Emergency surgical treatment of cervico-mediastinal lymph-haemangioma in a 2-month-old infant, indicated by acute inner tumour haemorrhage.

UNLABELLED: Cervico-Mediastinal Lymphangiomas (CML) are caused by atresia of the efferent lymphatics or lack of communication between lymphatics and venous channels. Cervico-Mediastinal Lymphangiomas in certain cases require emergency surgery to secure decompression of the airways. The purpose of this study is to present a multidisciplinary surgical approach in the treatment of urgently complicated Cervico-Mediastinal Lymphangiomas, and to asses the surgical tactics and satisfactory outcome after a two-stage operation. MATERIAL AND METHODS: The paper presents a case of a 48-day-old girl with acute haemorrhage of Cervico-Mediastinal Lymphangioma, resulting from an increased arterial blood pressure due to thrombosis of the internal jugular vein. This condition required the convening of an emergency multidisciplinary surgical team which resolved emergency decompression by removal of the cervical tumour component. DISCUSSION: The authors discuss the reasons for the emergency indications for operation in this case, the dynamics in multi-stage treatment, the regression of the mediastinal component resulting from the developed inflammation, the intraoperative difficulties and functional complications resulting from the strife after radicalism. CONCLUSION: The presented case shows indications for emergency surgical intervention in acute growing CML. It illustrates the need for a multidisciplinary surgical approach involving a team of experts in paediatric, vascular, cardiac and aesthetic surgery.

[Clinical manifestation of acute pancreatitis in children with caustic ingestion injury - the role of oxidative stress].

For a 10 years period (1996-2005) 66 children with severe caustic injuries of the esophagus and stomach were admitted at the Department of Pediatric Surgery. Subject of this article are 17 children with clinical, laboratory and intraoperative proven acute pancreatitis. The patients were admitted at the clinic 12 hours to 12 days after the ingestion of the corrosive agent. Fifteen of them underwent surgery and different surgical procedures were performed - gastric resection, transhiatal esophagectomy, gastrectomy, gastrostomy. In all patients were found elevated levels of alpha-amilase in blood serum and urine as well as elevated CRP in blood serum. Clinically manifested acute pancreatitis was diagnosed on ultrasound studies and laparotomy. The newest theories about the genesis of acute pancreatitis emphasize on the role of oxidative stress. Experimental models suggest that burn trauma (thermal or chemical) cause critical increase of free oxygen radicals and lipid peroxydation products in the tissue of the damaged organ and the bloodstream. The local tissue damage leads to release of inflammatory mediators which enter the bloodstream and cause distant organs damage of - lung, liver, kidneys and pancreas. In this preliminary report the authors discuss the pathogenesis of acute pancreatitis in children with acute corrosive ingestion injury of the esophagus and stomach. We call this phenomenon " caustic " oxidative stress. This is the first scientific report on this topic in the reviewed literature.

[Contemporary treatment of parapneumonic pleural complication in children: the role of Video - Assisted Thoracoscopic Surgery (VATS)].

AIM: To reveal the role of Video Assisted Thoracoscopic Surgery (VATS) in the treatment of different stages of pleural empyema in children. CLINICAL MATERIAL: Between 2004 and 2006, 87 children aged from 11 months to 18 years were treated at the Department of Thoracic pediatric surgery for parapneumonic pleural complications (pleural empyema). The children were admitted in a period from 5 to 30 days (mean 11.9) after the initial pulmonary symptoms. Of them 41 children were treated by means of VATS. The indications for this approach were based on clinical course, radiological features, chest ultrasound image and fluid examination. RESULTS: Primary thoracostomy underwent 22 children (53.6%). VATS was applied in a period of 3 to 12 days after the initial procedure. The indications for VATS includes: a) multiloculated pleural effusion, b) encapsulated empyema and c) failed tube drainage. According to the local finding VATS was performed for evacuation of the flocculated exudate and debridement of fibrinous adhesions in 25 children (61 %). In 16 children (39 %) VATS comprised debridement and decortication. The mean operative time amounts 74.1 min (from 50 to 125). There were 4 conversions to open thoracotomy due to evaluation of necrotic lung parenchyma. Pleural drainage lasts from 2 to 12 days (mean 4.8). The postoperative hospital stay takes from 5 to 24 days (mean 10.2). CONCLUSION: VATS is an appropriate and effective method for treatment of children with complicated parapneumonic effusion in the second (fibrino-purulent) stage as well by some indication in the third (organization) stage.

[Non-Hodgkin's primary intestinal lymphoma - a cause of acute abdominal manifestation in children].

AIM: Lymphomas of the gastrointestinal tract are the most common type of primary extranodal lymphomas, accounting for 5 to 10% of all non-Hodgkin's lymphomas (NHL). PATIENTS AND METHODS: From January 1996 to November 2005, 10 patients with primary intestinal lymphomas were submitted with clinical signs of acute abdomen to the Pediatric surgical department in Sofia. The children presented with radiologically proven intussusception, ileal obstruction or peritonitis due to bowel perforation. RESULTS: At exploration the tumor was located in the ileum in 4 cases, in the terminal ileum and coecum in 3 cases, appendix in one and multiple sites were found in 2 cases. Children with localized disease underwent radical resection of the tumor mass with ileo - transverso anastomosis (3), partial bowel resection (4), and appendectomy (1) whereas in 2 children with advanced disease diagnostic biopsy alone with temporary ileostomy in one were accomplished. According to histology, 5 patients had Burkitt lymphoma and 5 lymphoblast NHL. The children were treated according CHOP. Over five - years relapse - free survival for localized disease accounts 6 children. CONCLUSION: Primary NHL in children often presents with acute abdominal condition requiring surgical exploration. Prognosis depends of adequacy of surgical resection and the adjuvant chemotherapy.

[Malignant neurogenic tumors with retroperitoneal and mediastinal locations in infants].

INTRODUCTION: Malignant neurogenic tumors /MNT/ are the third by frequency malignancies in children with mainly localization in the retroperitoneal space and posterior mediastinum. THE AIM: of this study is to compare the clinical presentation and the treatment results by young children with retroperitoneal and mediastinal MNT. CLINICAL MATERIAL: For a period of 12 years (1993 -2004) 52 children aged fron 1 month to 3 years were admitted at the Department of Pediatric surgery-University Hospital "N.I.Pirogov", Sofia. The findings of different diagnostic methods are reviewed. Age and sex of the children, the frequency of location, maturity and stage of the tumor, type of operations and survival rate are compared. RESULTS: The MNT in young children encounter more common in the retroperitoneal space and are diagnosed in advanced clinical stage due to late clinical presentation. Most of them have an unfavorable histological variant and affect predominantly the adrenal glands. The mediastinal MNT are mainly manifested in the first age of life with good prognosis. The total survival up to 2004 year is 59,6 %.

[Surgical aspects of primary tuberculosis in children: clinical presentation and indications for surgical treatment].

AIM: During the last years a trend of increasing the cases with primary pulmonary tuberculosis (PPT) in our country is observed. The aim of this study is to analyze retrospectively the pediatric cases with PPT and to determinate the specific clinical features as well the indications for surgery. MATERIAL AND METHODS: For a period of six years (2000-2005) thirteen children with PPT were treated at the Department of pediatric surgery. The patients underwent different type surgical procedures. Lobectomy was the most frequent operation. RESULTS: The initial diagnosis at admission was: chronic pneumonia, mediastinal tumor, complicated hydatid cyst, congenital lung cyst and pleural complication of PPT. The radiological features were typical for PPT in only two cases. The remaining showed atypical presentation and the diagnosis were confirmed by histopathological study of the surgery specimens. There were no postoperative complications and no late morbidity. DISCUSSION AND CONCLUSION: We classify the clinical course of children with PPT into three groups: 1) Identified PPT - two children, 2) Suspected PPT according the criteria of Migliori - six children and 3) Non identified PPT - five children. The diagnosis of the childhood pulmonary tuberculosis presents a major challenge. The most common radiological features are similar to those of other pulmonary affections and a thorough examination of symptoms of disease is necessary. Surgery has a complementary role in the complex treatment in children with PPT.

[Pleuropulmonary blastoma in children: diagnosis and results of surgery and complex treatment]. / Plevropulmonalen blastom v detckata v'zrast - diagnostika i rezultati ot khirurgichnoto i kompleksnoto lechenie.

This is a report on a retrospective study of experience had with complex treatment of pleuropulmonary blastoma in ten children aged 2-11 years, covering a 27-year period. In all patients diagnosis is made on the ground of clinical symptomatology, imaging methods and histological findings. All patients undergo surgery, as follows: tumor extirpation (n = 3), lobectomy (n = 2) and pneumonectomy (n = 5). Three deaths occur in the early postoperative period (30%). In the remainder postoperative chemotherapy is conducted. Histologically the solid variant (type 3 according to Dehner's classification) is predominant. There are three recurrences (42.8%) among the cases with simple tumor extirpation (2) and lobectomy (1), followed by successful pneumonectomy (two patients) and atypical pulmonary resection (one patient). At long-term follow-up, five patients (50%) are still alive for periods ranging from 1 to 11 years postoperatively. Pleuropulmonary blastoma is a surgical rarity in children. The most important factors for long-term survivorship are both radical surgery, and adequate chemotherapy.

[Surgical tactics and surgical techniques in echinococcal cysts in the lung in children]. / Operativna taktika i khirurgichna tekhnika pri ekhinokokovite kisti na belite drobove v detskata vuzrast.

The differentiated surgical approach to hydatid lung cysts and the operative techniques used in 343 children treated in the Department of Pediatric Surgery over 24 years (1975-1998) are presented. The left lung is involved in 143 children (41.7%), the right--in 155 (45.2%), whereas in 45 cases (13.1%) it is a matter of bilateral location. Infectious complications occur in 198 cases (57.7%). In compliance with the anatomical location, size, extent and accompanying complications two surgical procedures are mainly used: 1) Total removal of the cyst without disrupting its continuity (closed echinococcotomy) in 19 per cent, and 2) Evacuation of the cyst fluid, as well as the germinative membrane, followed by appropriate management of the residual fibrous cavity in 81 per cent of cysts. Echinococcotomy with suture obliteration of the residual cavity in conjunction with sparing lung resection, yielding superior functional results postoperatively, is the method of choice.

[The surgical treatment of pulmonary and associated echinococcosis in childhood]. / Khirurgichno lechenie na belodrobnata i asotsiiranata ekhinokokkoza v detskata vuzrast,

Over a nine-year period (1990-1998), a total of 196 children with pulmonary and associated hydatid disease, aged 2 to 16 years, undergo treatment in the Department of Pediatric Thoracic Surgery--Emergency Medicine Institute "N. I. Pirogov"--Sofia. One hundred thirty children (62.1%) present isolated, and sixty-six (38.8%)--associated hydatid disease, of which with localization in the liver (63 cases), brain (1), kidney (1) and spleen (1). The pulmonary cysts are located in the left lung in 96 cases (48.9%), right lung--79 (40.3%) and bilateral involvement--21 (10.8%). In 74 children the disease runs an asymptomatic course, in 128 (65.3%)--with fever and cough, and in 65 (33.1%)--with thoracic pain. On admission 183 children (94.4%) are in a satisfactory and good general condition; 13 with complications in the cyst and pleural cavity are in a serious general condition accompanied by respiratory failure. In 129 children diagnosis is made on the ground of x-ray study, in 40 CAT study is additionally performed, and in 24--ultrasonography. Of 22 children with bilateral pulmonary location, 13 (59.9%) undergo operation in two stages, and nine (40.1%)--in one stage, with bilateral thoracotomy done in seven, and sternotomy in two instances. Intraoperatively more than one echinococcus cysts are discovered in 23 cases (11.7%). In 105 children (53.5%) echinococcotomy is performed, in 67 (34.2%)--atypical resection, in 8 (4.1%)--lobectomy, in 15 (7.6%)--segmentectomy and in one--pneumonectomy. In the early postoperative period, one child develops hemothorax from a bleeding intercostal artery, and another one--pneumothorax from unsutured bronchus in the cyst bed necessitating emergency re-thoracotomy. The outcome is fatal in one patient with malignant hyperthermia, and the remainder are discharged clinically cured.

[Traumatic lesions of the thoracic and abdominal organs in childhood]. / Prouchvaniia vurkhu travmatichnite uvredi na grudni i koremni organi v detskata vuzrast.

This is a retrospective analysis of 651 children, aged 0 to 14 years, presenting chest and abdominal injuries, treated over a 6-year period in the section of pediatric surgery of the Emergency Medicine Institute "Pirogov". The results of studies on the etiopathogenesis of chest and abdominal trauma, patterns of associated lesions and quality of prehospital aid are discussed. Experience with the application of updated noninvasive and invasive methods of diagnosis, as well as the scope of surgical approach to the variety of lesions by resorting to organ sparing and organ salvaging operative procedures are analyzed. On the basis of observations and experience gained to date, the indications for application of the prospective method of nonoperative treatment of certain organic lesions in the practice of pediatric surgery are broadened. The overall research project provides good reason to work out an algorithm of the therapeutic approach to children presenting abdominal and chest trauma.

[Bronchogenic cysts of the mediastinum in childhood]. / Bronkhogenni kisti na mediastinuma v detskata vuzrast.

Bronchogenic cysts are rare congenital anomalies result of abnormal development of the tracheobronchial tree. They develop in the lung parenchyma or in the mediastinum. For a period of 17 years (1975-1991) a total of 46 children with bronchogenic cysts have been treated; in 6 the cysts were localized in the mediastinum. Two patients were one-year-old, 3 were in the age group 1 to 3 years and 1 was older than 3 years. Four patients were boys and 2 girls. Two children had hacking cough and attacks of dyspnea; one had swallowing difficulties. In 3 children the disease produced no symptoms and was detected on examination for pneumonia (1 child) and acute upper respiratory tract infection (2 children). All children had conventional X-ray; 5 had esophagography as well, 4--computer axial tomography, 3--echography. All children were operated (total extirpation of the cyst) and left the hospital cured.

[The results of coloesophagoplasty in childhood]. / Rezultati ot koloezofagoplastikata v detskata vuzrast.

Over a six-year period (1988 through 1993), a total of 380 children with congenital and acquired esophageal diseases undergo treatment in the Second Pediatric Surgery Clinic. Plastic replacement of esophagus using a graft from the colon is performed in 31 children. The indications and procedures for colo-esophagoplasty in children are discussed. Two basic operative methods are employed--retrosternal transposition of the colon transplant (with preservation of the esophagus or in children with previous extirpation, as well as in children with esophageal atresia), or transhiatal (transabdominal) esophagectomy with simultaneous placement of the transplant into the esophageal bed. The underlying cases of early and late postoperative complications are analyzed. Emphasis is laid on the good results of the method described (operative lethality amounting to 9.7 per cent) accordingly considered as the most appropriate for children.

[Traumatic rupture of the diaphragm in combined trauma in childhood]. / Po vuprosa za travmatichnata ruptura na diafragmata pri suchetana travma v detskata vuzrast.

Blunt traumatic injuries to the diaphragm are comparatively rare and are always associated with other severe injuries to the chest, abdomen, head and extremities. In childhood they are exceptionally rare. No such complication in blunt abdominal and thoracic trauma has been observed at the Clinic of Pediatric Surgery of the "Pirogov" Emergency Hospital in Sofia for the last ten years. Experience is recorded with the treatment of traumatic rupture of the diaphragm in a six-year-old boy with severe combined trauma. Inference is made that during the operation existence of such injury, however rare, should be considered. Complete and thorough revision of the abdominal cavity and the retroperitoneal space is advised.

[The diagnosis and surgical treatment of teratogenic tumors of the mediastinum in childhood]. / Vurkhu diagnostikata i khirurgichnoto lechenie na teratogennite tumori na mediastinuma v detskata vuzrast.

Mediastinal tumors are leading tumors in pediatric chest oncology. Teratogenic mediastinal tumors are characteristic of early childhood. For a period of 7 years 4 children with teratogenic tumors of the mediastinum--7.8 per cent of all mediastinal tumors--have been diagnosed at the Department of Pediatric Surgery, thoracic unit. The authors analyse the clinical symptoms, the tools of diagnosis, emphasizing the diagnostic importance of computer tomography, echography and angiocardiography. All children were operated (total extirpation of the tumor). Three children had benign teratoma, 1 mature teratoma including malignant elements (ECT)). All children were in good state of well-being; in one of them chemo- and radiotherapy is still in progress.