Luciano Ferraz Schopf

Surgical Treatment for Pediatric Mediastinal Neurogenic Tumors

BACKGROUND Mediastinal neurogenic tumors are relatively rare in children, and controversies persist about the best surgical approach and long-term survival. METHODS With ethics approval we reviewed the case notes of 43 consecutive children (22 boys) operated on for mediastinal neurogenic tumor in two different institutions from March 1998 to June 2009. RESULTS The average age at diagnosis was 3 years (range, 0.6 to 4.7 years). Of the 43 operated tumors, 20 were neuroblastomas (47%), 13 were ganglioneuroblastomas (30%), and 10 were ganglioneuromas (23%). Only 6 (14%) of these tumors were discovered incidentally; the remaining 37 (86%) presented symptomatically: cough (30%), dyspnea (21%), wheezing (11.6%), neurologic spinal compression (7%), dancing eyes syndrome (7%), and Horner syndrome (7%). Tumor resection was undertaken by open operation in 38 cases (88%) and by thoracoscopy in 5 cases (12%). The children operated on by means of thoracoscopy had significantly smaller tumors (p = 0.01) and shorter duration of thoracic drain (p = 0.011) and hospitalization (p = 0.016) than those who were operated on by thoracotomy. There was not any surgical death. Postoperative complications occurred in 11 children (25.6%). Tumor recurrence occurred in 4 children (9.3%) operated on by open surgery, and there were 2 deaths of children with neuroblastoma. The overall survival was 95.4% in an average follow-up of 3.5 years (range, 0.7 to 4.4 years). CONCLUSIONS Surgical resection of children with mediastinal neurogenic tumors treated at two international tertiary hospitals was safe, and the thoracoscopic approach was appropriate for small tumors. The long-term survival was higher when compared with those reported for other primary neurogenic tumor locations.

Supraglotoplastia endoscópica em crianças com laringomalacia grave com e sem doença neurológica associada

OBJETIVOS: descrever as indicacoes e resultados da supraglotoplastia endoscopica em criancas com e sem lesao neurologica que apresentavam laringomalacia grave. METODOS: estudo retrospectivo de 8 criancas com laringomalacia grave submetidas a supraglotoplastia endoscopica com material de microcirurgia. Quatro criancas tinham paralisia cerebral (todas masculinas, idade media 6 anos) e 4 eram criancas sem doenca neurologica (3 femininas, idade media de 11,5 meses). As indicacoes da cirurgia foram dificuldade respiratoria em repouso e/ou esforco, dificuldade de degluticao, deficiencia de crescimento e baixa saturacao transcutânea de oxigenio. Estudo polissonografico realizado nas ultimas duas criancas mostrou dessaturacao na oximetria, apneia e hipoventilacao durante o sono. As criancas receberam corticoide e antibiotico no pre-operatorio. RESULTADOS: todas as criancas sem doenca neurologica apresentaram melhora significativa do estridor e da obstrucao ventilatoria. Das criancas com paralisia cerebral, uma necessitou traqueostomia logo apos a cirurgia por edema e tecido de granulacao supraglotico. As outras tres apresentaram melhora clinica inicial, mas pioraram progressivamente, apesar da realizacao de outros procedimentos: uma necessitou nova supraglotoplastia apos 6 meses; outra necessitou traqueostomia apos 7 meses. Aquelas sem traqueostomia persistem com obstrucao ventilatoria grave. Nao foi observada complicacao do procedimento cirurgico. CONCLUSOES: 1) a supraglotoplastia e bem tolerada e sem complicacoes na crianca; 2) a supraglotoplastia, neste estudo, mostrou-se eficaz no tratamento da laringomalacia grave em criancas sem paralisia cerebral; entretanto, a supraglotoplastia nao melhorou a obstrucao ventilatoria de criancas com paralisia cerebral e laringomalacia grave.

Thoracoscopy with mediastinoscope in pediatric complicated parapneumonic effusion

OBJECTIVE: To evaluate our experience with thoracoscopy with small mediastinoscope in complicated parapneumonic effusion in children.METHODS: From July 1995 to June 1997, seven children with complicated parapneumonic pleural effusion underwent thoracoscopy with mediastinoscope at Hospital de Clínicas de Porto Alegre. The procedure was carried out with a small mediastinoscope built in our hospital.RESULTS: There were six girls and one boy. The procedure was preformed under general anesthesia, without selective intubation. Six patients had previous intercostal tube drainage; one underwent thoracoscopy as a primary procedure. No complication was observed after the procedure. During follow-up, two children underwent pleurotomy due to residual pleural effusion with persistent fever; two others presented asymptomatic small pleural effusion.CONCLUSION: Thoracoscopy with small mediastinoscope is safe, efficient and without severe complications. It is very useful to remove loculated complicated parapneumonic effusion at fibrinopurulent stage and to enable lung expansion.

Experimental use of new absorbable tracheal stent

BACKGROUND/PURPOSE Silicone and metallic stents are not effective in children with tracheobronchial stenosis or tracheomalacia. Herein, we aimed to evaluate the clinical manifestations and histological reaction of rabbit trachea to the presence of a new poly(lactic-co-glycolic acid) with polyisoprene (PLGA/PI) polymer absorbable stent. METHODS Fourteen adult white rabbits (weight, 3.0-3.5kg) were randomly assigned to three groups: Group I (n=6): PLGA/PI spiral stent; Group II (n=6): PLGA/PI fragment; and Group III (n=2): controls. After a longitudinal incision on three cervical tracheal rings, the stents and fragments were inserted into the trachea and fixed onto the lateral wall with nonabsorbable sutures. RESULTS The stented group showed significantly more stridor at rest (p=0.0041), agitation (p=0.014), and use of accessory muscles (p=0.0002) and required more emergency endoscopies than the fragment group. Further, it showed significantly more remarkable histological inflammatory damage than the fragment and control groups (p=0.002). CONCLUSIONS The new PLGA/PI polymeric stent implanted into the trachea of rabbits caused more clinical manifestations and histologically verified inflammatory reaction than the PLGA/PI polymeric fragment. Future studies should be aimed at reducing the stent-wall thickness.