Portal hypertension in children: 27 years’ experience of surgical treatment

Surgical procedures are known to be most effective in preventing variceal bleeding (VB) in children with portal hypertension (PH). The quality of life, possibility of the portosystemic encephalopathy, and the deterioration of liver function after shunt procedures in children with PH are the aim of our study. Methods. 718 children with PH were treated in our hospital since 1989. 639 (89%) had extrahepatic PH. 577 patients underwent portal systemic shunting (PSS). In 81 children Rex-shunts were performed. In 24 patients Sugiura operations were done. Endoscopies, Duplex scanning, biochemical tests and psyhoneurological evaluation were performed after a one-year period. 172 patients were evaluated in 5-18 years after surgery to determinate the long-time results. Results: Re-bleeding occurred in 21 (3,7%) children with PPS. In the long–term period portal perfusion (PP) after PSS decreased down in 84%. No patient developed portal-systemic encephalopathy. No signs of liver function deterioration were found. The re-bleeding rate after Rex-shunt was 5,5%. In patients with Rex-shunt, a normal PP was restored in the early postoperative period. The Sugiura procedure produced the highest rate of re-bleeding – 25%. In 12 patients, we combined the Sugiura procedure with planned endoscopic sclerotherapy in the postoperative period. This decreased re-bleeding to 8,3%. Conclusions. The PSS is an effective and method of preventing of VB and does not seriously degrade quality of life of the child. The Rex shunt effectively restores PP in the post-operative period. In cases when shunt surgery is not possible, the Sugiura procedure is the operation of choice with endoscopic sclerotherapy for remnant varices

Surgycal treatment of children with gastroesophageal reflux: 15 years experience

Introdactions. Laparoscopic fundoplication for gastroesophageal reflux disease (GERD) is one of the most common procedures performed in children. We have used laparoscopic Nissen fundoplication (LNF) over the past 15 years as the procedure of choice. The aim of this study is to evaluate the effectiveness and long-term results of LNF on a large clinical material. Materials and methods. Since 2001, in 785 children with GERD had LNF performed. The median age was 4.7 years. Weights of children ranged from 2,7 to 120 kg. Long term results were evaluated over 2-15 years after operation. Indications for surgery were ineffective conservative treatment in all cases, severe esophagitis - in 383(56%) children, growth retardation - in 365 (46%), hiatal gernia - in 225 (30%), peptic stenosis - in 123 (15%), respiratory complication - in 143 (18%) children. Severe neurological disorders were found in 324 patients. In 21% GERd was associated with genetic synromes.Analysis of the treatment results tracked the following: 1) intraoperation complications; 2) postoperative complications; and 3) relapse of disease. Treatment results showed the absence of clinical displays of the disease, the knocking over of reflux-esophagitis, and the absence of GERD, according to pH-monitoring. Results. Hyatoplasty was performed in 32% of the cases. And in 39 children with huge hernias of esophageal apertures of a diaphragm a hernial sac excision and hyatoplasty was carried out. The average operating time was 51.3 ± 25.2 minutes. Intraoperative complications occurred in 11 (1.5 %) children (perforation of the stomach – 4, wound of a spleen – 4, pneumothorax – 3, and oppression of heart activity – 1). Postoperative complications developed in 15 (1.9 %) children (mediastinitis – 1, dysphagia – 8, and diarrhea – 6). Intraoperation complications in 2 cases required conversions to open operations. There were no mortalities. In 19 patients simultaneous opearations were performed (thoracoscopic closure of ductus arteriosus, lung resection, etc.). 15 patients were laparoscopicaly operated after failed previous open fundoplications. Good results were achieved in 678 (91,5%) patients. Relapse of the disease were found in 67 patients. In all cases, repeated LNF were performed. The positive results were gained totally in all children with GERD. Conclusion. LNF is a radical method of treatment of GERD in children, which has positive results after primary operation in 92% of cases

Slide tracheoplasty in children with congenetal tracheal stenosis

Introduction. Congenital tracheal stenosis (CTS) is a rare life-threatening condition that often requires early surgical intervention. Treatment of CTS remains challenging. Patients and methods. Between 2011 and 2016, 16 patients underwent slide tracheoplasty. The median age at surgery was 14.9 months (range, 18 days - 10.5 years). The median body weight was 9.4 kg (range, 1.8- 32.8kg) at operation. Thirteen (81%) patients had long-segment CTS (>50% of total tracheal length), including 6 (38%) patients withtracheal stenosis extended to the bronchus. Abnormal bronchial arborization presented by an anomalous right upper lobe bronchus was detected in 6 patients. Fourteen (88%) patients had associated cardiovascularmalformations, which were previously operated on 5(31%) patients and simultaneously operated on 8(50%) patients. These defects and CTS were repaired with intraoperative usage of ECMO in 9(56%) patients versus conventional ventilatory support under cardiopulmonary bypass (CPB) in 7(44%) patients. Results. There was no airway-associated mortality. One child died for some technical reason. Another died of multiple organ failure one year after the STP. The median follow-up period for the survivors was2.2 years (range, 0.2 – 5.1 years). In these15 patients, the median duration of ventilatory support was 8 (range, 1-25) days. The median duration of postoperative hospitalization period was 36 (range, 8-64) days, including the median duration of ICU stay 26 (range, 6-42) days. Post-STP airway intervention (bougienage or laser photocoagulation) was necessary in 6 of our patients, no one required additional surgical procedures, stenting was not required either.All survivors (100%, 15 out of 15) were asymptomaticat last follow-up. Conclusions. Our data suggest that children with CTS benefit from the usage of ECMO and the policy of simultaneous surgical treatment of associated cardiovascular malformations. Moreover, using intraoperative ECMO provides comfort conditions for surgeons facilitating a technically complicated operation and decreasing intra- and postoperative risks of common complications

Endoscopic division of the vascular rings in children

Introduction. Congenital anomalies of the aortic arch such as a double aortic arch and a right-sided aortic arch can result in a severe respiratory failure, which requires emergency surgery. Modern equipment and accumulated experience make it possible to perform thoracoscopic surgery for this type of pathology. Materials & methods. A total of 16 children (age from 1 months to 17 years, weight from 3,3 to 64 kg) who underwent thoracoscopic division of vascular rings from 2008 to 2016 in Filatov Pediatric Clinical Hospital No.13 were included in the study. The timing of surgery depended on the clinical picture and the severity of the respiratory failure. There were two types of vascular rings: double aortic arch - 7 children (40%), right-sided aortic arch with Botallo’s duct - 9 children (70%). Results. Mean operating time was 57 minutes. The average length of stay was 10 days. There was no intraoperative complications. In early postoperative period there was bleeding in one child due to failure of clipping the the distal segment of the aortic arch which required thoracotomy. Postoperative chylothorax was observed in one child, which was treated conservatively. Conclusion. The latest advances in surgical methods allowed to make thoracoscopic division of vascular rings in infants and children the method of choice with detailed intraoperative visualisation of the anatomy of the defect and secure mobilization of large vessels. Thoracoscopic surgery for congenital anomalies of the aortic arch is feasible to improve the postoperative outcomes and reduce the time of hospitalization

Esophageal substitution in children. Gastric transposition

For a long time colonic esophagoplasty were operations in choice in our institution. From 2009 we introduce stomach esophagoplasty to evaluate the results and long-term outcome of this surgical option as well as to provide a comparative analysis of this technique and colonic esophagoplasty. Materials and methods. From January 2009 till May 2015 44 children underwent stomach esophagoplasty in Filatov Children’s Hospital, Moscow. The patients were aged from 2 months till 13 years. Esophageal atresia was present in 15 (34%) cases, esophageal strictures – in 16 (36.4%), peptic stenosis – in 8 (18.2%), other disorders – in 5 (%) children. To evaluate both short-term and long-term outcomes we consider the following data: clinical examination, questionnaires, esophago gastroduodenoscopy, X-ray contrast study of GIT. In 32 children (72.8%) the stomach was moved through the posterior mediastinum, in 12 (27.2%) patients – trough the anterior mediastinum. Complications. In early postoperative period we had the following complications: pneumonia, pneumothorax, gastric-intestinal bleeding, eventration, enterocolitis, jejunum perforation. In the long-term follow up we diagnosed stenosis of gastroesophagoanasthomosis, aspiration pneumonia, hiatal hernia. Discussion. Stomachesophagoplasty is more easy from the technical point of view. Operation time makes from 50 minutes till 2 o’clock and 40 minutes. We had no necrosis of transplant. In 8 children this operation was made after unsuccessful colonic esophagoplasty. Average stay in the intensive care unit was 6 days. Feeding behavior of the patients after stomach esophagoplasty is strictly regulated by the compelled guidelines. Conclusion. Stomach esophagoplasty has its advantages and drawbacks. Our experience presents the comparative analysis of the outcomes of colonic esophagoplasty and stomach esophagoplasty, guidelines of how to choose the best way of esophageal repair. The above described surgical option gives way to more opportunities for a surgeon and helps to improve treatment outcomes in children with esophageal disorders

Criteria for Carotid Atherosclerotic Plaque Instability

© 2020 Elsevier Inc. Background: The study aim is to determine the criteria for carotid atherosclerotic plaque instability with the use of an advanced ultrasound technology, immunohistochemical analysis, and electron paramagnetic resonance (EPR) and assess their correlations with histologic results. Methods: A total of 92 patients were included in the study and were examined by ultrasound duplex scanning and ultrasound elastography. Plaques harvested during carotid endarterectomy were obtained for histologic analysis, immunofluorescent assay, and EPR spectroscopic measurements. Results: Multivariate logistic regression analysis showed that plaques with an area >90 mm2 (odds ratio [OR], 4.05; 95% confidence interval [CI], 1.32–13.2; P = 0.006), plaque volume index > 0.6 cm3 (OR, 2.72; 95% CI, 1.05–9.58; P = 0.04), and juxtaluminal black area ≥8 mm2 (OR, 2.82; 95% CI, 1.22–6. 23; P = 0.02) were statistically significant independent predictors of histologically verified unstable plaques. Unstable plaques occurred in 94% of the patients with these indicators. Significant increases in the number of CD68+ and CD36+ cells (inflammatory markers) and CD31+ cells (neovasculogenesis markers) were revealed in unstable plaques by the immunohistochemical assay. EPR data analysis showed that divalent manganese could serve as a marker of plaque instability. Conclusions: Additional ultrasound criteria, verified by histologic studies, significantly increased the information content for identifying patients with unstable plaques, which can be of great importance in stratifying the risk of ischemic stroke, especially in asymptomatic patients. The degree of calcification is not a mandatory criterion for plaque stabilization