Vol 25, No 6 (2021)
EDITORIAL ARTICLE
ORIGINAL STUDY
Endosonography of the pancreatobiliary area in pediatric patients. The first experience
Abstract
Introduction. The diagnostics of malformations and diseases in the organs of pancreatobiliary area in children is an actual problem. An increase in the number of pediatric patients with pancreatobiliary anomalies, complications of cholelithiasis, acute and chronic pancreatitis requires the development of new techniques of non-invasive diagnostics which would allow to choose the optimal curative tactics.
Material and methods. The article presents authors' experience of performing endosonography in 44 children, aged 2–17, during 2.5 years. Indications for endosonography were: complicated cholelithiasis, choledochal cyst, pancreatic duct dilatation, lithiasis of the Wirsung’s duct, cystic and solid formations in the pancreas and omental sac. Fine-needle aspirations under endosonography control were performed in 10 patients; transgastric drainage of pancreatic pseudocysts - in 6 children.
Results. In all cases, endosonography turned out to be an informative diagnostic option. The curative tactics was changed in 21 (47.7%) patients after receiving endosonographic findings. Besides, such findings clarified anatomical and topographic features of organs in the pancreatobiliary zone in 15 (34.1%) patients; endosonographic findings helped to define the optimal volume of surgical intervention in 6 (13.6%) patients. There were no complications during diagnostic procedures. Bleeding into the lumen of pseudocyst was noted in a patient with transgastric drainage.
Conclusion. Endosonography in children is an informative non-invasive technique for diagnosing malformations and diseases of the pancreatobiliary region because it allows to obtain the final picture of biliary and pancreatic ducts, of the site and nature of focal lesions in the pancreas, as well as to clarify indications for various interventions.
Experimental studies on risk factors of necrotizing enterocolitis
Abstract
Introduction. Necrotizing enterocolitis (NEC) is one of the most life-threatening conditions in the neonatal period. This disease is considered to be polyethiological one; however, the pattern of NEC pathogenesis is not clear yet. The aim of the present research is to study in details NEC risk factors and pathogenetic mechanisms in experiment.
Material and methods. NEC was induced in 28 rat pups (breed: Wistar). Newborn animals (21-day gestation age) were labored from three female rats aged 9-12 months. In the research, the experimental animals were induced: hypoxia, inadequate formula feeding and bacterial contamination. The observation period lasted for 96 hours; the obtained results were assessed by the following criteria: clinical symptoms, mortality, intraoperative findings, histological findings and microbiological spectrum.
Results. NEC clinical signs were seen both in subgroup 1A (animals had hypoxia and inadequate formula feeding) and in subgroup 1B (additionally, animals had microbial contamination). Clinical and morphological findings were more pronounced in subgroup 1B. Mortality in subgroup 1B was 50%. The histological picture in subgroup 1A corresponded to that of NEC stage 1A-2A and in subgroup 1B – to NEC stage 2B–3B (by Walsh and Kliegmann). In subgroup 1B, there was a massive intestinal colonization in the intestinal lumen.
Conclusion. Hypoxia and inadequate formula feeding are, as such, risk factors of necrotizing enterocolitis. Additionally, bacterial aggression significantly worsens the course of necrotizing enterocolitis and its prognosis. However, the lack of bacterial component does not rule out NEC onset in newborns.
Laser hair removal in the complex treatment of pilonidal cyst in children
Abstract
Introduction. A pilonidal cyst (PC) in children is a common congenital pathology that manifests in the puberty period.
Purpose. To improve outcomes of pilonidal cyst care in children.
Materials and methods. The researchers analyzed results of surgical treatment of 156 children with PC who were hospitalized to the department of emergency and purulent surgery in Filatov Children’s City Clinical Hospital (Moscow) and in the surgical department of Republican Children’s Clinical Hospital (Izhevsk) in 2018–2020. All patients were divided into groups depending on the type of preoperative preparation.
Results. Cases of 156 children with PC were assessed: 121 boys (77.56%, p < 0.05) and 35 girls (22.44%). Patients’ age ranged from 13 to 18. There were two groups. In Group 1 (n = 89, 57.05%), patients had dry shaving as a preoperative preparation; in Group 2 (n = 67, 42.95%), patients’ hair in the sacrococcygeal region was removed with laser technique.
Conclusion. A combined technique of surgical treatment of pilonidal cysts in the coccyx in children improves outcomes, , reduces the number of complications and relapses as well as promotes early social rehabilitation and good cosmetic results.
Life-threatening thrombotic complications in a pediatric in the intensive care unit
Abstract
Introduction. This article highlights the problem of thrombus formation in pediatric patients staying in ICU, namely, the problem of prevention and management of pulmonary embolism in children. Currently, there is a tendency to increasing pulmonary embolism occurrence in children, though there are no clear guidelines on the medicine dosage for the systemic thrombolytic therapy of pulmonary embolism in children and for the acute coronary syndrome in children with Kawasaki disease.
Clinical observations. The authors present two clinical cases from their practice when a successful management was obtained in children with life threatening thrombotic complications due to the applied systemic thrombolytic therapy.
Conclusion. The obtained success in the described clinical cases have resulted from a thorough analysis of ratios “risk-benefit” and “efficiency-safety”. But the authors conclude that further research work in this direction is still needed.
REVIEWS
Achalasia of cardia in children (literature review)
Abstract
Introduction. The achalasia cardia care in children has an extremely wide range of issues, many of which are still not completely solved. The variety of treatment options for achalasia cardia indicates the lack of an ideal technique as well as unsolved essence of this problem. Discussions on the choice of optimal treatment modality are still going on, and new minimally invasive techniques are being developed and implemented. Though there is a positive feedback on the results of per oral endoscopic myotomy (POEM) , one can face a number of problems concerning surgical techniques, effectiveness criteria for postoperative monitoring as well as development of secondary gastroesophageal reflux and ways how to combat its manifestations.
Material and methods. The following databases were used: National Center for Biotechnology Information (https://www.ncbi.nlm.nih.gov/), scientific electronic library – eLIBRARY (https://elibrary.ru/defaultx.asp).
Conclusion. This review is an attempt to systematize current material on existing treatment options for achalasia cardia – from endoscopic to surgical ones. The authors also present results of their comparative analysis on various curative techniques for achalasia of the cardia.
A systematic review on mechanical intestinal anastomoses in newborns and infants
Abstract
Purpose. To analyze outcomes after putting the mechanical intestinal anastomoses in neonates and infants.
Material and methods. Two independent experts had searched the material in two scientific literature database PubMed and Elibrary using the following terms “stapled anastomosis-механический анастомоз», «children-дети» and have found 134 articles published in English (131 articles ) and in Russian (3 articles). All included articles were retrospective treatment series. The researchers selected only those publications in which patients’ age was less than 1 year, and the number of patients was more than 5.
Results. Out of 134 articles found in the initial search, only 7 articles were deemed eligible for this systematic review, accounting for a total of 352 patients who had mechanical intestinal anastomoses before 1 year of age with more than 5 follow-ups. The largest trial included 106 patients, the smallest one – 7 patients. The average weight of patients included in the systematic review was 4.2 kg. The average age was 4.9 months. Most often, a mechanical intestinal anastomosis was put to close the preventive enterostomy (99); then, intestinal atresia (70), necrotizing enterocolitis and spontaneous intestinal perforation (65), intestinal intussusception (30). The average duration of surgery was 85.5 min. Anastomotic leakage was noted in 11 patients. Rectal bleeding was observed in 9 patients. Anastomotic stenosis was recorded in 3 patients. Mortality rate was 1.7%. Unfavorable outcomes were not associated with surgery, but were caused by generalized bacterial infection (sepsis).
Conclusion. Mechanical intestinal anastomoses can be used in newborns and infants. The effectiveness of staplers has been confirmed by the low level of postoperative complications.
CASE REPORT
Multiple posttraumatic pseudoaneurisms of the spleen in a 13-year old child
Abstract
Introduction. Until now, there is an ongoing controversy regarding the curative strategy in spleen pseudoaneurysms which are detected by CT imaging.
Purpose. To present a diagnostic and curative algorithm for treating spleen injury complicated by multiple pseudoaneurysms in a 13-year-old child.
Observation. A 13-year-old boy was injured in a traffic accident (a cyclist hit by a car) and was admitted to the hospital by an ambulance with brain concussion, abrasions and bruises of soft tissues. On the second day after the injury, the child complained of the pain in the left lumbar region. Multiphase spiral computed tomography (MSCT) revealed damage of the lower pole of the spleen with formation of multiple round hyperdense formations in the arterial phase disappearing in the portal phase. Ultrasound examination revealed multiple hypoechoic zones up to 8 mm in diameter in the lower pole of the spleen, in which blood flow was seen at the color Doppler mapping (CDM). Diagnosis: closed trauma of the spleen, Grade 4 (AAST). Multiple pseudoaneurysms of the lower pole of the spleen. Repeated MSCT on the 6th day after the injury registered disappearance of pseudoaneurysms, like it was at the ultrasound examination. In six months after the injury, there were no complaints; spleen structure at ultrasound examination corresponded to age normal parameters.
Conclusion. The presented clinical observation demonstrates the success of conservative treatment of spleen injury complicated by the formation of multiple pseudoaneurysms.
A successful treatment of total colonic aganglionosis in a child
Abstract
Introduction. The earliest mention of total colonic aganglionosis, as the form of Hirschsprung’s disease, is dated 1926. According to various sources, total colonic aganglionosis is met approximately in 1 per 500 000 live births. Currently, the curative strategy in total colonic aganglionosis is strongly personalized. There are various surgical techniques for managing this severe congenital colon anomaly. Recent achievements in pediatric coloproctology have minimized the mortality rate in children with intestinal neuronal dysplasia and total colonic aganglionosis. However, despite of the evident progress in coloproctology, questions about the volume of reconstructive surgery in total colonic aganglionosis, application of “reservoir” surgical techniques so as to promote child’s further development and socialization are still unsolved.
Material and methods. The patient was successfully treated with a reservoir technique which included an ileo-transverse anastomosis by Martin-Kimur with the formed conduit pulled to the anterior abdominal wall. Then, a radical intervention was made which consisted of combined abdominoperineal transanal endorectal pull through (TEPT) of the ileo-transverse conduit/reservoir, of the resection of rudimentary colon and a coloanal anastomosis by Boley.
Conclusion. The obtained small intestine-colon reservoir in total aganglionosis allows to preserve motor function due to peristaltic movements of the small intestine wall and to prevent intestinal obstruction, thereby facilitating the physiological function of the intestine. In addition, the colon wall in the reservoir saves the area of absorbing surface and minimizes water-electrolyte disorders.
Reconstructive laryngoplasty with T-shaped tube in a 2-years old child having cicatricial stenosis of grade III
Abstract
Introduction. Stenosis of the upper respiratory tract is a common pathology in childhood. The most common cause is a prolonged intubation resulting in a persistent cicatricial narrowing of the airway. In modern literature, there are many techniques for its surgical treatment. At the first curative stage, tracheostomy is put. Nowadays, reconstructive techniques are widely used. One of the successful curative options in this pathology is laryngeal plasty with T-tube placement followed by the long-term stenting of the lumen.
Purpose. To demonstrate potentials of performing reconstructive surgical treatment of upper respiratory tract stenosis in young children.
Material. A clinical case of a two-year-old patient with acquired cicatricial stenosis of the larynx of the subglossal space, grade III, was treated at the department of thoracic surgery in Filatov Municipal Children’s Hospital.
Conclusion. Our clinical observation has shown that plastic surgery of the upper respiratory tract with placement of T-tube in young children with cicatricial stenosis is an effective technique that forms a satisfactory air pathway, thereby providing the child with adequate breathing through the natural airways.
Torsion of the uterine appendages in an 11-year old girl with ovarian endometriosis
Abstract
Introduction. It is known that hormonal and immune disorders are the background for endometriosis development. In children, ovarian endometriosis is extremely rare. Enucleation of an endometrioid cyst with preservation of healthy ovarian tissue is an enough surgical volume. However, torsion of adnexa in adolescence is quite an often pathology, and even in case of true ovarian tumor absence, it requires adnexectomy which, as a rule, finishes with uterine appendages removal.
A clinical observation. An 11-year-old girl with a history of early menarche was admitted to the surgical department with a clinical picture of twisted adnexa: acute abdominal pain combined with repeated vomiting. After gynecologist’s examination, a torsion of the left appendage was suspected; the patient was transferred to the gynecological department where ultrasound examination revealed a volumetric formation in the left ovary. Indications for emergency surgical treatment were outlined. Laparoscopy and left adnexectomy were performed. Histological examination revealed no necrotic changes in the uterine appendages, but an endometrioid cyst was found. On day 7, the patient was discharged from the hospital. The article presents a clinical observation of 11-year-old girl with twisted adnexa and an endometrioid cyst. To treat this pathology, the girl had laparoscopy and adnexectomy.
Conclusion. Immediate and correct diagnosis was put due to a typical clinical picture of twisted adnexa in a teenage girl. The volume of surgical intervention is unreasonably large. Early menarche should be considered as a marker of endometriosis in preclinical diagnostics of the disease so as to prevent urgent conditions and to preserve the reproductive potential. Unjustified ovariectomy during the formation of hypothalamic-pituitary-ovarian axis in a teenager, with the initially unfavorable premorbid background, brings even greater aggravation of hormonal and immune disorders with the stress to homeostasis-regulating systems.