Halo-gravity traction in the treatment of complex spinal deformities in children with respiratory dysfunctions

HGT is a safe technique as the world literature describes complications in the form of loosening of the pins or superficial infections of the skin around the pins, which are not significant and do not pose a threat to the patient’s life. Purpose – to improve the results of the ventilation function of the lungs in patients with complex spinal deformities through the preliminary use of halo gravity traction and to introduce an effective and safe method for the treatment of complex spinal deformities in children with respiratory dysfunctions. Materials and methods. 64 children with complex spinal deformities (>100°) were treated in the orthopedic and traumatology department of the Okhmatdet NSPU using halo gravity traction during the period from 2003 until 2018. Of these, 38 are boys and 26 are girls. The average age of the patients was 11.6 years. The average Risser score was 3.8 (P>0.01). Results. According to the data of spirography performed, 46% of patients had moderate ventilation disorders and 54% – severe ventilation disorders (FVC<60% – grade 3 and 4 of ventilation failure). Mixed type disorders were recorded in 83% of patients, and restrictive type disorders in 17% (8/48) of children. After HGT, there was an improvement in pulmonary function indicators: an increase in FVC from 63.19% to 71.77% and FEV1 from 54.71% to 65.46%, Tiffeneau-Pinelli index – from 74.59% to 85.33%. Compared with the initial level of indicators, the improvement in FVC was 13.6% after HGT and 14.6% in dynamics during the year, and FEV1 – 19.6% and 21.6%, respectively. The results obtained indicate a significant improvement in the ventilation function of the lungs, especially due to the degree of FEV1 increase, which correlates with the degree of improvement in performance, mortality and life prognosis. Conclusions. The use of HGT makes it possible to improve the results of the final correction of spinal deformity, which in turn significantly improves the ventilation function of the lungs, which in turn helps to reduce the risks of mortality due to pulmonary insufficiency in adulthood. The choice of the appropriate methods of surgical correction for complex deformity of the spine is a prerequisite for successful treatment and the achievement of three-dimensional correction of the spine to maximally approximate its parameters to the physiological norm. The indication for halo gravity traction is a rigid scoliotic deformity of the spine with a deformity angle (>100°). This study was conducted in accordance with the principles of the Helsinki Declaration. The research protocol was approved by the Local Ethics Committee of the institutions mentioned in the work. Informed parental agreement was obtained for the research. No conflict of interests was declared by the authors. Key words: spinal deformity, respiratory dysfunctions, halo-gravity traction.

Postoperative condition of patients as a result of treatment of inguinal hernias by laparoscopic and open methods

Purpose – to analyze condition of patients after surgical treatment of inguinal hernias by laparoscopic and open methods. Materials and methods. A retrospective review of medical histories and outpatient charts of all patients who underwent inguinal hernia surgery at the Kyiv City Clinical Hospital No. 1 from January 2018 to July 2020 was conducted. Results. During the above period of time in our hospital open hernioplasty was performed in 86 patients, laparoscopic hernioplasty – 138 patients. With open hernioplasty, the average duration of surgical treatment was 40±12 minutes. The laparoscopic technique was 35±12 minutes. The length of hospital stay was significantly longer in the group of patients with the open method (48±12 hours) than in the group of laparoscopic plastic surgery (12±3 hours). From the group of patients who underwent open hernioplasty, 62 patients complained of long-term pain syndrome, from the group of laparoscopy – 12 patients. The cosmetic appearance was dissatisfied with 34 patients in the open access group and only 2 patients in the laparoscopic plastic group. Postoperative complications were observed in 34 patients who underwent surgical treatment through open access, and in 15 patients – by laparoscopy. Conclusions. The laparoscopic approach of inguinal hernia surgery is superior to open access, as it reduces the length of hospital stay, postoperative recovery, improves the aesthetic effect of the operation, reduces the frequency of infection of incisions. According to the results of the study, this technique gives a better result in the early postoperative period, a lower percentage of chronic pain and a higher degree of patient satisfaction compared to open access with the same low recurrence rate. Therefore, in our opinion, laparoscopic access to hernioplasty is the optimal method of treatment and can be recommended as a method of choosing inguinal hernia surgery. Postoperative assessment of the quality of life of patients after treatment of inguinal hernia by laparoscopic and open methods. 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 institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: inguinal hernia, laparoscopy, open access surgery, analysis of methods, operation.

Evolution of diagnosis and surgical treatment of intra-abdominal infiltrates, abscesses of primary and postoperative origin in patients

Purpose – to improve the results of surgical treatment of patients with intra-abdominal infiltrates and abscesses through the introduction of the latest imaging methods and surgical technologies. Materials and methods. In the clinic of the Department of Surgical Diseases No 1, on the basis of the Surgery Center of the Kyiv City Clinical Hospital No. 1 from 2006 to 2019 218 patients with primary and secondary intra-abdominal infiltrates, abscesses and fluid formations were treated. The patients’ age ranged from 16 to 85 years. There were 107 (49.08%) male patients, 111 (50.92%) female patients. Depending on the time of hospitalization (by years), the patients were divided into two groups: the control group (CG) (2006–2012) 117 (53.67%) patients and the study group (SG) (2013–2019) 101 (46.33%) patients. The SG used the latest imaging technologies and improved methods of surgical treatment. Results. The patients were divided into two groups: primary in 191 (87.61%) and secondary postoperative infiltrates and abscesses in 27 (12.39%). The causes of primary infiltrates and abscesses were: complicated forms of appendicitis in 74 (33.94%), perforated stomach and duodenal ulcer in 48 (22.02%), complicated forms of cholecystitis in 69 (31.65%). Postoperative infiltrates and abscesses were observed in 27 (12.39%) patients who underwent urgent surgery: adgeolysis of adhesive ileus in 14 (6.42%) and complicated hernias of various localization in 13 (5.97%). Postoperative complications were diagnosed in 43 (19.72%) patients, of whom 34 (15.59%) from the surgical wound and 29 (15.18%) of the abdominal cavity, who required relaparotomy or laparoscopy, with destructive appendicitis in 10 (13.51%), perforated gastric ulcer and 12 duodenal ulcer in 6 (12.5%), destructive cholecystitis in 9 (13.04%), adhesive intestinal obstruction in 13 (19.12%) and with strangulated and complicated hernias in 14 (17.28%) of the examined patients. During relaparotomy, incompetence of the intestinal wall and intestinal sutures was established in 11 out of 32 patients, an ileostomy was imposed in 7, and cecostomy in 1 patient. Actually, in the control group, 8 (6.84%) patients died on the background of ongoing peritonitis, thrombosis of mesenteric vessels and multiple organ failure and concomitant ailments and in the study group 4 (3.96%) patients died. Conclusions. Surgical treatment is individualized depending on the disease, so with destructive appendicitis from 74 (38.74%) laparotomic in 42 (21.99%), laparoscopic in 32 (16.75%), and in 12 (6.28%) with conversion; perforated gastric ulcer and duodenal ulcer in 48 (25.13%) open laparotomy; with cholecystitis of 69 (36.13%) patients, 48 (25.13%) had laparotomy and 21 (11.00%) had laparoscopic examination. The use of the latest imaging and treatment technologies: Doppler ultrasonography, hydrojet scalpel and laparoscopy in 64 (33.51%), allowed to have better near and long-term results and to reduce postoperative mortality from 6.84% to 3.96%, with an average of 5.5%. 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 these Institutes. The informed consent of the patient was obtained for conducting the studies. The authors declare no conflicts of interests. Key words: destructive appendicitis, cholecystitis, perforated gastric ulcer and 12-duodenal ulcer, adhesive leakage, strangulated hernias, diagnosis and treatment.

Nonoсclusive mesenteric ischemia (literature review)

Non-occlusive mesenteric ischemia is a relatively rare but extremely complex pathology in terms of diagnosis. A wide range of reasons for the development of non-occlusive impression dramatically complicates the diagnosis and differentiation with other abdominal pathology. The vast majority of publications in the domestic literature on acute disorders of mesenteric blood flow, mostly address the problems of diagnosis and treatment of occlusive types of mesenteric ischemia, while the topic of non-occlusive ischemia remains insufficiently covered. Given that in half of the cases NOMI is diagnosed at the stage of irreversible necrotic changes of the intestine – there is a real need to generalize the root causes and mechanisms of neoclustive mesenteric ischemia, modern methods of diagnosis and treatment. Purpose – to analyze of the causes, prevalence, classification, diagnosis and treatment of non-occlusive disorders of mesenteric blood flow. This research, based on literature review, showed that acute non-occlusive mesenteric ischemia (NOMI) is associated with poor prognosis due to the lack of accurate diagnostic measures. First of all, clarity regarding biochemical markers. Therefore, the research and development of the latter is seen as a priority. Contrast methods of examination (computed tomography, angiography) are the only possible diagnostic tools. Pharmacological correction is fundamental and presupposes the use of drugs with a vasodilating effect systemically or locally (catheter-associated). An important issue is the development of pharmacological agents that allow targeted action on the pathogenetic mechanisms of the development of NOMI. A multidisciplinary approach involving a specialized doctor, a surgeon, an X-ray endovascular surgeon and an intensive care physician in the treatment of a patient with suspected NOMI is the foundation for the success of therapy. The question of the use of laparoscopy remains controversial, given the invasiveness of the method and the difficulty of interpreting the changes detected in the early phase of the disease. No conflict of interests was declared by the authors. Key words: acute mesenteric ischemia, non-occlusive disorders of mesenteric blood flow.

The own experience of reconstructive-plastic operations on the bladder in children

In our country, complex surgical reconstruction of the distal urinary tract in severe bladder dysfunction in children is performed infrequently, given the number of children who need these operations. These operations were carried out in our country by specialists invited from abroad. Therefore, we want to share our first experience of performing a complex surgical reconstruction of the distal urinary tract in children. Purpose – to іmprove the quality of life of children with severe bladder dysfunction. Materials and methods. The results of reconstructive and plastic operations on the bladder in 7 children with severe bladder dysfunction were analyzed. Four patients had a neurogenic bladder 3 of them had a spinal bladder), and two patients had a microcyst after surgical correction of bladder exstrophy and total epispadias. Augmentation ileocystoplasty was performed in 3 children, two of them also underwent appendicocystostomy, 3 patients underwent only appendicocystostomy. An assessment of the urinary tract condition, the degree of urinary retention, postoperative complications and quality of life of operated children. Results. All operated children recovered. The bladders in three patients after augmentation have sufficient volume and fully provide reservoir function. We did not observe metabolic acidosis or other serious metabolic disorders described by other authors in the children we operated on. Urolithiasis was also not observed after surgery. In 5 patients who underwent appendicocystostomy, the latter is well catheterized, has a good cosmetic effect. In 4 out of 5 patients there is no leakage of urine through the stoma. All operated children were recovered for vesicoureteral reflux and chronic pyelonephritis. According to the results of the survey, the improvement of most parameters of quality of life of operated patients (cessation of urinary tract infection, complete urinary retention with more infrequent and controlled urination, the ability to visit children’s groups and social adaptation of these children in society). Conclusions. Based on the first own experience of augmentation ileocystoplasty and appendicocystostomy according to Mitrofanoff, the good efficiency of these reconstructive-plastic operations is noted. In all operated patients the quality of life significantly improved – controlled urination was achieved, the progression of kidney damage was stopped. All postoperative complications are successfully corrected. Of great importance for achieving a good effect of treatment is the correct choice of the the urinary tract surgical reconstruction type in each case. 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 institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: augmentation ileocystoplasty, appendicocystostomy, children.

Urinary tract infections in newborn children: microbial landscape and antibiotic resistance problems

Urinary tract infection is one of the most common bacterial infections in children, which in 30% of cases may be the first manifestation of the presence of congenital malformations of the urinary tract and urodynamic disorders in a child. Late diagnosis, initiation of therapy, and the choice of an inadequate antimicrobial drug increase the risks of disease progression, development of nephrosclerosis and patient disability. Purpose – to study the microbial landscape in urinary tract infections, its antibiotic resistance in newborns with anomalies in the development of the urinary system. Materials and methods. The results of microbiological examination of urine in newborns with urinary tract infections against the background of anomalies in the development of the urinary tract, which are being treated in intensive care units and neonatal pathology in the period 2016–2020, have been analyzed. Results. The main causative agents of urinary tract infections in newborns with anomalies of the urinary system are Enterobacterales (63.4%), 13.8% are producers of extended spectrum beta-lactamases. Cefoperazone/sulbactam, amikacin, meropenem and nitrofurantoin were most active against Escherichia coli. In relation to other representatives of the order Enterobacterales, only amikacin was highly active. The strains of Enterococcus spp., Detected in 20%, were resistant to reserve vancomycin in every fourth case. Representatives of non-fermenting gram-negative bacteria were found in 6.4% of cases, resistance to the main titrated antibiotics ranged from 44.4% to 100%. Conclusions. The main causative agents of urinary tract infections in newborns with anomalies of the urinary system are representatives of the order Enterobacterales, Enterococcus spp. and non-fermenting gram-negative bacteria, which were characterized by high resistance, including to reserve antibiotics. The high indices of resistance of the isolated microflora make it difficult to choose an effective antibacterial therapy in this category of patients and in most cases requires combined antibiotic therapy. 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 institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: Urinary tract infection, newborn babies, urinary tract abnormalities, antibiotic resistance.

Staged laparoscopic traction orchiopexy by Shehata: first experience, technical features, results

Purpose – to evaluate the results of proposed method of staged laparoscopic traction orchiopexy by Shehata on the basis of our own experience in the treatment of children with abdominal cryptorchidism. Materials and methods. During the period 2019–2021, 18 boys aged 9 months – 4 years were operated with staged laparoscopic traction orchiopexy procedure. Right unilateral abdominal cryptorchidism observed in 10 children, left – in 6, bilateral – in 2. Indications for the procedure were cases of intra-abdominal testicular retention with short vessels. Results. Pelvic and iliac retentions observed in 44% of cases. In 22% testicles were located close to the inner inguinal ring, in 33% the distance between testicle and inguinal canal opening reached 3–4 cm. The 2nd stage was carried out in 3 months. Successful orchiopexy was conducted then in 94% cases without any vascular tension. No cases of testicular dislocation or atrophy have been reported. The volume of operated testicles was smaller than the healthy ones in 78% cases objectively. Conclusions. The experience of Shehata operation showed good effect of the method for correction of abdominal cryptorchidism. Indications for staged laparoscopic traction orchiopexy are abdominal undescended testicles with insufficient length of vessels. The technique allows to achieve effective elongation of spermatic vessels in a short period of time and to minimize the risks of atrophy, compared with the 2-stage Fowler–Stephens operation. This study was conducted in accordance with the principles of the Helsinki Declaration. The research protocol was approved by the Local Ethics Committee of the institution mentioned in the work. Informed parental agreement was obtained for the research. No conflict of interests was declared by the authors. Key words: abdominal cryptorchidism, orchiopexy, staged treatment, Shehata procedure.

Cystoscopic features of the ureteral orifices in children with vesicoureteral reflux

Purpose – to establish cystoscopic prognostic criteria for vesicoureteral reflux (VUR) in children. Materials and methods. Clinical material covers 270 patients with VUR II–IV grades aged 9 months to 14 years and 22 healthy children. The study included patients with VUR in the period of clinical and laboratory remission without symptoms of neurogenic bladder. During cystoscopy, the condition of the bladder mucosa was assessed; location, shape, hydrodistention degree, and ureteral orifices contractility. Results. Patients with VUR were diagnosed ureteral orifices in the form of: horseshoes – 127 (47.04%) patients, stadium – 106 (39.26%) and golf holes – 37 (13.7%). They were in the zones: A – 13 (4.81%) children, B – 154 (57.04%), C – 67 (24.81%), D – 36 (13.33%), and were characterized by the hydrodistention degree: H0 – 7 (2.59%) patients, H1 – 173 (64.07%), H2 – 60 (22.22%) and H3 – 30 (11.11%). In children with VUR, sluggish peristalsis of the ureter orifices clearly prevailed – 252 (93.33%) cases, relative to active peristalsis in only 18 (6.67%) patients. Conclusions. For ureteral orifices in the form of a stadium and with more pronounced signs of deepening, which are shifted to zone B and laterally to the sidewall of the bladder, with a hydrodistention degree above H1 has a positive association with VUR at the highest specificity of tests. Unfavorable prognostic diagnostic markers for effective minimally invasive interventions in patients with VUR should be considered ureteral orifices, which combine such morpho-topographic characteristics as pronounced signs of deepening to the shape of a golf hole, lateralization to the sidewall of the bladder in zone D, and hydrodistention H3 degree. 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 institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: vesicoureteral reflux, ureteral orifice, cystoscopy, children.

Peculiarities of feminizing surgical correction in children with disorders of sexual development

Purpose – to analyze own results of surgical treatment of serious forms of disorders of sexual development (DSD) in children after feminizing surgeries. To define practical protocol guides on the choice of the type of surgical correction. Materials and methods. Over the past 5 years surgeons of Lviv regional paediatric clinical hospital «OHMATDYT» have examined 12 children with DSD, signs of hermaphroditism (intersex). After complex examination the following states were diagnosed: androgenital syndrome in 5 girls (referred for further treatment to Kyiv paediatric medical centres); true hermaphroditism – 1 child; mixed gonadal dysgenesis (MCG) – 3 children; female pseudohermaphroditism (without determining genesis) – 1 child; partial testicular feminization syndrome, Morris syndrome (male pseudohermaphroditism) – 2 children. In connection with marked masculinization of external genitalia two children with MCG and the girl with pseudohermaphroditism underwent feminizing surgery, namely genital zone reconstruction, mobilization and excision of urogenital sinus walls, excision of genital cavernous bodies (in children with MCG) with clitoroplasty, vulvoplasty with labioplasty and vaginoplasty. Children with Morris syndrome are being prepared to feminizing surgery. Results. Each child had a personal examination plan. Verification of a child’s state lasted from several weeks to 2–3 months. Children who underwent feminizing surgery did not have male structures and had relatively well-developed female structures. More «natural», less traumatizing correction was preformed for each specific case. In all children who underwent surgery vagina opened into urogenital sinus lower than external urethral sphincter, so there was no need to form front vagina wall (back and side walls were formed). Out of all children treated in our hospital gender was legally changed to the opposite. Conclusions. The birth of a child with DSD is a most challenging problem for parents, doctors, psychologists and social workers. Such states require complex examination. Children with severe hypospadias must undergo genetic examination. Statistic data and our own experience show higher frequency of feminizing surgeries in such cases. The most difficult part of such surgeries proves to be the excision of genital cavernous bodies with clitoroplasty and clitoris translocation; the most responsible part in functional sense is vaginoplasty. Surgical treatment is not the final stage of treatment for such patients. Children with DSD require constant further dynamic checkups by gynaecologists, urologists, oncologists, endocrinologists, psychologists with relevant therapy correction. 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 institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: disorders of sexual development (DSD), hermaphroditism, feminizing correction.

Complete duplication of the urethra in a boy with epispadias

Duplication of the urethra is a rare abnormality that can occur with other urogenital tract congenital pathologies. Ischemia at embryogenesis, urogenital sinus defect, Muller`s duct anomaly and incomplete mesodermal fusion are the pathophysiological mechanisms of the pathology onset. Duplication of the urethra diagnostics is based on clinical examination, disease anamnesis, urethrography and magnetic resonance imaging. It is nessessary to consider Effmann and Leibowitz classification, urethras and prostate location and urethral orifice distance on operation of additional urethra removing. Clinical case. Presenting a clinical case of a boy with grade I epispadias and complete duplication of the urethra. Urination was maintained and was performed from the dorsal-epispadic urethra, the ventral urethra was obliterated in the distal region. According to the data of magnetic resonance imaging: double urethra is traced, dorsal – comes out from the anterior parts of the bladder wall, continues along the dorsal surface under the dorsal neurovascular bundle, above the cavernous bodies. The urethra opening is traced at the level of the upper surface of the head of the penis. The distal / ventral urethra comes out from the posterior parts of the lower bladder wall, typically continues down through the prostate embryo, rotated forward between of the corporas cavernosas stipes, and had a typical location with except for the level of the penis head, where it bends and merges with the dorsal urethra, which opens with a single opening. The surgery of excision of an additional urethra on child was performed. During the examination of the child of 6 months after surgery: urination with one stream from the ventral urethra at the apex of the head of the penis, stream freely passes the Nelaton catheter No. 10, child holds urine, there was no complaints. Performing of the next stage of the operation (penis plastic surgery) is planned after 1 year of the previous stage. Conclusions. In cases of epispadias is possible a congenital defect – a complete douplication of the urethra with the ventral urethra obliteration at the top of the head, which may not be determined in epispadias surgery preparation. Doubling of the urethra in boys requires magnetic resonance imaging for a better orientation in the defect anatomy and to determine the tactics of further surgical treatment. 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 interest was declared by the authors. Key words: complete duplication of the urethra, surgical treatment, children.