卷 24, 编号 2 (2020)

Introduction. Currently, there is no any unified approach to the treatment of complicated forms of acute appendicitis in children. The purpose of our study is to evaluate the effectiveness of the local Protocol for diagnostics and treatment of appendicular peritonitis (AP) in children. Material and methods. 149 children with AP, aged 2 - 17 (11 ± 3.5 ), were included into the study. All of them were treated at the Clinical and Research Institute Emergency Pediatric Surgery and Trauma (CRIEPST) in 2015-2018. In the gender structure, boys (104; 69.8%) prevailed over girls (45; 30.2%). The following parameters were evaluated: AP structure, surgical tactics, postoperative course (incidence of postoperative intestinal failure syndrome (IFS), postoperative complications, length of hospital stay). A tactics for surgical treatment and volume of intensive care in the postoperative period were defined depending on AP severity and according to the local Protocol. Laparoscopic appendectomy was performed in 145 (97.3%) patients. There were no intraoperative complications and conversions in the studied group. In case of periappendiular abscess (PA) 3 (2.7%), patients had puncture and abscess drainage under ultrasound control. Results. While analyzing the AP structure by forms , the following picture was shown: free and abscessed forms were approximately equal - 72 (48.3%) and 77 (51.7%), respectively (p > 0.05). Diffuse peritonitis - 31.5%; generalized - 16.8%; combined - 17.4%; periappendicular abscess (PA) stage 1-14.8%; PA 2-16.8%; PA 3-2.7%. Postoperative complications - 4 (2.7%): postoperative abdominal abscesses - 3 (2.0%); early adhesive intestinal obstruction - 1 (0.7%). In postoperative abscesses, puncture and drainage were performed under ultrasound control; in early adhesive intestinal obstruction - laparoscopic adhesiolysis. All the children recovered. Length of intensive care was 2.9 ± 1.8 days; hospitalization - 12.0 ± 5.2 days. Conclusion. The local Protocol developed by the researchers helps to define a surgical tactics and volume of intensive care in the postoperative period. Laparoscopic surgery, in the vast majority of cases, is an optimal and effective technique for AP surgical treatment in children. Contraindications to laparoscopic surgery are PA 3 and total abscessing peritonitis.

Introduction. The bowel (intestinal) obstruction is a very common case in pediatric surgical practice. Intestinal transit disorders in children are caused by organic or functional problems of congenital origin or by acquired pathology. The incidence of intestinal obstruction is steadily increasing. This is due to an increasing number of cases with congenital gastrointestinal tract malformations as well as to an increasing number and volume of surgical intestinal interventions. Materials and methods. 76 patients, aged 0 months - 14 years, with various forms of intestinal obstruction were taken into the study. All patients were divided into 2 groups. The control group had 30 patients who were treated in medical facilities of the first level; the studied group included 46 patients who were operated in our clinic. In patients from the studied group, the viability of intestine and the level of resection were defined using the original technique “ Detection of the area of local necrosis and the level of intestine resection in children with intestinal obstruction “ , patent No 2 690744, Russian Federation, developed on the basis of another patent No 2 594 978 of Russian Federation “A technique for modeling local intestinal wall necrosis in the experiment.” The technique is as follows: While performing electrical stimulation of the intestinal wall with neurostimulator HNS 12, one can see a characteristic funnel-shaped depression indicating intestinal necrosis. The level of resection is determined by moving the electrode from the central part of the studied zone to distal and proximal directions until the circular contraction of the intestine appears. Results. This technique prevented relaparotomies, reduced transfer to enteral feeding by 33%, reduced the incidence of prolonged intestinal paresis by 62.5%, reduced patients’ stay in ICU by 41% and postoperative hospital stay by 24% as well as accelerated rehabilitation process by 27.3%. Conclusion. The technique developed for detecting the area of local necrosis and the level of intestinal resection promotes a most careful resection of the affected area of the intestine till healthy tissues, as well as prevents complications requiring surgical correction.

Introduction. The balance of the torso is the result of the interaction of various systems of the body, which provides a stable vertical position in space, which includes such components as afferentation, integration, effectors, and the peripheral nervous system. Material and methods. A clinical and radiological study of the coronal and sagittal alignment was carried out: 220 patients with idiopathic and neurogenic deformities of the thoracic and lumbar spine (n = 98) and hip instability (n = 122), capable of walking. The reference group is represented by 60 relatively healthy children without scoliotic spinal deformities with stable hip joints. Radiological parameters were evaluated by orthostatic X-rays for the indicated groups of children when comparing the obtained data with reference values. Results. The features of changes in the pelvic incidence (PI) and other parameters of the spin alignment in patients with hip instability, significantly different from patients with spinal deformities and the reference group, were revealed. Conclusion. The obtained results of the study call us to pay more attention to the parameters of the coronal and sagittal alignment as a total. Assessment and preoperative planning of only local X-ray anatomical parameters in order to predict their postoperative changes does not take into account changes in the coronal and sagittal balance, which, according to most published data, determines the further quality of life of patients.

Crohn’s disease (CD) and ulcerative colitis (UC) are pathologies that have various clinical manifestations, which sometimes cause problems in putting a correct diagnosis by clinicians. The review of domestic and foreign literature highlighted the relevance in improving the diagnostics of inflammatory bowel disease (IBD). Modern diagnostic techniques (computed tomography, magnetic resonance imaging, various endoscopic and radiological methods) are widespread in clinical practice, but they have a number of limitations in pediatric practice and are associated with certain risks. Significant drawbacks are radiation loading at the child’s organism and general anesthesia. So, a diagnostic tool which provides sufficient information, widely available, safe and non-invasive is a need . The ultrasound examination meets all the above mentioned demands. Unfortunately, currently there are no explicit protocols to be used for ultrasound examination of children with CD and UC. Researches in this direction should be continued, so as to confirm the effectiveness of this technique in diagnosing the intestinal tube pathology and to develop algorithms for practical application of this imaging technique, particular in pediatric patients with IBD.

A clinical case of intra-abdominal metastases of atypical teratoid-rhabdoid brain tumor because of ventriculoperitoneal shunt in a 1 y.o. child is presented. The child was hospitalized with a clinical picture of hypertension-hydrocephalic syndrome, right-sided hemiparesis. By neuroimaging findings, there was a massive tumor of the left lateral ventricle invading into the third, fourth, right lateral ventricles, Silvius aqueduct, metastases in the brain. An open biopsy of the tumor and external ventricular drainage were made. An atypical teratoid-rhabdoid brain tumor was verified histologically. Later, a ventriculoperitoneal shunt (VPS) was implanted. Chemotherapy was performed by ATRO-2006 protocol, though there was a simultaneous marked growth of the residual tumor. Nonprogressive survival period was 8 months. In 10 months after the initial diagnosis, during proton radiation with parallel Vincristine, intra-abdominal metastases were revealed. One month later, the child died. The authors have made a literature review on VPS-associated intra-abdominal metastases of malignant CNS neoplasms, the pathology which leads to an extremely unfavorable prognosis of the disease.

The central pancreatic resection is a complex organ-preserving surgical intervention used in patients with tumors located in the area of gland body. The laparoscopic access minimizes surgical trauma and shortens patients’ rehabilitation. The publication describes the first experience of laparoscopic central resection of the pancreas in a 13-year-old girl at the Morozovskaya City Children’s Clinical Hospital, Moscow.

Introduction. To assess SIRS and organ dysfunction in children with abdominal trauma using generally accepted scales is an actual issue for today. Purpose. To verify clinical criteria for SIRS and organ dysfunction in children with abdominal injuries in the perioperative period. Material and methods. 18 patients, aged 6 -12, with injury of their abdominal organs were treated at the Kusch Pediatric Surgery Clinic ( Republican Children’s Clinical Hospital) in Donetsk in 2014-2019. 11 (61.1%) patients with isolated blunt abdominal trauma and injuries of parenchymal organs were taken into Subgroup 1; 7 (38.9%) patients with open abdominal organ trauma and multiple injuries of internal organs - into Subgroup 2. Assessment of mechanical injury severity and prognosis were made using Pediatric Trauma Score (Tepas J.J., 1985) and Revised Trauma Score (Fitzmaurice L.S. 1997). Shock syndrome gradations were made by the FEAST criteria (Fluid Expansion as Supportive therapy) (2017). Results. Nosological configuration of the injury (closed or open, isolated or multiple) as well as the volume and character of surgical intervention were used for defining SIRS severity in children with abdominal injuries. In the perioperative period, parameters characterizing the degree of disorders of vital organs served as unified criteria of organ dysfunction in children with abdominal trauma. Conclusion. Before surgery, the most informative indexes were: tachypnea RR > 18.0 per min, SpO2/FiO2 < 264, HR > 130.0 beats per min, total leukocyte count > 13.5∙109/L or <4.5∙109/L. In the postoperative period: need in the inotropic support of systolic BP within normal limits, invasive / non-invasive mechanical ventilation, oxygen >50% FiO2 to maintain SpO2> 92%, SpO2 / FiO2<264.