossible, and in five cases, cisapride was given, with good results in four. Derivative surgery was performed in cases of diffuse involvement, and resection with anastomosis in those of localized forms. We conclude that: 1. Diagnosis is established according to histologic criteria. 2. Complementary examinations should be directed towards distinguishing localized from diffuse involvement. 3. Cisapride was effective in the treatment of neuropathies in the majority of cases.

Nonatretic cholestatic disorders exhibit differential features in the pediatric age group, at times not too obvious but always discernible. These characteristic differences, with the aid of increasingly more precise exploratory techniques, make a rapid and sound diagnosis possible. At present, echography, transparietohepatic cholangiography and endoscopic retrograde cholangiography allow us, within a short time, to reach a diagnosis of disorders that not long ago were only roughly profiled and on occasion were left undiagnosed. At the Children's Hospital Valle de Hebrón, treatment has been afforded, in the last seven years, to seven patients with a choledochal cyst, four with a long common biliopancreatic duct, one with a choleperitoneum due to spontaneous perforation of a choledochal cyst and one patient with congenital stenosis of the common hepatic duct. In all cases where echography was performed, an intra- or extrahepatic bile duct dilatation could be demonstrated, or otherwise the diagnosis of a choledochal cyst was established. Furthermore, four transhepatic and three retrograde cholangiographic examinations were carried out, via a fiber duodenoscopy, in those cases that failed to show, on echography, the existence of a choledochal cyst.

A case of testicular malacoplakia and epididymis in a 62 year old man is presented. A literature review is made (only 6 cases describing epididymal malacoplakia have been reported), commenting on the clinical, diagnostic, anatomopathological, pathogenic and therapeutic aspects of malacoplakia.

Posterior sagittal anorectoplasty (ARPSP) was described at first of the 80-90 decade like a new surgical technique for the anorectal malformation treatment and derived fecal incontinence. We have evaluated 35 of 67 ARPSP using biofeedback techniques (BFB) before surgery as restore system to striate muscle. Manometric values of the canal anal profile (PCA), postoperative external sphincter pressure and postoperative, first and last BFB voluntary contraction pressure shows clearly the differences between surgical intervention and BFB outcome. The author's opinion is that BFB is the indispensable therapy in the ARPSP postoperative to lend the patients get optimal fecal continence.

Between April 1987 and August 1988, 498 patients suffering renal or ureteral lithiasis, all of them with a 6 months or more follow-up period, have been treated in our Unit. Patients were treated in an ambulatory regime without need for anesthesia or analgesia. Up to 27% of the cases has surgical background for lithiasis. One hundred and twenty-six patients had a double J ureteral catheter placed prior to lithotripsy treatment. Fourty-four percent cases needed only one session, 25% two, 12% three and 18% more than three sessions. At the time of discharge 86% patients had no lithiasis or fragments less than 3 mm. Only 9% had fragments larger that 3 mm. It is our opinion than piezoelectric extracorporeal lithotripsy has been proven as a safe, effective and painless procedure in most renal lithiasis.

The present work deals with the histochemical, histoenzymological and micro-analytical study of the stomach of Littorina Littorea (L.). The results suggest the existence of intracellular digestion within the stomach cells. Thus, the occurrence of lysosomes in the mid-cytoplasm of stomach cells has been revealed by demonstration beta-glucuronidase activity in cryostat sections of frozen tissues. Other enzymatic activities have been proved with the same tissues. Accordingly, the results on lipid and pigment histochemistry indicate a certain digestion in this cell type. Mucocytes show a protective role for the epithelium, their main secretions being acid MPS. The elemental composition of electron dense concretions from the stomach cells indicate the presence of very high amounts of iron associated to lower peaks for sulphur, phosphorous and other cations found as calcium, copper and zinc.

In 1987, ninety-six surgical patients, of whom 44 were premature or newborn babies and 52 were infants or older children, received total parenteral nutrition (T.P.N.) at our hospital. A peripheral venous line was utilized on forty patients in the first group and only on 9 in the second group. The excellent results yielded by T.P.N. are self-evident from the low mortality showed by these patients. Thirty-three out of the 44 neonates and premature infants with serious surgical problems survived, being noteworthy the occurrence of just 3 deaths within a series of 13 necrotizing enterocolitis. In the series of 52 infants and older children, composed of 13 digestive patients (with 5 liver transplants), 6 tumoral, 9 neurologic, 4 renal (2 transplantations), 18 cardiac, 1 thoracic and 1 burnt, only 9 patients died. The average duration of T.P.N. was 10 days in the group of premature and newborn infants and 6 days for the nursing infants and older children, save for the 8 patients in whom the treatment had to be prolonged for a few months. We conclude that T.P.N., when applied in time and of short duration should entail no risk at all. In neonate and premature infant a peripheral vein shall be the route of choice. In the nursing infant and older child a central venous line is preferable, if possible the superior vena cava or its major tributary veins.

The oncocytoma constitutes 3-6% of the kidney neoplasiae. The authors report one case of calcified kidney tumor, Its presentation as a calcified kidney mass is exceptional and is not present in the largest series of calcified kidney tumors. The calcification prognosis is much debated, even more in the case of oncocytoma due to the very limited series available. For calcified kidney tumor, the oncocytoma should be included as one of the differential diagnosis, even if it is not very frequent.

A new type of nephrostomy is described with the following main characteristics: it uses a small multiperforated Silastic tube; its crosswise location allows perfect drainage of all of the calyces and the pelvis; it does not become obstructed nor move from its position; and it causes minimum traumatization of the renal parenchyma. It has a double purpose: its serves as a drain and safety measures as well as being used for the treatment of renal infection.

Complications of surgical aspect and which may occur after renal homotransplantation following the classical techniques in the vascular anastomosis as well as in the reestablishment of the continuity of the urinary excretory tract, and which jeopardize the future of a transplanted kidney are analysed. The authors describe the technique followed in a series of cases consisting of the conservation in totum of the receiver’s excretory tract (ureter and renal pelvis) performing a pyelo-pyelic anastomosis. No urinary drainage has been used, no catheters, either ureteral or urethral. No urinary complications were observed of the fistulas, stricture, urinary infection, extravasation, anastomosis dehiscence or ureteral reflux type. Complications of the graft excretory tract of immunological type are thus avoided. The technique to be followed in cases of anomalies in the excretory tract of the donor are also described. Concerning the vascular chapter, instead of the classic reno-iliac venous anastomosis, they perform the reno-cava anastomosis of easier execution which provides a better return circulation and moreover situates the kidney in a better position. They prefer the right kidney particularly if it proceeds from a cadaver. Whichever kidney selected, they situate it in an inverted right lumbo-iliac position. The same method applies for the homotransplantation of an adult kidney to a child. According to the results obtained with this new operating method submitted, a major safety is obtained with better functional results thus allowing the attainment of optima hemo and urodynamic conditions in the renal homotransplantation while eliminating the postoperative complications which frequently occur when using the traditional techniques which are the cause of immediate surgical failures and of tardy complications of the renal homotransplant.

In 11 years (1971-1981) 1.040 cases of anomalies of the cardio-hiatal sector have been controlled in the Children's Hospital of the Social Security of Barcelona, 101 patients were operated. Surgical indication was based on the following facts: size of the hernia, poor clinical evolution with postural treatment, or infants of more than 2 years who also presented a high gastric acidity or a clearly pathological pHmetry, or, lastly, a social cause. We have used a much more physiological technique than that of Nissen, based on the obtention of a large segment of the abdominal esophagus on which changes of pressure existing in the abdominal and thoracic cavities can act, clearly registered in manometric studies effected before and after operation. The few complications observed in this large series of operated children speak clearly in favour of its necessary diffusion and utilization.

A patient is described in whom a caliceal fistula occurred after renal transplantation due to secondary thrombosis of a branch of a revascularized polar artery. A review of the literature shows that caliceal fistula is an unusual vascular complication which can be avoided by careful removal and meticulous bench surgery. Study of the radionuclides should enable an early and reliable diagnosis. Surgical treatment is needed as soon as the diagnosis is confirmed. Omentoplasty gives the best results.

Anatomy and physiology of the anorectum has been studied with manometric techniques in a normal group (n = 34) and in patients with anorectal pathology (n = 477). Authors comment manometric anomalies found in anorectal atresias, Hirschsprung's disease, constipation, neurogenic disorders (spina bifida, sacral agenesia) and the value in diagnosis, prognosis and therapeutic measures that this technique demonstrates.

Eighteen patients received CP substituting AZ after renal transplantation following evidence of hepatitis. We have compared graft evolution before and after treatment with CP. Twelve patients showed no modification in graft evolution. In four patients the renal function decreased but it did not seem attributable to the change of the drug. Two patients showed intolerance attributable to the change of the drug. In one patient who received CP instead of AZ since the data of the transplant onwards, with no evidence of hepatic lesion, renal function decreased but this did not seem attributable to the use of the drug. The dose of CP in renal transplantation is discussed. We conclude that CP is a good substitute for AZ in renal transplanted patients. Adequate doses seemed to range between 0.7 and 1 mg/kg/day.

48 cases of embryonal sarcoma are reported. 41.6% of them are currently surviving, three for longer than five years, two longer than four, five longer than three, five longer than two, and five longer than twelve months. Treatment is based on surgery, chemotherapy and radiotherapy.

Anorectal dyschezia is due to a defect in the coordination between the forces which try and expel the stool and the relaxation of the anus. There are two types: congenital and acquired. In the first case, there is a distal aganglionic zone; these are in fact cases of Hirschsprung's disease. In the acquired cases, the mesenteric plexuses are normal and the aetiology lies in the painful process which affects the anus. Forced dilatation is the only treatment for anorectal dyschezia and it should replace the use of sphincterotomy. In cases of acquired dyschezia, medical treatment consisting of curing the anal cause of the pain, evacuating the rectum of faecalomas, lubricating the faeces recommending the use of a laxative, is successful in the majority of cases. In cases unresponsive to this treatment, forced dilatation of the anus will help achieve cure. We present 255 cases of anorectal dyschezia: 17 cases were congenital and 238 were acquired. In the first group, good results were obtained with forced dilatation in 14 cases. In the second group, this procedure had to be performed in 23 patients for whom medical treatment was unsuccessful. It resulted in remission of symptoms in 20 cases.

The methods and materials used at present for the intra-operative radiographic exploration of the kidney are somehow very deficient. This is reflected in the great number of recurrences which, in most cases, are due to residual calculi not detected at the time of surgery because of the poor quality of the radiographic material, or because it was not possible to find them, not having an adequate technique to localize the small fragments with exactitude in the renal space. The surgery and the radiographic exploration of renal lithiasis have up to now been carried out in a very simplistic manner.

Two cases of mediastinal lipoblastomatosis have been observed and cured by surgical excision: one, a circumscribed form, in a 6 months old boy, other, a diffuse form, in a 20 months old girl. Both are in good health for a 11 and 2 years period of follow-up observation respectively. The subject is reviewed.

In cases in which renal repair through conventional in situ surgery is not possible, we have proceeded to remove the organ outside of the human body and placed in on a work bench where exsitu repair is aided by microsurgery, x-ray films, and image amplifiers. In most cases the damaged kidney has recovered its function and a grave problem has been solved. Extracorporeal surgery means a new tactical solution to extreme situations.

Authors have employed biofeedback in functional rehabilitation of fecal incontinence after surgical treatment of high anorectal atresia. 34 patients have treated with that technique, of whom 27 underwent an levator plasty and 7 a muscular transplant procedure using a gracilis sling. A four channels Recording connected with a Arhan catheter and a TV-monitor visible to the patient have been employed. After a period of time variable from case to case, all patients of the "levator plasty" group prolonged the "alert-time" to a socially acceptable value, and all the patients of the "gracilis transplant" group obtained a complete fecal continence.

Study of gastric chemistry in patients with cardiohiatal anomalies is an efficient test for distinguishing those cases that can evolution with complications and thus require surgical intervention. From a total of 720 patients affected with this pathology and observed between 1976 and 1982, a group of 164 were submitted to this study, 72 resulted with gastric acid rates higher than normal. 55% of these patients were operated. It is an easy test to realize in any service of Pediatric Surgery.