卷 23, 编号 3 (2019)

Introduction. Traction and convergence of atreseal ends of the esophagus with subsequent anastomosis is the most common technique for treating newborns with the fistulous form of esophagus atresia. The performed literature analysis did not reveal any researches aiming to study the correlation between a postoperative histological picture and diastasis length between atresial esophageal ends. Purpose. To assess the potential for modeling esophageal surgeries with biological models; to study and analyze the histological picture of operated esophagus and its correlation with the diastasis distance between atresial ends. Material and methods. Rats were randomly divided into three groups (n = 5 in each group). Rats from Group 1 had a standard surgery with the end-to-end esophageal anastomosis and artificially created diastasis of 1.0 cm by esophageal segment resection. Rats from Group 2 had a similar surgery but without any esophageal segment resection; so, the anastomosis in them was put without diastasis and significant tension of esophageal ends. Rats from Group 3 did not have any surgery; they were controls. The experimental rats were monitored daily for seven postoperative days. Results. There was no any significant macroscopic difference in the esophagus length in traction, nontraction and control groups. However, microscopic examination revealed that mucous and muscular membranes thickness in the esophagus, as a rule, was slightly thinner in the traction group. Despite the muscle layer thinning, hypertrophy of muscle fibers, lymphoplasmacytic infiltration with some eosinophilic leukocytes as well as signs of perifocal epitheliotropism were noted.

Introduction. Advances in molecular genetics, imaging techniques (PET/CT), medicamentous therapy and surgical treatment in the recent decades have improved hypoglycemia control and , thus, improved treatment outcomes in children with congenital hyperinsulinism. Purpose. To define indications for different techniques of surgical correction in patients with congenital hyperinsulinism depending on the disease form. Material and methods. 23 children were operated on for congenital hyperinsulinism in the department of pediatric surgery in the Almazov Medical Research Center from 2011 till 2018. In 2011-2016, 5 children were operated on by the standard approach which included subtotal pancreas resection (95%). Since 2017, PET tomography with 18-F-DOPA and intraoperative rapid biopsy of the pancreas have been introduced into the curative algorithm. In 2017-2018, 18 children were operated: 6 patients with the diffuse form and 10 - with the focal one. Two more children had controversial outcomes. Results. Fifteen children (83%) had complete hyperinsulinism control and significant improvement in their psycho-motor function. Out of 18 children, 10 (56%) had a complete recovery: among them - 8 (89%) out of 9 children with the focal form of hyperinsulinism and 2 (22%) out of 9 children with the diffuse form. Two children (11%) had a marked positive dynamics. Six patients (33%) needed insulin therapy with minimal dosages - all were children with the diffuse form of hyperinsulinism (6 (67% ) out of 9). Conclusion. Partial pancreatectomy in patients with focal forms or subtotal pancreatectomy in patients with diffuse and atypical forms allow to eliminate hypoglycemia caused by the congenital hyperinsulinism and to prevent damage to the central nervous system in newborns and infants.

Until recently, only findings of local status and laboratory diagnostics were used as objective tests which defined terms and volume of therapeutic and preventive measures for clinical examination of patients who survived acute hematogenous osteomyelitis. The prescribed complex treatment does not take into account the following indexes: patient’s co-morbidity which is characterized by the autonomic reactivity; presence of stigmas of the connective tissue dysplasia, trophic status as well as psychological characteristics of patients. During the present study, connective tissue dysplasia was revealed in 70% of patients who had acute hematogenous osteomyelitis what was confirmed by the revealed phenotypic signs and biochemical blood markers. While assessing trophic status, a disharmonious body type and insufficient physical development were seen in patients who survived septic-pyemic form of the disease. Patients who had acute hematogenous osteomyelitis, even in the absence of markers of active inflammatory process, demonstrated signs of impaired adaptation-compensatory mechanisms involving the humoral regulation and a wide range of psychological problems which reflect tension of systems and play an important role in self-development and self-maintenance of the pathological process - the so-called principle of pathoautokinesis. Patients who survived hematogenous osteomyelitis, especially in the septic form, should continue their rehabilitation, have follow-up examinations and anti-relapse treatment. In this group of patients, multidisciplinary approach is needed for developing their rehabilitation program. Terms of this program should be individualized and defined by the normalizing of objective indicators (local status and comorbid conditions).

The present article is a literature review on etiopathogenesis, diagnosis, conservative and surgical treatment of chyloperitoneum in newborns. Chyloperitoneum is an extremely rare pathology in children and, not in all cases it is possible to find its cause. The management protocol for chyloperitoneum has not been developed. The most effective approach for managing this disease is a starvation pause, than transfer to full parenteral nutrition, administration of somatostatin (octreotide) and drainage of the abdominal cavity. Conservative therapy may take several months and, its effectiveness reaches 60-100%. Surgical treatment is aimed to indentify a focus of lymph leakage and its elimination; in severe cases, the fibrin glue is used.

Purpose. To improve the duodenum function after Kimura surgery which is performed for the congenital duodenal obstruction by restoring the horseshoe-shaped duodenum. Material and methods. A comparative analysis of two groups of patients was made: In Group 1 (n = 31) , patients were operated with the mobilization of lower horizontal duodenal branch and duodenoduodenal anastomosis by Kimura without restoring the horseshoe-shape of the duodenum. In Group 2 (n = 11), children had similar surgeries but the horseshoe-shaped configuration of the duodenum was restored by fixing the initial part of the jejunum to the Treitz ligament. After surgery, the researchers radiographically compared time of barium suspension passage through the duodenum in patients of both groups. Results. In children from Group 1, passage of the contrast suspension via duodenum lasted for 43.9 ± 3.9 sec., what is approximately 2 times faster than in the norm. In patients from Group 2, this indicator was 3-4 times larger than in patients from Group 1 and was 158.2 ± 18.2 sec. Such a slowdown in the chyme passage along the duodenum prolongs exposure of food masses to pancreatic juice, bile and intestinal juice and, consequently, improves the duodenal function. Conclusion. The authors recommend to end the surgical intervention for eliminating congenital duodenal obstruction by Kimura technique with the restoration of horseshoe-shaped duodenum by fixing the initial part of the jejunum to the Treitz ligament.

Introduction. Testicular torsion is an emergency condition requiring emergency medical care. Polymorphism of symptoms in testicular torsion makes diagnostics not easy and leads to late treatment what can results in irreversible damages to the testicle. Early diagnostics is a key point to organ preservation. Material and methods. The authors describe two clinical cases of testicular torsion in adolescents with errors in diagnostics. Clinical, laboratory findings and instrumental examination (MRI, ultrasound) were used for diagnostics. Results. A diagnostic error resulted in orchectomy which was made to one patient. In the other patient - despite a diagnostic error- testiclular detorsion and urgent surgical intervention resulted in patient’s complete recovery. Discussion. These examples illustrate how important is to carefully study the patient’s case-history - onset and nature of pain, associated vegetative symptoms - nausea and vomiting - which are not characteristic for other acute testicular diseases. Conventional tactics of urgent surgical intervention for all acute testicular diseases in children does not insure against diagnostic errors in case of testicular torsion with atypical symptoms. Ultrasound examination is of irreplaceable value, but one cannot be guided only by its findings in excluding testicular torsion. Conclusion. Any of the symptoms of testicular torsion - whether it is acute onset or severe pain, or a combination with vomiting, or severe pain on palpation, or ultrasound findings - is a reason to suspect testicular torsion and, it is an absolute indication for urgent surgery. The protocol for diagnostics and treatment of acute testicular diseases developed by us includes these diagnostic peculiarities and allows to choose an effective treatment modality.

75% of all emergency surgeries are surgeries for acute appendicitis. Annually, only in the Republican Scientific Center 700 appendectomies in children are made, in average. The article summarizes data obtained in the retrospective analysis of case histories of 6 256 patients with acute appendicitis and its complications who were hospitalized in the pediatric department of emergency surgery for 12 years. The following incidence of acute appendicitis in children is reported: from 1 to 3 years of age - 0.6 per 1 000; from 4 to 7-1.4-2.6 per 1 000; 13 years of age - 8 per 1 000. The authors discuss specific features in the clinical picture of acute appendicitis in children depending on patient’s age and anatomical location of the appendix. The clinical picture in children of older age and of the first three years of life is discussed separately. Out of 6 256 pediatric patients with acute appendicitis 72 (1.15%) were children younger than 3. The authors have substantiated a complex of diagnostic and therapeutic manipulations as well as tactic options to the treatment of this category of patients. Widespread implementation of the laparoscopic technique into surgical practice has significantly changed the tactics of treatment. The number of surgeries for simple appendicitis in children has decreased up to 3.9-7%.

The case of acute hematogenous osteomyelitis in a 3-year-old child with the development of a rare and life-threatening complication-deep vein thrombosis of the lower limb with a floating thrombus is described. Anticoagulant therapy under the control of ultrasound duplex scanning of veins of lower extremities allowed to avoid repeated surgery and other complications.