[Reconstruction of total portosystemic shunt into selective portosystemic shunt in a child]. / Rekonstruktsiya total'nogo portosistemnogo shunta v selektivnyi portosistemnyi shunt u rebenka.

To date, side-to-side splenorenal shunt (SRS) and its analogues (splenosuprarenal shunts (SSRS)) are mainly used for portal hypertension. These are total portosystemic shunts characterized by total blood shunt from portal vein into inferior vena cava. The latter is fraught with a significant risk of complications such as pulmonary hypertension, decreased portal liver perfusion, liver failure and hepatic encephalopathy. Prevention of these complications is still an urgent problem in modern surgery. However, we proposed a new method of treatment, i.e. reconstruction of SRS and SSRS into selective shunt. This procedure was performed in 37 patients after 2020. We present laparoscopic reconstruction in an 11-year-old girl with portal hypertension and signs of hepatic encephalopathy identified after previous SSRS.

[Hepatic encephalopathy after portosystemic bypass surgery]. / Pechenochnaya entsefalopatiya posle operatsii portosistemnogo shuntirovaniya.

The most effective modern treatment for gastrointestinal bleeding following portal hypertension is portosystemic bypass surgery. Hepatic encephalopathy after these procedures is still an urgent problem in modern pediatric surgery, and radical treatment is unknown. To optimize treatment outcomes in children with hepatic encephalopathy, we should choose adequate treatment considering the risk of hepatic encephalopathy in the future. In this review, the authors discuss modern data on hepatic encephalopathy regarding symptoms, advantages and disadvantages of various treatment methods. Risk of hepatic encephalopathy with and without surgical treatment, as well as methods of diagnosis and treatment are particularly analyzed. Total portosystemic bypass surgery, especially portocaval shunt, is followed by higher risk of hepatic encephalopathy compared to selective shunts and physiological mesoportal bypass. The last two approaches are advisable to improve treatment outcomes in children with hepatic encephalopathy.

[Heller laparoscopic cardiomyotomy with Douro fundoplication - a standard for the treatment of cardiac achalasia in children]. / Laparoskopicheskaya kardiomiotomiya po Gelleru s fundoplikatsiei po Doru ­ standart lecheniya akhalazii kardii u detei.

OBJECTIVE: To analyze 20-year experience in surgical treatment of cardiac achalasia. MATERIAL AND METHODS: A retrospective analysis included 35 children (20 boys and 15 girls) who underwent surgical treatment of cardiac achalasia at the Filatov Children's Clinical Hospital No. 13 for the period 2001-2020. RESULTS: Heller laparoscopic cardiomyotomy with Douro fundoplication was followed by favorable outcomes in 33 (94.3%) children. We also observed significant decrease of postoperative Eckardt score compared to baseline values. CONCLUSION: Methods of cardiodilation (balloon dilatation, bougienage) ensure a short-term effect and may be only used in addition to surgical treatment. Heller laparoscopic cardiomyotomy with Douro fundoplication results favorable outcome in more than 92% of patients and can be considered as a standard for the treatment of this disease in children. Oral endoscopic myotomy cannot be considered as an alternative to Heller laparoscopic cardiomyotomy with Douro fundoplication due to high risk of secondary gastroesophageal reflux and its complications. Therefore, additional fundoplication is required that makes treatment of cardiac achalasia more invasive and expensive compared to Heller laparoscopic cardiomyotomy with Douro fundoplication.

[Comparative analysis of the bile duct reconstruction methods in children with choledochal malformation]. / Sravnitel'nyi analiz sposobov rekonstruktsii zhelchnykh khodov pri mal'formatsii obshchego zhelchnogo protoka u detei.

OBJECTIVE: To compare various methods of bile duct reconstruction in children with choledochal malformation (CM). MATERIAL AND METHODS: There were 99 children with CM over 10-year period. Mini-laparotomy (ML), laparoscopy (LS) and laparotomy (LT) were used. We performed radical CM resection and bile duct reconstruction using Roux-en-Y hepaticojejunostomy (RYHJ) and hepaticoduodenostomy (HD). Surgery time, short-term and long-term postoperative outcomes were evaluated. RESULTS: ML was performed in 39 patients, LS - 51 patients, LT - 9 patients. In case of LS, hospital-stay was significantly lower after intracorporeal RYHJ formation compared to extracorporeal technique (p=0.02, Mann-Whitney U-test). Intracorporeal RYHJ requires more time (p=0.0003). Intestinal passage recovered 3 times faster in the ML RYHJ group compared to the LS RYHJ group (p=0.016, Mann-Whitney U-test). ML RYHJ was followed by significantly less duration of postoperative narcotic anesthesia compared to LS HD (3 vs. 4 days, p=0.02, Mann-Whitney U-test). In our study, ML RYHJ has an advantage over LS RYHJ regarding long-term outcomes. HD resulted higher incidence of severe postoperative pancreatitis (p=0.033) that required surgical correction (LT, p=0.043). CONCLUSION: ML RYHJ has some advantages over other methods of bile duct reconstruction. Therefore, we can currently recommend this method as a preferable one.

[Efficiency of minilaparotomy in the treatment of choledochal malformation in children]. / Otsenka effektivnosti mini-laparotomii pri lechenii mal'formatsii obshchego zhelchnogo protoka u detei.

OBJECTIVE: To evaluate an effectiveness of minilaparotomy in the treatment of choledochal malformation (CM) in children. MATERIAL AND METHODS: The study included children with CM who underwent surgery from January 2010 to May 2020. All patients were divided into 3 groups depending on surgical approach: minilaparotomy (ML), laparoscopy (LS) and laparotomy (LT). We analyzed surgery time, early postoperative outcomes and cosmetic results. RESULTS: There were 99 patients with CM for 10 years. ML was performed in 39 patients, LS - in 51 patients, and LT - in 9 patients. Significantly (p-value <0.001, Kruskal-Wallis test with Dunn paired comparison test, p<0.05) less surgery time was observed in ML group. According to Clavien-Dindo classification of surgical complications, we found a significant prevalence of complications in the LS group (p - 0.018, Kruskal-Wallis test). Moreover, LS was characterized by insignificant (p>0.05) predominance of the most severe complications requiring multiple redo surgeries. CONCLUSION: Currently, open surgery is a "gold standard" in the treatment of children with CM. LS is not preferred in children with CM. ML ensures favorable early outcomes in children with CM.

[Minimally Invasive Technologies in Surgery of the Chest Wall in Children].

Today, in our country, as well as throughout the world, there is no single approach to the tactics of managing patients with deformations of the anterior chest wall. These patients constitute a large and heterogeneous group. The team acquired great experience in treating children with pectus excavatum and pectus carinatum, as well as a unique experience in the surgical treatment of pediatric thoracic outlet syndrome and sternum clefts. Now in the world there are a lot of surgical methods used for the correction of congenital deformities of the chest wall, however, the majority of them are extremely traumatic for the patient, and the postoperative scar often presents a minor cosmetic problem than the deformation itself. In addition, almost all methods require the use of expensive technologies, the patient's long hospital stay and the use of potent drugs. As for the children with thoracic outlet syndrome and sternum clefts, these patients are extremely difficult in terms of timely diagnosis and surgical care, due to the fact that pediatric surgeons and pediatricians are very little aware of this pathology. The team of authors developed a number of techniques, based on the collaborative work of surgeons, anesthesiology and resuscitation specialists and pediatric services. They resulted in successful surgical correction of these malformations and gave patients the opportunity to lead a normal life.

[Laparoscopic decompression of celiac trunk in children]. / Laparoskopicheskaia dekompressiia chrevnogo stvola pri kompressionnom stenoze u detei.

MATERIAL AND METHODS: For the period 2013-2016 four patients were treated at the Filatov Children's City Clinical Hospital #13. There were 2 children aged 14 years and 2 children aged 17 years. All patients have been diagnosed via anamnesis, complaints, pulse-wave doppler sonography, contrast-enhanced MDCT and angiography. After comprehensive examination 3 patients underwent laparoscopic decompression of celiac trunk. In all cases celiac trunk compression was predominantly caused by median arcuate ligament of the diaphragm combined with neurofibrotic tissue of celiac plexus. RESULTS: All patients were discharged after laparoscopic decompression of celiac trunk. Intra- and postoperative complications, as well as cases of conversion were absent. Mean time of surgery was 65 minutes. In all cases postoperative period was smooth (4 days on the average). Two patients underwent follow-up examination in long-term postoperative period: pulse-wave doppler sonography, contrast-enhanced MDCT and angiography. In both cases reduced severity, incidence and duration of pain syndrome were observed. CONCLUSION: Clinical examples show some problems in diagnosis and treatment of compressive stenosis of celiac trunk due to rarity of pathology especially in childhood. Nevertheless, combination of abdominal ischemia and celiac trunk stenosis confirmed by instrumental diagnosis is indication for surgical treatment.

[Sliding traсheal plasty in children under extracorporeal membrane oxygenation (first experience in Russia)].

AIM: To improve the results of surgical treatment of children with extended tracheal stenosis. MATERIAL AND METHODS: Since 2013 slidingtraсheal plasty under extracorporeal membrane oxygenation was performed in 4 children aged 1 year 2 months - 4.5 years with extended tracheal stenosis in Children's City Clinical Hospital №13. Patients' weight was from 10,5 to 16 kg. Extended tracheal stenosis and complete cartilag inousrings were confirmed in all patients after peoperative survey. Indications for surgery were based on medical history data, the severity of respiratory failure and survey data. Sliding traсheal plasty by different approach esunder extracorporeal membrane oxygenation was applied in all patients. RESULTS: There were no intraoperative complications. In the study group 1 patient died in remote postoperative period after discharge due to deterioration of his condition caused by upper respiratory tract infection and acute respiratory failure. In immediate postoperative period 1 patient had pronounced growth of granulation tissue in the area of anastomosis followed laser photocoagulation and prolonged intubation. The average ICU-stay was 24 days, the duration of mechanical ventilation - 11 days. Follow-up carefor patients was conducted on terms of 4-6 and 12 months after surgery. In 2 patients moderate complaints of recurrent bronchitis without signs of respiratory insufficiency during 6-8 months postoperatively were observed. In one child complaints were completely absent.

[Laparoscopic operations for chronic duodenal obstruction in children].

Brief literature review devoted to chronic duodenal obstruction is presented in the article. We described an experience of treatment of 5 children with mechanical form of chronic duodenal obstruction. Duodenal stenosis was observed in 2 patients. Arteriomesenteric compression caused chronic duodenal obstruction in other children. Duodenal obstruction was cured using laparoscopy in all cases. Thus enteroalimentation has been started in early terms and intensive care unit stay and hospital stay was reduced.

[Thoracoscopic lung resection in children].

The spectrum of pulmonary surgical pathology in newborns and infants is mainly presented by congenital diseases. Surgery is the main radical method of treatment of children with congenital lung diseases. By this time in the N.F.Filatov City Children's Hospital No13 it is performed more than 1000 endoscopic operations on the thoracic cavity including more than 300 lung resections. More than 190 cases were caused by congenital lung disease. The results of treatment of 194 infants with congenital lung disease for the period 2005-2014 are analyzed in this article. 14 (22%) patients were operated urgently. 8 patients (12%) with compensated respiratory failure underwent surgery at the age of 8 to 46 days. Children with absence of clinical manifestations underwent thoracoscopic lung resection at the age of 3 to 8 months. Thoracoscopic lobectomy was performed in the 40 cases (62%). There were no intraoperative complications. Thoracoscopic lung resection for malformations in newborns and infants is currently the method of choice. It allows to visualize pathological focus intraoperatively and to perform precise dissection of pulmonary root structures using modern equipment. Thus, it improves course of postoperative period and reduces duration of hospital-stay. Repeated lung resection in patients with recurrent tuberculosis of operated lung (literature review and own data).

[Thoracoscopic thymectomy in children by myasthenia gravis].

The authors' experience of surgical treatment of myasthenia gravis in children was analyzed. 32 patients were operated on, mean age was 13±3 (5-21 years); girls were 26, boys were 6 (19%). Disease severity was IIB-IVB by the MGFA classification, all patients were on anticholinesterase and pednisolone therapy. The operation was indicated by certified neurologists, specialized in myasthenia. All patient were thoracoscopically thymectomized using left- or rightside access. There were no conversions and intraoperative complications. The operation duration was 77±23 min. The postoperative hospital stay was 6.6±3.6 (3-9) days. Excellent long-term results were achieved in 6 (25%) patients, good - in 20 (62.5%) children, no changes were registered in 2 and deterioration of myasthenia in 2 (6.25%) patients. The study proved that thoracoscopic thymectomy obtains the radicalism of open technique, proposing the easier postoperative period and being the method of choice for the surgical treatment of myasthenia gravis in children.

[Early results of thoracoscopic treatment of inborn and acquired lung diseases in children].

Thoracoscopic and traditional methods of treatment of the inborn and acquired lung diseases in children were comparatively analyzed. The main group, operated on thoracoscopically, consisted of 30 patients. The control group, operated on thoracotomically, consisted of the same number of children. Both groups were comparable to the age, gender, diagnostic algorithm, risk and preoperative prepare. Traumaticity of the operation and postoperative period were assessed. Thoracoscopic method proved to have indisputable advantages.

[Treatment of bronchiectasis in children].

The thoracoscopic and traditional thoracotomic surgical access for bronchiectesis treatment in children were compared. The first (thoracoscopic) group included 18 children. The control (thoracotomic) group included 26 patients. The mean operative time in the 1st group was 78.3±31 min; pleural draining lasted for 1.3 days and postoperative hospital stay was 9.93±2.08 days. The mean operative time in the 2nd group was 81.7±35.1 min; pleural draining lasted for 3.3 days and postoperative hospital stay was 14.4±3.4 days. Conversion was needed in 4 cases. Therefor, the thoracoscopic surgery proved to be much more preferable in children because of its' minimal invasiveness.

[The surgical correction of vascular tracheal rings in children].

The aortic arch and its branches anomalia compound 1-3.8% of all vessel inborn diseases. The treatment of such anomalia as tracheal vessel ring aims the liquidation of esophageal and tracheal compression. The authors introduce their experience of thoracoscopic tracheal vessel rings resection in 6 children. The time of the operation was 145±15min. There were no conversions to the traditional open surgery. The result was excellent in 4 of 6 children, who were completely releaed of tracheal obstruction symptoms. The rest 2 children demonstrated mild respiratory symptoms, cuased by the tracheomalation.

[The endoscopic operations by solid thoracic tumors in children].

20 patients were operated thoracoscopically on the cause of the solid tumors of the pleural cavity. Patients were aged from 1 day of life to 17 years. Minimal size of the tumor was 3.1×3.5×4.0 sm; maximal 10×10×20 sm. The control group was created of 22 children with thoracic tumors, operated via thoracotomy. The postoperative period and outcomes were statistically better among patients, treated thoracoscopically.

[Thoracoplasty by pectus carinatum in children].

91 children were operated on pectus carinatum. Patients were aged 9-15 years. Thoracoplasty by Ravich was performed in 32 children (the first group) and 59 patients were operated using the method of thoracoplasty, modified by the authors. The major features were: transverse skin incision not longer than 8 sm, mobilization of the skin, subcutaneous fat and pectoral muscles en block, bilateral subperichondral resection of the deformated ribs, resection of the most deformated part of the sternal body (up to 2.0-2.5 sm) and suturing the fragments end-to-end. The long-term follow-up results were studied in term from 6 months to 5 years. The comparative analysis of the results demonstrated obvious advantages of the author's method of thoracoplasty.

[Thoracoscopic treatment of esophageal atresia in infants].

Atresia of esophagus result in absolute lethality without surgical treatment. Posterolateral thoracotomy is a traditional access during such operations, however thoracoscopic methods esophageal atresia has come into practice. Since 2008 all infants (n=22) in our clinic with esophageal atresia have been operated on thoracoscopically. Conversion was performed in 3 observations, 2 children died. Anastomosis insufficiency was diagnosed in 3 patients. 11 children received gullet bougienage in different terms after the operation. Tracheoesophageal fistula recurrence was observed in 2 cases, both were successfully treated thoracoscopically.

[Laparoscopic reconstructive surgery by biliary tract malformations in children].

Treatment results of 18 children operated on various biliary tract malformations were analyzed. Laparoscopic portoenteroanastomosis by Kasai was performed in 10 patients with biliary atresia aged from 10 days to 3,5 months. Average weight of the operated children was 3640 +/- 124 g. 8 patients aged from 2 to 15 years operated on cystic common bile duct malformation. Laparoscopic dissection of cystic deformated biliary ducts with Roux-en-Y hepaticoenterostomy was performed in these cases. 5 troacars were used for both operations. First stage of portoenteroanastomosis formation represented of laparoscopic portal fibrous plate separation. By cystic common bile duct malformations, altered bile ducts were dissected. The second stage--Roux-en-Y enteroenteroanastomosis--was performed through a paraumbilical microincision. Portal anastomosis or common bile duct anastomosis was performed also laparoscopically. Recovery of patients was observed in all cases. Early postoperative course demonstrated a low invasiveness of the method. Thus, laparoscopic access can become a method of choice in treatment of biliary tract malformations in children.