Russian Journal of Pediatric Surgery

BACKGROUND: Acute hematogenous osteomyelitis is a purulent septic disease found in children at any age. This pathology still occupies a leading place in the structure of urgent pathologies in children which is characterized by difficult diagnostics, severe course and long-term complications leading to orthopedic problems and disability. Outcomes after its treatment directly depend on the effectiveness of early diagnostics. X-ray and CT examination at the first week of the disease are not effective in terms of accuracy and informativeness. Ultrasound is recognized as an effective method for diagnosing metaepiphyseal processes which are specific for young children. Osteoscintigraphy can be used, but in fact, it is rarely found in emergency departments; and besides, there is a probability that this technique in children can give false negative results. Osteotonometry and exploratory osteoperforation are invasive therapeutic and diagnostic procedures and should be used in case of strict indications. Magnetic resonance imaging (MRI) is an informative and non-invasive method that can be applied at the early intramedullary stages of the disease. MRI for differential diagnostics allows to avoid needless osteoperforation.

AIM: To conduct a retrospective analysis on MRI effectiveness for differential diagnostics in children with acute hematogenous osteomyelitis.

METHODS: The authors present their own experience in examining and treating children who were admitted to the City Emergency Clinical Hospital No 7 in Volgograd with acute pain in extremities and suspected arthritis or osteomyelitis in 2018-2021.

RESULTS: Patients were comparable in age, complaints, anamnesis and laboratory findings. In two clinical observations, retrospective analysis was done. In other two patients, MRI has proven its effectiveness when, in the first case, surgical aggression was avoided, and the patient was successfully cured with conservative techniques in a short time. In the second case, MRI helped to verify the diagnosis and to objectively justify indications for surgery.

CONCLUSION: MRI in children with suspected acute hematogenic osteomyelitis is justified and informative even at early stages of the disease. In some cases, it allows to avoid such invasive methods as exploratory osteoperforation.

Urolithiasis in children is a common disease nowadays. In many countries, medical expulsive therapy is actively used in such cases. The purpose of this research is to highlight principles and effectiveness of medical expulsive therapy, as well as advantages and disadvantages of α1-blockers over other pharmpreparations in children with urolithiasis. In the present review, the researchers have analyzed literature publications from 2004 to 2023. This systemic review was made using databases of Cochrane, PubMed, Web of Science, Scopus for the period from 2004 to 2023. The following Key words were used for search: urolithiasis, medical expulsive therapy. 32 full-text articles were included in the study.

While assessing results of medical expulsive therapy application in children with urolithiasis, it was noted that α₁-blockers can significantly increase stone expulsion rate and reduce expulsion time. Side-effects of the discussed technique are insignificant. They include: headache, dizziness, orthostatic hypotension or nasal congestion. Medical expulsive therapy is reasonable for application due to its high efficiency and due to α₁-blockers safety in children with urolithiasis. At present, adrenergic receptor blockers for medical expulsive therapy in children with urolithiasis are not allowed in Russia.

Since the first days of life nutrition is a necessary component of child's harmonious development. A particularly acute problem of child’s feeding is faced by physicians, if the child underwent any gastrointestinal surgery. Numerous studies have shown that malnutrition affects 50% of hospitalized children and 25–70% of seriously ill children. Natural nutrition is a real challenge for children in critical conditions. Currently, enteral nutrition is considered to be a preferred modality in pediatric patients with surgical pathology. A significant development of enteric formula industry over the past few years has put this type of nutrition at the forefront in helping operated children. Specialized mixtures for enteral nutrition which contain split protein or amino acid fragments gain an advantage over whole-protein mixtures. The lecture highlights main approaches to the prescription of enteral nutrition for children at the early postoperative and post-traumatic period.

BACKGROUND: Vacuum therapy (VAC^© Therapy, NPWT) is an effective method for treating wounds. Its principle is the following: a wound is covered with an airtight dressing, and negative pressure (50–125 mm Hg) is applied. Vacuum therapy is recommended for treating complex wounds.

CLINICAL CASE DESCRIPTION: In 2017, a patient, born in 2005, was diagnosed with “Juvenile arthritis with systemic onset, activity grade 2–1, X-ray stage 3, functional class 2”. Since then, he has been treated with immunosuppressants and corticosteroids. On November 9, 2022, edema, hyperemia, and hyperthermia of the medial half of the right gluteal region developed under immunosuppressive therapy. On November 11, 2022, necrotic discharge from the wound in the right gluteal region was noted. Diagnosis “Necrosis of subcutaneous fat of the right buttock spreading to the scrotum root” was put. On November 16, 2022, MRI was performed — a picture of widespread edema of fatty tissue to the right, in pararectal and gluteal regions with purulent content was revealed. The patient was transferred to the surgical department. Surgical debridement was performed under general anesthesia, and apparatus Suprasorb CNP P1 with intermittent negative pressure was put. On postoperative day 9, a stable positive effect was achieved in the form of wound healing with a tendency to secondary intention. During the wound revision on December 2, 2022, wound edges were clean; on December 16, 2022, the wound had a skin defect about 5×7 cm and no granulation in the wound depth. The wound was sutured. At the control examination on February 23, 2023, complete wound healing was seen.

CONCLUSION: Vacuum therapy is an effective tool for managing complex wounds in pediatric surgery which leads to positive outcomes. At the same time, such outcomes largely depend on the whole set of measures, including adequate surgical debridement, careful monitoring and appropriate antibiotic therapy. Comorbidities also play their role in the disease process.

BACKGROUND: The round liver ligament (RLL) is a fibrous cord-like remnant of the umbilical vein that fixes the liver to the anterior abdominal wall. Complications such as RLL abscess and necrosis are extremely rare in children compared to adults. Only isolated observations are described in the literature.

The etiopathogenesis of RLH necrosis has not been fully studied. Discussion on etiopathogenesis of this disease is still under way. A number of authors state that the inflammatory process spreads along the umbilical vein in case of inflammatory diseases of the abdominal organs. Timely diagnostics of RLL necrosis is extremely difficult, not only in the preoperative period, but also during surgery. Only in isolated cases, the diagnosis is put before surgery. In most cases, children are operated on with diagnosis of acute appendicitis, cholecystitis, perforated gastric ulcer.

AIM: To draw the attention of practicing doctors to such a rare pathology as necrosis of the round ligament of the liver.

CLINICAL CASE DESCRIPTION: The authors describe a clinical case of managing a 12-year-old child who was admitted to the pediatric surgical clinic by the ambulance with clinical signs of acute abdomen and acute cholecystitis. The authors mark difficulties which they faced in diagnosing and treating the case both before and during surgery. Coccygeal cartilage necrosis was put only intraoperatively. The early postoperative period was uneventful. The patient was discharged on day 12 after the surgery in the satisfactory state.

CONCLUSION: This clinical observation is of undoubted interest to specialists as a rare pathology which is difficult for diagnosing both before and during surgery.

BACKGROUND: The most common abdominal formations in fetuses and newborns of the female sex are ovarian cysts. The development of these cysts is induced by the excessive stimulation of fetal ovaries with maternal estrogens and placental chorionic gonadotropin which causes follicle dysgenesis. The diagnosis is put at antenatal and postnatal echography, computed tomography and magnetic resonance imaging.

CLINICAL CASE DESCRIPTION: The authors present their own clinical observation of an ovarian cyst complicated by intrauterine fallopian tube torsion and uterine appendages self-amputation in a patient operated at the age of 4 months.

CONCLUSION: Ultrasound screening is the main diagnostic technique for early detection of congenital ovarian pathology at the antenatal and postnatal stages. The authors suggest that the absence of clinical manifestations after birth, focal hemorrhages and diffuse massive petrifications in the macropreparation may be indicative of in utero torsion of the fallopian tube and self-amputation of uterine appendages. Like most other authors describing such observations, we consider that large size of the cyst, presence of suspension and additional echostructures in cyst liquid component may be indicative for surgical treatment of newborns.

BACKGROUND: The literature describes various causes of free gas in the abdominal cavity, or pneumoperitoneum, in the immediate postoperative period. In such cases, surgeons should find out if the residual gas is postoperative pneumoperitoneum, or it is some postoperative complication requiring surgical intervention. In the present article, the authors describe two clinical cases of pneumoperitoneum in children after elective surgeries.

CLINICAL CASE DESCRIPTION: First case: free gas was fund in a 6-year-old child at ultrasound examination and overview radiography of the abdominal organs. Perforation of some hollow organ was suspected. After conservative measures (infusion therapy with glucose-salt solution, anesthesia, cleansing enema), which did not give any positive dynamics, diagnostic laparoscopy was performed. No perforation in genital organs was detected. On the second postoperative day, the child was discharged in the satisfactory state.

Second case: ultrasound examination and overview radiography of the abdominal organs revealed free gas under the diaphragm dome in a 13-year-old patient. Taking into account the clinical picture and instrumental diagnostic findings, diagnostic laparoscopy was performed which revealed swollen intestinal loops without signs of perforation. The child was discharged on the third postoperative day. Control ultrasound examination of the abdominal cavity organs showed no any free gas; in the left iliac region, moderate edematous tissue 1×1.5 cm was seen.

CONCLUSION: Dynamic monitoring of patients with postoperative pneumoperitoneum and without signs of peritonitis should be performed. If there is no positive dynamics in child’s condition, diagnostic laparoscopy or laparotomy are recommended.