Vol 10, No 1 (2020)

Currently, the two main causes of diseases of the gallbladder in children are biliary dyskinesia and the formation of gallbladder stones. Biliary dyskinesia is an independent disease and is caused mainly by reduced motility of the gallbladder, which leads to its insufficiently good emptying and is accompanied by chronic pain abdominal syndrome. The causes of stone formation in children differ from the sources of stone formation in adults. Metabolic disorders, mainly against the background of obesity, lead to the formation of cholesterol stones, which is the most common cause of cholelithiasis in children. Blood diseases is another factor of cholelithiasis associated with hemolysis, such as sickle cell anemia, hereditary spherocytosis, and thalassemia. Symptoms of gallbladder disease are mainly in chronic abdominal pain syndrome. Inflammation of the gallbladder is a fairly rare form of the course of gallstone disease in children. The current surgical technology for treatment of gallbladder diseases in children, as in adults, is cholecystectomy, which can be realized depending on the degree of mastery of endosurgical skills using standard four-port laparoscopic techniques or a single laparoscopic approach. This review addresses the issues of semiotics, etiology, diagnosis, and surgical treatment of gallbladder disease in pediatric patients. The scientific work answers many controversial questions regarding the diagnosis of biliary dyskinesia, the choice of diagnostic method for concomitant choledocholithiasis, and the selection of the most effective surgical approach.

Duplication of the gastrointestinal tract is a relatively rare malformation. The incidence is approximately 1 in 10 000 live births with the small intestinal duplication in most cases. Malformations with a long duplication part are considered technically complex. A successfully treated clinical case of the subtotal small intestinal duplication in a child is presented in the article. The mid-median mini-laparotomy was performed and a subtotal 1 meter length small intestinal duplication was revealed (from the Treitz’s ligament to the ileum in 50 cm from the ileocolic valve). The proximal part of the intestinal duplication and its mucous membrane of the distal part with the common wall were completely removed. Histological examination found ectopia of the gastric mucosa and pancreatic tissue. Surgical treatment of this malformation is aimed at the complete removal of the duplication part due to possible ectopia of the gastric mucosa or pancreatic tissue. If the resection of an entire part of the intestinal duplication is technically impossible, the mucous membrane can be removed.

To demonstrate an interesting and rare case in the clinical practice of testicular feminization syndrome in a child, as an accidental finding when performing a planned surgical intervention. A mother with a child E., born in 2010 (at the time the child was 4 years old) was hospitalized with the mother’s complaints about the presence of protrusions in both inguinal areas from birth, the mother denied cases of infringement. The child was examined on an outpatient basis and the next day a scheduled surgical intervention was prescribed — hernia repair on both sides. At the opening of the hernial sac on the right, the contents were the testicle, 1.6 × 1.6 × 1.0 cm in size, with an appendage and vas deferens. Then an opening of the hernial sac was performed on the left, the contents of the hernial sac was also a testicle measuring 1.8 × 1.2 × 1.0 cm with an appendage and d. deference. Examination was performed: on an ultrasound of the pelvic organs — the bladder is full, the effusion in the pelvis is up to 12–15 mm high, the uterus and ovaries are not located at the time of the examination. In the abdominal cavity (in the iliac regions), ovarian testicles with mediastinum are located on both sides — 19 × 11 mm on the right, 16 × 10 mm on the left. The clinical case that we have provided will be of interest to pediatric surgeons and geneticists in view of the unusual and complex clinical diagnosis of this condition. In the presence of a female phenotype, the child completely lacked the organs of the female reproductive system, this disease was detected only due to the presence of a concomitant pathology in the child, a bilateral inguinal hernia. The early diagnosis of STF is especially important given the risk of malignancy of the gonads in the post-pubertal period.

Information from the upcoming congress of pediatric surgeons.

Description of the professional activities and merits of pediatric surgeons, celebrating their anniversaries.

Background. The cystic form of biliary atresia is a rare form of atresia of the biliary tract, which is a relatively favorable variant of the defect and can be diagnosed antenatally. In practice, it is important not only to suspect this diagnosis, but also to differentiate this variant of impaired development of the external bile duct from the cyst of the common bile duct. This is due to the difference in approaches and methods of surgical treatment of choledochal cysts and biliary atresia. Obliteration (atresia) of the bile ducts in the absence of timely surgical intervention quickly leads to the progression of cirrhosis and the development of liver failure. The method of choice in the treatment of AD is Kasai surgery, often palliative in nature, but allowing to delay the time until liver transplantation. The cyst of the common bile duct rarely requires early surgical treatment, and the risk of cirrhosis is significantly lower. Surgical intervention is aimed at removing the cyst and restoring the flow of bile by anastomosing the external bile ducts with the intestines, which is a radical method of treatment and leads to the recovery of the child. External similarity in ultrasound examination of the fetus and newborn baby of the cystic form of biliary atresia of the bile ducts with a cyst of the common bile duct does not always allow differentiation of one defect from another, which can lead to untimely correction of the defect and an unfavorable outcome.

Aim. Demonstrate a rare type of biliary atresia.

Materials and methods. Between 2001 and 2019, 33 patients with biliary atresia were treated in the Children’s City Multidisciplinary Clinical Specialized Center for High Medical Technologies in St. Petersburg, only two patients had a cystic form. Both children were initially treated as patients with bile duct cyst. Children were operated on at the age of 2 and 3.5 months. The first patient underwent surgery Kasai, the second — hepaticoyunoanastomosis.

Results. During the observation period (9 years and 4 years), the synthetic function of the liver is normal, and there are currently no indications for transplantation.

Conclusion. If a fetus or a newborn with neonatal jaundice is detected during ultrasound examination of a cystic formation in the gates of the liver, it is very important to correctly and quickly make a differential diagnosis between the cystic form of biliary atresia of the biliary tract and the common bile duct cyst.

Objective. The aim of this study is to evaluate the efficiency of transurethral incision of ureteroceles and incidence of vesicoureteral reflux in pediatric patients with duplex system ureterocele.

Materials and methods. This is a retrospective study of 155 pediatric patients with duplex system ureterocele. The age of patients at the time of surgery ranged from 5 days to 17 years (median — 8.0 months). Intravesical ureterocele had 108 patients (69.8%), extravesical — 47 (30.2%).

Results. Complications occurred in 2 patients (1.3%), recurrence obstruction was in 1 case (0.6%). Ipsilateral vesicoureteral reflux after surgery had 112 patients (72.3%): in the upper pole — 51 cases (32.9%), in the lower pole — 32 (20.6%), in both ureters — 29 (18.7%). In the long-term period after transurethral incision of ureteroceles 97 patients (62.5%) needed reoperation due to infection and voiding dysfunction. Statistically significant risk factors associated with the need for reoperation were the presence of vesicoureteral reflux on the ureteroceles side and non-functioning upper pole of the kidney.

Conclusion. Transurethral incision of ureteroceles for duplex system ureterocele is a safe and effective minimally invasive method of primary resolving of the obstruction. Vesicoureteral reflux on the ureterocele side after surgery had 72.3% of patients; reoperation in the long term was necessary in 62.5% cases. The main risk factor reoperation is vesicoureteral reflux on the ureterocele side.

Introduction. When revealing a sacrococcygeal tumor in pediatric patient (especially — newborn), a germ-cell tumor (GCT) (mostly — teratoma) should be suspected. Just observation in cases of such tumors of small size, which might look as an option, cannot be recommended.

Aim of study: to reveal the peculiarities of diagnostics and treatment of small-sized sacrococcygeal GCT in newborns.

Materials and methods. We analyzed the data of charts of patients with sacrococcygeal GCT from 2 clinics of St. Petersburg (pediatric surgical hospital CCMCSCHMT and pediatric oncological department of St. Petersburg Oncocenter) for past 15 years (2005–2019). Among 55 newborn patients the size of tumor varied, comprising 14 giant (over 14 cm in diameter), 18 large (10–14 сm in diameter), 21 medium-sized (3–9 cm), and 2 small-sized teratomas (under 3 cm in diameter).

Results. In both cases of small-sized GCT prenatal ultrasound was unable to reveal the tumor. Those patients appeared by surgeon occasionally (being either not transferred to hospital from the delivery house after birth or coming because of some other reason). Both patients underwent radical surgery with excision of coccyx (histological diagnosis being ‘mature teratoma’) and are still under observation of oncologist (with no signs of relapse during 6 months and 21 months). During the same period (2005–2019) there were 5 girls treated in St. Petersburg Oncocenter, with sacrococcygeal GCT first diagnosed at older age (10 months – 2 years 9 months). They all had less favorite course and prognosis (histologic variants being yolk sac tumor or embryonic carcinoma; having remote metastases in 2 cases, with relapse in 1 case, and lethal outcomes in 2 cases).

Conclusion. Small-sized sacrococcygeal GCT in newborns can bear a significant risk of delayed diagnosis with possible further malignization and formation of metastases, so active revealing and active surgical treatment in such cases is needed.

Aim. To identify the relationship between fluid overload in children who received infusion therapy in the postoperative period at surgical intensive care unit (ICU), the development of acute kidney injury (AKI), and the length of ICU stay.

Methods. A retrospective cohort observational study was conducted. Our study includes 75 newborns with malformations of the gastrointestinal tract, diaphragmatic hernias, gastroschisis, necrotizing enterocolitis and sacrococcygeal teratomas treated after surgery in the ICU. The Kidney Disease: Improving Global Outcomes (nKDIGO) scale was used to detect AKI. To assess the fluid overload, the ratio of the difference between the introduced and released liquid and entering the ICU weight was used (in %). Significant overload was adopted value more than 5%. The indicator “injected fluid” consisted of the volume of infusion and enteral nutrition. The indicator of “released fluid” included diuresis, fluid loss from the gastrointestinal tract, intestinal stomas, and drainages.

Results. The frequency of AKI was 28.0% (21 of 75). The average time of AKI development from the moment of surgical intervention was 5.9 ± 3.29 days. The duration of ICU stay after surgery was 8.0 [5.0; 16.0] days. In 18 of 75 (24%) children, the fluid overload of more than 5% was observed on the 1st postoperative day. In 12 out of 75 (16%) children, the fluid overload of more than 5% was observed on the 2^nd postoperative day. A fluid overload of more than 5%, observed on the 1^st day after the operation, was associated with a longer ICU stay. The rate of AKI is higher when a fluid overload of more than 5% on the 2^nd day after surgery was observed.

Conclusion. Severe fluid overload can be a significant factor of the AKI development. Fluid overload more then 5% on the 2^nd day after surgery may lead to an increase in the incidence of AKI. Liquid overload more then 5% on the 1^st day after surgery may lead to an increase in the length of ICU stay. In newborns, it is necessary to take into account the fluid load at the first two days after the operation and correct the infusion therapy in case of fluid overload detection.

The article provides an overview of modern methods of sedation and analgesia during therapeutic and diagnostic manipulations in children, indicates indications and contraindications. Special attention is paid to the assessment of sedation and anaesthesia effectiveness, scales used for this purpose in children of different ages are described, criteria of sedation depth are given, equipment and measures necessary to ensure patient safety during manipulation are described. It has been noted that BIS index values correlate with sedation scales in children and adults, but values that determine deep sedation in children are currently not clearly defined, which requires further research. Drugs for sedation, their main characteristics and limitations for use are presented. The differences between sedation and monitored anesthesiology care (MAC), which can be provided only by a qualified anesthesiologist, are described in detail. It has been demonstrated that monitored anesthesiologic care implies deep sedation with control of vital functions, control of breathing and hemodynamics during manipulation, and it is noted that capnography is a mandatory element of monitoring in this type of anesthesiologic care in order to detect apnea as early as possible. Criteria for recovery of consciousness after completion of sedation are specified, which include normal airway, adequate ventilation, stability of hemodynamic, restoration of initial level of consciousness, motor activity and possibility to receive liquids through mouth in absence of vomiting. It is noted that the average time from the end of procedural sedation to the restoration of the original state is about 2 hours.