Laparoscopic cholecystectomy in children.

UNLABELLED: In 95 children (age 6-18 y) treated for gallstones between 2002-2010, 95 laparoscopic cholecystectomies were carried out. Symptomatic cholecystolithiasis was the indication for laparoscopic cholecystectomy in most of the cases. In three patients, there was a conversion to open cholecystectomy. Postoperative complications due to failure of bile drainage arose in three patients. Restored bile drainage was secured for two biliodigestive anastomosis. Bile leak in a third patient solved a temporary biliary stent. Laparoscopic cholecystectomy is the gold standard for gallstones (Ref. 8). KEYWORDS: gallstones, laparoscopic cholecystectomy, cholecystolithiasis, bile drainage.

[Laparoscopy in the management of invagination in pediatric patients]. / Miesto laparoskopie v liecbe invaginácie u detí.

AIM: During the last decade, many articles on indications, contraindications, benefits and risks of laparoscopic desinvagination procedures in children have been presented in scientific literature. However, this therapeutic procedure has become a standard therapeutic option within the range of pediatric laparoscopic precedures. The aim of the authors was to establish this miniinvasive procedure in their clinic. PATIENTS AND METHODS: From January 2006 to December 2009, the authors operated 19 patients with ileocolonic invaginations, in whom prior hydrostatic desinvagination had failed. 11 pediatric patients underwent laparotomic revision. In 9 subjects, idiopatic invagination was detected, while in 2 subjects secondary intususception caused by a Meckel's diverticle was confirmed during the procedure. In 7 subjects aged 8-51 months, desinvagination was achieved using laparoscopic procedures. 3 ports were used during the procedures--one for optic devices, measuring 10 mm, was placed in the infraumbilical incision and 2 working ports of 5 mm were introduced into the left hypogastrium and the left mesogastrium. The desinvagination was achieved using a grasper and gentle traction on the invaginated colon. In two subjects with relapsing invagination, desinvagination was followed by ileo-coecopexy. In one subject, conversion was required during the laparoscopic procedure, because repositioning of the invaginated colon was not feasible. OUTCOMES: The mean duration of these laparoscopic procedures was 68.6 minutes and no intraoperative complications were recorded. Reallimentation was introduced on the first postoperative day, no reinvagination episodes were recorded and the mean duration of hospitalization was 4.3 days. CONCLUSION: Laparoscopic desinvagination has become a part of the algorithm for the management of invaginations in cases, where conservative approach failed, and should be used before open laparoscopic revision is indicated. However, the miniinvasive procedure must be performed by a surgeon with experience in laparoscopy.

[Type II bile duct cyst or accessory gall bladder?]. / Cysta choledochu II. typu alebo nadpocetný zlcník?

Choledochal and bile duct's cysts are well known, their morphological classification and also operative management had been described in detail. The most frequent are cysts' types I. and IV., in which the operation consists of cyst's resection and biliary tract reconstruction. Authors summarize nowadays knowledge and present case of 21-months old girl, who was diagnosed of choledochal cyst accidentally. She was operated on electively; the operative finding verified 2 cystic lesions with own bile ducts joined to choledochal duct. The proximal cyst had 3 diverticles and thus mimicked a choledochal cyst type IV. on the preoperative examinations. The resection of both cystic lesions was done. This is a unique case of biliary tract malformations.

[Position variability of the vermiform appendix and effect on diagnosis of appendicitis in children]. / Variabilita polôh apendix vermiformis a vplyv na diagnostiku apendicitídy u detí.

Vermiform appendix, seemingly inconspicious anatomical structure, may cause many complications. These result from its topographico-anatomical relations to surrounding structures in abdominal cavity, but also from potential position variability of the vermiform appendix. Variable position of the vermiform appendix can have effect on appendicitis diagnostic, as one of the most often cause of the acute abdomen in children.

Devastating injury of the groin with vascular lesion.

A 13-year-old girl suffered an injury of the left inguinal region in October 2002. The mechanism of the injury was a fall off a merry-go-round with subsequent trailing by the iron frame, which resulted in devastation of the soft tissues and vessels of her left groin. The patient was transported to the Department of Paediatric Surgery in a state of haemorrhagic shock. A part of the iron frame was still sticking out of her groin. Emergent surgery and haemostasis was followed by reconstructive vascular surgery. Vascular ischaemic-reperfusion syndrome appeared 8.5 hours after the injury. A second episode of haemorrhagic shock developed on the 6th post-operative day, after a dislodgement of an arterial thrombus from a small artery, which was not obvious during the surgery. The situation required emergent wound exploration and surgical control of the bleeding. A third episode of haemorrhagic shock developed on the 9th post-operative day, after an excessive administration of heparin. This time no surgical bleeding was detected during wound exploration. The last episode of haemorrhagic shock appeared 6 months later, during the patient's menarche. She was ashamed to tell her parents about her heavy bleeding for several days. Authors of this article conclude that it is not necessary to increase the dose of Heparin above 20 mcg/kg/hour, even though the value of aPTT is not as high as we would expect. We should expect also the possibility of severe bleeding due to menarche on the anticoagulant therapy in adolescent female patients. Authors also consider both arterial and deep venous reconstructions to be adequate methods of treatment in case of extensive devastating injury of the groin region in the adolescent period (Fig. 5, Ref. 5). Full Text (Free, PDF) www.bmj.sk.

[Use of allogenous material in the management of spina bifida aperta]. / Pouzitie alogénneho materiálu pri riesení spina bifida aperta.

AIM: "Conditio sine qua non" in the management of open neural tube defects includes closure of all layers with as minimum as possible tension left within the suture region, in order to prevent early, as well as long-term postoperative complications. In extensive fascial defects, the authors used the Gore-Tex patch as an alternative to myofascial or fasciocutaneous flaps. PATIENTS AND METHODS: From January 2004 to January 2008, 23 patients suffering from open spina bifida underwent surgery in the Bratislava Pediatric Surgery Centre. In 17 subjects, the fascia was sutured following a myofascial release, in 2 subjects the suture was secured with tissue adhesive. In 4 subjects, the Gore-Tex patch was implanted to secure the "tension free" plasty; the Gore-Tex Dual Mesh was used in 2 subjects as well as the Gore-Tex Spinal. RESULTS: Two subjects, who had the Gore-Tex Dual Mesh implanted, developed sequestration of the implant during the late postopertive period. Upon reoperation, the authors removed the Gore-Tex Dual Mesh in the both subjects. However, they found a firm fibrous membrane, which was considered sufficient to protect the dural sac. On the contrary, the both subjects who had the Gore-Tex Spinal implanted, healed with no complications recorded. CONCLUSION: Based on the experience, the Gore-Tex Dual Mesh, although implanted lege artis, does not appear a suitable material for fascia replacements in open spina bifida plastic procedures. Further experience will give more evidence, whether Gore-Tex Spinal would be a suitable alternative, however, the courses in the 2 subjects have hitherto been encouraging.

[Later age diaphragmatic hernia]. / Diafragmatická hernia manifestovaná v neskorsom veku.

INTRODUCTION: Congenital diaphragmatic hernia (CDH) is usually diagnosed antenatally or through the neonatal period at present. It is also used to treat and manage CDH in this date. However in rare cases CDH could be presented after finished neonatal period with non-specific and misleading symptoms. The aim of our presentation is to analyze the patients with late - presenting and diagnosed CDH. METHODS: During period 1996-2006 we operated on 54 children with CDH, 12 of them with late - presenting CDH, age variance was 9 months and 6 years. The spectrum of symptoms was from asymptomatic CDH (2 patients), mild respiratory (4 patients) and gastrointestinal symptoms (4 patients), combination of respiratory and gastrointestinal symptoms (2 patients) and finally the symptomatology of bowel incarceration (2 patients). RESULTS: Seven children presented with another associated malformations (m. Down, congenital heart failure, hydrocephalus, anorectal atresia). All 12 patients were operated on with a good results. The operation was composed of reposition of the herniated part of gastrointestinal tract (without need of resection) and diaphragmatic plastic. Two patients were reoperated on - once because of diaphragmatic relaxation and the second one due to consecutive heart operation. CONCLUSION: Congenital diaphragmatic hernia could be presented with chronic and non-specific respiratory or gastrointestinal symptoms. Time to time, presentation of diaphragmatic hernia as "acute abdomen" could be seen. The operation is indicated, also in asymptomatic patients as a prevention of life-threating events.

[Occlusive ileus caused by intestinal duplication]. / Obturacný ileus spôsobený crevnou duplikatúrou.

State with progressive development of intestinal obstruction may leads to the misinterpretation of acute gastroenteritis in infant period. After passing of newborn period the differential diagnosis is not easy. Loss of time which leads to the correct diagnosis is ufavourable for patient because of worsening of the condition. The authors present a case review of 5 months old girl in whom cystoid intestinal duplication caused complete ileo-coecal occlusion. Associated diagnosis in our patient were anus perinealis ventralis and diverticulum Meckeli. The treatment of enteral duplication and Meckel's diverticulum was done in one stage surgery.

Perinatal traumatism with gastroschisis.

Authors analyse 11 cases of perinatal traumatism in a group of 110 patients with gastroschisis during a period of 25 years. They point out its causes and consequences. To minimize perinatal traumatism, it is necessary to conduct suitable prenatal and perinatal management. In spite of preferring Caesarean section there are no differences between vaginal and Caesarean delivery when the delivery is properly managed (Tab. 1, Fig. 3, Ref. 12). Full Text (Free, PDF) www.bmj.sk.

[Paresis of the femoral nerve in pelvic extraperitoneal hematoma--case reports and literature review]. / Paréza femorálneho nervu pri extraperitoneálnom hematóme panvy--kazuistiky a prehl'ad literatury.

The authors describe two rare cases of femoral nerve paresis in pelvic extraperitoneal hematoma in children. The first case was a 13-year-old girl, with no trauma in her medical history, in whom the paresis was suspected to have inflammatory or tumorous etiology; the other case was a 14-year-old boy injured during playing football. In both patients, extraperitoneal pathology of the pelvis was evident clinically and was shown in CT scans; paresis of the femoral nerve was demonstrated by EMG. In both cases, surgical intervention revealed a hematoma causing neuropathy. This was removed and, within a year of first sign appearance, both patients were free from neurological symptoms. The authors consider early surgery to be a decisive factor in the course of this neurological complication, as the regeneration of nerve structures took nearly a year despite the adolescent age of the patients. No reports of similar conditions in children treated at the same institution were found in the relevant international literature.

Separation of Siamese twins in Bratislava.

At the pediatric surgical clinic in Bratislava, in the year 2000, we successfully carried out the separation of Siamese twins, which we classified as "ischiopagus tetrapus"+. The pelvic ring, the gastrointestinal tract and the urogenital system were all malformed. There was a common terminal ileum and only a short segment of the large intestine with a blind end. This was a case of non-developed anal segment and rectum. Each of the twins had two kidneys and two commonly shared urinary bladders. There were two uteruses, which were both bicornuate in nature with a fallopian tube arising from each of the horns as well as an ovary. The orifices of both urinary bladders and those of the two uteruses joined into a common urogenital sinus. The external ostia of this sinus represented a bizarre fissure with a single skin fold similar to the labium majus, located dorsally at the point of fusion of the pelvic structures. The act of separation was performed in two stages. Separation of the gastrointestinal tract was urgent due to the severe ileus caused by aplasia of the anus and the rectum. This first stage procedure was performed on the third day of admission (24.2.2000) after the babies had spent a month in other health institutions. The definitive separation was carried out a month after the first procedure (28.3.2000) following the optimal stabilization of the functions of the gastrointestinal tract. The uropoietic and genital systems were separated. A new pelvic ring and a pelvic floor were formed. The anterior abdominal wall was reconstructed and plastic correction of the skin in the gluteal and perineal regions was performed. The colostomies are functioning well and the twins pass well-formed stools. Lucia has long dry intervals between mictions. Andrea has shorter dry intervals. The girls have recently celebrated their third birthday. Their mental development is excellent; they speak Slovak and Hungarian languages. They have a well-developed locomotive apparatus, without any movement impairments. (Tab. 1, Fig. 16, Ref. 10.)

[Maffucci's syndrome--case report of a 5-year-old female patient]. / Maffucciho syndróm--kazuistika 5rocnej pacientky.

Maffucci's syndrome is a congenital non-hereditary syndrome characterized by a combination of dyschondroplasia (enchondromatosis) and haemangiomatosis. It is a rare disease. During the last 140 years only 200 cases were described [5]. 109 cases are described in the literature by other authors [21]. This disease is associated with a high risk of development of neoplastic processes, in particular sarcomatous transformation of enchondromatoses as well as other mesodermal and non-mesodermal malignities [13]. Based on the incidence of spinocellular haemangioendothelioma with other congenital syndromes, the presence at a young age of patients and the multicentric incidence support the assumption that spinocellular haemangioendothelioma may be the manifestation of genetically based mesodermal disease which may be associated with the picture of Maffucci's syndrome [6]. In their case-history the authors present a 5-year-old patient. They describe the clinical course and findings taking into account possible manifestations and risks associated with the disease. With regard to the low incidence of the disease and its interdisciplinary character the authors pen the question of possible causal, symptomatic or palliative treatment.

[A pediatrician's views on the treatment of extensive hemangiomas in childhood]. / Pohlad pediatra na liecbu rozsiahlych hemangiómov v detskom veku.

Haemangiomas are the most frequent tumours of child age. They are found in 10-12% of infants. The authors summarize contemporary knowledge of the treatment of haemangiomas as well as their own experience with their treatment. They follow-up 18 children with haemangiomas at different sites, incl. ten with extensive haemangiomas. The latter were treated conservatively with prednisone and interferon alpha.

[Supracondylar fractures of the humerus and disorders of circulation]. / Suprakondylická zlomenina humeru s poruchou cirkulácie.

Supracondylar fractures (SF) of the humerus are the third most common type of fractures in childhood. The highest rate of pulselessness fracture of the distal humerus is the extension-type. The aim of our treatment is to minimize potential complications. Our management of pulselessness supracondylar fracture is more aggressive compared with other dpts. 223 (100%) patients with SF were treated at the dpt. of Paediatric Surgery, University Children's Hospital in Bratislava, in the 5-year period of (1995-1999). 11 (4.93%) patients remained pulseless after reposition of bone fragments. These patients underwent surgical revision of the brachial artery. Spasms of the brachial artery (BA) occurred in six patients, a lesion of BA in three patients and thrombosis of BA in two patients. We performed revision of the brachial artery by a Fogarthy catheter in six patients--in four cases with thrombectomy. In two cases we released the vessel from bone fragments. In two patients was replaced the injured segment of the brachial artery by a venous allotransplant. Peroperative angiography was performed in six patients. We reoperated three patients with early postoperative complications. We did not record any case of Volkmann's contracture.

Dose-response effects of a new growth hormone receptor antagonist (B2036-PEG) on circulating, hepatic and renal expression of the growth hormone/insulin-like growth factor system in adult mice.

The effects of growth hormone (GH) in regulating the expression of the hepatic and renal GH and insulin-like growth factor (IGF) system were studied by administering a novel GH receptor antagonist (GHRA) (B2036-PEG) at different doses (0, 1.25, 2.5, 5 and 10 mg/kg/day) to mice for 7 days. No differences were observed in the groups with respect to body weight, food consumption or blood glucose. However, a dose-dependent decrease was observed in circulating IGF-I levels and in hepatic and renal IGF-I levels at the highest doses. In contrast, in the 5 and 10 mg/kg/day GHRA groups, circulating and hepatic transcriptional IGF binding protein-3 (IGFBP-3) levels were not modified, likely resulting in a significantly decreased IGF-I/IGFBP-3 ratio. Hepatic GH receptor (GHR) and GH binding protein (GHBP) mRNA levels increased significantly in all GHRA dosage groups. Endogenous circulatory GH levels increased significantly in the 2.5 and 5 mg/kg/day GHRA groups. Remarkably, increased circulating IGFBP-4 and hepatic IGFBP-4 mRNA levels were observed in all GHRA administration groups. Renal GHR and GHBP mRNA levels were not modified by GHRA administration at the highest doses. Also, renal IGFBP-3 mRNA levels remained unchanged in most GHRA administration groups, whereas IGFBP-1, -4 and -5 mRNA levels were significantly increased in the 5 and 10 mg/kg/day GHRA administration groups. In conclusion, the effects of a specific GHR blockade on circulating, hepatic and renal GH/IGF axis reported here, may prove useful in the future clinical use of GHRAs.

[Treatment of blunt injuries of the spleen in children]. / Liecba tupého poranenia sleziny v detskom veku.

The authors report study of patients with blunt splenic trauma treated at Paediatric Surgery Department in years 1991-1999. During 9 years period 50 patients (36 males, 14 females) with demonstrated rupture of the spleen were analyzed. 46 patients (92%) were treated conservatively (group A). Complications appeared in 7 patients (15.22%), rebleeding in two patients, arterio-venous fistula in early posttraumatical period in one patient and during control in one patient, fluidothorax in two patients and posttraumatic pseudocyst of the spleen in one patient. Four patients (8%) were operated (group B). Two of them submitted splenectomy, one patient was treated by splenorrhaphy and one patient by partial splenectomy. Period of the hospitalization in average lasted in group A 12,67 days, in group B 15 days. With regard to the immunologic functions of the spleen especially in childhood authors prefer conservative treatment, in case that laparotomy is inevitable authors try to preserve the spleen.

The effect of epidermal growth factor and IGF-I infusion on hepatic and renal expression of the IGF-system in adult female rats.

Systemic administration of epidermal growth factor (EGF) in neonatal rats results in reduced body weight gain and decreased circulating levels of IGF-I, suggesting its involvement in EGF-induced growth retardation. We investigated the effect of EGF and/or IGF-I administration for 7 days on circulating IGF-I and IGFBP levels and hepatic and renal IGF-system mRNA expression profiles in adult female rats. EGF administration (30 microg/rat/day) did not influence body weight, liver or kidney weight. In contrast, IGF-I (400 microg/rat/day) and EGF/IGF-I administration increased both body weight and kidney weight. Also, serum IGF-I and the 30 kDa IGFBPs (IGFBP-1 and -2) were significantly increased in these groups. Serum IGFBP-3 levels increased in the IGF-I group along with increased hepatic IGFBP-1 and -3 mRNA levels. In contrast, in the EGF administration group serum IGFBP-3 levels were significantly decreased; however, the mRNA levels remained unchanged. In the EGF/IGF-I administration group, serum IGF-I and IGFBP-3 levels were significantly lowered when compared with the IGF-I administration group. This was in contrast to the effect on kidney weight increase that was identical for the IGF-I and EGF/IGF-I groups. The decrease in serum IGFBP-3 was not reflected at the hepatic IGFBP-3 mRNA level. IGFBP-3 expression might be regulated at a post-transcriptional level although EGF induced IGFBP-3 proteolysis could not be demonstrated in vitro. We conclude that EGF administration reduced serum IGFBP-3 whereas IGF-I administration increased the level of IGFBP-3 and IGF-I and resulted in an increased body and kidney weight in adult female rats.

[An abdomino-scrotal hydrocele]. / Abdominoskrotálna hydrokéla.

Abdominoscrotal hydrocele is encountered rarely in child age. The authors present an account on two patients with abdominoscrotal hydrocele in a three- and fifteen-year-old boy. They discuss its development, draw attention to the not very marked clinical manifestations, diagnostic pitfalls and the contribution of sonography to diagnosis.

[Atresia of the large intestine]. / Atrézie hrubého creva.

The authors describe two patients with congenital atresia of the large intestine. Both patients had colostomy when neonates. A double colostomy was performed. The microcolon was dilated across the distal colostomy by physiological saline and semolina pudding to achieve dilatation of the distal portion. Occlusion of the colostomy, tapering and end-to-end colo-colo anastomosis was performed in both children at the age of four months. The passage was restored in both patients on the third day after occlusion of the colostomy. One patient had also other congenital defects, i.e. equinovarus of both feet and a defect of the atrial septum. One patient is four, the other three years old. They are doing well and have no digestive trouble.