Broncoscopia en unidad de cuidados intensivos neonatales / Bronchoscopies in neonatal intensive care units: safety and eficiency

El objetivo de nuestro trabajo fue analizar los factores de riesgo y las posibles complicaciones de las broncoscopias neonatales realizadas en las Unidades de Cuidados Intensivos. Realizamos un estudio prospectivo durante nueve años, en dos centros terciarios. Estudiamos un total de 142 broncoscopias realizadas a 81 pacientes en las Unidades de Cuidados Intensivos Neonatales (UCIN). La edad media de los pacientes fue de 1,6 ñ 1,4 meses (2 días-6 meses), con un peso de 2,5 ñ 1 kg (530 g-4,7 kg). Recogimos las complicaciones y los valores de la saturación arterial de oxígeno y la fracción inspirada de oxígeno (FiO2) a lo largo de la broncoscopia, y las comparamos en función del peso, tipo de anestesia empleado y el tipo de broncoscopio utilizado. La saturación basal de los pacientes fue 92 ñ 8,9 por ciento y la final 92,8 ñ 10 por ciento. Las necesidades de FiO2 basales fueron 0,5 ñ 0,3 (0,21-1).Descubrimos un mayor número de complicaciones en los pacientes más pequeños (p < 0,01) y en aquellos que se les realizaba una broncoscopia rígida (p < 0;05); sin embargo, no encontramos diferencia en cuanto al tipo de anestesia empleado. Asimismo, encontramos una caída significativa de la saturación arterial y mayores necesidades de oxígeno en los pacientes menores de 1.500 g (p < 0,05) y en las broncoscopias rígidas (p < 0,05). La realización de broncoscopias en el período neonatal puede considerarse una técnica segura y con alta rentabilidad diagnóstica. Consideramos que es más seguro el fibrobroncoscopio que el broncoscopio rígido, especialmente en niños menores de 1.500 g (AU)

[Bronchoscopies in neonatal intensive care units: safety and efficiency]. / Broncoscopia en unidad de cuidados intensivos neonatales.

The aim of our study is to asses the risks and complications in bronchoscopies at Neonatal Intensive Care Units (NICU). Between 1991 and 1999, we performed 142 bronchoscopies at the NICU. The mean age was 1.6 +/- 1.4 months (2 days-6 months) and mean weight was 2.5 +/- 1 kg (530 g-4.7 kg). We analysed the complications, arterial oxygen saturation and inspired oxygen fraction (FiO2) during bronchoscopy and we compared them related to weight, type of anesthesia and type of bronchoscope used. Mean basal saturation was 92 +/- 8.9% and end saturation was 92.8 +/- 10%. The basal FiO2 was 0.5 +/- 0.3 (0.21-1). There were more complications in patients weighting less than 1500 g and in those procedures made with rigid bronchoscopy (p < 0.05). There were no differences according to the anesthesia. Children who weight fewer than 1500 g and those who underwent rigid bronchoscopy suffered a descent in arterial oxygen saturation and needed higher FiO2 (p < 0.05). Bronchoscopy is a very useful technique and it is well tolerated in neonatal patients. We conclude that flexible fiberoptic bronchoscopy is safer than the rigid bronchoscopy, specially in children fewer under 1500 g.

Surgical approach to funnel-shaped congenital tracheal stenosis.

PURPOSE: The aim of this study was to evaluate the results obtained by 2 different techniques of tracheoplasty in the treatment of long-segment, funnel-shaped congenital tracheal stenosis (CTS) in 2 tertiary paediatric hospitals. METHODS: The clinical records of patients with long segment congenital tracheal stenosis during the period January 1990 to June 1999 were reviewed retrospectively. Age, gender, symptoms, imaging (x-ray, computed tomography, magnetic resonance imaging, or bronchography), endoscopic findings, associated anomalies, treatment, intubation time, postoperative treatment, intensive care unit stay, complications, hospital stay, evolution, and follow-up time were analyzed. Short congenital tracheal stenosis treated by resection and end-to-end anastomosis are not included. Results are given as mean +/- SEM. RESULTS: Ten (7 boys, 4 girls) of 14 patients with CTS had a funnel-shaped CTS. Mean age at treatment was 9.7 +/- 4.8 months (range, 3 days to 4.7 years). All of the patients presented with CTS affecting the distal third of the trachea and 4 of them extension to 1 main stem bronchus. They were treated by 2 different types of tracheoplasty: anterior costal cartilage graft (ACGT, 6 patients) and slide tracheoplasty (ST, 4 patients). All the patients treated by ACGT failed: 4 died and 2 required further surgery for restenosis. Causes of death were acute respiratory failure during surgery (2 cases) and anastomotic dehiscence (2 cases). The patients treated with ST are asymptomatic and doing well. Mean postoperative intubation time of the ACGT group was 35 +/- 25 days (10 to 60 days), whereas in the ST group it was 14 +/- 12 days (0 to 51 days). Mean hospital stays were 292 +/- 271 days (21 to 563 days) and 24 +/- 13 days (7 to 63 days), respectively. Mean follow-up time is 28 +/- 14 months (3 to 94 months). CONCLUSIONS: Surgery of long-segment congenital tracheal stenosis has a high failure and complication rate with vital implications in prognosis. Treatment should be done in a multidisciplinary basis by a highly trained and motivated team. Slide tracheoplasty seems to be the better option, although further multicentre studies should be conducted.

[Treatment of suprastomal tracheomalacia by anterior cricoid suspension]. / Tratamiento de la malacia supraestomal mediante suspensión cricoidea anterior.

BACKGROUND: One of the reasons of failure to decannulate patients after airway surgery or long-term tracheostomy is suprastomal tracheomalacia. OBJECTIVES: Evaluate the results obtained in the treatment of suprastomal tracheomalacia by anterior cricoid suspension. MATERIAL AND METHODS: We present 8 patients with suprastomal tracheomalacia associated to long-term tracheostomy corrected by this technique. Prior to surgery, other causes of airway obstruction, as well as the presence of gastroesophageal reflux disease should be ruled out. Results 5 females and 3 males wer treated by this technique. Mean age at surgery was 4,1 +/-0,97 years (range, 1,5-8,8 years). anteroposterior suprastomal collapse occluding 75% of the trachea was observed in 5 cases, and 75-90% in other three. All the patients were extubated successfully, although in one case stridor recurred because of residual suprastomal malacia that required a new surgical procedure. After a follow-up of 38,7+/-7,39 months (range, 1 month-4,6 years), the patients are decannulated and going well. Conclusions It is an safe surgical technique, easily reproducible and with low costs.

Splenic littoral cell angioma in an infant.

A 1-year-old girl presented with fever, asthenia, and splenomegaly with hypersplenism. Abdominal ultrasound scan and magnetic resonance imaging showed multiple nodular cystic masses in an enlarged spleen. The histological examination of the resected spleen showed a novel type of vascular tumor called littoral cell angioma. The histopathologic and immunohistochemical features of this rare lesion are described. Distinction from other splenic vascular tumors is stressed because the clinical behavior of this new entity seems to be benign.

Tratamiento de la malacia supraestomal mediante suspensión cricoidea anterior / Treatment of suprastomal tracheomalacia by anterior cricoid suspension

Antecedentes: Una de las causas de fracaso en la decanulación de pacientes después de cirugía de la vía aérea o traqueostomía de larga evolución es la malacia supraestomal. Objetivos: Evaluar los resultados obtenidos en la aplicación de la suspensión cricoidea anterior en pacientes con malacia supraestomal. Material y métodos Presentamos la corrección de esta afección en 8 pacientes con traqueostoma de larga evolución. Antes de la corrección quirúrgica se debe descartar la presencia de otras lesiones estructurales de la vía aérea, así como de enfermedad por reflujo gastroesofágico. Resultados Cinco niñas y 3 niños fueron tratados mediante esta técnica. La edad en el momento de la intervención quirúrgica fue de 4,1 ñ 0,97 años (rango 1,5-8,8 años). Se objetivó la existencia de un colapso traqueal supraestomal anteroposterior que ocluía la luz traqueal en un 75 por ciento en 5 casos y en un 75-90 por ciento en los tres restantes. Todos los pacientes fueron extubados con éxito, si bien en un caso se reprodujo el estridor, comprobándose por broncoscopia la existencia de malacia supraestomal residual que fue corregida repitiendo el mismo procedimiento. Tras un período de seguimiento medio de 38,7 ñ 7,39 meses (rango, un mes-4,6 años), los pacientes se encuentran decanulados y asintomáticos. Conclusiones: Se trata de una técnica quirúrgica sencilla, fácilmente reproducible y de bajo coste (AU)

Surgery of subglottic stenosis in neonates and children.

The excellent management of patients in the different Intensive Care Units has decreased mortality but, as a side effect, we have to treat an increasing number of patients with airway problems secondary to prolonged intubation. The clinical records of patients diagnosed of acquired or congenital subglottic stenosis (SE) between 1990 and 1995 were retrospectively reviewed. Types of treatment included conservative, endoscopic, and open surgery: anterior cricoid split (ACS), anterior laryngotracheoplasty (ALTP) and anteroposterior laryngotracheoplasty (APLTP). 46 patients had SE: 7 congenital and 39 acquired. According to Cotton's classification 13 had grade I, 16 grade II, 12 grade III and none grade IV. Eleven of twelve cases treated conservatively did well (92%); one out of six patients managed endoscopically required further surgery (7%); good results were obtained in 5 of 7 cases treated by ACS (71 %); 8 out of 9 patients treated by ALTP did well (89%) and 7 out of 8 managed by APLTP had good results (87.5%). One iatrogenic suture dehiscence required further surgery. There is no statistical difference in the complication rate between patients treated conservatively and those treated by open surgery, while the mean hospital stay was higher in the latter (p < 0.05). An appropriate surgical technique should be offered to those patients with SE who do not do well with conservative management, since these techniques have yielded good results with a low rate of complications. Long-term follow-up shows the absence of recurrence.

[Surgery of lung metastasis]. / La cirugía de las metástasis pulmonares.

INTRODUCTION: The 30-40% of the oncologic patients have pulmonary metastases. Lung can be the only organ affected. In selected patients, exeresis of the pulmonary nodules can mean their healing. MATERIAL AND METHODS: Between 1982-1997, twenty two patients presented metastases, 13 could be operated and 16 thoracotomies were done. There were 53% boys and 47% girls whose ages ranged from 3 to 15 years. We have considered: pulmonary tumour location, disease free interval, number of metastases, surgical technique and incomplete pulmonary tumour resection. RESULTS: Primary tumours were: Wilms tumours 23%, bone tumours 67% (Ewing and osteosarcoma). Disease free interval was < 2 years in 8 patients (61%) and > 2 years in 39%. X-Ray and CT were performed in every case and 66% presented a solitary nodule. Surgical techniques were: metastasectomy in two cases (12%), wedge resection in 8 (50%) and lobectomy in six cases (38%). We made thoracoscopy in two patients. There weren't postoperatory mortality but the patients with tumorectomy had an incomplete surgical resection. The overall survival is 54 percent and the 5 years survival is 23 percent (3 patients). CONCLUSIONS: The patients with a DFI < 2 years have a survival of 25% compared with 100% for patients who have a DFI > 2 years. The pulmonary resection in selected patients can offer better survival. We can use the thoracoscopy in same selected patients.

Bronchial mucoepidermoid tumor in a 3-year-old child.

A 3-year-old girl was evaluated for persistent middle lobe atelectasis. Fiberoptic bronchoscopy revealed a spherical mass occupying the middle-lobe bronchus. The biopsy specimen disclosed a low-grade mucoepidermoid carcinoma. A lobectomy was performed. The patient is in good condition 2 years after the operation. Mucoepidermoid tumors are rare bronchial adenomas comprising 1% of all lung neoplasms. Children are very infrequently affected. The clinical behavior of these tumors is controversial. Surgical resection of the low-grade-type tumor has an excellent prognosis.

Primary neuroblastoma presenting as a paratesticular tumor.

A 3-month-old boy was operated on for an inguinal tumor. Histological diagnosis was neuroblastoma. This is the second known case of primary paratesticular neuroblastoma reported in the literature. The treatment of choice for Evan's stage I is surgery.

[The treatment of the tracheobronchomalacia in pediatric age]. / Tratamiento de la traqueobroncomalacia en la edad pediátrica.

OBJECTIVE: Aortopexy is the more extended treatment for severe tracheomalacia, when it fails, reintervention and other procedures are necessary. We present our experience in the treatment of this pathology. MATERIAL AND METHODS: Tracheomalacia, bronchomalacia and tracheobroncomalacia cases during a twelve year period (1983-1995) were reviewed (type, age, symptoms, surgical procedures and results were collected). RESULTS: Nineteen patients (9 males, 10 females) presented tracheobronchomalacia in our Hospital. Diagnosis was made by bronchoscopy in all of them: nine cases of tracheomalacia, five bronchomalacias and five suprastomal malacias were found. Mean diagnosis age was twenty four months (newborn-twelve years). Ten patients were managed nonoperatively, five with anterior cricoideal suspension and two cases were treated by aortopexy; one of them, after 2 months of respiratory stridor and recurrent respiratory arrest, needed an endoscopically placed intraluminal expandable Palmaz Prothesis. This prothesis was removed two years later. In this moment, the patient is doing well without stridor or respiratory symptoms.

[Surgical treatment versus tracheostomy of the laryngeal stenosis in children]. / Cirugía versus traqueostomía en las estenosis laríngeas pediátricas.

Incidence of pediatric laryngeal stenosis has increased due to better Intensive Care Units. The medical records of the patients with laryngeal stenosis treated in the hospital between 1990 and 1995 were reviewed, analyzing the type of lesion, ethiologic factors, surgical technique employed and post-op result. The surgical technique was chosen conditioned by the age, weight of the patient, grade of the stenosis according to Cotton's classification and presence or absence of respiratory distress. 48 patients had laryngeal stenosis. 2 of them had acute glottic edema (4%) and 45 subglottic stenosis (96%), most of them after long term endotracheal intubation, 34 cases (75.5%). 19 of these occurred in the neonatal period. 7 cases (15.5%) were congenital stenosis (2 subglottic membranes, 1 subglottic cyst and 4 true congenital subglottic stenosis). 5 cases were a miscelanea. We found 13 grade I cases (29%), grade II 16 cases (35%) and grade III 12 (27%). No grade IV were seen. 8 patients (18%) had gastro-esophageal reflux, 5 of them required Nissen's funduplication before airway surgery. 12 patients followed medical treatment (27%), all of them grades I and II, with good results. Endoscopic treatment was done in 6 patients (13%), with good results in all but one that required a surgical approach. The anterior cricothiroid split was done in 7 patients (15%), all of them under 5 months of age. Good results were obtained in 71.4 percent of the patients. 9 cases (20%) underwent an anterior largingotracheoplasty with costal cartilage graft with good results in 88.9 percent of the patients. Anterior and posterior cartilage graft after double laringotracheoplasty was done to 8 patients (18%). One of them developed a subglottic sinequiae which was solved endoscopically, and another patient evolved to restenosis. 20 patients had a tracheostomy. All but four were decanulated in 11.7 +/- 12.3 (4-54) weeks. Mortality rate associated with the surgical technique has been zero, with excellent results in 82.5 percent of the series. The new surgical techniques developed in recent years for laringotracheal stenosis in childhood have made unnecessary the use of permanent tracheostomies in these children which have obvious inconvenient and potentially lethal complications.

Treatment of esophageal varices by endoscopic ligation in children.

Endoscopic variceal ligation (EVL) is an alternative technique to endoscopic variceal sclerotherapy (EVS) to treat esophageal varices. This method consists of mechanical ligature and thrombosis of varices using elastic rubber rings. During an 11-month period, nine pediatric patients with esophageal varices secondary to portal hypertension were treated by EVL. Extrahepatic portal vein obstruction was the cause of portal hypertension in 5 patients and in 4 cases the cause was intrahepatic disease. The average age of the patients was 8 years (range: 2-15). Five patients had bled from esophageal varices previously. Two were actively bleeding at the time of the procedure. Endoligature was performed prophylactically in four patients. Fifty varix ligations were performed in 26 separate sessions. In children older than ten years, EVL was performed under intravenous sedation. Two mild rebleeds have occurred in this group and responded to repeated ligature. Varices were reduced in grade in all patients. Six patients achieved variceal eradication. Recurrence of varices was not encountered. No major complications occurred and there were no treatment failures. These early results suggest that endoscopic ligation is a safe and effective method for the control of esophageal varices in children.

[Ambulatory surgery. Experience at a pediatric surgery department]. / Cirugía de corta estancia. Experiencia de un servicio de cirugía pediátrica.

In October 1987 we opened an Outpatient Surgical Unit, since January 1988 to December 1993 we have treated 8232 patients with an mean age (range of 2 weeks to 17 years). All the patients were given general anesthesia, loco-regional anesthetics or deep sedation. 33.5 percent of the total number of patients operated in our hospital were treated in this Unit, being 41.4 percent if related to programmed surgery. Only 2.5 percent of them were admitted in the inpatient area with no significant complications.

[Surgical alternatives in congenital tracheal stenosis]. / Alternativas quirúrgicas ante la estenosis traqueal congénita.

Congenital tracheal stenosis is a rare condition with a high mortality. In a 12-year period, 5 cases (ages 5 days to 4 years) with this anomaly were treated. 4 were corrected, the operative repair consisted of segmental resection and anastomosis in one patient, and rib-cartilage tracheoplasty in the other three. The other patient died 12 days after bronchoscopy without attempt of surgical correction. Two patients died during or just after surgery, both of them presenting a similar clinical course consisting on severe air trapping, mechanical pulmonary hypertension and low cardiac output. Long-term follow-up of the survivors is satisfactory.

[Surgery of the structural lesions of the respiratory tract]. / Cirugía de las lesiones estructurales de la vía aérea.

22 clinical files of patients treated in our institution since 1983 for structural lesion of the airway are reviewed. 3 cases presented congenital tracheal stenosis, 15 congenital or acquired subglottic stenosis, 1 severe tracheomalacia, 1 subglottic membrane, 1 congenital subglottic cyst and 1 subglottic granuloma. A conservative or surgical approach (endoscopic, anterior cricoid split, Fearon's laryngotracheoplasty, modified Rethi's procedure, Kimura's tracheoplasty and aortopex) was used. Good results were obtained in 55.5 percent of the conservative cases, 100 percent of the endoscopic procedures, 50 percent of the splits and 75 percent of the laryngotracheoplasties. The Kimura and aortopexy procedures gave also good results. 4 patients are waiting for surgery: 1 anterior laryngotracheoplasty for iatrogenic failure, 2 conservative cases for persistence of the symptoms and 1 congenitaltracheal stenosis. A case of difuse congenital tracheal stenosis died before surgery. There are no significant differences in the complication rates of the surgical and conservative groups, but mean hospital stay was shorter in the former (p < 0.05).

[Intestinal anastomosis by biodegradable rings]. / Anastomosis intestinal mediante anillos biofragmentables.

During an 9-month period (March to November 1992), six children underwent an intestinal anastomosis by means of a biofragmentable ring (BAR). Patients ages ranged from 5 to 16 years old. There were no mayor complications at surgery. The main technical problems was the difference of size between BAR and intestinal lumen. No patients in which BAR was used have presented fistulae, dehiscence or anastomotical stenosis.

[The indications, technics and results of the use of tissue expanders in pediatric surgery]. / Indicaciones, técnica y resultados del empleo de los expansores tisulares en cirugía pediátrica.

We review our experience in tissue expansion in twenty-four pediatric patients. The most frequent indications for the use of tissue expanders included congenital nevi and burn scars, they were also used with success in alopecia, congenital abdominal wall defects, mammary hypoplasia and microtia. Tissue expanders were always placed subcutaneously. Both, surgery and body deformity during expansion, were well tolerated. We found complications in five cases, but only in one patient treatment was interrupted. Results were considered excellent in nineteen cases.

[Results of the treatment of Hirschsprung's disease using Duhamel technique and mechanical sutures]. / Resultados del tratamiento de la enfermedad de Hirschsprung mediante la tecnica de Duhamel realizada con suturas mecanicas.

The original Duhamel procedure for the treatment of Hirschsprung's disease (HD) has undergone several important modifications over the years. The use of mechanical suture in recent years has added significant advantages to this surgical procedure. Sixteen patients with HD were operated on according to this surgical technique, from 1985 to 1990. We analyse clinical, radiological and surgical aspects. We concentrate on early and late postoperative complications and the results achieved after a maximum follow-up of 4.5 years.