Ministry of health of Ukraine

SELF extracurricular WORK STUDENTS



RARE BUGS IN CHILDREN

1. Background.

The frequency of congenital malformations is 0,1-1,9 New-born in 1000. It is noted 2-fold increase in the frequency of complex limb malformations in children in the last 10 years. The incidence of severe limb malformations increased from 18 to 64%.
Effects of treatment and the percentage of disability in children with developmental disabilities depend on timely treatment is started, the activities of medical, social and vocational rehabilitation. The knowledge students main groups of rare malformations significantly improve diagnosis and treatment of children.

2. Specific objectives:

1. Analyze the causes of malformations and syndromes in children.
2. Offer classification malformations, anomalies.
3. Interpret the basic principles of diagnosis and treatment of children with congenital malformations.
4. Identify the basic principles of rehabilitation of children with disabilities.

4.2. Theoretical questions to studies.

1. The concept of a bug, anomaly.
2. Etiology and pathogenesis of birth defects in children.
3. International Classification of malformations in children.
4. Rare limb malformations in children, classification and treatment.
5. Webbing, classification and methods of treatment.
6. Polydactyly, treatments.
7. Congenital synostosis, talipomanus are presented, methods of treatment.
8. Preventing defects.
9. Medical, social and vocational rehabilitation of children with disabilities.

TOPICS CONTENTS.

Among all defects is one of the first places are anomalies of the musculoskeletal system, with 3/4 to account for limb malformations.
International Classification
malformations of the musculoskeletal system includes 7 groups:
I. Anomalies resulting from failure of formation of parts of limbs. This group includes the following defects of the extremities.
Amelia - the complete absence of limbs (excluding the shoulder girdle and pelvis). There are upper and lower Amelia, in particular the absence of the two upper limbs (abrahiya), one upper extremity (monobrahiya), the two lower limbs of one lower limb (monopus)
Fokomeliya (tyulenopodibni limbs) - no proximal or middle parts of the limbs and the corresponding joints (shoulder, hip).
There proximal, distal and complete fokomeliyu. Proximal fokomeliya - no shoulder or hip, distal - no forearm (radioulnarna form) or leg (tibiofibulyarna form), complete fokomeliya - lack of arm and forearm or thigh and shin.
According fully formed hand or foot may depart directly from the trunk (full fokomeliya), connect it with the stored forearm bones, the tibia (proximal form) or attached to the shoulder, thigh (distal form).
Fokomeliya are one-and two-way, sometimes the process involved all four limbs.
Peromeliya - fokomelii option, combined with hypoplasia of the hands or feet. There are full (arm or leg is missing, the relevant department of the trunk ends a rudimentary finger or cutaneous projection) and incomplete (shoulder or hip underdeveloped, ending as a rudimentary finger or cutaneous projection).
There are also radial and ulnar talipomanus are presented, aplasia of the tibia, fibula aplasia, adaktiliya - no finger afalanhiya - no phalanx, monodaktyliya - the presence of one finger on the hand or foot, aheyriya - no brushes.
Splitting brush (ektrodaktiliya, kleshnopodibna brush "brush lobster") - aplasia of the central components of the hand (fingers and metacarpal bones often) with groove (cleft) in place of missing bones. There are typical and atypical forms. A typical form is characterized by aplasia III finger and (often) of the metacarpal bone, and (sometimes) the distal carpal row, hence the presence of a deep cleft. Atypical cleft appears hypoplasia (sometimes lack of) middle finger components hand or foot. In the atypical form of cleft shallow, but broad, sometimes it looks too wide interdigital gap. More common splitting right hand.
II. Anomalies resulting from insufficient differentiation of parts of the limb. These include malformations scapula (shoulder blade navicular raised shoulder), synostosis, sindaktylii, brahidaktyliya, congenital clubfoot, congenital hip dislocation, arthrogryposis, klinodaktyliya - shortening of the middle phalanx of fingers (usually thumb V), of course that is an integral component of syndromes of multiple malformations development, especially chromosome.
Kamptodaktyliya (kampilodaktyliya) - flexion contracture of proximal interphalangeal joints of fingers. The process can involve any finger except I. Rare.
Sirenomelia (simpodiya, simmeliya, caudal regression syndrome) - fusion of the lower limbs. Mergers may relate to soft tissue and (usually) some long bones, and accompanied by hypo-or aplasia of certain bones of the extremities and pelvis. Feet can be absent (sympus apus), are formed by two (sympus dipus) or one foot (sympus monopus). Sometimes there is one rudimentary foot with a single finger. Sirenomelia accompanied by aplasia of the external and internal genital organs, urinary system aplasia, atresia zadnoprohodnoho hole and rectum.
III. Anomalies caused by doubling: polydactyly, diplopodiya - doubling feet, polimeliya - increasing the number of lower extremities. Polimeliya be symmetric and asymmetric, usually combined with defects incompatible with life.
IV. Anomalies caused by excessive growth. Does the makotorodaktyliyu and gigantism limb (partial gigantism, unilateral makrosomiya, hemihipertrofiya) - extremely rare defect that appears on unilateral increase proportionally developed limbs.
V. Anomalies caused by insufficient growth. These include abnormalities manifested hypoplasia different parts of the bones of the extremities.
VI. Congenital constriction - a malformation of the amnion as a tissue strands that are within plodovmestylyscha and interconnect fetal surface litter the surface of the fruit, different points of fruit surface litter and a few points on the surface of the fruit.
VII. Generalized (systemic) skeletal deformity. They are based on a violation of embryogenesis connective tissues, including bone. This group includes hondrodysplazii (hondrodysplaziya) osteodysplazii.
Clinical manifestations of defects and prognosis depend largely on how vital the diseased organ, the degree of violation of its functions, as well as associated complications. Gross malformations vital organs, including most chromosomal syndromes caused lethal autosomal disorders, about 40% of defects are found only in the later life of the child, some may be unilateral asymptomatic.
Most defects corrected surgically, some, such as congenital hip dislocation successfully treated with conservative methods.
At malformation that directly threaten the life of the child (eg, atresia of the anus), the operation is performed in the first days after birth. In most cases, surgical correction carried out after 6 months or more older age (malformations of the heart and great vessels, most defects genitourinary, musculoskeletal).
There are mass and individual (family) preventing defects.
Bulk prevention - measures aimed at protecting people from exposure to mutagenic and teratogenic factors environmentalism.
Individual (family) prevention accomplished by medical genetic counseling and prenatal diagnosis.
Hypoplasia or absence of limbs - is rare. It is a difficult pathology. Variations underdevelopment of the upper and lower extremities are different.
Ektomeliya - the complete absence of one or two limbs or parts of limbs. In the complete absence of limb prosthesis. With partial - sometimes require surgical correction.

Hemimeliya - malformation in which there is no bottom limb (hand or wrist and forearm) and upper developed normally. Treatment consists of prosthetics.

Fokomeliya or Amelia - malformation, in which the upper limb missing completely, or missing arm and forearm, and the brush away from underdeveloped shoulder and resembles a seal flipper. Sometimes the underdeveloped shoulder leaving only one finger. This is called peromeliya.
Surgical treatment of this anomaly unpromising. Patients usually well trained to use the abnormal ending. Prosthetics performed to correct a cosmetic defect.

Congenital anomalies of the individual segments of the upper limb.

Congenital synostosis of the forearm bones or radioulnarnyy synostosis. This malformation occurs infrequently. During the prenatal period and radial ulna forearm combined bridge, which subsequently okostenivaye. Jumper occurs in the upper arm and can be of varying lengths. More common in boys.

The child's hand is not returned in the wrist (supination and pronation impossible), but flexion and extension at the elbow kept. This situation complicates the patient's life, even his self. Treatment initially is conservative and is the development arm. Some patients may well adapt to this defect. If you can not develop a hand, performed surgery. With a slight joined make it cut, with accretion of more than 4 cm resorted to removing part of the radius. Surgical treatment is performed at the age of 3 years.

Congenital talipomanus are presented. Congenital talipomanus are presented there in violation of the forearm muscles or underdevelopment of radiation, less ulna. Ulna talipomanus are presented develops if part of the ulnar forearm muscles underdeveloped ulna missing completely or partially. Simultaneous hypoplasia 4.5 fingers, bone fragments metacarpus and wrist with ulnar side. Brush with the state abruptly returned to the ulnar side (outward), its function impaired.
Radiation talipomanus are presented. This anomaly develops in the absence of the radius.

The defect may be bilateral. Simultaneously underdeveloped muscles of the forearm with radial hand, first finger brush carpal bones of the radial side. Brush tilted toward the radial (inward), its function dramatically affected, and in the absence of the thumb brushes impossible delight subjects. Treatment of congenital talipomanus involves many stages. Even immediately after birth prescribe massage, therapeutic exercise. To correct joint contractures overlapping casts. The first operation performed at the age of 2 years. Then may require additional surgery.

Chronic subluxation brush (Madelunha disease). This is a rare anomaly in which there is a malformation of the region wrist joint. Deformation progresses gradually to 12-14 years becomes noticeable. The pain in this disease there. There shtykopodibne distortion brush, which gradually increases. Limited movement in the wrist. Treatment operative. Performed plots bone resection, with subsequent fixation spokes. Then impose a plaster cast for a month, and then prescribe physical therapy and exercise therapy.
Webbing. This malformation in which there is complete or incomplete fusion of one or more fingers together.
Classification webbing
By type of fusion
1. M'yakotkani webbing
2. Bone webbing
In complementary growth in length
1. Incomplete form webbing
2. Complete form webbing
In lesions of the fingers
1. Simple form webbing
2. Complex forms webbing

The function of the hand is impaired. There is a cosmetic defect. Fusion can be m'yakotkanne if only adherent soft tissue and bone. Fusion normally developed fingers is called a simple form of webbing.

Complex fusion occurs when fused fingers have independent defects in development.
Most common cutaneous webbing. Thus fingers are fused throughout. Often fused third and fourth fingers. Membranous form occurs when fingers fused together skin bridge as flipper. When bone form webbing fused fingers of one or all of the phalanges. Occasionally no separation of the terminal phalanges - end seam.

Treatment webbing. Fingers disconnected surgically.

M'yakotkanna simple webbing treated at the age of 6 months. Complex defects operate after year. Fingers separated, and the lack of fabric cover by hand or tissue by skin grafting.
Cutaneous webbing require special training - stretching the skin to postoperative wound on each ¬ tion fingers could sew without stretching the skin, and healing took place by primary intention. If the skin is not enough of natya ¬ huvannya arises tissue necrosis or divergence of the wound edges, and formed as a result of severe scarring occurs during the growth of lateral curvature finger. Therefore, parents recommended for misya ¬ conduct this massage and stretching fingers together, after formation of the skin of the patient safety operate. Original method of training offered ON Gudushauri and LA Tvaliashvili - stretching your fingers through distraction apparatus.
After preparing the fingers separated by the method Didot so that the seams between the fingers do not match. To prevent scar ¬ Volyn seam at the base of the fingers is very important to form mizhpaltsovu fold by Zeller (triangular flap) or two intersecting triangular skin flaps, which re ¬ kryvayut interdigital space. If a defect in the skin, Zam ¬ based criteria free primary autodermoplastyku.
Patients with bone shape webbing operate in one or two stages. In a one-step operation fingers separated and ¬ kryvayut wounds between the toes skin graft. In a two-stage operation initially divide between a phalanx bone is transferred to the leather webbing, and then (after preparation ¬ tory) separated fingers.
The operation, performed technically correct, a positive func ¬ tional and cosmetic result. After surgery impose plaster splints, then prescribe physical therapy and exercise therapy.

Treatment with surgery alone. If an additional finger hanging on a thin stem, it should remove the first weeks of life. When properly developed, extra fingers, split vetch phalanges difficulty in deciding on the anatomical and functional disability vydalyayemoho finger or segment. Surgical intervention should be performed at the end of the first year of life, giving the possibility for normal growth and development of the last fingers.

Rehabilitation of children with disabilities.
Rehabilitation - a system of government, socio-economic, medical, professional and educational activities aimed at preventing the development of pathological processes that lead to temporary or permanent disability, effective and early return of sick and disabled people in society. In this regard, rehabilitation becomes of national importance and covers all persons with disabilities.
Medical rehabilitation aims to restore disturbed functions of the body, its systems or body parts, which contribute to the conservative, surgical treatments and their combination.
Social rehabilitation includes the creation of favorable conditions for participation in socialuseful work. Improved treatments, shortening hospital stay contributed to rapid return of the children to normal lifestyle. Parents and children should read the most rational regime for them, life and education.
Psychological rehabilitation nurturing optimal psychological background, a sense of usefulness to society. The role of this family, which helps the child as soon as possible to return to a normal rhythm of life.
Conducting rehabilitation of children in community-acquired conditions - a very important and difficult problem. Not meet the requirements at any stage can cause a relapse or complications that will need to start treatment again.

Materials for self-

Situational tasks:
Task 1. The child has one year left hand does not return to the wrist (pronation and supination impossible), but flexion and extension at the elbow kept. This situation parents noticed after year. The boy was born from the first pregnancy, which flows on the background of chronic kidney disease in the first trimester was observed viral disease in parents of hereditary diseases were observed. Injury to the left upper extremity in a child denied.
1. What disease should be thinking about the baby. Which survey plan should be a child?
2. What factors could lead to this disease?
3. Which type are malformation of the international classification.
4. What treatment should be child?
5. What is the plan for rehabilitation of the child would be in this case?
Responses.
1. The child radioulnarnyy synostosis. First it should be X-ray and MRI studies to identify areas of growth radial and ulnar bones, and be sure to perform ultrasound of internal organs to eliminate defects.
2. Chronic diseases and viral diseases may contribute to defects in children, especially viral diseases in the first trimester of pregnancy.
3. This issue relates to anomalies arising from insufficient differentiation of parts of limbs. These include malformations scapula (shoulder blade navicular raised shoulder), synostosis, sindaktylii, brahidaktyliya, congenital clubfoot, congenital hip dislocation, artrohripoz, klinodaktyliya - shortening of the middle phalanx of fingers (usually thumb V), of course that is an integral component of syndromes of multiple malformations development, especially chromosome.
4. The child should be therapeutic exercise, massage to improve the movements of the joints of the upper limb. Only after failure of treatment is surgery.
5. Child preventive measures, medical, social and vocational rehabilitation.

Task 2. In the newborn girl found innate talipomanus are presented, ulnar part of the forearm - muscles underdeveloped ulna missing completely, no 5.4 thumb and wrist part. Brush it dramatically returned to the ulnar side (outward), its function dramatically impaired. The mother was observed viral illness 6-9 weeks of pregnancy toxemia in the first half

1. Which survey plan should be a child?
2. What factors could lead to this disease?
3. Which type are malformation of the international classification.
4. What treatment should be child?
5. What is the plan for rehabilitation of the child would be in this case?
Responses.
1. The child should be x-ray and ultrasound of internal organs to eliminate defects.
2. The child malformation may be associated with disease mother in early pregnancy., For clarification that requires consultation genetics.
3. This issue relates to anomalies arising from insufficient differentiation of parts of limbs. These include malformations scapula (shoulder blade navicular raised shoulder), synostosis, sindaktyliyi, brahidaktyliya, congenital clubfoot, congenital hip dislocation, artrohripoz, klinodaktyliya - shortening of the middle phalanx of fingers (usually thumb V), of course that is an integral component of syndromes of multiple malformations development, especially chromosome.
4. Treatment of congenital talipomanus involves many stages. Even immediately after birth prescribe massage, therapeutic exercise. To correct joint contractures overlapping casts. The first operation performed at the age of 2 years. Then may require additional surgery.
5. Child preventive measures, medical, social and vocational rehabilitation

Problem 3. The boy 1 month, born from the second pregnancy of a bug found: while underdeveloped muscles of the forearm with radial side of the first finger of the hand, wrist bone with radiation side. Brush tilted toward the radial (inward), its function dramatically affected, and in the absence of the thumb brushes impossible delight. My father was webbing II-III fingers of his left hand, his brother - webbing II-III and hypoplasia of the fingers and thumb.

1. Which survey plan should be a child?
2. What factors could lead to this disease?
3. Which type are malformation of the international classification.
4. What treatment should be child?
5. What is the plan for rehabilitation of the child would be in this case?
Responses.
1. The child should be x-ray and ultrasound of internal organs to eliminate defects.
2. The child hereditary disease to elucidate this need advice genetics.
3. This issue relates to anomalies arising from insufficient differentiation of parts of limbs. These include malformations scapula (shoulder blade navicular raised shoulder), synostosis, sindaktylii, brahidaktyliya, congenital clubfoot, congenital hip dislocation, artrohripoz, klinodaktyliya - shortening of the middle phalanx of fingers (usually thumb V), of course that is an integral component of syndromes of multiple malformations development, especially chromosome.
4. Treatment of congenital talipomanus involves many stages. Even immediately after birth prescribe massage, therapeutic exercise. To correct joint contractures overlapping casts. The first operation performed at the age of 2 years. Then may require additional surgery.
5. Child preventive measures, medical, social and vocational rehabilitation.

Problem 4. A podiatrist asked parents 3 year old boy with webbing. In this third and fourth fingers fused throughout. Fingers fused together skin bridge as flipper. Function brush properly capture subjects a child performs. The mother observed webbing main phalanx II-III toes on the feet.

1. What type of disease in a child?
2. Etiology of disease continuity.
3. Classification webbing
4. Methods of treatment.
5. Rehabilitation of the child.
Responses.
1. The child webbing: soft tissue, complete, simple form.
2. The child Hereditary form of webbing.
3. Classification webbing:
By type of fusion
- M'yakotkani webbing
- Bone webbing
In complementary growth in length
- Incomplete form webbing
- Full form of webbing
In lesions of the fingers
- Simple form webbing
- Complex form of webbing
4. Methods of treatment. Fingers separated surgically.
Simple forms soft tissue webbing treated aged at least 6 months. Complex defects operate after year. Fingers separated, and the lack of fabric cover by hand or tissue by skin grafting.
Cutaneous webbing require special training - stretching the skin to postoperative wound on each ¬ tion fingers could sew without stretching the skin, and healing took place by primary intention. If the skin is not enough of natya ¬ huvannya arises tissue necrosis or divergence of the wound edges, and formed as a result of severe scarring occurs during the growth of lateral curvature finger. Therefore, parents recommended for misya ¬ conduct this massage and stretching fingers together, after formation of the skin of the patient safety operate.
After preparing the fingers separated by the method Didot so that the seams between the fingers do not match, or using other methods of plastics. To prevent scar ¬ Volyn seam at the base of the fingers is very important to form mizhpaltsovu fold by Zeller (triangular flap) or two intersecting triangular skin flaps, which re ¬ kryvayut interdigital space. If a defect in the skin, Zam ¬ based criteria free primary autodermoplastyku.
5. The operation, performed technically correct, a positive func ¬ tional and cosmetic result. After surgery impose plaster splints, then prescribe physical therapy and exercise therapy. Rehabilitation should be undertaken to complete the growth of the child.

Problem 5. A child of the third pregnancy (the previous two - a miscarriage in the early period), after childbirth neonatologist noticed extra finger and left foot and additional VI finger on the outer edge of the right foot on the leg. The upper and lower limbs formed right proportion to the body baby, movements in full, length of limbs equal. Continuity of the parents is not burdened, diseases during pregnancy have denied.

1. How to correctly formulate a diagnosis.
2. What group should include bug development.
3. Which test should execute child.
4. Treatment of the child.
5. Rehabilitation.
Responses.
1. Polydactyly left foot, doubling the first finger and foot. Polydactyly of the right foot, extra VI finger.
2. This issue relates to anomalies caused by doubling: polydactyly, diplopodiya - doubling feet, polimeliya - increasing the number of lower extremities. Polimeliya be symmetric and asymmetric, usually combined with defects incompatible with life.
3. It should be x-ray and ultrasound of internal organs to exclude defects.
4. When properly developed, extra fingers, split vetch phalanges difficulty in deciding on the anatomical and functional disability vydalyayemoho finger or segment. Surgical intervention should be performed at the end of the first year of life, giving the possibility for normal growth and development of the last fingers. Fingers on the tender can be removed in the first months of life.
5. The child should be made to complete rehabilitation of growth to prevent strain or dysfunction primarily left thumb and foot.

Quiz.
1. Identify the main groups of malformations in children.

2. Etiology pathogenesis of malformations. Prevention of mass and individual.
3. Treatment of malformations in children.
4. Treatment of congenital synoztozu forearm, talipomanus, webbing, polydactyly
5. Rehabilitation of medical, social, professional children with disabilities.

Intrauterine OPERATIONS

1. 
   Background: The level of development of modern medicine dictates the search for new treatments, particularly at the intersection of several disciplines. Significant progress was made in the pathophysiology of diseases of the fetus, technical equipment surgeries in children, as well as intra-and postoperative led and control groups of children with low body weight and prematurity.
   In addition, ultrasound diagnostics used in present everywhere, shows most defects in the early stages of embryogenesis, resulting in performance was possible to correct defects in utero.
   Fetal surgery, or surgery of the fetus - a set of operational activities which include hysterotomy, fetal surgery (placenta or umbilical cord) and the return of the latter in the womb for further development and birth. The range of interventions Vara, from minimally invasive percutaneous procedures (eg correction of placental vessels in feto-fetal; transfusion syndrome) to open surgery (eg fetal thoracotomy with lobectomy followed cystic malformation of the lungs).

   2. Specific objectives of employment:

   
   1. To determine the etiologic factors of congenital malformations (birth defects).
   2. Classify and analyze the typical clinical picture of BD
   3. Identify features of the course of BD in newborns and set a preliminary diagnosis.
   4. Draw up a plan of survey and analyze the data of laboratory and instrumental investigations pregnant with a typical course of fetal birth defects: general clinical, biochemical blood tests, Coagulation, immunological studies, ECG, x-ray, echocardiography, ultrasound.
   5. To demonstrate the principles of treatment of BD.
   6. To diagnose with birth defects.
   7. Conduct differential diagnosis of BD
   8. Identify development forecasts of children with birth defects.
   9. Possess moral and ethical principles of medical specialist and principles of professional subordination in pediatric surgery.
   

4.2. Theoretical questions to studies.
1. Determine the possibility of surgical intervention in the fetus depending on the current pregnancy and health of the pregnant woman?
2. What rules should be followed when exhibited indications for fetal surgery fetus?
3. Are all anomalies diagnosed by ultrasound in early pregnancy may operate vnutrishnotrobno?
4. What do you know how to correct fetal diaphragm hernia?
5. What's syndrome associated "mirror" the mother of the fetus at CCP?
6. What studies in pregnant women can with great certainty diagnose fetal neural tube defects?
7. How is the cosmetic effect reaches postoperative period when malformation facial skeleton, depending on the terms of their correction?
8. What determines the further development of fetal surgery?

4.3. Practical tasks performed in class:

1. Collect medical history including information about pregnancy.
2. Conduct survey of pregnant women.
3. Justify and to plan a survey of pregnant women.
4. Evaluate the results of ultrasonography and to define specific fetal malformations.
5. Identify the indications for surgical intervention in the fetus.
Content themes
The beginning of the direct treatment of anomalies of the fetus, placenta and umbilical cord determine from 1982-1983, when the first were performed shunt surgery for hydrocephalus and hydronephrosis. In the next few years, imposed a moratorium on executions ventrykuloamniotychnyh shunts in hydrocephalus due to the high percentage of fetal death and inappropriateness results. Despite Expected instantaneous effect of chrezshkiryanyh draining operations for hydronephrosis and obstructive uropathy, design features first catheters adversely reflected on the frequency of their occlusion and displacement.
Global priority in fetal surgery belongs to a group of experts led by prof. M. Harrison of the Center for Treatment of fetal University of California (San Francisco, USA). This group in 1982 was successfully performed the first open fetal surgery: Overlay bilateral ureterostomy about urinary tract obstruction in a 21-week fetus.
During the subsequent decade in fetal surgery achieved success in the treatment of congenital diaphragm hernia, cystic adenomatous malformation of the lungs, as well as obstructive uropatiy.
Significant progress in this area of ​​medicine is made possible in the 90-ies of the last century due to the development of laboratory diagnosis of the fetus. Simultaneously animal study conducted pathophysiological aspects of potential abnormalities for surgical correction. After studying in the laboratory of surgical, anesthetic and tocolytic features of hysterotomy and surgery on the fetus was proven safety performance intrauterine operations.
Breakthrough in this area were quick technique bloodless hysterotomy followed by watertight closure of the wound, creating telemetry monitoring equipment of the fetus and the development of aggressive tocolytic therapy that prevents premature birth mother. Experiments on rhesus monkeys showed no negative influence fetal surgery for further fertility mother. Numerous series of ultrasound examinations as healthy fetuses and fetuses with various abnormalities allowed to map timing of surgical interventions and to identify the main criteria indications and selection for prenatal treatment.
Ethical aspects of fetal surgery
In relation to mother
Treatment fetus associated with a number of ethical, personal and social issues. Basic principle is risk assessment of intrauterine correction for maternal and further give birth. The risk of surgical correction must zrivnyuvatysya the risk of continuing pregnancy without correction.
Patients given full information concerning possible diseases and ways to correct pathology that is in the arsenal of experts about possible complications correcting fetal surgery, a further course of pregnancy and child development. Rights and safety of mother always stand above the interests of the unborn child.
So, dear procedure with a high risk to life, performance or future fertility of the mother is impossible
In relation to the fetus.
The main purpose fetal surgery is an opportunity to correct or interrupt various pathological processes that lead to the forthcoming tragedy fetus or threatening the life of the newborn. Medical Society of the mother and the fetus was developed sequence when selecting candidates for fetal surgery:
1. Accurate and comprehensive diagnosis of the disease with the evaluation of the degree of damage and excluding concomitant damage the fetus.
2. Installing weather occurrence of disease.
3. Clearly approval futility of treating the disease after birth due to zapuschenist pathological process.
4. Demonstration of intrauterine fetal correcting flaws in previous experiments on animals.
5. The operation in a specialized center correction intrauterine fetal malformations after approval by the couple on the basis of information provided by them versatile.
Rationality approach to the selection of patients for surgery is prevented formation of inevitable organ damage that remains after birth.
However, some severe and fatal malformations incompatible with life (eg, renal agenesis), in such cases it is recommended terminating the pregnancy. On the other hand, most anomalies successfully corrected after birth, while the bulk of pregnant women previously transferred to a specialized center, which conducted keruyemi birth and immediately after birth provide qualified neonatal and surgical care. And Finally, a third is a group of malformations, the progression of the time of birth leads to the inevitable, during life incompatible changes in the baby.
According to the defects, which are adjusted include those that interfere with normal development of the body. At present there are only a few thoroughly studied directly threatening life conditions that justify the risk of fetal surgery.

Detecting fetal abnormalities in early stages of development has been made possible thanks to the progress of prenatal diagnosis. Widespread is not invasive and invasive methods of examination deepened our imagination about the pathophysiology, development and prognosis of most birth defects. Such methods include prenatal ultrasound, fetal echocardiography, fetal NMRI, amniocentesis, biochemical blood vessels of the umbilical pool samples of chorionic villi.

Technique of fetal surgery
The best period to perform surgery is 18-30 weeks of pregnancy. After this period greatly enhanced contractile ability of the uterus and with it an increased risk of preterm birth, which is the most unfavorable point of fetal surgery. Surgical treatment is carried out in two ways: open - by opening the uterus and endoscopic. In the first case, the fetus is removed from the uterus and placed directly next section. Thus blood flow to the placenta is not interrupted. Is constantly dynamic monitoring of mother and child.
Telemetry equipment used during surgery allows rehistruvaty changes in the heart muscle of the fetus, its temperature, pH and P02 of blood and amniotic fluid pressure. Small size forks (less than 30 grams) with battery (continuous operation for more than 4 months.) Facilitates observation and in the postoperative period. Tocolytic therapy begins with rectal administration of indomethacin, followed by halogenation, which provides relaxation of the uterus and is independent anesthesia for both mother and fetus. Muscle Relaxation in so doing promote the necessary blood flow in umbilical vessels. However, a slight excess doses of anesthetics can cause fetal and maternal myocardial depression and reduced placental circulation. Constant perfusion during operation warm Ringer-lactate maintains a constant volume amniotichnoho uterus, preventing the strengthening of its contractile activity. The second constant, a change which is inadmissible, is homeostasis, directly dependent on the utero-placental circulation. Operation completes the introduction of antibiotics and Ringer-lactate, tight suturing of all membranes and muscular wall of the uterus. In this case prevents the flow of amniotic fluid due to leakage of water on the background of contractile movements of the uterus.
The introduction of endoscopic techniques allow to minimize a number of complications, which primarily include premature birth, cooling and dehydration of fruit. Trocar (3-4, maximum diameter - 5 mm) inserted under ultrasound guidance. Terms mother is - on the left side to prevent compression of the lower Polo veins.
Postoperative management is carried out in the ICU, where continuously monitored arterial and central venous pressure mother figures homeostasis. Extended epidural analgesia reduces maternal stress, while allowing control uterine tone. After a few days on the background stabilization of general condition and eliminate the risk of preterm birth have transferred to the general office. Tocolytic therapy continues after discharge. Sonographic monitoring of fetal development is conducted each week until birth. Caesarean section is performed at break prolific shells or inability to further control the appropriate tone of the uterus, usually before the 36 th week.

Congenital diaphragm hernia (IDK). VDK is an anatomically simple bug that is exposed to adjustment after birth. At the same time removed from the chest cavity hernial cities and diaphragm defect ushyvayetsya. However, despite the simplicity of operational techniques, mortality among this group of patients remains high. Even in the case of apparatus for extracorporeal membrane oxygenation (ECMO) in silica, which is diagnosed before 24 weeks of gestation, the death of infants is 58-80%. This is associated with marked hypoplasia of lung tissue and pulmonary hypertension. Such immaturity New, despite that are needed for this week, or even months. After birth, ECMO time-limited support available in 1-2 weeks, respectively, patients with severe pulmonary hypoplasia doomed. Therefore, in the last decade intrauterine correction of defects is becoming more supporters. In numerous series on animals have conclusively shown that prenatal executed operation provides the time required for the growth and development of the lung parenchyma, morphometric characteristics which differ little from healthy tissue.

Being in the chest cavity left the fate of the liver is the main technical barrier correction of defects, as its simple Revert the abdominal cavity affects blood flow in umbilical veins. At the dawn of fetal surgery has been popular so-called two-step operation: removal prolabuyuchoyi hepatic fate, reconstruction of the diaphragm and the mechanical increase in the volume of the abdominal cavity after "re-acquisition of the".
But this consequent occlusion of venous duct, which was originally located above the diaphragm, pledged to abandon this technique. Accordingly, the definition of thoracic location of the liver is the most important tactical point. This solved during or ultrasound with color Mapping (estimate blood flow in the umbilical veins and venous duct) or by scanning in the sagittal plane NMR tomography. Existing medical diagnostic algorithm developed by VDK Center Staff Treatment of fetal University of California (San Francisco, USA).
If silica is isolated to 24 weeks gestation, family members are invited to make a choice of the following options: 1) to terminate a pregnancy, and 2) to bear a child to term and to continue treatment in the intensive care unit (with an expected favorable prognosis no more than 58%); 3) try to fix the bug of prenatally. Recommended algorithm and modern ultrasonic parameters help with the definition of treatment. In the case of the formation of silica at later stages of gestation, as well as hypoplastic lung parenchyma and minimal offset of the mediastinum and stomach optimally conducts treatment after birth. Fetal correction is made in the presence of these factors - early education silica, a significant shift of the mediastinum, enlarged stomach into the chest cavity, minimally rendered lung tissue, and polyhydramnios.
Search for new surgical approaches to the treatment of silica ended development methodology temporary occlusion of the trachea (TLPR - tamponade lungs to fully develop). Thus by preventing physiological outflow of fluid from the airways of the fetus increases the pressure in the lung tissue, which in turn promotes hipoplazovanyh lungs and the return of the abdominal cavity. Cases of excessive proliferation of lung parenchyma beyond the diaphragm.
Against this background, both are stimulated trophic factors. Pulmonary mass increases due to direct hyperplasia rather than hypertrophy. TLPR performed endoscopically and open way, internally and in terms pozaprosvitno 24-28 weeks. gestation. Provided various ways occlusion of the trachea - the introduction into the cavity occlusive plugs, overlay clips, setting the cylinder and umbrellas that change their volume during fetal growth. The comparative analysis of different methods of correction silica confirmed the high efficiency TLPR. Using minimally invasive techniques productions tracheal obturator reduces the risk of premature birth, which is the Achilles heel of fetal surgery.
Obstruction of the urinary tract (OSSH). Occurs as single-and double-sided OSSH. Hotel location is different. In the first case, a favorable prognosis with respect to postnatal functioning not only urinary system, but also the lungs. Bilateral OSSH, especially in combination with oligohydramnios often results in the loss of a child after birth next time. The boys usually cause bilateral lesions of the posterior urethral valve will appear. For girls the same characteristic Cloacal anomaly associated with chromosomal defects. Damage to the renal parenchyma ranged from moderate to severe hydronephrosis expression dysplasia. Observed in OSSH clear connection with the development of the lungs. Oligohydramnios due to critically low urine production fetus initiates processes hypoplasia of the pulmonary parenchyma. Perinatal mortality due to renal failure that develops against the backdrop of the posterior urethral valve in the absence of intrauterine correction reaches 50%. Ultrasound diagnosis in combination with biochemical studies of fetal urine can formulate the indications for correction of fetal defects. Renal dysplasia is characterized by increased echogenicity and numerous cysts in the cortical layer of parenchyma. Renal failure is manifested by high levels of urinary electrolytes and β2-microglobulin. Approximately 75% of fetuses with dilated urinary tracts do not require intrauterine correction. Average degree of bilateral hydronephrosis kidney transformation without reducing the volume of amniotic fluid is adjusted mainly after birth. However, the downward trend in both renal function and volume okoloplidnyh treatment is justified intrauterine intervention. The main method of fetal bladder decompression is cherezshkiryana installation shunt under ultrasound guidance. If this operation is necessary before 24 weeks of gestation, tsystostomiya held open method. taking into account the increased risk of premature birth. Growing interest generates Appliances chrezmihurovoho fetoscopic laser posterior urethral valves sectional. Trocar with a thin endoscope, avoiding the wall of the uterus and bladder, enters the lumen of the latter, to assess the condition of the mucosa, the confluence of the ureters and localization urethral valves. Timely executed operation, aimed at unloading the urinary tract, prevents decreased volume of amniotic fluid and irreversible pulmonary and renal hypoplasia.
Sacro-coccygeal teratoma (CCP). KKT - tumors, which often occurs in the neonatal period with minimal risk of malignancy and a good prognosis. However, the emergence of pathology at the early period of gestation (18-20% of the total), especially in combination with generalized edema of the fetus, leading to his death. This is associated with the development of heart failure on the background of the arteriovenous shunt tumor. Additional syndrome "mirror" the mother occurs because platsentomehaliyi mentioned above and edema. The aim of intrauterine correction, which is usually carried out at 28-31 weeks, is the termination of the arteriovenous shunt. During the operation of the uterus derived directly concerned area. After visual selection vascular pedicle ligation imposed on it. Tumor rezekuyetsya possible maximum. Later mother designate the reception dexamethasone.
Removing CCP, which in size comparable with the head of the fetus provokes rapid reduction in the size of the uterus. In this case, a constant perfusion during surgery warmed Ringer-lactate can maintain constant volume okoloplidnyh waters. Drastic changes in the working conditions of fetal heart dictates tight sonographic control throughout pregnancy. An alternative way to open ligaturing is fetoscopic coagulation specific vessels. Final removal KKT performed immediately after birth. Fetal surgery leads to the disappearance of edema of the fetus, but its performance on the background and platsentomehaliyi syndrome mirrors that evolved questioned favorable prognosis.
Another tumor, which leads to generalized edema and heart failure fetus is horionanhioma. Big its size (more than 5-7 cm) emphasize expressed therein arteriovenous shunt. The purpose of fetal surgery is endoscopic coagulation of vascular anastomoses tumor. Finished removing the last held in the near term after childbirth.
Miyelomeninhotselye. Neural tube defects occur less frequently, due to the developed technique early α-fetoproteinovoho screening. Since the disease early does not involve a threat to life, the question of intrauterine correction of defects strongly tied to risk of premature birth. However, progress fetal surgery to constantly expand the assistance provided. For in miyelomeninhotselye severity of neurological disorders including depends on the length of mechanical injury and amniotic aggressive action Wednesday to structure the spinal cord. The operation is performed on the early period of gestation (20-23 weeks of fetal development), as previously correct the defect increases the chance of adequate spinal cord. Surgery is performed as an open and endoscopic methods. In the first case, the operative technique did not differ from that after birth. During fetoscopic correction defect closure spinal cord is made with the help of allogenic bone paste.
Stenosis Silviyeho plumbing. Handicap outflow of cerebrospinal fluid leads to expansion of the ventricles, compression of brain structures and further manifestation of neurological disorders. If the negative trend has been observed in utero, early ventricular decompression can avoid typical hydrocephalus disorders. Fetal correction lies in chrezshkiryaniy installation ventrykuloamniotychnoho shunt.
Blockade of heart. Most of the fruits of well-formed heart, but gradually progressive total heart blockade on the background kolahenosudynoho disease in mothers born without intrauterine correction. However, in small part because of bradycardia (heart rate less than 50 per minute) may develop generalized edema with loss of the fetus. In case of failure of β-adrenoceptor antohonystiv and steroids performed intrauterine implantation of pacemaker (open or endoscopic means).
Stenosis of the pulmonary artery or aorta. Diagnosis of defects does not foresee difficulties for sonography. Contents of the operation lies in cleaning obstacles to the flow of blood through the aortic or pulmonary valve. This is done by chrezshkiryanoyi balloon dilatation space narrowing.
Stenosis or atresia of the trachea. In fetal syndrome congenital upper airway obstruction found in large masses, but inefficient lungs. This is due to their pereroztyahnutistyu because liquid that gathered in the airways. In this case, fetal tracheostomy is performed as the first stage of treatment malformations.
Malformations facial skeleton. Proved that wound healing during pregnancy occurs without scar formation. Fetal development technology enables fully use this feature fetus. Correction "wolf paste" and "cleft lip" (defects that often occur after birth) is not always accompanied by satisfactory cosmetic effect. Fetal correction data defects to avoid scarring, breach formation of the skull and facial nasal cavity. The results can be regarded as an example for all cosmetic surgery.
Amniotic bands syndrome (SAT). SAT is a whole group of fetal malformations, which are accompanied by amniotic constrictions. Early effect eliminating their collection can eliminate differ in the degree of severity of disorders of the extremities, as well as their possible intrauterine amputation. Diagnosis is made by normal ultrasound. The operation is performed fetoscopic at 21-24 weeks of gestation. During such operations usually enough prokoahulyuvaty and cross the existing cord. Simultaneously, the visual diagnosis of possible related defects. Restoration of blood supply to the extremities carried out immediately at the completion of the transaction. It is necessary to control the complete restoration of functional freedom.
Feto-fetal transfusion syndrome (FFTS) and fetal syndrome akardiyi-atsefaliyi (FSAA). A small percentage of cases of twin pregnancy in the placenta may be abnormal general chorionic vessels. Perinatal mortality in FFTS and FSAA reaches 75%. Excluding data from the general vascular blood flow to fetal surgery is being done under the supervision of percutaneous ultrasound, endoscopic or open.
During the last 20 years there has been looking at how to cure many diseases newborns who were previously incurable. The development of high diagnostic and surgical technologies, improved techniques of prenatal opens up new possibilities for helping your child at the stage of fetal development. The road fetal surgery is seen in the development of minimally invasive technologies and implemented, spread spectrum treatment and ultimately distribution on narrow areas (thoracic surgery, neurosurgery, etc.) similar to those seen in pediatric surgery.

Materials for self-

Situational tasks
Task 1. At 15 weeks pregnant woman with ultrasound detected fetal congenital diaphragm hernia. Obtained consent for fetal surgery. What is the duration of pregnancy is the most favorable in fetal surgery?
Answer:
18 -30 weeks

Task 2. An examination of a pregnant doctor used a fetal ultrasound and found renal agenesis. A recommended stop pregnancy. Why?

Answer:
This issue is not penal in utero and is not compatible with life.

Problem 3. When fetal ultrasound revealed omfalotsele. Pregnant women perevyly in a specialized center for keruyemyh birth. Which defects classification refers omfalotsele?

Answer:
This malformation that correctional after birth.

Problem 4. Intrauterine fetal surgery performed through an open uterus. Gynecologist conducted after removal of fetal sacro-coccygeal teratoma pretty tight closure of all membranes and muscular wall of the uterus. Why is this done?

Answer:
Large suturing prevents leakage and flow of amniotic fluid due to uterine contractile movements.

Problem 5. Pregnant woman offered intrauterine fetal surgery syndrome amniotic strand, recommended cross amniotic constriction, but women increased contractile ability of the uterus and increased risk of preterm birth What better way to perform surgery?

Answer:
Endoscopic, minimized a number of complications, premature birth, cooling and dehydration of fruit.

Tests
1. In which pregnancy should be carried ultrasound to detect fetal congenital malformations of urinary system and the gastrointestinal tract:

A. At 28 weeks of pregnancy
B. At 7 weeks of pregnancy
C. At 14-18 weeks of pregnancy

2. What methods during pregnancy least invasive and most reliable for the diagnosis of fetal malformations:

A. Plain radiography
B. Computed tomography
S. Ultrasound

3. Stretch stomach is in the chest in this fetal ultrasound shows:

A. esophageal atresia
B. Obstruction of 12 duodenal ulcer
C. Orifice bifida

4. Where to screening conducted by analysis of maternal serum blood levels alfafetoproteinu:

A. Congenital heart system
B. Congenital malformations of the neural tube
S. Congenital musculoskeletal
5. In pregnant for 26 weeks \ in this ultrasound revealed oligohydramnios. What kind of bug fetus can think of:
A. Congenital malformation of the gastrointestinal tract
B. 2-sided hydronephrosis
S. diaphragm hernia
Endoscopic methods of operations.

1. Background: The level of development of modern medicine dictates the search for new treatments, particularly at the intersection of several disciplines. Significant progress has been made in the technical equipment of surgical interventions in children.

The introduction into clinical practice fibroendoskopiv allowed not only greatly improve the diagnosis of diseases of the gastrointestinal tract, but also introduce a number of treatments. Among the techniques of surgical endoscopy especially valuable biopsy, excision of tumors of the stomach, duodenum and large intestines, upper airway opening parent membranes, stop bleeding, and leaders of the probe for bouginage strictures. Became effective endoscopic methods create artificial fistulas of the gastrointestinal tract, papillosphincterotomy and endoscopic cryosurgery sclerosing varices of the esophagus and stomach. In urology - opening ureterotsele, summing gel stenting.
2. Specific objectives:
1. Know the basic principles of the system of endoscopes.
2. Classify and analyze the typical clinical picture of disease of the gastrointestinal tract and the tracheobronchial tree.
3. Analyze the indications and contraindications for endoscopic intervention.
4.Proanalizuvaty preparation conditions and complications that can occur during endoscopic intervention.
5. To demonstrate the principles of treatment of diseases of the digestive and respiratory tract, urinary tract malformations.
6. Based on the data obtained endoscopy to perform differential diagnosis of defects and diseases.
7. Identify development forecasts of children with varying pathology.

4.2 Theoretical questions to studies.

1. What types of flexible endoscopes?
2. What are the indications for endoscopic surgery?
3. What are the contraindications for endoscopic surgery?
4. What are the main stages polypectomy?
5. What rules should be followed in the early postoperative period?
6. What do you know polypectomy complications?
7. What sclerosing drugs that are used for varicose veins of the esophagus?
8. What Do You Know the indications for removal of foreign bodies stomach?
9. What determines the success of endoscopic papillosfinkterotomiyi?
10. Endoscopic summing gel Wust ureteral stenting and dissection ureterotsele.
The development of endoscopy.
Endoscopic diagnosis of gastrointestinal tract began to be used from the end of XVIII century and has evolved several stages, and marked improvement of the equipment and the introduction of new methods.
The beginning of the first phase should be attributed to the end of 1795 when RN Bozzini made apparatus for the study of rectum and uterus, using as light a candle. [Berry L. , 1974]. In 1826 H.L. Segales reported using advanced machine RN Bozzini. A.G. Desormeaux in 1853, used for lighting during endoscopy alcohol lamp, which allowed a more detailed look at the rectum. A. Kussmaul in 1868, put into practice methods gastroscopy using a metal tube with a flexible obturator.
By the early 70-ies of endoscopic equipment used mainly for studies of adults, because the large size limit its use in pediatric practice, except for special models of hard-ezofaho, Recto-and bronchoscope.
Fibrooptychni endoscopes were used in 1971, when the company «Olympus» were developed thin managed fibrogastroscopy [Gans SL, Vehci G., 1971; Gans SL, Gohnson D., 1976]. Along with special gastroscope some authors [Gans SL, 1976] was used for examination of the stomach fibrobronhoskopy, especially in studies of young children.
Basic principles of system endoscopes
Modern endoscopes are complex opto-mechanical devices that are inserted into the internal organs and cavities of the body. With their help conducting diagnostic studies and therapeutic manipulation tool that passes through the channel endoscope.
All endoscopes are characterized by three main systems: the transmission of light that provides illumination research object, the system image transfer from the object to the eye of the observer and the mechanical system, which is needed for the devices for anatomical canal, as well as various manipulations which accompanied by endoscopy.
Tubusni endoscopes (esophagoscopy, cystoscopes, Rectoscope) are simple devices as polyh metal tubes through which the right eye is viewing oral object. Tubusni endoscopes usually fitted with a magnifying glass mounted on the end of the system, where is located the eye of the observer. Dandruff can be considered an object at a slight increase (about 1.5-2 fold.).
The optical system of the endoscope lens optics is usually done as a separate node optical tube, which is a thin-walled metal tube with engraved into it many optical elements, they convey the image of an object to the eye of the observer. Nowadays in optical tubes endoscopes used Fast optical system consisting of rod lenses. This optical system has improved lens that consists of more elements and more complex system image transfer.
In hard tubusnyh endoscope fiber for transmitting light mounted directly in the tube (between two rigid metal tubes) or placed in a separate rigid metal tube that is introduced into the lumen of the tube. Flexible fiber cable to transmit light from illuminator to the lightguide hard endoscope done with elementary beam optical fibers coated with a special film that allows the cable bend without breaking fibers. Fiber cable has standard sizes, providing work endoscopes with different light projectors. Device rigid endoscopes mechanical system depends on the functionality of a particular endoscope.
Flexible endoscopes with fiber optics differ from the hard fact that their working part performed flexible. This ensures the implementation of the endoscope in curved channels and anatomic study hard and deep-seated cavities. To transmit light using fiber bundle with irregular concluded elementary optical fiber, like fiber, is used in rigid endoscopes.
1.Zhorstki (rigid) endoscope.
a) esophagoscopy;
b) bronchoscope;
c) proctoscope.
2. Flexible fibroendoskopy:
a) ezofahohastroduodenoskop;
b) fibrokolonoskop;
c) bronchoscope.
Operative Endoscopy
The method of electrocoagulation of rectal polyps during rektoskopiyi widely used in adults and in children. However, manipulation through fibroendoskop different number of features. Chief among them is the fact that all operations are performed on endoscopic intraabdominal organs, so any injury can lead to dangerous complications such as peritonitis.
Removal of benign entities.
Attempts to cut polyps metal loops that were made earlier, as well as injectable treatments polyps have not found wide use because of the frequent massive bleeding due to inadequate hemostasis. Only after the introduction into clinical practice Electrosurgical techniques, endoscopic polypectomy gained considerable popularity. Nowadays, many hospitals have accumulated experience of many thousands of such interventions.
In pediatric practice, this technique is now widely used. However, in the works of many authors discussed the role and place of endoscopic polypectomy in children. These results allow us to recommend this effective and relatively low-invasive treatment of polyps of the gastrointestinal tract for use in general clinical practice.
Indications and contraindications. Ability to remove the polyp through fibroendoskop depends on anatomical (macroscopic) type of polyp.
Endoscopic polypectomy is possible with polyps on the stem, regardless of the size of the head, and the polyps on a broad basis, provided that the base does not exceed 1.5 cm in diameter. When polyps with wide legs than 1.5 cm, intervention research can be carried out by specialists using special techniques.
Common contraindications to endoscopic polypectomy are the same as before the diagnostic study, but if the polyp is the source of life-threatening bleeding, these contraindications are relative.
Contraindicated endoscopic removal of villous tumors, stretching and do not have clear boundaries. Since the majority of cases in children are juvenile polyps, the size of structures is not a contraindication to removal, especially in childhood malihnizovovani polyps almost never occur.
Contraindications to endoscopy
- Local - ulcer;
- General - hemorrhagic diathesis, blood diseases, portal hypertension
Training is conducted in the same way as in the diagnostic study. All endoscopic surgery in children performed under general anesthesia. It is only to point out that before the removal of colon polyps should examine the entire colon to determine the number and location of polyps.
Methods polypectomy. Endoscope to spend polyp, examine it, then on foot polyp impose loopy electrode cinch it and giving it a high frequency, cut off the polyp. Depending on the type and location of endoscopic polyp using various methods and techniques.
When a polyp on a long stalk looped electrode placed upon the foot closer to the head. Strangulation legs should not be excessive and prolonged as hard loopy electrode can cross legs an octopus, resulting in intense bleeding that is difficult to stop. Once loopy electrode tightened on the stem, changing modes of coagulation and cutting, cross leg polyp. Supply current loopy electrode should be short-term (2-3 pp.), with intervals of 1-2 sec. While supplying current to the electrode head loopy polyp constantly shifting movements of the instrument did not have to burn the body wall in the place where the head of the polyp touches to it.
Polyps are small diameter (less than 1.5 cm) on a broad basis removed this way. Polyp grab loop at the base, tighten it, then assign it to the center of the lumen of the body to form psevdonizhka of mucosal then spend coagulation and clipping polyp.
When removing polyps that have a broad base (over 1.5 cm) polyps removed piecemeal. Summary of the method is that the capture and excised much of the polyp. Then napivrozkrytoyu loop again coagulated cut off part of his way to cause destruction of the foundations that remained. Reintervention spend 2-3 weeks. By this time there is necrosis and rejection of coagulated tissue polyp is much smaller than in the primary intervention. Multistage method can be removed polyps with juvenile structure. This technique is also used in removing polyps in the large leg to avoid bleeding from large vessels such legs.
Polyps are small (diameter less than 5 mm) Looped grab electrode is difficult, therefore, to remove them using diathermic coagulation method described C. Williams (1974). The essence of the method is that the polyp biopsy forceps grasp so formed psevdonizhka, then curling submit current, resulting in coagulation of tissue that surrounds the tongs, and some polyp that is inside the forceps, remains intact and suitable for histological examination.
Intervention may be single or multiple depending on the number of polyps. Repeated polypectomy stages separating interval of 10-15 days. Stepwise endoscopic polypectomy is used for diffuse polyposis of the gastrointestinal tract in children as an independent intervention or as one of the stages of combined treatment.
Multiple polypectomy may be the main treatment in patients with diffuse polyposis in the absence of severe anemia and metabolic disorders. In these patients, at each stage of intervention dignity any one section of the colon. First remove polyps from the colon of where the largest of them. In children, this department usually happens cecum.
In total forms of diffuse polyposis, when the process involved all the organs of the gastrointestinal tract, endoscopic polypectomy is possible in the least affected organs.
In juvenile forms of diffuse polyposis, endoscopic intervention in the stomach, small and large intestines is often carried out at hamartomnomu polyposis in which polyps are not prone to retsyduvannya and their malignancy is extremely rare.
Endoscopic polypectomy is both total biopsy of the polyp, so after electrocoagulation it must extract. To do this, use suction to the distal end of the polyp endoscopic or capture polyp forceps biopsy and other instruments.
After clipping polyp examine his leg, then the distal end of the endoscope closer to the polyp and create vacuum in the aspiration endoscope, thereby polyp fixed to the distal end of the apparatus. Pull polyp by aspiration perhaps only using endoscopes with end optics. When using devices with lateral optics can not create a vacuum and polyp not constrained by the entrance to the channel biopsy.
Thus, the extraction of each polyp associated with repeated administration apparatus. Deleting multiple polyps in children should extract only the largest of them.
Deleting multiple colon polyps can use the following methods of reception: after surgery child is prescribed a cleansing enema, and all polyps breaking flushing water. If such method is difficult to define location of each polyp, but in children it is not essential, since malignancy occurs rarely.
Complications. Endoscopic polypectomy as Every surgery is accompanied by some risk of complications, the most dangerous are organ perforation and bleeding. Perforated wall of the stomach and intestines usually caused by methodological and technical errors. Treatment of perforated gastric and colon surgery (laparotomy, closure of the defect).
Bleeding after polypectomy can begin immediately after clipping polyp or after 3-7 days after surgery. Bleeding that occurs immediately after clipping polyp caused inadequate hemostasis. Deferred bleeding occur 4-7th day after surgery due to rejection scab, ulceration and erosion of the vessel, which is in the cult.
If you have any bleeding after clipping polyp should try again grab a leg and make it coagulate without clipping. If the vessel that bleeds, we can not see, then perform a set of conservative measures: applying hemostatic means conducting plasma transfusion, erytromasy, gastric lavage or enema with cold water (3-4 ° C). Conservative tactics will stop the bleeding in most patients.
If bleeding continues, reduced blood pressure, and there are other signs of bleeding continues, shown urgent surgical intervention.

Postoperative period was divided into early and late. In the early postoperative period after endoscopic polypectomy requires strict bed rest for 3 days. On the first day after polypectomy prescribed cold on the stomach, control the level of blood pressure, hemoglobin, hematocrit, drinking 2-3rd day; bezshlakovu diet, in the absence of the chair - light laxatives (liquid paraffin, magnesium sulphate solution). In diffuse polyposis colon when a lump is removed 10-15 polyps and more, and after removal of polyps larger than 3cm by fragmentation may experience fever to subfebrile digits, sometimes patients complain of abdominal pain, while pain on palpation along the intestine especially in remote projection polyps.

Duration late postoperative period determined by terms of full recovery of the mucous membrane of the digestive tract after endoscopic intervention, including comorbidities. On average, it is equal to 1 month.
The basic principles of diet therapy after removal of polyps in the stomach include mechanical, chemical and thermal calm mucosa of the gastrointestinal tract. It is advisable to appoint postoperative ulcer diet, table number 1 (in MI Pevsner). Food is often the patient takes, 6-8 times a day, which helps prevent peptic hypersecretion of the mucous membrane of the stomach and duodenum. In order to create mukoznoho protection, which is especially important if the stomach "fresh" ulcer, you must add the mucous soups. Patients with the following comorbidities is recommended to keep this diet for 1 year. After the clinical laboratory and endoscopic examinations at 1 year, with no signs of acute concomitant disease diet therapy overturned, but endoscopic control must be repeated annually.
In patients with colon polyps diet is the basic principle of functional bowel rest. For this purpose, appoint Table 4 (in MI Pevsner). Diet should keep for 1 month, and during the subsequent month for children of preschool and school age limit intake of certain foods (spicy, salty, seasoning, etc..).
Autopsy incomplete membranes
This method can be used only if there is a hole in the membrane and in the absence of stricture below the membrane. Interventions carried out under radiological control. According to the membrane through a thin catheter, through the biopsy channel of an endoscope, injected contrast material for inspection divisions that lie below. Convinced that there is no restriction in the hole injected papillotom and cut through the membrane in three directions. To avoid re-scarring, Looped electrode excised flap, formed.
Conducting probe and conductors for bouginage strictures.
Indications. Violation evacuation of the upper digestive tract in the early postoperative period (duodenostasis, swelling anastomosis) for enteral nutrition and elimination of dynamic intestinal intubation impenetrable shows the upper small intestine.
Natural passage of the probe (even the type of Miller-Abbott, Cantera) usually can not get. Endoscopy of the probe is the only way possible. Technically, this manipulation difficult.
Methods. Probe fixed to the endoscope thread that held through the biopsy channel or fixed at the distal end of the forceps biopsy. At the gastroscope probe is carried out in the right department and left there for some time.
The second method is more suitable when necessary enteral nutrition. Once gastroscope held below the anastomosis through the biopsy channel of promoting long thin polyvinyl chloride tube that remains in the lumen of the duodenum. This thin tube may serve as a guide for the larger diameter of the probe, and buzhiv at rubtsovomu stenosis.
When superimposed gastrostomy to bouginage cicatricial strictures of the esophagus ligatures greatly facilitated by endoscopic control. The thread can be introduced through the endoscope (by mouth or via gastrostomy) or biopsy forceps.
Endoscopic methods of creating artificial fistulas of the digestive tract.
Percutaneous gastrostomy.
Indications. Swallowing disorders in children with diseases of the nervous system, in which a very high risk of joint pain.
Methods. Use gastroscope with end optics (such as the GIF-P2, GIF-QW), diathermic loop catheter Pettsera number 16 on a scale Frenha.
Methods of manipulation described Gauderer and et al. (1980). Abdominal wall is treated the same way as for laparotomy and closed sterile cloth. In line connecting the navel and the middle part of the left costal arch, infiltrate 0.25% novocaine solution point on the border of the middle and upper third of the line. Thin scalpel make a skin incision length of 3-5 mm, nadsikayut as cutting sheet rectus aponeurosis.
Gastroscope introduced through the mouth into the stomach, which straighten the air so that it pushed the liver, spleen and colon of the planned puncture site. Making sure that the wall of the stomach firmly against the anterior abdominal wall, thin or thick trocar injection needle pierce the anterior abdominal wall and the anterior wall of the stomach under control gastroscope. A needle carried a silk thread, which will serve as a guide. End of capture Looped electrode, through the biopsy channel gastroscope and extracted with endoscope. By the end of the threads fastened Pettsera catheter with a special needle at the distal end, and then pulling the thread by catheter guided through the esophagus into the stomach and then through the abdominal wall and fix it.
This described technique is not accompanied by complications, and Gastrostomy functioning well.
Such interference can not be done in patients with narrowing of the esophagus, in which the possible formation gastrostomy controlled laparoscope.
Endoscopic papillosfinkterotomiya
Endoscopic papillosfynkterotomiya (CRT), first performed in 1973, L. Demling, M. and Slassenu Germany and K Kawai and co-author.
A necessary condition is the existence of papilotomiyi modern X-ray equipment, the source diathermic current and reliable diathermic knife (papillotomy).
For extraction of bile duct stones after endoscopic CRT created Dormia basket, which can be hard and soft.
Indications and contraindications. Indication for CRT:
1) common bile duct stones in patients with gallbladder removed;
2) common bile duct stones without gallstones;
3) common bile duct stones and jaundice in the presence of gallstones;
4) limited benign papillary stenosis;
5) contraction and narrowing holedohoduodenostomy.
Contraindications to CRT is divided into local and general. Local include - long stenosis of the common bile duct, an anatomical region holedohoduodenalnoyi (long, narrow and pointed terminal portion of the common bile duct, the location of diverticulum BAN), inability to establish papilotom in the right direction and at the proper depth, the presence of strictures in the proximal common bile Strait. General contraindications are serious violations of the properties of blood coagulation, acute pancreatitis, secondary biliary cirrhosis coronary and pulmonary heart failure, severe systemic disease: recent myocardial infarction, diabetes, obesity, hypertension.
Methods. The essence of the transaction CRT is that after opening BAN one of the existing methods stones away spontaneously, or extracted by Dormia basket. Technical performance and success of CRT determined knowledge of anatomy papilloduodenalnoyi area, especially sphincter apparatus, precision visual and radiologic diagnosis changes prostrumovyh BSD systems and duodenal ulcers, the possibility of control over the location papillotoma in BAN and bile duct (not in the main pancreatic duct) and others.
CRT may include the following steps:
1) duodenoskopiyu, which allows to study the anatomical and topographical features papilloduodenalnoyi region;
2) the introduction and proper installation papillotoma;
3) section BAN;
4) complete the mechanical extraction of stones and implementation of a number of medical interventions - washing common bile duct antiseptics, drainage of the biliary system, etc.;
5) control study to evaluate the results of operations and determining tactics patients.
The need for mechanical extraction of stones from the bile duct occurs in 22-64% of patients.
Mechanical extraction of calculus from the common bile duct is indicated for: 1) multiple, closely adjacent to each other stones. When you remove the lower basket of stones and manipulation destroyed their order, which facilitates migration of stones into the intestine, and 2) the presence of choledocholithiasis and cholangitis when filling defects is a conglomerate consisting of small stones and zamazkoobraznoho detritus and 3) concomitant choledocholithiasis and acute cholecystitis in which contraindicated use of choleretic drugs.
CRT fails with: 1) stenosis BAN and killed it stone, 2) yukstapapillyarnomu diverticulum, 3) resection Billroth, 4) lack of experience of the doctor. The frequency of failures was 7-14%.
When the CRT there is a risk of serious complications for the correction of which have even resort to surgery. The frequency of complications varies in the range from 6.9 to 10.5%, the mortality rate is 0,4-2,3%.
Complications of CRT:
1. Perforation of the duodenum and bile ducts.
2. Occlusion of the common bile duct, which is spread, contrast material in pozacherevnu fiber.
3. Bleeding after CRT occur in 0,8-6,5% of cases.
4. Pancreatitis - one of the most severe complications of CRT.
Removal of foreign bodies
Create endoscopes and development techniques endoscopy not only greatly improved the diagnosis of foreign bodies located in the gastrointestinal tract, but that is of particular importance, have created the conditions for their successful extraction.
Endoscopic removal of foreign bodies of the pharynx and esophagus practiced long and has become a common method of treatment. Despite the widespread adoption of flexible endoscopes, foreign body esophagus better extract using rigid esophagoscopy, using different methods and techniques [Rozantsiv would. Since, 1961 birch E., Grigoriev M. C, 1965].
Equipment and tools. Especially opportunities for removing foreign bodies from the gastrointestinal tract opened modern fibroskopy that allow you to enter under visual control a variety of tools (hoe, hinges, baskets, magnetic extractors, diverse in form and purpose clamps). As shown by numerous statistical efficiency extraction of foreign bodies from the gastrointestinal tract in recent years has increased dramatically. Previously deleted mainly foreign body stuck in the esophagus, it is now possible to distinguish them from the stomach, duodenum, small intestine and colon.
Removal of foreign bodies from the esophagus using endoscopic appeared almost simultaneously with the birth of the method of esophagoscopy, whose age - more than 100 years [Mikulicz.J.1881]. So far, just words AI Savitsky (1940), who argued that the extraction of foreign bodies from the esophagus - this is an area where progress esophagoscopy can not compete with any other method. This provision further strengthened after the creation and practical implementation of endoscopes with glass fibers optics.
Thus, the main treatment in the presence of foreign bodies is to remove them by esophagoscopy. Success of endoscopic surgery largely depends on the correct choice of anesthesia. Local anesthesia does not always provide the conditions necessary for the safe removal of foreign body, especially in the hard endoscope. In all cases it is advisable to apply joint pain.
Select type of endoscope to remove a foreign body depends on:
1) the nature, size, shape and structure of the foreign body;
2) its localization and developed complications;
3) abundance and age of the patient;
4) availability of appropriate tools;
5) experience endoscopist.
During endoscopy endoscopist must establish:
1) is it possible to remove a foreign body not to cause damage to the esophagus;
2) determine which device should be applied;
3) select the manipulator, the most efficient and safest technique of foreign body removal;
4) select the type of anesthesia, the corresponding abundance of the patient and the nature of the operation.
Depending on the type of foreign body using various techniques. Common technical requirements for removal of foreign bodies: 1) all manipulations should be under constant visual control, 2) extract the foreign body is safer with a constant supply of air for straightening the folds and increased body lumen, and 3) capture foreign body should be strong and smooth extraction without violence and speeding, especially in the field of physiological narrowings and krikofarinhealnoyi areas where it is easy to damage the wall of the esophagus, and 4) after the extraction of a foreign body should immediately conduct diagnostic esophagoscopy to exclude damage to the esophagus and to clarify the integrity of the walls of the esophagus in an area where there was a foreign body.
Foreign body in the stomach. Most of these foreign bodies in children under the age of 12 years. Children during games swallow coins, marbles, keys and so on. Indications for removal of foreign bodies is long (more than 24 g) stay smooth foreign bodies in the stomach (coins, marbles, round toys), foreign bodies with a diameter greater than 2 cm and a length of more than 5 cm, sharp or irregular foreign bodies, provided that they not penetrated the wall of the organ. Standard biopsy forceps that are packaged baby endoscope to capture foreign bodies unsuitable.
Smooth foreign bodies extracted Dormia basket or Looped electrode. Endoscopic extraction of sharp or angular objects rather difficult, since the extraction they can injure the stomach or esophagus. Remove pins, razor blades, etc.., Conduct, protecting the esophageal wall outer tube, which wears on the endoscope or gastroscope conducted through hard esophagoscopy.
Another type of gastric foreign bodies in children is bezoary (tryho and fitobezoary). Tryhobezoary not amenable to conservative practices, and large sizes shown their surgery. Formation of small diameter (3-4 cm) can be removed endoscopically.
Fitobezoary can be dissolved papain, sodium bicarbonate and other substances that dissolve cellulose. Summing drugs should be combined with a mechanical grinding bezoara (Demling L., et a1., 1976).
Removal of foreign bodies from the colon
As mentioned, a foreign body in the colon can get from the upper gastrointestinal tract with food supply. It is necessary to remove mostly small sharp objects (needles, bone pins), taken root in the mucous membrane of the intestine.
The indications for removal of foreign bodies through the endoscope is a long finding them in one place, which is judged according to diagnostic radiological controls, and on the basis of clinical symptoms (pain, inflammation, and others.). Small foreign bodies extracted after colonoscopic investigation, during which determine the presence of a foreign body and the nature of its fixation in the intestinal wall, choose the method of removal. Most foreign bodies from the colon is extracted using polipektomichnoyi loop as well as the stomach.
Larger foreign bodies get into the colon through accidental or deliberate introduction of through the rectum. Random foreign bodies are usually heads of cylinders for enemas and thermometers. Intentionally introduced foreign bodies may be varied in form and texture (wood, glass, metal); often be seen in persons with mental disorders. To remove such foreign bodies often requires general anesthesia. Use as rigid devices - Rectoscope and flexible - syhmoskopy. Retrieves the foreign body through loops, grippers, sometimes curved end of the endoscope lodged by a foreign body.
Koprolity often reach large sizes and are able to close the lumen of the colon, causing the phenomenon ileus or bowel wall bedsores. In the absence of effect of enemas can try to destroy or remove koprolit with endoscopes. Not very large (up to 4-5 cm in diameter) koprolity can extract curved tip endoscope.
More appropriate to destroy them with diathermic loop, forceps and other instruments. After the destruction of them can be removed with normal cleansing enema. Doing surgery should only convinced of the impossibility to remove the foreign body through the endoscope.
Stop the bleeding
Treatment of acute gastrointestinal bleeding - one of the most difficult problems of modern medicine. With intense bleeding conservative measures do not always lead to positive results, and surgery aggravates the serious condition of patients. Trying to stop the bleeding during emergency endoscopic intervention is certainly justified. However, you should clearly identify opportunities to stop the bleeding with endoscopes.
When jet bleeding from blood vessels located at the bottom of the ulcer, any endoscopic manipulation contraindicated and patients need urgent surgery.
At moderate bleeding source is the vessel submucosal layer on the edge of the ulcer may conduct electrocautery. If a bleeding vessel, well identified, then spend his sighting coagulation. In cases where the area that bleeds, see clearly, the method used circular coagulation lining, leaving a 3-4 mm from the edge of the ulcer.
For parenchymal hemorrhage type of area irrigated hemostatic means (ε-Aminocaproic acid, hydrogen peroxide) or conduct chemical coagulation surface such that sawed alcohol. After stopping bleeding and ulcers drying surface it is applied plivkozahysnyy drug (lifuzol, hastrozol).
Such methods of stopping bleeding as overlay clips, coagulation laser, possible only in children older age groups as special pediatric instruments such appointment to be developed.
Hardening of varices of the esophagus and stomach
A special group among patients with acute gastrointestinal bleeding are patients with bleeding from sklerozovanyh varices of the esophagus and stomach, which caused bleeding is liver disease, increased venous pressure in the portal vein.
Despite the progress made in the surgical treatment of esophageal-gastric bleeding caused by soil portal hypertension, mortality after these operations remains high and varies from 20 to 50%, and recurrence of bleeding in 12.3%.
The method, which is used to stop bleeding or prevent it is hardening varices of the esophagus and stomach by introducing sclerosing drugs with a needle through the endoscope channel.
Patients with gastrointestinal bleeding езофагогастродуоденоскопічне conduct emergency research that allows you to set the source of bleeding. Usually in detecting bleeding from eroded sites varices of the esophagus spend measures to temporarily stop the bleeding (esophageal probe input - obturator, gastric lavage through him ice water, the total intensity haemostatic therapy, and others.). The proposed method is effective and sclerotherapy vein favorably mentioned above.
Indications and contraindications. Sclerotherapy varices of the esophagus shows the patient at an altitude of bleeding, which is contraindicated perform shunting operations with the presence of portal vein thrombosis or decompensated liver function, as well as patients with thrombosis previously imposed portokavalnoho anastomosis.
Methods. Hardening of the veins of the esophagus is usually carried out under local anesthesia. At esophagoscopy under the control of punktuyut vein below the source of bleeding and she injected 2-3 ml of sclerosing drug. Often these purposes varykotsyda 5% solution, 1% or 3% solutions trombovara. Then punktuyut vein above the spot bleeding and injected into it the same amount of drug. Then plot vein puncture between points pressed for a while distal end system, thus preventing the spread of the drug on vascular anastomosis upper vena cava. During endoscopy should trombuvaty no more than two or three varices as complete cessation of outflow through the veins of the esophagus has greatly increased venous pressure in the cardia of the stomach, which can lead to profuznoy bleeding from varices of this site. Repeated sclerotherapy varices of the esophagus, the remaining performing 2-3 days, and treatment includes 4.3 sessions.
Endoskopichnni therapies used in the treatment of pediatric urology bladder-ureteral reflux (MSR). Designed indications for endoscopic correction of MCP in children:
1. MSR-II levels, in cases where no effect of conservative therapy conducted within 6-24 months, accompanied by frequent recurrences of pyelonephritis.
2. PMR II-IV degree against neurogenic dysfunction of the bladder with symptoms of reflux nephropathy and changes in urodynamic parameters ATC with these conservative measures.
3. Primary vesico-ureteric reflux II-IV degree of kidney dysfunction, severe urodynamic disorders and frequent exacerbations piyelonefritu history.
4. The combination of MSR with abnormalities of the ureter, such as doubling ureteral ectopia and vnutrishnomihurova his eyes.
5. Relapses reflux after losing inefficient operational
The method of endoscopic correction is vnutrishnomihuroviy paraureteralniy submucosa implantation POLIAKRILAMID gel "Interfal" to create antireflux mechanism. Adequate endoscopic antireflux correction in the absence of anatomical changes ATC provided by using a standard technique developed Matushek (1986). Features of endoscopic correction MSR related options from structural and anatomical changes ATC, such as lateral cell ectopia ureteral reflux and the lower segment twice the kidney in its full doubling.
Objective criteria of input hydrogel under eye ureter were endoscopic picture of implant placement, kind eyes ureter after implantation rates profilometriyi ATC obtained before and after antireflux correction. The results showed that antyreflyuksnyy mechanism thus achieved by reducing the lumen, extending vnutrishnomihurovoho of ureter and increase the pressure gradient ATC.
In modern terms have been used such invasive treatments ureterohydronephrosis as endoscopic dissection ureterotsele, stenting of the ureters.

Tests:
1. What applies to rigid endoscopes?

A. laparoscope
V. Ezofahohastroduodenoskop
S. proctoscope

2. Select contraindications to endoscopic surgery:

A. Portal hypertension
V. ulcer
C. Chronic pyelonephritis

3. Complications polypektomiyi:

A. Malignization
B. Bleeding
S. Perforation body

4. What dietary table is assigned in the postoperative period?

A. number 1
V. number 5
C. number 15
5. What do you know complications CRT?
A. Pancreatitis
B. Aggravation pyelonephritis
S. Perforating 12 duodenum
 
Situational task.
Task 1. Baby 3.5 years at home played small toys; surprise baby choked on `made manifest anxiety, cough, breathing became more frequent, noisy, with cyanosis appeared nasolabial triangle.
1. Preliminary diagnosis.
2. Additional methods of research.
3. The method of endoscopic treatment.
Answers:
1. Foreign body airway.
2. Applies plain film of the chest upright.
3. Needed bronchoscopy, remove the foreign body, and assess the condition of the mucosa.

Task 2. Child 12 years, complained of constipation for 2-3 days during the last 2 months. After the act of defecation, stool impurities in fresh blood. Condition of the child is satisfactory. Other complaints there.

1. Preliminary diagnosis.
2. Methods endoscopy and treatment.
3. Further observation of the child.
Answers:
1. Rectal polyp.
2. Applies sigmoidoscopy if polyp roztoshovan more proximally, then fibrokolonoskopiyu.
3. . Depending on the size and type of polyp held its removal or biopsy, 1 every 6 months a check endoscopy.

Problem 3. Child 5 years complaining of general weakness, pale skin, periodically after defecation cal type "melena." In general, the analysis of blood anemia 3. The child clinically enlarged spleen to 7cm beyond the costal arch.

1. Preliminary diagnosis.
2. Methods.
3. Methods endoscopy and treatment.
Answers:
1. The syndrome of portal hypertension, bleeding from the dilatation of esophageal varices and stomach.
2. Additionally performed ultrasound of the abdomen.
3. In FEHDS established source of bleeding, sclerotherapy performed varices of the esophagus and stomach by introducing sclerosing drugs with a needle through the endoscope channel.

Problem 4. Child '14 complains repeated vomiting fresh with blood with clots for 3 hours. Last 2 days treated outpatients about SARS. Took to reduce the temperature of aspirin.

1. Preliminary diagnosis.
2. Method endoscopy and treatment.
Answers:
1.Hostra ulcer or stomach, or 12PK.
2. In FEHDS is the source of bleeding, with no effect of conservative therapy performed coagulation ulcer.

Problem 5. A child 6 years of suffering for 7 days for left-sided pneumonia. Suddenly appeared with dyspnea, anxiety, auscultatory breath left is performed. The X-ray left total eclipse of mediastinal shift to the left.

1. Preliminary diagnosis.
2. Method endoscopy and treatment.
Answers:
1. Atelectasis of the left lung.
2. A Sanatsiyno bronchoscopy. In addition to the general treatment of pneumonia several times to conduct Sanatsiyno bronchoscopy.