PAEDIATRIC SURGERY. UKRAINE

The clinical case of diagnosis and treatment of the ovarian teratoblastoma in a child

О.М. Kulyk — 2024-03-28

Aim: to demonstrate the possibilities of surgical treatment of the child with teratoblastoma at the early stage of detection.

Clinical case. The article presents an experience of treatment a child with ovarian teratoblastoma. The anamnesis of the disease was studied. The child has been examined by laboratory (general blood test, biochemical blood test, alpha-fetoprotein, ovarian tumor marker) and instrumental methods (ultrasound diagnostics of internal organs and organs of the lesser pelvis, computer tomography of the organs of lesser pelvis). The patient was consulted by a pediatric gynecologist, urologist and oncologist. Taking into account the results of the study, surgical treatment was prescribed: biopsy of the tumor-like formation and ovaries. Ovarian cystectomy, unilateral operation. A multidisciplinary team was involved in the treatment.

The child recovered. Additional treatment is not required. The observation of the pediatric oncologist is recommended.

Conclusion. The described clinical case demonstrates the experience of treatment a child with teratoblastoma, which is a rare pathology in childhood and that needs to be remembered. Proper preoperative examination forms the tactic of the treatment. Intraoperative staging is a mandatory component (peritoneal lavage, examination of the contralateral ovary, biopsy of suspicious lesions of the peritoneum and the omentum, revision of the regional lymph nodes). When performing all protocol surveys and confirming the local process only surgical intervention without adjuvant chemotherapy is enough.

The research was carried out in accordance with the principles of the Declaration of Helsinki. The informed consent of the child's parents was obtained for conducting the studies.

No conflict of interests was declared by the authors.

Clinical case report: late correction of cleft palate in an 11-year-old boy with bilateral cleft lip and palate

O.B. Leshnevskyy — 2024-03-28

Clefts of the lip and palate remain one of the most common congenital malformations. Bilateral cleft is considered the most complex form of the defect. There is no consensus on the timing and method of surgical treatment. However, most publications focus on the two-stage method of defect closure and recommend complete correction by 24 months of age.

This clinical case deviates from the commonly accepted approach to treating children with bilateral clefts of the lip and palate. The patient sought medical help at a late age, specifically at 11 years old, due to a number of subjective and objective reasons.

The aim - based on a clinical case, analyze the timely and qualitative provision of medical care, the difference in the quality of life before and after surgical intervention in patients with the described pathology.

The first stage was performed at the age of 2 years. After preoperative preparation, including antibiotic therapy guided by throat swabs, the patient underwent a series of surgical procedures, including complete dissection of soft palate muscles, intravelar veloplasty, formation of a Vomer flap, and meticulous closure of the palate defect layer by layer. One month after the surgery, the patient exhibited soft palate movements (which were absent before surgery), improved feeding, and continued speech therapy sessions, resulting in significantly improved pronunciation.

Analysis of this clinical case will contribute to a better understanding of the approach to treating children with bilateral clefts of the lip and palate. Timely referral of patients for comprehensive treatment, including surgical correction, subsequent orthodontic treatment, speech therapy sessions, possible psychological rehabilitation, and so on, is crucial in children with bilateral clefts of the lip and palate.

The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies.

No conflict of interests was declared by the authors.

Chronic intestinal pseudo-obstruction in children (review)

A.A. Pereyaslov — 2024-03-28

Hirschsprung disease and chronic intestinal pseudo-obstruction (CIPO) in children are the most common and severe disorders of gastro-intestinal tract motility. While the problems connected with the Hirschsprung disease widely coverage in native literature, the publications that devoted the CIPO absent.

Aim of the study was to analyze the literature data that devoted to the diagnosis and treatment of children with CIPO.

Intestinal pseudo-obstruction refers to heterogeneous groups of disorders with a similar phenotypic presentation characterized by obstructive intestinal symptoms in the absence of true anatomical obstruction. CIPO classification based on the primary dysfunction: affected enteral nervous system (neuropathy), affected smooth muscle (myopathy) or interstitial cells Cajal (mesenchymopathy). Besides that, the intestinal pseudo-obstruction is divided into primary and secondary, congenital and acquired, total and segmentary.

The main clinical features, methods of investigation in suspected CIPO such as radiological (roentgenography and roentgenoscopy, computed tomography, cine magnetic resonance), endoscopic, manometry, pathohistological, etc. were listed.

The main principles of nutrition support, conventional therapy, and surgical management were presented.

Conclusions. CIPO is a severe disorder of gastrointestinal motility that caused by various factors, which can be congenital and/or acquired. Diagnosis of CIPO based on the results of clinical, instrumental, and pathohistological investigation. The management of children with CIPO should include nutritional support, conventional therapy, and, for the clear indices, surgical correction.

No conflict of interests was declared by the authors.

Evolution of views on the functional anatomy of the vesicoureteral segment and etiopathogenetic features of vesicoureteral reflux in children

A.A. Savitska — 2024-03-28

Bladder-ureteral reflux is a pathological condition in which there is a periodic and/or permanent retrograde flow of urine from the bladder into the urinary tract due to a malfunction of the anti-reflux mechanism of the vesicoureteral segment.

The aim - to study etio-pathological mechanisms of vesicoureteral reflux in children to improve diagnostic and therapeutic tactics.

Every year in Ukraine, 3,600-3,700 children with congenital defects of the urinary tract are diagnosed, with 1/3 of the defects occurring in their upper parts. According to statistics, there are 40-50 cases of congenital diseases of the urinary system per 1000 newborns. There are reports that the frequency of vesicoureteral reflux in the general pediatric population exceeds 2%. According to modern data, vesicoureteral reflux accounts for 0.1% to 1.0% of all pathology in the general pediatric population, accounting for 10% of all diseases of the urinary system in hospitalized children. Bladder-ureter is the initial link in the chain of pathological reflux in the urinary tract. The leading importance of the mechanism of the vesicoureteral reflux belongs to the study functional anatomy of the urinary tract as a whole. Bladder-ureteral reflux is most often detected during urination against the background of increased intravesical pressure, but it can occur during any of the stages of the urination cycle. Nephrosclerosis with vesicoureteral reflux is formed in 30-60% of cases, which leads to the development of the terminal stage of chronic renal failure in 25-60% of patients due to a decrease in the functional renal reserve, as an indicator of the compensatory capabilities of the kidneys.

Conclusions. Review of literature dataregarding the structure and functional anatomy of the vesicoureteral segment convincingly testifies to the complexity and multi-level organization of its antireflux mechanism. Therefore, any further research in this direction will undoubtedly contribute to a deeper understanding of the normal functioning of this complex anatomical part of the human urinary system, which will allow the development and implementation of the latest physiological treatment methods in the practice of pediatric surgeons.

No conflict of interests was declared by the authors.

Digital subtraction angiography of intrahepatic portal vein as the key visualization for mesoportal shunting in children with extrahepatic portal vein obstruction

O.S. Godik — 2024-03-28

Аn early consideration in pediatric patients with extrahepatic portal vein obstruction (EHPVO) is to be given for mesoportal shunt. A careful investigation is required to prove intrahepatic portal system patency. Conventional noninvasive imaging is not adequately reliable in assessing patency of the intrahepatic portal venous system. Retrograde portography in children brings additional invasive procedure. Antegrade, direct intraoperative digital subtraction angiography for mesoportal shunt feasibility assessment is poorly presented in literature.

Aim - to improve the rate of success of mesoportal shunting in children with EHPVO by analyzing our own experience in intraoperative digital subtraction angiography of the intrahepatic branches of the portal vein for the final assessment of the mesoportal shunting feasibility.

Materials and methods. 7 pediatric patients with EHPVO were selected for the study. Angiographies and surgeries in selected patients were performed within single center in a period from May 2022 to July 2023. Mean follow up of successful mesoportal shunting was 12.38±1.46 months.

Results. All patients were males. Men age at surgery was 8.71±1.72 years. 5 (71.4%) patients manifested bleeding episodes as the first sign of portal hypertension. In all patients ultrasound revealed splenomegaly and suspected portal hypertension for reduced volumetric portal flow. All 7 patients had high grade. Liver function was normal in all patients, and in none thrombophilia was confirmed. CT scans suspected patent left intrahepatic branch (Rex-zone). Digital subtraction angiography approved mesoportal shunt feasibility in 4 (57.1%) patients. The follow up period was 13.5±2.9 months.

Conclusions. Digital subtraction angiography of intrahepatic portal vein is effective visualization method to achieve with radiologic evidence of intrahepatic portal branches patency and make the decision on mesoportal shunting when favorable anatomy proved.

The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the participating institution. The informed consent of the patient was obtained for conducting the studies.

No conflict of interests was declared by the authors.

Clinical symptoms of colonic aganglionosis and its complications in children 3 to 6 years of age

V.P. Prytula — 2024-03-28

Clinical symptoms of colonic aganglionosis (CA) in children 3 to 6 years of age are difficult due to its clinical presentation which represents as the complications of this pathology, because of it the classic signs of Hirschsprung’s disease (HD) are partially eliminated or hidden, which makes it difficult for the effective diagnosis of this pathology in these children.

Purpose - to study the clinical symptoms of CA and its complications in children 3 to 6 years of age and to determine the significance of clinical symptoms for the verification of HD.

Materials and methods. We have done retrospective analysis of the clinical manifestations in 240 children 3 to 6 years of age with HD, considering the extent of CA, the presence of associated malformations and complications. There were 95 (39.58%) patients with the rectal form of CA, 143 (59.59%) with the rectosigmoid form, 2 (0.83%) with the subtotal form. There were no patients with total CA in this age group. There were 192 boys (80.0%), and 48 girls (20.0%). At the age of 3-4 years 71 (29.58%) patients were diagnosed with HD, at the age of 4-5 years - 79 (32.91%), and at the age of 5-6 years - 90 (37.51%) patients.

Results. The diagnosis of HD can be of course considered as late for patients from 3 to 6 years of age. We found associated malformations in 45 (18.75%) patients. Associated intestinal malformations were found in 26 (10.83%) patients, of which 19 (7.92%) had malformations that significantly increased the clinical symptoms of CA and its complications: malrotation (n=17 (7.08%)) and internal abdominal hernia (2 (0.83%)). Enterocolitis (EC) was found in 98 (40.83%) patients. The 1^st degree of EC was established in 9 (3.75%) children, 2^nd degree - in 34 (14.16%) and 3^rddegree - in 55 (22.91%) patients. Among these 55 with 3^rd degree of EC the critical moment in the progression of the course of EC was toxic megacolon (TM), which occurred in 14 (25.46%). Hypotrophy was established in 18 (7.49%) patients. Anemia of various degrees was diagnosed in 35 (14.58%) children. The acute stage of the course of HD was diagnosed in 98 (40.83%) patients, subacute - in 77 (32.08%) and chronic - in 65 (27.08%) children. The clinical course of HD was correlated with the extent of the colon affected with CA and is closely related to the presence of its complications: EC, anemia and hypotrophy.

Conclusions. Clinical symptoms of CA in children aged 3 to 6 years remains typical and informative upon careful evaluation of complaints, medical history, and objective and laboratory results. The severity of the course, associated developmental malformations and late diagnosis are the main reasons for the appearance of severe complications of HD in children 3 to 6 years of age - EC (40.83%), TM (25.46%), hypotrophy (7.49%) and anemia (14.58%). Variants of complications in CA are characteristic and predictable. Comparison of the clinical signs of CA and its complications contribute to the correct assessment of the patient's condition and timely establishment of the correct diagnosis.

The research was carried out in accordance with the principles of the Declaration of Helsinki. The research protocol was approved by the Local Ethics Committee of all institutions mentioned in the work. Informed consent of the children’s parents was obtained for the research.

No conflict of interests was declared by the authors.

Analysis of early morphological and functional perivulnar changes in the mucosa of the cecum after suturing with different surgical threads

S.M. Bilash — 2024-03-28

The correct choice of suture material is the key to successful treatment in abdominal surgery, particularly pediatric surgery. Given this, experimental studies on the effect of sutures made with different surgical threads are one of the most urgent surgery needs.

The aim - to conduct a comparative analysis of early morphological and functional changes in the perivulnar region of the mucosa of the rabbit cecum after suturing with polyglactin-910 and polycaprolactone modified with L-arginine.

Materials and methods. The study was conducted on 25 rabbits aged 8-10 months in compliance with all bioethical standards and recommendations. The control group consisted of 5 animals; the first experimental group, in which synthetic surgical polyfilamentous absorbable suture polyglactin-910 was used to close the wound defect, and the second experimental group, in which monofilamentous absorbable suture polycaprolactone modified with L-arginine was used to close the wound defect, consisted of 10 rabbits each. All stages of surgical access and sampling of intact cecal wall tissues were performed in the control group. The rabbits of the experimental groups underwent colotomy followed by suturing of the large intestine with appropriate suture material. Each experimental group was divided into two subgroups (5 rabbits in each), in which the condition of the perivulvar region was studied on days 3 and 7, respectively. The animals were not euthanised; during the second operation, tissues of the cecum were taken from the sutured area and the formed scar at the appropriate time. Histological, semi-thin serial sections, electron microscopic, morphometric, and statistical methods were used.

Discussion. The average thickness of the cecal mucosa after colotomy increased significantly on days 3-7 when using both surgical threads, but when using polycaprolactone modified with L-arginine, the above indicator was 63.06% and 22.46% lower, respectively, due to a decrease in hyperhydration of the connective tissue component of the mucosa, leukocyte infiltration in the perivulnar area and acceleration of reparative processes.

Conclusions. Polycaprolactone modified with L-arginine has a positive effect on the course of morphological and functional processes in the perivulnar region of the rabbit cecum's mucosa. In terms of its characteristics, it is not worse than polyglactin-910.

No conflict of interests was declared by the authors.

The effect of perioperative intravenous infusion of lidocaine on the quality of postoperative recovery after various types of surgical interventions in children

O.S. Goncharuk — 2024-03-28

Introduction. Early postoperative recovery in pediatric practice is an important problem for patients and the health care system as a whole.

Aim: to investigate the quality of postoperative recovery of children after various types of surgical interventions.

Materials and methods. The study involved 150 children who underwent trauma (group I), abdominal (group II) and urological (group III) surgical interventions. Each of these groups was divided into two subgroups: Іb (n=17), ІІb (n=19) and ІІІb (n=24) subgroups - included children who received intravenous lidocaine in the perioperative period, control Ia (n=23), IIa (n=29) and IIIa (n=38) subgroups - included children to whom lidocaine was not prescribed. The PaedQoR-15 questionnaire was used to assess the quality of postoperative recovery.

Results. The use of perioperative intravenous lidocaine infusion is associated with an increase, compared to the control group, in the PaedQoR-15 score by 10.6% at 24 hours after trauma surgical interventions, by 21.3% and by 17% after abdominal and urological surgical interventions due to a decrease in the frequency of postoperative nausea after abdominal surgery, skin itching after all analyzed types of surgical treatment, a reduction 26.7% reduction in the time until the first gas release and by 19.3% reduction in the time until the appearance of bowel movements/defecation after abdominal surgery. It was observed that the stay of patients in the intensive care unit (ICU) was reduced by 120 minutes after trauma surgery and by 1.8 times after abdominal surgery.

Conclusions. Perioperative lidocaine infusion may be useful in rapid postoperative rehabilitation programs.

The research was carried out in accordance with the principles of the Declaration of Helsinki. The study protocol was approved by the Local Ethics Committee of all participating institutions. The informed consent of parents and children was obtained for conducting the studies.

No conflict of interests was declared by the authors.

Dynamics of indicators of oxidant-antioxidant reactions in the postoperative period in patients with disseminated peritonitis

O.O. Bilyayeva — 2024-03-28

Purpose - to determine the effect of the developed treatment of patients with peritonitis on the dynamics of indicators of oxidant-antioxidant reactions and to justify the need for the use of the proposed drugs in the complex treatment of peritonitis.

Matherials and methods. The study included 124 patients with toxic and terminal stages of peritonitis, who were divided into 3 groups: the Group I included 39 patients in whose complex treatment we included cytochrome C; the Group II included 41 patients whose complex treatment included cytochrome C and a solution containing levocarnitine and arginine hydrochloride; the Comparison group included 44 patients in whom the specified drugs were not used. The content of diene conjugates, reactive oxygen species (ROS), S-nitrosothiols, superoxide dismutase (SOD), carbonyl groups, and sodium nitrite was determined in the patients. Statistical processing of the study results was performed using the Statistical software EZR v. 1.64.

Results. In patients of the Group I and the Group II, the use of the proposed treatment contributed to the optimization of oxidant-antioxidant reactions: a decrease in the production of diene conjugates, ROS, S-nitrosothiols, carbonyl groups, sodium nitrite during the study, optimization of SOD production, especially in the Group II. In patients of the Comparison group, decompensation in oxidant-antioxidant reactions was determined, associated with a significant increase in the production of diene conjugates, ROS, S-nitrosothiols and a decrease in SOD during the entire period. These trends developed against the background of an increase in the content of nitric oxide products and the activation of processes associated with the oxidative modification of blood plasma proteins.

Conclusions. The use of cytochrome C and a solution containing levocarnitine and arginine hydrochloride in the complex treatment of patients with disseminated peritonitis helps to optimize oxidant-antioxidant reactions, which leads to a decrease in the manifestations of inflammation.

The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of all participating institutions. The informed consent of the patient was obtained for conducting the studies.

No conflict of interests was declared by the authors.

Surgical treatment of congenital anorectal malformation with rectovesical fistula in boys

O.Р. Dzham — 2024-03-28

Congenital rectovesical fistula (RVF) is the most complex variant of anorectal malformations (ARM) in boys, characterized by a fistula connecting the rectum with the bladder.

Purpose - to evaluate the results of surgical correction of RVF in children, using a differentiated approach to the diagnosis of this defect, depending on the anatomical options, the clinical course of associated defects, and, based on this, to develop the main tactical requirements for the treatment of this complex congenital ARM in children.

Materials and methods. The study included 9 boys: 7 - RVF without pouch colon and 2 - RVF with congenital pouch colon, which accounted for 5.8% of all treated anorectal anomalies (n=154).

Results. In patients with RVF without pouch colon: a double-stem disconnecting colostomy was performed in 3 (33.3%) and a double-stem loop colostomy in 4 (44.4%) boys. In children with RVF and pouch colon: a longitudinal, narrowing, stapler coloplasty of the large intestinal "pouch" was performed, with removal of the terminal stoma (n=1); formation of a double-stem disconnecting stoma without separation of the RVF, and at the II stage - elimination of the RVF, removal of the large intestinal «bag» and preservation of the ileostomy - as a permanent, lifelong stoma (n=1). In 7 (100%) patients with RVF without pouch colon at the II stage, abdomino-perineal posterosagittal anorectoplasty with separation of RVF was performed (n=5). At the III stage, 5 patients with RVF without a pouch colon underwent local access stoma closure. At the stages of primary correction of RVF 55.6% (n=5) of children had coloproctological complications.

Conclusions. The use of a differentiated approach to diagnosis and methods of anorectoplasty, as well as the use of a complex of rehabilitation treatment in patients with RVF without a pouch colon made it possible to obtain good results in 50% and satisfactory results in 50% of children. Congenital pouch colon - a significant expansion of part or the entire colon already in the fetus, makes it possible to suspect and diagnose this defect in the prenatal period, and to carry out delivery and surgical correction in a specialized perinatal center.

The research was carried out in accordance with the principles of the Declaration of Helsinki. The research protocol was approved by the Local Ethics Committee of the institution mentioned in the work. Informed consent of the patients was obtained for the research.

No conflict of interests was declared by the author.

Study of relative deformations of interfragmentary regenerate in models of different osteosynthesis options of tibia bones with fractures in the middle third in children with osteogenesis imperfecta and incomplete growth

M.O. Korzh — 2024-03-28

Introduction. Osteogenesis imperfecta is a genetic pathology that leads to a violation of the processes of formation of collagen fibers, formation of bone matrix and its mineralization and, as a result, to the formation of bone tissue with low strength properties. The most promising means of stabilizing bone fragments under this condition are intramedullary fixators of various designs.

Aim. To investigate the relative deformations of the interfragmentary regenerate under the influence of various types of loads in models of the tibia with fractures of both bones in the middle third and their osteosynthesis using intramedullary rods of various designs in children with osteogenesis imperfecta and incomplete growth.

Materials and methods. Mathematical modeling of options for osteosynthesis of tibia bones with a fracture in the middle third in children with osteogenesis imperfecta was performed. Two variants for tibial osteosynthesis were modelled: a rod without rotational stability; rod with rotational stability. Osteosynthesis of the fibula was not modelled in all variants. The stress-strain state of the model under the influence of vertical compressive, bending and torsional loads, as well as the magnitude of the relative deformations of the interstitial regenerate, were studied.

The results. A “growing” intramedullary shear with rotational stability provides essential advantages in the case of torsional loads. The presence of rotational stability makes it possible to ensure two times lower values of relative deformations of interfragmentary regenerates compared to osteosynthesis with a rotationally unstable rod. Under compressive and bending loads, both rods showed almost identical results of relative deformations of bone regenerates. High rates of deformation of interfragmentary tibial regenerates are due to the lack of longitudinal axial stability of both rods, which is the basis for the possibility of increasing their length during the growth of the patient.

Conclusions. The use of osteosynthesis with intramedullary rods, which increase during the treatment of tibial fractures in patients with osteogenesis imperfecta, does not ensure a sufficient level of stability for the fixation of bone fragments under compression and bending loads, which leads to the greatest deformations of bone regenerates. A rod with rotational stability provides advantages in resistance to torsional loads, which is determined by twice lower relative deformations of interfragmentary regenerates.

No conflict of interests was declared by the authors.

Clinical effective risks of mortality in road traffic injury victims depending on the severity of damage

S.O. Guryev — 2024-03-28

Road traffic accidents cause significant trauma to the population and are one of the main causes of mortality in working age. The novelty of the study risk-oriented patterns of severity of damage and mortality of victims of road accidents have been established.

The aim - to create of a fundamental basis for the formation of clinical routes and protocols for victims of road accidents by establishing and verification the relationship between the severity of damage and the death of the victims.

Material and methods. An analysis of 1,696 cases of road traffic injuries was carried out, and the standardized New Injury Severity Score (NISS) assessment system was used.

Results. A probable, but indirect dependence of the clinical effective risk of a negative outcome of the traumatic process in victims on the severity of the damage was established. It was established that the sign of participation in the traffic the formation of clinical effective risks of a negative outcome of the traumatic process, starting with the severity of damage according to the NISS with 25 points. With the same qualitative characteristics, pedestrians have the highest risk of fatality, drivers have the lowest risk. The synergistic effect of the severity of damage and the clinical and anatomical form of the injury was established.

Conclusions. The risk of a fatal outcome of a road traffic injury in general directly depends on the severity of damage to the victim, although the dependence is not direct. The clinical and anatomical form of damage together with the severity of the damage have a synergistic effect on the formation of the clinically effective risk of mortality in victims of a road traffic accident, and the predominant influence is the clinical and anatomical form of damage.

No conflict of interests was declared by the authors.