Vol 10, No 1 (2020)

EDITORIAL

Diseases of the gallbladder in children — modern view of pediatric surgeon (systematic review)

Peter S., Kozlov Y.A.

Abstract

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.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(1):7-16
pages 7-16 views

ОРИГИНАЛЬНЫЕ ИССЛЕДОВАНИЯ

Cystic form of biliary atresia. Treatment experience

Borisova I.I., Kagan A.V., Karavaeva S.A., Kotin A.N.

Abstract

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.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(1):17-24
pages 17-24 views

Effectiveness of endoscopic treatment of duplex system ureteroceles in children

Dubrov V.I., Strotsky A.V., Shkutov A.O.

Abstract

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.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(1):25-34
pages 25-34 views

Gastric duplication cyst with localization in the pancreas in children

Sokolov Y.Y., Efremenkov A.M., Zykin A.P., Tumanova E.L., Omarova Z.R., Antonov D.V., Akhmatov R.A.

Abstract

Introduction. Gastric duplication cyst is a rare clinical observation. More often, these cysts are localized in the fundus or body of the stomach and have a common muscle layers and blood supply. Even more rarely, duplication cysts are not anatomically connected to the stomach and are located in other parts of the abdominal cavity or in the retroperitoneal space. Cystic duplication of the gastrointestinal tract, which are localized in the pancreas, is extremely rare.

The aim of the study is to demonstrate the possibility of using laparoscopy for this disease.

Materials and methods. The paper describes three rare clinical observations of gastric duplication cyst topographically associated with the pancreas. In the first clinical observation, gastric duplication cyst was combined with mediastinal duplication cysts, an esophageal bronchial fistula, and extralobar pulmonary sequestrations. In the second observation, a duplication cyst had communication with the pancreatic duct system and was clinically manifested by recurrent bleeding. In the third case, a duplication cyst is diagnosed behind the body and tail of the pancreas.

Results. In all cases, surgical treatment was carried out by the laparoscopic method, leading to complete recovery. Histological examination in all the described observations confirmed the gastric type of epithelium of the mucous membrane of the cysts. The article provides a review of the literature.

Conclusion. Thus, the efficiency of laparoscopic interventions in children with gastric duplications topographically associated with the pancreas was demonstrated. The described rare clinical manifestations, a combination of defects, as well as the possible presence of heterotopy of the mucous membrane of the duplication cyst confirm the need for surgical correction of the disease.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(1):35-42
pages 35-42 views

Sacrococcygeal teratomas in newborns: peculiarities in diagnostics and treatment of small-sized tumors

Gopienko M.A., Karavaeva S.A., Silkov V.B., Uskov O.I., Miagkova I.E., Belogurova M.B.

Abstract

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.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(1):43-52
pages 43-52 views

Unligature method of laparoscopic appendectomy in children

Svarich V.G., Perevozchikov E.G., Kagantsov I.M.

Abstract

Aim. On the basis of the accumulated clinical material to show the possibility of a ligature-free method of laparoscopic appendectomy in children.

Materials and methods. From 2000 to 2019, 2044 children with acute appendicitis were treated in the surgical department of the Republican children’s clinical hospital in Syktyvkar. Of these, 651 patients had an open appendectomy with treatment of the stump of the vermiform process by the submersible method, 1363 children had a laparoscopic appendectomy with ligature treatment of the stump of the process, and 32 patients had their first non-ligature laparoscopic appendectomy with the intersection of the vermiform process with the Ligasure device.

Results. On average, surgery for ligature-free laparoscopic appendectomy lasted 7 ± 3 minutes less than for laparoscopic appendectomy using the ligature method for treating the stump of the worm-like process. Experimentally, it was found that this method of appendectomy should not be used when the thickness of the worm-like process is more than 1.5 cm, with pronounced inflammatory infiltration of the caecum dome and perforation at the base of the process. With ligature-free appendectomy, the operation time was reduced. In the period from 1 to 6 months, there were no intra-abdominal postoperative complications associated with the new method of surgery.

Conclusion. Ligar-free laparoscopic appendectomy in children using modern high-energy platforms with a digital assessment of the degree of tissue coagulation readiness made it possible to avoid intraoperative and postoperative complications, simplify the technique of its implementation, and reduce the time of surgery.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(1):53-58
pages 53-58 views

Influence of fluid overload in the post-operative period in newborns on the development of acute renal injury and duration of ICU stay

Zolotareva L.S., Khorev V.V., Makulova A.I., Stepanenko S.M., Zil’bert E.V., Svetlichnaya T.O.

Abstract

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 2nd postoperative day. A fluid overload of more than 5%, observed on the 1st 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 2nd 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 2nd day after surgery may lead to an increase in the incidence of AKI. Liquid overload more then 5% on the 1st 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.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(1):59-68
pages 59-68 views

EXCHANGE OF EXPERIENCE

Turning of the uterine appendices in children

Okunev N.A., Okuneva A.I., Begoulova E.G., Kuptsova S.V., Kotelnikova A.V., Podshivalova I.A.

Abstract

Purpose. To analyze the clinical picture of the disease, diagnostic criteria and treatment tactics for girls with torsion of the uterus for 2016–2018 in the Children’s Republican Clinical Hospital in Saransk.

Materials and methods of the research: the study included 16 girls who were examined and treated at the state budgetary health institution of the Republic of Mordovia, the Saransk Children’s Republican Clinical Hospital.

Results. The largest number of torsions was found in patients aged 8 to 12 years. In 69% of cases, girls with this pathology lived in the city, 31% in rural areas. In the first 12 hours from the onset of the disease, most patients, namely 9 patients who were worried about nausea, vomiting, fever, pain on the side of the lesion, came to the emergency room. On examination, 5 patients showed a positive symptom of peritoneal irritation, in 2 it was doubtful, and in 6 negative. During the diagnosis, it was revealed that the right appendage is affected more often than the left. The possibility of preserving obviously unviable uterine appendages on the basis of ultrasound and intraoperative data is described, as well as further tactics of conservative management of girls with torsions are presented.

Conclusion. Removal of the uterine appendages was performed in cases of congenital torsions with necrosis, torsions with anomalies of development and necrosis of the appendages, as well as with a duration of torsion and necrosis of more than 5 days. In other cases, even with severe signs of malnutrition, organ-preserving operations were performed

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(1):69-74
pages 69-74 views

OBSERVATIONS FROM PRACTICE

Tubular subtotal form of the small intestinal doublication

Pisklakov A.V., Fedorov D.A., Moroz S.V., Ponomarev V.I., Lysov A.V., Lubavina A.E.

Abstract

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.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(1):75-80
pages 75-80 views

Results of operative treatment of omphalocele with an additional lobe of the liver, and pyloric stenosis

Shchukina A.A., Mokrushina O.G., Gurskaya A.S., Dyakonova E.Y., Akhmedova D.M.

Abstract

Purpose. Presentation of clinical cases of rare combination of omphalocele with pylorostenosis in the postoperative period and additional liver lobe.

Materials and methods. In National Medical Research Center for Children’s Health of health surgical ward of newborns and infants for the 2019 us operated 2 children who performed surgery involving intra-operative decision making about further surgical tactics.

Results. the results of surgical treatment of newborns with omphalocele combined with hypertrophic pylorostenosis and extra liver lobe are presented.

Conclusions. In patients with malformations of the anterior abdominal wall in the postoperative period, when regurgitation syndrome appears, it is necessary to make a differential diagnosis between the functional and organic causes of obstruction. When confirming the organic nature of the obstruction, surgical intervention is indicated. It is necessary to be able to timely and objectively assess the risks and expediency of the approach when choosing surgical tactics in each individual case.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(1):81-88
pages 81-88 views

Syndrome of complete insensitivity to androgens of the 4-years-old child

Gavrilyuk V.P., Kostin S.V., Statina M.I., Severinov D.A., Ageeva E.O.

Abstract

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.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(1):89-94
pages 89-94 views

Infradiaphragmatic extralobar pulmonary sequestration asossiated with duplication cyst of the gaster in newborn

Krivosheenko N.V., Gramzin A.V., Pavlushin P.M., Manakova Y.L., Shpak L.M., Koinov Y.Y., Chikinev Y.V.

Abstract

Introduction. The biggest difficulties of pulmonary sequestration treatment appear when they are combined with other congenital malformations.

Materials and methods. This article describes a rare case of combination of infradiaphragmatic extralobar sequestration of the lung and duplication cyst of the gaster. The antenatal ultrasound investigation at 21 week of gestation visualized a retroperitoneal mass that had a cystic-solid structure and a vessel that departed directly from the aorta. CT-scan that was performed after the birth, confirmed an existence of infradiaphragmatic cystic mass that had a vessel that departed directly from the aorta. We couldn’t exclude the neoplastic process because of structure and topography of mass. Tumor markers were without pathology. Surgical treatment was performed: laparotomy and removal of the cyst and extrapulmonary sequestration. The histological investigation confirmed a pulmonary sequestrum and duplication cyst of the gaster.

Conclusion. A nowadays method of visualization allows to find congenital malformation in earliest stages of gestation. The tradition surgical treatment and also minimal invasive surgical treatment are the main option of cure such congenital malformations. Also literature review of rare clinical forms of pulmonary sequestration presented in this article.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(1):95-102
pages 95-102 views

REVIEW OF LITERATURE

Sedation and analgesia during manipulation in children

Aleksandrovich Y.S., Pshenisnov K.V., Aleksandrovich I.V.

Abstract

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.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(1):103-112
pages 103-112 views

ANNOUNCEMENT OF SCIENTIFIC EVENTS

International congress of pediatric surgeons on lake Baikal

Petlakh V.I.

Abstract

Information from the upcoming congress of pediatric surgeons.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(1):113-113
pages 113-113 views

ANNIVERSARIES

Our anniversaries

Gorbachev O.S.

Abstract

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

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(1):114-116
pages 114-116 views

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