Inanimate 3D printed model for thoracoscopic repair of esophageal atresia with tracheoesophageal fistula

Background

Thoracoscopic repair of esophageal atresia (EA) and tracheoesophageal fistula (TEF) poses significant technical challenges. This study aimed to develop an inexpensive, reusable, high-fidelity synthetic tissue model for simulating EA/TEF repairs and to assess the validity of the simulator.

Methods

By using 3D printing and silicone casting, we designed an inexpensive and reusable inanimate model for training in thoracoscopic EA/TEF repair. The objective was to validate the model using a 5-point Likert scale and the Objective Structured Assessment of Technical Skills (OSATS) to evaluate participants' surgical proficiency.

Results

A total of 18 participants (7 medical students, 4 pediatric surgery trainees, and 7 experienced surgeons), after being instructed and trained, were asked to perform TEF ligation, dissection, as well as esophageal anastomosis using six sliding knots on the EA/TEF simulator. All participants in the expert group completed the task within the 120-minute time limit, however only 4 (57%) participants from the novice/intermediate completed the task within the time limit. There was a statistically significant difference in OSATS scores for the "flow of task" (p = 0.018) and scores for the "overall MIS skills" (p = 0.010) task distinguishing between novice and intermediates and experts. The simulator demonstrated strong suitability as a training tool, indicated by a mean score of 4.66. The mean scores for the model's realism and the working environment were 4.25 and 4.5, respectively. Overall, the face validity was scored significantly lower in the expert group compared to the novice/intermediate groups (p = 0.0002).

Conclusions

Our study established good face and content validity of the simulator. Due to its reusability, and suitability for individual participants, our model holds promise as a training tool for thoracoscopic procedures among surgeons. However, novices and trainees struggled with advanced minimally invasive surgical procedures. Therefore, a structured and focused training curriculum in pediatric MIS is needed for optimal utilization of the available training hours.

Laparoscopic management of the congenital chylous ascites in a newborn: Case report

Congenital chylous ascites (CCA) is a rare condition seen in the neonatal period. The pathogenesis is primarily related to congenital intestinal lymphangiectasis. Conservative treatment of chylous ascites involves paracentesis, total parenteral nutrition (TPN), medium-chain triglyceride (MCT)-based milk formula, use of somatostatin analogue and octreotide. Surgical treatment is considered when conservative treatment fails. We describe a laparoscopic treatment of CCA using the fibrin glue technique. A male infant, in whom foetal ascites was detected at 19 weeks of gestation, was born by caesarean section at 35 weeks of gestation weighing 3760 g. There was evidence of hydrops in the foetal scan. A diagnosis of chylous ascites was made by abdominal paracentesis. A magnetic resonance scan was suggestive of gross ascites, and no lymphatic malformation was identified. TPN and octreotide infusion was started and continued for 4 weeks, but the ascites persisted. The failure of conservative treatment led us to perform laparoscopic exploration. Intraoperatively, chylous ascites and multiple prominent lymphatic vessels around the root of the mesentery were noted. The fibrin glue was applied over the leaking mesenteric lymphatic vessels in the duodenopancreatic region. Oral feeding was started from post-operative day 7. After 2 weeks of the MCT formula, ascites progressed. Thus, laparoscopic exploration was necessary. We introduced an endoscopic applicator for fibrin glue and applied it into the place of leakage. The patient was doing well with no appearance of ascites reaccumulating and was discharged on the 45th post-operative day. Follow-up ultrasonography (1st, 3rd and 9th months after discharge) showed a small amount of ascitic fluid but with no clinical significance. Laparoscopic localisation and ligation of leakage sites could be difficult, especially in newborns and young infants due to the small size of lymphatic vessels. The use of fibrin glue to seal the lymphatic vessels is quite promising.

Prenatal and postnatal peculiarities and consequences of intestinal loop patency disorder with expansive giant cystic abdominal mass in a preterm newborn

AIM

To analyse the findings in a newborn (36 gestational weeks, birth weight: 4,030 grams, birth length: 48 cm, Apgar score 7/8/8 points) with prenatal suspicion of intestinal obstruction at the duodenum/jejunum level. The patient required urgent surgery on the first day of life.

RESULTS

Examination of the abdominal cavity confirmed the presence of a cystic mass with a volume of approximately 800 ml, which was located at the site of jejunal atresia. As part of the surgical solution, the cystic formation and the atretic segment of the intestine were resected with subsequent end-to-end jejuno-jejunal anastomosis and Bishop‒Koop ileostomy. The histological examination of 3 samples collected confirmed the presence of mucous membrane and smooth muscle.

CONCLUSION

The cyst anatomically communicated with the aboral section of the jejunum, but the lumen of the jejunum was functionally obturated by solid whitish masses. The histological examination confirmed the diagnostic features of a cyst of intestinal origin. The ileum and colon were patent throughout, but of smaller diameter, so a Bishop-Koop relieving anastomosis was indicated. The condition of the child at the age of 9 months was stabilised and surgical closure of the stoma was carried out (Tab. 1, Fig. 8, Ref. 21). Text in PDF www.elis.sk Keywords: newborn, jejunal atresia, intestinal cyst.

Minimally Invasive Partial Spleen Resection Preserving the Lower Pole in Children: A Technical Report on Feasibility and Safety

Background: Laparoscopic partial splenectomy is a surgical option for removing part of the spleen with a pathological mass in a way that ensures preservation of the spleen's physiological functions. We aimed to evaluate the efficacy and feasibility of this procedure, performed while preserving the blood supply from the left gastroepiploic artery, in children. Materials and Methods: Following institutional review board approval, this retrospective study was conducted on patients who, between January 2015 and December 2019, underwent laparoscopic partial splenectomy with preservation of blood supply from the left gastroepiploic vessels. In the article, we described patient indications for surgery, surgical technique, surgery time, complications, and follow-up outcomes. Results: Eleven patients (mean age: 12.3 ± 3.4 years) underwent laparoscopic partial splenectomy. Indications for surgery included nonparasitic cysts (n = 8), pseudocysts (n = 2), and hamartomas (n = 1). The mean benign mass diameter was 60 ± 22 mm. The mean operative time was 193.2 ± 55.1 minutes. The mean size of the retained lower pole was 31.1% ± 3.8%. There was no conversion to open splenectomy or any significant complication. The mean postoperative stay was 9 ± 0.7 days. No thrombosis of the splenic and portal veins was noted in the follow-up period, and no splenic remnant infarction occurred. Conclusions: Laparoscopic partial splenectomy with preservation of blood supply arising from the left gastroepiploic vessels seems to be safe in children. However, a larger study is needed to confirm our results.

A rare histopathological fi nding after lung resection in a child

BACKGROUND

The authors present a case of a patient with an extremely rare lung tumor in a child.

CASE

A 9-year-old girl with a 3-day history of dyspnea and stabbing pain in the xiphoid region, irradiating to the area under the left costal margin, both in rest and in physical activities. She was primarily examined in a regional hospital with bounded homogenous focus of the superior right lung lobe on the X-ray. After initial treatment with antibio-tics and persistent finding on X-ray, a CT scan of the chest was performed. It revealed an irregular oval lesion of a non-homogenous structure with a contrast dye in the S3 region merged to pericardium and parietal pleura, which the presence of several micronodules. Based on the negative tumor markers, positive PET-CT scan and a negative etiology, bio-psy or eventually a lesion exstirpation were indicated. Right-sided thoracotomy, mass enucleation and exstirpation of nodular lesions were performed 2.5 months after the onset of difficulties. Postoperative recovery was uneventful, no sign of recurrence occurred during a follow-up period. The final histological finding was verified as an inflammatory myofibroblastic tumor - an extremely rare pulmonary pathology in the pediatric population.

CONCLUSION

Inflammatory myofibroblastic tumor can be mimicking IgG4 sclerosing disease and inflammatory pseudotumor. It is essential to distinguish between these affections because of different (i.e. surgical vs. conservative) treatment approach.

Thyroid surgery in children: our experience

INTRODUCTION

Thyroid surgery in children is a rare operation. The aim of our paper is to point out the specifics of thyroid surgery in children.

METHODS

Retrospective analysis of patients hospitalized at the Department of Paediatric Surgery, Faculty of Medicine, Comenius University and National Institute of Childrens Diseases in Bratislava during a 10-year period (20072016) who underwent thyroid surgeries.

RESULTS

The retrospective analysis included 81 patients: 66 (81%) girls and 15 (19%) boys. The mean age of the patients was 14 years ±8 months (range 418 years). The most common indications for thyroid surgery were: a nodule in 36 (44.4%) patients, Graves Basedow thyrotoxicosis in 19 (23.5%) patients, and suspected thyroid carcinoma in 11 (13.6%) patients. Cervical lymph node metastases (mts) were diagnosed in 9 (11.1%) patients, and distant pulmonary metastases in 5 (6.17%) patients. Total thyroidectomy (TTE) was performed in 43 (53%) patients, total lobectomy (TL) in 20 (24.7%) patients. Extended surgery on regional lymph nodes was performed in 9 (11.1%) patients. Eight (9.9%) patients underwent reoperation. A total of 12 (14.8%) patients experienced postoperative complications. Unilateral transient recurrent laryngeal nerve (RLN) paralysis occurred in 2 patients, and permanent in one patient. Transient postoperative hypoparathyroidism with hypocalcaemia was reported in 8 (9.9%) patients; no permanent condition of this type was observed.

CONCLUSION

Multidisciplinary collaboration ensures that optimal surgical results are achieved in the patients. Experience of the surgeon performing thyroid surgery in children remains crucial.

A case report of positive Charcot´s triad from a rare infectious etiology

Chlamydia pneumoniae (C. pneumoniae) is an obligate intracellular bacterial pathogen, which has long been investigated as a potential developmental or exacerbating factor in various pathologies. C. pneumoniae infects mainly the respiratory tract, but also has been associated with extrarespiratory manifestations. We report on an uncommon case of young patient with acute acalculous cholecystitis (AAC) and acute pericarditis during the chlamydia pneumoniae infection with hematogenous / lymphogenous routes of systemic dissemination of Chlamydia pneumoniae infection.

Current management of pediatric appendicitis: A Central European survey

BACKGROUND

Appendicitis is one of the most common diagnoses in pediatric populations. Although new recommendations for the treatment of pediatric appendicitis were published, management varies among different institutions.

OBJECTIVES

To determine current practices in 4 (n = 4) representative pediatric surgical departments in Central Europe.

MATERIAL AND METHODS

One department from each of the 4 countries was surveyed using an online questionnaire. Questions focused on preoperative, operative and postoperative practices in 2018, particularly those related to antibiotic (ATB) therapy and laparoscopy.

RESULTS

A total of 519 appendectomies were performed, among which 413 (79.6%) were laparoscopic appendectomies (LAs), with a conversion rate of 5.1%. Appendectomy, as an elective procedure, was performed in 43 (8.3%) patients. One-quarter (129 patients) had complex appendicitis and 72.3% of these were operated laparoscopically. In 3 departments, ATB prophylaxis was administered, based on the decisions of the operating surgeon. One department used standard ATB prophylaxis (metronidazole). Whenever phlegmonous appendicitis was detected, ATB were administered therapeutically in 2 departments. Two other departments administered ATB based on surgeon decision. The choice of ATB was not standardized. If complex appendicitis was detected, all sites administered ATB therapeutically. The type of ATB treatment was standardized in complex cases in 2 departments. Thirty-four complications (6.6%) at surgical sites were recorded - 4.1% (16/390) after uncomplicated and 14% (18/129) after complex appendicitis. Thirty-two occurred after acute surgeries and 26 of these followed laparoscopic procedures. Postoperatively, intra-abdominal abscesses occurred in 3.5% of laparoscopic and in 2.9% of open appendectomy (OA) cases.

CONCLUSIONS

This questionnaire study showed that treatment outcomes for appendicitis in children in Central Europe are comparable with data reported in the literature. Laparoscopic appendectomy is the predominant surgical method, but there is a little consensus for ATB treatment in the management of appendicitis at our 4 pediatric surgical departments.

Rare causes of respiratory insufficiency in newborns

Congenital lung masses (CLM) the rare group of causes of acute respiratory insufficiency (RI) in newborns include congenital airway pulmonary malformation (CAPM), congenital overinflation, bronchopulmonary sequestration, and bronchial atresia. The presenting group consists of 13 newborns who were admitted to the Neonatal Department of Intensive Medicine (NDIM) during January 1st 2015-December 31st 2019 (8 males, 5 females, 2 premature/11 term newborns, spontaneous delivery: 2, caesarean section: 11) with positive prenatal diagnosis of CAPM in all cases. In 2 cases prenatal intervention was performed (drainage of the amniotic fluid, attempt of thoracentesis). Signs of acute RI immediately after delivery were seen in 5 newborns. Postnatal echocardiographic investigation confirmed the presence of increased pulmonary pressure in 8 patients, no patient had congenital heart abnormality. A thorax x-ray was positive also in asymptomatic patients. Computed tomography in patients brought detailed information about the position, size and character of CAPM. Six patients underwent surgery. In 15.4 % right lungs were affected by cystic malformation and in 23 % left lungs were affected. A final diagnosis of CAPM was confirmed in 5 patients using histopathologic examination. Multidisciplinary cooperation during prenatal as well as postnatal period is necessary.

Pacinian collagenoma: A distinct form of sclerotic fibroma

Sclerotic fibroma (storiform collagenoma) is a rare benign skin tumor. A solitary tumor, as well as multifocal lesions, are found either sporadically, or associated with Cowden syndrome. The tumor usually presents as clinically asymptomatic, slowly growing papule or nodule on the skin of the head, neck, and upper extremities. Microscopically the lesion is sharply demarcated, composed of hyalinized bands of collagen with low cellularity and a distinctive irregularly whorled or storiform pattern. We describe a case of a unique variant of this tumor in the scalp of a 33-year-old male. The tumor was microscopically composed of concentrically arranged collagen bundles with prevailing type III collagen, which resembled an enlarged Vater-Pacini corpuscle, with low density of CD34-positive and glucose transporter 1-negative spindle shaped cells. The specific microscopic appearance is suggestive of the term "Pacinian collagenoma" for this unique benign tumor.

The histological properties and possible origin of cervical thymus with cysts - A case report and hypotheses about its development

Ectopic accessory thymic tissue usually presents as an asymptomatic neck mass found at any level corresponding to the embryonic descent of the thymus. This tissue may contain smaller or larger cysts. However, the exact pathogenesis of "enigmatic" cervical thymic cysts remains controversial. A 7-year-old boy was referred to our workplace for the evaluation of a cervical mass. An ultrasound suggested a multi-loculated cystic mass, while CT and MRI indicated a left-sided, anteriorly located cervical mass beneath the sternocleidomastoid muscle. Following the radiological findings, surgical excision revealed a cystic mass. The mass of tissue was covered by a capsule. In H&E staining, the cervical mass had the same structure as normal thymus. Additionally, immunohistochemical findings suggest that the cellular microenvironment of cervical thymus also displays a place for development of T-lymphocytes. Within the parenchyma multiple cysts lined with cytokeratin-positive thymic epithelial cells were found. Inside the cysts, there were CD68-positive multinucleated giant cells and cholesterol clefts. A tendency to cystic degeneration inside the thymic tissue occurs more often in cervical thymuses than in normally located ones. The reason for the formation of cysts is unknown. We summarized seven possible histological, embryological and evolutional backgrounds for the development of these thymic cysts.

Laparoscopic treatment of bowel perforation after blunt abdominal trauma (BAT) in children

Minimally invasive techniques have now become standard for the treatment of many surgical conditions in children. There are a few studies that describe the utility of laparoscopy in BAT in children. In this article, we describe the complete laparoscopic surgical treatment of two patients after a single blunt abdominal trauma, both with bowel perforation. In both cases, the perforation was identified and closed, one laparoscopically with an ongoing suture, the second jejune perforation was closed by laparoscopic-assisted techniques. Both patients had an uneventful postoperative recovery. Therapeutic laparoscopic treatment of patients with upper gastrointestinal perforation is feasible. We hypothesize, that diagnostic laparoscopy provides important information for the treatment of children with abdominal trauma and is accompanied by improved diagnostic accuracy, reduction of nontherapeutic laparotomy rates, and a reduction of morbidity. Minimally invasive surgery in children after BAT is suitable for hemodynamic stable patients, could improve pain scores, cosmetic effect, shorter hospital stays, shorter operative times and shorter return to school/activities. However, at any point in the patients care, in case the unstable hemodynamic is encountered, exploratory laparotomy is the procedure of choice.Key words: miniinvasive surgery blunt abdominal trauma - laparoscopy bowel perforation.

An embryological point of view on associated congenital anomalies of children with Hirschsprung disease

The most common congenital gut motility disorder is the Hirschsprung disease (HSCR). This anomaly is characterized by absence of neural crest-derived enteric neuronal ganglia. The aim of our study was to analyze the relationship between HSCR and other congenital anomalies or malfunctions. We examined 130 patients with Hirschsprung disease from Slovakia for last 10 years. During patients examination we focused not only on morphological abnormalities, but also functional anomalies. The incidence of associated congenital anomalies in our patients with HSCR was 26.1 %. But if we add functional defects (hypothyroidism, malfunction in cellular immunity, neurological deficit) to the morphological congenital abnormalities, the rate of the patients with HSCR with additional defects achieves 50.1 %. Nine of our patients (6.9 %) had syndromic HSCR. The most frequent disorder (13.6 % of patients) was primary deficiency in cellular immunity. More than 12.3 % of patients with HSCR had genitourinary abnormalities, in 10.0 % of patients variable degree of psychomotor retardation was observed, and skeletal, muscle and limb anomalies involved 7.7 % of patients. In 7.6 % cases of patients we found congenital hypothyroidism (including 2 cases of agenesis of thyroid gland). More than 6.1 % of patients presented with an associated anomaly in gastrointestinal tract (mostly anorectal malformations). Up to 5.5 % patients had congenital anomaly of heart, 3.8 % had ophthalmic and 3.1 % had craniofacial anomalies. Down syndrome was the main diagnosis in 3.8 % patients. We discussed  the relationship between HSCR and other anomalies, which are probably caused by abnormal migration, proliferation, or differentiation, of neural crest cells during embryogenesis (Tab. 1, Fig. 2, Ref. 75).

Laparoscopic cholecystectomy in children

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]

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.

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.

[Later age diaphragmatic hernia]

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]

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.

[Exchange amnioinfusion in conceptus with laparoschisis (first experience)]

OBJECTIVE

During amnioinfusion exchange (AE) a certain amount of amniotic fluid is repeatedly extracted and the same amount of physiological solution is consequently instilled into the amniotic fetal cavity. The aim of this procedure is to dilute the amniotic fluid that surrounds the eviscerated organs of fetuses with laparoschisis so as to avoid the genesis of fibrous coating on these organs.

DESIGN

Prospective study.

SETTING

Gynekologicko-pôrodnícka klinika SZU, FNsP akad. L. Dérera, Bratislava, Slovakia.

METHODS

We have executed AE in five fetuses with laparoschisis since June 2002. Two patients underwent the treatment 2 times during the 32nd and 36th weeks of gestation. Two other patients were treated once during the 32nd week and one patient once during the 36th week. Under ultrasound control we used a spinal needle to extract 120-180 ml of dense, cloudy amniotic fluid. Consequently, we instilled the same amount of physiological solution warmed up to the temperature of 37 degrees C into the amniotic cavity through antibacterial filter. The fetuses were monitored cardiotocographically and with the help of ultrasound flowmetry in umbilical vessels, before and after the treatment.

RESULTS

The AE were successful and without complications in all five cases. All patients delivered via elective caesarean section during the 36th - 37th gestation week. One patient delivered 24 hours after second AE due to the danger of intrauterine fetal hypoxia that was verified cardiotocographically. The other patients delivered 1-4 weeks after AE.

CONCLUSION

The significance of AE lies primarily in the reduction of the occurrence of fibrous coating on eviscerated organs. It enables postnatal primary surgical closure of the defect in the front abdominal wall, an earlier onset of intestine peristalsis, transition from parenteral to peroral nutrition and shorter hospitalization.

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.)

[A pediatrician's views on the treatment of extensive hemangiomas in childhood]

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.

[Maffucci's syndrome--case report of a 5-year-old female patient]

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.

[Supracondylar fractures of the humerus and disorders of circulation]

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.

[Diastematomyelia and the tethered spinal cord syndrome. Case report]

The authors present a patient with diastematomyelia and associated congenital malformations of the spinal cord. They caused tethering of the spinal cord. Patient had cutaneous marks of malformation from birth. The congenital malformation was operated at the age 5 years. MRI and surgical findings confirm the existence of diastematomyelia together with thick tethered filum terminale and lipoma of filum terminale. On surgery the bony septum was removed, the filum terminale was resected and the lipoma was excised. Each of the anomalies caused the tethering of the spinal cord and restricted its physiological ascent. Only careful surgical revision with subsequent removal of all causes of the tethering of the spinal cord produced good result. Diastematomyelia is a congenital malformation with some morphological variations and coexistence of other malformations. The presented case is a typical example of malformations associated with diastematomyelia.

[Personal experience in the treatment of medial cervical cysts in children]

Twenty-five patients with thyreoglossal cysts were treated during a 7 years long period. Most of the cysts (in 64 of patients) were typically located between the hyoid bone and the thyreoid gland. The complete Sistrunk's operation was performed in 40% of the patients and 48% patients underwent an extirpation of thyroglossal cyst with a resection of the hyoid bone body. Three of the patients (12%) suffered a relapse. In one of the patients, this was due to the lateral cyst swapping and in two patients an incomplete extirpation of the ductus thyreoglossus remnant happened. In another patient, an iatrogenic hypothyreossis occurred. To avoid relapse, authors recommend to resect at least 10 mm of the hyoid body and 5 mm of the ductus thyreoglossus remnant behind the hyoid bone.

[Treatment of blunt injuries of the spleen in children]

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.

[Subacute appendicitis in children]

Over the period of 4 years from 1993 to 1996 the authors recorded a 6% incidence of patients with periappendicular mass (PM) in a group of 786 patients with acute appendicitis. The aim of the study is to compare the two methods in the management of patients (operation-A, conservative treatment-B) by applying the same criteria. In the subacute phase of the disease 22 patients (group A) were operated on, while 24 patients (group B) were successfully treated conservatively, with recommendation of elective appendectomy after 6 months. In group A indication for operation was PM in 7 patients, diagnostic problems (tumour, hydronephrosis) or complications (peritonitis, intestinal obstruction) in 15 patients. Antibiotic therapy was nearly the same in both group. Peritoneal drainage in postoperative care was performed in 10 patients of group A for 4.7 days on the average. In this group, secondary wound healing was recorded in 3 patients. In group B, elective appendectomy was performed only in 12 patients (50%). In 2 patients, however, a diagnostic error was revealed, i.e. Crohn's disease and an ovarian cyst had been suspected to be a periappendicular mass. Conservative treatment with subsequent elective appendectomy after 6 months seems to be an effective method in the treatment of patients with a typical clinical picture and well bordered periappendicular mass. Appendectomy in the subacute phase of the disease appears to be a safety technique of PM treatment in patients with complications or diagnostic problems.

[An abdomino-scrotal hydrocele]

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.

Effect of mushroom Pleurotus ostreatus and isolated fungal polysaccharide on serum and liver lipids in Syrian hamsters with hyperlipoproteinemia

In Syrian hamsters, a diet with 44% of the calories being fat and containing 52 mg cholesterol (C)/100 g induced an accumulation of blood plasma and liver C and triacylglycerol (TG). In these animals, we studied the effect of dried whole mushroom (Pleurotus ostreatus, 2% in the diet, 6-mo experiment) and ethanol-insoluble residue and structurally defined fungal polysaccharide, both isolated from the mushroom (in both cases, 4% in the diet, 2-mo experiments) on C and TG concentration in serum and liver. Whole mushroom effectively retarded the increase in C and TG in both serum and liver throughout the experiment. The mushroom also reduced the content of all lipids in lipoproteins with densities of less than 1.006 to less than 1.063 g/ml. Very-low-density lipoproteins played a substantial role in the decrease (65-80%) in serum lipids. As a result, the lipoprotein concentration of the specified density classes was reduced by 45-60%, and the concentration of the serum lipoprotein pool was reduced by 40%. Neither the chemical composition of high-density lipoproteins nor their serum concentration was affected by the mushroom. Ethanol-insoluble mushroom residue did not significantly affect serum lipid levels, but it reduced liver TG content. Fungal polysaccharide lowered the C content in serum and liver.

Effect of dehydrated apple products on the serum and liver lipids in Syrian hamsters

The effect of two dehydrated apple products (10% in diet)--apple pulp (crude fibre 3.5%, pectin 1.4%) and apple pomaces (crude fibre 13.5%, pectin 7%)--on the serum and liver lipids of growing Syrian male hamsters were studied. The animals were fed a natural diet (38% of energy substituted by milk fat; the diet contains 53 mg of cholesterol (CH) per 100 g) which resulted in an accumulation of CH and triacylglycerols (TG) in the serum as well as in the liver, and CH-rich very low density lipoproteins (VLDL) in the circulation. After two months both apple products decreased the levels of CH and TG in serum (by 40-70%) and the content of CH in VLDL with similar efficiency. Both products reduced CH content in the liver, and the apple pulp also decreased TG content. Up to the 6th month the apple pulp studied suppresses accumulation of CH and TG in both the serum and the liver. A complete analysis of lipoproteins of main density class at the time showed that the decrease of serum CH and TG to a decisive extent is due to the decrease of their concentration in VLDL (by more than 50%). Therefore, the concentration of VLDL and the whole lipoprotein pool decreased by 50%. The apple pulp doubled the amount of CH transported by HDL. Three months after the replacement of butter in the diet by corn germ oil the CH and TG levels in the serum and TG also in the liver decreased to the physiological level.(ABSTRACT TRUNCATED AT 250 WORDS)