卷 25, 编号 1 (2021)

Introduction. Recently, achievements in molecular genetics, imaging techniques (PET/CT), medicamentous therapy as well as in surgical treatment have promoted a better control of hypoglycemia and, consequently, better outcomes in children with congenital hyperinsulinism.

Purpose. To specify indications, volume and outcomes of surgical treatment in patients with congenital hyperinsulinism depending on pathology form, differential diagnostics with PET / CT and intraoperative express biopsy.

Material and methods. 41 children with congenital hyperinsulinism were operated in the department of pediatric surgery in Almazov National Medical Research Centre (Saint-Petersburg) during 2011 – September 2020. In Group 1, there were 6 children who had standard treatment with subtotal resection of the pancreas (95%). In Group 2, there were 35 patients who had PET tomography with 18-F-DOPA before surgery and intraoperative express biopsy of pancreas tissue. The analyzed patients were operated on in 2017-September 2020. PET tomography with 18-F-DOPA findings revealed that these children had 10 diffuse forms and 22 focal forms; the other 3 children had a disputable picture.

Results. After surgery, diffuse form was confirmed in 10 (29%) children; focal form - in 21 (60%) children; 4 (11%) patients had the atypical form which was diagnosed intraoperatively. Of 35 children from Group 2, 33 (94%) had complete hyperinsulinism reversal, significant improvement in their psycho-motor function; however, 10 (29%) of them require insulin replacement therapy with minimal dosages - 8 children with the diffuse form of hyperinsulinism and 2 children with the atypical one. There were no intra- and postoperative complications. 20 (95%) out of 21 children with focal forms recovered completely. The authors also describe problems and peculiarities of urgent histological examination.

Conclusion. Thus, partial pancreatectomy in focal forms, subtotal in atypical ones and almost total in diffuse forms allows to cope with hypoglycemia caused by congenital hyperinsulinism.

Introduction. The first publications about acute appendicitis in the conditions of the new COVID-19 coronavirus infection have appeared. Most authors point to the increased time of seeking medical help in such patients and an increase in the level of postoperative complications.

Material and methods. A retrospective study of 192 case histories of patients aged 3 to 17 years with various forms of acute appendicitis who were treated in the surgical Department of the Republican children’s clinical hospital in the period from 2019 to November 2020 was conducted. Children operated on during 2019 before the start of the new coronavirus pandemic were included in the first group (n = 114). Children operated on in 2020 after the development of a new coronavirus pandemic were included in the second group (n = 78).

Results. The age of patients in both groups compared did not differ significantly. The course of the disease was within the average accumulated indicators and the terms of hospitalization did not change significantly. According to our observations, the time of admission to the surgical hospital from the time of the disease in the pre-coronavirus period and during it also did not differ significantly, which indicates that the same availability of medical care remains even during the epidemic. Our study also showed that the number of requests for complicated appendicitis in children during the COVID-19 epidemic even decreased, which ultimately led to a decrease in the level of postoperative complications. The study did not establish a significant difference between the main results of treatment of children with acute appendicitis before and during the new COVID-19 coronavirus infection. Only the level of postoperative complications significantly decreased in patients operated during the COVID-19 epidemic, which is associated with a lower admission of children with complicated appendicitis.

Conclusion. With the onset of the pandemic, the organization of medical care for the child population with acute pathology in the Komi Republic did not change and did not have any restrictions, which made it possible to maintain the timely provision of surgical care to children with acute appendicitis at the proper level.

Introduction. Choledochal cyst is enlargement of the external bile duct system that can lead to liver dysfunction and biliary cirrhosis in childhood and malignant degeneration of the liver and bile ducts in adulthood. There are many theories explaining the origin of the common bile duct cyst. However, none of them can explain the formation of all five different types. Most of them are congenital. However, some of them may be aquired. The theory of a long common biliopancreatic canal has become widespread and is still used to explain the formation of this type of cystic anomalies. If the common canal is long and its part is not surrounded by the sphincter of Oddi, the secret of the pancreas begins to be thrown into the choledochus. Proteolytic enzymes from the pancreas are quite active and can damage the epithelium and the wall of the bile ducts, which leads to their weakness and, as a result, dilatation of the choledochus. Ultrasound examination is the initial and main method for diagnosing choledochal cysts. In some cases, there is a need for endoscopic or magnetic resonance retrograde cholangiopancreatography, intraoperative cholangiography. Removal of the cyst and anastomosis of the common hepatic duct with the lumen of the jejunum or duodenum, performed through the subcostal approach, are standard procedures for the treatment of patients with a choledochal cyst. The advent of laparoscopy and the accumulation of experience in performing complex surgical interventions introduced a minimally invasive approach for the production of laparoscopic biliodigestive anastomoses. Intra- and postoperative complications include damage to the structures of the hepatic hilum, torsion of the abduction loop, incompetence and stricture of biliodigestive anastomosis, cholangitis, stone formation, adhesive intestinal obstruction, and malignancy of the cyst remnants.

Conclusion. This literature review has demonstrated modern views on the origin, etiology, diagnosis and treatment of choledochal cysts. The scientific work discussed the versatile technical aspects of the surgical treatment of choledochal cysts in children and assessed its safety and effectiveness.

Introduction. Appendix invertus is a rare condition in which the appendix is invaginated into the cecum lumen. This pathology has a wide spectrum of clinical manifestations ranging from asymptomatic course to severe inflammation.

Purpose. To describe the first clinical experience in pediatric practice of successful appendix removal using flexible intraluminal endoscopy.

Material and methods. A clinical case of a 9-year-old female patient who was admitted to Irkutsk Municipal Pediatric Clinical Hospital was analyzed. On admission, the patient had clinical signs of acute abdomen with a history of previous appendectomy performed by the “invagination” technique. Based on the hypothesis, that the inverted appendix is in the intestinal lumen, it was decided to perform appendectomy with flexible intraluminal endoscopy.

Results. It has been demonstrated that intraluminal endoscopy in pediatrics may be applied in rare clinical situations; in our case, it was necessary to remove the inverted appendix.

Conclusion. Flexible intraluminal endoscopy is a curative modality which illustrates the progress in improvement and expansion of indications and techniques in the area of NOTES surgery.

Introduction. Despite of the fact that necrotic enterocolitis (NEC) is a common surgical disease in newborns, a significant breakthrough in its treatment has not been made yet.

Purpose. To analyze outcomes of surgical treatment at the NEC surgical stage in newborns.

Material and methods. Outcomes after surgical treatment of 71 newborns with necrotic enterocolitis at its surgical stage, who were admitted to the hospital in 2015-2020, have been analyzed.

Results and discussion. Diagnostic laparoscopy (DL) was prescribed if the surgical stage of the disease was not complicated with pneumoperitonitis. 37 patients had DL; of them 11 (29.7%) had conversion to laparotomy. In 26 (70.3%) patients, diagnostic laparoscopy was ended with therapeutic laparoscopy and video-assisted mini-laparotomy; among them there were 7 (26.9%) patients in whom gastric perforation was sutured. Resection of the necrotic part of the intestine with followed end-to-end anastomosis was made in 8 (30.7%) patients; in 11 (42.3%) patients, an intestinal stoma was created. In 45 newborns with the NEC surgical stage, surgeons chose the traditional surgical tactics. 34 (75.5%) patients with diagnosed pneumoperitoneum had laparocentesis to achieve decompression; 8 (17.7%) patients out of them died. 37 (82.2%) patients had laparotomy; in 5 (11.1%) out of them stomach perforations were sutured. In 32 (71.1%) patients, intestinal stomas were created. If to compare the obtained results after video-assisted laparoscopic surgeries, the mortality rate was as follows: 6 (23.1%) patients after laparoscopic interventions and 64.4% after traditional ones.

Conclusion. Diagnostic laparoscopy at the surgical stage of necrotizing enterocolitis allows to select tactics for radical surgical treatment, to transfer surgical treatment into non-surgical one, thus minimizing surgical trauma what impacts positively the postoperative survival of patients.

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