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BACKGROUND: Evidence suggests that a preoperative single-dose steroid improves lung function and decreases the incidence of postoperative symptoms; however, this has not been sufficiently proved in modified radical mastectomy for cancer. This study aimed to evaluate the efficacy of preoperative single-dose steroid administration for postoperative lung function and postoperative symptoms in women undergoing modified radical mastectomy for breast cancer. METHODS: In this controlled clinical trial, conducted between June 2014 and October 2018, we examined 81 patients. Patients received a preoperative single dose of 8 mg dexamethasone (n=41; treatment group) or placebo (sterile injectable water; n=40; control group). We obtained data on postoperative nausea and vomiting and pain intensity and performed spirometry 1 h before and 1, 6, 12, and 24 h after surgery. The use of additional analgesic or antiemetic drugs was recorded. We followed up patients 30 days after discharge and recorded any surgical or medical complications. RESULTS: The age distribution and anthropometric variables of the two groups were similar. Almost 50% of the patients in each group also underwent breast reconstruction. In the treatment group, pain intensity was always lower, the incidence of postoperative nausea and vomiting was lower at 6, 12, and 24 h, and additional analgesics or antiemetics were required less frequently (P<0.05 for all). Both treatment and control groups demonstrated a restrictive ventilatory pattern immediately after surgery, which in the treatment group was reversed after 24 h. However, the reconstructed patients had a more intense and prolonged restrictive pattern (P<0.05). Surgical morbidity included one seroma observed in the control group. No infections occurred at the surgical site or at any other level, and no patient developed any metabolic disorder. No mortality was observed in either group. CONCLUSIONS: This study establishes that a single preoperative dose of dexamethasone markedly decreased the incidence of postoperative nausea and vomiting and pain, improved respiratory parameters, and decreased the need for additional postoperative analgesic or antiemetic drugs. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov (ID NCT02305173).

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OBJETIVO: Comparar la seguridad y la eficacia de la atención fast-track vs. atención convencional en apendicitis no complicada en un hospital pediátrico. MÉTODO: Ensayo clínico controlado, aleatorizado, con dos grupos de 30 pacientes cada uno: A) fast-track, apendicitis no complicada que cumplieron el programa; y B) atención convencional, apendicitis no complicada con atención habitual. Variables de seguridad y eficacia: proporción de complicaciones y tiempo de estancia hospitalaria. RESULTADOS: Se incluyeron 60 pacientes, sin diferencia entre grupos: sexo masculino (53 vs. 60%), edad (8 ± 3 vs. 8 ± 2 años), tiempo de evolución (23 ± 21 vs. 24 ± 20 horas), tiempo desde ingreso a urgencias hasta inicio de cirugía (6 ± 4 vs. 8 ± 6 horas), y tipo de apendicitis edematosa (27 vs. 24%) o supurada (73 vs. 76%). La estancia hospitalaria promedio del grupo fast-track fue de 13 ± 5 vs. 72 ± 40 horas del grupo de atención convencional (p = 0.001). Hubo complicaciones en el 3 y el 6%, respectivamente (p = 1.0). La estancia hospitalaria disminuyó 2.45 días por paciente con el protocolo fast-track, lo que representa un ahorro de $ 6,731 pesos/día/paciente/hospitalización (US$ 373), sin un aumento de las complicaciones. CONCLUSIÓN: El protocolo fast-track en los niños con apendicitis no complicada es seguro y efectivo en un hospital universitario. El programa fast-track aportó beneficios clínicos y económicos, ahorrando en total $ 403,860 en los 30 pacientes. OBJECTIVE: To compare safety and efficacy of fast-track program vs. conventional attention in non-complicated appendicitis attending a pediatric university hospital. METHOD: Randomized clinical trial, comparing two groups with 30 patients each: (A) fast-track group, appendicitis agreeing the treatment protocol; and (B) conventional attention group, appendicitis following habitual surgical care. The efficacy and safety measures were length of hospital stay and proportion of complications. RESULTS: We included 60 patients, there were no significant difference between groups with regard: male gender (53 vs. 60%), age (8 ± 3 vs. 8 ± 2 years-old), time of evolution (23 ± 21 vs. 24 ± 20 h), time since admittance to emergency and beginning of surgery (6 ± 4 vs. 8 ± 6 h), and type of appendicitis edematous (27 vs. 24%) or suppurate (73 vs. 76%). Mean length of hospital stay in fast-track group was 13 ± 5 vs. 72 ± 40 h in conventional attention (p = 0.001). The complications were 3 and 6%, respectively (p = 1.0). Fast-track program diminished length of hospital stay in 2.45 days per patient, representing a mean cost saving of 6,731 Mexican pesos per day, per patient hospitalized (US$ 373), without increased complications. CONCLUSION: Fast-track program in children with non-complicated appendicitis is safe and effective in pediatric university hospital; there was cost-minimization without carelessness of safety. This program support clinical and economic benefits, a total saving of 403,860 Mexican pesos for the 30 patients in the fast-track group.

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BACKGROUND: Diagnosis-related groups (DRGs) are widely used in Europe. They allow performing comparisons in hospitals and incurrent hospital payment systems, defining the payment categories. We undertook this study to classify children who underwent appendectomy according to DRGs. METHODS: Cross-sectional study. Comorbidities, length of hospitalization, histopathologic classification, and DRG classifications were analyzed. RESULTS: We included 313 patients, 62% males, with an average age of 8 ± 3 years; 91% were referred by another hospital and 67% were treated at night. Average length of hospitalization was 4 ± 3 days. There were comorbidities in 8% and surgical complications in 11%. According to histopathology, appendicitis was edematous (11%), suppurative (36%), gangrenous (22%), perforated (29%), and abscessed (2%). At discharge, 97% of the patients were healthy. Total cost for DRG 343 was $10,470,173.00 (Mexican pesos), DRG 342 was $1,227,592.00 and DRG 340 was $511,521.00. The global amount was $12,209,286.00 (Mexican pesos). CONCLUSION: The unitary cost for treatment of appendectomy for DRG 343 was $37,935.00, for DRG 342 was $49,103.00 and for DRG 340 was $42,626.00 (Mexican pesos). Because 88% of the cases of appendicitis were uncomplicated, this amount of money could be spent to treat these patients in a second-level hospital, using reimbursement 343 without generating additional expenses.

Antecedentes: los grupos relacionados con el diagnóstico se utilizan ampliamente en Europa; permiten comparar el desempeño de los hospitales y facilitan el sistema de pago hospitalario. Objetivo: clasificar mediante grupos relacionados con el diagnóstico a los niños operados por apendicitis en un hospital de tercer nivel de atención. Material y métodos: estudio transversal. Se analizaron: comorbilidad, tiempo de hospitalización, histología de la apendicitis y clasificación mediante grupos relacionados con el diagnóstico. Resultados: se incluyeron 313 pacientes, 62% hombres, con edad promedio de 8 ± 3 años, 91% llegaron referidos de otra unidad. Recibieron atención en el turno nocturno 67%, y permanecieron hospitalizados durante 4 ± 3 días. Hubo comorbilidad en 8% y complicaciones quirúrgicas en 11%. La apendicitis fue: edematosa en 11%, supurada en 36%, gangrenada en 22%, perforada en 29% y abscedada en 2%. La condición de egreso fue: con mejoría en 97%. El gasto total del grupo relacionado con el diagnóstico 343 fue 10,470,173 pesos, del grupo relacionado con el diagnóstico 342 de 1,227,592 pesos, y del grupo relacionado con el diagnóstico 340 de 511,521 pesos, lo que sumó 12,209,286 pesos mexicanos. Conclusión: el costo unitario del tratamiento de la apendicitis correspondiente al grupo relacionado con el diagnóstico 343 fue de 37,935 pesos, del grupo relacionado con el diagnóstico 342 de 49,103 pesos y del grupo relacionado con el diagnóstico 340 de 42,626 pesos. Puesto que 88% de los casos de apendicitis ocurrieron sin diagnóstico principal complicado, esos pacientes se podrían haber intervenido en un segundo nivel de atención, utilizando el reembolso obtenido del monto 343, sin necesidad de generar gastos adicionales.

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AIM: To assess whether the use of fibrin sealant shortens the closure time of postoperative enterocutaneous fistulas (ECFs). METHODS: The prospective case-control study included 70 patients with postoperative ECFs with an output of < 500 mL/d, a fistulous tract of > 2 cm and without any local complication. They were divided into study (n = 23) and control groups (n = 47). Esophageal, gastric and colocutaneous fistulas were monitored under endoscopic visualization, which also allowed fibrin glue application directly through the external hole. Outcome variables included closure time, time to resume oral feeding and morbidity related to nutritional support. RESULTS: There were no differences in mean age, fistula output, and follow-up. Closure-time for all patients of the study group was 12.5 +/- 14.2 d and 32.5 +/- 17.9 d for the control group (P < 0.001), and morbidity related to nutritional support was 8.6% and 42.5%, respectively (P < 0.01). In patients with colonic fistulas, complete closure occurred 23.5 +/- 19.5 d after the first application of fibrin glue, and spontaneous closure was observed after 36.2 +/- 22.8 d in the control group (P = 0.36). Recurrences were observed in 2 patients because of residual disease. One patient of each group died during follow-up as a consequence of septic complications related to parenteral nutrition. CONCLUSION: Closure time was significantly reduced with the use of fibrin sealant, and oral feeding was resumed faster. We suggest the use of fibrin sealant for the management of stable enterocutaneous fistulas.

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OBJECTIVE: We undertook this study to determine the relationship between clinical symptoms as predictors for staging colorectal cancer (CRC). METHODS: We performed a cross-sectional study from January 2000 to January 2005 at the "Hospital Civil Fray Antonio Alcalde." All patients with histological diagnosis of CRC were included. Variables analyzed were gender, age, clinical manifestations and location of the tumor, as well as degree of differentiation and time of evolution. RESULTS: We studied 108 patients with CRC. There were 52 female patients (48.1%) and 56 male patients (51.9%). Twenty five patients were <40 years old (23.15%). Most tumors were well to mildly differentiated adenocarcinomas (88.9%). We observed 37% of proximal tumors with a median evolution time of 11.45 months. Distal tumors were observed in 68 patients with a median evolution time of 9.19 months (p = 0.20). Hemoglobin levels were lower in proximal carcinomas (p = 0.02). Advanced tumors (stages III and IV) corresponded to 82.4% of the cases. The three most common symptoms were rectal bleeding, change in bowel habits and nonspecific abdominal pain. All showed low sensitivity but moderately high specificity (rectal bleeding 89%, change in bowel habits 68%). Combinations of these last two symptoms to predict advanced stage were 55 and 68%. CONCLUSIONS: The majority of the patients were diagnosed with advanced stages of well-to-mildly differentiated adenocarcinomas. Symptom evaluation as predictors for staging showed a low sensitivity and a moderately high specificity due to a late diagnosis of advanced tumors. We attributed our results to a referral bias, the absence of screening programs and lack of clinical judgment to diagnose CRC at earlier stages.

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OBJECTIVE: We undertook this study to determine the relationship between clinical symptoms as predictors for staging colorectal cancer (CRC). METHODS: We performed a cross-sectional study from January 2000 to January 2005 at the [quot ]Hospital Civil Fray Antonio Alcalde.[quot ] All patients with histological diagnosis of CRC were included. Variables analyzed were gender, age, clinical manifestations and location of the tumor, as well as degree of differentiation and time of evolution. RESULTS: We studied 108 patients with CRC. There were 52 female patients (48.1%) and 56 male patients (51.9%). Twenty five patients were <40 years old (23.15%). Most tumors were well to mildly differentiated adenocarcinomas (88.9%). We observed 37% of proximal tumors with a median evolution time of 11.45 months. Distal tumors were observed in 68 patients with a median evolution time of 9.19 months (p = 0.20). Hemoglobin levels were lower in proximal carcinomas (p = 0.02). Advanced tumors (stages III and IV) corresponded to 82.4% of the cases. The three most common symptoms were rectal bleeding, change in bowel habits and nonspecific abdominal pain. All showed low sensitivity but moderately high specificity (rectal bleeding 89%, change in bowel habits 68%). Combinations of these last two symptoms to predict advanced stage were 55 and 68%. CONCLUSIONS: The majority of the patients were diagnosed with advanced stages of well-to-mildly differentiated adenocarcinomas. Symptom evaluation as predictors for staging showed a low sensitivity and a moderately high specificity due to a late diagnosis of advanced tumors. We attributed our results to a referral bias, the absence of screening programs and lack of clinical judgment to diagnose CRC at earlier stages.

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BACKGROUND: The effect of parenteral GLN on recovery from severe acute pancreatitis has not been thoroughly investigated. The aims of this study were to determine whether parenteral GLN improves nutrition status and immune function, and to determine its ability to reduce morbidity and mortality in patients with this condition. METHODS: In a randomized clinical trial, 44 patients with severe acute pancreatitis were randomly assigned to receive either standard PN (n = 22) or l-alanyl-l-glutamine-supplemented PN (n = 22) after hospital admission. Nitrogen balance, counts of leukocytes, total lymphocytes, and CD4 and CD8 subpopulations, and serum levels of immunoglobulin A, total protein, albumin, C-reactive protein, and serum interleukin (IL)-6 and IL-10 were measured on days 0, 5, and 10. Hospital stay, infectious morbidity, and mortality were also evaluated. RESULTS: Demographics, laboratory characteristics, and pancreatitis etiology and severity at entry to the study were similar between groups. The study group exhibited significant increases in serum IL-10 levels, total lymphocyte and lymphocyte subpopulation counts, and albumin serum levels. Nitrogen balance also improved to positive levels in the study group and remained negative in the control group. Infectious morbidity was more frequent in the control group than in the study group. The duration of hospital stay was similar between groups, as was mortality. CONCLUSION: The results suggest that treatment of patients with GLN-supplemented PN may decrease infectious morbidity rate compared with those who treated with nonenriched PN.

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BACKGROUND: We undertook this study to evaluate the results of surgical treatment of symptomatic cholelithiasis through laparoscopic cholecystectomy in a series of 47 consecutive pediatric patients. METHODS: During a 5-year period (2001-2005) we performed laparoscopic cholecystectomy in 47 patients <18 years old in one institution by the same surgical team. The population was comprised of 41 girls and 6 boys (age range: 6-18 years). All had symptomatic cholelithiasis confirmed at ultrasound examination. Associated pathology was studied in each case. The surgical procedure consisted of a four-port laparoscopic cholecystectomy under CO(2) pneumoperitoneum. No other concomitant procedure was performed in any case. RESULTS: Median age was 14.6 years old. The youngest patient of the series had a hematological disease. In girls we identified obesity in 62.5% of patients, with a body mass index (BMI) of 26.6 kg/m(2) (SD 3.0) vs. 21.5 kg/m(2) (SD 3.0) in boys (p <0.05), 30% of the girls had a positive medical history for pregnancies (range 1-3) and 15% regularly used oral contraceptives. All cases were symptomatic and 13% suffered from acute biliary pancreatitis. Average surgical time was 59.8 min, the conversion rate was 2.1% and the most frequent surgical complication was gallbladder rupture. No major morbidity was observed as well as no mortality. Postoperatively, all patients were asymptomatic, with a minimum follow-up time of 6 months. CONCLUSIONS: Laparoscopic cholecystectomy was highly effective in cases of symptomatic cholelithiasis. Etiologically, females showed risk factors for cholelithiasis similar to those usually observed in adults. Probably in the near future the incidence of cholelithiasis will increase in this age group. Pediatric surgeons should be familiarized with the minimal access technique to treat this disease.

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INTRODUCTION: Urethrocutaneous fistulas (UCF) and flap dehiscence (FD) are the most common postoperative complications after hypospadias (HS) surgical repair. The aim of this study was to evaluate whether the application of fibrin sealant over the site of surgery and suture lines reduces these complications. MATERIALS AND METHODS: A prospective cohort of consecutive patients was treated over a 3-year period. 30 patients were submitted to HS surgical repair plus application of fibrin glue over the suture line and surgical site; for comparison, another 56 subjects made up the control group which was submitted to surgical repair only. Variables assessed included: age, type of HS, fibrin sealant used, complications and number of surgical procedures required to treat recurrences. RESULTS: In general, the frequency of complications was 10 vs. 41% for UCF (p = 0.002), 13 vs. 50% for FD (p = 0.001), and for flap necrosis (FN) 6.7 vs. 28.6% (p = 0.01) for the treatment and control groups respectively. The number of surgical reinterventions to treat recurrences was higher in the control group than in the study group (p = 0.04). CONCLUSION: The incidence of UCF after HS surgical repair can be reduced by applying fibrin sealant over the site of surgery and the suture lines.

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Buschke-Löwenstein tumor or giant condyloma is a warty verrucous lesion, characterized by slow growth, locally infiltrating and disfiguring lesions. Despite its benign histological appearance and low risk of metastasis, Buschke-Löwenstein tumor is an intermediate lesion between condyloma acuminatum and verrucous carcinoma. It has been linked to human papilloma virus, mainly subtypes 6 and 11. Other factors implicated in this disease include poor hygiene, chronic irritation, promiscuity, and cellular immunocompromised states. It rarely occurs in children. The first line of treatment is radical surgical excision with or without adjuvant chemotherapy. We report the case of a 12-year-old girl with a giant perianal condyloma that was treated with surgical excision and a 6-week course of 5-fluorouracil beginning 6 weeks after surgery, with excellent functional and cosmetic results.

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