卷 27, 编号 5 (2023)

Introduction. Since the middle of the last century, the conservative treatment of ileocecal intussusception (ICI) has dominated in children. However, questions on choosing a technique for conservative treatment and indications for surgical treatment remain open.

Purpose. To assess the effectiveness of hydroechocolonoscopy (HEC) for ICI in children regardless of their age and disease duration.

Material and methods. 160 children with confirmed ICI were enrolled in the study. All children, who had developed uncomplicated ICI for the first time, had HEC regardless of their age and disease duration. Failed hydrostatic disinvagination and disease relapse after HEC were indications for surgical management (laparoscopy, colonoscopy, laparotomy). To evaluate the effectiveness of conservative treatment at different age groups and at different terms of disease duration, two comparable trials were performed: 1 – stratification of patients by age: main group (n=130) - children older than one year, comparison group (n=30) – children younger than one year; 2 – stratification of patients by disease duration: main group (n=107) – more than 12 hours, comparison group (n=53) – up to 12 hours. To assess outcomes, the following parameters were analyzed: HEC effectiveness and complications, incidence of early relapses after HEC, causes of HEC failure and relapses after HEC, frequency and surgical techniques applied for treating ICI.

Results. In the groups stratified by age, HEC effectiveness was 95.4% in the main group and 93.3% in the comparison group, p=0.216. Early relapses occurred in 10.3% in the main group and in 3.3% in the comparison group, p=0.128. In the groups stratified by the disease duration, HEC effectiveness was 93.5% in the main group and 98.1% in the comparison group, p=0.204. Early relapses occurred in 10.3% (11) in the main group and in 11.3% (6) of cases in the comparison group, p=0.841. There were no any complications during HEC procedure. Basic reasons for the conservative treatment failure were anatomical ones; for relapses – lymphoid hyperplasia of the abdominal cavity and anatomical reasons. Thus, HEC was effective in 95% of cases; relapses after HEC amounted up to 10.6%. Surgical interventions ( in 15.6%) were started with laparoscopy; laparoscopic disinvagination was effective in 68% of cases. Colonoscopy after successful laparoscopic disinvagination was performed in 5.6%, conversion to laparotomy was in 5% of the total number of observations.

Conclusion. HEC is a highly effective and safe option for HEC conservative management in children regardless of child’s age and disease duration. Indications for surgical treatment for uncomplicated ICI are hydrostatic disinvagination failure and disease relapse.

Introduction. Activation of the hemostatic system in the ischemia-reperfusion syndrome is a risk factor for thromboembolic complications during orthopedic surgical interventions associated with arterial tourniquet application. Therefore, it is relevant to find ways to mitigate reperfusion effects during such surgeries.

Purpose. To find out character and effects of conduction anesthesia at the thromboelastogram parameters in the ischemic limb reperfusion after removing a tourniquet during orthopedic surgeries in children.

Material and methods. The surgery which was performed in 20 patients from the traumatologic department in the City Children’s Clinical Emergency Hospital (Novosibirsk) required arterial tourniquet application. So, these patients were enrolled in the observational pilot study. The patients who had tourniquet application were distributed into two groups by the block randomization: Group 1 (n=10) – peripheric blockage; Group 2 (n=10) – no peripheric blockage. The basic technique used in the study was thromboelastography (TEG) with TEG5000 thromboelastograph (Haemonetics Corporation, USA). All patients had thromboelastography before tourniquet application (stage 1) and 5 minutes after its removal (stage 2). Main thromboelastogram parameters were assessed: R, measuring pathways for coagulation phases I and II; K – time, characterizing coagulation phase III; angle α, duplicating the information of “K” indicator; MA is the maximum amplitude of TEG branch divergence, characterizing the clot density which, in turn, depends on the function of platelet activity and on the amount of fibrinogen; LY30 is the percentage of clot lysed in 30 minutes.

Results. In the group with regional anesthesia, indicators R, K, angle α, MA did not change at stage II; LY30 index decreased at stage 2. In the group without regional anesthesia, but with powerful central analgesic, indicators R, K, MA decreased, and angle α and LY30 increased at stage 2.

Conclusion. In pediatric orthopedic surgeries with arterial tourniquet application , local anesthetic (Ropivacaine) in the conduction anesthesia technique prevented activation of the hemostastic system.

Introduction. The lack of unified therapeutic and diagnostic protocol for managing children with relapsed obstruction of the pyeloureteral segment after ureteropyeloplasty has stimulated us to make a systematic review with meta-analysis on publications that studied indications and effectiveness of resection and endopyelotomic techniques.

Material and methods. Primary selection found 276 and 1470 sources in PubMed and Google Scholar database. After reviewing them, five publications were taken for the analysis. The design of the articles was consistent with cohort studies.

Results. The total number of patients with recurrent hydronephrosis was 156. All patients included in the review were children aged from 0 to 18 years. The present trial compared the effectiveness of resection and endopyelotomic techniques in treating recurrent hydronephrosis in children. When evaluating fixed effects in the model, the resection techniques showed a statistically significant increase in the weighted average risk of favorable outcomes by 68% (p = 0.001). The average follow-up period of patients after endopyelotomies was 36.6 months, and after resection pyeloplasty – 45.3 months. While analyzing complications, the majority of them predominated in the resection techniques. However, while performing the meta-analysis, this parameter turned out to be statistically insignificant (p = 0.55).

Conclusion. The results obtained emphasize high effectiveness of resection techniques as a method for treating recurrent hydronephrosis in children; however, due to high heterogeneity of studies and due to the risk of publication bias, this systematic review requires inclusion of more studies with detailed characteristics of patients and static justification of curative modalities.

Introduction. The congenital absence of nerve ganglia in the intermuscular and submucosal nerve plexuses of the colon in Hirschsprung’s disease leads to impaired motility and the risk of intestinal obstruction. Most often, Hirschsprung’s disease diagnosis is put in the neonatal period or in early childhood. Rare cases of late diagnostics may be associated with a blurred clinical picture, as well as with delay in histological verification of aganglionosis.

Clinical observation. This clinical observation describes a case of 17-year-old patient who was admitted to the surgical department with complaints on the lack of independent stool, a large fecal stone, abdominal pain. The patient could not have the self-emptying stool since her birth. Conservative therapy had only a partial positive effect. Irrigography findings caused a suspicion on agangliosis pathology of the rectosigmoid colon; however, histological verification of the diagnosis has never been made. Immunohistochemical examination of bioptats of the rectal mucous for calretinin had confirmed the Hirschsprung’s disease, and the first stage of surgical treatment was performed – resection of the sigmoid colon section with a fecal stone and descendostomy formation. Radical surgery was postponed because of patient’s pregnancy.

Conclusion. Late diagnosis of Hirschsprung’s disease is still a problem even in classical forms of the disease. It is important to be alert in older children and adults with a history of long-lasting constipation. Morphological examination of the neural ganglia of the colon is a key point in verifying the diagnosis.

Introduction. The present research is a case series of laparoscopic treatment of pyeloureteral obstruction in 3 patients with a horseshoe kidney.

Material and methods. Laparoscopic treatment of hydronephrosis in three patients with the horseshoe kidney was performed by one surgeon (2 boys, 1 girl). Preoperative computed tomography confirmed the diagnosis and found a source of hydronephrosis – obstruction of the pyeloureteral segment. At laparoscopy, the horseshoe kidney anatomy was finally defined and the cause of the obstruction of the pyeloureteral segment was found too - high ureteral transposition from the pelvis or an aberrant vessel. Pyeloplasty performed by Anderson-Hynes technique was a final stage of the treatment.

Results. The lesion of the left kidney half was noted in 2 cases, of the right one – in 1 case. All three interventions were successfully performed laparoscopically without conversion to open surgery. Duration of surgical intervention varied from 60 to 90 minutes. Mean operative time was 75.0±15.0 min (median – 75.0 [67.5; 82.5] min). Average stay in ICU was 19.3±4.2 hours (median – 18.0 [17.0; 21.0] hours) with the longest interval being 24 hours in a younger patient due to tracheal decannulation problems .

The anteroposterior diameter of the pelvis was measured before surgery and 6 months after surgery. It was found that all patients had reduction in the pelvis size in average from 43.3±11.5 mm to 8.0±2.0 mm (median – 50.0 [40.0; 50.0] mm and 8.0 [7.0; 9.0] mm, respectively). Patients also showed a positive trend in the restoration of blood flow in the affected segment of the kidney. Resistance index changes were in averaged from 0.70±0.02 to 0.62±0.02 (median – 0.71 [0.70; 0.72] and 0.62 [0.61; 0.63], respectively).

Conclusion. Surgical treatment of hydronephrosis in patients with the horseshoe kidney is a complex problem, mainly because of the altered renal anatomy and variety of triggers that may cause hydronephrosis. Laparoscopic pyeloplasty is obviously a universal way to treat the discussed pathology.

Introduction. Bacterial brain abscesses and subdural empyema are often rare complications of rhinosinusitis, which is especially important in pediatric practice. Intracranial purulent clusters are life-threatening diseases which require urgent, and as a rule, surgical management.

Purpose. To illustrate successful surgical treatment of a patient with multiple bilateral brain abscesses and subdural empyemas as a result of purulent inflammation - paranasal sinusitis, which had not been diagnosed at the prehospital stage.

Material and methods. A case of a 6-year-old boy with multiple bilateral brain abscesses and subdural empyemas is described in the article. The patient had antibacterial therapy; paranasal sinuses were sanitized; all intracranial purulent foci were removed with minimally invasive approaches and accurate calculations based on findings of MRI examination.

Results. It had been confirmed that abscesses and subdural empyemas in the described patient was a complication of purulent inflammation in paranasal sinuses. To control treated foci and to exclude development of new purulent intracranial clusters in dynamics, multiple MRI examinations of the brain were performed. For successful management of purulent foci, the technique of incision, drainage, sanitation with antiseptic solutions and intraoperative exudate aspiration was applied.

Conclusion. Abscesses and empyemas of children’s brain are serious, life-threatening pathologies that always require hospitalization and emergency measures. Multiple abscesses and subdural empyemas is, as a rule, complication of rhinosinusitis. Multiple dynamic CT/MRI examinations of the brain is of a key importance, both for controlling removed foci and for excluding development of new purulent intracranial clusters. Active surgical tactics in the combination with antibacterial therapy leads to successful outcomes in patients with intracranial purulent lesions complicating the course of rhinosinusites.

Introduction. Skin aplasia is a developmental defect represented by a skin defect of varying extent, often in combination with the defect of underlying tissues – subcutaneous fat, muscles and with various forms of dysraphy - non-closured embryonic slits. By various authors, defect frequency ranges from 1 per 1 000 to 1 per 10 000 newborns. Congenital focal aplasia of the skin and subcutaneous tissues can be located in limited areas; most often it is diagnosed on the scalp looking like single or multiple focal skin defects. Quite often, focal aplasia also affects the skin on the trunk and limbs.

Description of observation. The article presents a clinical case of congenital focal aplasia of the scalp and skull bones in a newborn child. This type of skin congenital aplasia by I. Frieden classification corresponds to Group I of congenital aplasia of the skin with lesions on the scalp. At the expert examination with multispiral computed tomography, the absence of parietal bone was diagnosed. So, the defect bottom was dura mater. In this case, the authors considered conservative approach to be unacceptable because of long period of healing and high risk of secondary infection. The performed surgery has led to a satisfactory cosmetic result. The state of bone structures was assessed catamnetically.

Conclusion. Modern diagnostic techniques have proven that an active surgical tactics in children with congenital aplasia of the scalp is justified.