CHRONIC CONSTIPATION IN INFANTS: THINK ABOUT RECTAL DUPLICATION

Rectum is the least common site of gastrointestinal duplication. Up to now fewer than 100 cases have been reported in the literature. We present two infants with cystic rectal duplications manifested with chronic constipation as a main clinical symptom. The first patient was a 4-year-old boy who was admitted to emergency department because of chronic constipation unresponsive to fiber supplements and laxatives. Digital rectal exam revealed mass adjacent to posterior rectal wall. Abdominal ultrasound and magnetic resonance imaging confirmed oval, homogenous and hypoechogenic cystic mass (87x65x60 mm in size) behind the rectum. The size and location of the cystic mass was confirmed by magnetic resonance imaging. The second patient was an 11-month-old boy who was hospitalized due to rectal bleeding. He was suffering from chronic constipation over the last five months. Digital rectal exam revealed a mass behind the rectum. Abdominal ultrasound and computed tomography showed unilocular cyst (33X33 mm in size) in front of the urinary bladder, partly extending into retrorectal space. Both patients were operated on. Postoperative periods were uneventful in both of them. Cystic rectal duplication must be ruled out in all infants with chronic constipation unresponsive to conservative treatment. Different imaging techniques are currently used to determine the precise size and location of duplication. Surgery is the only possible therapy option

USE OF BISPECTRAL INDEX (BIS) FOR MONITORING OF SEDATION AND TOTAL INTRAVENOUS ANESTHESIA (TIVA) IN PEDIATRIC PATIENTS UNDERGOING COLONOSCOPY

The objectives of this study were to determine whether there was a correlation between bispectral index (BIS) and Ramsey Sedation Scale (RSS) in regard to the type of sedation and total intravenous anesthesia (TIVA) during colonoscopy procedures in children, and to assess the utility of ketamine and propofol combination (ketofol) for this kind of procedures at children’s age. In our prospective study, 40 ASA I-II patients, 3 to 17 years of age, were randomly divided into two groups of 20 patients each.   After premedication with atropine and midazolam, sedation was induced with propofol and fentanyl in Group PF, whereas in Group PK propofol and ketamine were used for induction. Both groups were further divided into two subgroups depending on whether anesthesia was maintained with intermittent doses or continuous infusion of propofol. Ketamine and/or fentanyl were administered as bolus doses. Heart rate (HR), peripheral oxygen saturation (SpO2), RSS and BIS values of all patients were recorded every 5 minutes throughout the colonoscopy procedures.  The strongest degree of correlation between RSS and BIS existed when sedation or TIVA was maintained by the boluses of propofol and fentanyl. The use of ketamine significantly reduced the doses of propofol and fentanyl. BIS can be monitored in all pediatric patients in whom sedation and TIVA are administered during colonoscopy, but the effect of different anesthetics on the EEG signal should be considered in order to adequately assess the depth of sedation and anesthesia.Key words: awareness, monitoring, child, anesthetics, endoscop

ADVANCED LYPOSARCOMA MYXOIDES OF THE EXTREMITY

Sarcomas are soft tissue tumors arising from primitive mesenchyme. Small incidence (4-5/100 000 in Europe) is the reason their pathogenesis is relatively unknown. Patient (38) complained of a growth on the upper part of right thigh, the size of a child’s head. A magnetic resonance imaging (MRI) scan was done and tumefaction was described: oval shape, 13.5 x 7.5 x 11cm in diameter, without infiltration of surrounding tissue. The tumor was surgically removed and was pathohistologically verified as low grade liposarcoma myxoides. After initial presentation the patient presented a series of recurrences and metastases in the abdominal wall, extremities and  liver. Soft tissue metastasis from the lower extremities to the liver occur in 0.5% of cases and they are usually small and multiple, as in the presented patient. The European Sarcoma Medical Oncologist’s guide recommends that every  extremity tumor larger than 5cm and suspicious of malignancy should be evaluated using biopsy and imaging methods. A biopsy should be done before excision under ultrasound or computerized tomography (CT) guidance with the goal of planning the best therapy protocol and prevention of a generalized disease with metastases. The recommended imaging method is an MRI scan, although sarcomas can have a benign presentation.  Standard therapy includes surgical resection with local radiotherapy.  Liposarcoma myxoides, a rare soft tissue tumor, demands biopsy and complete surgical removal with detailed and continuous postoperative imaging follow-up and oncological therapy. The therapeutic goal is to increase survival and preserve extremity function

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Importance of a Follow-Up Ultrasound Protocol in Monitoring Posttraumatic Spleen Complications in Children Treated with a Non-Operative Management

Background and objectives: For the last three decades, non-operative management (NOM) has been the standard in the treatment of clinically stable patients with blunt spleen injury, with a success rate of up to 95%. However, there are no prospective issues in the literature dealing with the incidence and type of splenic complications after NOM. Materials and methods: This study analyzed 76 pediatric patients, up to the age of 18, with blunt splenic injury who were treated non-operatively. All patients were included in a posttraumatic follow-up protocol with ultrasound examinations 4 and 12 weeks after injury. Results: The mean age of the children was 9.58 ± 3.97 years (range 1.98 to 17.75 years), with no statistically significant difference between the genders. The severity of the injury was determined according to the American Association for Surgery of Trauma (AAST) classification: 7 patients had grade I injuries (89.21%), 21 patients had grade II injuries (27.63%), 33 patients had grade III injuries (43.42%), and 15 patients had grade IV injuries (19.73%). The majority of the injuries were so-called high-energy ones, which were recorded in 45 patients (59.21%). According to a previously created posttraumatic follow-up protocol, complications were detected in 16 patients (21.05%). Hematomas had the highest incidence and were detected in 11 patients (14.47%), while pseudocysts were detected in 3 (3.94%), and a splenic abscess and pseudoaneurysm were detected in 1 patient (1.31%), respectively. The complications were in a direct correlation with injury grade: seven occurred in patients with grade IV injuries (9.21%), five occurred in children with grade III injuries (6.57%), three occurred in patients with grade II injuries (3.94%), and one occurred in a patient with a grade I injury (1.31%). Conclusion: Based on the severity of the spleen injury, it is difficult to predict the further course of developing complications, but complications are more common in high-grade injuries. The implementation of a follow-up ultrasound protocol is mandatory in all patients with NOM of spleen injuries for the early detection of potentially dangerous and fatal complications

CHARACTERISTICS OF CLINICAL SYMPTOMS IN CHILDREN’S INVAGINATIONS

Invagination (intussusception) is a specific cause of intestinal occlusion, which, according to its frequency, occupies high position in pediatrics’ abdominal surgical pathology. It is registered in children from 6 to 9 months of age, being more common in boys than in girls (3:2) with the incidence of 1-4 per 1000 newborns. In 80 % of cases, the ileocecal and ileocolic forms are registered. Invagination is usually idiopathic (90 %), but sometimes, pathoanatomic substrate may be seen (leading point) in the form of lymph nodes or Meckel’s diverticulum. Surgical therapy for the second group is more radical. The analysis encompassed 22 patients with invaginations - 14 boys (63, 63 %) and 8 girls (36, 36 %), which is 7, 33 yearly. In our study, the most frequent are ileocecal and ileoileal forms (90, 63 %); less frequent are ileocolic and colocolic forms of invagination (9, 09 %). Clinical symptoms are present in the form of characteristic triad: intermittent painful crises, vomiting and stool with blood (currant jelly). Sometimes, they are followed by temperature, collapse, adynamia and convulsions. This triad of symptoms (pain, vomiting and blood in the stool - "currant jelly") is pathognomonic for the diagnosis of this disease

Simultaneous correlation of the excess enthalpy and W-shaped excess heat capacity of 1,4-dioxane+n-alkane systems by PRSV-HVOS CEOS

In this work the Peng-Robinson-Stryjek-Vera (PRSV) equation of state coupled with the Huron-Vidal-Orbey-Sandler (HVOS) rule was tested for the correlation of the excess enthalpy (HE) and the excess heat capacity (cpE) alone and simultaneously. The HVOS mixing rule incorporates the NRTL equation as the GE model. All calculations were performed using the linear and reciprocal forms of the temperature dependent parameters of the models. For all the evaluations the 1,4-dioxane+n-alkane systems were chosen having in mind the unusually W-shaped concentration dependence of cpE for these systems. The correlation of the HE and cpE data alone for all the investigated systems using four coefficients and for the simultaneous correlation of HE+cpE data using six coefficients of the temperature dependent parameters of the PRSV-HVOS models could be considered as being very satisfactory

Vapour–liquid equilibria of the OPLS (Optimized Potentials for Liquid Simulations) model for binary systems of alkanes and alkanes + alcohols

The NpT - Gibbs ensemble Monte Carlo computer simulationmethod was applied to predict the vapour–liquid equlibrium (VLE) behavior of the binary systems ethane + pentane at 277.55 K and 310.95 K, ethane + hexane at 298.15 K, propane + methanol at 313.15 K and propane + ethanol at 325.15 K and 425.15 K. The optimised potentials for the liquid simulating (OPLS) model were used to describe the interactions of alkanes and alcohols. The simulated VLE predictions are compared with experimental data available for the pressure and phase composition of the analyzed binary systems. The agreement between the experimental data and the simulation results is found to be generally good, although slightly better for system in which both components were nonpolar

Excess molar volume of the acetonitrile + alcohol systems at 298.15 K. Part I: Density measurements for acetonitrile + methanol, + ethanol systems

The excess molar volume VE of the binary liquid systems acetonitrile + methanol and acetonitrile + ethanol has been evaluated from density measurements at 298.15 K and at atmospheric pressure over the entire composition range. A vibrating tube densimeter, type Anton Paar DMA 55, was applied for these measurements. The RedlichKister equation was used to fit the experimental VE data