Treatment of keloids and hypertrophic scars. Position statement of the Brazilian expert group GREMCIQ.

Keloids (K) and hypertrophic scars (HS) are abnormal responses to wound healing that occur as the result of dermal inflammation. Despite the advances on their treatment, many patients still suffer from the negative effects of excessive scarring; its approach is impaired by the lack of objective data on different treatments and the large genetic variability among patients and the difficulties in producing multicentre studies. Their incidence among the Brazilian population is high, as the result of an admixture of Amerindians, Europeans and Africans ancestral roots. With the aim of producing multicentre studies on K and HS, a panel of senior Brazilian dermatologists focused on their treatment was invited to contribute with the K and HS Treatment Brazilian Guidelines. In the first part of this study, different treatment modalities for keloids and HS are fully reviewed by the panel. The second part of the study presents a consensus recommendation of treatment for different types of lesions. More than a literature review, this article aims to show the pitfalls and pearls of each therapeutic option, as well as a therapeutic approach by the Panel of Experts on keloids and Scars on a highly mixed population, providing simple guidelines.

Ventral hernia secondary to giant omphalocele in a child: combined approach of botulinum toxin and preoperative progressive pneumoperitoneum.

Omphalocele is a congenital abdominal wall defect that occurs approximately 1 in 4000-6000 live births. The abdominal-visceral disproportion, large diameter of the defect, volume of liver in the sac along with high incidence of associated anomalies make the surgical management a real challenge. Currently, there are two strategies for managing giant omphaloceles, staged surgical closure and nonoperative delayed closure. The combined treatment with PPP and BoNT/A injection has recently been described in adults. There is strong evidence on safety and efficacy of the use of BoNT/As in other areas of pediatrics and no recent reports of PPP use in children. Also, there are no data available about the combination of both techniques in pediatric population. The purpose of this manuscript is to report a case of a 7-year-old female child that was referred to our institution with a large ventral hernia secondary to omphalocele. We opted for a combined approach with BoNT/A injection and PPP before the definitive surgery. The surgical result was great with midline closure with no tension and no need for prosthetic substitution or component separation needed. To our knowledge, this is the first case report of BoNT/A injection and PPP for large ventral hernias in children. BoNT/A application was safe and the PPP technique was also proved to be applicable on children. We believe that the combination of BoNT/A and PPP presented to be a safe approach with an excellent result, particularly for not needing abdominal wall prosthetic substitution.

Thyroid alar cartilage laryngotracheal reconstruction for severe pediatric subglottic stenosis.

BACKGROUND/PURPOSE: Laryngotracheoplasty has become an accepted treatment alternative for subglottic stenosis. However, the best autogenous material for laryngotracheoplasty remains controversial. Autogenous superior thyroid alar cartilage (TAC) has been used successfully in single stage laryngotracheal reconstruction in children with subglottic stenosis. METHODS: This is a retrospective study of 6 children (mean age, 16.6 months) undergoing TAC graft laryngotracheoplasty between September 1995, and June 1999. Two children had immediate tracheal intubation for congenital subglottic stenosis. Four others had previous tracheostomy: 3 for severe postintubation subglottic stenosis and 1 for congenital subglottic stenosis. After an anterior cricoid split, a piece of TAC was sutured between the cut ends of the cricoid, with the graft perichondrium facing intraluminally. Endotracheal intubation was maintained postoperatively. RESULTS: Four children underwent successfully extubation 9 to 21 days (mean, 15.5 days) postoperatively. Two required tracheostomy, which was maintained because of severe laryngomalacia and laryngotracheobronchomalacia. One child was treated with CO2 laser because of symptomatic recurrence of the subglottic stenosis 3 weeks after the surgery; another required fundoplication for gastroesophageal reflux 12 months after laryngotracheoplasty. There were no donor site complications in any of the 6 cases. Repeat laryngoscopy and bronchoscopy showed a patent subglottic airway. All of them are without symptoms after a mean follow-up of 26 months. CONCLUSIONS: (1) This preliminary experience indicates that the TAC graft technique is a viable option for laryngotracheal reconstruction; (2) the TAC graft has significant advantages, including a single operative incision and absence of donor-site morbidity.

[Experimental empyema in rats through intrapleural injection of bacteria] / Indução de empiema em ratos através da inoculação pleural de bactérias.

OBJECTIVE: To evaluate empyema formation in rats through the injection of two bacteria (Pasteurella multocida and Staphylococcus aureus), using a simple, easy-to-use surgical technique. METHODS: Twenty four anesthetized Wistar white rats, 250-300g in weight, submitted to right anterior thoracotomy, muscular retraction and injection of a 0.2ml solution into pleural space according the following scheme: Group I (n=12): injection of 10(10) Pasteurella multocida cultured in brain heart infusion broth. Group II (n=8): injection of 10(10) Staphylococcus aureus cultured in brain heart infusion broth. Group III (n=4): injection of bacterium-free brain heart infusion (control). The rats were sacrificed after seven days, and pleural reaction was assessed by macroscopy. Mortality, and intrathoracic liquid volume were evaluated, and bacteriological tests were also performed. RESULTS: Seven rats died within the first 48 hours in Group I (Pasteurella multocida); five completed the experiment, but none of them presented empyema. Only one animal died within the first 24 hours in Group II (Staphylococcus aureus); seven (88%) presented empyema at the time of sacrifice. All animals survived in Group III (control), without empyema or thoracic abnormalities. Pleural inoculation of Staphylococcus aureus (Group II) was significantly associated with empyema formation (P<0.001). In this group, the amount of pleural liquid ranged from 0.9 to 3.9ml. CONCLUSION: It is possible to induce empyema in rats through Staphylococcus aureus pleural injection by a simple surgical technique. Differently from other experiments, the pleural injection of Pasteurella multocida did not provoke empyema in rats.

[Endoscopic supraglottoplasty in children with severe laryngomalacia with and without neurological impairment] / Supraglotoplastia endoscópica em crianças com laringomalacia grave com e sem doença neurológica associada.

OBJECTIVE: To describe indications and results of supraglottoplasty for severe laryngomalacia in children with or without neurological impairment. METHODS: Eight children with severe laryngomalacia submitted to endoscopic supraglottoplasty were retrospectively studied. Four had neurological impairment (male, mean age 6 years), and 4 did not present neurological problems (3 female, mean age 11.5 months). Surgery indications were respiratory distress, feeding difficulties, failure to thrive, and low oxygen saturation. Polysomnographic evaluation was carried out on the last 2 children, showing abnormal oxygen saturation, obstructive apnea, and hypoventilation. All children received preoperative antibiotics and corticosteroids. RESULTS: All children without neurological impairment had significant relief of symptoms. Children with neurological impairment had different outcome: one needed tracheotomy immediately after surgery due to edema and supraglottic granulation tissue. The other three children presented initial relief of symptoms, but subsequent follow-up showed progressive airway obstruction: one needed another endoscopic surgery 6 months later; other needed tracheotomy 7 months later. The children who were not submitted to tracheostomy presented persistent severe airway obstruction. No endoscopic surgery complication was observed. CONCLUSIONS: 1) Endoscopic supraglottoplasty is well tolerated and does not present complications when used in children; 2) Endoscopic supraglottoplasty was efficient in the treatment of children with severe laryngomalacia and in without neurological impairment; however, supraglottoplasty did not resolve airway obstruction in children with neurological impairment.

Estudio experimental de técnicas de fijación testicular / Experimental study on orchipexy

La fijación testicular se realiza para prevenir la torsión del órgano y en la corrección de la criptorquidia.Se han utilizado para ello diversas técnicas,persistiendo discordancia respecto a cúal es la mejor,con menor daño testicular.Este estudio se realizó para comparar la fijación y el grado de lesión testicular con distintas técnicas quirúrgicas,utilizando dos tipos de sutura.Cuarenta ratas adultas de la raza Wistar,anestesiadas con eter etílico se sometieron a la incisión del escroto y exposición de ambos testículos.Se definieron en forma aleatoria cuatro grupos:grupo 1(n=10)fijación con un punto único,grupo 2(n=10)al que se fijó el testículo con dos puntos,grupo 3(n=10)en el que el testículo se fijó con tres puntos.En la mitad de los animales fue utilizado Vicryl 5-0,y en le resto se utilizó Mersilene 5-0,en el grupo 4 (n=10)el testículo se colocó en la bolsa sabdártica sin puntos de sutura.El testículo contralateral no tratado fue utilizado como control.Todos los animales se sacrificaron a los 30 días,evaluándose el grado de fijación macroscópica,eltamaño del testículo,y las alteraciones microscópicas del mismo.Todos los animales completaron el período previsto de observación.Se observó una diferencia significativa de la fijación entre los grupos(p<0,0038):los animales del grupo 1 presentaron una fijación menor respecto a los otrso grupos.Entre los grupos 2,3 y 4 no se observó una diferencia significativa en la fijación,tampoco hubo diferencia entre los animales del mismo grupo suturados con vicryl o mersilene.No se observaron alteraciones inflamatorias testiculares estadísticamente significativas entre los grupos ni entre los animales del mismo grupo fijados con las dos suturas.La fijación testicular con 2 o 3 puntos en la bolsa subdártica es superios a la realizada con un punto único.Esta última provoca alteraciones semejantes a las encontradas con las otras técnicas,que produce significativamente menor fijación

Estudio experimental de técnicas de fijación testicular / Experimental study on orchipexy

La fijación testicular se realiza para prevenir la torsión del órgano y en la corrección de la criptorquidia.Se han utilizado para ello diversas técnicas,persistiendo discordancia respecto a cúal es la mejor,con menor daño testicular.Este estudio se realizó para comparar la fijación y el grado de lesión testicular con distintas técnicas quirúrgicas,utilizando dos tipos de sutura.Cuarenta ratas adultas de la raza Wistar,anestesiadas con eter etílico se sometieron a la incisión del escroto y exposición de ambos testículos.Se definieron en forma aleatoria cuatro grupos:grupo 1(n=10)fijación con un punto único,grupo 2(n=10)al que se fijó el testículo con dos puntos,grupo 3(n=10)en el que el testículo se fijó con tres puntos.En la mitad de los animales fue utilizado Vicryl 5-0,y en le resto se utilizó Mersilene 5-0,en el grupo 4 (n=10)el testículo se colocó en la bolsa sabdártica sin puntos de sutura.El testículo contralateral no tratado fue utilizado como control.Todos los animales se sacrificaron a los 30 días,evaluándose el grado de fijación macroscópica,eltamaño del testículo,y las alteraciones microscópicas del mismo.Todos los animales completaron el período previsto de observación.Se observó una diferencia significativa de la fijación entre los grupos(p<0,0038):los animales del grupo 1 presentaron una fijación menor respecto a los otrso grupos.Entre los grupos 2,3 y 4 no se observó una diferencia significativa en la fijación,tampoco hubo diferencia entre los animales del mismo grupo suturados con vicryl o mersilene.No se observaron alteraciones inflamatorias testiculares estadísticamente significativas entre los grupos ni entre los animales del mismo grupo fijados con las dos suturas.La fijación testicular con 2 o 3 puntos en la bolsa subdártica es superios a la realizada con un punto único.Esta última provoca alteraciones semejantes a las encontradas con las otras técnicas,que produce significativamente menor fijación

[Thoracoscopy with mediastinoscope in pediatric complicated parapneumonic effusion] / Pleuroscopia com mediastinoscópio em crianças com derrame parapneumônico complicado.

OBJECTIVE: To evaluate our experience with thoracoscopy with small mediastinoscope in complicated parapneumonic effusion in children.METHODS: From July 1995 to June 1997, seven children with complicated parapneumonic pleural effusion underwent thoracoscopy with mediastinoscope at Hospital de Clínicas de Porto Alegre. The procedure was carried out with a small mediastinoscope built in our hospital.RESULTS: There were six girls and one boy. The procedure was preformed under general anesthesia, without selective intubation. Six patients had previous intercostal tube drainage; one underwent thoracoscopy as a primary procedure. No complication was observed after the procedure. During follow-up, two children underwent pleurotomy due to residual pleural effusion with persistent fever; two others presented asymptomatic small pleural effusion.CONCLUSION: Thoracoscopy with small mediastinoscope is safe, efficient and without severe complications. It is very useful to remove loculated complicated parapneumonic effusion at fibrinopurulent stage and to enable lung expansion.

Experimental trial of balloon-expandable, metallic Palmaz stent in the trachea.

OBJECTIVE: To determine the effect of the Palmaz stent, which has been successfully used to relieve airway obstruction in a small group of children, on the normal and operated on animal trachea. DESIGN: In this experimental trial, stents were placed bronchoscopically in the thoracic tracheae of 4 groups of 50 anesthetized cats. The cats in group 1 (adults, n = 10) and group 2 (kittens, n = 10) had normal tracheae; the cats in group 3 (adults, n = 15) underwent horizontal tracheal incision and closure; and the cats in group 4 (adults, n = 15) underwent pericardial patch tracheoplasty. In group 3 and 4, the stents were inserted in 10 cats and 5 cats served as controls. Stents were inflated to a 15-mm diameter in group 1 and an 8-mm diameter in the other groups. Half of the animals with stents were killed 5 weeks after the procedure, and the others, 10 weeks after the procedure. SETTING: The Hospital for Sick Children, Toronto, Ontario. RESULTS: In group 1, 1 animal died of tracheal perforation. A mild cough was noted in 15 of the 39 cats with stents. In group 4, 3 cats had difficulty eating and lost weight. The results of esophagoscopy excluded esophageal inflammation or obstruction in these 3 animals. The results of bronchoscopy indicated a nonobstructing rim of granulation tissue at the end of the stent in 15 of 20 cats in groups 1 and 2 and 17 of 20 cats in groups 3 and 4 and at the repair site in all animals with stents from groups 3 and 4. The results of autopsy indicated the cross-sectional area at the site of the stent was greater than normal in group 1 (P < .003) and smaller than the normal trachea at the site of the tracheoplasty in group 4 controls without stents (P < .02); however, the cross-sectional area at the tracheoplasty site with the stent was not smaller (P < .13). The results of histologic examination indicated a mild inflammatory reaction, with granulation tissue in all animals with stents, but in group 1, with overexpanded stents, the reaction was more severe, with epithelial ulceration, fibrosis, and sealed-off perforations in most animals. In group 3, the tracheae with stents had significantly more inflammatory reaction, granulation tissue, and epithelial damage than the controls without stents. CONCLUSIONS: The Palmaz stent provokes an inflammatory reaction in the normal trachea and the trachea recently operated on. With the exception of the group 1 animals with overexpanded stents, this reaction is clinically insignificant. The Palmaz stent is able to maintain a normal lumen size after pericardial tracheoplasty in cats.

Hexachlorocyclohexanes affect the arachidonic acid release from phosphatidylinositol but not from other phospholipid classes in tubular cell cultures.

Gamma- and delta-isomers of hexachlorocyclohexane caused marked decreases in the levels of radioactive phospholipids, and increases in the levels of [3H]arachidonate incorporated into free fatty acids in rat renal tubular cells. The increased radioactivity of free fatty acids arises from the decrease of [3H]arachidonate incorporated into phosphatidylinositol, but not into phosphatidylcholine, phosphatidylserine or phosphatidylethanolamine. This fact suggests that phosphatidylinositol can be broken down to the fatty acid from the sn-2 position and lysophospholipid by a phospholipase activity increased by hexachlorocyclohexanes. The observed specific toxicant action could be achieved in two ways: (a) operating upon a specific phospholipase A2 that acts on phosphatidylinositol, but not on other phospholipids as substrates and/or (b) involving substrate-phospholipase A2 interactions. Interestingly, the observed effect of the delta-isomer was more pronounced than that of the gamma-one.

The use of expandable metallic airway stents for tracheobronchial obstruction in children.

Expandable metallic angioplasty stents (Palmaz stent) have been implanted in the trachea and/or bronchi of seven children. Three children had severe tracheal stenosis after tracheoplasty for congenital tracheal stenosis repair, and four had tracheomalacia or bronchomalacia with or without vascular compression. The mean age at stenting was 9.7 months (range, 2 to 15 months). Balloon expandable stents were inserted into the trachea or bronchus through a 3.5-mm bronchoscope under fluoroscopic control. Initially a single tracheal stent was used for all patients except for one with obstruction in the trachea and both bronchi, in whom three stents were implanted. Three children had recurrent airway obstruction 1 month later; one was cured with a second stent; one child died 1 year later; and the other is being treated for heart disease. The others have no serious respiratory problems. The stents in all have been in place for 1 to 25 (mean, 11) months. No immediate complications were noted. Early and late bronchoscopy showed incomplete epithelialization of the stent and patches of granulation tissue on it. Two stents were removed bronchoscopically, one at the completion of treatment for tracheomalacia and the other at the time of recurrent airway obstruction. This preliminary experience indicates that expandable metallic stents have a useful role in the treatment of selected lower airway obstructions.

Urethral lengthening with anterior bladder wall flap for urinary incontinence: a new approach.

Urethral irregularity (impeding catheterization) and failure to achieve continence are common complications in surgery for urinary incontinence. We describe a surgical technique using an anterior bladder wall flap that is sutured to the posterior wall in an onlay fashion creating a flap valve mechanism. Experimental work in dogs demonstrated a significant increase in the leak point pressure in the surgical group when compared to controls (p = 0.019). Voiding cystourethrography and bladder inspection demonstrated an anterior flap valve with no fistula formation in all animals. Histological examination showed a viable anterior bladder wall flap in all cases. This technique was then applied to 6 patients with neurogenic bladder and low urethral resistance that failed to resolve with medical treatment. Urinary continence was achieved in 4 patients. In 1 patient a vesicourethral fistula developed 3 months postoperatively, since the mother failed to catheterize for 12 hours. This technique is a useful alternative in the treatment of urinary incontinence.

[Rigid respiratory endoscopy in children]. / Endoscopia respiratória rígida em criança.

From march 1989 to march 1992, three hundred and fifty six respiratory endoscopies were performed at "Hospital da Criança Santo Antônio", Porto Alegre, Brazil. The endoscopies were performed with a rigid pediatric bronchoscope and under general anaesthesia. The most common indications for endoscopy were stridor (52%), suspected foreign body (16%), atelectasis (16%) and difficult tracheal extubation (8%). The most frequent diagnosis were laryngomalacia (36%) and subglottic stenosis (6%) in the glottic and subglottic areas, and foreign body (9%) and tracheomalacia (7%) in the tracheobronchial area. Normal endoscopy was observed in 54 (21%) of the children. Only three slight complications of the endoscopy were observed. Two patients presented bradycardia during the exam, and the third needed tracheal intubation due to post-endoscopic subglottic edema. This confirms that the rigid endoscopy in children is efficient and has no serious complications.

Congenital rupture of scrotum: an unusual complication of meconium peritonitis.

Congenital rupture of the scrotum caused by meconium peritonitis occurred in a newborn with clinical findings of the Beckwith-Wiedemann syndrome. Ruptured omphalocele and jejunal atresia were present. Surgical repair 3 hours after birth was successful.

Seromuscular enterocystoplasty in dogs.

An experimental canine model was developed to evaluate the possibility of using seromuscular segments of intestine for bladder augmentation. Of the 10 dogs 5 had bladder augmentations with seromuscular segments of sigmoid and 5 with seromuscular segments of ileum. After 8 weeks we observed that the seromuscular segment was viable and covered with urothelium but intense shrinkage had occurred. Because of the many theoretical advantages of performing bladder augmentation with intestinal segments free of mucosa, we believe that further investigation to elucidate the possible cause of retraction of the seromuscular segment is needed.

[The development of the population of Cuba in the five-year period 1981-1985 and a comparison with 1976-1980: expected developments for the five-year period 1986-1990]. / Evolucion de la poblacion de Cuba en el quinquenio 1981-1985 y su comparacion con el de 1976-1980: evolucion perspectiva para el quinquenio 1986-1990.

PIP: Cuban demographic trends for the periods 1976-1980 and 1981-1985 are examined, and trends for the period 1986-1990 are forecasted. The results indicate that Cuban population trends are becoming increasingly similar to those of developed countries due to successful socioeconomic development. (SUMMARY IN ENG AND RUS)^ieng