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Vol 28, No 3 (2024)
- Year: 2024
- Articles: 10
- URL: https://jps-nmp.ru/jour/issue/view/48
- DOI: https://doi.org/10.17816/ps.2024-3
ORIGINAL STUDY
Per oral endoscopic myotomy in esophageal achalasia in children. First endoscopic procedures
Abstract
BACKGROUND: Achalasia is an esophagus lesion which is characterized by disorders of its motility. It is met extremely rare in childhood. Among the existing techniques of achalasia management, Heller's laparoscopic myotomy is a procedure of choice. Peroral endoscopic myotomy (POEM) is an endoscopic method for AP treating proposed by P. Pasricha in 2007.
AIM: To describe the experience of per oral endoscopic myotomy in children.
METHODS: The authors performed a retrospective analysis of data taken from the patients with confirmed esophageal achalasia who had had POEM. Clinical efficacy was assessed using the Eckard scale.
RESULTS: In 2018–2021, 8 children with average age 14.4 years were treated with POEM surgery. Before POEM, 2 children underwent balloon dilatation of the cardia. The surgery was technically performed in all children. Dysphagia was eliminated in all patients, and none of them required any additional intervention. A significant decrease in Eckard scale scores was registered in all children after surgery.
CONCLUSION: Our results confirm findings that POEM is an effective procedure for treating esophageal achalasia. However, a longer follow-up period and a larger group of patients are needed to confirm POEM role in the management of children with esophageal achalasia.
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Predictors of the effectiveness of initial therapy with antimuscarinic agents in children with neurogenic urination disorders
Abstract
BACKGROUND: Almost a third of patients with neurogenic urinary disorders have a refractory nature to therapy with antimuscarinic agents. The aim of the current trial was to identify predictors of the effectiveness of initial therapy with antimuscarinic agents in children with neurogenic urination disorders. For this, a comprehensive analysis of clinical parameters and video urodynamic findings in children was made.
AIM: The purpose of this study was to identify predictors of the successful initial therapy with M-anticholinergic preparations in children with neurogenic urinary disorders. For this, results of a comprehensive analysis of initial clinical and video urodynamic parameters were used..
METHODS: A prospective longitudinal cohort study involved 62 patients, aged 1.8–18 years, with neurogenic urination. In addition to the standard examination, all patients underwent a video urodynamic examination at Laborite Delphis UDS-600 device with parallel cystography at Siemens X-ray C-arc (Siemens, Germany). By the obtained results, 52 out of 62 patients were prescribed antimuscarinic agents as the first line therapy. Therapy effectiveness was assessed in 3 months. Analysed parameters were age, presence/absence of self-catheterization, as well as presence/absence of vesicoureteral reflux (VUR) revealed at conventional retrograde urethrocystography and/or video urodynamic examination.
RESULTS: The multivariate regression analysis demonstrated that the risk of ineffective antimuscarinic therapy increases by 75,6% in patients with VUR revealed at retrograde uretrocystography, regardless of patient's age and self-catheterization (OR=0.244; 95% CI=0.063-0.937; p=0.040) and by 89.8% (OR=0.102; 95% CI=0.019-0.554; p=0.008) when VUR is detected at video urodynamic examination. Unlike patients with a positive effect (n=24; 50%), 24 patients (50%) who had no response to antimuscarinic therapy were younger (median age 8 years); they also were self-catheterized and had VUR revealed at video urodynamic examination. Outcomes of the prescribed therapy were not associated with other video urodynamic parameters. The identified significant predictors (age, self-catheterization and VUR at video urodynamic examination) have allowed to develop a model for predicting antimuscarinic therapy effectiveness before its administration. This model can promote a rational selection of patients for antimuscarinic therapy, as the first line therapy, with a high probability of positive outcome in 84.9% of patients.
CONCLUSION: When prescribing antimuscarinic agents, patient's age, self-catheterization, VUR revealed at retrograde urethrocystography and video urodynamic examination should be taken into account. Predictors of effective antimuscarinic therapy in children with neurogenic urinary disorders, which increase the likelihood of successful outcomes, are patient's age (over 12 years), no self-catheterization and no VUR at video urodynamic examination. Patients younger than 12 years, with self-catheterization and VUR are less likely to respond to antimuscarinic therapy.
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REVIEWS
Modern methods of surgical treatment of obstructive genital malformations in girls
Abstract
Congenital anomalies of female genital tract in children and adolescents are more commonly detected at the age of menarche with several symptoms caused by obstruction. These diseases are rare, but without timely diagnostics and management they can cause a number of serious complications. This article is aimed to review modern approaches to diagnostics and management of this pathology and to highlight some aspects that require further research.
A literature search was conducted using the following databases: MEDLINE, Google Scholar, eLIBRARY, international guidelines and clinical recommendations. Key words that were used for search were: «congenital malformations», «distal vaginal atresia», «imperforated hymen», «OHVIRA», «transverse vaginal septum», «hematocolpos», «obstructive uterovaginal anomalies», «surgical treatment in pediatrics». International clinical trials which had been analysed by the authors were included in the review.
They have explored the current literature related to the following obstructive malformations: distal vaginal atresia, transverse vaginal septum, imperforated hymen and Herlin–Werner–Wunderlich syndrome.
Main conclusions are: further studies with a larger sample of patients, longer follow-up, long-term outcomes and effective preventive measures against complications. Another unresolved question is the age which can be recommended for surgical treatment of obstructive malformations. Potentials for developing new algorithms of earlier diagnostics are also among research priorities.
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Factors and nomograms determining the effectiveness of extracorporeal shock wave lithotripsy in children with urolithiasis: a literature review
Abstract
Extracorporeal shock wave lithotripsy (ESWL) is currently the priority method for treating urolithiasis in children. Due to the lack of extended indications for the application of this technique, an active search has been made over the past 30 years to define factors predicting ESWL outcome, to create objective preoperative planning tools, to increase ESWL effectiveness and to reduce the number of anesthetics and unnecessary surgical interventions.
Search for the information on predictive factors of ESWL successful intervention and on modern statistical tools predicting lithotripsy effectiveness in children with urolithiasis was made in foreign and domestic sources, like MEDLINE, eLIBRARY, CyberLeninka.
The literature analysis has showed that the following factors predispose positive ESWL outcomes: age before six years, smaller calculi size, and shorter skin-to-stone distance. Stone location in the lower calyx group, multiple concrements, and their high density has a negative impact at complete fragment detachment after ESWL. The probability of complete detachment of stone fragments from the lower calyx group decreases under the following anatomic features of kidney collecting system: number of draining calyces is more than one, calyx neck diameter is less than 4 mm, acute angle between the lower infundibulum and renal pelvis. Body mass index and prestenting have a controversial effect at successful ESWL too.
Nomograms and scoring systems based on predicting factors are widely used in both adult and pediatric practice. The two most commonly used nomograms in pediatric urology are Onal and Dogan nomograms developed in 2012 and 2015 in Turkey. These nomograms include the following parameters: patient's sex and age, history of ipsilateral surgical interventions as well as stone localization, number and size.
Thus, predicting ESWL outcomes using preoperative planning allows to choose the most appropriate treatment modality for a particular patient considering his/her individual anatomical and physiological characteristics and characteristics of the calculi.
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CASE REPORTS
Surgical treatment of diaphragmatic hernia in a 3-year-old child
Abstract
BACKGROUND: Congenital diaphragmatic hernia (CDH) is a serious condition associated with abnormal development of the diaphragm. Its occurrence among newborns ranges from 1 per 2000 to 1 per 4000. Depending on location, CDH can be divided into four types: diaphragmatic-pleural, parasternal, diaphragmatic-pericardial, and hernias at the esophageal opening of the diaphragm. Hernias can be classified as true or false depending on the presence or absence of the hernia sac. In case of diaphragmatic-pleural hernias, when the intestine, spleen, and stomach almost completely protrude into the pleural cavity, symptoms manifest early in the form of severe cardiorespiratory and gastrointestinal disorders.
CLINICAL CASE DESCRIPTION: The article discusses a case of a three-year-old child with a congenital diaphragmatic pleural hernia. From birth, the child experienced difficulty breathing at feeding, coughing; he also had recurrent pneumonia. X-ray examination and computed tomography of the chest revealed a left-sided hernia. Surgery was done via a left-sided thoracotomy, no complications. In four months after the surgery, X-ray examination showed straightened lungs and normal mediastinum; left diaphragm cupula was also normal. The child is considered to be completely healthy due to the absence of symptoms and normal chest X-ray findings. The authors' main goal was to raise awareness among doctors about rare congenital diseases such as CDH. Also, they would like to draw attention to the fact that congenital malformations of the lungs, intestines, and other organs can be unexpectedly manifested at any age. Children with frequent respiratory problems or cardiorespiratory conditions have to be X-rayed as soon as possible to detect congenital malformations of the diaphragm or other chest organs for timely surgical intervention.
CONCLUSION: As the authors have noted, in recent years X-ray examination of children often reveals undiagnosed at an early age "findings" related to diaphragm pathology, such as false and true diaphragmatic hernias and dome relaxation. CDH is rare in children older than 3 years and has no specific symptoms. It often leads to delayed diagnostics, often visits to pediatricians because of respiratory infections, retardation in physical development and, as a result, to late surgical treatment.
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Robot-assisted treatment of simple renal cysts
Abstract
BACKGROUND: The gold standard in the surgical treatment of simple renal cysts is laparoscopic cyst fenestration. However, laparoscopic procedures have disadvantages which include poor ergonomics of the instruments hindering surgeon's work in children's small abdomen. Robot-assisted surgery has the potential to make surgeon's work easier and to improve surgical outcomes in patients with kidney cysts for the instruments have seven degrees of freedom, hand tremor is filtered. It also promotes comfortable console positioning for the surgeon, and three-dimensional wide-angle imaging of the surgical field.
AIM: To present the first experience of applying robot-assisted surgery for fenestration (decortication) of the outer portion of the cyst and argon-plasma coagulation of its inner lining.
METHODS: The author's present retrospective data of all patients with simple renal cysts operated on with robot-assisted approach at the Irkutsk State Regional Children's Clinical Hospital. The diagnosis was put after ultrasound examination of kidneys and after computed tomography with intravenous contrast agent. Surgery was performed using a new model of the Versius robotic system manufactured by Cambridge Medical Robotics (UK).
RESULTS: Patients' mean age at the time of surgery was (13±5.3) years (median 15 [11; 16] years), mean weight — (46.7±17.2) kg (median 54 [40.5; 56.5] kg), smallest body weight — 27 kg, size of cysts — (1.8±2.4) cm (median 0.4 [0.4; 2.5] cm). Cystic formations in all patients were located on the left: in the upper pole in 2 patients, in the lower pole in 1 patient. During the surgical intervention, there were no complications in the form of bleeding from the kidney parenchyma or damage to neighbouring organs. Histological analysis revealed that the lining of the cyst wall contained transitional epithelium without signs of malignancy. Duration of surgery was (136.7±72.2) min (median 95 [95; 157] min), duration of patients' stay in the intensive care unit — (19.9±2.5) hours (median21.3 [19.1; 21.4] hours), duration of hospital stay — (9.3±2.3) days (median 8 [8; 10] days). Ultrasound examination made in 1, 3 and 6 months after the surgery revealed no signs of disease recurrence in the form of residual accumulation of fluid associated with kidney parenchyma.
CONCLUSION: The experience described in the article is encouraging and confirms the reasonability and safety of robot-assisted procedures in pediatric urology.
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Difficulties of the stage-by-stage surgical treatment of a teenager with bilateral advanced fibrotic-cavernous tuberculosis. Сlinical case
Abstract
BACKGROUND: To achieve success in the management of adolescents with tuberculosis, a comprehensive approach including surgical intervention is needed so as to eliminate disease clinical manifestations, to achieve persistent healing of tuberculous changes with restoration of bodily functions and complete social rehabilitation
CLINICAL CASE DESCRIPTION: In patient U., 17 y.o., sudden and acute onset of the disease broke out after her contacts with her aunt who had tuberculosis. The initial form was infiltrative pulmonary tuberculosis in the decay phase. A course of anti-tuberculosis therapy was prescribed considering the bacteria sensitivity to antibiotics. After the course, fibrous lesions and cavities were detected in both lungs at computed tomography examination of the chest organs. A personalized therapy was developed for the patient with consideration of her body weight and sensitivity to bacteria. In 7 months, an endobronchial valve was inserted at the bronchus mouth in the right superior lobe because of the large cavity in the right upper lung lobe and lack of changes in the cavity size. In six more months, the blocker was removed due to the lack of dynamics, and a video-assisted thoracoscopic combined resection of the right lung (upper lobectomy with resection of part SV, anatomical resection SVI with part SVIII) was performed. On analyzing surgical material, it was found out that the patient was resistant to Isoniazid, Rifampicin and fluoroquinolones, so therapy was corrected. In six months, a video–assisted thoracoscopy combined resection of the left lung (SI–III anatomical resection and marginal resection of SVI part) was made.
CONCLUSION: After the performed treatment, patient's oxygenation improved, persistent abacillation was achieved, due to which the patient could return to normal lifestyle.
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Successful treatment of cicatricial stenosis of the main, intermediate and upper lobe bronchi of the right lung complicated by total lung atelectasis in an infant: a clinical case
Abstract
BACKGROUND: The authors present a rare clinical case of stenosis of the main, intermediate and upper lobe bronchi of the right lung complicated by total lung atelectasis in an infant. They discuss issues of complex disease diagnostics, analyze X-ray and bronchological images, assess outcomes after multidisciplinary approach in the treatment of a premature baby as well as analyze data of catamnestic observation.
CLINICAL CASE DESCRIPTION: Girl T., one of monochorionic diamniotic twins, was born at 27 week gestation in 2021 with weight at birth 825 grams, Apgar score 4/5. Since her birth, she had artificial lung ventilation due to her deep immaturity and developed severe respiratory distress syndrome. At the age of 19 days, total atelectasis of the right lung was diagnosed in the child as a result of stenosis formation in the main, intermediate and upper lobe bronchi which was confirmed by clinical and radiological findings. A probable etiology of acquired stenosis is consequences of prolonged intubation under insufficiently formed cartilaginous framework. Chlamydial infection, detected in the child, could also support inflammatory process in the bronchi. The child was examined with the following instruments: radiography, multispiral computed tomography-angiography of the thoracic cavity, bronchofibroscopy, echocardiography. Laboratory tests: polymerase chain reaction of blood and sputum for herpes viruses type 1–6, mycoplasma, ureaplasma, Chlamydia pneumonia; blood enzyme immunoassays — antibodies to viruses of Herpesviridae type 1–6, Chlamydia trachomatis. Conservative therapy provided only temporal improvement; atelectasis was relapsing. At the age of 5 months and 20 days, the child underwent bronchoplasty with resection of damaged areas of the bronchi. Further, age-related diameter of the bronchial lumen was maintained by the staged bougienage. Catamnestic observation lasted for 3 years. Late timing of surgical intervention is explained by severe problems in a deeply premature and immature child that required immediate treatment (intraventricular hemorrhages, hydrocephalus, retinopathy, etc.). Effective surgical treatment (bronchoplasty), active growth of lung tissue at the first year of life as well as reasonable rehabilitation allowed to obtain good long-term outcomes. By the age of 1 year 2 months, normalization of right lung airiness was achieved. Currently, there is a slight reduction in right lung volume. Multispiral computed tomography-angiography revealed a few cylindrical bronchoectases in the segmental and subsegmental bronchi of the upper and middle lobes of the right lung which do not have clinical equivalents yet. The child is under pulmonologist's observation and management.
CONCLUSION: A multidisciplinary approach to the treatment of complicated patient's state and high compensatory capabilities of neonatal and infantile periods have promoted the restoration of normal lung aeration and functioning after long-lasting lung atelectasis
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Stab wounds of the neck in children
Abstract
BACKGROUND: Stab wounds in children are very rare and are described as isolated cases. Sharp metal foreign bodies in the neck pose a real threat to trachea, esophagus, large vessels and nerves. The risk of damage is still present when specialists try to remove foreign bodies, especially if they are fixed.
CLINICAL CASES DESCRIPTION: The aim of the study is to demonstrate outcomes after treating patients with neck injuries. We have two observations of stab wounds in the neck (with a knitting needle and a sewing needle) in children. To put diagnosis, we used clinical, laboratory, radiation and endoscopic methods. Surgery was done under general anesthesia, and the knitting needle and the sewing needle were removed from deep structures of the neck. Patients were discharged from the hospital in satisfactory state.
CONCLUSION: The described observations may be of interest to specialists because we could remove foreign bodies penetrated into the neck without damage to internal organs, vessels and nerves. To prevent complications, foreign bodies in the neck have to be removed by experienced specialists in an operating room under general anesthesia with artificial ventilation. In case of complications, radical surgery is indicated.
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JUBILEES
Yuri Yu. Sokolov is 60 years old!
Abstract
On May 27, 2024, Yuri Yu. Sokolov, Doctor of Medical Sciences, Professor, Member of the Editorial Board of journal “Russian Journal of Pediatric Surgery” celebrates his 60-year jubilee. The leading area of his scientific interest is minimally invasive surgery of malformations in the thoracic and abdominal cavities in children. Prof. Sokolov has conducted on-site master classes on pediatric endosurgery more than 50 times in various Russian cities and neighboring foreign countries. He was the first in Russia to perform laparoscopic (in 2005) and robot-assisted (in 2021) extirpation of a cyst in the common bile duct in a child.
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