Urokinase versus VATS for treatment of empyema: a randomized multicenter clinical trial.

BACKGROUND AND OBJECTIVE: Parapneumonic empyema (PPE) is a frequent complication of acute bacterial pneumonia in children. There is limited evidence regarding the optimal treatment of this condition. The aim of this study was to compare the efficacy of drainage plus urokinase versus video-assisted thoracoscopic surgery in the treatment of PPE in childhood. METHODS: This prospective, randomized, multicenter clinical trial enrolled patients aged <15 years and hospitalized with septated PPE. Study patients were randomized to receive urokinase or thoracoscopy. The main outcome variable was the length of hospital stay after treatment. The secondary outcomes were total length of hospital stay, number of days with the chest drain, number of days with fever, and treatment failures. The trial was approved by the ethics committees of all the participating hospitals. RESULTS: A total of 103 patients were randomized to treatment and analyzed; 53 were treated with thoracoscopy and 50 with urokinase. There were no differences in demographic characteristics or in the main baseline characteristics between the 2 groups. No statistically significant differences were found between thoracoscopy and urokinase in the median postoperative stay (10 vs 9 days), median hospital stay (14 vs 13 days), or days febrile after treatment (4 vs 6 days). A second intervention was required in 15% of children in the thoracoscopy group versus 10% in the urokinase group (P = .47). CONCLUSIONS: Drainage plus urokinase instillation is as effective as video-assisted thoracoscopic surgery as first-line treatment of septated PPE in children.

Therapeutic indications of fetoscopy: a 5-year institutional experience.

BACKGROUND: Prenatal ultrasound study allows the detection of fetal malformations. Intrauterine interventions are now contemplated to correct, or interfere with, the natural history of these anomalies. Minimally invasive techniques, such as the so-called "Fetendo" (fetal endoscopy), are now therapeutic possibilities. METHODS: From 2002 to 2007, 205 fetoscopies were performed in our hospital's fetal surgery program. Fetoscopic interventions were carried out under epidural anesthesia, accessing the uterine cavity with a fetoscope containing a 1.2-mm telescope. Following ultrasound-guided needle puncture of the amniotic cavity, the fetoscope was inserted through a 3-mm sheath by the Seldinger technique. Visibility was maintained with an amnioinfusion system. This procedure offers access to the placental surface, umbilical cord, and fetus. RESULTS: Fetoscopy was used to perform laser coagulation of communicant placental vessels in 148 biamniotic monochorionic gestations with twin-to-twin transfusion syndrome (TTTS) and to occlude the umbilical cord in 32 cases of discordant monochorionic twins with a severe or lethal anomaly in one of the fetuses, and 5 cases of reversed arterial perfusion (TRAP) sequence. In addition, fetoscopy was performed in 18 cases to treat severe congenital diaphragmatic hernia by tracheal occlusion with an endotracheal balloon. Finally, in 2 cases, fetoscopic release of amniotic bands was performed to rescue extremities and the umbilical cord. The most common complications (10%) were preterm rupture of membranes, which resulted in preterm delivery. Other indications for fetoscopy, which we are currently using in experimental animal models, include low urinary tract obstruction, sacrococcygeal teratoma, and repair of myelomeningocele defects. CONCLUSIONS: Fetoscopy can lower the incidence of preterm labor that occurs in response to the aggression of open surgery. At present, fetoscopy is effective for treating several fetal anomalies. Preterm rupture of membranes remains the weak link of fetoscopy. Refinement of the technique and technologic advances will help this problem and allow the use of fetoscopy for other pathologies in the future.

Endoscopic repair of late-presenting Morgagni and Bochdalek hernia in children: case report and review of the literature.

BACKGROUND: Delayed presentation of a congenital diaphragmatic hernia (CDH) is not usual. Primary laparoscopic repair is becoming the standard in many centers. Different approaches and techniques have been proposed. There is not enough evidence in the literature to recommend one technique over another. PATIENTS AND METHODS: In this paper, we report one case of Morgagni hernia (MH) and one case of Bochdalek hernia (BH), 2 and 6 years old, respectively, operated on in our hospital. In the first case, the diaphragmatic defect was directly sutured with extracorporeal interrupted nonabsorbable sutures, passed through the abdominal wall with a Reverdin needle. In the second one, intracorporeal nonabsorbable stitches were placed. A search of the literature was made using PubMed and the following words: congenital diaphragmatic hernia, laparoscopy or thoracoscopy, and children. The neonatal Bochdalek hernias were discarded. Data about surgical approach, suturing technique, management of the hernia sac, complications, and recurrence were summarized for both pathologies. RESULTS: Both patients were discharged 48 hours after surgery. There were no complications. No recurrence was evident after 6 months. Eleven articles on the treatment of MHs were found, with a total of 30 patients. For BHs, 10 articles met the inclusion criteria, with a total of 54 patients. In both groups, all the papers were case reports or retrospective reviews of case series. The MH is best approached through laparoscopy, and the BH can be treated through thoracoscopy or laparoscopy. Most researchers prefer direct suture with nonabsorbable material. Both complication and recurrence rates are very low. CONCLUSIONS: The endoscopic approach of late-presenting Morgagni and Bochdalek CDH is a safe technique. It offers all the advantages of minimally invasive surgery (MIS), and laparoscopy also permits the diagnosis and treatment of other associated conditions. There are a short number of cases reported and no prospective study comparing open with the MIS approach for the treatment of diaphragmatic malformations.

Cirurgia endoscòpica: aplicacions en pediatria / No disponible

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Aspiració de cossos estranys: la nostra experiència / Foreign body aspiration: the experience of a single institution

Fonament. L'aspiració de cossos estranys és una patologiad'elevada incidència a l'edat pediàtrica, i té greuscomplicacions si passa desprevinguda.Objectiu. Analitzar els registres dels pacients ambsospita d'aspiració de cossos estranys, i intentar obtenirconclusions per millorar el diagnòstic i el maneig d'aquestspacients.Mètode. S'ha fet un estudi retrospectiu dels 68 infantsals quals es va fer una broncoscòpia sota l'orientaciódiagnòstica d'aspiració de cos estrany, entre gener de 1998i juny de 2002, analitzant les variables demogràfiques elementalsi les característiques més significatives de la històriaclínica i l'evolució.Resultats. L'edat mitjana dels pacients va ser de 2,85anys. La simptomatologia més freqüent va ser la tos. El91.2% dels casos presentava un antecedent d'ennuegada.La majoria eren fruits secs (82.3%). El temps mitjà d'evolucióva ser de 8.96 dies.Conclusions. Els avenços tècnics han permès millorarel tractament, però el diagnòstic continua basant-se ambl'anamnesi, l'exploració i la sospita clínica. La prevenció ésla mesura fonamental per millorar el maneig d'aquestaentitat

Background. Foreign body aspiration is commonin children, and may have important consequences ifundiagnosed.Objective. To review our experience with the evaluationof patients with a suspected foreign body aspiration,and to develop guidelines to improve diagnosis and treatment.Method. Retrospective study including children whounderwent a bronchoscopy for the presumptive diagnosisof aspiration of a foreign body, between January 1998 andJune 2002.Results. Sixty-eigh patients (median age 2.85 years)were identified. The most common symptom was cough.In 91.2% of the cases there was history of chocking. Inmost cases (82.3%), the foreign body was a nut. The mediantime of symptoms was 8.96 days.Conclusions. New technologies have contributed toimproved treatments, but the most important diagnostictools remain the clinical history, physical examination, andthe high level of suspicion; preventive measures are critical

Epidural analgesia in the surgery of congenital tracheal stenosis: slide tracheoplasty on cardiopulmonary bypass.

Epidural analgesia in children is highly effective and safe; however, it has not enjoyed great popularity in surgery that requires cardiopulmonary bypass. A major concern is the possibility of damage to blood vessels with the epidural needle or catheter and epidural hematoma formation. There seems to be a low incidence of epidural hematoma if certain guidelines are followed, so that in children, epidural analgesia can be used in selected patients, with safety, when surgical repair requires cardiopulmonary bypass. Epidural morphine has been used for clinical pain relief in pediatric cardiac surgery. Improved pulmonary function, suppressed hormonal and metabolic stress responses, easy early tracheal extubation, and good analgesia and sedation that allows neurological examination to alert any possibles hidden complications, are the advantages. A dedicated medical team is essential in the perioperative management to achieve maximum benefit for these patients.

Análisis del gen HOX11 en un paciente con asplenia / Analysis of HOX11 gene in a patient with asplenia

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Tratamiento conservador de las estenosis cáusticas del esófago / Conservative treatment of esophagus caustic stenosis

Los autores presentan su experiencia en los útlimos 22 años del tratamiento conservador de 1296 casos de ingestas de caústicos en niños. Hacen dos grupos de estudio, uno de 1974 a 1989 y el otro comprendiendo el período de 1990 a 1996, comparando los diferentes enfoques terapéuticos empleados en cada grupo. El tratamiento se basó fundamentalmente en dilataciones anterogradas con bujías de mercurio, bujías de Savary-Guilliard, o dilataciones retrógadas guiadas con hilo exteriorizado por gastrostomía. También emplearon dilataciones neumáticas o tutores de silicona en los últimos casos. En el segundo grupo se empleó fundamentalmente la fibroesofagoscopía precoz como valoración de las lesiones esofágicas y como ayuda...

Cuerpo extraño en esófago: presentación de un caso / Strange body in esophagus: presentation of a case

Presenta el caso de un paciente de 4 años de edad que acudió a nuestro centro por un cuadro clínico de "bronquitis de repetición" y rechazo de los alimentos sólidos de 1 mes de evolución tras sufrir un episodio de atragantamiento mientras comía. Se discuten las peculiaridades clínicas que pueden presentarse en niños pequeños, el alto índice de sospecha necesario para su diagnóstico y la exploración radiológica idónea en estos casos.