[Multidisciplinary approach to surgical disorders of the pancreas in children]. / Multidisciplinární prístup k chirurgickému onemocnení pankreatu v detském veku.

INTRODUCTION: Surgical diseases of the pancreas in children are not common and may be associated with significant morbidity and potential mortality. A multidisciplinary approach is essential for correct diagnosis, surgical strategy and postoperative as well as follow-up care. METHOD: Retrospective analysis of patients operated on due to a pathological lesion of the pancreas focused on diagnostics, operating procedures, postoperative complications, and long-term results. Between 1991 and 2016, eighty-nine children were treated in our department for a pathologic lesion of the pancreas. 39 of them were boys and 50 were girls. RESULTS: Mean age of the patients was 9.3 years (1 month-18.4 years). Patients were followed from the operation to the age of 19, after which they were referred for follow-up to adult specialists. The indications for surgery were trauma in 34 children, solid pseudopapillary tumor in 23 children, biopsy in 10, hyperinsulinism in 8, chronic pancreatitis in 4, pancreatic cyst in 3, insulinoma in 3, carcinoma in 2, and serous cystadenoma and pancreas divisum in one patient. The most frequent procedures performed on the pancreas were distal pancreatectomy in 35 cases, the duodenum-preserving pancreatic head resection in 23 cases, pseudocystogastroanastomosis in 11 cases, 9095% pancreatic resection in 5 cases, Whipple operation in two cases, Puestow procedure in one case, tumor enucleation in one case, and tumor biopsy for cancer in one case. In 5 patients after major pancreatic injury, ERCP and papillotomy with insertion of a stent into the pancreatic duct was performed. 3 patients died, one after a polytrauma with severe pancreatic injury and two patients with pancreatic cancer. CONCLUSION: Pancreatic surgery in children is not a common operation, and individual as well as institutional experience remains limited. After more than 20 years of experience with pancreatic surgery, we believe that close cooperation with surgeons, pediatric gastroenterologists, radiologists, anesthesiologists, intensivist, pathologists and ERCP specialists is necessary for successful diagnosis and treatment of pancreatic disease in children.Key words: pancreas pancreatic surgery in children duodenum preserving head resection of the pancreas.

Selective lung intubation during paediatric thoracic surgeries.

Selective lung intubation is a necessary prerequisite for the completion of most interventions comprising thoracotomy and thoracoscopy. In paediatric care, our site uses Univent tubes for children up to the age of three years and double-lumen tubes (DLT) for children from 6-8 years of age. In younger children, we usually use regular endotracheal intubation, with the lung being held in the hemithorax position being operated on using a surgical retractor. The article presents the analysis of 860 thoracic surgeries, of which 491 comprised selective intubation (Univent 57 cases, DLT 434 cases). The use of the aforementioned devices is connected with certain complications. Univent tube can be connected with intraoperative dislocation of the obturating balloon (29.8%) and balloon perforation (5.2%). DLT insertion may be connected with failure of tube fitting. In 84 cases we had to repeat DLT insertion (20.6%). In 8 cases we were not able to insert DLT at all (1.8%). Standard use of selective intubation methods in paediatric patients from two years of age improved the conditions for surgical interventions (Tab. 2, Fig. 2, Ref. 19).

Continuous epidural analgesia, a new prospect in analgesia of newborns.

The popularity of continuous caudal epidural block in post-operative analgesia in very young children has been growing. This method of analgesia is used in major abdominal and urological surgeries. A local anaesthetic, usually levobupivacaine, is administered through an epidural catheter introduced via hiatus canalis sacralis. The usual type of the catheter is Arrow G20 armed with a metal spiral, which can be used for children of up to approximately 2000 g of body weight. We want to introduce a modification of the method which uses the thin silicone catheter Premicath G28. This catheter allows for the administration of caudal epidural analgesia even in premature children of approximately 500 g of body weight. This solution eliminates adverse effects of systemic opioid analgesia, accelerates surgical wound healing and disconnection from ventilation system, and improves the potential of enteral nutrition. Depth and quality of analgesia in very young children are monitored using a complex scheme called Comfort Neo Scale (Tab. 1, Fig. 2, Ref. 7).

Technical innovation in minimally invasive repair of pectus excavatum.

The aim of study was to introduce technical innovation of MIRPE which reduces the risk of cardiac injury. Modification of MIRPE method with semiflexible thoracoscope and sternum elevating technique has been used. Volkmann bone hook has been inserted percutaneously to the sternum. The hook elevates the sternum forward and enlarges the retrosternal space for safer passage of thoracoscopically guided introducer. Using semiflexible thoracoscope allows better view from various angles via one site of insertion. During the period 2005-2012, the MIRPE was performed on 29 girls and 151 boys; the mean age at the time of surgery was 15.9 years (range 13-18.7 years). The mean Haller index was 4.7 (range 2.7-20.5). The most common complication was pneumothorax (3.3 %) and the incidence of bar displacement was 2 %. The most serious complication was cardiac perforation when inserting Lorenz introducer. This occurred in a 16-year-old girl; she required urgent sternotomy with right atrial repair and recovered well. External elevation of sternum with the hook was used since this case. Subsequent 113 patients underwent surgery without any serious complications. Technical innovation using semiflexible thoracoscope and hook elevation of the sternum reduces the risk of cardiac injury. The hook opens the anterior mediastinum space effectively and makes the following dissection relatively safe and straightforward.

[Surgical technique changes in the repair of pectus excavatum between 1991 and 2012]. / Zmeny chirurgické techniky pri resení Pectus excavatum v letech 1991-2012.

INTRODUCTION: The aim of this article is a retrospective analysis of the results of three methods used for the repair of pectus excavatum between 1991 and 2012. MATERIAL AND METHODS: 508 patients were operated on at the Department of Paediatric Surgery of the Second Faculty of Medicine, Charles University, and the Teaching Hospital in Motol between 1991 and 2012. 16 patients were older than 19 years (19-28 years). The average age of paediatric and adolescent patients was 14.2 years (5-19 years range). Boys (408) prevailed over girls (82), the ratio being 4.9:1. Open Holcomb technique was used to operate on 87 patients (17%), the Welch method was applied in 208 patients (41%). Minimally invasive repair of pectus excavatum (MIRPE) was used in 213 patients (42%) during the entire period of time. RESULTS: As for the 295 patients operated on by the open Holcomb and Welch method, the outcome was excellent in 239 (81%) of them. A favourable result with a small deformity remaining occurred in 44 patients (15%). Unfavourable result was found in 7 patients (2.5%): in these children, a deep excavation occurred 3-5 years postoperatively. In 5 patients (1.5%) we evaluated the result as recurrent chest wall deformity. The minimally invasive method (MIRPE) produced an excellent result in 182 out of 213 patients (85%). A favourable outcome was observed in 27 (22%), unfavourable result in 1 (0.5%) patient. CONCLUSION: In the last 15 years, minimally invasive repair of pectus excavatum has become popular worldwide. Due to very favourable cosmetic results and a relatively small, gradually decreasing number of complications, the proportion of patients requiring surgery to correct their deformity has risen sharply.

Surgical management of major pancreatic injury in children.

INTRODUCTION: Major or complicated pancreatic trauma in children is uncommon and management strategies remain controversial. The aim of this study was to evaluate our experience with both early and delayed surgery in these pediatric cases. METHODS: We carried out a retrospective analysis of data of pediatric patients with major or complicated pancreatic injury operated on between January 1994 and December 2005 in our pediatric trauma center. RESULTS: Thirteen children (9 boys and 4 girls) with a mean age of 8.5 years (range 3 - 16 years) were operated for major or complicated pancreatic injury. The extent of injury was: grade II (major contusion without duct injury or tissue loss) in 4 children; grade III (distal transection) in 5 children and grade IV injury (proximal transection) in four patients. Pseudocyst developed in 8 children: 4 with grade II injury, 2 with grade III injury and 2 with grade IV injury (one with abdominal pseudocyst and one with an abdominal and a mediastinal pseudocyst). Early diagnosis and operation was achieved in 5 cases, while delayed diagnosis and operation occurred in 8. Three children underwent cystogastrostomy; 6 had a spleen-sparing distal pancreatectomy and 4 had resection with Roux-en-Y jejunostomy drainage. Endoscopic retrograde cholangiopancreaticography (ERCP) was the most useful diagnostic tool in assessing ductal injury. There were no deaths or long-term morbidity in our group of patients. CONCLUSIONS: Our results support the view that early operation is important in ductal pancreatic injury. We recommend transferring children with a suspected ductal injury to a tertiary center with experience in both pediatric ERCP and pancreatic surgery.

Congenital solitary liver cysts.

AIM: The aim of the study was to describe clinical and pathological findings in children with rare congenital solitary liver cyst. MATERIAL AND METHODS: Six children with congenital liver cyst were treated at the authors' institution from 1995 to 2002. Clinical records and operative findings of these patients were reviewed retrospectively. RESULTS: Age at presentation ranged from neonatal to 14 years, and there were four girls and two boys. Hepatomegaly was the most common symptom in neonates while the older children presented with abdominal pain. Ultrasound was conclusive for diagnosis in all children, prenatal ultrasound in three. Intrahepatic cyst was found in five children. Partially extrahepatic cyst in the porta hepatis was found in one. The cyst diameters varied from 8 to 10 cm. Cysts were excised via an open abdominal approach in all patients. Histological findings confirmed the diagnosis of congenital liver cyst. Columnar epithelium was found in newborns while atrophic changes of epithelial lining were seen in older children. In a case of a 13-year-old girl the cyst was lined by metaplastic squamous epithelium with foci of slight dysplasia. Immunohistochemical studies were available in three recent children with positive findings in all of them. The postoperative course was uneventful in all patients. The follow-up period ranged from 36-120 months and no recurrence was observed. CONCLUSION: With appropriate selection of symptomatic patients, total excision of a congenital liver cyst is a safe procedure with excellent long-term results. Given the possibility of malignant degeneration of a congenital liver cyst we recommend its surgical excision in most cases.

[Radical surgery in the complex treatment of hepatoblastoma]. / Chirurgická radikalita v komplexní lécbe hepatoblastomu.

BACKGROUND: Evaluation of treatment results in children with hepatoblastoma--a retrospective study of clinical and pathological data of surgically treated children. METHODS AND RESULTS: At the clinic of authors, 28 children were operated for hepatoblastoma during 1991 to 2002. Average age of patients was 2.2 years. When tumors were classified according to PRETEX system, 3 children were in the stadium I, 12 children in stadium II, 12 children in stadium III, and one child in the stadium IV. At the diagnosis, lung metastases were found in 3 children. Till 1996 the treatment was initiated by a primary operation, since 1996 by a preoperative chemotherapy. Chemotherapy was administered according to the SIOP protocols. Primary operation was done in 13 children, 15 children were operated after the pre-operation chemotherapy. Liver resection included right-sided lobectomy in 7 cases, extended right-sided lobectomy in 4 cases, left-sided lobectomy in 8 cases, right-sided trisegmentectomy in 5 cases, left-sided trisegmentectomy in 3 cases. In our studied group the three years of event free survival was achieved in 75%, overall survival in 86%. Four children died, two of them because of the progression of the disease, two for the complication during the therapy. CONCLUSIONS: Combination of the radical surgical resection with preoperative and postoperative chemotherapy enables successful treatment of the childhood hepatoblastoma.

[Hepatic resection technique in children]. / Technika resekce jater v detském veku.

The authors present their experience with resection of the liver in children. In 1986-1993 they performed a total of 34 major resections of the liver. The mean age of the operated children was 4 years and 5 months, the youngest patient was operated at the age of 4 days and the oldest one at the age of 17 years. The group was divided into two time periods which are compared, because in 1990 the authors changed their surgical tactics and technique and also the procedure used for general anaesthesia. During the first period/1986-1989/they made 12 resections of the liver and during the second period/1990-1993/22 resections. The two groups of patients are compared as regards mortality during operation, early and late deaths. In the first period the mortality was 25%, in the second period no death occurred during operation. Early deaths were recorded during the first period in 25%, during the second period in 4.5%. Patient survival during the first period is 33% and during the second period 86.5%. The authors describe the technique of resection of the liver they use at present with emphasis on isolation of the vena cava inferior with the possibility of easier control of haemorrhage and the use of an ultrasonic aspirator/CUSA/and laser during resection proper which makes easier identification of hepatic structures and control of blood losses on operation possible. In malignant tumours the radicality of surgery increased as manifested on patient survival. From the first period 15% patients survive, from the second period 83% without signs of relapse.

[Transanal resection of the recto-sigmoid--the future in the treatment of classic Hirschsprung's disease?]. / Transanální resekee rektosigmoidea--budoucnost v lécení klasické Hirschsprungovy choroby?

INTRODUCTION: The technique of transanal resection (TAR) of aganglionary part in rectosigmoid, published in 1998, has gradually become a standard operation technique in the treatment of Hirschsprung's disease (H.d.). Since the TAR technique for H.d. is not yet generally widespread and has not been used in the Czech Republic yet, the authors intended to share their own experience and early results obtained by this surgical technique. COHORT OF PATIENTS: Seven patients (five boys and two girls) suffering from the classical recto-sigmoid form have been operated on since June 2003. One girl was affected with the Down's syndrome. The age of the patients at the time of operation was between one and 24 months. SURGICAL TECHNIQUE: The extent of intestinal resection was determined on the basis of per-operation biopsy. The length of the rectrosigmoid resection was between 25 and 35 cm. The colorectal anastomosis with partial sphincteromyectomy of internal anal sphincter was performed by the technique according to Swenson. The antibiotic prophylaxis was secured by three doses of cefoxitin and one dose of isepamycin. RESULTS: Intestinal passage reestablished 8-12 hours after the surgery, and complete oral intake began on day 3 or 4 after the operation. All patients healed up without complications, the period of hospitalization was seven days on the average. The final diagnosis of H.d. was confirmed by biopsy examination of the dissected portion in all cases. CONCLUSION: TAR is univocally the method of first choice in the surgery of classical Hirsprung's disease when compared with laparotomy or laparoscopy.

[Esophageal reconstruction using the stomach in children]. / Náhrada jícnu zaludkem v detském veku.

The authors present an account of their experience with oesophageal replacement by gastric transposition in 10 children during the period between November 1992 and January 1999. Indications for oesophageal replacement was in seven children atresia of the oesophagus at the age of 9-36 months and in three children (2.5, 3 and 14 years) a long stricture of the oesophagus after caustic injury which did not respond to balloon dilatation. Replacement after caustic injury was made in children aged 2.5, 3 and 14 years. In eight patients the replacement was made without thoracotomy, by blunt resection of the mediastinum, in two patients after caustic injury thoracotomy had to be performed. In three patients after surgery a temporary fistula developed at the site of anastomosis which healed spontaneously. Eight patients are in a satisfactory condition after surgery, one patient five months after operation swallows with difficulty, his birth weight was 1500 g. One female patient died one year after oesophageal replacement, apparently due to aspiration and respiratory arrest. Gastric transposition is a considerate and relatively simple method in child age. The functional results are favourable.

Duodenum-sparing technique of head resection in solid pseudopapillary tumor of the pancreas in children.

AIM OF STUDY: Aim of the study was to assess the complications and long-term results in children operated on for solid pseudopapillary tumor of the pancreas (SPTP) between 1993-2008 at the authors' institution with a focus on a novel duodenum-sparing technique to treat tumors of the head of the pancreas. METHODS: Retrospective analysis was performed of patient data including demographics, diagnostic measures, the operative technique focusing on tumor of the head of the pancreas, complications and long-term results. RESULTS: There were 13 patients (12 girls and one boy) with an average age of 14 years (9-17.5 years) at operation. In 7 patients the tumor was localized in the head of the pancreas, in 4 patients in the tail, and in 2 patients both the body and tail were involved. Patients with body and tail involvement underwent distal pancreatic resection. In 6 patients with head involvement a duodenum-sparing resection of the head and end-to-end anastomosis of the excluded jejunal loop either to the corpus or tail of the pancreas were performed. One girl underwent a modified Whipple operation. She developed a biliary fistula which closed after three weeks with endoscopic stenting. One patient with head resection developed a biliary fistula which closed after two weeks of stenting. One patient who underwent resection of the pancreatic head complained of recurrent abdominal pain one year postoperatively. All patients are alive without tumor recurrence at 6 months to 16 years after operation. CONCLUSION: SPTP is a rare pancreatic tumor with a low degree of malignancy. No perioperative chemotherapy is necessary. Therefore duodenal resection in cases of SPTP in the head of the gland seems too invasive and mutilating. The authors consider the duodenum-sparing technique to be more appropriate for the developing organism of a child. Favorable short and long-term results support this opinion.