[Management of pediatric iatrogenic tracheobronchial lesions in pediatric patients]. / Manejo de las lesiones traqueobronquiales pediátricas iatrogénicas en pacientes pediátricos.

AIM: To present our experience in the management of three cases of tracheobronchial iatrogenic injuries and the literature revision about this pathology. MATERIAL AND METHODS: We present 3 patients treated in our center with tracehobronchial iatrogenic injuries since 2005. RESULTS: Case 1. 8 year old boy who present cervical, mediastinal and facial emphysema after foreign body extraction. After 9 days of conservative management without endotracheal intubation all emphysema remited, and the bronchial injury healed. Case 2. 1 month old toddler who presented after cardiovascular surgery and endotracheal tube extraction dyspnea and hypoxia. Fibrobronchoscopy showed subglotic posterior tracheal disrupture. Fifteen-day endotracheal intubation throughout the injury was enough management on this patient. One month later the tracheal injury was completely healed. Case 3. 5 year old girl with tracheobronchial iatrogenic injury after orotracheal intubation who developed neumothorax and subcutaneous emphysema. After fiteen-day conservative management without intubation the injury healed. CONCLUSION: After iatrogenic tracheobronchial injury suspicion there were confirmed by fibrobronchoscopy. Conservative treatment in this patients was successful. Orotracheal intubation prevented air leaking through the tracheal injury allowing complete healing of the trachea. Bronchial injuries healed without needing intubation or mechanical ventilation. Articles reviewed recommend surgical treatment in those cases who had complete or large airway disrupture or in those who were misdiagnosed.

[Evaluation of the long-term results of surgical treatment of palmar hyperhidrosis]. / Valoración de los resultados a largo plazo del tratamiento quirúrgico de la hiperhidrosis palmar.

INTRODUCTION: Palmar hyperhidrosis (PH) is a relative frequent pathology which basically affects patients' life quality limiting social and laboral life. The treatment of choice is thoracoscopic sympathectomy, most frequently done during adulthood. The aim of our study was to evaluate the degree of satisfaction of the pediatric patients treated in our centre. MATERIAL AND METHODS: We retrospectively reviewed the clinical records of the patients controlled and treated in our centre during the last 4 years evaluating the symptoms before surgery, the level of the sympathectomy and postoperative complications. To evaluate the long-term results we developed a telephone questionnaire for all the patients centralized on the grade of satisfaction, the efficiency of the treatment, the compensatory sweating and the observed changes in life quality. The medium follow-up time was 26.5 months (rango 6 months to 4 years). RESULTS: In total 6 patients were reviewed (4 female, 2 male), medium age 12, 8 years (rango 8 to 18 years). Thoracoscopic sympathectomy was done at the level of T2 or T3 associating T4 in 1 case. We just observed 1 postoperative complication which consisted in a disestesia of the upper extremity and which disappeared spontaneously without sequels. Patients referred total relief of palmar sweating. Only 1 case reported residual sweating unilaterally in the tenar region, but in all of them sweating of feet still persisted (3 of low grade and 3 of moderate grade). In 50% of the cases we observed compensatory sweating localized at the back of moderate grade in 2 patients and at the upper legs of more severe grade in 1 of them. Only this last patient reported that the compensatory sweating affected his everyday life. We also observed that the patients where the sympathectomy had affected more than 1 ganglia (T2+T3; T3+T4; T2+T3+T4) referred a higher grade of compensatory sweating. All the cases reported an important improvement in life quality, in the social as in the formative manner. They were all very satisfied with the results of the surgery and none of them (neither the children nor the parents) regretted the intervention. The cosmetic result of the surgical scars was also satisfactory. CONCLUSIONS: The thoracoscopic sympathectomy is an efficient procedure for the treatment of palmar hyperhidrosis. Despite the compensatory sweating patients usually are very satisfied with the results. Since palmar hyperhidrosis is not a pathology which improves spontaneously and the surgical treatment has minimal complications we do not think that the surgery should be postponed in pediatric patients.

[Percutaneous gastrostomy: when should antireflux surgery be associated?]. / Gastrostomía percutánea: ¿cuándo asociar cirugía antirreflujo?

INTRODUCTION: Percutaneus gastrostomy placement is a procedure widely performed in children with failure to thrive or intolerance to oral feeding. At the moment of making the indication, the need of an antir-reflux surgery in the same procedure comes to question. The aim of this study was to analyse which preoperative factors are associated with a higher risk of a posterior fundoplication. MATERIAL AND METHODS: We realized a retrospective review of 67 patients divided in 2 groups (cases and controls) in which a percutaneus gastrostomy (PEG) had been made by our service in the period of 1997 to 2008. We compared these two groups: Group A (n=11) - patients with severe gastroesophageal reflux who required a Nissen procedure afterwards; Group B (n=56) - patients who kept without reflux after PEG. We analyzed the different preoperative factors that could have been in association to severe reflux after gastrostomy. RESULTS: Mean age at the moment of undergoing PEG was 15 months. Mean time of follow up was 3,5 years. Only neurological impairment and documented reflux pregastrostomy were associated with the need of an antirreflux surgery after PEG. CONCLUSIONS: Neurological impairment and documented pregastrosotmy GER could be an indication of concurrent antirreflux surgery at the time of gastrostomy.

Human papillomavirus infection in Honduran women with normal cytology.

OBJECTIVE: This study was aimed at estimating type-specific HPV prevalence and its cofactors among Honduran women with normal cytology in order to provide valuable information to health policymakers about the epidemiology of this important sexually transmitted infection. METHODS: A total of 591 women with normal cytology from Tegucigalpa, Honduras were interviewed and tested for HPV using the SPF10 LiPA25. A structured epidemiological questionnaire was administered to each woman. RESULTS: The overall HPV prevalence was 51%. Twenty-three types of HPV were detected; HPV 16, 51, 31, 18, and 11 were the most common. The highest prevalence of cancer associated HPV types (15.0%) was found in the women less than 35 years. Besides the association with age, the main independent predictors of HPV infection were the lifetime number of sexual partners and having a low socioeconomic status and less than 5 previous Pap smears. CONCLUSIONS: In the population studied, there was a broad diversity of HPV infections, with high-risk types being the most common types detected. The establishment of a well-characterized population with regard to the community prevalence of type-specific HPV infection will provide a valuable baseline for monitoring population effectiveness of an HPV vaccine.

[Prognostic value of pH and glucose in complicated parapneumonic pleural effusion]. / Valor pronóstico del pH y la glucosa en el derrame pleural paraneumónico complicado.

INTRODUCTION AND AIMS: Although the incidence of emphyema is increasing it continues to be a widely debated pathology in relation to its management. We analyzed the last 36 cases treated by our service in the last 2 years. MATERIAL AND METHODS: We retrospectively studied the last 36 cases of parapneum6nic pleural effusions that needed some type of treatment at our service from March, 2005 to May, 2007. For this we analyzed: average age, time of evolution before admission to hospital, time of evolution from admission to surgery, location of the pneumonia, echographic characteristics, value of the pH and glucose, the relation between the presence of echoes in the ultrasound scan with the value of the pH and of the glucose, the relation between value of the pH and glucose with the evolution, type of treatment and evolution. We used for the statistical study ANOVA's test and paired t-test and the student's T test. RESULT: The average age was 5.4 years (range 9 months-15 years). The average time of evolution prior to admission to the hospital was 5.6 days (range 0.5-20 days) and the average time from admission to surgery was 5.1 days (range 0-65 days). The pneumonia was multilobar in 38.2% of the cases, in low lobes in 52.9% (29.4% in the left lower lobe and 23.5% in the right lower lobe). Ultrasound scan was performed in 97.2% of the patients, being severely septated in 31.4% of the cases, clear liquid 25.7%, moderately septated 22.8% and minimally septated 17.1%. The pH was analyzed in 69.4% of the effusions, the average value being 7.16 (range 6.75-7.45). The glucose was analyzed in 61.1% of the effusions, the average value being 61.1 (range 1-123). Septated effusions in the ultrasound scans were related to the lowest values of pH and glucose (p = 0.0001 in both cases). When we analyzed the relationship between clinical evolution and the pH we observed that a lower value of pH was related to a worse evolution, finding that pH values below 7 are related to a bad evolution (p = 0.001). The same results were found when we analyzed the relationship between the evolution and glucose (p < 0.005). CONCLUSIONS: The pH and the glucose in complicated parapneumonic pleural effusion have a pronostic value for evolution, regardless of what treatment was used. We found that pH values below 7 are related to a bad evolution.

[Tracheal stenosis: outcome analysis of the last 14 years]. / Estenosis traqueal: análisis de los resultados obtenidos en los últimos 14 años.

UNLABELLED: Tracheal stenosis (TS) is an unusual and sometimes lethal condition. It's treatment is basically surgical and different techniques have been proposed. AIM: Analyze the outcome of patients with TS diagnosed and treated in our institution realted to the applied surgical technique during the study period. MATERIAL AND METHODS: The clinical records of patients with TS (period 1991 to 2006) were reviewed analyzing the following variables: age, gender, associated malformations, intubation time, medium hospital stay and outcome. Patients were divided in 4 groups: conservative and endoscopic management (2 conservative, 1 dilatation, 1 laser), tracheal resection with termino-terminal anastomosis (RTA) (9 patients), tracheoplasties (slide or modified plasties) (20 patients) and anterior tracheoplasty with costal cartilage graft (TAIC) (6 patients). Results are expressed as media +/- standard error, comparative analysis was done using Chi square with continuity correction. Differences were considered statistically significant with a p < 0.05. RESULTS: 39 patients were reviewed (23 male, 16 female), medium age was 2.23 years. Associated malformations were: 12 vascular rings, 7 cardiac malformations, 4 Down syndromes, 1 pulmonary agenesia, 2 hemivertebtebrae, 1 renal agenesia and 1 cervicothoracic angiomatosis. Nineteen patients had short segment stenosis, 15 long segment stenosis (more than 1/3 of tracheal length) and 5 patients presented associated bronchial stenosis (most frequently right main bronchus). All TAIC failed: 4 deaths, 1 reestenosis and 1 persistent stenosis. In the tracheoplasty-group there were 2 exitus (1 due to a neurological lesion after a prolonged preoperative cardiorrespiratory arrest, one due to a surgical treatment delay with previous inadequate management). Patients treated with tracheoplasties and RTA had a favourable evolution and are asymptomatic in more than 80% of the cases after a mean follow-up of 59.9 +/- 7.4 months. In the conservative management group 2 patients died and 2 had a uneventful outcome. Global mortality was 20.5% (8 deaths). Differences observed in the mortality percentage between the study groups were statistically significant. (p = 0.0034) (50% in conservative management, 0% in RTA, 10% in tracheoplasties, 66.67% in TAIC). No statistically significant differences were found in the medium intubation time, medium hospital stay and medium follow-up time. CONCLUSIONS: The fundamental treatment of the tracheal stenosis is the surgical approach. Patients should be studied with great detail taking into account associated malformations (mostly heart defects and vascular rings) and should be treated by a multidisciplinary group. Short segmental TS should be corrected with RTA, long TS with tracheoplasties (slide), remaining the TAIC technique obsolete.

[Diode laser application for the treatment of pediatric airway pathologies]. / Utilización del láser diodo en la vía aérea pediátrica.

UNLABELLED: Laser application for the treatment of pediatric airway pathologies represents a very attractive option because of the limited inflammatory reaction after photocoagulation. One novel laser used for such pathologies is the diode laser. AIM: The purpose of this report is to present our preliminary experience in the use of diode laser in the treatment of pediatric airway lesions. METHODS: A retrospective review of 22 patients (11 males and 11 females) who underwent laser procedures from 1999 to 2006 was performed. Nineteen patients were treated at our center while 3 were referred after a laser application from other institution. In all procedures flexible bronchoscopy was used. The mean age was 1.25 years (range 1 month-4.8 years). Lasers were applied for various lesions: laryngomalacia and arytenoid lesions (n = 5), angiomas (n = 3), lymphangiomas (n = 3), sacular cyst and other mucous lesions (n = 3), granulomas, scarring lesions (n = 4) and paralysis of vocal cord in adduction (n = 1). RESULTS: None of the patient developed complications related to the endoscopic laser application. The mean number of laser therapy attempts were 1.4 per patient (range 1-3). The patients remained intubated for a mean of 2.8 days (range 4 hours-13 days) after the procedure. The duration of PICU stay after laser therapy was a mean of 4.6 days (range 1-8 days). The best outcomes were seen in sacular cysts (excelent in 3 patients). Also, all 3 patients with granulomas showed a good response to treatment. Multiple laser sessions (1-3; mean 1.4) were required to sucessfully manage the artynenoid lesions. However, the children with vascular lesions demonstrated differents outcomes. Of the 3 patients with subglottic angioma, 2 underwent a subsequent surgical procedure due to the development of subglottic stenosis; and one requiered further systemic steroid therapy. Of the children with lymphangioma, one needed 3 laser sessions and two required surgi- cal resections. Despite laser treatment, 3 of the 4 patients with scarring lesions required surgery. CONCLUSIONS: The endoscopic application of diode laser for the management of pediatric airways lesions provides good outcomes in selected patients. Sacular lesions, granulomas and arytenoid lesions are, in our experience, excellents indications. In other anomalies laser is a good adjuvant. The application of laser should be tailored according to the pathology.

[Modified "trap-door" thoracotomy for pediatric patients]. / Toracotomía de "trap-door" modificada en pacientes pediátricos.

INTRODUCTION: Surgical approach of the cervicothoracic junction has been traditionally done by cervicotomy and/or thoracotomy. Nevertheless, this access does not allow a suitable control of vasculonervous structures. Due to this we present our experience with a variation of the "Trap-door" thoracotomy which gives the best access to this area applied to pediatric patients METHODS: We present 4 patients of 2.8 +/- 1.9 years of age treated in our hospital by a cervicothoracotomy transmanubrial approach without clavicular luxation. One patient presented a stage IV cervicothoracic neuroblastoma, 1 patient had a cervicothoracic lymphangioma, one a severe cervicothoracic scoliosis and one a total cricoid atresia associated to an oesophageal atresia type IIIc (Vogt). This surgical approach allowed a perfect control of brachiocefalic and nervous structures as well as a correct visualization of all the cervicothoracic intervertebral foramina. Postoperative pain was controlled by epidural catheters, oral analgesic treatment was introduced in the fifth postoperative day. RESULTS: Complete resection and surgical treatment was possible in all patients, not being necessary the section of any vascular or nervous structure. There were no intraoperatory or postoperative complications. One patient presented a temporary Homer's syndrome. No tumoral recurrence has been noted after a mean follow-up of 2.3 +/- 3.1 years. CONCLUSION. The modified "Trap-door" approach allows a good control of the brachiocephalic structures and a complete visualization of the upper thorax and posterior mediastinum. Due to its low morbidity this access may be very useful since it allows an important vascular control and an excellent surgical field. Our modification of the "Trap-door" approach avoids clavicular luxation and has the advantage of no sequelaes in the functionality of the escapulo-humeral articulation.

[Is stridor a banal symptom in infants?]. / Es el estridor un síntoma banal en el lactante?

OBJECTIVES: To analyze the causes of stridor in infancy and its treatment. MATERIAL AND METHODS: Ninety patients under 1 year of age with stridor (93.06 +/- 82.4 days) were included. All patients were diagnosed by fiberoptic bronchoscopy. RESULTS: Thirty-eight patients were referred from the pediatric and neonatal intensive care units, 23 from an outpatient clinic and 29 from other hospitals. Diagnoses were subglottic stenosis in 21 patients, tracheobronchomalacia in 20, laryngomalacia in 20, tracheal stenosis in 17, cervical hemolymphangiomas in five, vocal cord palsies in four, and glottic edema in three. Forty-six patients (51.1 %) required surgery: 14 for functional disorders and 32 for anatomical anomalies. Six patients required further surgery: five with subglottic stenosis and one with tracheal stenosis. Outcome was very good or good in 75 patients (83.4 %) and was fair or poor in eight (8.8 %). Seven patients (7.8 %) died. Causes of death were an associated congenital heart disease in four patients, sepsis in one, bronchopneumonia in one, and suture dehiscence in an anterior cartilage graft tracheoplasty in one. CONCLUSION. According to our results, fiberoptic bronchoscopy should be performed in infants with stridor, as an underlying anomaly requiring surgical treatment is frequently found. The severity of stridor does not always correlate with the severity of the lesion. Potentially lethal causes can be found, requiring early treatment.

[Airway foreign bodies removal with flexible bronchoscopy in children]. / Extracción de cuerpos extraños en la vía aérea en niños mediante fibrobroncoscopia.

INTRODUCTION: Aspiration of foreign bodies in children is a frequent and potentially serious condition. Traditionally it has been solved by rigid bronchoscopy. Nowadays an increasing number of authors support the use of flexible bronchoscopy for its resolution. AIM: Analyze our experience in airway foreign body removal in children using flexible bronchoscopy. MATERIAL AND METHODS: We retrospectively analyzed 65 patients diagnosed of foreign body aspiration with a mean age of 3.65 + 3.1; 60% males and 40% females. We compared two historical cohorts of homogeneous distribution. The first one (group A), from 1994 to 1998, included 41 children treated by rigid bronchoscopy, and the second one (Group B) (1999-2006) 24 patients treated with the flexible bronchoscope. We studied: rate of success of initial extraction (RSIE), foreign body localization, type of foreign body, hospital stay, complications and mortality. Statistical analysis was done using t-student for cuantitative variables, and chi square for cualitative. Only a p < 0.05 was considered statistically significant. Data are presented as mean +/- standard error of the mean. RESULTS: Group A had a medium hospital stay of 1.89 + 2.6 days. RSIE was 85.36%. Six patients needed a second therapeutic procedure (5 rigid bronchoscopies, 1 flexible brochoscopy). Complication rate was 4.87%: 2 cases of bronchitis. Group B presented a medium hospital stay of 1.34 +/- 0.27 days with a RSIE of 70.83%, needing a second intervention 7 children (4 fiberbonchoscopies, 3 rigid bronchoscopies). Postextraction complications in this group consisted of 1 bronchitis episode and a pneumothorax in 2 patients (8.33%). No deaths occurred in any group. No statistically significant differences were found in hospital stay, RSIE, type of second therapeutic procedure and complication rate. CONCLUSIONS: Our experience shows that flexible bronchoscopy removal of airway foreign bodies is safe and efficient; therefore, we think that it should be taken into account as first choice method of treatment at any age.

[Are there some clinical factors that indicate the best moment of the surgery in the congenital diaphragmatic hernia?]. / Existen factores clínicos que indiquen el mejor momento de la cirugía en la hernia diafragmática congénita?

AIM: To determine if the needs of cardiopulmonary support of neonates with congenital diaphragmatic hernia (CDH) they can be indicators for the election of the most suitable moment to the surgery. METHODS: We treated 16 consecutive neonates with congenital diaphragmatic hernia (CDH) from 2004 to 2005. Mean birth weight was 2900.63 +/- 531.51 g. Patients was divided in 2 groups. Group A: newborns without adrenaline nor noradrenaline like vasoactive drugs and conventional respiratory assistant; the surgery was performed during the first 48 hours of life. Group B: newborns with adrenaline or noradrenaline like vasoactive drugs, high-frequency oscillatory ventilation or extracorporeal membrane oxygenation; surgery was delayed (10.66 +/- 8.26 days). RESULTS: Four neonates died during the first 24 hours of life without surgical treatment not fulfilling criteria of support ECMO. Five patients were operated during the first 48 hours, fulfilling all of them the clinical criteria of the group A. Mortality does not exist in this group. Seven patients were operated late fulfilling the criteria of the group B. They all needed VAFO. Two patients of this group needed support ECMO. The survival rate in this group was 83.3%. DISCUSSION: In our opinion, the patients with CDH that need initially high cardiopulmonary support, VAFO and/or ECMO would be necessary a time of wait to realize the surgery. In those patients who don't need this level of treatment the delay would not justify itself in the surgical intervention.

[Spinal cord and vertebral column injuries in children]. / Lesiones raquimedulares en la infancia.

AIMS: Analysis of main factors of spinal cord and vertebral column injuries in our environment. METHODS: We reviewed the data collected from the patients (n = 2640) admitted to our hospital because of trauma and included in our Registry from January 1995 to April 2002. Among this group, 86 patients (3.3%) had spinal cord and vertebral column injuries and were included in the study. RESULTS: Group gender distribution was 45 males and 41 females. In our group, 71 patients suffered vertebral fractures, 3 of them with spinal cord injuries (4.2%), 13 patients with vertebral subluxation, 11 of them between C1-C2, and 2 patients with spinal cord injury without radiographic abnormality. Only 71 patients, 4.9% of the total of the patients who were admitted with any type of fracture (n=1457), suffered vertebral fractures. These patients suffered 130 vertebral fractures, 35 of them (49.3%) suffered multiple fractures. Thoracic vertebrae were the most frequently affected (n=82, 63%). The most frequent localization was T4 toT8 (n=50, 38.5% and T11 to L2 (n=41, 31.5%). Age ranged between 12 and 15 years (n=35, 49.3%), with only 5 patients under 6 years. 90.9% of the patients with lumbar fractures were older than 8 years and 76.9% of the patients with cervical fractures were over 8 years. Motor vehicle accident was the most common cause in our series (n=20, 23.3%). 81% of these patients did not use safety belt. Ten children with cervical injuries were seen by medical staff at the prehospital stage, and only 4 of them arrived to Hospital with cervical collar. There were thirty five patients with thoracic or lumbar injuries but only 27 of them were transferred to our Institution by ambulance. Surgery was required in 2 patients, both of them with unstable fractures. Mean hospital stay was 17,1 days (range 2-37 days). CONCLUSIONS: Group gender distribution is similar between males and females and the incidence in our series is higher than other series of the literature. Thoracic injuries are the most frequent. It is necessary to improve prehospital management of these patients and to increase the use of safety belt. Spine injury incidence increased with age.

[Management of infantile subglottic hemangioma]. / Manejo del angioma subglótico en lactantes.

INTRODUCTION: Subglottic hemangioma is an unusual lesion which can be treated in various ways. Multiple therapeutic attitudes with variable clinical results have been described. We present our experience in the management of these patients. PATIENTS AND METHODS: During last the three years we have treated four patients with subglottic hemangioma. The mean age was of 4.5 +/- 2.8 months and the mean weight of 6.9 +/- 2.04 kg. We present its presenting symptoms, location and size of the lesion, grade of obstruction (according to the classification of subglottic stenosis of Cotton), the treatment applied, complications and results in the long term. RESULTS: The lesions produced a mean obstruction of 83.75% of the airway (range 75-90%), being located in the right posterolateral region (2), left posterolateral region (1) and the last was completely to circulate. All the patients have been treated initially with steroids, but recurrence of symptoms when steroid dosage was decreased. All angiomas were removed surgically by submucous resection. No tracheotomy was performed. One patients developed a grade III subglottic stenosis that required an open surgery (laryngotracheoplasty with anterior a posterior graft). One patien suffered an overwhelming sepsis probably secondary to medical treatment. All patients had not had further respiratory difficulties. Postoperative follow-up is 18 months (range from 6 months to 3 years). CONCLUSIONS: Treatment of subglottic hemangioma is difficult to standarize. Treatment with steroids have many adverse effects in children. The surgical treatment offer a good option in the treatment of the angiomas of great size. Traqueostomy as must be avoided in the management of these patients.

[Fiberoptic bronchoscopy, 3-D reconstruction of the airway and virtual bronchoscopy in patients with airway malformations. Preliminary report]. / Fibrobroncoscopia, reconstrucción tridimensional de la vía aérea y broncoscopia virtual en pacientes con patología de la vía aérea: estudio preliminar.

UNLABELLED: Bronchoscopy is the diagnostic gold standard in patients with airway malformations. Helical CT scan has produced studies such as virtual bronchoscopy or 3-D reconstruction of the airway. The purpose of this study is to analyze the correlation between fiberoptic bronchoscopy, virtual bronchoscopy and 3-D reconstruction of the airway in patients with airway malformations. METHODS: From January 2001 to March 2002 we evaluated the airway of 17 patients with airway malformations by means of a diagnostic protocol consisting on fiberoptic bronchoscopy, and Helical CT scan with 3-D reconstruction of the airway and virtual bronchoscopy. The radiologist had no access to bronchoscopic information. Age at study, associated cardiovascular anomalies, indications, localization, degree of diagnostic concordance, etiology and influence in treatment were analyzed. RESULTS: 20 studies were done to 17 patients whose mean age was 1.64 +/- 0.48 years (7 days-7 years). Twelve patients had associated anomalies of the aorta, pulmonary arteries or supraortic vessels. Excellent concordance was obtained in 13 cases (65%), good in 6 (30%) and poor in one (5%). 3-D reconstruction of the airway and adjacent vascular structures provided additional information in 14 cases (70%): in 3 exact length of the tracheal lesion and in 11 defined the cause of the compression. In all the cases, absolute concordance in localization was obtained. CT scan information modified treatment in 6 patients (35%). In 7 patients with associated vascular anomalies, no further image studies were done, confirming the anatomy concordance during surgery. CONCLUSIONS: 3-D reconstruction of the airway and virtual bronchoscopy are excellent diagnostic tools in patients with airway malformations, and contribute to define the etiology, length and diameter of the lesion. Excellent diagnostic correlation was obtained between analogic and virtual bronchoscopies, although further multicentric studies should be conducted.

[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.

[Analysis of treatment failure in pediatric subglottic stenosis]. / Análisis de los fracasos del tratamiento de la estenosis subglótica en la infancia.

BACKGROUND: The good results obtained until nowadays in the surgery of subglottic stenosis is followed by an analysis of the failures. METHODS: We study retrospectively 48 cases treated in the last eight years in two institutions. Study variables were: age, previous diagnosis, grade os the stenosis, surgical treatment, complications and evolution. RESULTS: Mean age was 2.8 +/- 0.43 years (newborn-17 years). In 13 cases (27%) the result obtained was considered a failure. Failure indexes were: treatment selection (7,7%), surgical technique selection (23%), due to the technique itself (23%), iatrogenia (15,4%), associated diseases (30,7%). Mortality of the series was 8.3%. CONCLUSIONS: The learning curve of these techniques is difficult although once the necessary experience is achieved the results are excellent.

Results of the Azizkhan procedure for long-term suprastomal tracheomalacia.

One of the reasons of failure to decannulate patients after airway surgery or long-term tracheostomy is suprastomal tracheomalacia. We present 7 cases with long-term tracheostomies treated by an anterior cricoid suspension described by Azizkhan in 1993. Prior to surgery, other causes of airway obstruction, as well as the presence of gastroesophageal reflux disease should be ruled out. All of them are decannulated. This procedure is a safe surgical technique, easily reproducible and with low costs.

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.