El papel de las prótesis traqueobronquiales endoluminales en la patología obstructiva de la vía aérea del niño / The role of tracheobronchial stenting in the management of pediatric airway obstruction

Introducción. Las prótesis traqueobronquiales endoluminales (PTBE) constituyen una opción terapéutica válida en el manejo de los pacientes con patología estenosante de la vía aérea. Mostramos nuestra experiencia en su empleo, estableciendo los criterios para su utilización, y analizamos los resultados obtenidos. Material y métodos. En el periodo entre 1991- 2006 16 niños (rango de edad: 10 días- 19 años) han sido tratados con 28 PTBE. La elección del tipo de prótesis ha dependido de la edad y la localización de la lesión. La colocación de la prótesis y su control posterior se efectuó en todos los casos por medio de broncoscopia. Hemos analizado los siguientes datos: el tipo patología obstructiva, PTBE seleccionada, malformaciones asociadas, las complicaciones, resultado final y el tiempo de seguimiento. Resultados. La indicación de colocación de PTBE ha sido malacia traqueal y/o bronquial en 13 pacientes (81,3%), estenosis traqueal en 2 (12,5%) y estenosis glótica en un caso (6,2%). Se han utilizado las siguientes prótesis: 15 prótesis metálicas tipo Palmaz (53,5%), 7 de silicona tipo Dumon (25%), 4 tipo Montgomery (14,5%), 1 tipo Poliflex (3,5%) y una prótesis traqueobronquial tipo Dynamic (3,5%). En siete pacientes (43,7%) se colocó más de una prótesis. Se han colocado 16 traqueales, 11 bronquiales y una carinal. Cinco pacientes presentaron complicaciones (granuloma en dos casos, migración en 2 pacientes y atelectasia en un caso) y cinco pacientes han fallecido (1 por complicaciones relacionadas con la PTBE). Hemos obtenido un buen resultado en 14 pacientes (87,5%) con un tiempo medio de seguimiento de 2 años y 10 meses (rango 2 meses-12años y 6 meses). Conclusiones. La colocación de PTBE es una alternativa terapéutica válida en pacientes seleccionados. El resultado a corto y medio plazo es satisfactorio pero la evolución a largo plazo es todavía una incógnita (AU)

Purpose. Tracheobronchial stenting can aid in the management of pediatric airway problems. We reviewed our experience to determine the role of endoscopic airway stents in children. Methods. Sixteen children (Age range: 10 days- 19 years) underwent 28 tracheobronchial stents in the period 1991-2006. The stent type chosen depended on patient age and location. All procedures were done under general anesthesia with bronchoscopy. The following features have been taken into account: etiology, obstruction diagnosis, stent type, localization,,associated anomalies, complications, results, and time of follow-up. Results. Etiology of the tracheobronchial obstruction included tracheobronchiomalacia in 13 patients (81.3%), tracheal stenosis in 2 (12.5%) and glotic stenosis in one case (6.2%). The stent used were 15 Palmaz( 53.5%), 7 Dumon (25%), 4 Montgomey (14.5%), 1 Poliflex (3.5%) and one Dynamic stent (3.5%). More than one stent were undertaken in seven cases (43.7%). 16 patients had tracheal stents, 11 children had bronchial stent and one infant a carinal stent. Five complications are reported ( two patients developed granulation tissue, two stents migrated, and a child presented a left lung atelectasis) and five patients died (only one case related to tracheobronchial stenting) Results have been satisfactory in 14 patients (87.5%) and the mean time of follow-up has been two years and ten months (range 2 months- 12 years and 6 months). Conclusions. The tracheobronchial stenting in children may represent a valid treatment option for many sick children in particular circumstances. The long-term outcome remains uncertain but the medium- term outlook is encouraging (AU)

Empiema pleural. Tratamiento toracoscópico / Pleural empyema. Thoracoscoopic treatment

Objetivo. Comparar el uso de la toracoscopia primaria y secundaria en niños con empiema paraneumónico. Material y métodos. Efectuamos un estudio retrospectivo de 24 niños ingresados en nuestro hospital entre los años 1998 y 2003. Resultados. La toracoscopia precoz no influye en el número de días de ingreso tras la misma. De los 24 niños, 12 (50%) fueron tratados con drenaje pleural previo y otros 12 (50%) sin él. La mayor diferencia se establece en cuanto a la estancia media total. El número de días de desaparición de la fiebre tras toracoscopia es el mismo, no así desde el inicio de la enfermedad que se disminuye notablemente. Conclusión. La toracoscopia precoz disminuye en número de días de estancia media en el hospital y de desaparición de la fiebre desde el inicio de la enfermedad (AU)

Objective. To compare the use of primary and secondary thoracoscopy in children with parapneumonic empyema. Material and méthods. We present a retrospective study of 24 children entered our hospital between years 1998 and 2003. Results. Early thoracoscopy doesn’t influence in length of stay. 12 children (50%) were treated with previous chest tube and other 12 children (50%) without it. There is statistical significance in length of hospital stay. The days with postoperative fever didn’t decrease, but it was seen if we compare it from the beginning of the disease. Conclusions. An early thoracoscopy decrease length of hospital stay and the duration of fever postoperative (AU)

[Primary lung tumors]. / Tumores broncopulmonares primarios.

Pulmonary neoplasia in children is usually due to methastatic disease because primary lung tumors are very unfrequent. Due to its' rarity they are usually not included in the differential diagnosis of lung masses, so treatment is delayed and prognosis is worsened. Herein, we show our experience in the management of five primary tumors of the lung or the airway: one tracheal, three bronchial, and another intraparenchymatous. We study the clinical behaviour, diagnostic work-up, treatment, histology, and follow-up. Despite its rarity, a diagnosis of pulmonary tumor should be considered in any child with respiratory symptoms that does not improve with standard therapy. An early and accurate diagnosis and an adequate treatment are crutial in the prognosis of these patients.

[Results of laparoscopic treatment of complicated appendicitis]. / Resultados del tratamiento laparoscópico en la apendicitis complicada.

Laparoscopic appendectomy in children is a generally accepted procedure for the treatment of non-complicated acute appendicitis. Nevertheless, the role of laparoscopy in complicated cases is controversial. We show our experience with 40 cases of complicated acute appendicitis treated by means laparoscopy between February 2000 and October 2002. In every case we used 3 ports, one umbilical and the other two in both lower quadrants. The appendix was gangrenous in 31 patients and in the other 9 was perforated. Appendectomy was performed in an extracorporeal way in most of the cases. Average surgical time was 71 minutes and mean hospital stay was 8.8 days. Intraoperative complications occurred in 8 cases (20%) and postoperative complications were observed in 9 patients (22.5%). Four patients were reoperated (2 open and 2 laparoscopic) in order to drain two abscesses and treat two obstructions. The results of this serie is compared with another group of 40 complicated appendicitis operated in a classic open way in the same period of time. Postoperative complications were less often in the laparoscopic group. Oral intake, need for analgesia and hospital stay are more favorable in the laparoscopic group.

Resultados del tratamiento laparoscópico en la apendicitis complicada / Results of laparoscopic treatment of complicated appendicitis

La apendicectomía laparoscópica (AL) en niños es un método cada vez más aceptado para el tratamiento de la apendicitis aguda no complicada. Sin embargo, el papel de la laparoscopia en la apendicitis complicada es más controvertido y, a su vez, está menos estudiado. Presentamos 40 casos de apendicitis complicadas dentro de una serie de 120 pacientes apendicectomizados por laparoscopia entre febrero del 2000 y octubre del 2002 en el Servicio de Cirugía Pediátrica del Hospital 12 de Octubre de Madrid. En todos los casos se utilizaron 3trócares, uno umbilical para la óptica y otros dos de trabajo colocados en ambas fosas ilíacas. En los 40 casos el apéndice era gangrenoso, estando además perforado en 9 de ellos. Encontramos absceso apendicular localizado en 28 casos y peritonitis más o menos diseminada en 24. La apendicectomía se realizó en la mayoría de los casos deforma extracorpórea y en otros mediante sección intraabdominal. El tiempo quirúrgico medio fue de 71 min y la media del ingreso postoperatorio fue de 8,8 días. Las complicaciones intraoperatorias se produjeron en 8 casos (20%) (6 roturas del apéndice y 2 reconversiones por mala visualización) sin que tuvieran repercusión posterior. Hubo algún tipo de complicación postoperatoria en 9 de los pacientes (22,5%):4 abscesos intraabdominales (10%), 2 casos de obstrucción (5%), 2abscesos de la herida de alguno de los trócares (5%) y un caso de íleoprolongado que cedió con tratamiento conservador. Fueron reintervenidos4 de los pacientes (2 por vía laparoscópica y 2 por vía abierta),para drenar 2 de los abscesos intraabdominales y resolver las 2 obstrucciones. El resto evolucionaron bien con antibioterapia. Los resultados se compararon con los de otro grupo de 40 apendicitis complicadas intervenidas en el mismo periodo por vía abierta (AA). Las complicaciones postoperatorias fueron menos frecuentes en las AL. El inicio de la tolerancia oral, la necesidad de analgesia, el tiempo de antibioterapia y el ingreso postoperatorio fue menor en el grupo de las AL.A pesar de que el número de casos es pequeño parece que la laparoscopia es un método válido para el tratamiento de las apendicitis complicadas (AU)

Laparoscopic appendectomy in children is a generally accepted procedure for the treatment of non-complicated acute appendicitis. Nevertheless, the role of laparoscopy in complicated cases is controversial. We show our experience with 40 cases of complicated acute appendicitis treated by means laparoscopy between February 2000 and October 2002. In every case we used 3 ports, one umbilical and the other two in both lower quadrants. The appendix was gangrenous in 31patients and in the other 9 was perforated. Appendectomy was performed in an extracorporeal way in most of the cases. Average surgical time was 71 minutes and mean hospital stay was 8.8 days. Intraoperative complications occurred in 8 cases (20%) and postoperative complications were observed in 9 patients (22.5%). Four patients were reoperated (2 open and 2 laparoscopic) in order to drain two abscesses and treat two obstructions. The results of this serie is compared with anothergroup of 40 complicated appendicitis operated in a classic open way in the same period of time. Postoperative complications were less of tenin the laparoscopic group. Oral intake, need for analgesia and hospital stay are more favorable in the laparoscopic group (AU)

[Thoracoscopic repair of esophageal atresia]. / Tratamiento toracoscópico de la atresia de esófago.

We present the first three cases of esophageal atresia with tracheoesophageal fistula treated with a thoracoscopic approach in our Service. The technique was accomplished through three trocar inserted in the right hemithorax. Carbon dioxide insufflation was required for lung retraction Primary correction was carried out in all the cases without major perioperative complications. The mean surgical time was 240 minutes. One patient had an anastomotic leak, resulting in a complicated postoperative course. The leak healed on conservative treatment. The others two patients were fed at the seventh postoperative day. Mean hospital stay in these cases was 12 days. Although thoracoscopic repair of esophageal atresia with fistula is a currently feasible technique that offers different advantages on the conventional open technique, a greater number of cases is needed in order to advance in the learning curve and determine the exact place that this technique can have in the future treatment of esophageal atresia.

Influencia del reflujo gastroesofágico en el desarrollo de enfermedades de la vía aérea superior / No disponible

No disponible

Tratamiento de la traqueobroncomalacia grave con prótesis traqueobronquiales endoluminales / Severe tracheobronchomalacia in children: treatment with metallic expandable stents

La traqueomalacia es una entidad poco frecuente que se caracteriza por un colapso antero-posterior de la luz traqueal durante la espiración. Se presenta generalmente asociada a atresia de esófago pero también se han descrito casos de traqueomalacia primaria y secundaria a compresiones extrínsecas. En la mayoría de las ocasiones se produce una resolución espontánea del cuadro clínico y sólo un reducido grupo de pacientes precisa tratamiento quirúrgico. Cuando la corrección quirúrgica fracasa, o está contraindicada, existe la posibilidad de colocar prótesis traqueobronquiales endoluminales (PTBE), que proporcionan un soporte interno a la vía aérea. Hemos tratado dos pacientes con cuadro PTBE metálicas expandibles: uno con traqueomalacia asociada a atresia de esófago y otro con traquebroncomalacia secundaria a compresión extrínseca por cardiomegalia y ventilación mecánica prolongada. El resultado ha sido satisfactorio en los dos casos (AU)

[Tracheal stenosis: individualized treatment]. / Estenosis traqueales: tratamiento individualizado.

INTRODUCTION: Stenosing airway disease is unfrequent in the pediatric age group and includes intraluminal obstructions, extrinsic compressions and malacias. OBJECTIVE: To show our experience in the treatment of congenital and acquired tracheal stenosis (CTS and ATS) and suprastomal tracheal collapse (STC). PATIENTS AND METHODS: Since 1990, 24 patients have been evaluated in our Unit: Ten CTS, 5 ATS and 9 STC. We have studied the following parameters: Sex, age at diagnosis, ethiology, type of lesion, associated anomalies, treatment, postoperative intubation, length of hospital stay, number of bronchoscopies, complications and follow-up. RESULTS: 14 girls and 10 boys are included in this survey. Age at diagnosis ranged from 3 days to 12 years and associated anomalies were present in 75% of cases. We have treated 22 of the 24 patients with the following procedures: Costal cartilage tracheoplasty (6 cases), slide tracheoplasty (2), resection and anastomosis (3), anterior cricoid suspension (8), dilation (2) and laser resection (1). We have achieved good results in 17 patients (77%), bad in 4 (18%) and fair in one. CONCLUSIONS: Due to the variety of stenotic lesions, we think that treatment should be tailored to each particular case and performed by a multidisciplinary pediatric team in order to achieve the best results.

[Treatment of tracheobronchomalacia with expandable metallic stents]. / Tratamiento de la traqueobroncomalacia grave con prótesis traqueobronquiales endoluminales.

Tracheomalacia is an unfrequent disease that causes tracheal collapse during breathing. It is generally associated to esophageal atresia, but cases of primary tracheomalacia and others secondary to extrinsic compression, have also been described. Spontaneous resolution is generally the rule and only a few cases need surgical treatment. When this therapy fails or is not indicated for any reason, endoluminal tracheobronchial stents may be used. We have treated two patients with four expandable metallic stents: one had severe tracheomalacia associated to esophageal atresia and the other tracheobronchomalacia secondary to cardiomegaly. Results have been good in both cases.

Tratamiento del colapso traqueal supraestomal: alternativas quirúrgicas / Treatment of suprastomal tracheal collapse: surgical options

Fundamento. El colapso traqueal supraestomal es una de las causas de fracaso en la decanulación de pacientes traqueostomizados. Objetivo. Valorar las posibles causas y los resultados obtenidos en el tratamiento de esta complicación utilizando dos técnicas quirúrgicas diferentes: la suspensión cricotraqueal anterior y la plastia con injerto de cartílago costal.Material y métodos. Desde 1990, han presentado colapso traqueal supraestomal 9 pacientes. Hemos estudiado diversas variables incluyendo: sexo, edad, anomalías asociadas, causa de la traqueostomía, técnica quirúrgica, tiempo hasta decanulación quirúrgica, hallazgos endoscópicos, complicaciones, tiempo de evolución y resultados. Resultados. Seis niñas y 3 niños han sido estudiados por presentar colapso supraestomal grave. La edad media a la que fueron traqueotomizados era de 17 meses. La técnica quirúrgica consistió en una ventana traqueal con colgajos laterales en 6 pacientes y es desconocida en los otros 3. La indicación de la traqueostomía fue por: soporte ventilatorio prolongado (5 casos), dificultad respiratoria grave (2 casos) y estenosis subglótica (2 casos). El tiempo medio transcurrido entre la realización de la traqueostomía y la decanulación quirúrgica fue de 23 meses. En la endoscopia preoperatoria se observó en todos ellos un colapso traqueal anterior supraestomal que ocluía la luz traqueal en aproximadamente el 75 por ciento. Se ha realizado una pexia cricotraqueal anterior en 8 casos y una reconstrucción con injerto de cartílago costal en un caso. El resultado de la cirugía ha sido satisfactorio en todos los casos, si bien un paciente requirió la repetición del procedimiento de pexia, debido a colapso residual. Después de un tiempo de seguimiento medio de 45,3 meses (intervalo 1-5, 6 años), todos los pacientes se encuentran decanulados y asintomáticos. Conclusiones. Las dos técnicas correctoras ofrecen buenos resultados, pero la pexia cricotraqueal por su simplicidad es la más recomendable. En el contexto de una laringotraqueoplastia con cartílago costal en un paciente con estenosis subglótica, la estabilización de la zona malácica traqueal con el mismo cartílago es una buena alternativa (AU)

[Complete congenital cartilaginous trachea in a girl with Crouzon's syndrome]. / Tráquea cartilaginosa completa congénita en una niña con síndrome de Crouzon.

A tracheostomy was performed in a 4-month-old girl with Crouzon's syndrome because of upper respiratory obstruction. During the procedure the absence of tracheal rings was observed. These findings were confirmed by postoperative bronchoscopy. Subsequent surgical correction of the patient's craniofacial anomalies enabled decannulation when the patient was 10 months old. Complete cartilaginous trachea is very rare and is always associated with craniosynostotic syndromes. Tracheobronchial anomalies should be investigated in patients whose respiratory symptoms are not due to upper airway obstruction.

[Treatment of congenital tracheal stenosis using a slide tracheoplasty]. / Tratamiento de una estenosis traqueal congénita mediante una traqueoplastia deslizada.

Congenital tracheal stenosis (CTS) is a rare malformation that usually require corrective surgery. Resection and tracheal anastomosis is the treatment of choice when the stenosis is short. However, such an approach is not usually viable when the CTS is long, given that anastomotic pressure would be too great. New surgical techniques have allowed this serious airway malformation to be corrected satisfactorily. We report the case of a three-year-old boy with a long CTS (51% of the length of the trachea) treated with a new reconstructive technique called slide tracheoplasty. Outcome was excellent.

Diuresis renography in the diagnosis and follow-up of nonobstructive primary megaureter.

Due to the widespread use of obstetrical ultrasonography with concomitant fetal screening, congenital uropathies are usually diagnosed in asymptomatic neonates. The main issue is to distinguish those cases of dilatation which are clearly obstructive and need surgical treatment from those which are within the normal anatomical range. Out of 47 patients with primary megaureter, 23 were nonobstructive and these are the subject of our study. There were 16 males and 7 females. Thirteen were located on the left side, 7 on the right side and 3 were bilateral, adding up to 26 renoureteral units. Prenatal diagnosis was made in 16 cases, the oldest patient diagnosed was 9 years old. All infants were evaluated with ultrasonography, voiding cystourethrography, excretory urography and diuresis renography. The latter has been the most important test inducing us to adopt a conservative attitude. Differential renal function was more than 40% in 24 units and in 2 it was more than 35%. Diuretic renograms were type IIIa (dilated, nonobstructed) in 19 cases and IIIb (dilated, partially obstructed) in 7. There were 2 cases with vesicoureteral reflux in the contralateral system. We performed ultrasonography and diuresis renography during the follow-up. There were 8 cases with type I (normal) renograms and 17 cases with type IIIa. Only one patient developed an obstruction and was operated on. Differential renal function did not deteriorate in any of the cases. Urography was performed in 9 cases during the follow-up. All the patients have remained asymptomatic during the surveillance, except for 2 cases which presented urinary tract infection. BUN, creatinine and other biochemical figures remained within the normal range. The follow-up period of time ranged between 1 and 8 years. We conclude that primary megaureter must be assessed and followed up and that the main test to be used is diuresis renography.