Russian Journal of Pediatric Surgery

BACKGROUND: Currently, the most effective technique for treating children with portal hypertension is vascular bypass surgery and, for a number of reasons, splenorenal anastomoses (SRA) — which are total portosystemic shunts (PSS) — are predominantly used in practice. However, these shunts can promote the development of some complications: total discharge of the portal blood into the inferior vena cava can also cause some complications such as minimal manifestations of pulmonary arterial hypertension, decreased portal perfusion of the liver (PPP), hyperammonemia, and latent hepatic encephalopathy. An alternative to SRA is distal splenorenal anastomosis (DSRA), which is a selective PSS and which maintains PPL, thus reducing a risk of developing the listed complications. However, in practice, its use is limited due to high frequency of anastomotic thrombosis and ascites/chyloperitoneum at the early postoperative period.

AIM: Prevention of all the above-mentioned complications of artificial PSS continues to be a pressing issue in modern paediatric surgery. However, we have proposed a new curative option — reconstruction of the SRA into a DSRA, which reduced the risk of all mentioned complications, thereby improving the quality of patients’ life.

METHODS: From February 2020 to May 2024, 54 children were operated on with this type of surgery. The goal was to change the direction of the mesenteric venous blood flow (in SRA it is directed towards the anastomosis) towards the liver by clipping/ligating the splenic vein to the right of the anastomosis. All children, before and after the anastomosis reconstruction, underwent a comprehensive examination in full or in part, including a biochemical blood test, magnetic resonance imaging of the brain, echocardiography, ultrasound of the abdominal organs, angiography, esophagogastroduodenoscopy, neuropsychological examination (36 patients were followed-up at late stages after the surgery).

RESULTS: On a comparative findings, improvement of cognitive functions was seen in 60% of children, relief of hyperammonemia — in 71%, relief of signs of manganese salts accumulation of in the central nervous system — in 43%, improvement of hemodynamic parameters according to echocardiography — in 75%, improvement of PPL — in 78%. No patients had anastomotic thrombosis. Ascites/chyloperitoneum was registered only in 5% of cases.

CONCLUSION: The developed surgical technique is a promising one for it prevents/treats complications of artificial PSS, such as pulmonary arterial hypertension, decreased PPL, hepatic encephalopathy, anastomotic thrombosis and ascites.

BACKGROUND: Congenital giant pigmented nevi (CGPN) occur in 1:20 000 to 1:500 000 newborns. They are small (1.5 to 5 sq. cm), medium (5 to 50 sq. cm) and a truly gigantic (more than 50 sq. cm) types of pigmented nevi. CGPN create a psychological problem in children, due to aesthetic discomfort. Various techniques for their removal are not always effective and may cause complications: relapse (6–41%), skin scarring (6%), malignancy is possible in adults (10%). The question of CGPN effective removal remains open. This stimulates search for the optimization of applied curative options; and one of the ways is to use laser light for CGPN removal in children. Previously, individual researchers used infrared radiation (λ 10.6 microns) generated by pulsed periodic CO₂ laser for this purpose; some experimental work on "blue" (λ 0.45) light generated by diode laser was done too. Experimental studies on the skin of laboratory animals could define features of exposure and promising modes of these types of laser radiation for surgical application in CGPN removal.

AIM: To improve outcomes of treatment of various CGPN forms in children with optimized laser techniques.

METHODS: The CGPN removal was done with "blue" laser light (λ 0.45 micron) using Lasermed 10-03 device manufactured by Russian Engineering Club LLC (Tula) and laser light (λ 10.6 microns) generated by pulsed periodic CO₂ laser device ALDAN (manufacturer IOF RAS, Moscow, Russia). 35 children with various CGPN forms were treated in the Clinical and Research Institute of Emergency Pediatric Surgery and Trauma. Among them: 18 patients with a small form, 11 children with an average form, and 6 with a true gigantic form. Children’s age ranged from 6 to 18 years. In 13 children, CGPN located on the face, in 6 — on the anterior surface of the chest, in 8 — on the lower and upper extremities, in 4 — on the abdominal wall and in 4 — on the back.

RESULTS: The final good clinical and aesthetic outcome was registered in 29 children with small and medium CGPN forms. In 6 patients with true gigantic forms, good clinical and satisfactory aesthetic results were registered preliminary, at the treatment stage. No unsatisfactory results were seen.

CONCLUSION: Our experience with optimized techniques using mentioned types of laser light for the removal of various CGPN forms in children has confirmed their clinical and aesthetic effectiveness and outlined the prospect of their application in pediatric surgery.

A skin scar is a serious psychosocial problem for a person. Scars and cicatrices are synonymous terms. Interpretation of scar characteristics is necessary for monitoring purposes and, if necessary, for determining management tactics. Subjective characteristics of the scar (pain, itching, etc.) are very important for comprehensive understanding of its nature. Healing of skin wounds can lead to the formation of different types of scars: from minor lines to keloids. Physical and psychosocial aspects arising from a skin scar can worsen the patient's quality of life. Currently, an issue of the criteria, which are necessary to include them into a particular tool (scale) for comprehensive assessment of scars, remains controversial. The ideal scar rating scale should be easy for filling-in, and the measured parameters should be easily reproducible and interpretative. It is also important to define the scar impact at person’s psychosocial aspects (quality of life, self-esteem, social functioning). This literature review includes 19 full-text articles about 10 developed skin scar rating scales. The literature review was carried using data bases of PubMed, Web of Science, Google Scholar and Elibrary. The authors also have made a critical evaluation of the developed scales by clinimetrics requirements and denote their benefits for clinical practice.

BACKGROUND: Soft tissue ossificates is not a frequent complication in adults, and are even less common in pediatric practice. The described clinical case is an example of revealing a plantar surface ossificate in an 8-year-old patient with an unburdened somatic history, without previous severe injury. The acute onset of the disease, local pain syndrome with local tissues reaction and impaired walking function demanded exclusion of acute inflammatory disease, bone traumatic injury. Clinical and instrumental examination as well as surgical intervention revealed ossificates in the plantar surface in the calcaneus projection confirmed by morphological testing. Foci of pathological ossification which develop outside the skeleton bones (ossificates) can complicate the course of severe trauma, including central nervous system impairments, or they may be symptoms of genetic or systemic disease of the skeleton. In the literature, there are described cases of ossificates in adults, less often in children.

CLINICAL CASE DESCRIPTION: The patient was 8 years old. She was hospitalized in an urgent order with the preliminary diagnosis “M86.9 osteomyelitis of the left calcaneus(?)”. The patient complained of pain on the plantar surface of the left heel, lameness — inability to step on the left heel, local edema, hyperemia and marked tenderness during palpation of soft tissues. Disease history: 3 days before hospitalization, being home, she jumped to the floor from the height of 40–50 cm, and immediately felt pain, inability to walk, swelling on the plantar surface of the left heel.

CONCLUSION: The presented clinical case required additional instrumental and differential diagnostics to exclude acute inflammatory reaction in the calcaneus and in the surrounding tissues. Diagnostic and curative procedures revealed an ossificate in soft tissues of the plantar surface in projection of the calcaneus.

BACKGROUND: In the structure of childhood traumatism, thoracic trauma occurs in less than 10% of cases, but it is the second most likely cause of death in children. A bronchial rupture that disrupts adequate ventilation of the lungs can be the culprit of the fatal outcome. The purpose of our publication is to demonstrate a rare clinical observation of successful endoscopic treatment of an intermediate bronchus rupture in a 4-year-old child with polytrauma.

CLINICAL CASE DESCRIPTION: A 4-year-old boy was injured in a traffic accident as a pedestrian. During the first three days, he was treated for multiple injuries (Injury Severity Score 41) in a local hospital where, because of emergency indications, drainage of the right pleural cavity with two drains for tension pneumothorax and laparotomy for intra-abdominal bleeding due to liver rupture were done. Because of patient’s relative stabilization by the 3rd post-trauma day, he was transferred to our clinic (level 1 trauma center). We could stabilize his hemodynamics; however, air blowing through the drains was maintained, complete straightening of the parenchyma of the right lung was not reached, and blood gas composition remained subcompensated. On day 5 of the post-traumatic period, laryngotracheobronchoscopy was performed, and the rupture of intermediate bronchus measuring 3×9 mm was diagnosed. Its occlusion with a positive effect was done. After 7 days, laryngotracheobronchoscopy was repeated, and blockers were removed. After that, complete straightening of the right lung was reached; no recurrence of bronchopulmonary fistula. Long mechanical ventilation and long hospital stay were results of severe traumatic brain injury. At the follow-up visit in a year, no pathology in respiratory organs was detected at clinical laboratory, radiological and endoscopic examination.

CONCLUSION: Bronchial rupture may be a cause of inadequate ventilation and aggravation of the post-traumatic period in a polytrauma patient. The present observation demonstrates that intraluminal endoscopy allows to timely detect the rupture of the large bronchus and to perform a minimally invasive surgical treatment. Such a tactics ensured further positive dynamics in child's condition and favorable outcomes after polytrauma, as a whole.