Krunkaitytė, Ugnė

Introduction Traumatic diaphragmatic hernia (TDH) is a rare pediatric injury (<1% of trauma cases). Leftsided defects are more common but may be overlooked, particularly when initial imaging is negative. Delayed diagnosis increases the risk of visceral herniation, respiratory compromise, and life-threatening complications [1]. Case Presentation An 11-year-old girl presented with severe respiratory distress, abdominal pain, and persistent vomiting. She was initially treated for suspected pneumonia; however, chest X-ray revealed herniation of the stomach into the right thoracic cavity. Medical history revealed severe polytrauma with predominant head injury following a motor vehicle accident two years earlier, with an initially unremarkable thoracic CT scan. In the preceding months, the patient experienced recurrent self-limiting episodes of vomiting and abdominal pain. The patient was transferred to a tertiary center where emergency laparotomy revealed herniation of a markedly distended stomach containing approximately 4 liters of gastric contents, along with the left hepatic lobe, through a 5-cm diaphragmatic defect. Primary diaphragmatic repair was performed. Postoperatively, the patient developed right lung consolidation, suspected to be aspiration pneumonia, requiring high-flow oxygen therapy. Broad-spectrum antibiotics were initiated. The patient was discharged in good condition 9 days postoperatively and remained asymptomatic at follow-up. Discussion Traumatic diaphragmatic rupture in children is uncommon and often clinically occult, particularly in polytrauma patients where associated injuries dominate initial management. Respiratory symptoms are frequently nonspecific, and normal breath sounds or oxygen saturation do not exclude diaphragmatic injury [2]. Small tears may remain undetected on initial imaging and enlarge over time, allowing delayed herniation of abdominal viscera months or years after trauma. From a pediatric surgical standpoint, timely recognition is critical, as leftsided defects carry a high risk of gastric or intestinal incarceration, necrosis, and perforation [2,3]. Once diagnosed, surgical repair should not be delayed to prevent life-threatening complications [4]. Conclusions In pediatric patients with respiratory symptoms and a history of high-energy blunt trauma, TDH should be considered to avoid delayed diagnosis and prevent life-threatening complications.

TYRIMO TIKSLAS: Vaikų populiacijoje blužnies sužalojimai yra dažniausiai pasitaikančios parenchiminių organų traumos, tačiau potrauminė blužnies pseudoaneurizma (BPA) išlieka reta komplikacija. Šiuo metu nėra aiškių gairių, apibrėžiančių optimalią BPA gydymo taktiką. Šio atvejo tikslas – pabrėžti laiku taikyto gydymo svarbą, siekiant išvengti gyvybei pavojingų komplikacijų. ATVEJO APTARIMAS: 5 metų berniukas buvo pristatytas į LSMUL KK VSPS dėl bukos pilvo traumos. Pradinės apžiūros metu stebėtas saikiai išpūstas pilvas su pilvaplėvės dirginimu kairiojoje pilvo pusėje. Ultragarsinio tyrimo metu buvo stebėta blužnies laceracija su nedideliu kiekiu laisvo skysčio pilvo ertmėje. Atliktoje pilvo KT stebėtas IIׄI° blužnies plyšimas. Pacientas stacionarizuotas, paskirtas konservatyvus gydymas. Gydymo eigoje, bendra berniuko būklė pagerėjo. Šeštą hospitalizacijos dieną berniukui pakartota pilvo echoskopija, kurios metu rasta blužnies apatinio poliaus pseudoaneurizma su aktyvia kraujotaka. Besiruošiant išrašyti pacientą, tos pačios dienos vakarą, berniukas pasiskundė stipriu pilvo skausmu, stebėta hipotenzija, sąmonės sutrikimas. Atliktoje echoskopijoje stebėtas ženkliai padidėjęs laisvo skysčio kiekis pilvo ertmėje. Įtariant kraujavimą į pilvo ertmę, berniukas skubiai operuotas – atlikta laparotomija ir splenektomija dėl BPA plyšimo. Pooperacinis laikotarpis sklandus, berniukas išrašytas į namus devintą dieną po operacijos. IŠVADOS: Nors šiuo atveju buvo išvengta mirties, tačiau šis atvejis pabrėžia aiškių BPA gydymo gairių trūkumą, kas galėtų padėti išvengti tolimesnių gyvybei grėsmingų komplikacijų kitiems pacientams.

Over the past decades, bacterial microbiome studies have become increasingly important. The development of the gut microbiome has been shown to play an essential role in human health, and to be especially decisive in infants [1]. It influences nutrient absorption, metabolism regulation, and immune system development. Various factors have been proposed to modulate the development of the microbiome and therefore shape the growth and health of newborns [2]. Premature babies are often lowweight and even more sensitive to health issues. This study aims to analyse the development of the microbiome in preterm neonates over the first two months of life and look for patterns and alterations associated with several factors, like delivery mode, gestation time and necrotizing enterocolitis (NEC). A total of 78 preterm newborns were included in the study, with stool samples being taken at several timepoints from each baby. In total 515 samples were collected. The timepoints varied between ages of one and 61 days and were grouped in six age groups during the analysis. Genomic DNA was extracted from stool samples, and the bacterial V3–V4 hypervariable region of the 16S rRNA gene was amplified and sequenced on the Illumina MiSeq platform. The data were processed using bioinformatical tools and analysed bioinformatically and statistically to access microbiome composition, abundancies, alpha- and beta-diversities. The analysis revealed significant differences in the bacterial profiles across different timepoints, gestational ages, delivery modes, and in relation to the development of NEC. Alpha diversity indices increased over time; however, fewer or no significant differences were observed between the later timepoints. Consistent patterns emerged from both PCoA and PERMANOVA analyses. Notably, NEC was associated with distinct bacterial. Additionally, the abundance of several bacterial taxa correlated with gestational age. The bacterial profile of premature, low-birth-weight newborns varies according to factors such as age, delivery mode, gestational age, and the presence of disease. Comparing these microbiome dynamics in low-birth-weight infants with those in full-term newborns could provide valuable insights into the development of neonatal diseases such as necrotizing enterocolitis.

There is low-certainty evidence on the impact of extended pharmacological prophylaxis on venous thromboembolism-associated morbidity and mortality. The aim of this study was to determine the efficacy and safety of extended prophylaxis after major abdominopelvic surgery for the prevention of clinically relevant venous thromboembolism after hospital discharge.

Cardiovascular complications after major surgery are associated with increases in morbidity and mortality. There is confusion over definitions of cardiac injury or complications, and variability in the assessment and management of patients. This international prospective cohort study aimed to define the incidence and timing of these complications and to investigate their impact on 30-day all-cause mortality. We performed a prospective, international cohort study between January 2022 and May 2022. Data were collected on consecutive patients undergoing major abdominal surgery in 446 hospitals from 28 countries across Europe. The primary outcome measure was cardiovascular complications as defined by the Standardised Endpoints for Perioperative Medicine-Core Outcome Measures for Perioperative and Anaesthetic Care initiative up to 30 days after surgery. The secondary outcome was 30-day postoperative mortality. This study included 24,203 patients, of whom 611 (2.5%) developed cardiovascular complications. In total, 458 (1.9%) patients died within 30 days of surgery, of which 123 (26.9%) deaths were judged to be cardiac-related. Mortality rates were higher in patients who developed postoperative cardiovascular complications than in those who did not (19.8% vs. 1.4%), which persisted after risk adjustment (hazard ratio (95%CI) 4.15 (3.14-5.48)). We estimated an absolute risk reduction (95%CI) of 0.4 (0.3-0.5) in mortality in the absence of all cardiovascular complications. This would confer a relative risk reduction in mortality of 21.1% if all cardiovascular complications were prevented. Postoperative cardiovascular complications are relatively common and occur early after major abdominal surgery. However, over 1 in 5 postoperative deaths were attributable to these complications, highlighting an important area for future randomised trials.

Tyrimo tikslas: sukurti inovatyvią skaitmeninę platformą pacientams, turintiems skirtingas stomas (gastrostominė tracheostomija, ileo/kolostomija), jų globėjams ir medicinos personalui, kurioje jie galėtų rasti informaciją apie stomas, pildyti dienoraštį, gauti pranešimus, bendrauti su kiekvienu kitas. Metodai: sukurta pirminė popierinė versija ir išbandyta su 100 Lietuvos sveikatos mokslų universiteto Kauno klinikų Vaikų chirurgijos skyriaus pacientų. Ši versija buvo patobulinta atsižvelgiant į jų pageidavimus. Po to buvo sukurta skaitmeninė jos versija – programėlė ir svetainė. Pagrindiniai rezultatai: platformoje MySTOMA pacientai gali lengvai rasti informaciją apie gastrostomiją, tracheostomiją, ileostomiją ar kolostomiją, jos kasdienę priežiūrą, pagrindinius problemų sprendimo būdus, gali pildyti stomos dienyną, gauti pranešimus apie stomos priežiūrą ir būtinus vizitus į ligoninę.Pacientas gali aktyviai dalyvauti stomos palaikymo grupėse per šios platformos forumus, bendrauti, dalytis patirtimi ir siūlyti pagalbą kitiems, turintiems stomas.
Išvados: Pasitelkus inovacijas ir skaitmenizuotus sprendumus, galime sukurti naudingą įrankį pacientams, jų globėjams ir sveikatos priežiūros specialistams.

Yra daug medicininių situacijų (dažniausiai lėtinės ar įgimtos ligos), kai vaikas pats negali valgyti ar gerti, o tam, kad būtų užtikrinta tinkama mityba ir hidratacija, reikalingas gastrostominis maitinimas, kai vaikas maitinamas tiesiai į skrandį per gastrostominį vamzdelį. Nors pradžioje tėvai patiria daug nerimo ir baimių dėl vamzdelio pilvo sienoje, tačiau paciento gydyme gastrostoma vaikams - žingsnis į priekį, o ne atgal. Vis tik didžioji dalis tėvų pastebi, kad suformavus gastrostomą pagerėja tiek jų, tiek vaikų gyvenimo kokybė. Suformavus gastrostomą vaikams, kurių rijimas sutrikęs, suteikiama galimybė gauti pakankamai maistinių medžiagų, energijos, vitaminų, būtinų tolesniam augimui ir vystymuisi. Tačiau pagalba ir paslaugos teikiamos vaikams, turintiems gastrostominį vamzdelį, visoje Lietuvoje labai skiriasi, ypač atokiose vietovėse, dėl sveikatos priežiūros specialistų, turinčių patirties su gastrostomos priežiūra, trūkumo. Labai svarbu, kad sveikatos priežiūros specialistai turėtų žinių ir įgūdžių, kad galėtų teikti saugią ir tinkamą priežiūrą, o paslaugos būtų veiksmingos, prieinamos ir struktūrizuotos taip, kad atitiktų pacientų ir jų šeimų poreikius. Įvairaus amžiaus vaikams, vėliau ir suaugusiems žmonėms gali prireikti maitinimo per gastrostominį vamzdelį, o teikiant tinkamas priežiūros paslaugas, dauguma tokių pacientų gali saugiai funkcionuoti bendruomenėje. Ankstyvojo pooperacinio periodo gastrostomos priežiūra reikalauja ypač daug dėmesio. Šiuos pacientus prižiūrintiems asmenims reikia daug informacijos ir sveikatos priežiūros specialistų laiko bei konsultacijų. Nepaisant gydymo įstaigoje suteikiamos informacijos, pacientams ir juos prižiūrintiems asmenims kyla daug klausimų. Taigi tinkamas slaugančio personalo ir slaugančių asmenų apmokymas bei maitinimo namuose paslaugų sukūrimas gali būti ekonomiškai efektyvus ir gali sumažinti perteklinių vizitų į sveikatos priežiūros įstaigas ar pakartotinių hospitalizacijų dėl komplikacijų, kurių būtų galima išvengti, kiekį. Ši mokomoji knyga „Vaikų su gastrostoma priežiūra: nuo vamzdelio Įvedimo iki pašalinimo“ - tai daugialypis su vaikais dirbančių specialistų (slaugos specialistų, gydytojų vaikų gastroenterologų ir vaikų chirurgų) bendradarbiavimo rezultatas.

Background: Multimorbidity poses a global challenge to healthcare delivery. This study aimed to describe the prevalence of multimorbidity, common disease combinations and outcomes in a contemporary cohort of patients undergoing major abdominal surgery. Methods: This was a pre-planned analysis of a prospective, multicentre, international study investigating cardiovascular complications after major abdominal surgery conducted in 446 hospitals in 29 countries across Europe. The primary outcome was 30-day postoperative mortality. The secondary outcome measure was the incidence of complications within 30 days of surgery. Results: Of 24,227 patients, 7006 (28.9%) had one long-term condition and 10,486 (43.9%) had multimorbidity (two or more long-term health conditions). The most common conditions were primary cancer (39.6%); hypertension (37.9%); chronic kidney disease (17.4%); and diabetes (15.4%). Patients with multimorbidity had a higher incidence of frailty compared with patients ≤ 1 long-term health condition. Mortality was higher in patients with one long-term health condition (adjusted odds ratio 1.93 (95%CI 1.16-3.23)) and multimorbidity (adjusted odds ratio 2.22 (95%CI 1.35-3.64)). Frailty and ASA physical status 3-5 mediated an estimated 31.7% of the 30-day mortality in patients with one long-term health condition (adjusted odds ratio 1.30 (95%CI 1.12-1.51)) and an estimated 36.9% of the 30-day mortality in patients with multimorbidity (adjusted odds ratio 1.61 (95%CI 1.36-1.91)). There was no improvement in 30-day mortality in patients with multimorbidity who received pre-operative medical assessment. Conclusions: Multimorbidity is common and outcomes are poor among surgical patients across Europe. Addressing multimorbidity in elective and emergency patients requires innovative strategies to account for frailty and disease control. The development of such strategies, that integrate care targeting whole surgical pathways to strengthen current systems, is urgently needed for multimorbid patients. Interventional trials are warranted to determine the effectiveness of targeted management for surgical patients with multimorbidity.

AIM OF THE STUDY: Although splenic traumas are the most frequent solid organ injuries in the pediatric population, post-traumatic splenic pseudoaneurysm (SPA) is a rare condition seen in up to 9% of cases. Regrettably, there are no guidelines addressing the optimal timing for SPA angioembolization in children. This case report aims to consider the importance of angioembolization, which could reduce the risk of fatal complications. CASE DESCRIPTION: A 5-year-old boy was presented to the Emergency Department due to blunt abdominal trauma. Initial observation revealed a distended abdomen with tenderness on the left side. Ultrasound showed a spleen injury and a small amount of intraabdominal fluid, although there were no signs of anemia. Abdominal CT confirmed a III° laceration of the spleen (Image 1). Nonoperative management was chosen and the patient‘s general condition improved. On 6th day, the patient was symptom-free and ready for discharge; however, the ultrasound revealed a pseudoaneurysm in an inferior pole of the spleen. Later that day, the boy suddenly experienced severe abdominal pain, hypotension, and collapse, prompting a bedside ultrasound that identified an increased volume of intraabdominal fluid, along with a decreased hemoglobin level in a blood test. The patient underwent urgent laparotomy and splenectomy due to a rupture of splenic pseudoaneurysm. The post-operative period was uneventful, and the patient was discharged on the 9th day. CONCLUSION: While this case resulted in a successful outcome it emphasizes the current lack of clear guidelines for the timely consideration of angioembolization of SPA - potentially a lifesaving decision.

AIM OF THE STUDY: To identify factors associated with mortality risk in newborns with abdominal wall defects. METHODS: A retrospective study of newborns with abdominal wall defects (gastroschisis and omphalocele) between 2001 and 2021 in Kaunas Clinics. Prenatal and postnatal demographic, clinical and surgical data of patients and their mothers were collected. Ethical approval No. BEC-MF-199 was obtained. Data analysis was done by IBM SPSS V29.0. MAIN RESULTS: Data of 93 newborns (64 – with gastroschisis, 29 – with omphalocele) were collected. In the gastroschisis group: 48 (75.0 %) patients were born with simple and 16 (25.0 %) – with a complex defect. In the omphalocele group: 15 (51.7 %) patients were born with a small defect (≤ 5 cm in diameter) and 7 (24.1 %) – with a large defect ( > 5 cm). In the gastroschisis group, the overall mortality rate (14, 21.9%) was higher in patients with complex gastroschisis 8 (50.0 %) vs. simple gastroschisis – 6 (12.5%) (p=0.002), however overall mortality rate (4, 13.8 %) in the omphalocele group was not affected by the size of the defect (p>0.05). Prematurity seems to be a predisposing mortality risk factor for all newborns born with abdominal wall defects (10, 71.4%,p=0.026 in the gastroschisis group and 3, 75.0 % p=0.04 in the omphalocele group). Moreover, patients who had more than one additional surgery due to post-operative complications had lower survival rates in both groups (p<0.05). CONCLUSIONS: Prematurity and re-operations due to postoperative complications are associated with increased mortality in newborns with abdominal wall defects.