Manejo de los niños con epidemia: drenaje pleural no siempre es necesaria / Management of children with epidemic pleural drainage is not always necessary

El tratamiento de niños con neumonía bacteriana y derrame paraneumónico (empiema) nunca ha sido directoy aún no está claro que los pacientes se beneficien con el drenaje pleural. En la actualidad, el drenaje pleural, principalmente a través de tubo torácico con fibrinolíticos o cirugía vídeo toracoscópica (CVT) es ampliamente utilizada.

Laparoscopic and thoracoscopic esophagomyotomy for children with achalasia.

BACKGROUND: Minimally invasive esophagomyotomy, consisting of a laparoscopic or thoracoscopic approach, has become a preferred surgical treatment for adults with achalasia. This multicenter study reports on the clinical status of children who have undergone minimally invasive esophagomyotomy for achalasia. METHODS: Symptomatology for achalasia was assessed in 22 pediatric patients who underwent minimally invasive esophagomyotomy for achalasia between 1995 and 2000. All patients were evaluated for duration of hospitalization, postoperative resumption of feeds, postoperative complications, and symptomatic relief. Participants were assigned pre-and postoperative symptom severity scores ranging from 0 (no symptoms) to 3 (severe). RESULTS: The median age of the 10 females and 12 males at time of surgery was 11.3 years +/- 3.4 (standard deviation). Transabdominal laparoscopic esophagomyotomy with fundoplication was performed in 18 patients, and thoracoscopic esophagomyotomy without fundoplication was performed in 4. Two patients required conversion from transabdominal laparoscopic esophagomyotomy to open esophagomyotomy because of intraoperative esophageal perforation. The mean duration of postsurgical follow-up was 17 +/- 16 (standard deviation) months (range, 1-54 months). Mean duration of hospitalization (days +/- standard error or mean) was less for transabdominal laparoscopic esophagomyotomy than for converted open esophagomyotomy (2.7 +/- 0.3 vs. 9.0 +/- 3.0 days; P < 0.05) or for thoracoscopic esophagomyotomy (4.8 +/- 1.7 days; P = not significant). Mean time to resumption of soft feedings (days +/- standard error or mean) occurred sooner after transabdominal laparoscopic esophagomyotomy than after converted open esophagomyotomy (2.0 +/- 0.2 vs. 5.5 +/- 0.5 days; P < 0.001) or after thoracoscopic esophagomyotomy (4.0 +/- 1.3 days; P = not significant). Patients experienced significant pre-to postoperative improvement in mean severity score with regard to dysphagia (2.6 vs. 0.4; P < 0.001) and regurgitation (1.7 vs. 0.2; P < 0.001). CONCLUSIONS: Minimally invasive esophagomyotomy can provide excellent symptomatic relief from dysphagia and regurgitation for children with achalasia.

The learning curve associated with pediatric laparoscopic splenectomy.

BACKGROUND: Laparoscopic splenectomy (LS) is technically difficult compared with open splenectomy. This report examines our experience with LS to define the learning curve. METHODS: The first 49 consecutive laparoscopic splenectomies were reviewed. Indications, complications, operative time, and costs were recorded. RESULTS: Indications included hereditary spherocytosis, immune thrombocytopenia purpura, beta-thalassemia, lymphoma, splenic cysts, and abscesses. Surgical time averaged 196 minutes for the first 10 patients, decreasing to 105 minutes for the last 10. Blood loss for the first 10 patients averaged 50 cc and less than 5 cc for the last 10. There were 3 complications and 1 conversion to open operation. Operative and hospital charges averaged $6,670 and $13,402, respectively, for the first 10 cases compared with $5,278 and $10,863 for the last 10. CONCLUSIONS: LS can be performed safely with few complications. LS has a steep learning curve in the first 20 patients after which operative times decrease along with overall costs.

Routine intraoperative cholangiography during laparoscopic cholecystectomy minimizes unnecessary endoscopic retrograde cholangiopancreatography in children.

PURPOSE: The aim of this study was to determine the necessity for intraoperative cholangiography (IOC) during pediatric laparoscopic cholecystectomy (LC). METHODS: A retrospective review of 100 consecutive patients undergoing LC was conducted. RESULTS: Ninety-eight children underwent successful LC. The average age was 11.3 years. IOC was successful in 55 of 63 studies. Operating time for patients with IOC averaged 91 minutes, and without IOC, 67 minutes. Twenty children had preoperative ultrasound, laboratory, or clinical evidence of common bile duct (CBD) stones. Fifteen of these 20 children actually had CBD stones. Three additional children who lacked any ultrasound, clinical, or laboratory evidence of choledocholithiasis had unsuspected CBD stones. Eight children, therefore, had ultrasound, clinical, or laboratory findings not predictive of the actual state of the CBD. Sixteen children underwent endoscopic retrograde cholangiopancreatography (ERCP), 9 preoperatively and 7 postoperatively. Four preoperative ERCP studies showed no CBD stones. There were no complications from performing IOC. CONCLUSIONS: (1) CBD stones are common in children with gallstones, (18 of 100 patients). (2) Preoperative studies and clinical findings may not predict accurately the presence or absence of CBD stones. (3) IOC should be routinely performed in children before the use of ERCP to avoid unnecessary ERCP unless CBD stones are specifically visualized by ultrasound scan. J Pediatr Surg 36:881-884.

Intussusception: hospital size and risk of surgery.

OBJECTIVE: To determine whether the risk of operative management of children with intussusception varies by hospital pediatric caseload. DESIGN: A cohort of all children with intussusception in Washington State from 1987 through 1996. SETTING: All hospitals in Washington State. METHODS: Five hundred seventy children with a hospital discharge diagnosis of intussusception were identified. Sixty-two were excluded because of missing data. Procedure codes for operative management and radiologic management were also identified. RESULTS: Fifty-three percent of the children had operative reduction and 20% had resection of bowel. Children with operative reduction did not differ from those with nonoperative care by median age or gender; however, children with operative care were significantly more likely to receive care in hospitals with smaller pediatric caseloads and to have a coexisting condition associated with intussusception. Sixty-four percent of children who received care in a large children's hospital had nonoperative reduction, compared with 36% of children who received care in hospitals with 0 to 3000 annual pediatric admissions and 24% of children who had care in hospitals with 3000 to 10 000 annual pediatric admissions. Median length of stay and charges were significantly less in the large children's hospital, compared with other centers. CONCLUSIONS: Children who received care for intussusception in a large children's hospital had decreased risk of operative care, shorter length of stay, and lower hospital charges compared with children who received care in hospitals with smaller pediatric caseloads.

Deep soft tissue infections in the neutropenic pediatric oncology patient.

PURPOSE: Necrotizing fasciitis and myonecrosis can be rapidly fatal without prompt and aggressive medical and surgical therapy. We reviewed our experience with necrotizing fasciitis and myonecrosis in neutropenic pediatric oncology patients to describe associated clinical characteristics and outline therapeutic interventions. PATIENTS AND METHODS: A retrospective chart review was performed for all cases of deep soft tissue infection found in neutropenic pediatric oncology patients during an 11-year period. RESULTS: Seven cases of necrotizing fasciitis and/or myonecrosis associated with chemotherapy-induced neutropenia were diagnosed during the study period. Deep soft tissue infection was diagnosed a median of 14 days after the initiation of chemotherapy. All of the patients presented with fever and pain, generally out of proportion to associated physical findings. Most patients (86%) also had tachycardia and subtle induration at the site of soft tissue infection. The pathogenic organism in four of seven patients originated in the gastrointestinal tract. Patients were treated with antibiotics, surgical debridements, granulocyte colony-stimulating factor, and hyperbaric oxygen. Granulocyte transfusions were administered if there were no signs of neutrophil recovery. Five patients survived their deep soft tissue infection. CONCLUSIONS: The diagnosis of necrotizing fasciitis and/or myonecrosis should be considered in any neutropenic patient with fever, tachycardia, and localized pain out of proportion to the physical findings. Appropriate therapy includes broad-spectrum intravenous antibiotics and urgent surgical intervention. Granulocyte colony-stimulating factor should be administered to all patients to enhance neutrophil recovery. Granulocyte transfusions should be considered if a prolonged period of neutropenia is anticipated.

Transplantation of adult living donor kidneys into infants and small children.

HYPOTHESIS: We hypothesized that improved outcomes following renal transplantation in high-risk infants and small children primarily are due to advances in immunosuppression and accurate diagnosis of rejection. Optimizing renal allograft perfusion is critical to achieving good early graft function and decreasing early graft loss. DESIGN: Twenty-eight consecutive recipients (weighing <20 kg) of adult living donor kidneys transplanted at our center from 1984 to 1999 were reviewed. Two groups were identified based on differing immunosuppression protocols and clinical surveillance. Actuarial graft and patient survival reported at 1, 3, and 5 years were compared for group 1 (1984-1991) and group 2 (1992-1999). Graft losses, categorized as immunologic or nonimmunologic, and the incidences of delayed graft function, vascular thrombosis, and rejection were compared. RESULTS: Graft and patient survival in group 1 (n = 13) at 1, 3, and 5 years was 77% and 92%, 54% and 85%, and 54% and 85%, respectively. In group 2, all 15 patients are alive with functioning grafts to date. Immunologic graft loss occurred in 5 of 13 patients in group 1 who developed chronic rejection. Nonimmunologic causes (vascular thrombosis [2 patients]) and patient death [1]) resulted in early graft failure within 2 weeks in 3 of 13 patients in group 1. The overall incidences of delayed graft function (10.7%) and thrombosis (7.1%) were low and did not differ between groups. Percutaneous renal biopsy was used more frequently in group 2 to evaluate graft dysfunction and guide treatment. CONCLUSIONS: We conclude that improved overall graft and patient survival in group 2 is owing to advances in immunosuppression and better treatment of rejection. Percutaneous renal biopsy allows prompt and accurate histological diagnosis of graft dysfunction. Surgical technique and aggressive fluid management aimed at maximizing renal allograft perfusion is critical in optimizing early graft function and decreasing vascular complications.

Acute appendicitis risks of complications: age and Medicaid insurance.

OBJECTIVES: To describe the epidemiology of acute appendicitis in children from Washington State, and to determine important risk factors for complications. DESIGN: Retrospective cohort study. SETTING: All children (<17 years old) treated in Washington State who were identified by hospital discharge diagnosis codes from 1987 through 1996. METHODS: The hospital discharge data were reviewed for all children with a primary diagnosis code for acute appendicitis. Complicated disease was defined as perforation or abscess formation. RESULTS: Young children (0-4 years old) had the lowest annual incidence of acute appendicitis, but they had a 5-fold increased risk of complicated disease (odds ratio: 4.9; 95% confidence interval: 4.0-5.9), compared with teenagers. Children with Medicaid insurance had a 1.3-fold increased risk of complicated disease, compared with children with commercial insurance (odds ratio: 1.3: 95% confidence interval: 1.2-1.4). Children with Medicaid insurance had significantly longer average length of stay (4.0+/-3.7 days) than all other payers (commercial insurance: 3.3+/-4.0 days; health maintenance organization: 3.5+/-3.1 days; and self-insured: 3.7+/-5.8 days). CONCLUSIONS: Very young children had the greatest risk of complicated disease. Children with Medicaid insurance had increased risk of complicated disease, compared with children with commercial health insurance and longer length of stay. Additional studies are needed to evaluate barriers to care for children with Medicaid insurance.

Pediatric postoperative abdominal wound dehiscence: transverse versus vertical incisions.

BACKGROUND: Fascial dehiscence is uncommon in children but can have serious consequences when it occurs. There are multiple risk factors for fascial dehiscence, including the type of incision used. Pediatric surgeons often use a supraumbilical transverse incision particularly in infants because of the access this incision provides to the entire abdomen. This article details the experience with fascial wound dehiscence at a large tertiary children's hospital and focuses on problems with the types of incision used. STUDY DESIGN: This is a retrospective review of 2,785 intraabdominal operations performed over a 5-year period at Children's Hospital and Regional Medical Center in Seattle. Risk factors for dehiscence were reviewed for each case of fascial dehiscence. Statistical analysis using chi-square was used to examine for differences in complication rates between transverse and vertical incisions. RESULTS: In this series, 2,442 children (88%) had transverse incisions and 343 (12%) had vertical incisions. Twelve children had abdominal fascial dehiscence post-operatively. Six cases involved transverse incisions and six involved vertical incisions. Five of the children suffered evisceration. One child died as a direct result of the dehiscence. There were multiple risk factors for dehiscence in 10 of the 12 children. Vertical incisions were found to be much more likely to dehisce than were transverse incisions, especially in children under 1 year of age (p < 0.001). CONCLUSIONS: Vertical incisions are more apt to dehisce than transverse incisions in children, particularly babies. We recommend the use of transverse incisions whenever possible in babies less than 1 year of age, especially when other risk factors for dehiscence are present.

Minimally invasive surgery and clinical decision-making for pediatric malignancy.

BACKGROUND: Minimally invasive surgery (MIS) is an ideal way to obtain biopsy specimens in children with cancer. We examined the safety, reliability and outcome of decisions made based on tissue obtained using MIS. METHODS: Fifty-nine oncology patients underwent 62 MIS procedures between January 1994 and July 1998. Complications, biopsy results, and outcomes were reviewed. RESULTS: The study population comprised 32 boys and 27 girls, with an average age of 8.8 years. There were 47 thoracoscopic and 15 laparoscopic operations. Laparoscopic procedures included initial biopsy, determination of resectability, and second-look exam. Thoracoscopic procedures included 40 lung biopsies and seven biopsies/resections of mediastinal masses. Diagnostic accuracy was 100% in all cases. No patient was found retrospectively to have been inadequately treated based on decisions made from tissue obtained by MIS. CONCLUSION: MIS is a safe and accurate means of obtaining tissue in pediatric oncology patients. Treatment decisions can be made accurately and with confidence using these techniques.

Outcome after surgical repair of junctional epidermolysis bullosa-pyloric atresia syndrome: a report of 3 cases and review of the literature.

BACKGROUND: Junctional epidermolysis bullosa-pyloric atresia syndrome is recognized as a distinct autosomal recessive entity. Affected infants present with skin fragility and inability to feed due to intestinal obstruction. Despite successful surgical repair of the anatomical defect, the outcome is poor owing to poor feeding, malabsorption, failure to thrive, and sepsis. OBSERVATIONS: In 70 cases of intestinal obstruction and epidermolysis bullosa reported in the medical literature and the 3 reported here, surgical intervention was attempted 51 times. In all except 16 infants, death occurred before age 11 months (mean age, 70 days). Renal involvement and continued failure to thrive accompanied the skin disease in survivors, who ranged in age from 30 days to 16 years (mean age, 4.0 years). CONCLUSIONS: The poor prognosis of this condition must be considered when decisions are made regarding surgical correction. Attempting surgical correction may be warranted in individual circumstances, but withholding surgical intervention and providing palliative support is an acceptable alternative.

Cholecystectomy is becoming an increasingly common operation in children.

PURPOSE: To determine the cause of a marked rise in cholecystectomy at a regional children's hospital. METHODS: Retrospective review of 185 patients undergoing cholecystectomy since 1984. The years 1984 to 1990 (group I) and 1991 to 1996 (group II) were compared. RESULTS: Cholecystectomy for gallbladder disease increased from 4.4/year (group I) to 16.3/ year (group II). Abdominal ultrasound examinations increased during this time. The ratio of children diagnosed with gallstones and then undergoing cholecystectomy also increased (P = 0.005). In group 11, 43% of children had no apparent etiology for gallstones, and more children developed complications of gallstones and evidence of choledocholithiasis. CONCLUSIONS: (1) The increased incidence of cholecystectomy is probably multifactorial. (2) Gallstone identification has increased owing to increased patient visits and more liberal use of ultrasonography in patients with abdominal pain. (3) More patients with cholelithiasis now undergo cholecystectomy perhaps because of a change in physician perception of the disease and an apparent increase in complications from gallstones.

Post-traumatic hepatic pseudoaneurysms in children.

BACKGROUND: Post-traumatic hepatic artery pseudoaneurysms are rarely seen in children. MATERIALS AND METHODS: We retrospectively reviewed the radiologic studies and medical records of three patients treated at our institution and reviewed the literature. The patients (ages 5-13 years) presented immediately to 2 months after blunt (two patients) and penetrating (one patient) trauma. The hepatic pseudoaneurysms were discovered during work-up for fever (one patient), gastrointestinal bleeding and hyperbilirubinemia (one patient), or widened mediastinum (one patient) on chest radiograph. In two patients, the diagnosis was initially suspected by computed tomography (CT) examination and confirmed by angiography. In the third patient, the diagnosis was made initially by angiography. All three pseudoaneurysms were treated with transcatheter embolization. RESULTS: All three embolizations were initially technically successful. However, there was recurrence in one case, in which embolization distal to the neck of the pseudoaneurysms was not technically possible. With conservative management, however, the residual lesion demonstrated spontaneous occlusion by ultrasound (US) at 6 months. CONCLUSION: This uncommon complication of liver trauma in children can have a delayed presentation, can be clinically unsuspected, and can follow blunt or penetrating trauma. Endovascular embolotherapy is the treatment of choice.

Delayed presentation of popliteal artery injury during Ilizarov limb lengthening.

Major vascular injury can result during use of the Ilizarov technique for lower extremity limb lengthening. Vascular reconstruction may be accomplished while leaving the external fixation ring in place. Continued distraction is made possible by leaving sufficient redundancy in the vascular graft.

Needle localization for thoracoscopic resection of small pulmonary nodules in children.

BACKGROUND: Children who have malignant disease and pulmonary nodules frequently need a tissue diagnosis to direct therapy. Computed tomography (CT)-guided needle localization and methylene blue marking allow thoracoscopic resection of nonvisible nodules. METHODS: Malignant disease was diagnosed in three patients aged 2, 2.5, and 11 years. Pulmonary nodules seen on chest CT, representing either metastatic disease or infection developed in each patient. All lesions were 1 to 2 cm deep to the pleural surface, precluding thoracoscopic visualization. A Homer mammographic needle was placed near the lesion using CT guidance under general anesthesia. The pleura overlying the lesion was also marked with methylene blue. Under the same anesthetic, patients went to the operating room where the lesions were thoracoscopically resected. RESULTS: Needle localization and methylene blue staining accurately localized the lesion in all cases. Thoracoscopic resection provided a diagnosis of metastatic disease or infection in all cases. There were no complications. CONCLUSION: CT-guided needle localization of pulmonary lesions deep to the pleural surface, is a safe, accurate method for allowing thoracoscopic resection in these children who would otherwise need open thoracotomy for diagnosis.

The early history of congenital heart surgery: closed heart operations.

The history of cardiovascular surgery before the development of open heart techniques is presented. Emphasis is placed on the creativeness and boldness of the visionary pioneers whose skills and determination led to the modern era of the routine surgical treatment of heart disease.

Necrotizing fasciitis after Plastibell circumcision.

Necrotizing fasciitis is a potentially life-threatening infection of subcutaneous tissues and Scarpa's fascia that rarely affects neonates. We report the occurrence of this devastating infection in two neonates after routine Plastibell circumcision. These case reports highlight the presentation and management of this complication after a relatively routine and frequently performed operation. This report also emphasizes the differences between cellulitis and necrotizing fasciitis and suggests strategies for management.