Luís Marcelo Inaco Cirino

The etiology of extensive pleural effusions with troublesome clinical course among children

CONTEXT In São Paulo, pneumonia is the main infectious cause of death among children. Parapneumonic pleural effusion is a possible complication and has to be treated surgically when the patient does not respond to antibiotics. OBJECTIVE Assessment of the etiology of complicated parapneumonic pleural effusions that needed surgical intervention. TYPE OF STUDY Retrospective study. SETTING University hospital of the University of São Paulo. METHOD Analysis of 4,000 files on children hospitalized with pneumonia from November 1986 to November 1996 had shown that 115 of these children presented a total of 117 cases of pleural empyema that required surgical procedures. The childrens clinical condition was assessed in relation to radiological findings and to their nutrition and immunization status. Previous antimicrobial therapy and pleural effusion bacterioscopy were also evaluated. RESULTS Streptococcus pneumoniae was the agent found most commonly, as frequently in blood cultures as in pleural effusions. DISCUSSION Data on vaccination coverage, birth weight and nutritional status are analyzed and compared to other publications. We observed that pleural effusion has a high potential for discomfort, and in most cases it is not a complication of the first pulmonary disease episode. Previous use of antibiotics interfered with culture positivity. The agent most frequently found was Streptococcus pneumoniae, which is in accordance with the findings from other authors. Nonetheless, the antibiotics used to treat the patients after the procedure were the same used in non-complicated pneumonias, which has led us to conclude that the worse outcome in this cases was not due to drug resistance. CONCLUSION The bacteriological profile in our series of complicated pneumonia cases was similar to what has been described for non-complicated pneumonia cases. Future studies will be necessary to determine why these children presented a worse outcome.

Prefabricated flap composed by skin and terminal gastromental vessels. Experimental study in rabbits.

BACKGROUND The angiogenic induction property of the omentum makes it a promising pedicle for prefabricating flaps. Therefore, the objective of this paper is to establish the abdominal area to be prefabricated by the omental pedicle and to analyse the prefabricated potential (PP) according to the time delay between the pedicle introduction and the flap release. METHODS Forty-four rabbits were divided into four groups (A, B, C and D). In group A, a piece of skin, subcutaneous tissue and abdominal cutaneous muscle was fully released and sutured again in place. In the other groups, a 9-cm2 omental pedicle containing the gastromental vessels distally tied was transposed and sutured to abdominal cutaneous muscle. A second procedure, consisting of incision and release of the flap that contained skin, subcutaneous and cutaneous abdominal muscle pediculated only by the omentum, was carried out. The only variation was the time delay between the two procedures: 7, 21 and 56 days for groups B, C and D, respectively. The flaps were inspected 15 days after the last procedure. The pieces of viable area were immunostained using anti-CD31 for estimation of the microvascular density. RESULTS The mean and maximum viable areas in group D were 45.29 and 99.37cm2, respectively (average PP=5.03 and maximum PP=11.04). There was no significant difference between the viable areas in groups C and D. The mean microvascular densities of groups B, C and D were 24.54, 33.20 and 27.03 vessels/mm2, respectively. CONCLUSION The omental tissue has great potential for prefabrication of flaps, and the delay time for the second procedure should be at least 21 days.

Classificação ultra-sonográfica do derrame pleural e do empiema parapneumônico

We correlated the anatomopathological abnormalities of the pleural space with the ultrasound findings in patients with pleural effusion and/or parapneumonic empyema and proposed a classification based on these results. Ultrasonography is a reliable method to infer the anatomopathological phase of pleural disease and consequently may be of help in the choice of the most suitable treatment.

Contribuição da ultra-sonografia na orientação do tratamento cirúrgico do empiema pleural em crianças

The authors used the findings at ultrasonography as a criterium to choose the most suitable surgical alternative for the resolution of pleural empyema in children. The preoperative ultrasonographic findings and the intraoperative aspects were compared, concerning parapneumonic pleural empyema in 77 children operated on in the Hospital Universitario of Sao Paulo University, during the period from between November 1986 to November 1996. A numerical classification of these findings is proposed. as well as a correlation between those data and the empyema pathological phase of the exsudative process is accomplished. It is included a description of respective postoperative clinical course, based on the need of a supplementary surgical intervention for a definitive cure to be reached. The authors conclude that ultrasonography is a reliable method to evaluate the evolutive phase of pleural empyema in children and to rationalize the most suitable choice in its surgical therapeutics.

Tratamento da síndrome da veia cava superior

The superior vena cava is formed by the union of the right and left brachiocephalic veins. It is located in the middle mediastinum, to the right of the aorta and anterior to the trachea. Superior vena cava syndrome consists of a group of signs (dilation of the veins in the neck, facial swelling, edema of the upper limbs, and cyanosis) and symptoms (headache, dyspnea, cough, orthopnea and dysphagia) caused by the obstruction of blood flow through the superior vena cava to the right atrium. This obstruction can be caused by extrinsic compression, tumor invasion or thrombosis. Such obstruction may also occur as a result of insufficient venous return secondary to intra-atrial or intraluminal diseases. From 73% to 93% of all cases of superior vena cava syndrome occur during the development of an intrathoracic tumor. Most patients presenting superior vena cava syndrome secondary to malignant neoplasms are treated without surgery, through radiotherapy, chemotherapy or the use of intraluminal stents. When the etiology of superior vena cava syndrome is benign, it can be treated with clinical measures (anticoagulation, raising the head, etc.) or, in refractory cases, with angioplasty, stents or surgery.

Diagnóstico e tratamento dos tumores mediastinais por toracoscopia

Objectives: Thoracoscopic management of mediastinal tumors is still subject to analysis. Seventy-three patients were submitted to thoracoscopy for the treatment of mediastinal masses and were analyzed retrospectively, in order to evaluate the effectiveness and complications of the procedure. Methods: Between 1983 and 1999, 21 conventional thoracoscopies and 52 video-assisted thoracic surgeries were performed (33 for diagnostic purposes and 40 for therapy). Patient ages ranged from two to 81 years (mean 43.8) with a slight predominance of females over males (41 versus 32). All underwent general anesthesia using simple (22) or double lumen (51) intubation. Results: The histological type of tumor was identified in all patients. For therapeutic purposes, conversion to thoracotomy was necessary in nine patients. The reasons were tumor size and invasion of nearby structures, difficulty to continue dissection, to perform an upper lobectomy, and to suture the iatrogenic diaphragm lesion. Four patients died during the first 30 postoperative days as a consequence of their primary pathology. Conclusions: Thoracoscopy was confirmed to be an effective diagnostic and therapeutic alternative for the treatment of mediastinal disorders.