Toxins and virulence factors of enterotoxigenic Escherichia coli associated with strains isolated from indigenous children and international visitors to a rural community in Guatemala.

Diarrhoea remains a common cause of illness in Guatemala, with children suffering most frequently from the disease. This study directly compared the frequency, enterotoxin, and colonization factor (CF) profiles of enterotoxigenic Escherichia coli (ETEC) strains isolated from children living in a rural community in Guatemala and from Western visitors to the same location during the same seasons, using similar detection methodologies. We found that ETEC accounted for 26% of severe cases of diarrhoea in children requiring hospitalization, 15% of diarrhoea in the community, and 29% of travellers' diarrhoea in visitors staying ⩾2 weeks. The toxin and CF patterns of the ETEC strains isolated from both groups differed significantly (P < 0·0005) as determined by χ 2 = 60·39 for CFs and χ 2 = 35 for toxins, while ETEC phenotypes found in Guatemalan children were comparable to those found in children from other areas of the world.

[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.

Manejo de las lesiones traqueobronquiales pediátricasiatrogénicas en pacientes pediátricos / Management of pediatric iatrogenic tracheobronchial lesions in pediatric patients

Objetivos. Presentar nuestra experiencia en tres casos de lesiones traqueobronquiales traumáticas y la revisión de la literatura. Material y método. Presentamos 3 pacientes tratados conservadoramente por lesiones traqueobronquiales traumáticas durante los últimos5 años en nuestro centro. Resultados. Caso 1. Niño de 8 años de edad que, tras extracción de cuerpo extraño en bronquio principal derecho, presenta enfisemafacial, cervical y mediastínico. Tras 9 días de manejo conservador, el enfisema remitió y la lesión bronquial se resolvió espontáneamente. Caso 2. Lactante de 1 mes de vida que en el postoperatorio de trasposición de grandes vasos presenta disnea e hipoxia tras la extracción de tubo endotraqueal. La fibrobroncoscopia mostró ruptura traqueal subglótica posterior. La intubación endotraque al sorteando el defecto durante 15 días permitió la resolución de la lesión. Un mes después latráquea se encontraba íntegra y sin estenosis. Caso 3. Niña de 5 años de edad con ruptura iatrogénica de la tráqueatras intubación orotraqueal que desarrolló neumotórax, neumomediastino y enfisema subcutáneo. Tras 15 días de manejo conservador se observó la cura de la lesión. Conclusiones. Al sospechar las lesiones traqueobronquiales traumáticas, estas fueron confirmadas por fibrobroncoscopia. El tratamiento conservador en estos pacientes fue exitoso. La intubación endotraquealdistal a la lesión traqueal permitió una cura completa del defecto previniendo la fuga de aire a través de éste. La lesión bronquial se resolviós in necesidad de ventilación mecánica. La literatura revisada recomienda el tratamiento quirúrgico en los casos de lesiones completas oextensas de las vías aéreas y en las lesiones con diagnóstico tardío (AU)

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 emphysemaremited, 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-dayendotracheal 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 afterorotracheal 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 fibro bronchoscopy. 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 (AU)

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

Introducción y objetivos. La hiperhidrosis palmar es una patología relativamente frecuente que fundamentalmente afecta a la calidad de vida del paciente limitando su vida social y laboral. El tratamiento de elección es la simpatectomía toracoscópica, realizada con frecuencia en edad adulta. El objetivo de nuestro estudio es valorar el grado de satisfacción a largo de plazo de los pacientes pediátricos tratados en nuestro centro. Material y métodos. Realizamos un estudio retrospectivo de las historias clínicas de los pacientes controlados y tratados en nuestro centro en los últimos 4 años, valorando la clínica previa a la cirugía, el nivel de la simpatectomía toracoscópica y las complicaciones postoperatorias. Para el estudio de los resultados a largo plazo se realizó una encuesta telefónica a todos los pacientes, centrada en el grado de satisfacción, la eficacia del tratamiento, la sudoración compensatoria y los cambios (..) (AU)

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 last4 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 (..) (AU)

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

Introducción. La gastrostomía percutánea es un procedimiento ampliamente realizado en niños con dificultad para la deglución o intolerancia a la alimentación oral. A la hora de realizar la indicación, con frecuencia se plantea la necesidad de una cirugía antirreflejo en el mismo procedimiento. El objeto de este estudio es analizar qué factores preoperatorios se relacionan con un riesgo mayor de precisar posteriormente una funduplicatura. Material y métodos. Estudio retrospectivo de casos y controles de67 pacientes a los que se ha realizado gastrostomía endoscópica percutánea (PEG) por nuestro servicio desde 1997 a 2008. Comparamos dos grupos: Grupo A (n=11), pacientes con reflujo grave tras la realización de PEG, que han precisado cirugía antirreflujo; grupo B (n=56), pacientes que permanecen sin reflujo tras la gastrostomía. Analizamos los distintos factores preoperatorios que podrían relacionarse con la aparición de RGE grave postgastrostomía. Resultados. La media de edad en el momento de la realización de la PEG fue de 15,7 meses (rango), y el tiempo medio de seguimiento 3,5 años. Solo la presencia de enfermedad neurológica y pruebas preoperatorias compatibles con RGE se (..) (AU)

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 antirreflux 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 67patients divided in 2 groups (cases and controls) in which a percutaneous gastrostomy (PEG) had been made by our service in the period of 1997 (..) (AU)

[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.

Valor pronóstico del pH y la glucosa en el derramepleural paraneumónico complicado / Prognostic value of ph and glucose in complicated parapneumonic pleural effusion

Introducción y objetivos. Pese a que la incidencia global del empiema está en aumento, continúa siendo una patología con un amplio debate en relación con su manejo. Analizamos los últimos 36 casos tratados por nuestro servicio en los últimos 2 años. Material y métodos. Estudiamos retrospectivamente los últimos36 casos de derrames pleurales paraneumónicos que precisaron algún tipo de actuación por nuestro servicio desde marzo del 2005 hasta mayo del 2007. Para ello, analizamos: edad media, tiempo de evolución previa al ingreso, tiempo de evolución desde el ingreso hasta la cirugía, localización de la neumonía, características ecográficas del derrame, valor del pH y de la glucosa, la relación de la presencia de tabiques en la ecografía con el valor del pH y de la glucosa, la relación valor del pHy de la glucosa con la evolución, tipo de técnica empleada y evolución. Utilizamos para su estudio estadístico test de ANOVA y T de Student (..) (AU)

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 parapneumónic 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 (..) (AU)

Análisis del tratamiento quirúrgico de las estenosis subglóticas complejas / Analysis of the surgical treatment of complex subglottic stenosis

Introducción. El tratamiento de las estenosis subglóticas (ES) complejas es difícil, existiendo diferentes técnicas según el tipo y grado de estenosis, el estado del paciente y las patologías asociadas. Hemos realizado un estudio del manejo de pacientes complicados en nuestro centro, analizando el tipo de tratamiento, el tipo y grado de estenosis y el resultado obtenido con el fin de desarrollar un protocolo de manejo de la estenosis subglótica compleja. Material y métodos. De un total de 120 pacientes en seguimiento por ES en nuestro centro, revisamos de forma retrospectiva a 15pacientes (5 niños, 10 niñas; edad media 1,63 años; rango 0,05 a 13años) que habían sufrido complicaciones mayores y habían requerido de reintervenciones (entre 1 y 6). Analizamos las técnicas empleadas en relación con las complicaciones observadas y con el tratamiento previo realizado, el resultado y el índice de de canulación. Todos los diagnósticos se establecieron por fibrobron coscopia y el tratamiento inicial se realizó siguiendo las pautas de actuación de Cotton. Resultados. El índice de de canulación global en este grupo de pacientes ha sido del 80%.Los pacientes en los que inicialmente se había realizado un splitcricotiroideo (n=8) evolucionaron a reestenosis y ES grado III. El tratamiento de rescate consistió en laringotraqueoplastia anterior en 7 casos, logrando la decanulación en 6 pacientes (75%). El número de reintervenciones medio fue de 2,5.Los pacientes tratados inicialmente con Laser (n=4) evolucionaron a ES grado III en 2 casos y a ES grado IV en el resto. Las ES grado (..) (AU)

Introduction. The management of complex subglottic stenosis isdifficult, existing different surgical techniques for its treatment, depending on type and grade of stenosis, comorbidities and the state of the patient. We studied the management of the complicated patients in our centre analyzing the applied treatment, the type and grade of stenosis, and the results in order to develop a treatment protocol of complex subglottic stenosis. Matherial and methods. Of a total of 120 patients diagnosed of subglottic stenosis in follow-up in our centre we retrospectively reviewed15 patients (5 boys, 10 girls; medium age 1.63 years, range 0.05 to 13years) who had suffered mayor complications and who had required reinterventions ( 1 to 6). We analyzed the employed techniques in relation to the observed complications and the previous treatment, the results and the de canulation index. All diagnoses were established by fiberbronchoscopy and the initial treatment was realized following the actuation guidelines of Cotton. Results. The global decanulation index in this group of patients was 80%.The patients in who initially a anterior cricoid split had been done and who developed a subglottic stenosis grade III were 8. Rescue treatment consisted in anterior laringotracheoplasty in 7 cases managing (..) (AU)

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.

[Analysis of the surgical treatment of complex subglottic stenosis]. / Análisis del tratamiento quirúrgico de las estenosis subglóticas complejas.

INTRODUCTION: The management of complex subglottic stenosis is difficult, existing different surgical techniques for its treatment, depending on type and grade of stenosis, comorbidities and the state of the patient. We studied the management of the complicated patients in our centre analyzing the applied treatment, the type and grade of stenosis, and the results in order to develop a treatment protocol of complex subglottic stenosis. MATERIAL AND METHODS: Of a total of 120 patients diagnosed of subglottic stenosis in follow-up in our centre we retrospectively reviewed 15 patients (5 boys, 10 girls; medium age 1.63 years, range 0.05 to 13 years) who had suffered mayor complications and who had required reinterventions (1 to 6). We analyzed the employed techniques in relation to the observed complications and the previous treatment, the results and the decanulation index. All diagnoses were established by fiberbronchoscopy and the initial treatment was realized following the actuation guidelines of Cotton. RESULTS: The global decanulation index in this group of patients was 80%. The patients in who initially a anterior cricoid split had been done and who developed a subglottic stenosis grade III were 8. Rescue treatment consisted in anterior laringotracheoplasty in 7 cases managing decanulation in 6 patients (75%). The medium number of reinterventions was 2.5. Patients treated initially with Laser (n=4) developed a subglottic stenosis grade III in two cases and grade IV in the rest. Subglottic stenosis grade IV were corrected by cricotracheal resection and subglottic stenosis grade IV by anterior laringotracheoplasties with a medium reoperation Lumber of 1.25. All patients achieved decanulation (100%). Failed anterior laringotracheoplasties with cartilaginous grafts (n=2) developed grade III subglottic stenosis, one was treated with a double laringotracheoplasty and the other with a cricotracheal resection reaching decanu-lation in both patients (100%). Reintervention number was one to four. Only one cricotracheal resection as initial treatment failed. This patient required 3 reinterventions not being decanulation possible (0%). CONCLUSIONS: Patients with complex subglottic stenosis often require more than one reintervention until reaching decanulation. Decanulation index in these patients is satisfactory. The development of a management protocol for these cases is very difficult and treatment should be individualized.

[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.

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

La estenosis traqueal (ET) es una malformación poco frecuente y grave. Su tratamiento es fundamentalmente quirúrgico y múltiples técnicas han sido propuestas hasta ahora. Objetivo. Analizar los resultados obtenidos en los casos ET diagnosticados y tratados en nuestro centro en relación a las técnicas quirúrgicas utilizadas a lo largo del período de estudio. Material y métodos. Se estudiaron forma retrospectiva las historias clínicas (período 1991-2006) analizando las siguientes variables: edad, sexo, enfermedades asociadas, técnicas quirúrgicas, tiempo de intubación, estancia media, evolución y tiempo de seguimiento. Se dividió a los pacientes en 4 grupos en función del tratamiento realizado: tratamiento conservador (2 tratamientos conservadores, 1 dilatación neumática y 1 láser), resecciones traqueales con anastomosis termino-terminal (RTA) (9casos), traqueo plastias (tipo slide (TS) y mixtas (TM))(20 casos) y traqueoplastias anteriores con injerto costal (TAIC) (6 casos). Los resultados se expresaron en forma de media ± el error estándar, y el análisis comparativo se realizó a través de la Chi cuadrado con corrección de continuidad. Consideramos las diferencias estadísticamente significativas para una p<0,05.Resultados. Se revisaron 39 pacientes (23 niños y 16 niñas) de edad media 2,23 años. Las anomalías asociadas eran: 12 anillos vasculares, 7 cardiopatías, 4 síndromes de Down, 1 agenesia pulmonar, 2 hemivértebras,1 agenesia renal y 1 angiomatosis. Diecinueve pacientes presentaban estenosis de segmento corto, 15 de segmento largo (más de 1/3 de la longitud traqueal) y 5 asociaban estenosis bronquiales (fundamentalmente BPD). Todas las TAIC fracasaron: hubo 4 exitus, 1 reestenosis y 1 persistencia de la estenosis. En el grupo de las traqueoplastias hubo 2 exitus (1 debido a lesión neurológica tras parada cardiorrespiratoria prolongada, 1 debido a retraso del tratamiento quirúrgico y manejo previo inadecuado), evolucionando los pacientes tratados con RTA y traqueoplastias favorablemente y encontrándose asintomáticos en más del 80% de los casos tras una media de 59,9 ± 7,4 meses de seguimiento. En el grupo del tratamiento conservador 2 fallecieron y los otros 2casos evolucionaron sin incidencias. La mortalidad global fue 20,5% (8 exitus). Las diferencias observadas en el porcentaje de mortalidad entre los diferentes grupos fueron estadísticamente significativas (p=0,0034) (50% tratamiento conservador, 0% RTA, 10% TS y 66,67%TAIC). No se encontraron diferencias estadísticamente significativas en el tiempo de intubación medio, la estancia media y el tiempo medio de seguimiento entre los diferentes grupos. Conclusiones. El tratamiento fundamental de la ET es la cirugía. El paciente debe ser estudiado en profundidad teniendo en cuenta las anomalías asociadas (sobre todo cardíacas y de grandes vasos) y ser tratado por un equipo multidisciplinario. Las formas cortas de ET deben tratarse mediante RTA, las formas más extensas mediante TS, habiendo quedado obsoleta la TAIC (AU)

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 related 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 cervicothoracicangiomatosis. 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 cardiorespiratory 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 (AU)

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

Introducción y objetivo. El tratamiento con láser de las lesiones de la vía aérea es una opción terapéutica muy atractiva por la limitada reacción inflamatoria tras la fotocoagulación. Uno de los láseres de más reciente introducción en este campo es el láser diodo. El objetivo de nuestro trabajo es presentar la experiencia preliminar en la utilización del láser diodo para el tratamiento de las lesiones de la vía aérea en niños. Material y métodos. Hemos realizado una revisión retrospectiva de los pacientes tratados con láser desde el año 1999 hasta el 2006. Diecinueve pacientes fueron tratados en nuestro centro primariamente con técnicas con láser de diodo y otros 3 enfermos fueron derivados a nuestro centro tras un tratamiento con láser. Todos los procedimientos fueron realizados a través del fibrobroncoscopio. La edad media fue de1,25 años con un rango de edad entre 1 mes y 4,8 años. Once pacientes eran hombres y once mujeres. Las indicaciones que nos han llevado a realizar una resección endoscópica con láser de la lesión fueron enormemente variadas: laringomalacia y lesiones de aritenoides (n=5), angiomas(n=3), linfangiomas (n=3), quistes saculares y otras lesiones mucosas(n=3), granulomas intraluminales (n=3), lesiones cicatriciales (n=4)y parálisis en adducción de las cuerdas vocales. Resultados. Ningún paciente ha presentado complicaciones relacionados con la aplicación del láser diodo endoscópico. La media del número de procedimientos realizados en cada paciente ha sido 1,4 (1a 3). El tiempo medio de intubación tras el tratamiento ha sido de 2,8días (de 4 horas a 13 días). La media de tiempo de estancia en UVI tras la aplicación del tratamiento ha sido de 4,6 días (1-8 días). Los mejores resultados se han conseguido en los pacientes con quistes saculares o lesiones mucosas, excelente en los 3 casos y en los 3 pacientes común granuloma endotraqueal. En los 5 pacientes con lesiones de aritenoides hemos obtenido un resultado funcional excelente tras una media de1,4 procedimientos (rango de 1 a 3). Los enfermos con lesiones vasculares han presentado un resultado variable. De los pacientes con angioma subglótico 2 han requerido una reintervención por presentar estenosissubglótica residual y otro ha precisado corticoterapia a altas dosistras el láser. De los enfermos con linfangioma, uno se ha resuelto tras3 procedimientos endoscópicos y 2 han precisado cirugía posterior. Delos 4 pacientes con lesiones cicatriciales, 3 han precisado una intervención quirúrgica tras el tratamiento con láser. Conclusiones. El láser diodo como tratamiento endoscópico es altamente eficaz en pacientes seleccionados. Las lesiones saculares, mucosas, granulomas y la patología de los aritenoides son, en nuestra experiencia, una excelente indicación. En otras situaciones el láser es un buen complemento precisando siempre hacer un enfoque individualizado (AU)

Laser application for the treatment of pediatric airway pathologies represents a very attractive option because of the limited inflamatoy 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 paediatric airwaylesions. Methods. A retrospective review of 22 patients (11 males and 11females) 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 tothe 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 4.6days (range 1-8 days). The best outcomes were seen in sacular cysts(excellent 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 successfully 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 surgical 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 inselected 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 (AU)

Toracotomía de “Trap-door” modificada en pacientes pediátricos / Modified "Trap-Door" thoracotomy for pediatric patients

Introducción. El abordaje quirúrgico de la unión cervicotorácica ha sido realizado clásicamente a través de incisiones cervicales y/o toracotomías laterales. Este tipo de accesos no permite un óptimo control vasculonervioso. Es por ello que presentamos la utilidad en niños de una variante de la toracotomía de “Trap-door” para el mejor acceso a esta área. Material y métodos. Presentamos 4 pacientes con una edad media de 2,8 ± 1,9 años tratados en nuestro centro mediante cervicotoracotomía transmanubrial sin luxación clavicular. Los diferentes diagnósticos de este grupo de pacientes fueron: neuroblastoma cervicotorácico estadio IV (1), linfangioma cervicotorácico gigante (1), escoliosis torácica grave con componente cervical (1) y atresia total de cricoides asociada a atresia de esófago tipo III c (Vogt). El abordaje quirúrgico permitió un perfecto control del paquete vasculo nervioso braquiocefálico, así como la correcta visualización de todos los orificios intervertebral escervico-torácicos. El dolor postoperatorio inmediato fue controlado con catéteres epidurales, y analgesia oral a partir del 5º día postintervención. Resultados. La exéresis completa fue posible en los dos pacientes con masas, no precisando la sección de ningún tronco vascular o nervioso. No hemos tenido complicaciones intraoperatorias ni postoperatorias inmediatas. Un paciente presentó un síndrome de Horner temporal con recuperación completa. Actualmente no existen recidivas tras un seguimiento de 2,3 ± 3,1 años. Conclusiones. El abordaje de “Trap-door” con nuestra variante nos permite un buen control de los troncos braquiocefálicos y una completa visualización del tórax y el mediastino posterior. Este acceso puede ser de gran utilidad por su baja morbilidad, por permitir el control vascular y el excelente campo quirúrgico que nos proporciona. Nuestra modificación al abordaje de “Trap-door” evitando la luxación clavicular tiene la ventaja de evitar secuelas en la funcionalidad de la articulación escapulo-humeral (AU)

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 linfangioma, one a severe cervicothoracic scoliosis and one a total cricoid atresia associated to an esophageal atresia type Iliac (Vogt). This surgical approach allowed a perfect control of braquiocefalic 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 Horner’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 braquiocephalic 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 (AU)

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

RESUMEN: Introducción. La aspiración de cuerpos extraños en niños es un problema frecuente y potencialmente grave. Tradicionalmente resuelta por medio del broncoscopio rígido, cada vez más autores apoyan el uso del broncoscopio flexible en niños para su resolución. Objetivo. Analizar nuestra experiencia en la extracción de cuerpos extraños en la vía aérea en niños mediante broncoscopio flexible. Material y métodos. Analizamos retrospectivamente a 65 pacientes diagnosticados de aspiración de cuerpo extraño. Comparamos dos cohortes de distribución homogénea. El grupo A (1994-1998) incluye a 41 niños tratados mediante broncoscopio rígido y el grupo B (1999-2006) a 24 tratados con fibrobroncoscopio. Las variables del estudio son edad, sexo, tasa de éxito en la extracción inicial (TEEI), tipo de segundo procedimiento realizado, tipo de cuerpo extraño, lateralidad, tiempo de estancia hospitalaria (EM), complicaciones y mortalidad. El análisis estadístico se realizó mediante T de Student para variables cuantitativas y Chi cuadrado para las cualitativas. Una p < 0.05 se considera estadísticamente significativa. Los datos se presentan como media ± error estándar de la media. Resultados. El grupo A tuvo una EM de 1,89+0,42 días. La TEEI fue del 85,36%. Seis necesitaron un segundo procedimiento terapéutico (5 broncoscopias rígidas, 1 fibrobroncoscopia).Las complicaciones postextracción para este grupo consistieron en un episodio de bronquitis en 2 pacientes (4,87%). El grupo B presentó una EM de 1,34±0,27, con una TEEI del 70,83%, precisando un segundo procedimiento 7 de los niños (4 fibrobroncoscopias, 3 broncoscopias rígidas).Las complicaciones postextracción para este grupo consistieron en un episodio de bronquitis y un neumotórax en 2 pacientes (8,33%). La mortalidad en ambos grupos fue nula. No existieron diferencias estadísticamente significativas en la EM, TEEI, tipo de segundo procedimiento ni tasa de complicaciones. Conclusiones. La extracción de cuerpos extraños mediante fibrobroncoscopia en la vía aérea en niños es segura y eficaz por lo que consideramos que debería tenerse en cuenta como método inicial de tratamiento (AU)

ABSTRACT: 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 (AU)

[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.