Free technical library

Children's surgery. Lecture notes: briefly, the most important

Directory / Lecture notes, cheat sheets

Comments on the article

Table of contents

1. Peculiarities of treatment of children with surgical diseases (General principles of examination and diagnosis. Preoperative preparation)
2. Preoperative preparation. Features of preoperative preparation for acute surgical diseases accompanied by intoxication (Preoperative preparation against the background of traumatic shock. Therapy of traumatic shock)
3. Acute diseases of the lungs and pleura (Lung malformations. Lobar emphysema. Complicated congenital lung cysts)
4. Malformations of the esophagus. Esophageal obstruction (Esophageal obstruction)
5. Esophageal-tracheal fistulas. Damage to the esophagus. Perforation of the esophagus (Esophageal-tracheal fistulas. Damage to the esophagus. Chemical burns. Perforation of the esophagus)
6. Bleeding from dilated veins of the esophagus in portal hypertension
7. Diaphragmatic hernia. Phrenico-pericardial hernia (Hernias of the diaphragm proper. Complicated false hernias of the diaphragm proper. Complicated true hernias of the diaphragm proper. Hiatal hernias. Hernias of the anterior part of the diaphragm. Complicated phrenico-pericardial hernias)
8. Hernia of the umbilical cord
9. Strangulated inguinal hernias
10. Gastric obstruction (Prepyloric gastric obstruction. Pyloric stenosis)
11. congenital intestinal obstruction
12. Recurrent congenital intestinal obstruction (Circular intestinal stenosis. Ledd syndrome. Internal abdominal hernias. Compression of the intestinal lumen by cystic formations)
13. Acute intestinal intussusception
14. Adhesive intestinal obstruction (Early adhesive intestinal obstruction. Late adhesive intestinal obstruction)
15. Dynamic intestinal obstruction (Spastic ileus. Paralytic ileus)

LECTURE No. 1. Features of the treatment of children with surgical diseases

General principles of examination and diagnosis

Successful treatment of children with acute surgical diseases primarily depends on timely diagnosis and early implementation of the necessary set of therapeutic measures.

The latter includes rational preoperative preparation (the duration and intensity of which depends on the general condition of the child, the presence of concomitant diseases, etc.), as well as targeted postoperative treatment, the nature of which varies significantly depending on the age of the child, the type of disease and the degree of homeostasis disturbance.

Equally important is the correct choice of the method of anesthesia and sufficient experience of the surgeon in performing pediatric operations.

The complexity of diagnosing many surgical diseases and malformations is mainly associated with the mental immaturity of the child and the functional characteristics of his systems and organs.

Patients of early age cannot complain, and anamnestic data have to be obtained from the mother or the attendants of the maternity hospital. This does not always make it possible to navigate the symptoms of the disease and the sequence of their occurrence.

Many acute surgical diseases of the newborn should be recognized in the maternity hospital. Early diagnosis depends on the awareness of the obstetrician, pediatrician and radiologist in these matters.

The most serious difficulties arise in the diagnosis of malformations of internal organs.

General symptoms do not always arouse the alertness of the attendants, since they are too often observed in various physiological conditions and functional disorders.

In some cases, differential diagnosis requires relatively long-term observation of the child and the prescription of drug treatment ex juvantibus for therapeutic diseases with similar symptoms.

In infants, for the recognition of acute surgical pathology, the correct assessment of changes in the behavior of the child is important.

Periodic restlessness, sudden "unreasonable" cry, refusal to eat - everything should be taken into account by the surgeon when examining the patient.

General symptoms of the disease (deterioration, high body temperature, vomiting, etc.) in some cases play a lesser role in establishing a diagnosis than "insignificant" objective data.

Thorough examination and well-known clinical methods used in pediatrics and general surgery should be combined in the diagnosis of acute diseases in children with various additional examinations, the implementation of which has a number of fundamental features.

X-ray examination of the digestive tract in newborns is carried out in an upright position using a non-contrast method.

For certain indications, contrasting is carried out with iodized oil or a 20% solution of sergosin. Examination using barium sulfate can cause severe complications (aspiration, blockage of the narrowed intestines).

In older children, more complex methods of X-ray examination (retropneumoperitoneum, pneumomediastinography, angiography) should be used. Full x-rays in many cases allow you to clarify or identify the disease.

However, the interpretation of the data should be made taking into account age-related anatomical features (physiological enlargement of the thymus gland, various periods of the appearance of ossification nuclei).

Special and instrumental research methods (esophagoscopy, bronchoscopy, splenoportography) are widely used in emergency surgery.

The choice of the method of surgical treatment, as well as medical tactics, is impossible without taking into account the peculiarities and originality of the further development of the growing body of the child.

In acute surgical diseases, the need for surgical treatment is usually dictated by absolute indications. However, in debilitated and premature infants with severe malformations or concomitant diseases, surgical intervention should sometimes be abandoned in favor of less risky conservative methods of treatment (for example, with hematogenous peritonitis, some forms of hernia of the umbilical cord, etc.).

Absolute contraindications, which are extremely rare and only in newborns, include only the obvious non-viability of the child, who will not benefit from surgery. It should be noted that due to the rapid development of childhood surgery and the improvement of surgical treatment methods, the scope of absolute contraindications to interventions is steadily narrowing.

The final judgment is usually made by the surgeon after appropriate therapeutic measures, consultation with a pediatrician and an anesthesiologist.

Preoperative

In emergency surgery in the preoperative period, the tasks of non-specific preoperative preparation come to the fore: solving the problem of a "full stomach", improving the function of vital organs and systems, and conducting premedication.

The method of premedication depends on the subsequent choice of anesthesia and therefore will be discussed in the appropriate section.

The problem of "full stomach" is of no small importance for the prevention of regurgitation and aspiration of gastric contents.

Regardless of the time elapsed since the last meal, the emergency patient should be considered a potential aspiration hazard at the time of anesthesia.

First of all, this applies to patients with peritonitis of various types of intestinal obstruction and other diseases of the "acute abdomen".

Before the start of anesthesia, each child is inserted into the stomach with a probe to suck out gastric contents. Then the probe is removed so that it is not a conductor for subsequent regurgitation.

Aspiration can be prevented to some extent by using nitrous oxide with oxygen for induction of anesthesia (2: 1 or 1:

1) in combination with fluorotane or cyclopropane, ketalar. With this anesthesia, the cough reflex is suppressed relatively late, which reduces the risk of gastric contents entering the respiratory tract.

At the same time, the child must be given the Trendelenburg position.

During tracheal intubation, it is advisable to press the thyroid cartilage towards the spine. With the help of this technique, the exit from the esophagus is reliably blocked, which prevents food masses from entering the trachea.

If, despite the measures taken, aspiration still occurs, then it is necessary to immediately intubate the trachea with thorough washing of the tracheobronchial tree with saline sodium chloride solution with antibiotics; if it is ineffective, bronchoscopy is indicated.

Measures to improve the function of vital organs and systems depend on the nature of the pathological syndrome that dominates the clinical picture of an acute surgical disease.

Most often, preoperative therapy requires intoxication, traumatic shock, and respiratory failure. Special preparation is necessary for newborns and premature babies, in whom physiological borderline conditions during surgery can turn into a pathological process. It should be emphasized that the task of training does not include the complete normalization of the function of the main organs and systems.

It is only necessary to "push" the process of recovery, that is, to transfer the pathological state from decompensation to compensation.

LECTURE № 2. Preoperative preparation. Features of preoperative preparation for acute surgical diseases accompanied by intoxication

Intoxication is a condition with a characteristic combination of clinical and laboratory signs of pathology of the nervous system, microcirculation system and water-electrolyte metabolism against the background of an infectious and inflammatory process. Diseases of the “acute abdomen”, toxic and toxic-septic forms of acute purulent-inflammatory diseases occur with intoxication.

In emergency surgery, the peculiarity of intoxication is that it occurs against the background of infections caused by staphylococcal or gram-negative bacterial flora. Unlike viral and viral-bacterial infections, in these cases, neurological symptoms do not prevail in the clinical picture.

Most often, hyperthermia and lethargy serve as a background. where a local process unfolds with a generalized reaction of the microcirculation system. Changes in peripheral blood flow are manifested in rheological disorders, intracapillary disorders with intravascular coagulation and activation of the kinin system.

Frequent involvement in the pathological process of the organs of the gastrointestinal tract leads to isotonic or salt-deficient dehydration.

In combination with the pathology of the transmembrane transfer of sodium and potassium, typical of any intoxication, dehydration causes the symptoms of disorders of water and electrolyte metabolism.

An imbalance of water and electrolytes is diagnosed based on the causes of its occurrence, the clinical picture and laboratory data.

An analysis of the causes and ways of fluid loss makes it possible to suggest the nature of disorders of water and electrolyte metabolism.

Loss with vomiting or fluid sequestration in paretically distended bowel loops or in peritoneal exudate leads to salt deficiency or isotonic dehydration; hyperthermia or hyperventilation of any origin - to water deficiency.

Intoxication without clinical signs of dehydration is accompanied by intracellular overhydration and hypokalemia due to intracellular sodium retention and potassium loss.

The diagnosis is confirmed by the results of an objective examination of the child. However, in the course of treatment, one type of dehydration may be replaced by another, which greatly complicates the assessment of the clinical picture.

Therefore, the final diagnosis is based on the results of a laboratory study. Normal values ​​of plasma sodium concentration or hematocrit are by no means proof of the absence of dehydration in a patient, just as not all types of dehydration show the whole triad of symptoms of hemoconcentration.

Hyperproteinemia does not occur in dehydration in children with purulent-inflammatory diseases of the chest and abdominal cavities and in malformations of the gastrointestinal tract, accompanied by malnutrition II-III degrees. The level of total serum protein in this pathology may be normal or be at the lower limit of the age norm.

Confirmation of hemoconcentration in such situations is a high hematocrit. And, conversely, if isotonic or salt-deficient dehydration develops against the background of anemia, an increase in the number of erythrocytes and hematocrit is not expressed, only hyperproteinemia has diagnostic value.

As long as the body is able to maintain stable hemodynamics, we can talk about the stage of dehydration compensation, decompensation occurs with the appearance of circulatory disorders.

With isotonic and hypotonic (salt-deficient) dehydration, signs of decompensation are arterial hypotension, acrocyanosis, hypothermia and oliguria. Decompensation occurs only with dehydration, corresponding to a loss of 10% of body weight.

If the phenomena of intoxication and water-electrolyte imbalance are not reduced before surgery, then during the intervention the sensitivity to blood loss increases, the insufficiency of peripheral blood flow worsens, and the prognosis worsens. Hyperthermia caused by the inflammatory process, water-deficient dehydration, intoxication, increases sensitivity to hypoxia and narcotic drugs.

In this regard, the tasks of preoperative preparation for intoxication are reduced to normalizing the patient's body temperature, improving peripheral blood flow and reducing the degree of dehydration. These tasks are solved by infusion therapy.

The sequence of goals for infusion therapy in this situation should be as follows:

1) providing a volume of liquid corresponding to the degree of water deficiency;

2) reduction of energy deficit with normalization of electrolyte transport through the cell membrane and prevention of intracellular edema with the help of concentrated glucose solutions with insulin;

3) improvement of blood rheology and detoxification using low molecular weight plasma substitutes;

4) normalization of the acid-base state of the blood. Potassium deficiency in the preoperative period, as a rule, is not corrected, since this requires a long period of time.

In addition, at this point it is not always clear how impaired kidney function is and what the danger of a relative overdose of potassium is.

The volume of fluid that the patient needs to eliminate the deficit of water and electrolytes in the preoperative period is calculated taking into account the degree of dehydration and the age of the child. With isotonic or salt-deficient dehydration, the most common in surgical diseases, the calculation is based on the hematocrit value.

The lower part of the nomogram shows the fluid volumes in liters required to correct the water deficit in the preoperative period, depending on the patient's hematocrit. Horizontal scales correspond to the degree of hemoconcentration in percent or the difference between the patient's hematocrit and normal age-related hematocrit.

The volume of liquid is determined as follows: the direct scale of body weight is connected in the upper and lower parts of the nomogram at the point of its intersection with the scale, which corresponds to the difference in hematocrits, and the required volume of liquid in liters is determined.

To determine the daily needs for water and electrolytes, the perpendicular is restored from the age or weight of the patient to the intersection with the wrong curve in the middle part of the nomogram.

From this point, a horizontal line is drawn parallel to the base, and in the corresponding vertical columns, the necessary values ​​\uXNUMXb\uXNUMXbof physiological needs for water and electrolytes, pathological losses with vomiting, intestinal paresis, hyperthermia, dyspnea and the volume of fluid supplemented for detoxification are obtained.

In cases where it is not technically possible to determine the hematocrit or there are no laboratory signs of hemoconcentration, the liquid for the preoperative period is prescribed in the amount of 2-3% of body weight (20-30 ml / kg).

The composition of the injected solutions depends on the state of hemodynamics and the stage of dehydration. In case of circulatory decompensation, the infusion begins with the transfusion of volemic drugs: plasma (10 ml/kg), 10% albumin solution (10 ml/kg) or rheopolyglucin (20 ml/kg). The remaining volume is administered in the form of a 10% glucose solution with insulin (1 unit - 5 g). With normal indicators of central hemodynamics and the predominance of intoxication over dehydration, volemic preparations are replaced with low molecular weight blood substitutes of the hemodez group (10 ml/kg). Infusion in these cases begins with concentrated glucose solutions.

The need for correction of the acid-base state is determined by the results of laboratory control carried out after the introduction of basic solutions.

Therapy should only be initiated when standard blood bicarbonate falls below 15 mmol/L. In clinical practice, 1,3-5% sodium bicarbonate solutions are used to treat metabolic acidosis.

In children older than 2 months, it is advisable to use hypertonic solutions of sodium bicarbonate. The dose is calculated according to the formula: the number of milliliters of a 5% sodium bicarbonate solution is equal to the body weight multiplied by half the base deficiency.

In children under 2 months of age, the administration of hypertonic bicarbonate solutions should be approached with caution. Due to the immaturity of renal osmoregulation, children at this age are more sensitive to disturbances in serum osmotic concentration than to disturbances in the active blood reaction. The dose of 1,3% (saline) sodium bicarbonate solution (in ml) is equal to the newborn's body weight in kilograms multiplied by twice the base deficit.

If laboratory control is not carried out, then alkalizing solutions should be used very carefully. The absolute indications for their use are: insufficiency of peripheral circulation with pallor, marbling of the skin; “white spot” symptom with arterial hypotension; oligoanuria, which occurs as a result of spasm of the afferent arterioles of the kidneys.

Sodium bicarbonate in these cases is prescribed at a dose of 0,12-0,25 g of dry matter or 5-7 ml of a 5% solution per 1 k1 of the child's body weight.

Despite the relative effectiveness of sodium bicarbonate transfusion, success in the treatment of metabolic acidosis primarily depends on measures aimed at restoring impaired blood circulation and kidney function. A significant role in this case is played by transfusions of blood and low molecular weight blood substitutes, ganglion blocking drugs.

Correction of metabolic alkalosis in the preoperative period is not carried out. Respiratory disorders of the acid-base state are eliminated during the treatment of respiratory failure.

It should be noted that all the above calculation formulas are conditional. Therefore, rehydration therapy must be carried out without fail, taking into account the dynamics of laboratory data and the clinical picture.

If, under the influence of treatment, the patient's diuresis increases, the specific gravity of urine decreases, blood pressure stabilizes, and hemoconcentration and hypernatremia disappear, then the amount of fluid is chosen adequately. If signs of dehydration persist, then the volume of injected solutions should be increased.

Infusion therapy, measures to normalize peripheral blood flow and kidney function contribute to the elimination of fever accompanying intoxication. In addition, the patient is prescribed antipyretics and neuroleptics: intramuscularly or intravenously, a 5% solution of amidopyrine (1 ml / kg) with a 50% solution of analgin (0,1 ml / kg) and a 2,5% solution of pipolfen ( 0,1-0,15 ml/kg). If there is no effect after 45-60 minutes, repeat the injection of antipyretics in combination with droperidol (0,25% solution - 0,05-0,1 ml / kg).

Of great importance is the duration of preoperative preparation for this group of patients. In the preoperative period, one should only begin the treatment of intoxication, dehydration, and fever.

It must be taken into account that the desire for complete normalization may unnecessarily delay the preparation for the operation. The task of the preoperative period is to eliminate hypovolemia, improve peripheral blood flow and prevent a further rise in the patient's body temperature. These problems can be solved within 3-4 hours.

Preoperative preparation against the background of traumatic shock

Therapy for traumatic shock

Treatment of trauma shock is one of the most difficult tasks of preoperative preparation in emergency surgery. However, the success of the fight against traumatic shock depends on how early it is started.

In children, the classic picture of traumatic shock is rarely observed. The younger the child, the less pronounced are the differences between the erectile and torpid phases of shock. With the same probability, against the background of clinical signs of circulatory insufficiency, psychomotor agitation or lethargy can be found.

Even with a severe concomitant injury in children, a normal level of blood pressure is maintained for a long time, although the general condition is severe, tachycardia, pallor, sometimes marbling of the skin, cyanosis of the lips and nail beds, cold extremities, and oliguria are expressed.

Often, symptoms of respiratory failure due to circulatory disorders in the pulmonary circulation come to the fore.

The discrepancy between the severity of the injury and the clinical condition of the patient, on the one hand, and "satisfactory" indicators of central hemodynamics, on the other, is apparently the most characteristic feature of traumatic shock at an early age.

In the absence of appropriate treatment, a period of apparent well-being is suddenly replaced by hemodynamic decompensation. The latter in children is much more difficult to treat than in adults. Hence, the younger the child, the more unfavorable prognostic sign in shock should be considered arterial hypotension.

Due to the paucity of clinical symptoms of traumatic shock in childhood, its classification should take into account the nature and severity of the injury, the state of hemodynamics and the effect of the therapy.

This is all the more necessary because, from a practical point of view, it is important that the diagnosis of shock be made before the development of arterial hypotension.

There are four degrees of severity of traumatic shock in children.

Light shock(I). Most often observed in injuries of the musculoskeletal system (damage to more than two bones, excluding fractures of the pelvic bones), blunt abdominal trauma without damage to internal organs.

Within 3 hours from the moment of injury, the patient steadfastly maintains a shock clinic in the stage of centralization of blood circulation.

This stage is characterized by psychomotor agitation or depression, systolic blood pressure within the age norm or increased by 20 units, a decrease in pulse pressure, a tense pulse, tachycardia up to 150 beats / min, sometimes bradycardia.

The skin is pale, cold, cyanotic shade of mucous and nail beds. Central venous pressure (CVP) is often higher than normal. The volume of circulating blood (VCC) is reduced by 25% of the age norm.

Respiratory alkalosis, metabolic acidosis with base deficiency up to 6 mmol/l on average, oliguria. The effect of therapy is manifested within 2 hours.

Moderate shock (II) usually accompanies injuries to the pelvic bones, extensive soft tissue injuries with significant crushing of the tissues, traumatic amputations of one of the limbs, isolated injuries of the abdominal organs, chest trauma with rib fractures and pulmonary contusion.

During the first hour from the moment of injury, there is a rapid transition from the stage of centralization of blood circulation to the transitional stage.

In the transitional stage, the child's behavior is inhibited. Systolic blood pressure is reduced, but not more than 60% of the age norm. Pulse of weak filling, its frequency is more than 150 beats / min of the age norm.

There is shortness of breath. Pallor of the skin, distinct acrocyanosis is pronounced. CVP is below normal. BCC is reduced within 34-45%. Metabolic lactic acidosis with base deficiency on average up to 9,5 mmol / l. An increase in hematocrit. Oliguria.

The effect of therapy occurs within two hours, but there is an undulating course with repeated deterioration.

Severe shock (III) is typical for combined and multiple injuries of the chest and pelvis, for traumatic amputation of several limbs, for bleeding from large vascular trunks. During the first hour from the moment of injury, the stage of decentralization of blood circulation develops.

This stage is manifested in the fall of systolic blood pressure below 60% of the age norm. Diastolic blood pressure is not determined. The pulse is thready, tachycardia with a pulse rate of more than 150 beats / min. The skin is pale cyanotic.

Breathing is frequent, shallow. CVP is below or above normal, depending on the degree of heart failure. BCC is reduced by more than 45% of the norm. respiratory acidosis. Metabolic acidosis with base deficiency in the range of 14-20 mmol / l. An increase in hematocrit. Increased bleeding tissue Anuria.

The effect of therapy occurs two hours after the start of treatment, or it cannot be obtained at all.

Terminal shock (IV) with the clinic of the agonal state. The severity of the course of shock dictates the intensity of therapeutic measures and determines the prognosis.

The stage of hemodynamic disturbance allows assessing the patient's condition at each specific stage of his management and developing a plan for pathogenetically substantiated therapy in the current situation.

The treatment of traumatic shock should be complex with the use of intensive care and timely surgical intervention, which plays the role of the most important anti-shock measure. Indications for surgical intervention in traumatic shock are differentiated depending on the nature of the injury.

Emergency operations for shock of any severity are indicated for abdominal trauma with damage to internal organs and bleeding; with traumatic brain injury with external bleeding or symptoms of cerebral compression; with a spinal injury with symptoms of spinal cord injury; with detachments and injuries of the limbs with a violation of the integrity of large vessels and nerve trunks; with thoracic injury with suspected injury to the heart; intrapleural bleeding; massive crushing of the lung tissue; open valvular or tension pneumothorax; thoracoabdominal wounds.

Do not require urgent surgical intervention closed and open bone fractures, not complicated by massive damage to soft tissues, blood vessels and nerves; fractures of the pelvic bones with the formation of pelvic and retroperitoneal hematomas; penetrating wounds of the chest with pneumothorax or hemothorax amenable to conservative therapy.

Operations in these cases are carried out only after removing the patient from shock.

The complex of intensive care depends on the stage of hemodynamic disturbance, during which anti-shock measures are started.

Stage of centralization of blood circulation:

1) temporary or permanent stop of external bleeding;

2) alcoholone-vocaine (trimecaine) blockade of the fracture area or nerve trunks throughout;

3) immobilization of injured limbs;

4) in the absence of suspicion of an injury to the skull or abdominal organs, the patient may be given narcotic analgesics (omnopon, promedol 1% solution - 0,1 ml / year of life);

5) analgesia by inhalation of methoxyflurane. Neuroleptanalgesia is possible with a reduction in the dose of fentanyl to 0,05 ml/kg of a 0,25% solution. Central anticholinergics (amizil, metamisil) are indicated;

6) Intravenous fluid administration begins with any medium molecular weight or protein blood substitute (polyglucin, polyvinol, plasma, albumin, etc.). In an emergency setting, it is advisable to initially administer a 20% glucose solution with insulin (5 ml/kg), vitamin B6 and cocarboxylase;

7) at the first intravenous puncture, blood sampling is necessary to determine the group and Rh factor of the patient, tests for individual compatibility. After receiving the results of these studies, they switch to a transfusion of the corresponding blood to the patient. The total blood volume of medium molecular and protein blood substitutes under conditions of stopped internal or external bleeding should be at least 15-20 ml / kg. This dose must be transfused within two hours, and at least 1/3 of the volume must be canned blood;

8) it is desirable to control blood substitution according to the dynamics of the CVP (gradual decrease to normal values, i.e. 8 cm H₂O (0,78 kPa) and average hourly diuresis (up to 1 year - 20-25 ml, 3-5 years - 30-40 ml, 6-14 years - 50-60 ml). Finally, the adequacy of the transfusion is assessed by the disappearance of pallor of the skin, cyanosis of the nails and lips, tachycardia against the background of normal blood pressure and red blood values ​​(erythrocytes, hemoglobin, hematocrit);

9) in doubtful cases, when the final effect of infusion therapy is not clear, especially with persistent high central venous pressure and the appearance of signs of congestion in the pulmonary circle, the administration of ganglion-blocking drugs is indicated. A decrease in blood pressure after gangliolytics serves as an indication for further blood transfusion;

10) the question of the operation is decided depending on the indications. If an emergency intervention is necessary, the operation is started simultaneously with the start of blood transfusion, pain relief and treatment of respiratory failure. Transitional stage of hemodynamic disturbance:

1) immobilization of the damaged organ and anesthesia is carried out according to the same principles as in the stage of centralization of blood circulation;

2) infusion therapy begins with any medium-molecular or protein plasma substitute, followed by the fastest possible transition to single-group blood transfusion. Under the condition of stopped bleeding, the total volume of transfused drugs is at least 25-30 ml / kg for two hours, of the total volume, canned blood should be at least half. If the patient does not have chest injuries, then during the first hour of therapy he needs to transfuse sodium bicarbonate (4% solution - 5 ml / kg of body weight);

3) clinical and laboratory signs of the adequacy of blood replacement are the same as in the stage of centralization of blood circulation;

4) after normalization of blood pressure, if there is doubt about the adequacy of transfusion, with signs of stagnation in the pulmonary circulation, reduced hourly diuresis, the administration of gangliolytics is indicated, followed by blood transfusion in case of repeated hypotension;

5) after normalization of central hemodynamics, it is advisable for the patient to transfuse mannitol (10-15% solution - 10 ml / kg);

6) the appointment of a complex of vitamins of group B is mandatory;

7) a single administration of hydrocortisone 5-10 mg/kg is indicated, especially with a tendency to arterial hypotension;

8) antibiotic therapy should be started;

9) tactics in relation to surgical intervention is the same as in the stage of centralization of blood circulation. Stage of decentralization of blood circulation:

1) start of treatment with immediate blood transfusion: initially O (C Rh (-) with subsequent transition to the introduction of blood corresponding to the group and Rh factor of the patient. The transfusion rate should be 30-40 ml / min. If in the first 15-20 minutes, it is not possible to achieve a positive effect from the treatment, then the infusion rate should be doubled by transfusion into the second vein.The introduction of fluid into the second vein begins with a 4% solution of sodium bicarbonate (5 ml / kg) and low molecular weight plasma substitutes (10 ml / kg Then blood is also injected into this vein. The total dose of transfused blood and blood substitutes is dictated by the dynamics of the patient's condition, however, with stopped bleeding, it should be at least 40 ml / kg. 0,5 ml of a 10% solution of calcium chloride per 100 ml of blood) and the advisability of direct blood transfusion, 100-150 ml for every 1000-1500 ml of blood;

2) in the absence of the initial effect of blood transfusion, in parallel with the transition to infusion into the second vein, the patient should be transferred to mechanical ventilation against the background of neuroleptanalgesia or anesthesia with sodium oxybutyrate. During mechanical ventilation, it is desirable to use active exhalation with a negative pressure of 20-30 cm of water. Art. (1,96-2,94 kPa);

3) early introduction (in the first minutes) of hormones of the adrenal cortex (adreson, hydrocortisone - 10-15 mg/kg);

4) after the start of infusion therapy and the transfer (if necessary) of the child to mechanical ventilation, immobilization (without reposition) of the injured limbs is performed using conduction anesthesia or blockade of fracture sites;

5) permanent catheterization of the bladder is required, taking into account hourly diuresis. Monitoring the effectiveness of therapy by the ratio of blood pressure, central venous pressure, hourly diuresis and circulating blood volume, followed by the choice of appropriate treatment;

6) infusion of 4% sodium bicarbonate solution (5 ml / kg) and concentrated glucose with insulin and vitamins (20% glucose solution - 5 ml / kg, 1 unit of insulin per 25 ml of this solution, B vitamins, and also C - 150 mg);

7) tactics regarding surgical intervention is the same as in the previous stages.

LECTURE No. 3. Acute diseases of the lungs and pleura

Respiratory tract injuries requiring emergency care are diverse. These include congenital malformations of the lung tissue (lobar emphysema, congenital lung cysts), inflammatory diseases of the lungs and pleura (destructive pneumonia with intrapulmonary and pulmonary-pleural complications).

Clinically, each pathological condition is manifested by specific features. For malformations, signs of respiratory failure are characteristic, the degree of which may be different.

In inflammatory diseases, in addition to respiratory failure, signs of intoxication of the body are usually expressed to a large extent.

Diagnosis of pulmonary-pleural complications is often difficult. This is especially true of lung lesions in destructive pneumonia.

Correct recognition of the pathological process, its nature, prevalence determines the timeliness and volume of surgical care. The range of intervention is wide: from puncture to segmentectomy or, extremely rarely, removal of the affected lung.

Despite the differences in surgical treatment, the principles of postoperative management of patients are to a certain extent the same: in addition to the fight against respiratory failure, sanitation of the pleural cavity and tracheobronchial tree, they provide for antibacterial, restorative and stimulating therapy.

It should only be emphasized that the diverse nature of pathological processes determines the indications for the use of various forms of treatment, which are based on an individual approach to each patient.

1. Malformations of the lungs. Lobar emphysema

Congenital lobar emphysema is rare. It occurs as a result of rupture of the alveolar septa in stenoses of the adducting bronchi of various origins (malformation of the lobar bronchus, partial blockage of the excessively growing mucosa, compression by an abnormally located vessel) or is a consequence of a defect in the development of the lung parenchyma (fibrous dysplasia, collagenization).

With lobar emphysema, the altered lobe of the lung is enlarged, stretched by air, tense, and does not collapse. As a result, the remaining parts of the lung are compressed and do not participate in breathing. The upper lobes of the lung are most often affected, less often the middle and lower lobes.

clinical picture

Lobar emphysema is manifested by shortness of breath, often with prolonged expiration, bouts of cyanosis, shortness of breath, cough. The severity of symptoms depends on the degree of bronchial obstruction. According to the clinical course, lobar emphysema should be divided into acute and chronic.

Acute course of lobar emphysema is usually observed in children during the first months of life (often soon after birth). The disease is manifested by a progressive increase in signs of respiratory failure.

The general condition of the child is severe, the skin is pale with a cyanotic tint; punctate subcutaneous hemorrhages are visible, cyanotic lips. Sharp shortness of breath is determined, auxiliary muscles are involved in breathing. The chest is barrel-shaped.

Percussion over the lung field on the side of the lesion reveals high tympanitis, with auscultation there are no respiratory sounds. The boundaries of the heart are shifted to the healthy side. Heart sounds are muffled.

X-ray data are of decisive importance in making the diagnosis of lobar emphysema. A plain X-ray of the chest shows that the affected part of the lung is sharply swollen, with shadows of medium- and large-caliber vascular branches against its highly airy background. Neighboring areas of the lung are collapsed. The swollen lobe partially penetrates into the opposite side of the chest, displacing the mediastinum and forming a mediastinal hernia.

In addition to the usual clinical and radiological methods, bronchography and bronchoscopy help to establish the correct diagnosis, in the chronic form of the disease, in which narrowing of the lobar bronchus, displacement and convergence of the bronchi of healthy parts of the lung are determined.

In the acute course of lobar emphysema, other additional diagnostic methods of research are often impossible, since the growing deterioration in the general condition of the child requires immediate surgical care.

Chronic lobar emphysema is extremely rare.

In such cases, the phenomena of respiratory failure increase slowly, the body adapts to the changes that have occurred and compensates for them. The disease is usually detected during preventive examinations or x-ray examinations.

Differential diagnosis

Lobar emphysema should be differentiated from pulmonary cyst and diaphragmatic hernia.

With a pulmonary cyst, the clinical manifestations of the disease can be acute or chronic, with signs of respiratory failure.

X-ray data help to make a correct diagnosis. Pulmonary cysts on radiographs look like well-defined air cavities of a rounded shape, without a mesh pattern characteristic of lobar emphysema. Quite often nevertheless the differential diagnosis on the basis of clinical and radiological data is extremely difficult.

Finally, the nature of the pathological process in such cases is revealed during surgery and after a histological examination of the drug.

Diaphragmatic hernia in the presence of an asphyxic component in newborns is similar to the acute form of lobar emphysema. In doubtful cases, the final diagnosis is made after x-ray examination with a contrast agent. Contrasting intestinal loops located in the pleural cavity makes the diagnosis of diaphragmatic hernia undoubted.

Treatment

Treatment of congenital lobar emphysema in all cases is surgical. In the acute course of the disease with a clinical picture of severe respiratory failure, the operation should be undertaken according to emergency indications. In cases of a chronic course, intervention is carried out in a planned manner.

Preoperative preparation. The volume and duration of the patient's preparation for surgery depend on the nature of the clinical manifestations.

In acute cases, preoperative preparation is limited to a few (2-3) hours. The patient is prescribed oxygen, cardiac agents, warmed up and transferred to the operating room.

Surgical treatment. The nature of the surgical intervention is determined by the localization of the lesion and comes down to lobectomy. Removal of the lung lobes is performed from an anterolateral thoracotomy approach in the fourth or fifth intercostal space with the patient in a semilateral position.

Technically, lobectomy is carried out according to the rules set out in special guidelines for operative surgery, with the obligatory separate processing of the elements of the lung root.

After removal of the affected lung section, high drainage is established in the pleural cavity, which is introduced through a separate incision - a puncture in the seventh-eighth intercostal space along the midaxillary line. The operation is completed by layer-by-layer suturing of the thoracotomy wound. The skin is sutured with nylon threads.

postoperative treatment. High drainage is left in the pleural cavity for active aspiration of exudate during the first 24-48 hours. For pain relief in the immediate postoperative period, prolonged epidural anesthesia is performed. It is advisable to prescribe parenteral fluid administration for the first 12-24 hours after surgery (10% glucose solution with insulin, protein preparations) according to the weight and age of the child.

In the absence of vomiting, the next day after the intervention, the child begins to feed through the mouth. Blood transfusions are done taking into account the indicators of red blood tests, as well as taking into account the amount of exudate aspirated from the pleural cavity.

To prevent pulmonary complications (blockage of the bronchial tree, atelectasis), from the first hours after the operation, the patient is prescribed respiratory and cough exercises, alkaline aerosols.

If these measures are ineffective, direct laryngoscopy is performed with suction of the secret and the introduction of antibiotics into the respiratory tract. From the 3-4th day, older children begin to walk.

The presence of atelectasis is an indication for the appointment of more intense breathing exercises, which usually leads to the complete elimination of this complication, and in case of ineffectiveness, tracheobronchoscopy is resorted to.

In the postoperative period, patients receive broad-spectrum antibiotics for 6-7 days, vitamins, oxygen therapy, physiotherapy and massage. The sutures are removed on the 7-8th day.

2. Complicated congenital lung cysts

Lung cysts are a relatively rare disease of childhood, occurring from 3,5 to 5,5% in relation to the total number of patients with various nonspecific lung diseases. Cysts are single and multiple. Multiple lung cysts include their polycystic lesion.

Cysts are more common in the right lung than in the left. The sizes of cysts vary widely. They can be single or multi-chamber, very small, sometimes reaching gigantic sizes, occupying almost the entire lobe or lung. If the cysts do not communicate with the tracheobronchial tree (closed), then they usually contain a sterile mucous liquid, colorless, yellowish or brown. Cysts communicating with the bronchi are filled with air and infected fluid.

In cases of air cysts, fluid from them is well evacuated through the draining bronchus.

All lung cysts are usually divided depending on their origin into true and false, and according to the nature of the clinical course - into uncomplicated and complicated. In children, true cysts (lung malformation) are more common. Uncomplicated cysts, as a rule, do not manifest themselves clinically, and therefore are usually an incidental finding during an X-ray examination of a child.

The majority of congenital pulmonary cysts are detected when there are complications that require urgent surgical treatment. Festering and air strained cysts are most often observed.

clinical picture

Each of the complications is characterized by specific features of the clinical manifestation.

Suppurated cysts of the lungs. With suppuration of single lung cysts, the disease develops acutely, with a sharp deterioration in the general condition of the child, an increase in body temperature to high numbers, chills, and sweating.

On examination, the patient noted pallor of the skin, cyanosis in the area of ​​the nasolabial triangle. Breathing is fast, pulse is tense.

Physical data depend on the size of the cyst, the degree of its drainage through the bronchus, and other factors. On the side of the localization of the cyst, areas of dullness of percussion sound and tympanitis are revealed, respectively, inflammatory infiltration, accumulation of exudate and air.

During auscultation in these places, breathing is weakened, after coughing, moist coarse rales appear. Changes in the blood indicate an acute inflammatory process: high leukocytosis with a shift to the left, increased ESR.

X-ray examination reveals a cavity filled with fluid, around which there is an inflammatory infiltrate. With partial emptying of purulent contents, a horizontal level appears in the cyst cavity.

Differential diagnosis

It is necessary to differentiate infected cysts with lung abscess and pyopneumothorax.

The clinical course of an infected cyst and lung abscess is very similar. Radiographically, these processes are also difficult to differentiate.

The final diagnosis of a lung cyst can be made in cases where the anamnesis indicates the presence of an air cavity in the lung, which was previously found during an X-ray examination, or there is repeated suppuration in the lung with the same localization of the focus.

Pyopneumothorax develops against the background of severe asbestos pneumonia and is its complication. Radiologically, the cavity is located along the outer edge of the lung field. In doubtful cases, a dynamic x-ray examination helps to make the correct diagnosis, as well as additional examination methods - tomography, bronchography, which reveal the normal structure and location of the airways.

With a purulent-inflammatory lesion of a polycystic lung, if infection occurs at an early age, the disease becomes protracted with frequent exacerbations. The general condition of the child is progressively deteriorating, the phenomena of intoxication are increasing, the patient is exhausted, the body temperature rises.

When examining a child, a rigid chest wall is revealed on the side of the lesion, which is not involved in the act of breathing. The borders of the heart are not changed. Percussion above the pulmonary field - a motley picture: areas of pulmonary sound alternate with tympanitis and dullness.

Auscultatory determined a large number of different-sized moist rales. X-ray shows multiple thin-walled air cavities of various sizes with horizontal levels. There is no noticeable displacement of the mediastinal organs.

A polycystic lung with suppuration should be differentiated from abscess pneumonia and bronchiectasis. The course of destructive pneumonia is characterized by a rapid onset. X-ray reveals characteristic infiltrative (with subsequent abscessing) changes in the lungs.

With bronchiectasis, the course of the disease is chronic with periodic exacerbations, with expectoration of purulent sputum. X-ray and bronchography revealed deformed, dilated rigid bronchi in all lobes of the lung.

However, correct recognition is often extremely difficult. Sometimes even a histological examination does not clarify the final diagnosis.

Air tight lung cysts are clinically manifested by the development of severe respiratory failure with frequent attacks of suffocation. Children lag behind in physical development A severe clinical picture develops with lung cysts with a valve mechanism in the afferent bronchus. The valve is formed due to the kink of the bronchus, its oblique communication with the cavity of the cyst, hypertrophy of the mucous membrane, blockage of the bronchus with sputum, mucus.

Often, from the first days of life, such children experience shortness of breath, shortness of breath with the participation of all auxiliary muscles. Even at rest, they retain a cyanotic shade of the skin. Scream and anxiety are accompanied by bouts of asphyxia. This condition may develop gradually with progressive deterioration, but sometimes it comes on suddenly.

During a clinical examination of a child on the side of the lesion, a lag in the act of breathing of half of the chest is determined.

Percussion sound over the lung field is tympanic in nature. The boundaries of the heart are shifted to the healthy side, breath sounds are not auscultated

X-ray reveals a vast air cavity occupying the entire half of the chest, there is no pulmonary pattern, the shadow of the heart and mediastinal organs is sharply shifted to the healthy side. There are signs of a mediastinal hernia

Treatment

All congenital pulmonary cysts are subject to surgical treatment, however, the timing of the operation is determined by the course of the disease, the condition of the child. The same factors dictate the volume and duration of preoperative preparation.

Preoperative preparation depends on the nature of the complication. An infected cyst or cysts of the lung require intensive complex therapy, which is a kind of preoperative preparation. Therapeutic measures in these patients are aimed at removing intoxication and restorative therapy.

Sanitation of the purulent cavity is carried out by puncturing it, with the suction of pus, washing with antiseptic solutions and the introduction of antibiotics. The cyst is punctured again after 2-3 days (depending on the accumulation of exudate). At the same time, the patient is prescribed therapeutic exercises with a drainage position.

With insufficient drainage function of the afferent bronchus, it is advisable to include repeated tracheobronchoscopy in the complex of therapeutic measures. The degree of sanitation of the cavity is controlled by crops of its contents. Often it is possible to achieve complete inhibition of the growth of pathogenic microflora. The patient receives alkaline aerosols with antibiotics and local anti-inflammatory physiotherapy.

Drainage of festering cysts with the establishment of passive or active aspiration is not indicated due to the possible formation of a persistent internal bronchial fistula.

As a result of the rehabilitation of the purulent focus, the patient's symptoms of intoxication are reduced, which is also facilitated by vigorous general strengthening therapy - transfusion of blood, plasma, intravenous fluids, parenteral administration of vitamins and massive antibiotic therapy.

With giant strained cysts, as well as cysts with a valve mechanism, an emergency measure of assistance that allows the child to be taken out of a serious condition due to respiratory failure is the puncture of the cyst. Reducing intrapulmonary pressure can significantly improve the general condition of the patient and successfully carry out urgent surgical intervention.

Operative treatment. The extent of the operation depends on the nature of the pathological process. It should be remembered that the introduction of anesthesia in patients with tense cysts has its own characteristics: forcible injection of air into the lungs and into the cyst during artificial respiration leads to an increase in pressure in the air cavity, and therefore the conditions of pulmonary ventilation significantly worsen.

There is a vicious circle - despite vigorous artificial respiration, hypoxia continues to grow. This complication can be prevented by puncturing the cyst with an open needle prior to intubation of the patient and maintaining the needle in its cavity until the moment of thoracotomy.

With single cysts, surgery can be reduced to thoracotomy and cyst exfoliation.

Operation technique. Thoracotomy is performed according to the general rules with an anterolateral incision. The lung is isolated from the adhesions Above the cyst, the pleura is carefully dissected, after which the lung is gradually exfoliated from the cyst wall. Fibrous strands, by which the cyst is connected with the surrounding lung tissue, are cut and ligated.

There are especially many strands at the basal pole of the cyst. Here, quite large vessels and one or more bronchial branches that communicate with the cyst can pass.

They are ligated with silk. Bleeding areas of the lung edge are sheathed with catgut. If it is impossible to enucleate the cyst, a lobectomy is performed according to the general rules. After removal of the cyst in the pleural cavity, drainage is left for 24-48 hours.

The extent of surgery for polycystic lung depends on the extent of the lesion. With lobar localization, the operation is reduced to a lobectomy. In the case of cystic degeneration of the entire lung, a pneumonectomy is performed.

Drainage of the pleural cavity after pneumonectomy is not mandatory.

However, after a traumatic operation or if there are doubts about the reliability of the bronchus suture, it is better to introduce drainage for 36-48 hours, with the help of which the exudate is passively aspirated.

postoperative treatment. Basically, the treatment of patients who underwent surgery for lung cysts does not differ from that for lobar emphysema. After removal of previously infected cysts, special attention should be paid to antibiotic therapy. Careful care of the postoperative wound is also necessary - daily dressings, suture treatment, ultraviolet irradiation.

In children who have undergone pneumonectomy, after removal of the drainage, the residual pleural cavity is filled with a displaced mediastinum and an organizing blood clot. In these cases, it is especially important to prevent infection of the cavity and the development of pleural empyema, so careful antibiotic therapy takes on special meaning.

The fight against intoxication and respiratory failure is carried out systematically by intravenous infusions of blood, plasma, constant oxygen therapy. Such children require dispensary observation and periodic sanatorium treatment.

LECTURE № 4. Malformations of the esophagus. Obstruction of the esophagus

Various diseases of the esophagus occur in children of all age groups. Most often, the need for urgent surgical intervention arises in connection with congenital malformations and injuries of the esophagus.

Somewhat less often, indications for emergency care are due to bleeding from the dilated veins of the esophagus with portal hypertension.

Malformations of the esophagus are among the diseases that often cause the death of children in the first days of life or the occurrence of serious complications in them that disrupt further development. Among the numerous congenital defects of the esophagus for emergency surgery, those types that are incompatible with the life of a child without urgent surgical correction are of interest: congenital obstruction (atresia) and esophageal-tracheal fistulas.

Obstruction of the esophagus

Congenital obstruction of the esophagus is due to its atresia. This complex malformation is formed in the early stages of intrauterine life of the fetus and, according to studies, occurs relatively often (for every 3500 children, 1 is born with esophageal pathology).

In atresia, in most cases, the upper end of the esophagus ends blindly, and the lower part communicates with the trachea, forming a tracheoesophageal fistula (90-95%). Amniotic fluid and fluid that the baby swallows after birth cannot enter the stomach and accumulate along with mucus in the upper blind sac of the esophagus, then regurgitate and aspirate. The presence of a fistula in the upper segment of the esophagus accelerates aspiration - after swallowing, the liquid partially or completely enters the trachea. The child quickly develops aspiration pneumonia, which is aggravated by the throwing of stomach contents into the trachea through the esophageal-tracheal fistula of the lower segment. A few days after birth, death occurs from aspiration pneumonia. Such children can only be saved by urgent surgical correction of the defect.

A successful outcome of the treatment of congenital obstruction of the esophagus depends on many reasons, but above all - on the timely detection of atresia. Early initiation of special treatment reduces the possibility of aspiration. A diagnosis made in the first hours of a child's life (before the first feeding) will prevent or greatly alleviate the course of aspiration pneumonia.

clinical picture

The first earliest and most consistent sign that suggests esophageal atresia in a newborn is a large amount of frothy discharge from the mouth and nose. Suspicion of esophageal atresia should be increased if, after the usual suction of mucus, the latter continues to accumulate rapidly in large quantities.

Mucus at times has a yellow color, which depends on the throwing of bile into the trachea through the fistula of the distal segment of the esophagus. In all children with obstruction of the esophagus, by the end of the 1st day after birth, quite distinct respiratory disorders (arrhythmia, shortness of breath) and cyanosis can be detected.

Auscultation in the lungs is determined by an abundant amount of moist rales of various sizes. When the upper esophagus communicates with the trachea, aspiration pneumonia is diagnosed immediately after birth. Abdominal distension indicates an existing fistula between the distal esophagus and the airways.

If the first indirect signs of atresia were detected in the maternity hospital, the diagnosis should be confirmed or rejected by probing the esophagus. With atresia, a freely pushed catheter is delayed at the level of the top of the bag of the proximal segment of the esophagus (10-12 cm from the edge of the gums). If the esophagus is not changed, then the catheter easily passes for a greater distance.

It must be remembered that in some cases the catheter can develop, and then a false impression is created about the patency of the esophagus. To clarify the diagnosis, the catheter is carried to a depth of more than 24 cm, and then its end (if there is atresia) is inevitably found in the child's mouth.

At the first feeding obstruction of a gullet comes to light quite definitely. All drunk liquid (1-2 sips) immediately pours back. Feeding is accompanied by a sharp violation of breathing: the newborn turns blue, breathing becomes superficial, arrhythmic, it stops. These phenomena occur during each feeding.

Gradually increasing cyanosis. When auscultating the lungs, an abundant amount of different-sized moist rales is revealed, more on the right. The general condition of the child progressively worsens.

With exhaustive completeness and reliability, the diagnosis is made on the basis of an X-ray examination of the esophagus using a contrast agent, which is carried out only in a surgical hospital. The data obtained are a necessary part of the preoperative examination and serve as a guideline for choosing the method of surgical intervention. X-ray examination of children with suspected esophageal atresia begins with a plain chest x-ray (it is very important to carefully assess the condition of the lungs).

Then, a rubber catheter is passed into the upper segment of the esophagus and the mucus is sucked off, after which 1 ml of iodolipol is injected through the same catheter into the esophagus with a syringe. The introduction of a large amount of iodized oil can lead to an undesirable complication - overflow of the blind upper segment of the esophagus and aspiration with filling of the bronchial tree with a contrast agent.

Pictures are taken in the vertical position of the child in two projections. The contrast agent after X-ray examination is carefully sucked off.

The use of barium sulfate as a contrast agent for examination of the esophagus in newborns with any form of atresia is contraindicated, since its entry into the lungs, which is possible during this study, causes atelectatic pneumonia.

In the general serious condition of the child (late admission, prematurity III-IV degree), you can not undertake examinations with a contrast agent, but limit yourself to the introduction of a thin rubber catheter into the esophagus (under the control of an X-ray screen), which will allow you to fairly accurately determine the presence and level of atresia. It should be remembered that with the rough introduction of a low-elastic thick catheter, the pliable film of the blind oral segment of the esophagus can be displaced, and then a false impression is created about the low location of the obstruction.

A characteristic radiological symptom of esophageal atresia when examined with a contrast agent is a moderately dilated and blindly ending upper segment of the esophagus. The level of atresia is more accurately determined on lateral radiographs.

The presence of air in the gastrointestinal tract indicates an anastomosis between the lower esophagus and the respiratory tract.

The visible upper cecum and the absence of gas in the gastrointestinal tract suggest atresia without a fistula between the distal esophagus and the trachea. However, this radiographic finding does not always completely rule out a fistula between the distal esophagus and the airways.

The narrow lumen of the fistula is clogged with a mucous plug, which serves as an obstacle to the passage of air into the stomach.

The presence of a fistula between the upper segment of the esophagus and the trachea can be detected radiologically by throwing a contrast agent through the fistula into the respiratory tract. This examination does not always help to detect a fistula, which in such cases is found only during surgery.

Differential diagnosis

Differential diagnosis must be made with asphyxial conditions of the newborn caused by birth trauma and aspiration pneumonia, as well as isolated tracheoesophageal fistula and “asphyxial strangulation” of the diaphragmatic hernia. In such cases, esophageal atresia is excluded by probing.

Treatment

The success of surgical intervention depends on the early diagnosis of the defect, and hence the timely start of preoperative preparation, the rational choice of the method of operation and the correct postoperative treatment.

Many combined defects have a significant impact on the prognosis.

It is extremely difficult to treat premature babies; newborns of this group have rapidly developing pneumonia, reduced resistance, and a peculiar reaction to surgical intervention.

Preoperative preparation. Preparation for the operation begins from the moment the diagnosis is established in the maternity hospital. The child is continuously given humidified oxygen, antibiotics and vitamin K.

The mucus secreted in large quantities is carefully aspirated through a soft rubber catheter inserted into the nasopharynx at least every 10-15 minutes. Feeding by mouth is absolutely contraindicated.

Transportation of the patient to the surgical department is carried out according to the rules provided for newborns with the obligatory continuous supply of oxygen to the child and periodic suction of mucus from the nasopharynx.

Further preparation for the operation is continued in the surgical department, striving mainly to eliminate the phenomena of pneumonia. The duration of preparation depends on the age and general condition of the child, as well as the nature of pathological changes in the lungs.

Children admitted in the first 12 hours after birth do not require long-term preoperative preparation (1,5-2 hours is enough). At this time, the newborn is placed in a heated incubator, humidified oxygen is constantly given, and mucus is sucked out of the mouth and nasopharynx every 10-15 minutes. Antibiotics, heart medications, and vitamin K are administered.

Children admitted later after birth with symptoms of aspiration pneumonia are prepared for surgery 6-24 hours after birth.

The child is placed in an elevated position in a heated incubator with a constant supply of humidified oxygen. Every 10-15 minutes, mucus is suctioned from the mouth and nasopharynx (the child needs an individual nursing post). With long-term preparation, every 6-8 hours, mucus is aspirated from the trachea and bronchi through a respiratory bronchoscope or by direct laryngoscopy.

Antibiotics, cardiac agents are administered, an aerosol with alkaline solutions and antibiotics is prescribed. Late admission shows parenteral nutrition.

Preoperative preparation is stopped with a noticeable improvement in the general condition of the child and a decrease in the clinical manifestations of pneumonia.

If during the first 6 hours the preoperative preparation does not have a noticeable success, the presence of a fistulous tract between the upper segment and the trachea, in which mucus inevitably enters the respiratory tract, should be suspected.

Continuation of preoperative preparation in such cases will be useless, it is necessary to proceed to surgical intervention.

Surgery for esophageal atresia is performed under endotracheal anesthesia. The operation of choice should be the creation of a direct anastomosis. However, the latter is possible only in cases where the diastasis between the segments of the esophagus does not exceed 1,5 cm (if the upper segment is located high, anastomosis can only be created with a special stapler).

The imposition of anastomosis with a high tension of the tissues of the esophageal segments does not justify itself due to technical difficulties and the possible eruption of sutures in the postoperative period.

In newborns weighing less than 1500 g, multi-stage, "atypical" operations are performed: delayed anastomosis with preliminary ligation of the esophageal-tracheal fistula.

On the basis of clinical and radiological data, it is almost impossible to establish the true distance between the segments. Finally, this issue is resolved only during surgery.

If during thoracotomy a significant diastasis (more than 1,5 cm) between the segments or a thin lower segment (up to 0,5 cm) is detected, then the first part of the two-stage operation is performed - the esophageal-tracheal fistula of the lower segment is eliminated and the upper end of the esophagus is brought to the neck.

These measures prevent the development of aspiration pneumonia, thereby saving the life of the patient. Created lower esophagostomy serves to feed the child until the second stage of the operation - the formation of an artificial esophagus from the colon.

The operation of creating an anastomosis of the esophagus

Technique of extrapleural access. The position of the child on the left side. The right hand is fixed in a raised and retracted anterior position. A diaper rolled up in the form of a roller is placed under the chest. The incision is made from the nipple line to the angle of the scapula along the V rib.

Bleeding vessels are carefully ligated. The muscles are carefully dissected in the fourth intercostal space. The pleura is slowly peeled off (first with a finger, then with a damp small tuff) along the incision up and down 3-4 ribs. Using a special small-sized screw retractor, the hooks of which are wrapped in damp gauze, the edges of the chest cavity wound are spread apart, after which the pleura-covered lung is retracted anteriorly with a Buyalsky spatula (also wrapped in gauze). The mediastinal pleura is peeled off above the esophagus up to the dome and down to the diaphragm.

Measure the true length of diastasis between the segments. If the anatomical relationship allows you to create a direct anastomosis, then proceed to the mobilization of the segments of the esophagus.

Technique of mobilization of segments of the esophagus. Find the lower segment of the esophagus. The reference point is the typical location of the vagus nerve. The latter is removed inside, the esophagus is relatively easily isolated from the surrounding tissues and taken on a holder (rubber strip).

The lower segment of the esophagus is mobilized over a short distance (2-2,5 cm), since its significant exposure can lead to impaired blood supply. Directly at the point of communication with the trachea, the esophagus is tied up with thin ligatures and crossed between them.

Stumps are treated with tincture of iodine. The ends of the thread on the short stump of the esophagus (near the trachea) are cut off. Additional suturing of the tracheal fistula is usually not required. Only a wide lumen (more than 7 mm) is an indication for applying one row of continuous suture to the stump. The second thread at the free lower end of the esophagus is temporarily used as a "holder". The upper segment of the esophagus is found by the catheter inserted into it before the start of the operation through the nose.

A suture is applied to the top of the blind sac, for which it is pulled up, exfoliating the mediastinal pleura, and carefully isolated upward with a wet tupfer. The oral segment has a good blood supply, which allows it to be mobilized as high as possible.

Tight adhesions to the posterior wall of the trachea are carefully dissected with scissors. If there is a fistula between the upper segment and the trachea, the latter is crossed, and the holes formed in the trachea and esophagus are sutured with a double-row continuous marginal suture with atraumatic needles.

The mobilized segments of the esophagus are pulled towards each other by the threads. If their ends freely go behind each other (which is possible with diastasis up to 1,5 cm, in premature babies - 1 cm), then they begin to create an anastomosis.

Anastomosis technique. Creating an anastomosis is the most difficult part of the operation. Difficulties arise not only in connection with diastasis between the segments of the esophagus, but also depend on the width of the lumen of the distal segment.

The narrower its lumen, the more difficult it is to suture, the greater the likelihood of their eruption and the occurrence of narrowing of the anastomosis site in the postoperative period.

Due to the variety of anatomical options for esophageal atresia, various methods of creating an anastomosis are used. Atraumatic needles are used for suturing.

Anastomosis by connecting segments of the esophagus in an end-to-end fashion. The first row of separate silk sutures is applied through all layers of the lower end of the esophagus and the mucosa of the upper segment.

The second row of sutures is passed through the muscle layer of both segments of the esophagus. The greatest difficulty of this method lies in the imposition of the first row of sutures on extremely thin and delicate tissues, which cut through with the slightest tension. Anastomosis is used for small diastasis between the segments of the esophagus and the wide lower segment.

To connect the ends of the esophagus, you can use special seams such as wrapping. Four pairs of such threads, superimposed symmetrically on both segments of the esophagus, first serve as holders, for which the ends of the esophagus are pulled up.

After approaching their edges, the corresponding threads are tied. When tying the sutures, the edges of the esophagus are screwed inward. The anastomosis is strengthened with a second row of separate silk sutures. Such sutures make it possible to impose an anastomosis with some tension without fear of cutting through the delicate tissues of the organ with threads.

The technique of oblique anastomosis of the esophagus significantly reduces the possibility of stricture formation at the suturing site.

Double esophagostomy according to G. A. Bairov is the first stage of a two-stage operation and consists of the elimination of esophageal-tracheal fistulas, removal of the oral segment of the esophagus to the neck and the creation of a fistula from its distal segment for feeding the child in the postoperative period. The milk entering through the lower esophagostomy opening does not flow out after feeding, since during this operation the cardiac sphincter remains preserved.

Technique of the operation of the lower esophagostomy. After making sure that the creation of a direct anastomosis is impossible, proceed to the mobilization of the segments of the esophagus. First, the upper segment is isolated for as long as possible.

In the presence of a tracheal fistula, the latter is crossed, and the resulting hole in the esophagus and trachea is sutured with a continuous marginal suture. Then the lower segment is mobilized, tied up at the trachea and crossed between two ligatures. Several separate silk sutures are applied to the short stump at the trachea.

The vagus nerve is removed inside, the esophagus is carefully isolated to the diaphragm. In a blunt way (opening the inserted Billroth clamp), the esophageal opening is expanded, the stomach is pulled up and the peritoneum is dissected around the cardial section (attention should be paid to the close location of the vagus nerve).

After that, the child is turned on his back and an upper laparotomy is performed with a right paramedian incision. The mobilized distal segment is passed into the abdominal cavity through the dilated esophagus.

In the epigastric region to the left of the midline, a transverse incision (1 cm) is made through all layers of the abdominal wall. A mobilized esophagus is passed into the formed hole in such a way that it rises above the skin by at least 1 cm. Its wall is fixed from the inside with several sutures to the peritoneum, and sutured to the skin from the outside.

A thin tube is inserted into the stomach through the withdrawn esophagus, which is fixed with a silk thread tied around the protruding part of the esophagus. Wounds of the abdominal wall and chest are sewn up tightly. The operation ends with the removal of the upper segment of the esophagus.

postoperative treatment. The success of the operation largely depends on the correct conduct of the postoperative period. For more thorough care and careful observation in the first days after surgery, the child needs an individual nursing post and constant medical supervision. The child is placed in a heated incubator, giving the body an elevated position, constantly giving humidified oxygen. Continue the introduction of antibiotics, vitamins K, C, B, prescribe UHF currents on the chest. 24 hours after the operation, a control radiograph of the chest cavity is performed. The detection of atelectasis on the side of the operation is an indication for sanitation of the tracheobronchial tree.

In the first hours after surgery, the child may progressively develop respiratory failure, which requires urgent intubation and assisted breathing (after suction of mucus from the trachea).

After a few hours, the child's condition usually improves, and the tube can be removed from the trachea. Re-intubation after anastomosis should be done with great care and only by a clinician experienced in neonatal re-intubation.

The erroneous introduction of the tube instead of the trachea into the esophagus threatens to rupture the sutures of the anastomosis.

Oxygenobarotherapy gives a positive effect. In the postoperative period after the simultaneous restoration of the continuity of the esophagus, children receive 1-2 days of parenteral nutrition. The correct calculation of the amount of fluid required for parenteral administration to a child is very important. A single amount of liquid on the first day of feeding should not exceed 5-7 ml. In the following days, breast milk and glucose are gradually added (5-10 ml each), bringing the daily volume of fluid to the age norm by the end of the week after the operation. Feeding through a probe is carried out with the child in an upright position, which prevents fluid regurgitation through a functionally defective cardiac sphincter in a newborn. With an uncomplicated course, the probe is removed on the 8-9th day.

The patency of the esophagus and the condition of the anastomosis are monitored after 9-10 days by X-ray examination with iodolipol. The absence of signs of anastomotic leakage allows you to start feeding by mouth from a bottle or from a spoon. At the first feeding, the child is given 10-20 ml of 5% glucose. and then - breast milk in half the dose of the amount that the newborn received when feeding through a tube.

In the following days, the amount of milk is increased daily by 10-15 ml for each feeding, gradually bringing it to the norm for age and body weight. Fluid deficiency is compensated parenterally by fractional daily administration of a 10% solution of glucose, plasma, blood or albumin. This avoids a noticeable drop in body weight in the newborn.

On the 10-14th day, the child is applied to the chest for 5 minutes first and a control weighing is carried out. Feeding the child from the horn. During this period, the required amount of food is calculated based on the body weight of the child: it should fluctuate between 1/5 and 1/6 of the body weight of the newborn.

Gradually increase the time of attachment to the breast and at the beginning of the 4th week they switch to 7 meals a day.

Postoperative management of a child who underwent the first part of a two-stage esophageal plasty has some differences due to the possibility of feeding through the esophagostomy opening. The small size of the stomach of a newborn, a violation of its motor function due to trauma during the creation of a fistula, requires fractional feeding with a gradual increase in the amount of fluid administered. From the 7th day after the operation, the volume of the stomach increases so much that up to 40-50 ml of liquid can be slowly injected through the esophagostomy opening (3/4 of the total amount of liquid is replenished with breast milk and 10% glucose solution). From the 10th day they switch to 7 meals a day with normal dosages.

In the first days after the intervention, careful care of fistulas on the neck and anterior abdominal wall is necessary. The latter especially needs frequent dressing changes, skin treatment with antiseptic pastes, and exposure to ultraviolet rays. A thin rubber drainage inserted into the stomach is not removed for 10-12 days until the lower esophageal fistula is completely formed. Then the probe is inserted only at the time of feeding.

The sutures are removed on the 10-12th day after the operation. Children are discharged from the hospital (with an uncomplicated course) after a stable weight gain is established (week 5-6). If a newborn has had a double esophagostomy, the child's mother should be taught proper fistula care and feeding techniques.

Further monitoring of the child is carried out on an outpatient basis by a surgeon together with a pediatrician. Preventive examinations should be carried out every month before the child is sent to the second stage of the operation - the creation of an artificial esophagus.

Surgical complications in the postoperative period occur mainly in newborns who have undergone simultaneous esophageal plastic surgery.

The most severe complication should be considered the failure of the anastomotic sutures, which, according to the literature, is observed in 10-20% of operated patients. The resulting mediastinitis and pleurisy are usually fatal, despite the creation of gastrostoma, drainage of the mediastinum and pleural cavity.

With early recognition of the divergence of the anastomotic sutures, an urgent rethoracotomy and the creation of a double esophagostomy are necessary.

In some cases, after the creation of a direct anastomosis, recanalization of the tracheoesophageal fistula occurs, which is manifested by sharp bouts of coughing with each attempt to feed through the mouth. The complication is recognized when examining the esophagus with a contrast agent (iodolipol flows into the trachea), and the final diagnosis becomes by subanesthetic tracheobronchoscopy. Treatment is carried out by creating a gastrostomy and draining the mediastinum (with an increase in the phenomena of mediastinitis). After the subsidence of inflammatory changes and the final formation of the fistulous tract, a second operation is indicated. Sometimes recanalization is combined with stenosis in the anastomosis area.

After the simultaneous creation of an anastomosis of the esophagus, all children are subject to dispensary observation for at least 2 years, since late complications may occur during this period.

In some children, 1-2 months after the operation, a rough cough appears, which is associated with the formation of adhesions and scars in the area of ​​the anastomosis and trachea. Carrying out physiotherapeutic measures helps to get rid of this late complication, which is usually eliminated at the age of 5-6 months.

In the period up to 1-2 years after surgery, an isolated narrowing of the esophagus in the area of ​​the anastomosis may occur. The treatment of this complication usually does not cause difficulties: several sessions of bougienage (under the control of esophagoscopy) lead to recovery.

In rare cases, conservative measures are unsuccessful, which is an indication for repeated thoracotomy and plastic surgery of the narrowed esophagus.

LECTURE No. 5. Esophageal-tracheal fistulas. Damage to the esophagus. Esophageal perforation

1. Esophageal-tracheal fistulas

The presence of a congenital anastomosis between the esophagus and the trachea without other anomalies of these organs is rare.

There are three main variants of the defect, among which there is mainly a short and wide fistulous course. The fistula is usually located high, at the level of the first thoracic vertebrae.

The presence of a fistulous tract between the esophagus and trachea leads to the rapid development of pneumonia due to the aspiration of fluid swallowed by the child. An unrecognized and untreated fistula usually causes the death of a child. Only a narrow anastomosis sometimes proceeds with mild symptoms, and in such cases, patients can live for a long time.

clinical picture

Clinical symptoms of esophageal-tracheal fistula appear in most cases after the first feeding of the child, but their intensity depends on the variant of the malformation.

A narrow and long fistulous tract, as a rule, is not detected in the neonatal period.

These babies occasionally have severe coughing spells while feeding. Parents do not attach importance to them, since feeding in a certain position of the child saves him from seizures. The child often suffers from pneumonia.

In cases of a wide and short fistula, feeding a newborn is almost always accompanied by a fit of coughing, cyanosis, and frothy discharge from the mouth. These children quickly develop aspiration pneumonia.

After eating, the number of wet coarse rales in the lungs increases. Feeding the child in an upright position reduces the possibility of milk flowing through the fistulous tract into the trachea, and coughing occurs less often, without being accompanied by cyanosis.

A large fistula, in which both organs at some distance are represented as if by one common tube, appears at the first feeding.

Each sip of the liquid triggers a coughing fit. Respiratory failure is prolonged, accompanied by severe cyanosis.

The general condition progressively worsens due to severe pneumonia and extensive atelectasis of the lungs.

X-ray examination is of some importance for the diagnosis of esophageal-tracheal fistula. Survey pictures reveal the nature of pathological changes in the lungs.

If aspiration pneumonia is clinically and radiographically determined, special studies are postponed until the process subsides in the lungs (treatment of pneumonia is part of the preoperative preparation).

In older children, the fistulous tract can be detected radiologically when examining the esophagus with a liquid contrast agent.

The child is placed under the screen on the x-ray table in a horizontal position.

The contrast medium is given from a spoon or injected through a catheter placed in the initial part of the esophagus. It is generally accepted that partial or complete filling of the bronchial tree with a contrast agent indicates the presence of an anastomosis. The latter is usually not determined on the radiograph, since the yodolipol cannot linger in a wide and short fistulous course.

By carefully observing through the screen the passage of the contrast agent through the esophagus, one can sometimes catch the moment of its passage through the fistula into the trachea.

Clinical and radiological data on the presence of an esophageal-tracheal fistula can be confirmed by esophagoscopy. When an esophagoscope is inserted and the esophagus is examined, the fistulous tract becomes noticeable by small air bubbles emerging from it in time with breathing. A narrow fistula is usually not visible during esophagoscopy, it is masked by mucosal folds.

A clearly fistulous course is determined only with tracheobronchoscopy, which is performed under anesthesia for all children with suspected esophageal-tracheal fistula.

With the introduction of a bronchoscope to a depth of 8-12 cm, usually 1-2 cm higher than the bifurcation of the trachea, a slit-like defect (fistula) located along the cartilage ring is visible on its posterior right surface.

Identification of the fistula is facilitated by the introduction of a 1% solution of methylene blue into the esophagus, which, penetrating into the trachea through the fistula, emphasizes its contours.

Differential diagnosis

Differential diagnosis is difficult in children of the neonatal period, when it is necessary to exclude an esophageal-tracheal fistula if the child has a birth injury, accompanied by a violation of the act of swallowing or paresis of the soft palate.

When feeding, such newborns periodically experience coughing fits, respiratory rhythm disturbance, and pneumonia increases.

X-ray examination of the esophagus with iodolipol in these cases does not clarify the diagnosis, since in both diseases, throwing (aspiration) of the contrast agent into the respiratory tract (bronchography) can occur. For differential diagnosis, the child begins feeding only through a probe inserted into the stomach. After subsiding aspiration pneumonia, tracheobronchoscopy is performed, which allows you to make or cancel the diagnosis of esophageal-tracheal fistula.

Treatment

Elimination of congenital esophageal-tracheal fistula is possible only by surgery. Surgical intervention is carried out after the diagnosis is established.

Preoperative preparation. Preoperative preparation begins immediately after the detection of clinical symptoms of the esophageal-tracheal fistula.

The child is completely excluded from feeding through the mouth - all the necessary amount of liquid is injected into the stomach through a tube, which is removed after each feeding. From the first day, active antipneumonic treatment begins: antibiotics. oxygen therapy, UHF currents on the chest, alkaline aerosol with antibiotics, mustard wrap, intravenous administration of blood plasma, vitamins.

The child is in a heated incubator with high humidity. Several sessions of oxygen barotherapy are performed. The duration of preoperative preparation varies: 7-10 days (until the elimination or noticeable reduction of pneumonia).

The operation for congenital esophageal-tracheal fistula is performed under endotracheal anesthesia and with blood transfusion. The position of the child is on the left side.

Operation technique. The most convenient access in infants is extrapleural. On the fourth intercostal space on the right (with a high fistula, access is recommended through a cut on the neck).

The lung covered with pleura is retracted forward and inward, the mediastinal pleura is exfoliated above the esophagus. The esophagus is mobilized for 1,5-2 cm up and down from the place of its communication with the trachea.

In the presence of a long fistulous passage, the latter is isolated, tied up with two silk ligatures, crossed between them, and the stumps are treated with an iodine solution.

Over the crossed fistula tract, one row of submersible silk sutures is applied to the esophagus and trachea with an atraumatic needle.

With a wide and short fistula, the esophagus is carefully cut off with scissors from the trachea, and the resulting holes are closed with a two-row continuous suture with atraumatic needles. To prevent postoperative narrowing of the esophagus, the latter is sutured in the transverse direction (over the catheter inserted before the operation).

The most difficult to eliminate is a large esophageal-tracheal fistula, in which both organs have common walls for some length (0,7-1 cm).

In such cases, the esophagus is transected above and below the junction with the trachea. The holes formed on the trachea are sutured with two rows of sutures, then the continuity of the esophagus is restored by creating an end-to-end anastomosis.

A thin polyethylene tube is inserted into the stomach to feed the baby. With extrapleural access to the mediastinal space, a thin (3-4 mm) polyethylene tube is brought to the area of ​​the sutures of the esophagus (through a separate puncture in the sixth intercostal space) for 2-3 days. The chest cavity is closed tightly.

With transpleural access, the mediastinal pleura is sutured. The air remaining after suturing the chest wall in the pleural cavity (detected on control radiographs) is sucked off with a syringe during puncture.

postoperative treatment. In the postoperative period, the child continues to receive active antipneumonic therapy, since usually the operation causes an exacerbation of the process in the lungs.

An elevated position is created for the patient, an aerosol is prescribed, humidified oxygen is constantly given, antibiotics, cardiac agents are administered.

On the first day after the operation, mustard plasters are placed on the chest on the left, and from the next day, an UHF electric field is assigned to the lung area. According to indications, bronchoscopy and suction of mucus are performed.

On the first day, the child needs parenteral nutrition, then feeding is carried out in fractional doses every 3 hours through a thin tube left during the operation. The amount of fluid is calculated depending on the age and body weight of the child.

Within 2-3 days, 1/3 of the volume of liquid is injected through a probe, the rest is intravenous drip. The probe is removed on the 5th-6th day (when creating an end-to-end anastomosis, feeding through the probe is continued for 9-10 days). By the 6-8th day, the child should receive the usual age norm of breast milk. Older children are prescribed liquid food from the 7-8th day after the operation.

The patient is discharged home on the 20-25th day when the phenomena of pneumonia are eliminated (in infants, in addition, a stable weight gain should be established).

Before discharge, a control X-ray examination of the esophagus with a contrast mass is performed. In cases where narrowing is detected in the area of ​​the former fistula, a course of bougienage should be carried out, which begins no earlier than a month after the operation.

2. Damage to the esophagus. Chemical burns

In children, damage to the esophagus is relatively rare, occurring mainly due to chemical burns or perforation of the organ wall (foreign bodies, instruments).

The severity of the burn of the esophagus and the degree of its pathological changes depend on the amount and nature of the chemical swallowed by the child.

When exposed to acids, the depth of damage to the esophageal wall is less than when exposed to alkalis. This is due to the fact that acids, neutralizing the alkalis of tissues, coagulate the protein of the cells and at the same time take away water from them.

As a result, a dry scab is formed, which prevents the penetration of acids into the depths. The impact of alkalis on tissues is accompanied by colliquat necrosis. The absence of a scab leads to a deep penetration of the caustic substance into the tissues and damage them. There are three degrees of burns of the esophagus: mild, moderate and severe.

Mild degree is characterized by damage to the mucous membrane such as desquamative esophagitis. In this case, hyperemia, edema and areas of superficial necrosis are noted. The inflammatory process subsides and epithelization occurs within 7-10 days. The resulting superficial scars are elastic, do not narrow the lumen of the esophagus and do not affect its function.

With an average degree, the lesions are deeper. Necrosis extends to all layers of the organ. After 3-6 weeks (as necrotic tissue is rejected), the wound surface becomes covered with granulations and then scars. The depth and prevalence of scar changes depend on the severity of damage to the esophageal wall.

Severe degree is characterized by deep and extensive damage to the esophagus with necrosis of all layers of its wall. The burn is accompanied by mediastinitis.

clinical picture

The clinical picture of a burn of the esophagus depends on the nature of the substance that caused the burn and the degree of damage to the esophagus. From the first hours after the burn, the condition of children is severe due to the developing phenomena of shock, swelling of the larynx and lungs, as well as intoxication and exsicosis.

As a result of rapidly growing inflammation, profuse salivation is noted, often repeated and painful vomiting. From the moment of contact with a caustic substance, there is a burning pain in the mouth, in the pharynx, behind the sternum and in the epigastric region. It intensifies with swallowing, coughing and vomiting movements, so all children stubbornly refuse to eat and drink.

The inflammatory process is accompanied by an increase in temperature to high numbers. Dysphagia can be explained by both pain and swelling of the esophageal mucosa.

Three periods are distinguished in the clinical course of the disease. The first period is characterized by acute inflammation of the mucous membrane of the mouth, pharynx and esophagus, and in the coming hours the swelling and pain increase, the child refuses to eat, there is a high fever.

This condition often lasts up to 10 days, and then improves, pain disappears, swelling decreases, temperature normalizes, esophageal patency is restored - children begin to eat any food. The acute stage gradually passes into the asymptomatic period. The apparent well-being sometimes lasts up to 4 weeks.

3-6 weeks after the burn, a period of scarring begins. Gradually, the phenomena of obstruction of the esophagus increase. In children, vomiting occurs, retrosternal pains join.

X-ray examination with a contrast agent during the scarring period reveals the nature, degree and extent of the pathological process.

Treatment

A child who has received a chemical burn of the esophagus requires emergency hospitalization. In the acute stage of the disease, measures are taken to remove the state of shock and vigorous detoxification therapy aimed at preventing or reducing the local and general effects of the poison. For this purpose, painkillers and cardiac drugs are administered to the victim, the stomach is washed through the tube. Depending on the nature of the caustic substance, washing is done either with a 0,1% solution of hydrochloric acid (with an alkali burn), or with a 2-3% solution of bicarbonate of soda (with an acid burn) in a volume of 2-3 liters. As a rule, there are no complications from the introduction of a gastric tube.

The complex of anti-shock measures, in addition to the introduction of cardiac agents and oinopon, includes intravenous infusions of plasma, glucose solution, vagosympathetic cervical novocaine blockade.

To prevent pulmonary complications, it is advisable to constantly supply the patient with humidified oxygen and an elevated position.

The possibility of layering a secondary infection dictates the early use of antibiotic therapy (broad-spectrum antibiotics).

Gastric lavage is used not only in emergency care, but also 12-24 hours after the burn. This removes the remaining chemicals in the stomach.

An important therapeutic factor is the use of vitamin therapy hormones and the appointment of a balanced diet. In severe cases, when children refuse to drink and water, protein preparations and liquid are administered intravenously for 2-4 days to relieve intoxication and for the purpose of parenteral nutrition. To improve the general condition, the patient is prescribed oral feeding with high-calorie, chilled food, first liquid (broth , milk), and then well-mashed (vegetable soups, cottage cheese, cereals).

From the first days after the injury, children should receive one dessert spoon of vegetable or vaseline oil through their mouths, it has a softening effect and improves the passage of the lump through the esophagus.

Until recent years, bougienage has been considered the main method of treating burns of the esophagus. Distinguish between early, or preventive, bougienage and later, therapeutic - with cicatricial stenosis of the esophagus. The tactics of treatment is determined by the degree of burns of the oral cavity, pharynx and esophagus. To identify and assess the nature of the lesion and its prevalence, diagnostic esophagoscopy is performed.

Early bougienage prevents the formation of cicatricial stenosis of the esophagus. Bougienage is started from the 5-8th day after the burn.

Only special soft bougie are used. By this time, acute inflammatory changes in the wall of the esophagus subside, granulations appear, the general condition of the child improves, and the temperature returns to normal.

Bougienage is carried out without anesthesia three times a week for 1,5-2 months. During this period, the child is in the hospital.

Then he is discharged for outpatient treatment, having prescribed bougienage once a week for 2-3 months, and in the next six months - 1-2 times a month.

In rare cases, with severe and widespread burns, accompanied by mediastinitis, the child cannot eat. To prevent exhaustion, they resort to the creation of a gastrostomy, which is also necessary for complete rest of the organ.

This favorably affects the course of inflammation and promotes regeneration. Only after the child is taken out of a serious condition, they decide on the method of further treatment.

Usually, from the 5-7th week, attempts at direct bougienage with the help of an esophagoscope begin. The presence of a gastrostomy allows the use of "bougienage by thread".

With timely and correct treatment of chemical burns of the esophagus in children, good long-term results are obtained in almost 90% of cases. The cicatricial obstruction of the esophagus that occurred after the burn is an indication for plastic surgery of the esophagus with an intestinal graft.

3. Perforation of the esophagus

Perforation of the esophagus in children occurs mainly during bougienage due to cicatricial stenosis, damage by a sharp foreign body, or during instrumental examination. Up to 80% of these complications occur in medical institutions. which creates favorable conditions for their early recognition and provision of the necessary medical assistance. However, due to the fact that damage to the esophagus is more common in children of the first years of life, timely diagnosis of complications can be extremely difficult.

Usually, the attending physician thinks of perforation of the esophagus arises in connection with the development of signs of mediastinitis. Most surgeons explain the extremely severe course and prognosis of this complication in children by the anatomical features of the structure of the mediastinum.

clinical picture

The clinical picture of acute purulent mediastinitis in children, especially young children, is variable and largely depends on the nature of the damage to the esophagus.

With the slow formation of perforation observed in connection with a decubitus of the esophageal wall by a foreign body (coin, bone), the surrounding tissues are gradually involved in the process, which react with inflammatory demarcation.

This leads to some delimitation of the process, and it is extremely difficult to catch the moment of damage to the esophagus. A complication in such cases is diagnosed by a combination of rapidly developing general symptoms, physical and radiological data.

One of the first symptoms of acute purulent mediastinitis is chest pain. It is difficult to find out localization, and only in older children can it be clarified that it is retrosternal and intensifies when swallowing.

The child's resistance to examination usually excludes the possibility of using "pain" symptoms for diagnosis - the appearance of pain when the head is thrown back or the trachea is passively displaced.

The child becomes inactive, any change in position in bed causes anxiety due to increasing pain. The general condition of the patient is rapidly deteriorating. Shortness of breath appears. The disease is often accompanied by persistent cough Body temperature rises to 39-40 °C.

Physical examination reveals moist rales, in some cases shortening of percussion sound in the interscapular space.

When examining blood, there is a sharp increase in the number of leukocytes, neutrophils with a shift to the left.

The X-ray method of research, as a rule, confirms the presumptive diagnosis. Widening of the mediastinal shadow, the presence of emphysema, and examination with a contrast medium usually allow you to determine the level of damage to the esophagus.

Esophagoscopy in acute purulent mediastinitis in children is usually not performed, since additional trauma to the organ can worsen the already serious condition of the patient.

Mediastinitis that occurs in children with perforation of the esophagus by sharp foreign bodies is diagnosed with less difficulty.

The very fact of the presence of a sharp body in the esophagus allows us to think about damage to the wall of the organ. If the instrumental removal of the foreign body turned out to be impossible and the patient experienced a sharp deterioration in his general condition, chest pain appeared, body temperature increased, there is no need to doubt the diagnosis.

Recognition of mediastinitis is helped by X-ray data (stationary position of a foreign body, expansion of the shadow of the mediastinum, and sometimes the presence of gas in it). In such cases, immediate surgical removal of the foreign body is indicated.

Perforation of the esophagus with instruments usually occurs during bougienage for cicatricial narrowing or during esophagoscopy. Diagnosis is usually not difficult due to the appearance of sharp pain at the time of damage to the esophageal wall.

Perforation is accompanied by phenomena of shock: the child turns pale, the filling of the pulse becomes weak, and blood pressure noticeably decreases. After removing the bougie and conducting special therapy (painkillers, intravenous infusion of calcium chloride, blood, anti-shock fluid), the patient's condition improves somewhat, but chest pain continues to bother the child.

The general symptoms of mediastinitis develop rapidly: the temperature rises, pneumonia appears, shortness of breath, the blood picture changes, and the state of health deteriorates sharply.

If the esophagus is damaged and inflammation is localized in the lower mediastinum, pain under the xiphoid process and symptoms of peritoneal irritation are noted. Subcutaneous emphysema is often found.

X-ray examination plays a leading role in establishing the diagnosis of esophageal perforations. Direct radiological symptoms are: the presence of air in the soft tissues of the mediastinum and neck, as well as the leakage of the contrast mass beyond the contours of the esophagus.

Treatment

Surgical treatment begins with the creation of a gastrostomy. Further surgical tactics depend on the nature of the damage to the esophagus and the extent of mediastinitis.

The presence of an acute foreign body in the esophagus, which led to perforation and the development of mediastinitis, is an indication for urgent mediastinotomy. The operation in such cases has a dual purpose - the removal of a foreign body and drainage of the mediastinum. Delay in surgical intervention worsens the course of the postoperative period.

With the slow formation of a perforation (pressure sore) associated with a long stay of a foreign body in the esophagus, drainage of the mediastinum is indicated. The nature of the operative access depends on the level of inflammation: the upper sections are drained by cervical mediastinotomy according to Razumovsky, the middle and posterior ones - by extrapleural access according to Nasilov. Regardless of the methods of drainage during intervention, it is necessary to spare the adhesions formed in the mediastinum, which to a certain extent prevent the spread of the purulent process.

In cases where the complication is diagnosed relatively late and the child has a formed delimited abscess, mediastinal drainage surgery is also necessary and often effective.

Damage to the esophagus and the rapid spread of a purulent process in the mediastinum usually lead to a breakthrough of the abscess into the pleural cavity. In such cases, urgent thoracotomy with pleural drainage is indicated. Often we have to deal with extremely severe damage to the esophagus requiring resection.

Postoperative treatment of children with esophageal perforation and mediastinitis requires persistence and great attention in identifying the entire range of therapeutic measures.

After the operation, the child is placed in an elevated position, constantly humidified oxygen is prescribed. Painkillers are administered after 4-6 hours. Drip intravenous infusion continues for 2-3 days. Transfusion of blood and protein preparations (plasma, albumin) is performed daily in the first week, then after 1-2 days. The child is prescribed broad-spectrum antibiotics (according to sensitivity), replacing them after 6-7 days. Tampons are tightened after 2-3 days, then removed. Drainage in the mediastinum is left until the purulent discharge stops. An esophageal fistula usually closes on its own. The child is undergoing physiotherapy (for example, UHF). If there is a communication of the mediastinal abscess with the pleural cavity and the latter has been drained, then a minimum negative pressure of 5-7 cm of water should be created in the active aspiration system. Art. (490-686 Pa, or 0,490-0,686 kPa). The tube from the pleural cavity is removed after the elimination of the esophageal fistula and pleurisy.

The child is fed through a gastrostomy with high-calorie food. After elimination of mediastinitis and healing of the wound of the esophagus, feeding through the mouth is started (if there is no stenosis). Plastic surgery on the esophagus (intestinal transplantation, resection) is possible after at least 2 years after complete recovery from mediastinitis.

LECTURE No. 6. Bleeding from dilated veins of the esophagus with portal hypertension

The most severe and frequent complication of portal hypertension syndrome is bleeding from esophageal varices.

The cause of bleeding is mainly an increase in pressure in the portal system, peptic factor, as well as disorders in the blood coagulation system. Bleeding from dilated veins of the esophagus may be the first clinical manifestation of portal hypertension.

clinical picture

The first indirect signs of incipient bleeding are the child's complaints of weakness, malaise, nausea, and lack of appetite.

The body temperature rises. Sudden profuse hematemesis explains the sharp deterioration in the general condition of the child.

Vomiting is repeated after a short period of time. The child turns pale, complains of headache, dizziness, becomes lethargic, drowsy. A tarry, fetid stool appears.

Blood pressure drops to 80/40-60/30 mmHg. Art. When examining the blood, an increasing anemia is detected. The volume of circulating blood decreases sharply. After 6-12 hours, the severity of the condition is aggravated by intoxication as a result of the absorption of blood decay products from the gastrointestinal tract.

Differential diagnosis

The symptom of bloody vomiting in children can be caused not only by bleeding from varicose veins of the esophagus. To determine the cause of bleeding, anamnestic data are of primary importance.

If the child is admitted to the surgical clinic again due to bleeding in the syndrome of portal hypertension or he underwent surgery for this disease, then the diagnosis should not be in doubt.

It is more difficult to make a differential diagnosis if bleeding was the first manifestation of portal hypertension, since similar clinical symptoms occur in children with a bleeding stomach ulcer, with a hernia of the esophageal opening of the diaphragm, after severe nosebleeds (in children with Werlhof's disease and hypoplastic anemia).

Children who bleed from chronic gastric ulcers usually have a characteristic and long-term "ulcerative" history. Profuse bleeding is extremely rare.

Acute ulceration in children receiving long-term hormone therapy is also rarely complicated by bleeding (perforation is more common), but with an appropriate history, the diagnosis is usually not difficult.

In children with a hernia of the esophageal opening of the diaphragm, intermittent hematemesis is not abundant, the presence of a "black" stool is not always observed.

The general condition of the child worsens slowly over many months.

Children usually come to the clinic for mild anemia of unknown etiology. Clinical and radiological examination establish the presence of a hernia of the esophageal opening of the diaphragm.

The cause of bloody vomiting that occurs after nosebleeds is clarified with a detailed history taking and examination of the patient.

Treatment

In all cases of bleeding, therapeutic measures should begin with complex therapy.

Conservative therapy in some cases leads to a stop of bleeding. After the diagnosis is established, the child is given a transfusion of blood products.

The amount of blood administered depends on the general condition of the child, hemoglobin levels, red blood cell count, hematocrit and blood pressure.

Sometimes 200-250 ml is required, and in case of severe unstoppable bleeding, 1,5-2 liters of blood products are transfused on the first day.

It is necessary to resort to direct transfusions more often, combining them with transfusion of conservative blood. With a hemostatic purpose, concentrated plasma, vikasol, pituitrin are administered; inside designate aminocaproic acid, adroxon, thrombin, hemostatic sponge.

The child is completely excluded from feeding by mouth, prescribing parenteral administration of an appropriate amount of liquid and vitamins (C and group B).

The infusion is carried out slowly, since a sharp overload of the vascular bed can lead to re-bleeding. An ice pack should be placed on the epigastric region.

All children are prescribed broad-spectrum antibiotics, detoxification therapy. To combat hypoxia, humidified oxygen is constantly given through nasal catheters. In case of severe non-stopping bleeding, hormone therapy is included (prednisolone 1-5 mg per 1 kg of body weight of the child per day).

Patients with an intrarenal form of portal hypertension for the prevention of liver failure are prescribed a 1% solution of glutamic acid. With successful conservative treatment after 4-6 hours, the general condition improves somewhat.

The pulse and blood pressure are aligned and become stable. The child becomes more contact and active. All this suggests that the bleeding has stopped, but despite the improvement in the general condition, therapeutic measures should be continued.

In the absence of repeated bloody vomiting, the drip infusion apparatus is removed after 24-36 hours. The child begins to drink chilled kefir, milk, and cream. Gradually, the diet is expanded, on the 3rd-4th day, mashed potatoes, 10% semolina porridge, broth are prescribed, from the 8th-9th day - a common table.

Blood transfusions are carried out 2-3 times a week, the administration of vitamins is continued. The course of antibiotics is completed on the 10-12th day. Hormonal drugs are canceled, gradually reducing their dosage.

After the child's general condition improves, a detailed biochemical blood test, splenoportography and tonometry are performed to determine the shape of the portal system block in order to choose a rational method for further treatment.

Along with the specified conservative therapy, resort to an attempt to mechanically stop bleeding. This is achieved by introducing into the esophagus an obturating Blackmore probe, the inflated cuff of which presses the varicose veins of the esophagus.

Sedatives are prescribed to reduce the anxiety associated with the presence of the probe in the esophagus. If during this period the conservative measures taken have not led to a stop of bleeding, the question of urgent surgical intervention should be raised.

The choice of the method of surgical treatment at the height of bleeding primarily depends on the general condition of the patient and on whether the child was operated on for portal hypertension earlier or bleeding occurred as one of the first manifestations of portal hypertension.

In children who have previously been operated on for portal hypertension (splenectomy, creation of organ anastomoses), the operation is reduced to direct ligation of varicose veins of the esophagus or the cardia of the stomach. In patients who have not previously been operated on for portal hypertension syndrome, surgery should be aimed at reducing blood pressure. portae by reducing blood flow to esophageal varices.

This operation cannot be considered radical, and, moreover, it has a number of disadvantages.

At the time of suturing varicose veins, severe bleeding may occur, esophagotomy is sometimes complicated by infection of the mediastinal space, the development of purulent mediastinitis and pleurisy.

In order to reduce blood flow to varicose veins of the esophagus, a modified Tanner operation is used - suturing the precordial veins without opening the lumen of the stomach. The latter significantly shortens the time of surgical intervention (which is especially important during surgery at the height of bleeding), reduces the risk of infection of the abdominal cavity and minimizes the possibility of gastric suture failure.

In children who have not previously been examined for portal hypertension, surgical splenoportography and splenometry are performed to resolve the issue of the form of the disease and the extent of intervention. If an intrahepatic block is detected, in addition to suturing the cardiac part of the stomach, it is rational to simultaneously create organoanastomoses: suturing the omentum to the decapsulated kidney and to the left lobe of the liver after its marginal resection. In the presence of pronounced hypersplenism, the spleen is removed. The abdominal cavity is then closed tightly after antibiotics are administered.

Postoperative treatment is a continuation of the activities carried out before the operation. A child needs parenteral nutrition for 2-3 days. Then the patient begins to drink, gradually expanding the diet (kefir, 5% semolina, broth, etc.). By the 8th day, the usual postoperative table is prescribed. Hormonal therapy is canceled on the 4-5th day, the administration of antibiotics is completed on the 7-10th day after surgery. Blood and plasma transfusions are prescribed daily (alternating) until anemia is eliminated.

With a smooth postoperative period on the 14-15th day, the children are transferred to a pediatric clinic for further treatment.

LECTURE No. 7. Diaphragmatic hernia. Frenico-pericardial hernias

Congenital diaphragmatic hernias are a kind of malformation of the diaphragm, in which the abdominal organs move into the chest cavity through natural or pathological holes in the diaphragm, as well as by protrusion of its thinned area.

Depending on the size of the hernial orifice, their location, the number and size of the displaced organs, a violation of the function of respiration, digestion and cardiovascular activity develops.

All this can be compensated and not detected for a long time. Decompensation often occurs soon after birth, or severe complications occur at an older age.

Depending on the location of the hernial orifice, congenital diaphragmatic hernias are divided into:

1) hernia of the diaphragm itself (false and true);

2) hiatal hernia (usually true);

3) hernias of the anterior part of the diaphragm - parasternal (true) in the region of the sternocostal triangle (Lorrey's fissure) and phrenic-pericardial, arising in the presence of defects in the diaphragm and pericardium (false). Aplasia (absence) of the dome of the diaphragm can be regarded as an extensive false hernia of the diaphragm itself, and relaxation is referred to as true hernias with protrusion of the entire dome.

The so-called true diaphragmatic hernia occurs due to the underdevelopment of the muscular and tendon layer of the diaphragm, which, becoming thinner, protrudes into the chest cavity, forming a hernial sac.

The underdevelopment of all layers of the thoracic obstruction is accompanied by the formation of through defects of various shapes and sizes.

In such cases, the abdominal organs move freely into the chest cavity, and a false diaphragmatic hernia is formed that does not have a hernial sac.

1. Hernia of the diaphragm itself. Complicated false hernia of the diaphragm proper

Among congenital malformations of the diaphragm, false hernias of the diaphragm proper are most common, and true ones are somewhat less common.

The clinical course, prognosis and technique of surgical interventions in these groups of congenital diaphragmatic hernias differ quite significantly from each other, although sometimes, when similar complications occur, the symptomatology and surgical tactics are the same.

Congenital defects of the diaphragm, through which the abdominal organs move into the chest, are usually of three types: a slit-like defect in the lumbocostal region (Bogdalek's fissure), a significant defect in the dome of the diaphragm, and aplasia - the absence of one of the domes of the diaphragm.

clinical picture

In the presence of a slit-like defect in the region of the lumbocostal region (Bogdalek's fissure), an acute course of a false hernia of the diaphragm proper occurs, usually in the first hours or days after the birth of a child.

In most cases, a hernia is manifested by symptoms of increasing asphyxia and cardiovascular insufficiency, which develop as a result of flatulence of the intestinal loops and stomach moved into the chest cavity.

In such cases, compression of the lungs and displacement of the mediastinal organs occur - a condition called "asphyxial infringement".

In older children, true infringement of the abdominal organs displaced through a defect in the diaphragm is possible. The clinical manifestation of these complications of false hernias of the diaphragm itself has its own characteristics.

"Asphyxial infringement" can only conditionally be called a complication of congenital diaphragmatic hernia. This is rather a common clinical manifestation of a false hernia of the diaphragm itself, if the displacement of hollow organs into the pleural cavity occurred before the birth of the child.

In the first hours of life, intestinal loops and the stomach are filled with gas, their volume increases sharply and the compression of the organs of the chest cavity increases.

With a narrow slit-like defect, the hollow organs are unable to move back into the abdominal cavity on their own.

The most constant sign of "asphyxic infringement" is progressively increasing cyanosis. The child becomes lethargic, the cry is weak, vomiting occurs periodically. Breathing is difficult, superficial and relatively rare (20-30 per minute).

The participation of auxiliary respiratory muscles is noticeable, the sternum and false ribs sink down. When inhaling, the epigastric region is retracted funnel-shaped (more on the left). The abdomen is small, somewhat asymmetrical due to the protruding liver. During a cry or an attempt to feed a child, cyanosis increases markedly.

The phenomena of asphyxia are somewhat reduced when the child is transferred to a vertical position with a slight inclination towards the hernia.

It should be remembered that artificial respiration is not indicated if a complication of a diaphragmatic hernia is suspected, since it sharply worsens the child's condition: the suction of the abdominal organs into the chest cavity increases, and hence the displacement of the mediastinal organs and compression of the lungs increase. Physical data greatly help in making a diagnosis.

On the side of the hernia (usually on the left), breathing is sharply weakened or not audible.

In older children, faint noises of intestinal peristalsis are detected. On the opposite side, breathing is weakened to a lesser extent.

Heart sounds are heard clearly, as a rule, dextrocardia is detected.

At the birth of a child, heart sounds are heard in the usual place, but relatively quickly (1-2 hours) shift to the right beyond the midline or even the nipple line.

Absence of the dome of the diaphragm (aplasia) is extremely rare, and children with this severe defect are born dead or live no more than 1 hour.

The clinical picture is not much different from the above with an acute false hernia of the diaphragm. However, the dysfunction of the respiratory and circulatory organs increases so rapidly that it is extremely difficult to make a correct diagnosis, transport to the surgical department and perform an operation in a short period of time.

X-ray examination is crucial for clarifying the diagnosis. The main symptoms of a diaphragmatic hernia are a displacement of the boundaries of the heart (usually to the right) and the appearance in the lung field of cellular cavities of uneven size, corresponding to the filling of displaced intestinal loops with gas.

When examining a child in the first hours after birth, the cavities are relatively small, their number gradually increases, and they become larger.

Sometimes, when the stomach is displaced into the chest cavity, a large air cavity is visible, which has a pear-shaped shape. In the abdominal cavity, the intestinal loops are slightly filled with gas.

A contrast study, which is carried out with iodolipol, is indicated only if the diagnosis is in doubt. For these purposes, a newborn is injected through a tube into the stomach with 5-7 ml of iodized oil (iodolipol), which, spreading, well contours the wall of the stomach.

A re-examination after 2-3 hours can show the passage of the contrast agent through the small intestine and reveal its displacement into the chest cavity.

In some cases, X-ray examination can diagnose such concomitant malformations as congenital intestinal obstruction. At the same time, a sharp swelling of individual intestinal loops moved into the chest cavity with horizontal levels of fluid or flatulence of the adductor intestine is seen.

Infringement of false diaphragmatic hernias. Due to the presence of "hard" hernial orifices in false diaphragmatic hernias, infringement of the displaced abdominal organs is possible more often than in other hernias of the abdominal obstruction. Infringement of hollow organs is characterized by a sudden onset.

The phenomena of acute obstruction of the gastrointestinal tract in combination with respiratory failure come to the fore.

An early sign that allows you to suspect infringement are bouts of cramping pain. Infants suddenly begin to worry, toss about in bed, grab their stomachs with their hands.

Older children indicate emerging pain in the chest or upper abdomen. The duration and intensity of attacks can be different, usually contractions are repeated every 10-15 minutes.

In between, patients behave relatively calmly. The general condition progressively worsens. Vomiting always accompanies infringement, occurs during an attack of pain, often repeated.

Delay of a chair and gases is observed in all cases. Only at the beginning of the disease is sometimes a scanty stool (with infringement of the upper intestines).

The chest on the side of the infringement lags behind in movement during breathing; revealed: shortness of breath, cyanosis, increased heart rate. The abdomen is slightly retracted, mildly painful on palpation in the epigastric region.

Percussion and auscultation is determined by the displacement of the mediastinal organs in the opposite side of the hernia, the weakening or absence of breathing on the affected side. At the beginning of the disease in the chest cavity, ringing peristalsis noises are often heard.

Infringement develops more often in children with subacute hernia. In this regard, the patient may have chronic pulmonary insufficiency, pneumonia. During the examination, the doctor should pay special attention to the condition of the lungs.

X-ray examination

X-ray examination reveals symptoms typical of a diaphragmatic hernia: mediastinal displacement; the presence of cellular cavities due to intestinal loops moved into the chest cavity.

Characteristic of obstruction caused by infringement. is the presence of several large or multiple horizontal levels.

Differential diagnosis

The differential diagnosis of a false diaphragmatic hernia in a newborn should be carried out with some congenital heart defects and birth trauma of the brain, in which cyanosis and general weakness of the child give reason to suspect "asphyxial infringement".

However, the absence of characteristic changes in the respiratory system and X-ray data help to make the correct diagnosis.

Attacks of cyanosis are also observed in a newborn with acute lobar emphysema or lung cyst. Clinical symptoms in such cases are of little help in the differential diagnosis.

X-ray examination in these diseases, as well as in diaphragmatic hernia, shows a sharp shift in the boundaries of the heart, but in acute emphysema there is no characteristic cellular structure of the pulmonary field on the side of the lesion, corresponding to gas bubbles of intestinal loops.

A lung cyst manifests itself as separate large cavities, but unlike a hernia, there is a visible closed diaphragm contour, a normal gastric bladder and the usual number of intestinal loops in the abdominal cavity. A contrast study of the digestive tract helps to make a definitive diagnosis.

Differentiation of infringements of false diaphragmatic hernias has to be carried out with pleurisy, which, with staphylococcal pneumonia, begins acutely, has a variable x-ray picture, and in older children it is multi-chamber.

To clarify the diagnosis, it is sufficient to conduct a contrast X-ray examination. It is clear that diagnostic puncture in case of suspected strangulated hernia is categorically contraindicated.

Treatment

Congenital false diaphragmatic hernia of the diaphragm itself with an acute course in newborns ("asphyxic strangulation") and the phenomenon of strangulation in infants and older children are an absolute indication for immediate surgery.

Underestimation of the importance of emergency surgical intervention entails the death of the patient with symptoms of asphyxia (in newborns) or acute obstruction of the gastrointestinal tract. Preoperative preparation for emergency operations is short-term.

The newborn is placed in an oxygen tent (couveuse), warmed. In some cases, if there is severe hypoxia and the effects of asphyxia increase, the child is immediately intubated and begin to conduct controlled breathing.

In newborns and children of the first months of life, in some cases there are difficulties in suturing the wall of the abdominal cavity, the dimensions of which are insufficient, and it does not contain the reduced organs.

In such children, a two-stage closure of the abdominal cavity should be resorted to, which reduces the tension of the diaphragm sutures and reduces intraperitoneal pressure.

2. Complicated true hernia of the diaphragm proper

The nature of the course of the disease depends mainly on the degree of displacement of the abdominal organs into the chest. In some cases, the hernial gates are small in size, and the hernial sac is stretched to a significant extent and filled with organs moved into the pleural cavity.

Compression of the lungs, displacement of the heart and mediastinal vessels with a significant violation of their function. The patency of the gastrointestinal tract may be impaired.

clinical picture

The acute course of a true congenital hernia of the diaphragm itself occurs in the presence of a total displacement of the abdominal organs into the chest, which is usually observed in newborns and children in the first months of life.

In older children, infringement of the displaced abdominal organs may occur in the presence of a relatively small defect in the diaphragm proper and a significant hernial sac. The clinical manifestations of these complications have some differences.

The acute course of true hernias and relaxation of the diaphragm usually manifests itself in the first days after birth as a symptom of "asphyxial infringement".

The general condition of the child progressively worsens, cyanosis increases, breathing becomes superficial, slow. The abdomen is retracted, while breathing, the epigastric region sinks. There is vomiting.

However, the listed symptoms are less pronounced than with false hernias, and are not so constant.

Infringement of true hernias of the diaphragm itself is extremely rare. This is mainly due to the absence of clearly defined ("hard") hernial orifices or their significant diameter.

With a limited diaphragm defect, infringement manifests itself with a sudden onset. The clinical picture is characterized by sharp pains in the chest and abdomen, respiratory failure and intestinal obstruction.

X-ray examination

X-ray examination allows you to clarify the diagnosis. The pictures show the movement of intestinal loops into the pleural cavity and a sharp shift of the mediastinum in the opposite direction.

A characteristic radiological sign of significant true hernias of the diaphragm itself, as well as its relaxation, is the high standing and paradoxical movement of the abdominal obstruction. With multi-axis transillumination, the diaphragm is visible in the form of a thin regular arcuate line below which gas bubbles of the stomach and intestinal loops are located.

Differential diagnosis

Differential diagnosis should be carried out, as in the acute course of a false hernia, with some congenital heart defects, birth trauma of the brain and lobar emphysema of the lung.

Treatment

In case of an acute course or infringement of a true hernia of the diaphragm itself, an urgent operation is indicated. Preoperative preparation is minimal.

The young child is warmed after transport, the necessary drugs for anesthesia are administered, and an intravenous fluid infusion machine is applied.

The operation is performed under endotracheal anesthesia. The position of the child with transthoracic access is on the side opposite to the hernia, with laparotomy - on the back.

With the parietal location of the hernial sac, so-called sliding hernias are usually observed. In such cases, it is more convenient to dissect the thinned zone in an arcuate manner over the displaced organs and move the latter in a blunt way (together with part of the hernial sac) downwards.

postoperative treatment. In the postoperative period, newborns are placed in a heating incubator and an elevated position is created (after the child has recovered from anesthesia), humidified oxygen is prescribed.

On the first day, every 2 hours, the accumulating contents are sucked out of the stomach with a thin probe. Parenteral nutrition is carried out for 24-48 hours. After 2-3 days, for the purpose of stimulation, blood transfusions are performed in the amount of 20-25 ml. Feeding by mouth usually begins on the 2nd day after surgery: every 2 hours, 10 ml of glucose solution, alternating with breast milk. The fluid deficiency is replenished by intravenous administration of a glucose solution, and after the removal of the drip infusion apparatus, by single-stage transfusions.

If there is no vomiting, then from the 3rd day the amount of fluid is increased, gradually bringing it to the age norm. On the 7-8th day, the child is applied to the chest.

Older children are also transferred to parenteral nutrition on the first day, then a liquid postoperative table with a sufficient amount of proteins and vitamins is prescribed. The usual diet starts from the 6-7th day.

All children after surgery are prescribed broad-spectrum antibiotics to prevent pneumonia and heart medications. Physiotherapy (UHF currents, then KI iontophoresis) is prescribed from the day following the operation. Therapeutic breathing exercises begin from the first days, gradually moving to more active exercises.

After the operation, the first x-ray examination is carried out on the operating table, while determining the level of standing of the diaphragm and the degree of expansion of the lung. Re-examination in a satisfactory condition is done in 3-5 days.

If prior to this, an effusion in the pleural cavity is clinically detected and the child's condition remains severe, an X-ray examination is performed on the 2nd day after the operation. In some cases, this helps to identify indications for puncture (presence of profuse effusion).

3. Hiatus hernia

A hiatal hernia is usually called the displacement of abdominal organs into the posterior mediastinum or pleural cavities through an enlarged esophageal opening. The stomach is displaced, mainly to the right.

clinical picture

In children with a hernia of the esophageal opening of the diaphragm, as a rule, regurgitation is noted already in infancy, then vomiting, which is permanent. As a result, aspiration pneumonia recurs.

A lag in physical development is characteristic, pallor, a decrease in hemoglobin are noted. Relatively often, patients develop hemorrhagic syndrome: vomiting of blood, hidden or visible blood in the stool.

Older children complain of rumbling and pain in the chest coughing fits.

Infringement of a hernia of the esophageal opening occurs acutely. Strong cramping pains appear in the epigastric region. The child becomes restless, there is vomiting "fountain".

In vomit, mucus and food, sometimes stained with blood, bile, as a rule, is not visible. When the esophagus is infringed (kinked), vomiting occurs after each sip of food. The diagnosis is clarified by X-ray examination.

X-ray examination

A child with a suspected strangulated hernia of the esophagus is given anteroposterior and lateral images, which show a gas bubble of the displaced stomach with a large horizontal level of fluid on one or both sides of the midline.

In some cases, the gas bubble is not determined, since the displaced and strangulated stomach is filled with liquid. For better orientation in the pathology, it is necessary to supplement the examination with images with a contrast agent administered through the mouth. The study is carried out in the usual vertical position and lying down with moderate compression of the epigastric region.

In hernias with an elevated esophagus, the contrast agent enters the stomach above the site of strangulation. In paraesophageal hernias, the contrast agent stops in the esophagus above the diaphragm. Displacement of intestinal loops into the pleural cavity through the esophageal ring is rarely observed.

Treatment

With a strangulated hernia of the esophageal opening in children, a radical operation is performed by transthoracic access.

4. Hernias of the anterior part of the diaphragm. Complicated phrenic-pericardial hernias

The movement of the abdominal organs through the Lorrey fissure, or Morgagni's hole, into the retrosternal space is commonly called hernia of the anterior diaphragm. There are parasternal and frenic-pericardial hernias.

clinical picture

The clinical picture of phrenic-pericardial diaphragmatic hernia manifests itself acutely from the first hours or days of a child's life: constant cyanosis, shortness of breath, vomiting, anxiety.

In some cases, the displacement of the abdominal organs into the heart sac through a defect in the tendon part of the diaphragm and pericardium disrupts the function of the heart so much that a sharp arrhythmia occurs or it stops.

X-ray examination

X-ray can make the correct diagnosis. In the study in two projections, there is a layering of the contours of the intestine on the shadow of the heart.

Treatment

The operation for phrenic-pericardial hernia of the diaphragm is performed after the diagnosis is made.

LECTURE No. 8. Hernia of the umbilical cord

Hernia of the umbilical cord is a severe congenital disease, the mortality rate in which to date is from 20,1% to 60%.

clinical picture

The hernia of the umbilical cord has a typical external manifestation. At the first examination after birth, a child is found in the center of the abdomen with a tumor-like protrusion that is not covered by skin, emanating from the base of the umbilical cord. The protrusion has all the elements of a hernia: a hernial sac, consisting of stretched amniotic membranes, a hernial ring formed by the edge of a skin defect and aponeurosis, as well as the contents of the hernia - the abdominal organs.

Classification of the defect: small hernias (up to 5 cm in diameter, for premature babies - 3 cm); 2 medium hernias (up to 8 cm in diameter, for premature babies - 5 cm); large hernias (over 8 cm in diameter, for premature babies - 5 cm).

All hernias, regardless of their size, are divided into two groups:

1) uncomplicated;

2) complicated:

a) congenital eventration of the abdominal organs;

b) ectopia of the heart;

c) combined malformations (occur in 45-50% of children);

d) purulent fusion of the membranes of the hernial protrusion.

An uncomplicated hernia of the umbilical cord is covered with moist, smooth, grayish, stretched amniotic membranes. In the first hours after birth, the membranes are so transparent that you can see the contents of the hernia: liver, intestinal loops, stomach and other organs.

In places, the membrane is thickened due to the uneven distribution of Wharton's jelly, which usually accumulates at the top of the hernial sac. A dense circular groove is felt at the entry point of the umbilical vessels (a vein and two arteries). The amniotic membranes pass directly into the skin of the anterior abdominal wall along the edge of the "hernial ring". The transition line has a bright red color (the zone of break of the skin capillaries), a width of up to 2-3 mm.

In some cases, the skin spreads on the base of the hernia in the form of a ring up to 1,5-2 cm high.

With an inattentive examination of the child in the maternity hospital, such an "umbilical cord" can be tied up along with the intestinal loops located there.

The contents of small hernias is the intestines. The general condition of such newborns does not suffer. Medium-sized hernias are filled with a significant number of intestinal loops and may contain part of the liver.

Children usually come to the clinic in serious condition, with severe cyanosis, chilled. Newborns with large hernias of the umbilical cord, as a rule, do not tolerate transportation from the maternity hospital, and their condition is regarded as severe or extremely severe.

In the hernial sac, a significant part of the liver is always determined, in addition to the intestine. The volume of the hernial protrusion significantly exceeds the size of the abdominal cavity.

Complications of hernias of the umbilical cord have a peculiar clinical picture, are congenital or acquired.

The most severe complication is rupture of the hernial sac. A child is born with intestinal loops that have fallen out of the abdominal cavity.

Among the children admitted to the clinic with this type of complication, there are two main groups:

1) with intrauterine congenital eventration characterized by altered prolapsed intestinal loops - they are covered with fibrinous plaque, the walls are edematous, the vessels of the mesentery are dilated. Abdominal wall defect, usually small (3-5 cm), its edges are rigid, the skin partially passes into the remains of the amniotic membranes of the umbilical cord;

2) with "obstetric" congenital eventration, which arose in connection with a partial rupture of the membranes during the birth of a child with a large hernia of the umbilical cord. The membranes are usually damaged at the base of the hernial protrusion. The prolapsed intestinal loops are quite viable, there are no visible signs of peritonitis (the serous membrane is shiny, clean, fibrinous raids are not determined). Children with congenital eventration are usually delivered to the clinic in the first hours after birth. Their general condition is extremely difficult. Ectopia of the heart occurs in children with large hernias of the umbilical cord. Diagnosis of the defect is simple, since on examination, a pulsating protrusion is clearly defined in the upper part of the hernia under the amniotic membranes - a displaced heart.

The combined malformations for the most part do not change the general condition of the newborn and do not require emergency surgical intervention (facial clefts, deformities of the limbs, etc.).

However, some concomitant congenital diseases make it difficult or impossible to surgically treat a hernia of the umbilical cord.

Incomplete reverse development (non-closure) of the vitelline duct is detected during the first careful examination of the hernial protrusion: at the base of the umbilical remnant an intestinal fistula with bright red edges of the inverted mucous membrane is determined. Its diameter usually does not exceed 0,5-1 cm. Meconium is periodically released from the hole, which contaminates and infects the surrounding tissues.

Exstrophy of the bladder is often combined with hernia of the umbilical cord. In the presence of these defects, the abdominal wall is absent almost along its entire length - in the upper part it is represented by a hernial protrusion, the membranes of which directly pass into the mucosa of the split bladder and urethra.

Congenital intestinal obstruction is the most “insidious”, from a diagnostic point of view, combined developmental defect.

More often there is a high obstruction due to duodenal atresia or a violation of the normal rotation of the middle intestine. Persistent vomiting with bile, which occurs by the end of the first day after birth, makes it possible to suspect the presence of this disease. With low obstruction, the first sign is meconium retention. X-ray examination clarifies the diagnosis.

Severe congenital heart defects sharply worsen the general condition of the newborn and are identified by the corresponding set of clinical signs.

Purulent melting of the superficial membranes of the hernial sac inevitably occurs in cases where the child was not operated on in the first day after birth. In such children, the hernial protrusion is a dirty gray purulent wound with mucous discharge and areas of necrosis in the form of dark clots.

In the first days, inflammatory changes are distributed only to the superficial layers of the hernial sac (amnion, Wharton's jelly), and the phenomena of peritonitis are not detected. The general condition of the newborn is usually severe, the body temperature is elevated, and symptoms of intoxication are pronounced. Blood tests show significant leukocytosis with a neutrophilic shift to the left and anemia.

X-ray examination

X-ray examination of a newborn with a hernia of the umbilical cord is carried out in order to clarify the nature of the contents of the hernial protrusion and identify associated anomalies.

In the survey pictures taken with the child in the vertical position in two mutually perpendicular projections, intestinal loops and the size of the edge of the liver protruding into the hernial protrusion are clearly visible.

Uniform filling of intestinal loops with gas eliminates congenital obstruction. The revealed horizontal levels in the stomach and duodenum give grounds to diagnose high congenital obstruction. The presence of wide multiple levels suggests low obstruction. To clarify the diagnosis, irrigography is performed.

Treatment

The main treatment for a hernia of the umbilical cord is immediate surgery. The child should be transferred directly from the hands of the obstetrician to the surgical department. In the first hours after birth, the hernia shells are not inflamed, thin, tender - they are easier to surgically treat, the intestines are not distended with gases and its reduction into the abdominal cavity is less traumatic.

Delay in hospitalization causes a deterioration in the general condition of the child, significant infection of the hernial membranes, their adhesion to the underlying organs, primarily the liver.

Operative treatment. The main purpose of the operation is to reduce organs into the abdominal cavity, excise the membranes of the hernial sac and close the defect of the anterior abdominal wall. The choice of a rational method of surgical intervention depends on the size of the hernia, the existing complications and the presence of such combined malformations that simultaneously need urgent correction.

Preoperative preparation should begin from the moment the child is born. Immediately after the newborn's usual toilet, wipes moistened with a warm antibiotic solution are applied to the hernial protrusion.

In cases of congenital rupture of the membranes with eventration of the internal organs, the latter are closed with a multilayer gauze compress, abundantly moistened with a warm 0,25% solution of novocaine with antibiotics.

The child is wrapped in sterile diapers and covered with heating pads. Vitamin K and antibiotics are injected subcutaneously. Upon admission to the surgical department, the patient is placed in a heated incubator with a constant supply of humidified oxygen. Before the operation, the stomach is washed through a thin tube. A gas tube is placed in the rectum.

The duration of preparation should not exceed 1-2 hours. During this time, the necessary studies are carried out, the patient is warmed up, antibiotics and cardiac agents are re-introduced. Children with hernias complicated by rupture of the membranes, or with an identified fecal fistula, require immediate delivery to the operating room and an urgent start of the operation. Before the intervention, all children are prescribed appropriate drug preparation for anesthesia and an intravenous drip infusion device is installed. In this group of patients, all intravenous infusions, both during surgery and after it, should be carried out only in the vessels of the basin of the superior vena cava due to the fact that during the intervention outflow from the inferior vena cava may be disturbed.

Anesthesia is always an endotracheal method. The greatest difficulties arise when administering anesthesia during the period of immersion of the hernial contents into the abdominal cavity. An attempt to switch to spontaneous breathing at the time of increased intra-abdominal pressure during hernia reduction should not be made, as this worsens the child’s condition and does not allow assessing his adaptation to the new situation.

Surgical treatment of uncomplicated hernias of the umbilical cord has its own characteristics, which depend on the size of the hernial protrusion and its shape.

In newborns with hernias of the umbilical cord, the abdominal cavity is developed normally, and the reduction of the viscera from the hernial protrusion during surgery cannot cause complications, just like suturing a relatively small defect in the anterior abdominal wall. These children undergo a one-stage radical operation.

Newborns with medium-sized hernias are mostly subject to one-stage radical surgery. However, in some of them (especially in premature II degree), the reduction of internal organs and especially the suturing of the aponeurosis defect is accompanied by an excessive increase in intra-abdominal pressure due to the relatively small size of the abdominal cavity and the presence of a part of the liver in the hernial sac.

An objective criterion for the possibility of simultaneous correction of a hernia can only be a comparison of the dynamics of pressure in the superior and inferior vena cava.

If, in the process of immersion of organs, the pressure in the inferior vena cava progressively increases (to measure the pressure before surgery, the child undergoes a venesection of the great saphenous vein of the thigh with the introduction of a catheter by 5-6 cm), and in the superior vena cava (Seldinger catheterization) drops to zero or also increases to the level of pressure in the inferior vena cava, then the depth of immersion of the intestines and liver into the abdominal cavity should be minimized.

The surgeon needs to change the operation plan, ending it with the first stage of the two-stage technique.

Surgical treatment of newborns with large hernias of the umbilical cord presents significant difficulties and the prognosis remains extremely difficult until recently. This is due to the fact that the abdominal cavity in such children is very small, and the contents of the hernia (part of the liver, intestinal loops, sometimes the spleen) cannot be reduced into it during a radical operation.

Forced immersion of the viscera inevitably causes an increase in intra-abdominal pressure and is accompanied by severe complications:

1) respiratory failure due to displacement of the diaphragm and mediastinal organs;

2) compression of the inferior vena cava with subsequent difficulty in blood outflow;

3) compression of the intestinal loops and stomach, causing partial obstruction.

These complications for the newborn are so severe that they usually lead to death within a few hours to two days after surgery.

In this regard, in the treatment of children with large hernias of the umbilical cord, only a two-stage operation can be used, which avoids the listed complications.

Premature newborns weighing up to 1,5 kg (III degree), with medium and large hernias, are subject to conservative treatment methods. Only in case of complications with rupture of the membranes and eventration of the internal organs should an attempt be made to surgically correct the defect.

Surgical treatment of complicated hernias of the umbilical cord is an extremely difficult task. Newborns with intrauterine rupture of the hernia membranes and eventration of the internal organs are admitted to the surgical clinic, as a rule, in the first hours after birth. The condition of children in this group is extremely difficult due to developing peritonitis and cooling of prolapsed intestinal loops.

The volume of surgical intervention changes in connection with the combined defects revealed in the child. The operation may be complicated due to the presence of incomplete reverse development (non-closure) of the vitelline duct.

In rare cases, with large hernias of the umbilical cord, there are multiple combined malformations of the digestive tract, creating extreme difficulties in planning surgical intervention.

The choice of the method of operation is carried out individually, however, the main and mandatory principle is the primary elimination of the malformation that is incompatible with the life of the child.

postoperative treatment. The nature of postoperative treatment depends on the general condition of the child, his age and the method of surgical intervention.

In the first 2-3 days after the operation, all children are given prolonged epidural anesthesia, an elevated position is created.

Humidified oxygen is constantly supplied to the flask. Prescribe broad-spectrum antibiotics (5-7 days), cardiac drugs (according to indications) and physiotherapy. Produce 1-2 times a week transfusion of blood or plasma.

Children with small and medium-sized hernias begin to be fed orally 6 hours after surgery (in more severe cases - after 10-12 hours), dosed at 10 ml every 2 hours, adding 5 ml with each feeding. The fluid deficiency is replenished by intravenous drip. By the end of 2 days, the child should receive a normal (in terms of body weight and age) amount of breast milk; apply to the breast on the 3-4th day. Skin sutures are removed on the 8-10th day.

Children with large hernias after stage I of a two-stage operation are given parenteral nutrition for 48 hours. From the beginning of day 3, they begin to give 5-7 ml of a 5% glucose solution through the mouth, then expressed breast milk every 2 hours, 10 ml.

The total daily amount of fluid administered intravenously should not exceed the age-specific dosage, taking into account the child’s body weight. Gradually increasing the amount of breast milk, by the 8th day the baby is transferred to normal feeding (expressed milk). It is applied to the mother's breast on the 12-14th day.

Children are given daily control dressings and careful wound care. The sutures are removed on the 9-12th day, depending on the degree of tension of the edges of the surgical wound.

In cases of surgical interventions on the intestine, the child is prescribed a diet indicated after resection of the intestine in a newborn.

The most significant problem in the management of the postoperative period during stage I of a two-stage intervention or radical correction is the child's adaptation to high intra-abdominal pressure. This adaptation is facilitated by a set of measures, which includes oxygen barotherapy, prolonged epidural blockade and a late start of feeding the child. In premature infants after the first stage of correction of large hernias, if signs of circulatory disorders in the lower extremities appear on the operating table, it is advisable to use prolonged nasotracheal intubation for 2 days. It reduces dead space and reduces ventilation disturbances due to the high standing of the diaphragm and the restriction of its mobility. Oxygen therapy should be carried out in the same cases with repeated sessions every 12-24 hours for 12 days.

Complications in the postoperative period. Damage at the time of surgery of the inner plate of the hernia membranes (avascular peritoneum) can lead to adhesions and the development of obstruction (usually 3-4 weeks after surgery).

Such a complication can be prevented by prescribing anti-adhesion therapy from the first days after surgery. The complication is manifested by periodic mild anxiety of the child. Vomiting occurs, which is persistent. Through the skin of the abdominal wall (hernial protrusion) the peristalsis of the intestinal loops is visible. There may be stool, but it is scanty, then the passage of feces stops. Characteristic is a gradual increase in symptoms of obstruction. Contrast examination of the gastrointestinal tract helps establish the diagnosis: a long delay (4-5 hours) of iodolipol administered orally indicates obstruction. In such cases, laparotomy and elimination of obstruction are indicated.

Conservative treatment. The conservative technique consists of general strengthening measures and local treatment.

Reinforcing activities. Feeding expressed breast milk strictly according to the norm. From the 8-10th day of life, when the child is strong enough, they are applied to the mother's chest (control weighing is required). If the child sluggishly sucks or vomits, the fluid deficiency is replenished by intravenous administration of solutions of glucose, blood plasma, and vitamin albumin.

From the day of admission, broad-spectrum antibiotics begin to be administered. A change of antibiotics is necessary after 6-7 days, depending on the results of sowing the purulent discharge and the sensitivity of microbes (starting from the 2nd course, nystatin is administered). Antibiotics are canceled after the appearance of granulations and cleansing of the wound from necrotic deposits (15-20 days).

local treatment. The child is daily changed ointment dressings and toilet hernial protrusion. Removing the dressing and treating the wound requires great care because of the danger of rupture of the membranes. Areas of superficial necrosis of the amniotic membrane depart spontaneously, and then granulations begin to appear, going from the periphery to the center. Cleansing of the wound is facilitated by electrophoresis with antibiotics and irradiation of the wound during dressings with ultraviolet rays.

After the appearance of granulations (7-10th day of treatment), daily hygienic baths are used. Marginal epithelialization and scarring lead to a decrease in the size of the hernial protrusion. This is facilitated by tight bandaging used in the treatment process. The wound heals by the 40-50th day after the birth of the child.

The ventral hernia formed as a result of conservative treatment is eliminated surgically, as well as in a two-stage operation, after the age of the first year.

LECTURE No. 9. Strangulated inguinal hernia

Incarcerated inguinal hernia occurs in children of various age groups. The internal organs of the abdominal cavity with a slight tension can go into the hernial sac. The resulting spasm of the muscles creates an obstacle to their return to the abdominal cavity. It should be noted that in younger children, for the same anatomical and physiological reasons, spontaneous reduction of a hernia often occurs, and strangulated organs rarely undergo irreversible changes. In older children, the outer inguinal ring thickens, becomes fibrous and, when a spasm occurs, does not stretch, holding the restrained organs.

clinical picture

The most constant sign of strangulated hernia in infants is anxiety, which occurs in the midst of complete well-being and is permanent, periodically intensifying. However, this symptom is often assessed incorrectly, since infringement in 38% of cases occurs against the background of other diseases that have a similar course.

In addition, in some children (often premature), the anxiety may be minor, and the behavior of the child - without noticeable disturbances.

Sometimes the swelling appears for the first time and may go unnoticed for some time due to the small size and pronounced subcutaneous fat layer in the inguinal regions in newborns. All this complicates the diagnosis and gives rise to late recognition of strangulated hernia.

In older children, the clinical manifestations of infringement are more distinct. The child complains of sudden sharp pains in the inguinal region and a painful swelling that appears (if the hernia was incarcerated at the first appearance). In those cases when the child knows about the presence of a hernia, he indicates its increase and the impossibility of reduction.

Soon after the infringement, many children (40-50%) have a single vomiting. Stools and gases first depart on their own. When the loop of the intestine is infringed, the phenomena of intestinal obstruction develop (70% of observations).

In rare cases, intestinal bleeding is noted. The general condition of the child in the first hours after the infringement does not noticeably suffer. Body temperature remains normal. When examining the inguinal regions, swelling is revealed along the spermatic cord - a hernial protrusion, which often descends into the scrotum. In girls, the hernia may be small and hardly noticeable on examination.

Feeling the hernia is sharply painful. The protrusion is smooth elastic consistency, irreducible. Usually, a dense cord is palpated, going into the inguinal canal and filling its lumen.

When a child is admitted late from the onset of the disease (2-3rd day), the following are revealed: a serious general condition, fever, severe intoxication, clear signs of intestinal obstruction or peritonitis.

Locally, hyperemia and swelling of the skin appear, associated with necrosis of the strangulated organ and the development of phlegmon of the hernial protrusion. Vomiting becomes frequent, with an admixture of bile and fecal odor. There may be urinary retention.

Differential diagnosis

The differential diagnosis in young children, first of all, has to be carried out with an acutely developed dropsy of the spermatic cord. In such cases, accurate anamnestic data are important - with dropsy, swelling occurs gradually, increases over several hours.

Anxiety at the beginning of the disease is little expressed, but in the following hours there are general symptoms characteristic of a strangulated hernia.

Vomiting is rare. The basis for differential diagnosis is palpation data: a tumor with dropsy is moderately painful, oval in shape, with a clear upper pole, from which a dense cord characteristic of a hernial protrusion does not extend into the inguinal canal.

Quite often, an acutely developing cyst of the spermatic cord can be extremely difficult to distinguish from a strangulated hernia. In such cases, the diagnosis is made during surgery.

Incarcerated communicating dropsy of the spermatic cord sometimes gives rise to an erroneous diagnosis. In such cases, it is known from the anamnesis that the boy had a swelling in the inguinal region, which periodically decreased (especially in the morning), but became painful and tense in the following hours.

In contrast to a strangulated hernia, the child has no symptoms of intestinal obstruction, and a thin cord is determined, coming from the swelling into the inguinal canal. In doubtful cases, an operation should be prescribed.

Torsion of the spermatic cord ("torsion of the testicle") is also manifested by the sudden anxiety of the child. Other general phenomena (refusal of the breast, reflex vomiting) may also occur.

Palpation of the swelling in the inguinal region is sharply painful, the spermatic cord is thickened due to twisting, palpable in the inguinal canal, resembling the neck of a hernial sac. It is extremely difficult to distinguish testicular volvulus from a strangulated hernia in a newborn, but this is of no practical importance, since both diseases require urgent surgical intervention.

Inguinal lymphadenitis in children of early and preschool age (especially girls) is sometimes impossible to distinguish from a strangulated hernia.

An incomplete history of the disease, the child's anxiety during the examination, and difficult palpation of the external inguinal ring (tissue infiltration) suggest inflammation of the strangulated hernia.

The absence of general symptoms and phenomena of obstruction does not exclude infringement of the uterine appendages or parietal incarceration of the intestine. Thus, with pronounced symptoms of inguinal lymphadenitis, even the slightest suspicion of a strangulated hernia should be regarded as an indication for immediate surgery.

Treatment

The presence of a strangulated inguinal hernia is an indication for urgent surgery. However, it should be clarified that in children of the first months of life, infringement usually occurs when the child cries, strains or anxiety, which are accompanied by tension in the abdominal muscles, which are of primary importance in the mechanism of infringement.

The pain that occurs when the infringement increases the child's motor anxiety and intensifies muscle spasms. If you create conditions under which the pain decreases, then the child calms down, the muscles surrounding the inguinal canal relax, and the hernia self-reduces.

In addition, strangulation in young children rarely leads to necrosis of the hernia contents, which, however, can occur, but not earlier than 8-12 hours from the moment of complication. This allows some surgeons to recommend non-surgical reduction of the strangulated hernia in children (manual reduction, repeated baths, irrigation hernia with ether, giving anesthesia). In infants, a strictly individual approach to the treatment of a strangulated hernia should be followed.

In newborns and children of the first months of life, emergency surgery is absolutely indicated:

1) in cases where the anamnesis is unknown or more than 12 hours have passed since the infringement;

2) in the presence of inflammatory changes in the area of ​​hernial protrusion;

3) in girls, since they usually have appendages with hernial contents, which are not only infringed, but rotated, which leads to their rapid necrosis. Normally developed older children who do not have serious comorbidities should be operated on following diagnosis.

Conservative treatment. All children who do not have absolute indications for surgery, upon admission to the surgical hospital, undergo a set of conservative measures, creating conditions for spontaneous reduction of the hernial protrusion.

The patient is given a single age dose of pantopon, then a warm bath (37-38 C) lasting 10-15 minutes is taken or a heating pad is placed on the area of ​​the hernia.

Gradually, the child calms down, falls asleep, and the hernia is spontaneously reduced. Non-operative reduction, according to experts, is observed in 1/3 of infants. Conservative treatment is carried out for no more than 1 hour. If during this time the hernia has not reduced, then the child is subjected to surgical intervention, and the measures taken will be preoperative preparation.

In those cases when the hernia spontaneously reduced before the onset of anesthesia (or the infringement was eliminated by conservative measures), the child is left in a surgical hospital, the necessary studies are carried out and the operation is planned.

Preoperative preparation. Children who have absolute indications for surgery do not receive special preoperative preparation.

The exception is patients admitted late from the onset of the disease (3-4 days). The general condition of such children is extremely difficult due to intoxication against the background of peritonitis and dehydration.

Prior to surgery, such a child must be intravenously administered a 10% glucose solution, blood transfusion, and antipyretic and cardiac drugs. For 2-4 hours the child's condition noticeably improves, the body temperature decreases, and then proceed to the operation.

Surgical treatment consists in the elimination of infringement and radical plastic surgery of the inguinal canal. Surgical intervention is performed under general anesthesia.

postoperative treatment. The child is prescribed antibiotics for 2-3 days. To prevent edema, the scrotum is pulled anteriorly with a bandage, physiotherapy (sollux) is used. The child's activity is not limited, they are allowed to turn in bed, sit up on their own on the 2-3rd day after the operation. The patient is prescribed a normal (by age) diet.

Children of the first months of life are applied to the mother's breast 5-6 hours after the operation. To prevent complications from the wound in infants, the sticker should be changed when contaminated. The sutures are removed on the 5-6th day after the operation, the next day the child is discharged.

In the postoperative period, an infiltrate is sometimes observed in the suture area. The appointment of UHF currents and the extension of the course of antibiotics stop the complication. With suppuration of the postoperative wound in a child, the general condition sharply worsens, the body temperature rises. The data of blood tests (leukocytes with a shift of the formula to the left) are changing. However, local changes are initially expressed slightly - slight infiltration of the scar, sometimes swelling of the scrotum.

If you suspect the occurrence of suppuration, you should (except for antibacterial and restorative measures) dilute the gluing edges of the wound with a bellied probe and put a thin rubber graduate on the first day. This is usually enough to eliminate the complication. In some cases, the removal of sutures and dilution of the edges of the entire wound is required.

School-age children after being discharged home are exempted from classes for 7-10 days and from physical activity for 2 months. Subsequently, dispensary observation of the surgeon for the child is necessary, since in 3,8% of cases there are recurrences of the hernia, requiring a second operation.

LECTURE No. 10. Gastric obstruction

Congenital gastric obstruction in children in the first days of life can be caused by abnormalities in the development of the prepyloric region or pyloric stenosis. Some of these anomalies lead to emergency conditions that require urgent surgical intervention.

1. Prepyloric obstruction of the stomach

Malformations of the stomach, localized in its prepyloric section, are an extremely rare pathology. Violation of the patency of the stomach usually cause atresia and stenosis, most often of the membranous type.

According to the classification, there are three main variants of gastric anomalies: membranous, cord-like and segmental aplasia of the mucosa. With all types of atresia and stenosis of the stomach, the obstruction is localized only in the mucous and submucosal layers, the muscular and serous membranes retain their continuity.

The membrane can close the lumen of the stomach completely (atresia) or partially (stenosis), having holes of various sizes on the side or in the center of the septum: from a pinpoint to a large one, occupying more than half of the membrane. The thickness of the latter ranges from a thin sheet to a thick folded "hypertrophied" wall protruding into the pyloric canal of the stomach.

Histological examination of the membranes reveals an altered gastric mucosa with a submucosal layer and muscle tissue in the form of single fibers. The thick septum has the structure of the wall of the stomach.

clinical picture

The time and intensity of manifestation of symptoms of the disease depend on the degree of stenosis of the lumen of the stomach, the general condition of the child, and the presence of concomitant diseases.

Prepyloric atresia of the stomach and decompensated stenosis usually appear from the first hours or days of life. The main symptom is profuse vomiting of gastric contents without an admixture of bile. Due to overstretching of the stomach and irritation of its walls from frequent vomiting, a "hemorrhagic symptom" often joins (vomit of the color of coffee grounds or with streaks of blood and tarry color of the stool - with stenosis). In children, meconium passes in sufficient quantities.

Frequent, vomiting usually leads to exsicosis with a large drop in body weight (0,25-0,3 kg per day). On examination, swelling of the epigastric region is revealed, which disappears after vomiting or suction of gastric contents. On palpation, waves of peristalsis and the contours of a distended stomach are visible, often descending below the navel.

X-ray examination

X-ray examination is one of the main diagnostic methods. On the survey radiograph of the abdominal cavity in a vertical position, a large gas bubble and a liquid level are noted, corresponding to a distended stomach, there is no gas in the intestinal loops. Sometimes a "silent belly" is detected - the absence of gas throughout the gastrointestinal tract. In the presence of a similar x-ray picture, other research methods are usually not required. Some surgeons suggest introducing iodolipol into the stomach - with gastric atresia, a protrusion of the pyloric membrane into the lumen of the duodenum is observed.

Prepyloric stenosis may appear days or weeks after the baby is born. The time of onset of symptoms depends on the size of the hole in the membrane. The disease begins with regurgitation without an admixture of bile, turning into vomiting. Soon vomiting takes on the character of vomiting "fountain" Decreased body weight. The chair becomes more scarce. On examination, swelling of the epigastric region and visible peristalsis of the distended stomach are revealed.

X-ray examination is of great help in establishing the correct diagnosis. Plain radiographs of the abdominal cavity with the child in an upright position show a large level of fluid in the stomach and a small amount of gas in the bowel loops. In such cases, a contrast study with iodolipol is undertaken, in which a long-term retention of iodolipolam in the stomach is detected.

Complications

The most common complication of congenital obstruction of the stomach is aspiration pneumonia, resulting from the ingestion of vomit into the respiratory tract.

Frequent vomiting leads to a violation of water and electrolyte metabolism. Perforation of the atrezirovanny stomach is possible.

Differential diagnosis

The differential diagnosis has to be carried out with diseases that occur in the first days and weeks of life and are accompanied by regurgitation and vomiting that does not contain bile. First of all, this applies to malformations of the output section of the stomach.

Pyloric stenosis. It is most difficult to differentiate this anomaly from prepyloric stenosis of the stomach, if the symptoms of the latter arose from the 2-3rd week of the child's life. The clinical manifestations of the diseases are extremely similar. In all cases, it is necessary to produce an X-ray examination with a contrast agent. Often, this examination does not definitively establish the cause of gastric obstruction. In such cases, the diagnosis is made on the data of laparotomy, in which one should be very careful and remember this such a rare malformation. Otherwise, even during the operation, an error may occur.

Pylorospasm. Due to the fact that with this pathology, symptoms occur from the first days of a child's life, it is necessary to differentiate pyloric spasm with atresia or decompensated gastric stenosis. Persistent numerous vomiting, causing a violation of the general condition of the child and leading to a sharp drop in body weight, are not characteristic of pylorospasm. In addition, the effectiveness of antispasmodic drugs indicates the functional nature of the disease.

Congenital obstruction of the duodenum when the obstacle is located above the Vater nipple has a similar clinical and radiological picture. Usually the final diagnosis is made during surgery. In other types of congenital intestinal obstruction, vomit contains bile, which makes it possible to exclude an anomaly in the development of the stomach.

Congenital diaphragmatic hiatal hernia in some cases is manifested by vomiting from the first day of a child's life, but the vomit usually contains bile or blood. In addition, X-ray contrast studies help the diagnosis, in which a diaphragmatic hernia is confirmed by the location of the stomach above the level of the abdominal obstruction.

Treatment

Establishing the diagnosis of congenital obstruction of the stomach is an indication for surgery.

Preoperative preparation for atresias and decompensated stenoses usually does not exceed 24 hours and is aimed at restoring homeostasis, treating aspiration pneumonia or preventing the latter (suction of gastric contents after 2-3 hours). In case of stenosis, preparation for surgery, if necessary, can be extended to several days.

Postoperative treatment is aimed at correcting impaired water-salt metabolism, restoring the functioning of the gastrointestinal tract, preventing and treating aspiration pneumonia.

Within 2-3 days the child is on parenteral nutrition, which is calculated depending on the body weight of the patient's age, violations of water and electrolyte metabolism, the presence of combined anomalies or complications.

If the patient had a probe below the anastomosis site during the operation, then a day later they begin to introduce breast milk (5-10 ml every 3 hours), increasing the amount of the latter by 10 ml per feeding daily. The probe is removed after 4-5 days and oral feeding is started. The child receives antibiotic therapy, blood transfusions, administration of plasma, albumin. In the presence of pneumonia, aerosols are used up to 5-6 times a day. physiotherapy. The stitches are removed on the 10-12th day.

2. Pyloric stenosis

Acute forms of pyloric stenosis include such a kind of clinical manifestation of this malformation, in which the symptoms of the disease begin suddenly and proceed rapidly.

clinical picture

The time of onset of symptoms of the disease depends on the degree of narrowing of the pyloric canal and the compensatory capabilities of the body. In addition, the layering of pylorospasm plays an important role, which, apparently, is the reason that leads to the rapid onset and course of the disease. The first signs of the disease appear between the ages of several days and 1 month. The main symptom of the acute form of pyloric stenosis is “fountain” vomiting, which begins suddenly in the middle of full health. Vomit does not contain bile; its amount exceeds the amount of milk sucked during the last feeding. Often, vomit has a stagnant, sour odor, which indicates retention of gastric contents. In some cases, streaks of blood can be seen in the vomit. Sometimes quite severe stomach bleeding occurs. Prolonged, debilitating vomiting leads to a deterioration in the child’s general condition and disruption of water-salt metabolism (hypochloremia, exicosis, and sometimes hypokalemia). The acute stage of the disease is characterized by the fact that the child develops complete obstruction of the gastric patency within a few days. Feeding becomes impossible; a few sips of milk cause vomiting. Children lose up to 1-2 kg of body weight in 0,4-0,5 days. The number of urinations decreases. There is stool retention or dyspeptic “hungry” stool appears.

Upon admission to the department, patients with an acute form of pyloric stenosis rarely worry, greedily grab the pacifier, but soon severe vomiting appears. If hospitalization is carried out on the 2-3rd day from the onset of the disease, then the child’s condition is severe, symptoms of exicosis are pronounced, and there is a large loss of body weight. An indicator of the serious condition of a child with pyloric stenosis is the daily loss of body weight in relation to birth weight (as a percentage). This classification distinguishes three forms of the disease: mild (0-0,1%), moderate (0,2-0,3%) and severe (0,4% and above). In children with acute pyloric stenosis, weight loss reaches 6-8%. Upon examination, the child reacts poorly to his surroundings, with a pained expression on his face. The skin is pale, mucous membranes are bright and dry. The fontanelle sinks. Noteworthy is the swelling of the epigastric region, which decreases or disappears after vomiting. When stroking the abdominal wall or after several sips of food, you can notice waves of stomach peristalsis. Often the stomach takes on an hourglass shape. This symptom is a constant sign of congenital pyloric stenosis and is of great importance for establishing the diagnosis. Another symptom characteristic of pyloric stenosis - palpation of a thickened pylorus through the anterior abdominal wall - is variable, since it is not possible to determine it in all children.

If in children with a chronic form of pyloric stenosis in the biochemical blood test there are moderate changes due to a gradual increase in the symptoms of the disease, then in patients with an acute form (especially with late diagnosis), there is a sharp increase in hematocrit, a decrease in chlorine, metabolic alkalosis and sometimes hypokalemia. Changes in proteins and protein fractions are rare. In urine tests, traces of protein, single erythrocytes can be detected. The oliguria is distinctly expressed.

X-ray examination

X-ray examination of children with suspected pyloric stenosis is of decisive diagnostic importance. First, a survey radiograph of the abdominal cavity is made in the vertical position of the child. At the same time, a large gas bubble and a high level of liquid are found in the distended stomach. There is little gas in the intestinal loops, or the latter is absent. Then they proceed to a contrast study. In newborns of the first days of life, iodolipol (5 ml) is used as a contrast, observing its passage through the gastrointestinal tract. The absence of evacuation from the stomach for more than 24 hours indicates an obstruction in the pyloric region.

Differential diagnosis

The differential diagnosis of the acute form of pyloric stenosis should be carried out with pylorospasm, obstruction of the stomach, congenital high intestinal obstruction, habitual vomiting.

In children of the first days of life, differentiation with pylorospasm is of the greatest importance due to the different tactics used in their treatment. It should be borne in mind that with spasm, the disease begins gradually, with regurgitation, which is intermittent, without significantly affecting the general condition of the child and his body weight. In addition, the acute form of pyloric stenosis is so acute and violent that the attending physicians assume an "acute surgical disease" and refer the child to the surgical department. In those cases when an X-ray examination is performed to differentiate these conditions, it should be borne in mind that with pylorospasm, gastric emptying begins 10 minutes after taking a contrast agent and ends after 3-6 hours.

Congenital obstruction of the stomach is clinically and radiographically extremely difficult to distinguish from the acute form of pyloric stenosis. Usually the final diagnosis is established during surgery.

Congenital anomalies of the duodenum, in which the obstruction is located below the nipple of Vater, is usually easy to distinguish from pyloric stenosis by bile-stained vomit and a characteristic x-ray picture. In those cases of obstruction of the duodenum, when the obstruction is located above the nipple of Vater, the diagnosis becomes difficult. It should be remembered that with congenital intestinal obstruction, vomiting usually begins from the first day of life, while with pyloric stenosis, it starts much later.

Palpation determination of the thickened pylorus and the establishment of lengthening and narrowing of the pyloric canal during x-ray examination speak in favor of pyloric stenosis. Sometimes the contrast agent (with pyloric stenosis) remaining in the stomach may appear on the x-ray as two depots located on both sides of the spine, which is similar to the x-ray picture with high intestinal obstruction. In these cases, the diagnosis is aided by lateral radiography—the dilated duodenum is usually located posterior to the stomach.

Habitual vomiting and regurgitation are quite common in children in the first months of life, but this dysfunction of the stomach usually does not change the general condition of the child, does not cause a drop in body weight.

Treatment

The only treatment for acute pyloric stenosis is surgery.

Preoperative preparation. The duration and intensity of preoperative preparation depend on the timing of the child's admission to the department, the severity of his condition. Preparation for surgery, together with the examination, does not exceed 24 hours and is aimed at reducing disturbances in water-salt metabolism, as well as treating aspiration pneumonia. Immediately before the operation, the gastric contents are aspirated.

As a rule, endotracheal anesthesia is chosen as the method of anesthesia.

postoperative treatment. 3-4 hours after the operation, if there was no injury to the mucous membrane of the stomach or duodenum, the child is given 7-10 ml of a 5% glucose solution through the nipple, after 1 hour - 10 ml of expressed breast milk, and then (in the absence of vomiting) is prescribed every 2 hours for 10 ml of milk. Subsequently, 100 ml of milk per day is added daily. After 7-10 days, the child is applied to the breast with a transfer to 7 meals a day.

In cases of damage to the mucous membrane of the duodenum, feeding is started no earlier than 24 hours after the operation. If the child continues to vomit, then the amount of milk is somewhat reduced and a 1% solution of novocaine is prescribed, one teaspoon three times a day. The missing amount of fluid and salts is replenished by the parenteral method, taking into account comparative data from blood tests, the child's body weight, and his condition.

With the phenomena of aspiration pneumonia, the active therapy started in the preoperative period is continued. In order to prevent infection of the wound and the occurrence of complications, antibiotics are used (6-7 days). Vitamin therapy is prescribed. Sutures are removed on the 10-12th day after the operation.

LECTURE No. 11. Congenital intestinal obstruction

Violation of intestinal patency can be associated with various factors of a congenital nature. The most common acute obstruction (in newborns). Malformations of the intestine, mesentery and other organs of the abdominal cavity can create anatomical prerequisites for the periodic occurrence of attacks of obstruction in children of any age (recurrent congenital obstruction). These conditions also require urgent surgical care.

Acute congenital intestinal obstruction

Acute obstruction is most often caused by a malformation of the intestinal tube itself (atresia and stenosis of the intestine). Atresias and subtotal stenoses are clinically indistinguishable from each other. Acute congenital obstruction is often caused by compression of a normally formed intestinal tube (external type of obstruction). Compression can be caused by various reasons: improperly located vessels of the mesentery (more often the duodenum is compressed by the superior mesenteric artery); peritoneal adhesions, a tumor or cyst of the abdominal cavity, an annular pancreas that covers the duodenum in the descending part; violation of embryonic rotation of the midgut.

Meconium ileus, which is the earliest and most severe manifestation of congenital cystofibrous degeneration of the pancreas, stands somewhat apart. Unlike other types of obstruction, the lumen of the intestinal tube with meconium ileus is preserved. Obstruction occurs due to blockage of the terminal ileum by altered meconium. Its expanded part can be perforated in utero, which leads to the occurrence of adhesions. In some cases, the contents of the intestine, entering the abdominal cavity, cause a reaction in the body in the form of diffuse small calcification of the peritoneum. Perforation that occurs after the birth of a child is accompanied by the development of peritonitis. Congenital obstruction is usually divided into two groups: high, in which the obstruction is located in the duodenum or the initial part of the jejunum, and low, when obstruction occurs in the more distal parts of the small and large intestines. Combining anatomically different anomalies into one group based on the totality of similarity of symptoms makes possible early and correct diagnosis, as well as pathophysiologically determined preoperative preparation.

Clinical picture of high congenital obstruction

The clinical picture of high congenital obstruction appears, as a rule, from the first day of life, and sometimes in the first hours after birth. The most consistent and early symptom is vomiting. With duodenal obstruction, vomiting occurs soon after birth, the amount of vomit is abundant, and does not contain any admixture of bile, which enters entirely into the intestine. In case of duodenal obstruction below. Vateri, and also in the presence of an obstruction in the initial part of the jejunum, the vomit is colored with bile. After the newborn is placed on the mother's breast, vomiting becomes repeated and profuse, exceeding the amount of milk the baby has taken. The frequency of vomiting and the amount of vomit varies somewhat depending on the type of obstruction. With atresia it is more frequent, continuous, striking in its abundance. There is sometimes an admixture of blood in the vomit. With partially compensated stenoses, vomiting occurs on the 2-4th day of the child’s life and usually not immediately after feeding, but 20-40 minutes later, sometimes in a “fountain”.

Children with high congenital obstruction usually have meconium. If the obstruction is located above p. Vateri, the amount and color of meconium is almost normal and its discharge is observed until the 3-4th day. With lower obstruction, the amount of meconium is small, the consistency is more viscous than in a healthy child, and the color is grayish. These properties of meconium are associated with the impossibility of passage of bile and amniotic fluid into the distal intestines. With atresia and subtotal stenosis, there is usually a single discharge of meconium or in small portions several times within 1-2 days, and thereafter is absent. In newborns with multiple intestinal atresia, no meconium is observed. With congenital torsion, meconium departs, but in a meager amount. This can be explained by the fact that obstruction (volvulus) is formed in the later period of uterine development, after the intestinal tube is largely filled with bile and amniotic fluid. In some cases, in children with incomplete compression of the intestinal lumen, scanty transitional stools may appear on the 6-7th day.

The behavior of a child with congenital high intestinal obstruction is normal on the first day, but later lethargy may appear. At first, the newborn actively sucks, but as the general condition worsens, he refuses to breastfeed. Characteristic is the progressive loss of body weight (0,2-0,25 kg per day). Already from the 2nd day the dehydration phenomena are clearly expressed.

The abdomen is swollen in the upper sections (especially in the epigastric region) due to the distended stomach and duodenum. In the first days, you can see the waves of peristalsis. After profuse vomiting, swelling in the epigastric region decreases, sometimes completely disappears. There is some retraction of the lower abdomen.

On palpation, the abdomen is soft and painless throughout. If the obstruction is caused by a tumor or cyst, then usually these formations are quite easily palpable through a thin and somewhat flabby abdominal wall. In some cases, in children with congenital volvulus, it is possible to palpate a conglomerate with fuzzy outlines in the abdominal cavity.

In the blood of patients with high obstruction, biochemical changes occur. Due to prolonged vomiting, hypochloremia develops, the ratio changes and the amount of K ions decreases.^-and Na+. Against the background of exicosis, thickening of the blood is noted: an increase in hematocrit, hemoglobin, an increase in the number of erythrocytes and leukocytes.

X-ray examination

In the recognition of congenital intestinal obstruction, the radiological method is extremely valuable. The correct interpretation of radiological data helps to navigate the level of obstruction, its nature and is necessary for differential diagnosis.

The study of the newborn begins with a survey radiography of the abdominal cavity in the anteroposterior and lateral projections with the child in the vertical position. With high obstruction, radiological symptoms are quite characteristic. Anteroposterior images show two gas bubbles with horizontal levels of liquid, which corresponds to a distended stomach and duodenum, and two horizontal levels located at different heights are also visible on lateral images. The size of gas bubbles is different. With a complete interruption of patency in the underlying sections of the intestine, gas is not detected. Sometimes it is also absent in the stomach, and then the “silent” abdomen is revealed radiologically. In rare cases, with partially compensated stenoses and congenital torsion, single small gas bubbles in the intestine can be seen.

The presence of such a radiological picture in combination with clinical data allows us to consider the diagnosis of high congenital obstruction as undoubted. However, children with this type of obstruction are advised to have barium enema to clarify the position of the colon. If the colon is partially filled with contrast, located on the left, one should think about the presence of a torsion of the midgut in a newborn. This clarification of the anatomical cause of obstruction is necessary for the correct calculation of the time of preoperative preparation.

Differential diagnosis

High congenital obstruction has to be differentiated from some congenital and acquired diseases with similar symptomatology.

Pylorospasm is manifested in the first days after birth by vomiting, which is intermittent and less abundant in quantity than with congenital intestinal obstruction. In addition, there is no admixture of bile in the vomit during pylorospasm. However, in cases of duodenal obstruction, p. Vateri bile in vomit also does not happen Plain radiographs usually allow you to clarify the diagnosis by the symptom of two bowls characteristic of high obstruction and the absence of gas in the intestine. X-ray examination with a contrast agent in case of obstruction shows a partial retention of iodolipol in the stomach and its free passage into the duodenum.

Suspicion of pyloric stenosis occurs in children with congenital subcompensated stenosis, in which there is a partial intestinal patency. Persistent vomiting, progressive dehydration and emaciation, scanty stools, and epigastric distention with visible gastric peristalsis make these diseases similar. However, permanent staining of vomit with bile can completely eliminate pyloric stenosis. The diagnosis is confirmed by x-ray examination: with pyloric stenosis there is one large gas bubble corresponding to the dilated stomach, in the remaining parts of the intestine a uniform distribution of gas is visible.

Congenital diaphragmatic hernia is sometimes accompanied by vomiting, which gives rise to differential diagnosis with high congenital obstruction. In contrast to obstruction in congenital diaphragmatic hernia in a newborn, dysfunctions of the respiratory and cardiovascular systems come to the fore. X-ray examination reveals displacement of the intestine into the chest cavity.

Birth trauma to the brain is often accompanied by vomiting with an admixture of bile. However, the passage of meconium is normal. With a brain injury, symptoms of damage to the central nervous system are revealed. The diagnosis is clarified by X-ray examination.

Clinical picture of low congenital intestinal obstruction

One of the main symptoms of low intestinal obstruction is the absence of meconium. After the introduction of a gas outlet tube or an enema, only lumps of colorless mucus stand out in a newborn.

Vomiting appears relatively late, by the end of the 2nd - on the 3rd day of life, and is usually not associated with food intake. The amount of vomit varies (vomiting is often profuse, sometimes resembling regurgitation), but there is always bile staining. Soon the vomiting takes on a meconium character and acquires an unpleasant odor.

The child’s behavior in the first hours after birth does not give reason to suspect pathology, but very soon motor restlessness appears, the newborn kicks his legs, refuses to breastfeed or sucks very sluggishly and does not sleep. The general condition quickly deteriorates, intoxication symptoms increase, the child becomes lethargic, adynamic, the skin takes on a gray-sallow color, and the body temperature may be elevated (37,5-38 °C).

On examination, even on the first day, a uniform bloating is detected, which progresses rapidly. The size of the abdomen after vomiting does not decrease. Through the anterior abdominal wall, intestinal loops stretched by meconium and gas are contoured. Their peristalsis is often visible, which is not traced in the later periods, since intestinal paresis occurs. Percussion determined tympanitis in all parts of the abdomen. Auscultation revealed rare deaf noises of intestinal peristalsis. Palpation of the abdomen is painful, accompanied by anxiety and the cry of the child.

With meconium obstruction, sometimes (on the first day after birth) it is possible to palpate a sausage-shaped mobile tumor corresponding to the terminal ileum stretched by meconium.

If there is an obstruction caused by compression of the intestine by a cyst or tumor, then the latter are determined quite clearly. Digital examination through the rectum is sometimes able to identify a neoplasm that may close the entrance to the pelvis. Examination in other cases of low obstruction does not reveal pathology. Colorless mucus leaves behind the finger.

Atresia of the ileum, as well as the large intestine, can be complicated by meconium peritonitis, which occurs due to perforation of the overstretched blind end of the intestine. The general condition of the child at the same time deteriorates sharply, vomiting becomes continuous, body temperature rises. The anterior abdominal wall becomes pasty, a network of dilated venous vessels is visible. Swelling soon appears in the groin and perineum (especially the scrotum). The abdominal wall is tense. Only early diagnosis of this complication can give some confidence in a favorable outcome of treatment.

X-ray examination

X-ray examination begins with survey pictures of the abdominal cavity. Radiographs show swollen intestinal loops with multiple uneven horizontal levels (obstruction of the distal ileum and colon) or several large gas bubbles with wide levels (obstruction of the jejunum or ileum, meconium ileus). If low intestinal obstruction is suspected, a study is performed with a water-soluble contrast agent injected into the rectum with a syringe through a catheter. With low obstruction, radiographs show a sharply narrowed large intestine filled with a contrast agent. Perforation of the expanded part of the intestine above the site of obstruction is usually detected radiographically by the presence of free gas in the abdominal cavity.

Differential diagnosis

With low congenital obstruction, there are similar symptoms with dynamic obstruction (intestinal paresis) and Hirschsprung's disease. These diseases must be excluded, since an erroneous laparotomy in the presence of dynamic obstruction or Hirschsprung's disease will lead to a sharp deterioration in the general condition of the child.

Paralytic obstruction (as opposed to congenital) occurs gradually against the background of a severe general illness (peritonitis, pneumonia, sepsis, enterocolitis), usually 5-10 days after the birth of a child. The phenomena of obstruction in intestinal paresis are not expressed clearly enough, less constantly. From the anamnesis, it turns out that the meconium in the child departs normally, and on examination there is usually a stool (after a gas tube or an enema). Differential diagnosis is helped by X-ray examination with the introduction of a contrast agent through the rectum. With paralytic obstruction, well-formed rectum and sigmoid colon with a normal lumen are detected.

Hirschsprung's disease (acute form) from the first days of life is manifested by the absence of an independent stool. Unlike congenital mechanical low obstruction, it is relatively easy to achieve discharge of gases and fecal masses by conservative methods (abdominal massage, introduction of a gas outlet tube, enema). Decisive in the diagnosis is a contrast X-ray study, which reveals the expansion of the lumen of the large intestine, characteristic of Hirschsprung's disease, with the presence of a narrowed zone of agangliosis.

Treatment

Treatment of congenital intestinal obstruction is a complex section of childhood surgery. Mortality remains high until recently. The prognosis of the disease depends mainly on timely diagnosis, correct surgical correction of the defect, rational preoperative preparation and postoperative management.

Preoperative preparation is carried out strictly individually. In newborns with high intestinal obstruction, the duration and quality of preoperative preparation depend on the severity of the condition, the time of admission to the hospital, and the presence of complications.

If the diagnosis is established on the first day after birth, then the preparation for the operation does not exceed 3-6 hours and is limited to general measures (warming the child, the introduction of cardiac drugs, oxygen therapy), as well as removing the contents of the stomach through a thin rubber catheter, which is inserted through the nose. Suction of liquid and gas from the stomach is necessary in all cases. The catheter is left in the stomach to continuously aspirate fluid during surgery.

In case of late admission (2-4 days), in addition to general measures, it is necessary to begin compensation of the water-salt balance sharply disturbed as a result of prolonged vomiting before the operation. In addition, in these children, in connection with the phenomena of associated pneumonia, respiratory acidosis is often expressed, which also requires correction. The child is given a venesection of the external jugular vein or a puncture of the subclavian vein and intravenous fluids are started (10% glucose solution, protein preparations - albumin, plasma). The duration of preoperative preparation of children in this group is 12-24 hours. If congenital volvulus is suspected after an X-ray examination (irrigography), then the duration of preparation is sharply reduced (3-4 hours) due to the risk of intestinal necrosis. When conducting fluid therapy, one should not achieve a quick and complete correction (until normal blood tests are obtained) of water-salt disorders.

In the preoperative period, children are in an incubator (28-32 °C) and constantly receive oxygen. In cases of aspiration pneumonia, active anti-inflammatory therapy is prescribed. The degree of preparation for surgery is judged by the improvement in general condition and the emerging trend towards normalization of biochemical blood parameters.

With low intestinal obstruction, preoperative preparation usually does not exceed 2-3 hours and consists of general measures (warming the child, the introduction of cardiac drugs, vitamins, antibiotics, gastric lavage) and in severe cases (with pronounced intoxication, hyperthermia) is aimed at an intensive fight with these conditions. The short duration of preoperative preparation in children with low intestinal obstruction is associated with early developing severe complications: intestinal perforation, peritonitis.

postoperative treatment. The patient is placed in a heated incubator with a temperature of 29-3 ° C and 100% humidity, constantly given humidified oxygen, cardiac drugs and antibiotics for 7-8 days.

A feature of caring for newborns who have undergone surgery for obstruction is the mandatory constant suction of the contents from the stomach (every 3-4 hours) until the discharge of green fluid stops.

Extensive manipulations on the intestine lead to a profound violation of its motility within a few days. In cases where an anastomosis has been created, its patency is restored gradually, and the accumulation of a significant amount of intestinal contents above the anastomosis may be accompanied by suture divergence. In order to prevent intestinal paresis and more quickly restore its function, epidural anesthesia is used in all newborns operated on for congenital intestinal obstruction.

In the first 2-3 days, children are completely on parenteral nutrition. Feeding through the mouth after surgery for high obstruction begins on the 3-4th day, low - not earlier than the 4-5th day. First give expressed breast milk in fractional doses (5-7 ml) after 2 hours (alternating with 5% glucose solution). The amount of milk is gradually increased, bringing to the age norm by the 8-12th day. After the creation of intestinal anastomoses, a slow increase in the amount of fluid administered through the mouth is shown (due to the insufficient function of the formed anastomosis).

In children, after the formation of a “unloading” Y-shaped anastomosis, fluid administration through the drainage begins the next day after surgery (3-5 ml every 2 hours), and from the 3-4th day dosed oral feeding is prescribed. A drainage inserted into the proximal (dilated) section of the intestine serves for periodic (every 2-4 hours) suction of stagnant contents, a decrease in which indicates the normal function of the anastomosis. This is usually noted on the 6-8th day. Then the drains are removed.

A newborn is applied to the breast of the mother's mother after the amount of fluid administered through the mouth corresponds to the age norm.

From the first days after the operation, UHF currents are prescribed to the area of ​​the solar plexus, and then, from the 5-6th day, potassium iodide iontophoresis for the prevention of adhesive obstruction. The skin sutures of the wound of the anterior abdominal wall are removed on the 10-11th day after the operation.

The management of children with meconium ileus after the operation of creating an enterostomy according to Mikulich has some features. The child is injected with a 5% solution of pancreatin (7-5 ml) twice a day for 4-5 days into the afferent and outlet ends of the excreted intestine, which helps soften the meconium and mechanically remove it. Parenteral nutrition is carried out for the first 3-4 days, and then fractional feeding through the mouth begins according to the above scheme. At the same time, it is recommended (V. Toshovsky and O. Vichitil) 6-fold injection into the stomach of 0,5 ml of a 5% solution of pancreatin (3 ml per day). Establishing a diet in the future, it is necessary to introduce a lot of proteins and vitamins (especially vitamin A) with food, sharply limiting fats.

Complications in the postoperative period are observed mainly in children admitted late after birth. The most severe complication is peritonitis, which occurs due to insufficiency of the anastomotic sutures.

Fecal peritonitis develops so quickly that the measures taken (reoperation, antibiotics, general strengthening treatment) are rarely successful. Therefore, only the prevention of such a complication is an effective measure to reduce postoperative mortality.

Aspiration pneumonia is a frequent and severe complication that occurs mainly when the basic rules for managing such patients are violated at all stages of treatment.

A set of measures recommended by specialists and for all children after surgery is aimed at preventing and treating aspiration pneumonia (constant suction of the contents of the stomach, cardiac agents, alkaline aerosols, humidified oxygen, physiotherapy).

Adhesive obstruction. This complication is rarely observed in the postoperative period. Treatment begins with conservative measures. The ineffectiveness of the therapy within 18-24 hours is an indication for surgical intervention - the formation of a bypass anastomosis or separation of adhesions (with late obstruction).

The divergence of the edges of the postoperative wound and bowel eventration are most often associated with early removal of sutures. In such cases, emergency surgery is indicated - layer-by-layer suturing of the abdominal wall.

LECTURE No. 12. Recurrent congenital intestinal obstruction

Malformations of the intestine and mesentery in some children cause incomplete narrowing of the lumen of the intestinal tube with a violation of its function, which creates the prerequisites for the periodic occurrence of attacks of acute obstruction. Such conditions can also be associated with the presence of congenital cystic formations of the abdominal cavity and other causes. The first signs of the disease usually occur months or years after birth due to the weakening of the body's compensatory capabilities and changes in the child's diet.

Recurrent intestinal obstruction most often occurs in connection with congenital circular stenosis of the ileum and colon, disruption of the normal embryonic turn of the "midgut", incarceration of the intraperitoneal hernia and compression of the intestinal lumen by cystic formation. All types of this disease are characterized by inconsistency of symptoms, but the intermittent nature of obstruction is common. It is far from always possible to establish the cause of congenital recurrent obstruction before surgery, but at the same time there are some features of the clinical picture and treatment of each of the listed groups.

1. Circular stenoses of the intestine

clinical picture

The clinical picture depends on the degree of narrowing and its localization. The first signs of obstruction with significant narrowing of the lumen of the small intestine are observed in early infancy. The child has periodic bouts of anxiety, bloating, vomiting. The chair is rare, but independent, gases depart. Attacks are short-term, occur several times a day, sometimes much less frequently. The child does not take the breast well, gains little weight. Gradually, the attacks of pain become more intense, stool retention appears, the general condition worsens, and the child is sent to a surgical hospital with a diagnosis of intestinal obstruction.

When examining a patient, attention is drawn to bloating and some asymmetry of the abdomen. Visible peristalsis is usually determined. Intestinal noises are heard, percussion - tympanitis. The abdomen is slightly painful, muscle tension is not detected. On digital examination of the rectum, the ampoule is empty, there may be a small amount of feces. There is no chair, gases do not depart. After an enema, a temporary improvement may occur, gases can pass. In cases of acute complete closure of the lumen of the narrowed intestine, bloating is more pronounced, the skin is shiny, palpation is painful. Overstretching of the prestenotic part leads to partial necrosis of the intestinal wall and the development of peritonitis.

X-ray examination helps in making a diagnosis. Plain radiographs show many horizontal levels in the upper abdomen and gas-distended loops of the small intestine. A study with a contrast agent is possible only in the "light" interval. Given through the mouth, a liquid suspension of barium sulphate in a serial study (every 2 hours) can be detected due to a long delay above the site of narrowing. In acute cases, such a study is unacceptable.

The presence of stenosis of the colon appears at an older age, usually after a year. Initially, parents note frequent stool retention, the presence of vomiting, loss of appetite, an increase in the abdomen, and a lag in physical development. Occasionally there is anxiety, bloating intensifies, but after an enema there is a chair, gases leave, and the child calms down. The phenomena of chronic intoxication are noted. In rare cases, the narrowed section of the intestine can become blocked with a fecal stone or a foreign body, and then a picture of acute obstruction occurs.

Less pronounced stenoses for a long time may be accompanied by very poor symptomatology: constipation, mild pain attacks, decreased appetite. With age, the compensatory possibilities of the hypertrophied wall above the located intestine weaken, and the clinical picture becomes more definite. Attacks of pain intensify, repeat more often, usually combined with a long delay in stool. Gradually the stomach increases, there is vomiting. Chronic intoxication, hypochromic anemia develops. On palpation of the abdomen, the large intestine is distended with feces.

X-ray examination

Diagnosis is aided by radiological examination with a contrast mass, which shows prestenotic expansion and normal distal colon. In some cases, it is possible to contour the place of narrowing.

Treatment

In the period of recurrence of obstruction, an emergency operation is indicated. Surgical intervention is performed under endotracheal anesthesia and blood transfusion, median laparotomy is performed.

2. Ledd's syndrome

clinical picture

The clinical picture of recurrent volvulus of the midgut is notable for its inconstancy. Most often, the first signs of obstruction are vomiting and regurgitation of bile in children during the first months of life. In some cases, the disease is asymptomatic for many years. Characteristic pain attacks can be single, repeated daily or have intervals of several months and even years. In such children, the appetite is usually reduced, they lag behind their peers in physical development. Sometimes the initial manifestations go unnoticed, and the first attack is accompanied by a distinct clinical picture of acute intestinal obstruction.

Thus, periodic paroxysmal pain in the abdomen and frequent vomiting suggest recurrent obstruction associated with impaired intrauterine rotation of the midgut.

In some cases, one of the recurrences of volvulus is accompanied by a pronounced picture of acute intestinal obstruction. Suddenly, paroxysmal severe abdominal pain appears, repeated vomiting, stool and gas retention. The child's condition deteriorates sharply, he tosses about in bed, takes a forced position. The face has a pained expression, the eyes sink, the pulse is frequent, thready. The collaptoid state develops.

When examining a child during a painful attack, there are some swelling of the epigastric region and retraction of the lower abdomen. Palpation is slightly painful, no formations in the abdominal cavity are not determined. On digital rectal examination, the sphincter is well contracted, the rectal ampulla is empty.

X-ray examination

The most objective data, speaking of obstruction, are obtained by X-ray examination. Plain abdominal radiographs (upright child) show two horizontal levels of fluid corresponding to a distended stomach and duodenum. There is a relatively small amount of gas in the intestines. A contrast study clarifies the diagnosis. This per os suspension of barium sulphate accumulates at the bottom of the stomach and contours the distended duodenum. After a few hours, barium is distributed in small portions throughout the small intestine, the loops of which are presented in the form of a conglomerate. In cases of suspected volvulus, barium enema is desirable to locate the caecum. If the latter is located high, then one can think of Ledd's syndrome or duodenal compression of an abnormally fixed caecum. In a child with normal anatomical relationships, the large intestine (S - shaped, transverse, colon, ascending and blind) has the shape of the letter "P", forming an angle of about 90 in the hepatic and splenic curvature. In children with Ledd's syndrome, the barium-filled sigmoid colon lies more medially, so the transverse colon is, as it were, shortened, located somewhat lower, and the angle between it and the descending colon is rounded and reduced.

Differential diagnosis

The differential diagnosis is carried out with diseases accompanied by vomiting and bouts of abdominal pain.

Worm infestation is a relatively common disease of older children, causing bouts of abdominal pain. Localized pain in the navel. During an attack, there is vomiting, nausea. The brevity of attacks, history data (the presence of worms in the child, etc.), laboratory tests (blood, feces) and examination of the child usually help to recognize the cause of the disease. However, in some children, attacks of pain during helminthic invasion are so strong and prolonged that the surgeon has a reasonable suspicion of mechanical obstruction. In such cases, conventional conservative measures help the differential diagnosis. With helminthic invasion, the pain then stops, gases go off. Sometimes the spasm of the small intestine caused by the presence of ascaris does not go away, attacks of pain remain, and one has to resort to a trial laparotomy.

Giardia cholecystitis is similar to recurrent obstruction, the presence of paroxysmal pain in the abdomen. However, their localization in the right hypochondrium, the presence of typical pain points, an enlarged liver, X-ray and laboratory data allow a correct diagnosis.

Treatment

Treatment of recurrent midgut volvulus can only be surgical.

Preoperative preparation of children is limited to gastric lavage. Anesthesia - general, intubation method

3. Internal abdominal hernias

The movement of intestinal loops into defects of the mesentery, omentum or pockets of the peritoneum (without the exit of the viscera from the abdominal cavity) is commonly called internal hernias, which in children, as a rule, are congenital.

If the displaced intestinal loops are covered with sheets of peritoneum, which form a kind of hernial sac, then such internal hernias are called true. In cases of displacement of organs through the opening in the mesentery or other congenital defects, hernias occur that are not covered by the hernial sac, and they are called false. In children, paraduodenal hernias are predominantly found.

clinical picture

Internal abdominal hernias (both true and false) can be asymptomatic indefinitely and are first detected by intestinal obstruction in adults or older children. It is not excluded the possibility of acute intestinal obstruction in the neonatal period. However, for internal abdominal hernias in children, the symptomatology of recurrent obstruction is most characteristic.

X-ray examination

X-ray examination is of little help in recognizing internal abdominal hernias. In rare cases, it is possible to identify gas-filled loops of the small intestine on survey images, concentrated in the form of a regular rounded conglomerate (hernial sac limitation).

To clarify the diagnosis, you can use a contrast study of the colon, which has an unusual position, bending around the hernial sac filled with strangulated loops of the small intestine.

Differential diagnosis

The differential diagnosis, as with other types of congenital recurrent obstruction, is carried out with diseases accompanied by abdominal pain, vomiting and intestinal discomfort.

Treatment

The operation is usually carried out according to urgent indications. Before the operation, the stomach is washed and intravenous drip infusion of fluid is started.

The duration of preoperative preparation is minimal - it is limited by the time necessary for drug preparation for anesthesia.

4. Compression of the intestinal lumen by cystic formations

Cysts of the abdominal cavity and retroperitoneal space, as well as cystic doubling of the gastrointestinal tract in some cases narrow the lumen of the intestinal tube and cause a symptom complex of recurrent obstruction. This complication can occur at any age.

clinical picture

In cases of compression of the intestinal lumen by a cyst, paroxysmal abdominal pain periodically occurs, the localization of which cannot be detected in young children. Older children complain of pain below the navel. Attacks are accompanied by vomiting, stool retention. When examining a child, one can note the asymmetry of the abdomen due to the protruding tumor-like formation and visible intestinal motility. Superficial careful palpation sometimes manages to determine a moderately mobile and painful cystic mass in the abdominal cavity. Its presence is confirmed by digital examination through the rectum. Identification of a mesenteric cyst of small size is almost impossible due to its easy displacement and difficulties associated with the patient's anxiety. However, often the pain attack goes away on its own, and the child feels healthy again. During the period of pain subsidence, persistent and correctly conducted palpation examination usually reveals a cyst. The cyst of the mesentery, complicated by volvulus of the corresponding loop of the intestine, is manifested by a picture of acute intestinal obstruction.

X-ray examination

X-ray examination in such cases rarely helps to recognize the true cause of the disease.

Differential diagnosis

Complicated cysts have to be differentiated from mechanical intestinal obstruction (chronic and acute) caused by other causes. Recognition of the true cause of the disease is difficult due to similar symptomatology and a certain mood of the surgeon, who does not think about the possible presence of a cyst that is rare in children. However, a detailed analysis of the anamnestic data (periodic attacks of pain, constipation, vomiting, abdominal enlargement) and clinical symptomatology (the presence of a cystic mass in the abdominal cavity, atypical manifestations of the alleged intussusception, helminthic obstruction), some radiological findings should be alarming in relation to the complicated mesenteric cyst.

Treatment

Children with complicated mesenteric cysts should be operated on following the diagnosis. The choice of the method of surgical intervention is determined by the nature of the cyst and the patient's condition.

postoperative treatment. All children are prescribed antibiotics intramuscularly, vitamins of groups B and C, heart medications (according to indications), oxygen for the first 2-3 days. In order to prevent pneumonia, the child is given an elevated position, physiotherapy, breathing exercises, and frequent turning in bed are carried out. In the presence of vomiting, the stomach is washed 1-2 times a day with a warm 1% soda solution. If the Ledd operation or the separation of adhesions was performed without violating the integrity of the intestine, then the child begins to drink by the end of the 1st day. For the prevention of pain and the fight against intestinal paresis, long-term epidural anesthesia (3-4 days) is indicated. In cases where a bowel resection was performed or a bypass anastomosis was formed, the child is on parenteral nutrition for 2 days. Compensation for the lack of proteins resulting from chronic malnutrition and losses during surgery is of great importance. The amount of blood plasma and albumin administered depends on age. Blood transfusions are performed no more than 2 times a week. It should be remembered that the best way to restore all types of metabolism is through the mouth, which starts from the 2nd-3rd day. First, the child receives liquid food (broth, jelly, kefir, liquid semolina, grated apple). Then gradually the diet is expanded and increased in volume. In the absence of complications, walking is allowed from the 7-8th day. The stitches are removed on the 9-10th day. Tampons are tightened after 6-7 days, followed by their gradual removal by the 14-16th day. The residual cavity is again loosely plugged after washing with antibiotics, changing the tampons after 3-4 days, preventing the closure of the external opening. Obliteration of the cavity is completed by the end of the 2nd month.

In cases where Ledd's operation was performed, X-ray control is performed before discharge to determine the location of the caecum. Surgical treatment of recurrent obstruction in most cases ends successfully.

LECTURE No. 13. Acute intestinal intussusception

The introduction of a certain section of the intestine into the lumen below (or above) the located area is called invagination. At the same time, at the injection site, the intestine has three cylinders: an external and two internal - intussusception. The top of the intussusceptum is usually called the head, which corresponds to the transition of the inner cylinder to the middle one. An increase in the length of the intussusceptible part of the intestine occurs only due to the screwing of the outer cylinder, the "head" of the intussusceptum remains unchanged. The advancement of the invaginate is accompanied by "tightening" and infringement of the mesentery of the implanted part of the intestine between the inner and middle cylinders (the serous membrane facing each other). In rare cases, "double" intussusceptions are observed, in which the invaginate complex is introduced into the lower intestine, forming 5 cylinders. The introduction of the intestines in children occurs mainly isoperistaltically in the aboral direction.

Intussusception, being the most common type of acute intestinal obstruction in children, can occur at any age. In the 1st month of life, it is observed extremely rarely. In infancy between four months and one year of age, intussusception occurs most frequently (80%). The second year of life accounts for about 10% of diagnosed cases of intussusception.

The direct cause of intussusception in children of the first year of life is considered to be a change in the dietary regimen characteristic of this age period. Various intestinal diseases (dyspepsia, colitis) are of some importance. In children older than 1 year, mechanical causes of intussusception (polyps, diverticula, tumors of the intestinal wall, stenoses) are relatively often observed.

Intussusception can occur at any level of the intestinal tract. Isolated introduction of the large intestine into the large intestine and small intestine into the small intestine is relatively rare, mainly in children over the age of 1 year. Most often, the introduction occurs in the region of the ileocecal angle, which is associated with the anatomical features of this section of the intestine in infancy: greater mobility of the caecum and ileum, the frequent presence of a common mesentery, underdevelopment of the valvular apparatus of the Bauhinian valve, a discrepancy between the diameter of the ileum and its ampulla.

Not only the clinical picture, therapeutic measures, but to a certain extent the prognosis of the disease depend on the localization of the primary introduction (the level of formation of the vaginate head) and the nature of further progress. The most acceptable for practical purposes can be considered the classification of X. I. Feldman's intussusceptions:

1) small intestine intussusception (3,5%) - the introduction of the small intestine into the large intestine;

2) ileocolic intussusception (41%) - the introduction of the ileum into the ileum and then into the colon through the Bauginian damper (simple ileocolic intussusception). With further advancement of the intussusceptum, the blind and further located sections of the colon are involved (double, complex ileocolic intussusception);

3) blind colonic invagination (52,7%) - the head of the invaginate is the bottom of the caecum. The appendix and the terminal ileum are passively retracted between the cylinders of the intussusceptum;

4) colonic invagination (2,8%) - the introduction of the colon into the colon;

5) rare forms of intussusception (isolated invasion of the appendix, retrograde intussusception, multiple).

Pathological changes in the intestine during invagination depend on the location of the introduction and its duration. Clinical and pathoanatomical studies show that with small intestinal invaginations, necrosis of the intestine usually occurs after 12-24 hours, and with ileocolic invaginations (due to additional incarceration in the area of ​​​​the Bauhinian valve), necrosis can be expected in the first 6-12 hours. Only with blindness In colonic and colonic invaginations, circulatory disorders develop slowly, and necrosis of the intestinal wall occurs much later.

clinical picture

The clinical picture of acute intussusception depends on the level of introduction of the intestine, the age of the child and the time that has passed since the onset of the disease.

Due to the fact that in children under 1 year of age, intussusception is most often observed in the region of the ileocecal angle (blind-colon and iliac-colon), the clinical picture of these forms in infancy can be considered typical. Small intestinal and large intestine intussusceptions have some features of symptoms that require separate coverage. Retrograde and multiple invaginations are manifested by symptoms of the usual introduction of the corresponding localization. Analysis of the clinical picture of the disease in many cases makes it possible to establish not only the diagnosis of invagination, but also to suggest the form of administration. To a certain extent, X-ray methods of research contribute to this.

Clinical picture of cecum-colon and ileo-colon intussusception. The disease begins acutely, among full health. Suddenly, the child begins to worry sharply, screaming convulsively with legs. The face becomes pale, sometimes covered with cold sweat. Older children grab their stomachs with their hands, tend to take a knee-elbow position. The child does not calm down in the mother's arms, refuses to breastfeed. An attack of pain is usually short-lived (3-7 minutes). accompanied by vomiting and stops as suddenly as it started. The child immediately calms down, his behavior becomes normal; sucks mother's breast, interested in toys. After a few minutes (5-10, sometimes 15-20), the attack of pain is repeated with the same force. Again, the child begins to twist his legs, scream, worry sharply, toss and turn in bed or in the arms of his parents. The vomiting is repeated. The "light" intervals between contractions gradually become longer, but the general condition of the child progressively worsens. He becomes lethargic, adynamic, loses interest in the environment, refuses food. Recurring attacks gradually lose their severity, are not accompanied by a sharp motor restlessness.

The occurrence of pain depends on the infringement and tension of the mesentery, a sharp spasm of the intestine in the area of ​​intussusception. A periodic increase in peristalsis, followed by a weakening of the motor function of the intestine (a response to a sudden pain irritation), explains the cramping nature of the pain. Their intensity depends on the force of compression by the invaginate cylinders of the implanted mesentery and the degree of its tension.

As edema and circulatory disorders increase, pain sensations decrease due to the onset of neurological changes and limitation of invaginate advancement in the aboral direction.

In the first hours of the disease, the child may have an independent fecal stool. Often, a normal stool is obtained after an enema, which is given to the child before the doctor's examination by the parents. However, after a chair, the nature of the attacks does not change. A few hours after the onset of the disease, the child has a stool with a large amount of dark blood without feces, but with the obligatory presence of mucus.

Sometimes the discharge from the rectum has the character of a bloody jelly-like mucous mass. In some cases, the presence of blood is determined only after an enema. It should be noted that the release of blood with mucus from the anus is one of the most important signs of intussusception. Typical anamnestic data allow suspecting intussusception with a certain reason. No less valuable information for diagnosis is obtained by the doctor during the examination of the child.

The general condition upon admission to the clinic in the first hours of the disease is usually assessed by the surgeon on duty as moderate (28%) or severe (66%). The skin and visible mucous membranes are somewhat pale or normal in color. The tongue is moist, slightly coated with white coating. The pulse is frequent (100-120 beats per minute), satisfactory filling. Body temperature is normal or subfebrile. The stomach is of the correct shape, not bloated.

Visible peristalsis is usually not observed. Palpation of the abdomen is painless, the tension of the muscles of the anterior abdominal wall is not determined. One of the earliest and most persistent symptoms of intussusception is the presence of a tumor-like formation in the abdominal cavity, which is palpable along the colon (corresponding to the progress of the intussusception), more often in the right hypochondrium. The intussusceptum is palpated as an elongated smooth roller, soft elastic consistency moderately mobile. In most cases, palpation or displacement of the intussusceptum is accompanied by minor pain sensations (short-term anxiety of the child, resistance to examination) or causes a recurrence of an attack of sharp pains.

With the restless behavior of the child, it is extremely difficult to obtain the correct diagnostic data when examining the abdomen. In such cases, it is necessary to find a way to calm the child. You can wait a while until the attack of pain passes and the patient falls asleep. In rare cases (more often with inept examination) it is necessary to resort to short-term anesthesia or to relax the muscles of the abdominal wall by introducing short-acting muscle relaxants. It should be remembered that only an experienced anesthesiologist can use relaxants for the diagnosis of intussusception.

An auxiliary symptom, which is determined by palpation of the abdomen in almost half of infants with cecum-colon and ileo-colon intussusception, is the desolation of the right iliac region due to displacement of the caecum during its implementation.

All children with suspected intussusception should have a digital examination through the rectum. This simple technique often helps the diagnosis, allowing you to detect some of the signs characteristic of intussusception. If the child has an obstruction, then the doctor may sometimes note a noticeable relaxation of the sphincter when inserting a finger into the rectum. This symptom is not permanent, but it should be taken into account in the examination complex. For invagination, the absence of feces in the rectal ampulla (empty ampule) is quite characteristic. With a low location of the intussusceptum, the head of the implanted intestine can be detected with a fingertip. Sometimes, with a bimanual examination, it is possible to palpate a "tumor" that is not determined by simple palpation of the abdomen through the abdominal wall. At the end of the examination, it is very important to look for rectal spotting that stains the finger or appears after it is removed from the anus. The presence of dark blood and mucus without feces can be considered one of the most reliable symptoms of intussusception obtained when examining the rectum with a finger.

The clinical picture performed is typical for early manifestations of intussusception (the first 6-12 hours). If the diagnosis is not made during this period, then in some children the severity of the symptoms of obstruction begins to smooth out (stage III). The behavior of patients changes, they worry less, their cry becomes weak, and the phenomena of intoxication and dehydration increase. Body temperature rises to subfebrile levels. The tongue is dry and covered with a brown coating. There comes an apparent subsidence of the phenomena of obstruction. By the end of the 2nd - beginning of the 4th day of illness, the behavior of the infant bears little resemblance to that noted in the initial stages of intussusception. Sharp periodic anxiety is replaced by complete indifference to the environment. The phenomena of intoxication are increasing. Body temperature rises, pulse is frequent, weak filling. Signs of peritonitis and intestinal paresis appear. The abdomen is swollen, tense, there is no stool, gases do not pass away. By digital examination through the rectum, you can obtain symptoms characteristic of intussusception (flaccid sphincter, empty rectal ampulla, palpation of the head of the intussusception, discharge of blood and mucus behind the removed finger). Plain radiographs of the abdominal cavity show multiple horizontal levels - Kloiber's cups. The diagnosis of intussusception during a late initial examination is usually extremely difficult.

The clinical picture of small intestinal intussusception has some features depending on the severity of neurotrophic disorders in the intestine. The first signs of beginning implantation in infants will be severe anxiety and, as a rule, a high-pitched, loud cry. Older children complain of sharp pain. The child's face turns pale and vomits, usually repeatedly. The duration of anxiety and screaming varies (10–20 min). Then the patient calms down somewhat, but the typical “light” period does not occur, the child does not take the pacifier, refuses the mother’s breast, older children note a subsidence, but not the disappearance of pain.

After a short period of time, a sharp anxiety arises again, the child screams, takes a forced position. Vomiting is repeated, vomit is colored with bile, has an unpleasant fecal odor. Pain attacks after a few hours from the onset of the disease become less prolonged and intense, but the general condition of the patient progressively worsens. The pulse is frequent, weak filling, arterial pressure decreases. The child becomes lethargic, adynamic, groans at times, the body temperature rises to 37,5-38 C. The skin is pale, with a grayish tinge. The stool remains normal for a long time, bloody discharge from the rectum appears after 12-24 hours or later. The abdomen is not swollen, soft. On palpation, the intussusceptum is palpated with certain difficulties, since its location is unstable (usually in the navel), it is mobile and usually of relatively small size. Examination of the abdominal cavity is complicated by persistent pain in the abdomen, in connection with which the child resists examination, actively strains the abdominal press. To identify intussusception in doubtful cases, one should resort to short-term anesthesia.

A digital examination through the rectum provides less information than when inserted into the ileocecal angle. Only the desolation of the rectal ampulla and some relaxation of the sphincter can serve as indirect signs of obstruction. Intussusceptum (even with bimanual examination) is not determined. After the finger removed from the rectum, some stool without blood is usually excreted. Only in the later stages can you get dark ("high") blood with an admixture of mucus.

Clinical picture of colonic intussusception. The introduction of the large intestine into the small intestine is manifested by less pronounced clinical signs than with other types of invagination. Especially erased symptomatology is observed in older children, who rarely show a typical set of signs of intussusception.

In an infant, the disease begins with a mild short-term anxiety. The general condition remains unchanged, pain attacks are relatively rare, there may be a single vomiting. Parents do not always pay due attention to the change in the behavior of the child, and only early (in the first hours from the onset of pain attacks) the appearance of blood in the stool makes you see a doctor. In older children, the onset of the disease may be different.

When examining a patient, it is always possible to feel the invaginate, which is localized in the left upper quadrant of the abdomen or the left iliac region. Finger examination through the rectum often allows you to determine the head of the intussusceptum. A significant amount of raspberry-colored mucus and liquid blood is released behind the extracted finger. Fecal masses, as a rule, do not exist.

In rare cases of the introduction of the distal colon, the head of the intussusceptum falls out through the anus. The mucous membrane of the prolapsed intestine is cyanotic, somewhat edematous, with areas of hemorrhage.

Isolated intussusception of the appendix in clinical manifestations resembles acute appendicitis. The disease occurs mainly in children older than 4-5 years. Typical main signs of intussusception are either absent or not clearly expressed. Isolated invagination of the appendix is ​​manifested by pain in the right iliac region, which at first is usually not very intense. Pain attacks are replaced by short-term relief of pain. However, the child cannot always accurately characterize these "light" intervals, and the doctor does not attach due importance to them. If in the first hours, with a targeted survey, it is possible to establish paroxysmal pain, then after a few hours, they become permanent.

At this time, the child's behavior changes, he refuses food, stops outdoor games that are usual for this age. The general condition remains satisfactory for a long time.

Body temperature is normal. Vomiting is more often single. The stool is normal, urination is painless. The tongue is moist, clean, or slightly coated with white. The pulse is rapid, satisfactory filling.

The abdomen is of the correct form, participates in the act of breathing, on palpation it is soft in all departments, somewhat painful in the right iliac region. Some patients have a slight tension of the rectus abdominis muscles on the right, which becomes more distinct in the later stages from the onset of the disease. Shchetkin-Blumberg's symptom in older children in some cases is mildly positive. Palpation of the lumbar regions is painless. A digital examination through the rectum does not reveal symptoms characteristic of intussusception. There is no bloody discharge from the rectum.

Data from laboratory studies in children with intussusception usually do not represent significant features.

X-ray methods of research

Non-contrast survey radiography of the abdominal cavity does not provide significant assistance in establishing the diagnosis of intussusception and reveals only some indirect signs of obstruction (absence of gas in the large intestine, a homogeneous shadow due to intussusceptum, several loops of the small intestine swollen with gas with the presence of single horizontal levels of fluid). However, a similar x-ray picture in children, especially infancy, can be observed in other diseases. More valuable data for the diagnosis of intussusception is provided by a contrast study of the colon with the introduction of air. An indication for this method of research is a doubt in the diagnosis or the need to clarify the type of invagination, but only in cases where the use of a conservative method of treatment is acceptable (in infants and only in the first 12 hours from the onset of the disease).

Differential diagnosis

Differential diagnosis has to be carried out with diseases accompanied by bouts of abdominal pain, vomiting, bloody discharge from the rectum, the presence of a tumor-like formation in the abdominal cavity. Various combinations of these symptoms at the first examination of a child with intussusception are often mistakenly interpreted by a pediatrician as a manifestation of dysentery, dyspepsia, appendicitis and other acute diseases. This is primarily due to insufficient knowledge of the variants of the clinical picture and the characteristics of the course of invagination, as well as an incomplete examination of the patient. Less often, children are diagnosed with intussusception or other surgical conditions that have similar symptomatology.

In infants, intussusception is most often mistaken for dysentery. In such cases, a carefully collected anamnesis, a correct assessment of the child's behavior and objective examination data almost completely exclude the possibility of diagnostic errors. For dysentery, such an acute onset of the disease that occurs in the midst of complete health is uncharacteristic and is accompanied by severe bouts of abdominal pain, followed by "light" intervals, which is typical for intussusception. Differentiating these diseases, it is necessary to carefully examine the discharge from the rectum.

Dysentery is characterized by the presence of liquid feces and mucus, mixed with lumps of pus, with streaks or blood clots. With intussusception, liquid dark blood with mucus (sometimes in large quantities) is released from the anus, but without feces. A cylindrical (sausage-shaped) formation palpable in the abdominal cavity confirms the diagnosis of implantation. Examination with a finger through the rectum often reveals some spasm of the sphincter in dysentery. With intussusception, you can feel the "head" of the intussusceptum with your fingertip. In rare cases of difficult diagnosis, the use of additional research methods is indicated: palpation of the abdominal cavity under anesthesia, contrast X-ray examination of the colon with air.

Abdominal syndrome in Henoch-Schonlein disease often has manifestations similar to intussusception: sudden attacks of abdominal pain, vomiting, and bloody stools. An erroneous diagnosis of intussusception, entailing a vain laparotomy, significantly worsens the prognosis in Henoch-Schonlein disease. Even more severe consequences are caused by the unrecognized introduction of the intestines, which is observed in hemorrhagic vasculitis. The abdominal syndrome of Shenlein-Genoch disease is characterized by inconstancy and instability of symptoms, while with intussusception they persist and grow. A clinical feature of uncomplicated forms of abdominal purpura can be considered a discrepancy between the severity of the general condition of the patient and local signs of the disease.

Children may vomit with blood, which is uncommon for intussusception. Intestinal bleeding in Henoch-Schonlein disease occurs along with fecal stools, while intussusception is characterized by the presence of blood and a large amount of mucus. The age of the patients should also be taken into account. Intussusception in Henoch-Schonlein disease is most often observed in children after 3 years of age. The main objective symptom of invagination is the presence of a mobile and painful sausage-like tumor in the abdominal cavity. To detect it in restless patients, palpation of the abdomen under short-term anesthesia should be performed.

In older children, intussusception often has to be differentiated from acute appendicitis. This occurs when the most typical symptoms of implantation are absent at the onset of the disease. Symptoms of intussusception in older children are usually less pronounced than in typical cases in infants, however, consistent clinical examination reveals characteristic signs of the introduction of the intestines. In contrast to appendicitis during invagination, abdominal pain is cramping in nature with "light" intervals. Signs of intestinal obstruction (stool retention, gases) are also not characteristic of appendicitis. With intussusception, the abdomen is always soft, while tension in the abdominal wall is the most constant symptom of acute appendicitis. Only with a late admission of the patient, when a child with intussusception develops the phenomena of peritonitis, the differential diagnosis is practically impossible, and the true cause of the catastrophe in the abdominal cavity is clarified during an urgent laparotomy.

Isolated invagination of the appendix is ​​accompanied by a clinical picture similar to that observed in acute appendicitis, which usually leads to misdiagnosis. Cramping pain attacks with short-term intervals of pain relief often occur with appendicitis, and the introduction of the process may be accompanied by local pain on palpation and tension of the rectus muscles of the abdominal wall in the right iliac region; the final diagnosis in such cases is established during the operation.

The most difficult differential diagnosis of intussusception with peptic ulcer of Meckel's diverticulum or intestinal hemangioma. In these diseases, intestinal bleeding is the first and main symptom. Unlike intussusception, bleeding is not preceded by pain attacks, the child remains calm. Older children do not complain about pain. Bleeding is usually so significant that symptoms of acute anemia are soon revealed, not observed during intussusception. The secreted blood from ulcers of Meckel's diverticulum or hemangiomas does not contain mucus, which is characteristic of intussusception. Palpation in the abdominal cavity does not reveal a sausage-like tumor, which can almost always be felt during intussusception (in doubtful cases or when the child is worried, palpation is performed under short-term anesthesia). X-ray examination is of little help in differential diagnosis.

Colon polyposis is often accompanied by massive bleeding. However, the pain syndrome in such children is not observed, the stool remains fecal, with an admixture of scarlet or darker blood with clots; marked anemia. Finger examination through the rectum, sigmoidoscopy and irrigography clarify the diagnosis.

Blockage of the intestinal lumen by a ball of ascaris or a tumor is relatively difficult to distinguish from intussusception. The absence of bleeding through the rectum makes it possible to some extent to doubt the presence of the introduction of the intestines, however, with small intestinal intussusception, blood in the stool may be absent for a long time. The shape and consistency of the tumor palpable in the abdominal cavity have some difference - during intussusception it is oblong, smooth, moderately mobile.

A twisted cyst of the abdominal cavity, in contrast to invagination, is accompanied by non-intensive pains of a permanent nature. There are no pronounced symptoms of intestinal obstruction (gas passes, normal stools). In the first hours of the disease, the cyst can be felt through the abdominal wall. It differs from intussusceptum in its rounded shape and sharp soreness. In later periods, the phenomena of peritonitis develop, the abdomen becomes inaccessible for palpation, which creates serious difficulties for differential diagnosis. An erroneous diagnosis in such cases does not cause serious consequences - both diseases equally need urgent surgical intervention.

Treatment

The main principle of treatment of invagination of the intestines is possibly early disinvagination. Surgical tactics and methods of therapeutic measures depend on the localization and form of implementation, the timing of admission and the age of the child. There are two main methods of disinvagination - conservative and operative. Each of these non-competing methods has strict indications and contraindications, depending on which tactics of individual choice of treatment method are carried out.

Conservative treatment of intussusception is relatively simpler and more atraumatic than the surgical method. It is based on the principle of mechanical action on the intussusception of liquid or air introduced under pressure into the colon. There are a significant number of reports in the literature about the successful use of high enemas with barium suspension, carried out under the control of an X-ray screen. However, the use of this technique is relatively difficult, and the ability to clarify the form of intussusception is limited and it is difficult to determine the fluid pressure that has arisen in the intestine.

In this regard, recently, for the conservative treatment of invagination, mainly dosed air injection into the colon is used. The method recommended by the authors saves the child from laparotomy and possible postoperative complications, reduces the time spent in the hospital. However, as observations and literature data show, conservative treatment should be limited by several factors.

1. Technically, small intestinal intussusception cannot be straightened. The impact of air injected through the rectum (or a suspension of barium sulphate) does not apply with sufficient force to the invaginate located in the small intestine.

2. Ileocolic implantation due to infringement in the Bauhinian valve of the intussusceptum and its edema is not dealt with by conservative measures even at the earliest dates of the child's admission to the clinic. The establishment of this form of invagination is possible only with a sufficiently qualified X-ray examination of the colon with the introduction of air during attempts at conservative treatment.

3. Conservative straightening is dangerous after 12 hours from the onset of the disease or with an unclear history, since necrosis of the intestine in the region of the intussusceptum head is possible. A false impression about the spreading of the introduction can lead in such cases to serious consequences. Later terms of conservative treatment (up to 24 hours) are acceptable in cases of accurate diagnosis of cecum-colon or colonic intussusception.

4. Conservative treatment is ineffective in the presence of mechanical causes that cause invagination (polyps, diverticula). Straightening achieved conservatively in such cases will inevitably be complicated by a relapse of the disease. Due to the fact that mechanical causes occur mainly in children older than 1 year, and the presence of a polyp or diverticulum can be established only when examining the intestine during surgery, we consider conservative treatment of intussusception contraindicated at this age.

5. Recurrence of intussusception of any form and localization should not be dealt with conservatively, since even in infants, re-implantation is usually associated with the presence of mechanical causes, the prompt elimination of which is necessary to prevent a new recurrence of the disease.

Thus, conservative treatment of intussusception is indicated in infants with early admission to the hospital (up to 12 hours from the onset of the disease) and the localization of the intussusceptum head in the colon.

The use of a conservative method is permissible only in a specialized pediatric surgical hospital and only by a surgeon who has sufficient experience in clinical and radiological diagnosis and surgical treatment of intussusception in children.

Conservative treatment of intussusception by injecting air into the colon. 30-40 minutes before the intervention, the patient is injected subcutaneously with a solution of promedol and atropine at the age dosage. Straightening of intussusception produced in the x-ray room. Restless children are given short-term mask anesthesia with nitrous oxide. The child is placed horizontally on the table of the X-ray machine and air is introduced into the colon. Clinically, the straightening of invagination is accompanied by a noticeable improvement in the general condition of the patient. The child ceases to worry, willingly takes the mother's breast, quickly falls asleep. On palpation of the abdomen, the intussusceptum is not determined. The chair appears in 5-12 hours.

Partial expansion is characterized by:

1) preservation of the invaginate shadow on the radiograph with its movement in the oral direction;

2) a change in the contours and shape of the shadow of the invaginate;

3) air filling of the caecum, but the absence of gas in the small intestine. In such cases, the child continues to worry, refuses food. Palpation can sometimes determine the intussusceptum, the size of which becomes smaller and the localization is different (closer to the iliac region).

An unsuccessful attempt at disinvagination is radiologically detected by the presence of a shadow of an invaginate of the original size and shape, located in the same place. The contours of the colon are not completely filled with air, gas in the small intestine is not traced.

The clinical picture after an unsuccessful attempt at conservative straightening of the intussusceptum does not change compared to that before the start of treatment.

In case of an unsuccessful attempt or partial straightening of the intussusception, the child must be immediately transferred to the operating room and proceed with surgical intervention.

The management of the patient after conservative straightening of intussusception does not require special therapeutic measures. The patient is placed in the recovery room for observation. The slightest changes in behavior (anxiety, crying, vomiting) require a careful examination of the child by a surgeon (possible recurrence of the disease or a reviewed partial expansion of the intussusception). An hour later, they begin to give the patient water, if there is no vomiting, they prescribe the usual diet for his age.

Children are discharged home after a conservatively straightened intussusception in 1-2 days. Parents are warned about the need to immediately consult a doctor if the child's anxiety appears.

Preoperative preparation should be short-term and intensive, individually planned for each patient. In rare cases, if the general condition is satisfactory, one should limit oneself to general surgical measures - gastric lavage, drug preparation for anesthesia. If upon admission the child exhibits severe intoxication, dehydration, and peritonitis, then preparation for surgery is carried out within 2-3 hours, aiming to improve the general condition. To do this, a venesection is performed and intravenous administration of 10% glucose solutions and hemodesis begins. At the same time, antipyretics are prescribed (at body temperature above 38 C). The operation is performed under endotracheal anesthesia with controlled breathing and protective blood transfusion.

Postoperative treatment. The patient is placed in an intensive care unit, cardiac medications, broad-spectrum antibiotics, and oxygen therapy are prescribed. All children undergo prolonged epidural anesthesia for 4-5 days to prevent and treat intestinal paresis. Anti-adhesion physiotherapy is prescribed.

The intravenous drip infusion apparatus is left for 1 day, and if parenteral nutrition is necessary, for longer periods.

To detect relatively frequent hyperthermia, the child’s body temperature is measured every 2 hours. An increase in temperature above 38 °C is an indication for antipyretic measures.

Feeding of patients in whom the operation ended with disinvagination begins 6 hours after the intervention. Breastfed children are prescribed expressed human milk 15-20 ml every 2 hours. After a day, in the absence of vomiting and improvement in general condition, 10-15 ml of milk is added to each feeding, bringing to the 4-5th day to a normal amount corresponding to the mass body and age of the child.

These days, the missing amount of fluid is administered intravenously. If vomiting occurs after the first feeding, then the child is prescribed parenteral nutrition for a day, gastric lavage every 3-4 hours, and only after that fractional feeding begins again.

Older children 6-8 hours after the disinvagination operation are allowed to drink warm tea or glucose in the amount of 30-50 ml, prescribing parenteral nutrition at the same time. From the 2nd day, if there is no vomiting, a liquid diet is used, transferring to the postoperative table after 2-3 days, and the usual diet is allowed from the 6-7th day.

For children who underwent resection of the intestine, parenteral nutrition is carried out for three days, allowing them to drink a limited amount of liquid from the second day. Then a liquid postoperative table is prescribed and the diet is continued for up to two weeks. With an uncomplicated postoperative period, the child is discharged on the 12-14th day.

Complications in the postoperative period are observed relatively often. Most of them are associated with late admission of children to the hospital or erroneous surgeon tactics.

Hyperthermia appears in the first hours after surgery due to the adsorption of toxic products from the invaginated segment of the intestine.

Timely preventive measures taken before surgery and at the beginning of the temperature increase, the correct set of pharmacological and physical cooling measures make it possible to eliminate this serious complication in almost all cases.

Intestinal paresis, which occurs due to extensive circulatory disorders of the invaginated intestine, intoxication and, in some cases, peritonitis, was observed in 1/3 of the operated patients.

In advanced cases, when the child has severe intestinal paresis, systematic suction of stagnant contents from the stomach is necessary. Enterostomy with intestinal paresis experts consider contraindicated.

Suppuration of the postoperative wound. The introduction of a rubber graduate into the subcutaneous tissue during surgery for 1-2 days usually limits the possibility of extensive suppuration. However, in some cases, inflammation of the wound develops, despite the ongoing conservative measures. Appear: edema, hyperemia of the skin, the general condition of the child worsens, the body temperature rises.

In such cases, part of the skin sutures is removed and a suction bandage is applied. After the inflammation subsides, the edges of the wound are pulled together with strips of adhesive tape. Healing occurs by secondary intention.

In some cases, suppuration of the postoperative wound can lead to bowel eventration. The main measures to prevent this complication are the fight against intestinal paresis, antibiotic therapy and physiotherapy. The resulting eventration is an indication for urgent surgery under general anesthesia.

Peritonitis in the postoperative period occurs due to the failure of the anastomotic sutures or necrosis of the intestinal wall with an incorrect assessment of its viability during disinvagination. The general condition of the child progressively worsens, the body temperature rises, vomiting occurs, the pulse becomes frequent, the tongue is lined, dry. Exsicosis and intoxication develop.

Increased intestinal paresis. In blood the considerable leukocytosis with shift to the left comes to light. The abdomen is tense, sharply painful on palpation. The diagnosis of peritonitis is an indication for a second laparotomy.

In a severe general condition, a short-term intensive preoperative preparation is prescribed (transfusion of liquids, blood, antipyretics). Surgical intervention is performed under endotracheal anesthesia and protective blood transfusion.

In the postoperative period, broad-spectrum antibiotics are prescribed (parenterally and through irrigators into the abdominal cavity), physiotherapy, systematic gastric lavage, and prolonged epidural anesthesia.

LECTURE No. 14. Adhesive intestinal obstruction

The adhesive process accompanies any inflammation or injury of the abdominal cavity. Any laparotomy, even carried out under aseptic conditions, can be a predisposing moment to adhesion formation due to the inevitable damage to the serous membrane with tampons, surgical instruments. The process of adhesion formation is associated with the ability of the peritoneum to produce an adhesive exudate that appears when the peritoneum is damaged or inflammation.

If there is no infection, then fibrin in the form of thin filaments settles on the damaged surface, and the cellular elements of the exudate undergo evolution and give rise to the formation of elastic and collagen fibers, which, intertwining with fibrin filaments, form a mesh. The surface of the mesh is covered with a thin layer of mesothelium, and thus the peritoneal cover is restored very quickly (in a few hours). In those cases where there is peritonitis, the process of adhesion formation is slower and with various perversions.

There is little fibrin in the exudate in the first hours, and its increase is noticeable by the 4-6th day. The death of the mesothelium during inflammation releases thrombase, under the influence of which fibrinogen is converted into fibrin. Other enzymatic processes lead to the formation of elastic and collagen fibers, which, settling on the damaged surface of the intestine, form a delicate mesh, which is subsequently covered with mesothelium. If for some reason these processes do not occur in a timely manner, then granulation tissue appears in the lesion, which gives rise to planar adhesions. This is facilitated by postoperative intestinal paresis.

In the next 5-7 days, with a favorable course of the underlying disease, adhesions usually resolve spontaneously. However, the process of eliminating planar adhesions can be longer, and then some of them grow into thin blood capillaries. Gradually (by the 4-6th week) separate cord-like adhesions are formed, the fate of which is different. Most of the resulting adhesions due to the restored peristalsis are overstretched, thinned and atrophied. Less commonly, they grow into larger vessels, muscle fibers, nerve elements, and their resorption becomes impossible.

In the postoperative period, in most children, the adhesive process proceeds within the physiological framework and does not cause complications. However, in some cases (especially with persistent intestinal paresis), multiple adhesions stick together intestinal loops, disrupting the passage of contents and creating conditions for the occurrence of obstruction, which is in the nature of obturation. A similar complication of the postoperative period is also observed when the intestinal loops are sealed into the resulting inflammatory infiltrate (abscess) of the abdominal cavity.

Formed cord-like adhesions usually do not manifest themselves, but in some children months or years after surgery, they can cause strangulation intestinal obstruction.

Thus, acute adhesive intestinal obstruction should be divided into two main groups with certain differences in clinical manifestations, surgical tactics and methods of surgical treatment: early adhesive obstruction - obstructive, developing in the first 3-4 weeks after surgery (kinks of intestinal loops and compression by multiple spikes); late adhesive obstruction - strangulation - occurring months and years after surgery (constriction and compression of the intestine by the remaining cord-like adhesions).

Both early and late adhesive obstruction is observed mainly after various acute diseases and injuries of the abdominal organs, less often occurs in connection with "planned" laparotomies. Most often adhesive obstruction complicates acute appendicitis.

1. Early adhesive intestinal obstruction

The occurrence of early adhesive obstruction can occur at various stages of the postoperative period. There is a certain relationship between the timing of the development of complications, its nature and the course of the underlying disease.

clinical picture

In children with severe intestinal paresis and peritonitis, an early adhesive-paretic form of obstruction develops in the first days after surgery. Due to the severe general condition of the patient and the pronounced symptoms of the underlying disease, the symptomatology of obstruction at first is not clearly expressed and develops gradually. The child complains of periodically increasing persistent pain in the abdomen, not much different from those that occurred due to intestinal paresis. Gradually, the pain becomes cramping, vomiting - more frequent and profuse. If a permanent tube was inserted into the child's stomach, then an increase in the amount of aspirated fluid can be noted. Uniform abdominal distension, typical for paresis, somewhat changes its character - asymmetry appears due to individual intestinal loops overflowing with gas. At times, sluggish peristalsis can be traced through the abdominal wall. Auscultatory periodically revealed weak intestinal noise.

Palpation of the abdomen is painful due to existing peritoneal phenomena. Stroking the abdominal wall increases peristalsis and causes repeated bouts of pain. There is no independent stool, after a siphon enema, you can get a small amount of feces, mucus and gases.

X-ray examination helps to confirm the diagnosis of obstruction. Plain abdominal radiographs show multiple horizontal levels and gas bubbles in distended intestinal loops.

In those cases when the phenomena of adhesive obstruction arose against the background of intensive antiparetic therapy (prolonged epidural anesthesia), the diagnosis is greatly facilitated. After the intervention, the child has a gradual improvement in his general condition, the phenomena of paresis begin to subside, and during this period there are cramping pains in the abdomen, vomiting, asymmetric bloating, visible intestinal motility. They stop passing gases. Voiced intestinal noises are clearly auscultated. However, the period of more vivid symptoms of mechanical obstruction is relatively short, and intestinal paresis progresses.

It should be remembered that in the first hours of the onset of adhesive obstruction, each injection of trimecaine into the epidural space increases pain attacks, is accompanied by vomiting, a noticeable revival of the visible peristalsis of intestinal loops located above the site of obstruction.

It is extremely rare that acute intestinal obstruction develops in the first 2-3 days after a relatively mild operation, performed on an urgent basis or in a "scheduled" manner. Symptoms occur suddenly against the background of the usual postoperative condition. The child begins to scream from severe pain in the abdomen. There is vomiting of gastric contents.

On examination, the abdomen is not swollen, sometimes its asymmetry and visible peristalsis are determined. Palpation is somewhat painful. Periodic ringing intestinal noises are heard. There is no chair, gases do not depart. In such cases, the surgeon should think about the resulting concomitant disease - acute mechanical obstruction of the strangulation type.

A simple form of early adhesive obstruction, which develops during the period of subsiding of peritoneal phenomena and improvement in the general condition of the child (5-13 days after surgery), manifests itself most clearly. The child suddenly has paroxysmal pain in the abdomen, the intensity of which gradually increases. Vomiting appears, first with food masses, then with an admixture of bile.

When examining the abdomen, asymmetry is revealed due to distended intestinal loops. From time to time you can observe visible peristalsis, which is accompanied by attacks of pain. Loud bowel sounds are heard on auscultation. By percussion, tympanitis is determined over areas of swollen intestinal loops. Palpation may be accompanied by increased peristalsis and repeated pain attacks. In the intervals between attacks, the abdomen is soft and accessible to palpation. Gases periodically pass, the stool may initially be independent.

Characteristic of a simple form of early adhesive obstruction is the increase in clinical symptoms. After a few hours, the general condition noticeably worsens, vomiting becomes frequent, the child is sharply worried due to bouts of abdominal pain. There are signs of dehydration. The tongue becomes dry, with a white coating. The pulse is frequent. Data from blood and urine tests without features. Plain radiographic images of the abdominal cavity reveal uneven horizontal levels, without characteristic localization.

Attacks of pain can end spontaneously, but more often a temporary cessation of pain is replaced by a repetition of a complex of symptoms of intestinal obstruction. Gases cease to depart, there is no chair.

For early adhesive obstruction caused by an inflammatory infiltrate, a relatively gradual onset is also characteristic. However, the phenomena of obstruction are usually preceded by a deterioration in the general condition of the child, an increase in body temperature. A painful dense infiltrate is palpated in the abdominal cavity. The results of blood tests indicate a purulent process. In rare cases, the infiltrate is formed without a noticeable general reaction on the part of the patient, and then the examination of the child in connection with the phenomena of obstruction makes it possible to diagnose the main cause of the developing catastrophe in the abdominal cavity.

Early delayed adhesive obstruction, which occurred on the 3-4th week of the postoperative period, usually complicates severe, long-term peritonitis. Clinical symptoms in such cases are more often characteristic of simple early adhesive obstruction - they develop gradually, periodically intensifying. However, obstruction may occur in a child who successfully underwent surgery or was discharged home after surgery for acute appendicitis, abdominal trauma. In this case, obstruction usually proceeds with a violent clinical picture and may be due to strangulation by cord-like adhesions.

Treatment

Treatment of early adhesive obstruction requires an individual approach depending on the general condition of the child, the development of the underlying disease, associated complications and the time elapsed since the first operation. In all cases, treatment begins with a set of conservative measures, which, being a preoperative preparation, relatively often make it possible to eliminate obstruction.

The most difficult and responsible task of the surgeon is to correctly determine the acceptable terms of conservative treatment and, if it is ineffective, to choose a rational method of surgical intervention.

Conservative treatment begins after identifying the earliest signs of adhesive obstruction. In all cases, oral feeding is stopped, a set of measures is prescribed that enhance intestinal motility, prevent intoxication and dehydration, and also increase the body's reactive forces. The intensity and duration of conservative treatment depends on the general condition of the child, the presence and stage of intestinal paresis, as well as the timing of the onset of symptoms of early adhesive obstruction.

If a complication arose in the first days after surgery against the background of existing peritonitis and severe intestinal paresis II-III degree, then conservative treatment should primarily be aimed at eliminating or reducing the paretic component of obstruction.

If in the postoperative period, antiparetic measures included prolonged epidural anesthesia, then usually by the time the child develops adhesive obstruction, intestinal motility is partially restored. In such cases, the introduction of trimecaine into the epidural space is continued at the usual time, and at the same time other therapeutic measures are carried out: the stomach is washed with a 2% soda solution, a siphon enema is administered, a hypertonic saline solution and prozerin are administered intravenously. A similar complex is repeated every 2,5-3 hours.

It is more difficult to carry out conservative treatment with the development of adhesive obstruction in children in whom prolonged epidural anesthesia was not used in the postoperative period. In such cases, treatment begins with puncture of the epidural space and administration of trimecaine. At the same time, the stomach is washed, a siphon enema is given and general strengthening measures are carried out. Only after 3-7 blockades (after 7-12 hours) there is usually some improvement in the general condition, and noticeable intestinal motility appears. At the same time, the amount of gastric contents sucked through the tube decreases somewhat. From this time on, the child, simultaneously with the epidural blockade, is prescribed medications that enhance intestinal motility (hypertonic solutions, proserin), gastric lavage and siphon enemas are continued, i.e., the entire complex of conservative treatment begins. In the presence of mechanical obstruction, this contributes to the appearance of characteristic symptoms of ileus - the child begins to periodically worry, complain of increased attacks of pain, abdominal asymmetry appears, and sometimes visible peristalsis.

In children with adhesive obstruction and severe intestinal paresis, conservative measures continue for at least 10-12 hours. If during this period the pain attacks increase or remain the same intensity, then an operation is prescribed. In cases where a noticeable improvement in the general condition has occurred, pain has decreased and the amount of sucked gastric contents has decreased, or gases have disappeared with a siphon enema, treatment is continued for another 10-12 hours. Remaining by this time or recurring symptoms of obstruction require surgical intervention.

Early adhesive obstruction that occurs during the period of subsiding of peritoneal phenomena and improvement in the general condition of the child is also subject to conservative treatment. First, the patient is washed with a stomach and put a cleansing, and then a siphon enema. If, at the same time, gases have not passed and stool has not been obtained, prolonged epidural anesthesia is started. After the introduction of the "dose of action" of trimecaine, intravenous prozerin, a hypertonic saline solution are prescribed, a siphon enema is repeated, and the stomach is washed. All these activities are usually accompanied by some increase in pain (sometimes repeated vomiting) due to the activation of intestinal motility. However, in 1/3 of the children, after 2-3 courses of such therapy, the obstruction phenomena subside, in such cases, conservative measures continue up to 18-24 hours, and they can end with the complete elimination of the complication. If during the first 5-6 hours conservative treatment does not bring relief to the child or has only a temporary effect, relaparotomy is indicated.

The same tactics are followed for early adhesive obstruction that has arisen with limited peritonitis due to the emerging infiltrate of the abdominal cavity.

If obstruction occurs on the 3-4th week of the postoperative period, the strangulation nature of the ileus is possible. In this regard, short-term intensive conservative therapy is allowed. The patient is washed with a stomach, put a siphon enema. In rare cases, the phenomena of obstruction are eliminated, but usually there is no improvement in the condition, and the child is prescribed an operation.

Operative treatment. The volume and nature of the surgical intervention are determined by the form of early adhesive obstruction. It should be remembered that the separation of multiple planar adhesions and the simultaneous "radical" elimination of obstruction is the most risky operation. The inevitable damage of the organized adhesions and the serous cover of the intestine during this intervention creates conditions for the rapid spread of the adhesive process and the recurrence of obstruction. At the same time, if planar "fresh" adhesions are not injured, then with active anti-inflammatory and physiotherapeutic treatment, their reverse development in children occurs relatively quickly. Therefore, in case of early adhesive obstruction, the most correct surgical intervention is the formation of a temporary enterostomy with the expectation of resorption of adhesions and spontaneous restoration of the normal passage of intestinal contents.

Surgery for early adhesive obstruction is performed under endotracheal anesthesia and protective blood transfusion.

postoperative treatment. All children are given prolonged epidural anesthesia for 4-5 days, and in the presence of an adhesive-paretic form of obstruction, medications are additionally prescribed that enhance intestinal motility. Continue intensive treatment of the underlying disease. Parenteral nutrition is carried out by drip infusions into the subclavian vein. From the 2nd day, anti-adhesion physiotherapy is prescribed.

In the presence of an enterostomy, the wound is toileted several times a day and the skin is treated with zinc paste. Sterile napkins are placed on the fistula (do not bandage), which are changed as they get wet and dirty.

When a normal stool appears (intestinal patency is restored), the fistula is covered with fatty bandages and bandaged. More often, the enterostomy closes on its own, in some cases it is necessary to eliminate the intestinal fistula by surgery.

From the 4th-5th day after the operation of turning off the intestine sealed into the infiltrate, they begin to inject a 5% glucose solution through the fistula (15-20 ml every 2-3 hours), then the amount of liquid is increased to 30-50 ml.

When the patency of the disconnected section of the intestine is restored, nutrient solutions of 3-4 ml (broth, glucose, cream) are slowly introduced through the fistula 100-150 times a day, which are partially absorbed. Children are discharged after the stool normalizes.

Parents in the clinic are specially trained in the proper care of the child. Repeated examinations by the surgeon are necessary every 2-3 weeks before referral to stage II of the operation.

2. Late adhesive intestinal obstruction

Late adhesive obstruction usually develops several months or years after the transferred laparotomy among the full health of the child. Less often, obstruction is preceded by periodic pain attacks in the abdomen or other symptoms of discomfort associated with adhesive disease.

clinical picture

The child suddenly develops severe cramping pains in the abdomen. Soon the vomiting starts. Attacks of pain become sharp and frequent. Small children periodically scream worried, take a forced position. There is no chair, gases do not depart.

The abdomen is asymmetrical due to the protruding swollen loop of the intestine. Peristalsis is clearly visible, which increases when the abdominal wall is stroked. Initially, the abdomen is painless on palpation. Percussion determined moving tympanitis.

A digital examination of the per rectum shows some relaxation of the sphincter of the anus and an empty ampoule of the rectum. Colorless mucus or a small amount of feces may pass behind the finger. The general condition of children with late adhesive obstruction rapidly worsens due to dehydration, intoxication and adjoining intestinal paresis.

X-ray examination

X-ray examination helps the diagnosis. Plain abdominal radiographs show horizontal levels and low levels of gas in the lower regions.

Differential diagnosis

Differential diagnosis is carried out with other types of acute intestinal obstruction. Anamnesis data (transferred laparotomy) or a postoperative scar on the anterior abdominal wall found during examination usually allows you to correctly resolve the issue of the causes of obstruction.

Treatment

Treatment of late adhesive obstruction, as a rule, should be prompt. Delay in surgical intervention can lead to necrosis of the intestinal wall due to the likely strangulation of cord-like adhesions.

Preoperative preparation. If the patient was admitted within the first 12 hours after the onset of obstruction symptoms and his general condition is regarded as satisfactory, then preoperative preparation should simultaneously serve as a conservative treatment of obstruction.

Gastric lavage, siphon enema, prozerin are prescribed, bilateral perirenal novocaine blockade according to A. V. Vishnevsky is performed.

If during the period of 2-3 hours of treatment the pain in the abdomen does not stop, the stool is not obtained and the gases are not removed, the child is operated on. In cases of complete resolution of the phenomena of obstruction, the patient is left in the clinic for active observation and anti-adhesion therapy.

With late admission, the general condition of children is usually severe. In such cases, intensive treatment is begun, aimed at eliminating exicosis and intoxication. Install the device for intravenous drip infusion. At the same time, a clinical and biochemical blood test is performed, the state of the acid-base state is determined.

According to the indications, cardiac agents, oxygen therapy are prescribed. Produce gastric lavage and siphon enema. Improving the general condition, reducing intoxication and dehydration allow you to proceed with the operation. Preoperative preparation is carried out no more than 2-3 hours.

postoperative treatment. The child is given epidural anesthesia for 3-5 days (in the presence of paresis of II-III degree, the whole complex of antiparetic therapy is performed), hormones are prescribed at an age dosage (2-3 days), antibiotics (5-7 days) and cardiac drugs (according to indications) . In cases of severe paresis or bowel resection, parenteral nutrition is indicated for 3-4 days.

All children from the 2nd day undergo physiotherapy (5 days of UHF currents, then iontophoresis with KI). From the 2nd day (if the operation was not accompanied by bowel resection), the patient is allowed to drink and a liquid table is prescribed. After the discharge of the child, anti-adhesion physiotherapy and long-term dispensary observation are indicated.

LECTURE No. 15. Dynamic intestinal obstruction

In emergency surgery of childhood, a special place is occupied by dynamic intestinal obstruction, which can occur after surgical interventions or accompany a number of surgical and other diseases.

The cause of dynamic intestinal obstruction has not yet been elucidated. It is believed that the basis of dynamic obstruction is a violation of regional mesenteric circulation, a change in the excitability of the peripheral and central nervous apparatus that regulates the motor function of the intestine.

The state of parabiosis of the neuromuscular structures of the intestine develops as a result of a violation of the blood circulation of its wall. Circulatory disorders can be the result of an inflammatory process (peritonitis), overstretching of the intestinal wall, dehydration and hypoxemia of various origins.

As a result of inflammation and edema, functional and then organic damage to nerve devices develops, followed by a decrease in the susceptibility of the intestinal muscle elements to natural mediators of motor regulation.

The excitability of the neuromuscular apparatus of the intestine also decreases with the pathology of electrolyte metabolism (potassium and sodium deficiency) and with changes in body temperature.

Dynamic intestinal obstruction can be considered as an independent nosological unit in those cases when it occupies a leading place in the clinical picture of the disease and when it becomes necessary to exclude mechanical obstruction that requires urgent surgical intervention.

Among all types of intestinal obstruction in children, dynamic obstruction is 8-11%. It is customary to distinguish between spastic and paralytic forms of dynamic intestinal obstruction.

1. Spastic intestinal obstruction

Spastic intestinal obstruction is relatively rare. Usually the cause of its occurrence is helminthic invasion.

clinical picture

The clinical picture of spastic intestinal obstruction is characterized by the occurrence of short-term attacks of severe pain in the abdomen without a specific localization. In the vast majority of cases, the general condition of the child remains satisfactory.

Body temperature is normal or subfebrile. Sometimes there is a single vomiting. Gases usually move away, there is no stool, but it may be normal.

The abdomen is not swollen, symmetrical, sometimes sunken, on palpation - soft in all departments; in rare cases, it is possible to determine a spasmodic intestine. Auscultation clearly revealed peristaltic noises. There are no changes in hemodynamics. Blood and urine tests - no pathology.

X-ray examination

X-ray examination of the abdominal cavity has only differential diagnostic value.

Differential diagnosis

The differential diagnosis is carried out with mechanical obstruction and renal colic.

In cases of acute and severe intestinal spasms, it is sometimes difficult to exclude mechanical obstruction. A carefully collected history (indication of existing ascariasis) and objective examination data (lack of visible peristalsis, local pain or tumor-like formations) allow us to think about intestinal spasm.

Of certain importance is an x-ray examination of the abdominal cavity, which, with mechanical obstruction, helps to recognize the disease. Significant assistance in the diagnosis is provided by bilateral pararenal blockade or short-term epidural anesthesia.

The persistent disappearance of pain after the blockade makes it possible to exclude mechanical intestinal obstruction, in which pain attacks do not go away, but often intensify. In doubtful cases, surgery should be considered as a last resort.

Renal colic, in contrast to spastic obstruction, proceeds with excruciating attacks of pain, which are localized in the lumbar regions and are usually accompanied by typical irradiation.

In addition, dysuric disorders and pathological urinalysis are characteristic of renal colic, and shadows of calculi can be detected on plain x-rays.

Treatment

Treatment of spastic obstruction usually consists of conservative measures. The child is prescribed antispastic agents, a cleansing enema, and a heating pad is placed on the stomach. In most cases, this is enough to relieve pain.

In severe cases, a bilateral pararenal blockade according to A.V. Vishnevsky or prolonged (1-2 days) epidural anesthesia is performed several times. The cause of spastic obstruction (ascariasis, etc.) identified during the examination of the child is an indication for appropriate treatment (under the supervision of a surgeon).

2. Paralytic ileus

Paralytic ileus, which is the most frequent and serious complication of the postoperative period, has the greatest practical significance in emergency surgery in children.

In the presence of peritonitis (even after the elimination of the source of its origin), intestinal paresis in most cases acquires a leading role in a complex chain of developing systemic and local disorders.

The increased intra-intestinal pressure resulting from paresis exacerbates circulatory disorders in the intestinal wall.

Functional changes in intra-intestinal nerve endings are replaced by their organic damage.

Loss of fluid, proteins, electrolytes in the intestinal lumen, a violation of the absorption process in it, leading to hypovolemia. corresponding disorders of central and peripheral hemodynamics.

The permeability of the intestinal wall increases, and there is a risk of secondary infection of the abdominal cavity. Dehydration, bacteremia close the resulting vicious circle, which is the more difficult to break, the more time has passed since the onset of paresis.

The failure of conservative treatment of postoperative intestinal paresis is mainly due to the following reasons:

1) insufficient assessment of systemic disorders that occur with paresis and their role in maintaining it;

2) the lack of sufficiently clear ideas about the nature of local pathophysiological disorders developing in the intestinal wall;

3) irrational treatment, ignoring the staging of systemic and local disorders in the clinical course of postoperative paresis.

The restriction of intestinal motor function that occurred after the operation should probably be considered as a biologically justified, reflex protective reaction that develops in response to bacterial, mechanical or chemical irritation of the peritoneum and nerve endings of the abdominal organs.

The chain of this reflex can be closed not only in the higher ones. but also in the spinal regions of the central nervous system. The latter, obviously, is responsible for the occurrence of intestinal paresis in pneumonia, trauma and inflammatory processes of the urinary tract.

In accordance with modern pathophysiological views, it is believed that, regardless of the causes that caused intestinal paresis, two interrelated circumstances contribute mainly to maintaining it: the degree of disturbances in the peripheral nervous apparatus and the severity of microcirculation disorders in the intestinal wall.

clinical picture

Stage I occurs immediately after surgery. At this stage of paresis, there are no organic changes in the intramural plexuses; microcirculatory changes in the intestinal wall are transient (spasm of arterioles and metaarterioles with arteriovenous shunting in the intestinal vessels).

The general condition of patients, indicators of hemodynamics and external respiration, shifts in water and electrolyte balance are due to the trauma and duration of surgery and are not threatening in case of replenished blood loss.

The abdomen is moderately, evenly swollen; during auscultation, peristaltic noises, uneven in strength, are clearly heard throughout; vomiting is frequent (with light stomach contents) or rare (with a small admixture of duodenal contents). It is possible that this stage of paralytic ileus is preceded by a spastic stage, but it cannot be detected clinically in a postoperative patient.

II stage. With it, along with functional, there are also organic changes in the peripheral nerve devices, due to more pronounced microcirculation disorders.

The general condition of the patients is severe. Children are restless, there is shortness of breath, tachycardia; blood pressure is kept at normal levels or increased.

The study of water and electrolyte balance reveals: hyponatremia, hypochloremia, in some cases hypokalemia; BCC is reduced to 25% in comparison with the initial data, mainly due to plasma volume.

The abdomen is significantly swollen, with auscultation it is occasionally possible to listen to sluggish single peristaltic noises; vomiting of duodenal contents is often repeated.

III stage. In this stage of paresis, morphological changes in the nervous apparatus of the intestinal wall and abdominal autonomic nerve plexuses predominate; microcirculatory changes are characterized by paretic expansion of precapillaries and pathological deposition of blood in the capacitive veins. The general condition of the patients is very serious.

Children are rarely excited, more often inhibited. Severe tachycardia and tachypnea, a decrease in systolic blood pressure to 90 mm Hg are noted. Art. and lower, oliguria up to anuria, Biochemical studies reveal: a decrease in BCC ranging from 25 to 40% compared with baseline data, hyponatremia, hypochloremia, hypokalemia, a shift in CBS towards metabolic acidosis (in children under the age of one year, quite often metabolic alkalosis).

The abdomen is sharply, evenly swollen, sometimes rises above the costal arches; during auscultation, it is not possible to listen to peristalsis throughout its entire length - "dumb stomach".

With percussion, dullness in sloping places is most often determined; the latter is more due to the accumulation of fluid in the lumen of the stretched loops ("heavy intestine") rather than its presence in the free abdominal cavity. This stage of paresis is characterized by vomiting with an admixture of stagnant intestinal contents.

Stages II and III of intestinal paresis are most often a manifestation of peritonitis, which continues to develop, despite the prompt elimination of the source of its occurrence. Therefore, the treatment of advanced intestinal paresis is almost identical to the treatment of peritonitis.

The clinical picture of paralytic ileus that develops in children with severe toxicosis of any etiology usually corresponds to a condition characteristic of the stage

Differential diagnosis

The differential diagnosis is carried out with early postoperative adhesive obstruction.

Mechanical obstruction differs from the paralytic acuteness of its first manifestations (cramping abdominal pain, vomiting, gas and stool retention, increased intestinal peristalsis).

It is much more difficult to diagnose early postoperative adhesive obstruction 8 hours or more after its onset, when there is no or almost no symptom of visible peristalsis. L. M. Roshal in such cases recommends the use of contrast irrigography.

The presence of a collapsed colon indicates mechanical obstruction; its normal or enlarged diameter makes it possible to suspect intestinal paresis.

In complex cases, for differential diagnosis, a set of measures aimed at restoring the motor-evacuation function of the intestine should be carried out; after repeated epidural blockades (2-3 with an interval of 2-2,5 hours), inject the child intravenously with the age dose of prozerin.

With dynamic obstruction, the patient's condition improves, vomiting stops, gas discharge is restored, and sometimes stools pass.

With mechanical obstruction, after the measures taken, abdominal pain and bloating increase, vomiting becomes more frequent, and gas and stool do not pass.

Treatment

Treatment of paralytic ileus consists of the correction of systemic disorders of homeostasis and the fight against local manifestations of paresis. In the elimination of systemic disorders, the leading role belongs to rational infusion therapy.

Measures for the treatment of local manifestations of paresis can be conditionally divided into three groups.

1. Activities aimed at passive evacuation of stagnant contents: constant probing of the stomach; operational methods of decompression of the intestine by probing it through the gastrostomy, through the enterostomy, through the cecostomy, retrograde insertion of the probe through the rectum.

2. Activities aimed at enhancing intestinal motility due to the direct activation of its neuromuscular apparatus:

1) strengthening the tone of parasympathetic innervation with the help of cholinesterase inhibitors (prozerin), M-cholinomimetics (aceclidin);

2) activation of the smooth muscles of the intestine (pituitrin);

3) strengthening of local reflexes: enemas, intestinal electrical stimulation;

4) the impact on the intestinal osmoreceptors by intravenous administration of a hypertonic solution of sodium chloride sorbitol, sormantol.

3. Measures aimed at improving regional blood flow, interrupting the flow of pathological impulses from the inflammatory focus and creating "functional rest" of the intestine:

1) repeated one-time perirenal blockades; prolonged pararenal blockade;

2) repeated introduction into the abdominal cavity of a 0,25% solution of novocaine;

3) intramuscular and intravenous administration of gangliolytics;

4) prolonged epidural blockade;

5) hyperbaric oxygenation.

In the treatment of late-stage paresis, continuous transnasal intubation of the stomach is an indispensable condition as long as the stagnant nature of the contents persists. It is necessary to take into account the volume of losses every 6 hours and adequately replenish it during parenteral nutrition.

Fractional feeding with liquid food with a gradual expansion of the diet (taking into account the underlying disease and the nature of the surgical intervention) begins only after the elimination of congestion in the stomach.

The use of group II measures in children with stage III paresis only aggravates it and may eventually force the surgeon to perform an extremely risky and unjustified relaparotomy.

To restore impaired bowel function, regional vegetative blockades (perinephric, epidural) are of paramount importance. The antiparetic effect of epidural blockade is most pronounced with its prophylactic use.

In this regard, prolonged epidural anesthesia is absolutely indicated in all children operated on for peritonitis, intestinal obstruction and other severe diseases of the abdominal organs.

When using prolonged epidural anesthesia in children operated on for peritonitis, the effects of intestinal paresis of stage II-III stop in the vast majority of cases no later than 2 - the beginning of 3 days.

Prolonged epidural blockade leads to the restoration of the motor-evacuation function of the intestine in the first days after surgery and thus largely prevents the increase in intoxication.

The beneficial effect of epidural blockade in the treatment of postoperative paresis is due to the following factors:

1) long-term regional sympathetic blockade;

2) anesthesia and reduction of intra-abdominal pressure by reducing muscle tension;

3) a distinct effect of enhancing intestinal motility and early recovery of its motor-evacuation function.

It is difficult to overestimate the importance of any of these factors. However, the first one is the most important.

Only in the case when regional sympathetic blockade is achieved during epidural anesthesia, one can count on the maximum effect in the treatment of late stages of paresis and peritonitis.

Moreover, by analogy with the known effect of perinephric blockade according to A.V. Vishnevsky, epidural anesthesia actively affects the inflammatory process in the abdominal organs by eliminating vasospasm and improving microcirculation in the intestinal wall and peritoneum.

The maximum blockade of sympathetic innervation to the greatest extent contributes to the activation of parasympathetic activity, leading to an increase in intestinal motility.

To achieve regional sympathetic blockade during epidural anesthesia (if it is used to treat late stages of paresis), it is necessary that the injected anesthetic block the roots of the IV-XI thoracic spinal segments - the site of formation of the celiac nerves. As you know, the large, small and smallest celiac nerves make up the sympathetic portion of the celiac plexus - the main autonomic center for regulating trophism and motor function of the intestine.

Systematic X-ray monitoring and analysis of treatment results revealed a clear regular dependence of the antiparetic effect on the level of the end of the catheter inserted into the epidural space.

The most optimal is the location of the inner end of the catheter, introduced into the epidural space, at the level of IV-V thoracic vertebrae.

In children under the age of 3 years, this is achievable with puncture and catheterization in the lower thoracic region; due to the small size of the peridural space, the injected anesthetic will also cover the upper thoracic segments.

In older children, it is necessary to catheterize the epidural space at the level of the VI-VIII thoracic vertebrae.

Currently, in all cases, X-ray control of the location of the catheter inserted into the epidural space is performed.

In order to contrast the catheter during radiography, it is necessary to introduce any water-soluble contrast agent (urotrast, diode, verografin) into its lumen at the rate of 0,1-0,15 ml of the solution for every 20 cm of the catheter length; preference should be given to radiopaque catheters.

The location of the catheter shadow medial to the base of the transverse processes on the direct image and in front of the base of the spinous processes on the lateral one suggests that the catheter is in the projection of the bony spinal canal.

The absence of symptoms of a spinal block after the introduction of a "dose of action" of trimecaine indicates the location of the catheter in the epidural space.

With x-ray confirmation of the location of the catheter in the epidural space at the appropriate level (IV-VI thoracic vertebrae), the complete absence of signs of resolution of intestinal paresis after successive 6-8 epidural blockades allows us to assume with a high degree of probability the occurrence of a situation requiring repeated surgical intervention (mechanical obstruction). Equally, this provision applies to cases of resumption of intestinal paresis after its temporary resolution in the early stages.

Authors: Drozdov A.A., Drozdova M.V.

We recommend interesting articles Section Lecture notes, cheat sheets:

▪ Medical statistics. Crib

▪ Teria of the organization. Crib

▪ History of world and domestic culture. Crib

See other articles Section Lecture notes, cheat sheets.

Read and write useful comments on this article.

<< Back

Latest news of science and technology, new electronics:

Artificial leather for touch emulation 15.04.2024

In a modern technology world where distance is becoming increasingly commonplace, maintaining connection and a sense of closeness is important. Recent developments in artificial skin by German scientists from Saarland University represent a new era in virtual interactions. German researchers from Saarland University have developed ultra-thin films that can transmit the sensation of touch over a distance. This cutting-edge technology provides new opportunities for virtual communication, especially for those who find themselves far from their loved ones. The ultra-thin films developed by the researchers, just 50 micrometers thick, can be integrated into textiles and worn like a second skin. These films act as sensors that recognize tactile signals from mom or dad, and as actuators that transmit these movements to the baby. Parents' touch to the fabric activates sensors that react to pressure and deform the ultra-thin film. This ... >>

Petgugu Global cat litter 15.04.2024

Taking care of pets can often be a challenge, especially when it comes to keeping your home clean. A new interesting solution from the Petgugu Global startup has been presented, which will make life easier for cat owners and help them keep their home perfectly clean and tidy. Startup Petgugu Global has unveiled a unique cat toilet that can automatically flush feces, keeping your home clean and fresh. This innovative device is equipped with various smart sensors that monitor your pet's toilet activity and activate to automatically clean after use. The device connects to the sewer system and ensures efficient waste removal without the need for intervention from the owner. Additionally, the toilet has a large flushable storage capacity, making it ideal for multi-cat households. The Petgugu cat litter bowl is designed for use with water-soluble litters and offers a range of additional ... >>

The attractiveness of caring men 14.04.2024

The stereotype that women prefer "bad boys" has long been widespread. However, recent research conducted by British scientists from Monash University offers a new perspective on this issue. They looked at how women responded to men's emotional responsibility and willingness to help others. The study's findings could change our understanding of what makes men attractive to women. A study conducted by scientists from Monash University leads to new findings about men's attractiveness to women. In the experiment, women were shown photographs of men with brief stories about their behavior in various situations, including their reaction to an encounter with a homeless person. Some of the men ignored the homeless man, while others helped him, such as buying him food. A study found that men who showed empathy and kindness were more attractive to women compared to men who showed empathy and kindness. ... >>

Random news from the Archive Casio watch in the style of the series Stranger Things 28.05.2023 Casio has announced the A120WEST, a Netflix collaboration inspired by the mega-hit "Stranger Things". Stranger Things is a Netflix action adventure series set in the small American town of Gokins, Indiana in the 1980s. One day, a 12-year-old boy goes missing in the city. His friends, family and the local police search for answers, but find a little girl with the number 011 on her wrist and become involved in unraveling an extreme mystery involving top-secret experiments, terrifying supernatural forces, monsters and the world of Dogoridrigo. The design of the new watch contains many references to the culture of the 1980s and to the series itself, especially to the alternate dimension Dogoridrigo, which exists in parallel with the human world. The dial depicts the world of Marvelous Wonderland characters, the bright buttons on the front are reminiscent of the 1980s, and the Demogorgon in the center. Pressing the LED illuminated button brings up the name of the series printed upside down, hinting at the presence of another world on the other side. The back of the case and the translucent strap depict eerie tentacles extending from the underworld. Four seasons of Stranger Things are now available to watch worldwide on Netflix. The decisive, fifth, is still a long time to wait - it is expected to be released closer to the summer of 2024. But there is a plus in this - there is time to review the first four. Even several times.

Other interesting news:

▪ Controller Renesas R9A02G011

▪ The air in the subway destroys the human body

▪ MicroCHIPS implantable chip successfully tested in humans

▪ smallest satellite telescope

▪ TDA8939TH - class D digital amplifier

News feed of science and technology, new electronics

Interesting materials of the Free Technical Library:

▪ section of the site Wonders of nature. Article selection

▪ article Folding table. Tips for the home master

▪ article What does the moon smell like? Detailed answer

▪ article Finisher of furniture parts, engaged in gluing parts on pneumatic clamps with conductive heating. Standard instruction on labor protection

▪ article Summary table of wire cross-sections, current, power and load characteristics. Encyclopedia of radio electronics and electrical engineering

▪ article Telepathic Cube. Focus Secret

Leave your comment on this article:

All languages ​​of this page

Arabic	Hebrew	Polish
Bengali	Hindi	Portuguese
Chinese	Italian	Spanish
English	Japanese	Turkish
French	Korean	Ukrainian
German	Malay	Vietnamese

Home page | Library | Articles | Website map | Site Reviews

www.diagram.com.ua
2000-2024