[A diagnostic and therapeutic algorithm in cases of acute corrosive burns of esophagus and stomach in childhood - 36 year clinical experience].

Introduction: The chemical burn of the esophagus and stomach, caused by concentrated acids or alkalis, is related to the development of a multitude of serious surgical complications and represents an actual social and medical problem. Aim: Presentation of an algorithm of therapeutic measures in cases of corrosive burns of esophagus and stomach in children with the acute and chronic phase of the disease, developed on the grounds of our long-term clinical experience. Clinical Material: The studies and practical conclusions were based on out 36-year experience (from the year 1976 to 2012) in the treatment of 816 children with corrosive disease, treated at the Department of Pediatric Thoracic Surgery and the Department of Pediatric Toxicology of the General Hospital "N. I. Pirogov" -Sofia. Results: 581 children (71.2%) in the acute phase of the corrosive intoxication were admitted for treatment. The rest 235 children (28.8%) were admitted for treatment in the late phase with formed fibrotic stricture of esophagus or stenosis of pylorus. Early diagnostic endoscopy was performed in 244 children (41.9 %). 83 children (34 %) had corrosive burn of 0-1 degree; 30 (13.3 %) -burn of 2-a grade; 123 (50 %) - burns of II-B and III grade; and 9 (3.7 %) - burn of 4 grade. Conservative treatment with bougienage was performed in 345 children (89.4 %). Esophageal replacement was performed in 81 children - colon was used in 57 of them, and whole stomach - in 24. Early surgical complications in the acute phase of the corrosive disease were observed in 99 children (25.1 %). Lethal outcome occurred in 9 children - colon was used in 57 of them, and whole stomach - in 24. Early surgical complications in the acute phase of the corrosive disease were observed in 99 children (25.1 %). Lethal outcome occurred in 9 children (2.4 %) died in the course of the conservative and surgical treatment. Conclusion: The corrosive disease is a complex pathological process, which involves not only the upper digestive tract, but also the entire organism. The main burden during the course of disease falls over the surgical complications in the acute phase. The treatment of the late sequelae of the corrosive disease requires complex conservative and surgical approach, which on its turn requires availability of a sophisticated multidisciplinary medical team.

[Congenital cystic lung lesions--review of the literature with three clinical cases].

Congenital cystic lung lesions are rare. Mainly affects the lower respiratory patishta.i are congenital cystic malformation and adematozna bronchopulmonary sequestration (BPS). The pathogenesis of the occurrence of these malformations is not clear but they have a common clinical course. In most cases, the anomaly is asymptomatic and occurs with infections of the lung during the first year of life. Currently congenital lung lesions were classified into five types and is considered by most authors. The anomaly is due to the abnormal proliferation of terminal bronchioles accompanied by inhibition of alveolar development between 7-17 weeks, obstructed airway dysplasia and metaplasia of normal lung tissue. Early diagnosis is vital in making a medical decision on how to treat CCAM. Associated with abnormalities of the urinary tract, cardiovascular system, gastrointestinal atresia, diaphragmatic hernia skeletal abnormalities. In pregnancies in which prenatal lung lesions weighs registered necessary series of ultrasound examinations to track finding and using the Doppler to assess how the blood supply of the fault. The clinical presentation of malformations is respiratory distress, respiratory infection, and dyspnea. The use of CT and MRA allows better visualization of the pulmonary lesions. With its combination with arteriography and bronchoscopy are used to differentiate CCAM and pulmonary sequestration. We present three cases with lung lesions were born in Neonatologia clinic at the University Hospital of Obstetrics and Gynecology "Maternity" Sofia for the period 2010-2012 three cases CCAMs type 1, operated by 5 meters after birth with a good final outcome without complications in the postoperative period and lack of pulmonary symptoms up to 1 year after birth.

[Transversal vaginal septum in two months old patient--case report].

The current publication describes a case of a two months old girl with a transverse vaginal septum presented. The clinical debut is with a large hydromucocolpos. It is concomitantly presented with a bilateral postaxial polydactyly of the upper limbs, typical for McKusick-Kaufmann syndrome.

[Fetal meconium pseudocyst secondary to in utero perforation of colon transversum and meconium peritonitis].

Fetal bowel intrauterine perforation causes sterile inflammation of the peritoneum, known as meconium peritonitis. In some cases the perforation closes spontaneously, thus forming a meconium pseudocyst between the intestinal loops and the omentum. Meconium peritonitis, complicated by pseudocyst formation, should always be considered when a fetal abdominal mass with diverse echogenicity and hyperechogenic calcifications is observed on prenatal ultrasound. Usually, this is associated with ascites and/or polyhydramnios. The differential diagnosis necessitates exclusion of all other fetal abdominal tumors. We present a case report of meconium pseudocyst diagnosed prenatally at 32 weeks of gestation which was successfully treated by surgery after birth.

[Sacrococcygeal teratoma--a case report and literature review].

Sacrococcygeal teratoma (SCT) is the most frequent solid congenital tumor in the fetus and newborn. We present a case report of prenatally detected SCT with a favorable outcome after vaginal birth complicated by mechanic dystocia.

[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 %.

[Migration of an ingested foreign body (sewing needle) to the pancreas tail and spleen].

A case of a penetration of the stomach by a sewing needle with migration to the tail of the pancreas and the spleen in a 22-years old woman is reported. The patient was referred to us with a chief complaint of abdominal pain and nausea. A plain roentgenogram showed a needle in the upper left abdominal area. An contrast X ray and abdominal computed tomography scan revealed foreign body (broken needle) to be located at the hilum of the spleen. At laparotomy the needle in the spleen and tail of the pancreas was impossible to be extirpated safely which required splenectomy and partial resection of the pancreas. A perforation of the gastrointestinal tract by an ingested foreign body is difficult to presume when no peritonitis or abscess formation is observed. A plain X-ray and CT scan is useful to establish the diagnosis.

[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.

[Congenital cystic adenomatoid malformation of the lung--report of two cases].

Congenital cystic adenomatoid malformation (CCAML) is a rare anomaly of the fetal lung which can be diagnosed prenatally by ultrasound. We present two cases of CCAML with different pregnancy outcome diagnosed at 17 and 24 weeks gestation, respectively, and discuss the major aspects of the obstetrical and therapeutical management.

[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.

Long term survival in five rare cases with multiple primary neuroblastomas.

PURPOSE: Multiple primary neuroblastomas are a very uncommon disorder in infancy. The tumors may arise simultaneously in different parts of the sympathetic nervous system. The purpose of this paper was to present 5 new cases with multifocal neuroblastomas. This is a representative study based on the largest clinical material in Bulgaria. PATIENTS AND METHODS: The records of children treated for neuroblastoma during a 26 year-period (1979-2005) were reviewed and analysed retrospectively. RESULTS: Out of 193 children treated for neuroblastoma and followed in our department, 5 (2.6%) had multifocal lesions. All were boys aged from 2 months to 4 years at the time of diagnosis, and all were treated successfully with radical surgery. Four children were also administered chemotherapy with vincristine, cyclophosphamide and epirubicin; one of them received postoperative radiotherapy as well. All 5 patients are alive and disease-free for a period ranging from 7 to 26 years. CONCLUSION: The excellent prognosis of those rare cases with multiple primary neuroblastomas elucidates questions concerning the tumor's biological behavior and the role of different factors affecting cell differentiation, tumor growth and dissemination.

[Severe combined corrosions of the esophagus and stomach--diagnostic and treatment]. / Kombinirani korozivni porazheniia na khranoprovoda i stomakha u detsa -- diagnostichna i khirurgichna taktika.

For a 12 year period (1991-2002) 152 children aged from 2 to 17 years with severe caustic ingestion were treated at the University Department of Pediatric Surgery. 21 of them received severe combined lesions of the esophagus and the stomach. Early diagnostic gastroscopy was attempted in most of the children, followed by emergent laparotomy and appropriate surgical procedure including local or extended stomach resection, with or without esophagectomy. Four children underwent gastrectomy, transhiatal esophagectomy, jejunostomy. Two infants died in the early postoperative period. At the late phase of the corrosive disease 19 children underwent different surgical procedures: Nissen fundoplication (n=5), pyloroplasty (n=3), retrosternal colon transpositions (n=8).

[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.

[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.