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{\f2\fbidi \fmodern\fcharset204\fprq1{\*\panose 02070309020205020404}Courier New;}{\f34\fbidi \froman\fcharset0\fprq2{\*\panose 02040503050406030204}Cambria Math;}{\f43\fbidi \froman\fcharset204\fprq2{\*\panose 02020603050405020304}Times New Roman CYR;}
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{\f482\fbidi \froman\fcharset178\fprq2 Times New Roman CYR (Arabic);}{\f483\fbidi \froman\fcharset186\fprq2 Times New Roman CYR Baltic;}{\f484\fbidi \froman\fcharset163\fprq2 Times New Roman CYR (Vietnamese);}
{\f488\fbidi \fmodern\fcharset0\fprq1 Courier New CYR;}{\f486\fbidi \fmodern\fcharset238\fprq1 Courier New CYR CE;}{\f489\fbidi \fmodern\fcharset161\fprq1 Courier New CYR Greek;}{\f490\fbidi \fmodern\fcharset162\fprq1 Courier New CYR Tur;}
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{\flomajor\f31511\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\flomajor\f31512\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\flomajor\f31513\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}
{\flomajor\f31514\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\flomajor\f31515\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\flomajor\f31516\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}
{\fdbmajor\f31520\fbidi \froman\fcharset0\fprq2 Times New Roman;}{\fdbmajor\f31518\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fdbmajor\f31521\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}
{\fdbmajor\f31522\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fdbmajor\f31523\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fdbmajor\f31524\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\fdbmajor\f31525\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fdbmajor\f31526\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fhimajor\f31530\fbidi \fswiss\fcharset0\fprq2 Calibri Light;}
{\fhimajor\f31528\fbidi \fswiss\fcharset238\fprq2 Calibri Light CE;}{\fhimajor\f31531\fbidi \fswiss\fcharset161\fprq2 Calibri Light Greek;}{\fhimajor\f31532\fbidi \fswiss\fcharset162\fprq2 Calibri Light Tur;}
{\fhimajor\f31533\fbidi \fswiss\fcharset177\fprq2 Calibri Light (Hebrew);}{\fhimajor\f31534\fbidi \fswiss\fcharset178\fprq2 Calibri Light (Arabic);}{\fhimajor\f31535\fbidi \fswiss\fcharset186\fprq2 Calibri Light Baltic;}
{\fhimajor\f31536\fbidi \fswiss\fcharset163\fprq2 Calibri Light (Vietnamese);}{\fbimajor\f31540\fbidi \froman\fcharset0\fprq2 Times New Roman;}{\fbimajor\f31538\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}
{\fbimajor\f31541\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fbimajor\f31542\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fbimajor\f31543\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}
{\fbimajor\f31544\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fbimajor\f31545\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fbimajor\f31546\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}
{\flominor\f31550\fbidi \froman\fcharset0\fprq2 Times New Roman;}{\flominor\f31548\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\flominor\f31551\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}
{\flominor\f31552\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\flominor\f31553\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\flominor\f31554\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\flominor\f31555\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\flominor\f31556\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fdbminor\f31560\fbidi \froman\fcharset0\fprq2 Times New Roman;}
{\fdbminor\f31558\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fdbminor\f31561\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fdbminor\f31562\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}
{\fdbminor\f31563\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fdbminor\f31564\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fdbminor\f31565\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}
{\fdbminor\f31566\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fhiminor\f31570\fbidi \fswiss\fcharset0\fprq2 Calibri;}{\fhiminor\f31568\fbidi \fswiss\fcharset238\fprq2 Calibri CE;}
{\fhiminor\f31571\fbidi \fswiss\fcharset161\fprq2 Calibri Greek;}{\fhiminor\f31572\fbidi \fswiss\fcharset162\fprq2 Calibri Tur;}{\fhiminor\f31573\fbidi \fswiss\fcharset177\fprq2 Calibri (Hebrew);}
{\fhiminor\f31574\fbidi \fswiss\fcharset178\fprq2 Calibri (Arabic);}{\fhiminor\f31575\fbidi \fswiss\fcharset186\fprq2 Calibri Baltic;}{\fhiminor\f31576\fbidi \fswiss\fcharset163\fprq2 Calibri (Vietnamese);}
{\fbiminor\f31580\fbidi \froman\fcharset0\fprq2 Times New Roman;}{\fbiminor\f31578\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fbiminor\f31581\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}
{\fbiminor\f31582\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fbiminor\f31583\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fbiminor\f31584\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\fbiminor\f31585\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fbiminor\f31586\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}}{\colortbl;\red0\green0\blue0;\red0\green0\blue255;\red0\green255\blue255;\red0\green255\blue0;
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{\pntxtb (}{\pntxta )}}\pard\plain \ltrpar\qc \li0\ri0\sl360\slmult1\nowidctlpar\wrapdefault\hyphpar0\faauto\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af43\afs28 \ltrch\fcs0 \f43\fs28\cf1\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af43\dbch\af31505\loch\f43 
ODESSA NATIONAL MEDICAL UNIVERSITY
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\par \hich\af43\dbch\af31505\loch\f43 Department of pediatric surgery
\par }\pard \ltrpar\qj \li0\ri0\sl360\slmult1\nowidctlpar\wrapdefault\hyphpar0\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs28 \ltrch\fcs0 \b\f43\fs28\cf1\lang1058\langfe1033\langnp1058\insrsid1786095 
\par 
\par 
\par 
\par 
\par 
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Methodical recommendations for students of V\'b2\loch\f43  year
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Congenital anomalies in children, which are followed}{\rtlch\fcs1 \ab\af43\afs36 \ltrch\fcs0 \b\f43\fs36\lang1058\langfe1033\langnp1058\insrsid8600493 \hich\af43\dbch\af31505\loch\f43  with respiratory insufficiency}{\rtlch\fcs1 \ab\af43\afs36 
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\par 
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\par \hich\af0\dbch\af31505\loch\f0                                         \hich\af0\dbch\af31505\loch\f0                                 Head of the department Losev O.O.
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\par }\pard \ltrpar\qc \li284\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin284\itap0 {\rtlch\fcs1 \af43\afs28 \ltrch\fcs0 \f43\fs28\lang1058\langfe1033\langnp1058\insrsid1786095 
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\par 
\par 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid1654750 {\rtlch\fcs1 \af43\afs28 \ltrch\fcs0 \f43\fs28\lang1058\langfe1033\langnp1058\insrsid8600493 
\par }\pard \ltrpar\qc \li284\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin284\itap0 {\rtlch\fcs1 \af43\afs28 \ltrch\fcs0 \f43\fs28\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af43\dbch\af31505\loch\f43 Odessa 20}{\rtlch\fcs1 \af43\afs28 \ltrch\fcs0 
\f43\fs28\insrsid8600493 \hich\af43\dbch\af31505\loch\f43 2}{\rtlch\fcs1 \af43\afs28 \ltrch\fcs0 \f43\fs28\insrsid1654750 \hich\af43\dbch\af31505\loch\f43 1}{\rtlch\fcs1 \af43\afs28 \ltrch\fcs0 \f43\fs28\insrsid1786095 
\par }{\rtlch\fcs1 \af43\afs28 \ltrch\fcs0 \f43\fs28\insrsid1654750\charrsid8600493 
\par }\pard \ltrpar\qj \fi720\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af44\afs24 \ltrch\fcs0 \b\f44\fs24\cf1\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Concrete aims:
\par }\pard \ltrpar\qj \fi-360\li720\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin720\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\cf1\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 1.\tab \hich\af44\dbch\af31505\loch\f44 
To master classification of anomalies of development of the respiratory system, esophagus and diaphragm.
\par \hich\af44\dbch\af31505\loch\f44 2.\tab To recognize the basic clinical symptoms of anomalies of development, which are accompanied with respiratory insufficiency. 
\par \hich\af44\dbch\af31505\loch\f44 3.\tab \hich\af44\dbch\af31505\loch\f44 To differentiate the anomalies of development.
\par \hich\af44\dbch\af31505\loch\f44 4.\tab To interpret the auxiliary methods of examination: esophagus tube insertion, ultrasonic examination, fibroesophagogastroduodenoscopy, sciagraphy, bronchography, bronchoscopy, computer tomography, angiograph
\hich\af44\dbch\af31505\loch\f44 \hich\f44 y, and others like the laboratory and biochemical analyses, indexes of hemodynamics (\'d0\loch\f44 \hich\f44 , BP,\'cd\loch\f44 t, Hb), and immunological.
\par \hich\af44\dbch\af31505\loch\f44 5.\tab To show the review of child with the anomaly of development of esophagus, diaphragmatic hernia and lobar emphysema.
\par \hich\af44\dbch\af31505\loch\f44 6.\tab To identify the\hich\af44\dbch\af31505\loch\f44  features of course of anomalies of development.
\par \hich\af44\dbch\af31505\loch\f44 7.\tab To offer the algorithm of action of doctor and tactic of conduct of patients with the anomalies of development.
\par \hich\af44\dbch\af31505\loch\f44 8.\tab To interpret general principles of medical treatment of anomalies of development.
\par }\pard \ltrpar\qj \li284\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin284\itap0 {\rtlch\fcs1 \ab\af44\afs24 \ltrch\fcs0 \b\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 4. The \hich\af44\dbch\af31505\loch\f44 
plan and organisation of lessons.
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10\brdrcf1 \trbrdrl\brdrs\brdrw10\brdrcf1 \trbrdrb\brdrs\brdrw10\brdrcf1 \trbrdrr\brdrs\brdrw10\brdrcf1 
\trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvmgf\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 
\cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvmgf\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth851\clshdrawnil \cellx3828
\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth3685\clshdrawnil \cellx7513\clvmgf\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl
\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1701\clshdrawnil \cellx9214\pard \ltrpar\qj \li284\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin284 {\rtlch\fcs1 \af44\afs24 
\ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Work type\cell \hich\af44\dbch\af31505\loch\f44 Time \cell }\pard \ltrpar\qc \li284\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin284 {\rtlch\fcs1 
\af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Activity\cell }\pard \ltrpar\qj \li284\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin284 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Equipment \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af44\afs24 
\ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10\brdrcf1 \trbrdrl\brdrs\brdrw10\brdrcf1 \trbrdrb\brdrs\brdrw10\brdrcf1 \trbrdrr\brdrs\brdrw10\brdrcf1 
\trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvmgf\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 
\cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvmgf\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth851\clshdrawnil \cellx3828
\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth3685\clshdrawnil \cellx7513\clvmgf\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl
\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1701\clshdrawnil \cellx9214\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10\brdrcf1 \trbrdrl
\brdrs\brdrw10\brdrcf1 \trbrdrb\brdrs\brdrw10\brdrcf1 \trbrdrr\brdrs\brdrw10\brdrcf1 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb
\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvmrg\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 
\cltxlrtb\clftsWidth3\clwWidth851\clshdrawnil \cellx3828\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1417\clshdrawnil \cellx5245
\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2268\clshdrawnil \cellx7513\clvmrg\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl
\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1701\clshdrawnil \cellx9214\pard \ltrpar\qj \li284\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin284 {\rtlch\fcs1 \af44\afs24 
\ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \cell \cell \hich\af44\dbch\af31505\loch\f44 Students\cell \hich\af44\dbch\af31505\loch\f44 Teacher\cell \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10\brdrcf1 
\trbrdrl\brdrs\brdrw10\brdrcf1 \trbrdrb\brdrs\brdrw10\brdrcf1 \trbrdrr\brdrs\brdrw10\brdrcf1 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb
\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvmrg\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 
\cltxlrtb\clftsWidth3\clwWidth851\clshdrawnil \cellx3828\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1417\clshdrawnil \cellx5245
\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2268\clshdrawnil \cellx7513\clvmrg\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl
\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1701\clshdrawnil \cellx9214\row \ltrrow}\trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10\brdrcf1 \trbrdrl
\brdrs\brdrw10\brdrcf1 \trbrdrb\brdrs\brdrw10\brdrcf1 \trbrdrr\brdrs\brdrw10\brdrcf1 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb
\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 
\cltxlrtb\clftsWidth3\clwWidth851\clshdrawnil \cellx3828\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1417\clshdrawnil \cellx5245
\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2268\clshdrawnil \cellx7513\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl
\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1701\clshdrawnil \cellx9214\pard \ltrpar\qj \li284\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin284 {\rtlch\fcs1 \af44\afs24 
\ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Organisation of the practical class\cell \hich\af44\dbch\af31505\loch\f44  5\cell \hich\af44\dbch\af31505\loch\f44 Listen \cell 
\hich\af44\dbch\af31505\loch\f44 Presence control\cell \hich\af44\dbch\af31505\loch\f44 Journal \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af44\afs24 
\ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10\brdrcf1 \trbrdrl\brdrs\brdrw10\brdrcf1 \trbrdrb\brdrs\brdrw10\brdrcf1 \trbrdrr\brdrs\brdrw10\brdrcf1 
\trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 
\cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth851\clshdrawnil \cellx3828
\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1417\clshdrawnil \cellx5245\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl
\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2268\clshdrawnil \cellx7513\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr
\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1701\clshdrawnil \cellx9214\row \ltrrow}\pard \ltrpar\qj \li284\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin284 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Aim setting\cell \hich\af44\dbch\af31505\loch\f44 5\cell \hich\af44\dbch\af31505\loch\f44 Listen\cell \hich\af44\dbch\af31505\loch\f44 Explain \cell \cell 
}\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \trowd \irow3\irowband3\ltrrow
\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10\brdrcf1 \trbrdrl\brdrs\brdrw10\brdrcf1 \trbrdrb\brdrs\brdrw10\brdrcf1 \trbrdrr\brdrs\brdrw10\brdrcf1 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb
\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth851\clshdrawnil \cellx3828\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 
\cltxlrtb\clftsWidth3\clwWidth1417\clshdrawnil \cellx5245\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2268\clshdrawnil \cellx7513
\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1701\clshdrawnil \cellx9214\row \ltrrow}\pard \ltrpar
\qj \li284\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin284 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Checking of the knowledge of students \cell 
\hich\af44\dbch\af31505\loch\f44 15\cell \hich\af44\dbch\af31505\loch\f44 Make \cell \hich\af44\dbch\af31505\loch\f44 Control \cell \hich\af44\dbch\af31505\loch\f44 Tests \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \trowd \irow4\irowband4\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10\brdrcf1 
\trbrdrl\brdrs\brdrw10\brdrcf1 \trbrdrb\brdrs\brdrw10\brdrcf1 \trbrdrr\brdrs\brdrw10\brdrcf1 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb
\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 
\cltxlrtb\clftsWidth3\clwWidth851\clshdrawnil \cellx3828\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1417\clshdrawnil \cellx5245
\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2268\clshdrawnil \cellx7513\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl
\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1701\clshdrawnil \cellx9214\row \ltrrow}\pard \ltrpar\qj \li284\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin284 {\rtlch\fcs1 
\af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Seminar \cell \hich\af44\dbch\af31505\loch\f44 60\cell \hich\af44\dbch\af31505\loch\f44 Answer \cell \hich\af44\dbch\af31505\loch\f44 Control
\cell \hich\af44\dbch\af31505\loch\f44 X-ray-grams\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \trowd \irow5\irowband5\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10\brdrcf1 \trbrdrl\brdrs\brdrw10\brdrcf1 \trbrdrb\brdrs\brdrw10\brdrcf1 \trbrdrr\brdrs\brdrw10\brdrcf1 
\trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 
\cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth851\clshdrawnil \cellx3828
\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1417\clshdrawnil \cellx5245\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl
\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2268\clshdrawnil \cellx7513\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr
\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1701\clshdrawnil \cellx9214\row \ltrrow}\pard \ltrpar\qj \li284\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin284 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Clinical discussion\cell \hich\af44\dbch\af31505\loch\f44 30\cell \hich\af44\dbch\af31505\loch\f44 Listen\cell \hich\af44\dbch\af31505\loch\f44 Discuss patients\cell 
\hich\af44\dbch\af31505\loch\f44 Patients \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \trowd \irow6\irowband6\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10\brdrcf1 \trbrdrl\brdrs\brdrw10\brdrcf1 \trbrdrb\brdrs\brdrw10\brdrcf1 \trbrdrr\brdrs\brdrw10\brdrcf1 
\trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 
\cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth851\clshdrawnil \cellx3828
\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1417\clshdrawnil \cellx5245\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl
\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2268\clshdrawnil \cellx7513\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr
\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1701\clshdrawnil \cellx9214\row \ltrrow}\pard \ltrpar\qj \li284\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin284 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Personal student\hich\f44 \rquote \loch\f44 s work\cell \hich\af44\dbch\af31505\loch\f44 60\cell \hich\af44\dbch\af31505\loch\f44 Make \cell 
\hich\af44\dbch\af31505\loch\f44 Control\cell \hich\af44\dbch\af31505\loch\f44 Patients \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \trowd \irow7\irowband7\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10\brdrcf1 \trbrdrl\brdrs\brdrw10\brdrcf1 \trbrdrb\brdrs\brdrw10\brdrcf1 \trbrdrr\brdrs\brdrw10\brdrcf1 
\trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 
\cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth851\clshdrawnil \cellx3828
\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1417\clshdrawnil \cellx5245\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl
\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2268\clshdrawnil \cellx7513\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr
\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1701\clshdrawnil \cellx9214\row \ltrrow}\pard \ltrpar\qj \li284\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin284 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Results of the lesson\cell \hich\af44\dbch\af31505\loch\f44 10\cell \hich\af44\dbch\af31505\loch\f44 Listen\cell \hich\af44\dbch\af31505\loch\f44 
Appreciation of each activities\cell \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \trowd \irow8\irowband8\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10\brdrcf1 \trbrdrl\brdrs\brdrw10\brdrcf1 \trbrdrb\brdrs\brdrw10\brdrcf1 \trbrdrr\brdrs\brdrw10\brdrcf1 
\trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 
\cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth851\clshdrawnil \cellx3828
\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1417\clshdrawnil \cellx5245\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl
\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2268\clshdrawnil \cellx7513\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr
\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1701\clshdrawnil \cellx9214\row \ltrrow}\pard \ltrpar\qj \li284\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin284 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Task for the next lesson\cell \hich\af44\dbch\af31505\loch\f44 5\cell \hich\af44\dbch\af31505\loch\f44 Listen\cell \hich\af44\dbch\af31505\loch\f44 
Explain the task. Indicates the literature.\cell \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \trowd \irow9\irowband9\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10\brdrcf1 \trbrdrl\brdrs\brdrw10\brdrcf1 \trbrdrb\brdrs\brdrw10\brdrcf1 \trbrdrr\brdrs\brdrw10\brdrcf1 
\trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 
\cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth851\clshdrawnil \cellx3828
\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1417\clshdrawnil \cellx5245\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl
\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2268\clshdrawnil \cellx7513\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf1 \clbrdrl\brdrs\brdrw10\brdrcf1 \clbrdrb\brdrs\brdrw10\brdrcf1 \clbrdrr
\brdrs\brdrw10\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1701\clshdrawnil \cellx9214\row }\pard \ltrpar\qj \li284\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin284\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 
\par }\pard \ltrpar\qj \fi720\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af44\afs24 \ltrch\fcs0 \b\f44\fs24\cf1\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
Congenital cysts of lungs, pulmonary hypoplasia.
\par \hich\af44\dbch\af31505\loch\f44 Actuality of problem
\par }{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\cf1\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 1. The congenital cysts of lungs meet in 3 - 5% cases of patients with the unspecific diseases of lungs.
\par \hich\af44\dbch\af31505\loch\f44 2. There are the single or multiple cysts of lungs depending on the term of influencing of endogenous and exogenous factors at violation of embriogenes\hich\af44\dbch\af31505\loch\f44 is.
\par \hich\af44\dbch\af31505\loch\f44 3. Due to their course the cysts are divided on complicated and noncomplicated.
\par \hich\af44\dbch\af31505\loch\f44 Complications of the congenital cysts are suppuration of cyst, tension of cyst, drainage to pleural cavity or bronchial tree.
\par \hich\af44\dbch\af31505\loch\f44 4. Clinical symptoms:
\par \hich\af44\dbch\af31505\loch\f44 - limited action of the \hich\af44\dbch\af31505\loch\f44 thorax in the act of breathing on the side of anomaly,
\par \hich\af44\dbch\af31505\loch\f44 - percussion \hich\f44 \endash \loch\f44  tympanit,
\par \hich\af44\dbch\af31505\loch\f44 - heart displacement in a healthy side.
\par \hich\af44\dbch\af31505\loch\f44 5. Medical treatment of the congenital cysts of lungs is surgical after establishment of diagnosis.
\par \hich\af44\dbch\af31505\loch\f44 In patients with the tension of cyst\hich\af44\dbch\af31505\loch\f44 , followed with displacement of mediastinum, puncture of cyst and its drainage before a surgery shoud be done to decrease the intrathoracic pressure.

\par \hich\af44\dbch\af31505\loch\f44 The volume of the operation depends on the localization of cyst and its distribution on adjoining tissues.
\par }{\rtlch\fcs1 \ab\af44\afs24 \ltrch\fcs0 \b\f44\fs24\cf1\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Pulmonary hypoplasia  - }{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\cf1\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 undevelopment of all elements of pulmonary structure. Among the congenital anomalies of lungs, it keeps 85%. Simple and cystic forms.}{\rtlch\fcs1 \ab\af44\afs24 
\ltrch\fcs0 \b\f44\fs24\cf1\lang1058\langfe1033\langnp1058\insrsid1786095 
\par }{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\cf1\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 The clinical symptoms depend on the volume of undevelopment of lungs and presence of infection.
\par \hich\af44\dbch\af31505\loch\f44 T\hich\af44\dbch\af31505\loch\f44 here are the important physical, functional methods of examination to make a diagnosis: bronchscopy, bronchography, angiopulmonography.
\par \hich\af44\dbch\af31505\loch\f44 Methods of medical treatment: conservative or operative. It  depends on a volume, presence of complication, features of \hich\af44\dbch\af31505\loch\f44 
course of disease, function of the pulmonary tissue and breathing effectency.
\par \hich\af44\dbch\af31505\loch\f44 Operative treatment: typical resection, limited resection, segmental resection, bronchi exsirpation, combined resections.
\par }{\rtlch\fcs1 \ab\af44\afs24 \ltrch\fcs0 \b\f44\fs24\cf1\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Congenital lobar emphysema.
\par \hich\af44\dbch\af31505\loch\f44 Actuality of problem.
\par }{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\cf1\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 1. The\hich\af44\dbch\af31505\loch\f44 
 congenital lobar emphysema is the enough rare anomaly of development of the respiratory system, the consequences of disease depend on the time of diagnostics. 
\par \hich\af44\dbch\af31505\loch\f44 2. Etiology of congenital lobar emphysema consists of aplasia of the smooth and shiny muscles o\hich\af44\dbch\af31505\loch\f44 
f terminal respiratory bronchioles, absence of intermediate generations of bronchial tree or aplasia of respiratory part of particle lungs.
\par \hich\af44\dbch\af31505\loch\f44 3. The clinical symptoms depend on the form of the congenital lobar emphysema: compensated, subcompensated, decompen\hich\af44\dbch\af31505\loch\f44 sated.
\par \hich\af44\dbch\af31505\loch\f44 
The compensated form is diagnosed in children after one year age. A child has a shortness of breath, frequent pulmonary diseases, there is deformation of thorax with the explosion of the staggered half. This form can be diagnosed during roentgenolog
\hich\af44\dbch\af31505\loch\f44 ic examination.
\par \hich\af44\dbch\af31505\loch\f44 
The subcompensated form appears considerably earlier, in age 1-3 months, a  child has the disorders of breathing or attacks of cyanosis, which pass quickly, his growth and development are retardated. During roentgenologic examination the an
\hich\af44\dbch\af31505\loch\f44 omaly of development is found.
\par \hich\af44\dbch\af31505\loch\f44 
The decompensated  form (acute form) of the congenital lobar emphysema is diagnosed in newborn during the first days of life. This form is characterized by the  syndrome of intrapulmonary tension. Child  has a respiratory ins
\hich\af44\dbch\af31505\loch\f44 ufficiency, that  grows progressively. X-ray exposes darkening, the dome of diaphragm descends, there is a displacement of organs of mediastinum in a healthy side.
\par \hich\af44\dbch\af31505\loch\f44 4. Medical treatment of the congenital lobar emphysema in newborn is only operative. In chil\hich\af44\dbch\af31505\loch\f44 
dren with decompensated form the operation is performed in an urgent order, in case of subcompensated form the terms of operative treatment depend on the state of child and course of disease, at compensated form - medical treatment is performed in the pla
\hich\af44\dbch\af31505\loch\f44 n\hich\af44\dbch\af31505\loch\f44  order.
\par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
THORACIC INSUFFICIENCY SYNDROME ASSOCIATED WITH DIFFUSE SKELETAL DISORDERS
\par \hich\af44\dbch\af31505\loch\f44 Thoracic insufficiency syndrome may be defined as any disorder that produces the inability of the tho\-rax to support normal respiration or lung growth. It includes a spectrum of disorders including asphyxiat\-
ing thoracic dystrophy (Jeune's syndrome), acqu\hich\af44\dbch\af31505\loch\f44 i\hich\af44\dbch\af31505\loch\f44 red asphyxiating thoracic dystrophy (after open pec\-
tus excavatum repair), spondylothoracic dysplasia (Jarcho-Levin syndrome), congenital scoliosis with multiple vertebral anomalies and fused or absent ribs (jumbled spine), and severe kyphoscoliosis. Thes\hich\af44\dbch\af31505\loch\f44 e
\hich\af44\dbch\af31505\loch\f44  disorders have been viewed and treated as separate entities, with little coordinated effort between special\-
ties. However, they are best addressed with a unified approach integrating pediatric general and orthopedic surgeons as well as pediatric pulmonol\hich\af44\dbch\af31505\loch\f44 o\hich\af44\dbch\af31505\loch\f44 gists.
\par }\pard \ltrpar\qj \fi360\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Jeune's syndrome is an autosomal recessive inher
\-ited osteochondrodystrophy with variable expres- sions. In mild forms, the chest may support adequate respiration. In more severe cases, the thorax is nar\-rowed both transversely and vertically, with \hich\af44\dbch\af31505\loch\f44 
short, wide horizontal ribs and irregular costochondral junc\-tions. This chest wall configuration pro\-duces a rigid chest with very little intercostal excursion for normal respiration, leading to ventilatory depen\-
dence and death from respiratory failure.\hich\af44\dbch\af31505\loch\f44  \hich\af44\dbch\af31505\loch\f44 Patho\-
logic examination of pulmonary structures varies, with some findings of pulmonary hypertension. However, most patients have normal bronchial development with variable alveolar density. This suggests that the extrinsic chest wall plays a significant 
\hich\af44\dbch\af31505\loch\f44 r\hich\af44\dbch\af31505\loch\f44 ole in the underlying hypoplasia. Other associated skel\-
etal abnormalities in Jeune's syndrome include short stubby extremities, fixed elevated clavicles, hypoplastic iliac wings, and a high incidence of C1 spinal ste\-nosis. These patients also have varyi\hich\af44\dbch\af31505\loch\f44 n
\hich\af44\dbch\af31505\loch\f44 g degrees of renal dysplasia.
\par \hich\af44\dbch\af31505\loch\f44 Spondylothoracic dysplasia (Jarcho-Levin) syndrome occurs in two forms with different inheritance pat\-terns. Type I is an autosomal recessive deformity char\-
acterized by multiple vertebral hemivertebrae and posterior rib fusio\hich\af44\dbch\af31505\loch\f44 ns.}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 85}{\rtlch\fcs1 
\af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44  This produces a marked short\-ening of the thoracic spine and a crab-like appearance of the chest on a standard radiograph .}{\rtlch\fcs1 
\af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44  }{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
Associated malformations are noted in 30% of patients and include cardiac and renal anomalies. The type I form is often fatal \hich\af44\dbch\af31505\loch\f44 by age 15 months, and a high inci\-dence is reported in Puerto Rican families. 
\par \hich\af44\dbch\af31505\loch\f44 Type II spondylothoracic dysplasia has an autosomal domi\-nant inheritance pattern and is associated with near- normal longevity. It is seen most commonly in white children.
\par \hich\af44\dbch\af31505\loch\f44 Thor\hich\af44\dbch\af31505\loch\f44 acic insufficiency also may arise secondary to too early or too extensive pectus operations. Com\-
plex spine anomalies producing the so-called jumbled spine, unilateral thoracic hypoplasia seen with the VACTERL association, and kyphoscoliosis may be a caus\hich\af44\dbch\af31505\loch\f44 e\hich\af44\dbch\af31505\loch\f44  of thoracic insufficiency.

\par \hich\af44\dbch\af31505\loch\f44 Surgical techniques to correct the spectrum of these complex disorders have attempted to address the issue of thoracic volume by various approaches. In both con\-
genital (Jeune's) and acquired (post-pectus) thoracic dystrophy, on\hich\af44\dbch\af31505\loch\f44 e approach has been an anterior lon\-
gitudinal sternal split with widening of the sternum. This has been accomplished with methylmethacry- late, bone grafts or rib, and metal plates. A staged approach with a methylmethacrylate plate followed by secondary r\hich\af44\dbch\af31505\loch\f44 e
\hich\af44\dbch\af31505\loch\f44 
moval of the plate and latissimus dorsi flaps to cover the created sternal cleft also has been described. Sternal elevation has also been reported in cases of acquired thoracic dystrophy by both the open and the minimally invasive techniques used for stan
\hich\af44\dbch\af31505\loch\f44 d\hich\af44\dbch\af31505\loch\f44 
ard pectus repair. A lateral staged approach with staggered rib osteotomies, staggered division of the chest wall, intercostal muscles, and pleura, with transposition of alternating ribs by using metal plate fixation, also has been described.
\par \hich\af44\dbch\af31505\loch\f44 These approac\hich\af44\dbch\af31505\loch\f44 
hes have had variable results because they are not easily revised to allow continued growth of the chest wall to allow lung expansion. The lateral thoracic expansion may also interfere with intercostal muscle function after division of multiple intercosta
\hich\af44\dbch\af31505\loch\f44 l\hich\af44\dbch\af31505\loch\f44 
 muscles and nerves. In regard to patients with Jarcho- Levin syndrome, jumbled spine, and kyphosis, pediat- ric general surgeons have done little to approach these problems that they considered either lethal or solely in the domain of the orthopedic surg
\hich\af44\dbch\af31505\loch\f44 e\hich\af44\dbch\af31505\loch\f44 on.
\par \hich\af44\dbch\af31505\loch\f44 
A promising technique to address patients with the spectrum of causes for thoracic insufficiency syndrome rejoins the disciplines of pediatric general, thoracic, and orthopedic surgery. Expansion thoracoplasty and the use of a vertical expandable prost
\hich\af44\dbch\af31505\loch\f44 
hetic titanium rib (VEPTR) developed by Campbell and Smith addresses many problems in the spectrum of these disorders. This technique allows serial expansion of the chest wall to allow continued growth of the thorax and spine until skeletal maturity is ac
\hich\af44\dbch\af31505\loch\f44 h\hich\af44\dbch\af31505\loch\f44 ieved. More than 300 patients with various disorders have been treated with this approach. In Jeune's asphyxiating thoracic dystrophy, 14 patients have undergone staged bilat\-
eral expansions. Anterior rib osteotomies adjacent to the costochondral junction\hich\af44\dbch\af31505\loch\f44  \hich\af44\dbch\af31505\loch\f44 
and posterior osteotomies adjacent to the transverse process of the spine in the 3rd to 9th ribs are performed. This creates a mobilized segment of chest wall that is distracted posterolater- ally and anchored to a curved VEPTR that is attached to the 2nd
\hich\af44\dbch\af31505\loch\f44  \hich\af44\dbch\af31505\loch\f44 and 10th ribs. The segment is anchored to the VEPTR with 2-mm titanium rings, sta\-
bilizing the segment and allowing reossification of the multiple osteotomies. The second stage is performed 3 months later, and then the devices are expanded every 6 months.
\par \hich\af44\dbch\af31505\loch\f44 
In patients with fused or absent ribs and scoliosis, a wedge thoracostomy through the fused segment of ribs not only allows expansion of the chest, but also correction of the scoliosis and the rotational spinal deformity (producing a windswept thorax). It
\hich\af44\dbch\af31505\loch\f44  \hich\af44\dbch\af31505\loch\f44 also stimulates increased spinal height in both congenital scoliosis and Jarcho-Levin syndrome, in which bilat\-eral devices are placed.
\par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 TRACHEAL OBSTRUCTION AND REPAIR
\par \hich\af44\dbch\af31505\loch\f44 T) ediatric surgeons are often involved in the man\-agement of acute or chronic airway ob\hich\af44\dbch\af31505\loch\f44 
struction. Moreover, iatrogenic injury of the pediatric airway occasionally occurs. The large number of operative techniques for the treatment of tracheal stenosis shows that no single procedure or technique is universally applicable and successful. Preve
\hich\af44\dbch\af31505\loch\f44 n\hich\af44\dbch\af31505\loch\f44 tion of, or prompt therapy for, injury is all-important.
\par \hich\af44\dbch\af31505\loch\f44 PRACTICAL EMBRYOLOGY AND ANATOMY
\par \hich\af44\dbch\af31505\loch\f44 A working knowledge of the embryonic develop\-ment of mediastinal structures aids in understand\-ing the etiology and associated anomalies of tracheal obstruction. Malf\hich\af44\dbch\af31505\loch\f44 
ormations of the great vessels (vas\-
cular rings) should be suspected and investigated when evaluating a child with complete tracheal rings. The most common vascular malformation associated with complete tracheal rings is a pulmonary vascular sling. This a\hich\af44\dbch\af31505\loch\f44 n
\hich\af44\dbch\af31505\loch\f44 
omaly occurs when the left pulmonary artery arises to the right of the trachea, around which it curves and compresses just above the carina, and then passes between the trachea and esophagus before reaching the left lung. Other vascular ring malformations
\hich\af44\dbch\af31505\loch\f44  \hich\af44\dbch\af31505\loch\f44 may produce varying degrees of tracheal, bronchial, and esophageal compression.
\par \hich\af44\dbch\af31505\loch\f44 TRACHEAL MALFORMATIONS Congenital Subglottic Stenosis
\par \hich\af44\dbch\af31505\loch\f44 The anatomy of the pediatric airway has been com\-pared to an inverted cone, with the trachea fitting telescopically into t\hich\af44\dbch\af31505\loch\f44 
he cricoid above it, the cricoid into the thyroid cartilage, and then the thyroid into the hyoid space, as illustrated in Figure 21-2. Congenital subglottic stenosis is the most common morphologic abnormality of the trachea and presents as a narrow\-
ing of\hich\af44\dbch\af31505\loch\f44  \hich\af44\dbch\af31505\loch\f44 
the airway at the distal end of the larynx, just at the beginning of the trachea. This subglottic region lies at the junction of the cricoid cartilage and trachea and is the narrowest point of the child's airway. The cricoid cartilage is the only normally
\hich\af44\dbch\af31505\loch\f44  \hich\af44\dbch\af31505\loch\f44 complete carti\-laginous ring in the airway. Congenital abnormalities of this subglottic area consist of narrowing or malfor\-
mation of the cricoid cartilage, the etiology of which is not truly known.
\par }\pard \ltrpar\qj \fi360\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
When compared with an adult, the anatomy of the trachea a\hich\af44\dbch\af31505\loch\f44 
nd larynx differs in several ways. The child's epiglottis is short and small, and the valleculae are very shallow. Also, the larynx points posteriorly toward the nasopharynx, and the arytenoid apparatus is large in relation to the lumen of the larynx. Fin
\hich\af44\dbch\af31505\loch\f44 a\hich\af44\dbch\af31505\loch\f44 
lly, the narrowest point of the normal pediatric airway is the cricotracheal junction. In the adult, it is the glottis. Cricoid stenosis is exceeded only by laryngomalacia and vocal cord paralysis in the frequency of congenital airway anomalies.
\par \hich\af44\dbch\af31505\loch\f44 In the nor\hich\af44\dbch\af31505\loch\f44 
mal trachea, the cartilaginous rings are horseshoe shaped, with the posterior wall composed of connective tissue and muscle. Thus, the lumen may change as the trachea expands or contracts with res\-piration. Long stenotic segments in the trachea usu\-
ally c\hich\af44\dbch\af31505\loch\f44 o\hich\af44\dbch\af31505\loch\f44 
nsist of tracheal rings that are complete. When the cartilaginous rings are complete, the lumen is rigid and usually much smaller than the normal trachea. If it does not produce early respiratory distress, complete cartilaginous rings may be detected when
\hich\af44\dbch\af31505\loch\f44  \hich\af44\dbch\af31505\loch\f44 an inflam\-
matory process within the trachea produces mucosal edema, which further compromises the rigid lumen and results in acute airway obstruction. Occasionally, tracheal intubation for an elective operative proce\-dure may be impossible and the narrowe
\hich\af44\dbch\af31505\loch\f44 d\hich\af44\dbch\af31505\loch\f44  segment is discovered.
\par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Acquired Subglottic and Tracheal Stenosis
\par \hich\af44\dbch\af31505\loch\f44 Acquired airway malformations usually result from intrinsic injury with subsequent inflammation, ulceration, and scarring, leading to severe subglottic or tracheal scarring and narrowing. Oc
\hich\af44\dbch\af31505\loch\f44 casionally exter\-nal trauma is the initiating event,}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 2}{\rtlch\fcs1 \af44\afs24 
\ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44  but an iatrogenic event can exacerbate an unstable situation. For exam\-
ple, a child with a congenitally small airway might be asymptomatic until an endotracheal tube is inserted. The tube may be of an a\hich\af44\dbch\af31505\loch\f44 
ppropriate size but, because of the congenital stenosis, it will fit tightly and can lead to ulceration and stricture. Particularly difficult to treat are those injuries that occur well below the subglottic region, usually produced by an endotracheal ball
\hich\af44\dbch\af31505\loch\f44 o\hich\af44\dbch\af31505\loch\f44 on that has caused compression and ulceration in the tra\-
chea. Frequently, these areas of injury are below the usual site for a tracheostomy. The cuff may even erode into overlying vessels .
\par \hich\af44\dbch\af31505\loch\f44 VASCULAR COMPRESSIONS
\par \hich\af44\dbch\af31505\loch\f44 Compression and partial obstruction of the \hich\af44\dbch\af31505\loch\f44 
trachea may be caused by abnormalities of the aortic arch that impinge on or encircle the trachea or esophagus or both. When both the trachea and esophagus are compressed, swallowing frequently produces acute airway compression and respiratory distress. V
\hich\af44\dbch\af31505\loch\f44 a\hich\af44\dbch\af31505\loch\f44 scular rings are often asymptomatic in neonates and infants, yet can lead to significant airway obstruction in a child.
\par }\pard \ltrpar\qj \fi360\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
The physiologic impingement on the trachea by a vascular ring is similar to that seen in patients after repair of esophageal atresia. Th\hich\af44\dbch\af31505\loch\f44 e persistently distended upper esophageal pouch can displace the trachea ante\-
riorly, producing tracheomalacia, or softened tracheal rings. Particularly with swallowing, the dis\-tended esophageal pouch may compress the trachea against the innominate arter\hich\af44\dbch\af31505\loch\f44 y\hich\af44\dbch\af31505\loch\f44 
. This sequence of events is thought responsible for a condition called reflex apnea. Consequently, surgical correction of this problem consists of anterior mobili\-
zation and suspension of the innominate artery. The treatment of a pulmonary vascular sling\hich\af44\dbch\af31505\loch\f44  \hich\af44\dbch\af31505\loch\f44 
usually requires not only relocation and reimplanta- tion of the pulmonary artery but also tracheal repair for the stenotic distal trachea. Stridor and dyspnea are symptoms that may be produced by vascular impingement on the trachea. Patients with severe 
\hich\af44\dbch\af31505\loch\f44 c\hich\af44\dbch\af31505\loch\f44 
ompression from a double aortic arch are usually symptomatic, but their manifestations are variable. Some patients are initially seen with frequent coughing and stridor accompanied by dyspnea and cyanosis, whereas small infants may have reflex apnea. The 
\hich\af44\dbch\af31505\loch\f44 s\hich\af44\dbch\af31505\loch\f44 ymptoms of vascular impingement on the trachea are usually more dramatic than those of compression of the esophagus.
\par \hich\af44\dbch\af31505\loch\f44 The diagnosis of vascular ring anomalies has classically been made or suspected from a barium esophagogram with indentations on the esophag\hich\af44\dbch\af31505\loch\f44 
eal column of barium and a decrease in the tracheal air column. Offset of the axis of the barium column above and below the indentation is diagnostic of a double aortic arch. Newer imaging techniques with rapid computed tomographic (CT) scans allow a grap
\hich\af44\dbch\af31505\loch\f44 h\hich\af44\dbch\af31505\loch\f44 
ic reconstruction of the trachea and adjacent vessels. Magnetic resonance imaging (MRI) enhanced with intravenous administration of a contrast agent allows excellent visualization of the trachea and vessels.
\par \hich\af44\dbch\af31505\loch\f44 Occasionally, a child will appear with acute air\-\hich\af44\dbch\af31505\loch\f44 
way obstruction or other medical problems requiring intensive care, during which endotracheal intubation and a concomitant nasogastric tube are inserted. The presence of tubes in both airway and esophagus makes detection of a vascular ring difficult and 
\hich\af44\dbch\af31505\loch\f44 c\hich\af44\dbch\af31505\loch\f44 an gener\-
ate complications. In a child who is already intubated, performance of contrast radiographic procedures may not be possible. Ultrasonography or CT and contrast- enhanced MRI may delineate the vascular abnormal\-ity. When both tracheal and esophage
\hich\af44\dbch\af31505\loch\f44 a\hich\af44\dbch\af31505\loch\f44 
l intubations are necessary in a patient with a double aortic arch, the encircling vessels may sustain pressure necrosis. Erosion into the aortic arch produces an acute aorto- esophageal fistula that may not be manifest until either the endotracheal or th
\hich\af44\dbch\af31505\loch\f44 e\hich\af44\dbch\af31505\loch\f44 
 esophageal tube is removed. A sentinel hemorrhage may occur before a massive, and often fatal, hemorrhage into the esophagus. The passage of a Sengstaken-Blakemore tube with inflation of the esophageal balloon can be lifesaving by tam- ponading the fistu
\hich\af44\dbch\af31505\loch\f44 l\hich\af44\dbch\af31505\loch\f44 
a. Because no reliable diagnostic study is available to demonstrate an aortoesophageal fistula, the observation of a sentinel hemorrhage in such a patient with ultrasound confirmation of a dou\-
ble aortic arch is a clear indication for urgent cardio- pulmo\hich\af44\dbch\af31505\loch\f44 n\hich\af44\dbch\af31505\loch\f44 ary bypass and repair.
\par \hich\af44\dbch\af31505\loch\f44 Vascular rings cause airway constriction and not vascular problems. Thus, simple division of the vascu\-lar ring is often not enough to relieve tracheal com\-
pression. Significant numbers of patients are now being treated by the thorac\hich\af44\dbch\af31505\loch\f44 oscopic approach. A vessel that continues to compress the airway must not be dis\-
sected away from the trachea but suspended anteriorly, often to the back of the sternum, so that the vascular tracheal attachments will lift the anterior tracheal wall and en\hich\af44\dbch\af31505\loch\f44 l\hich\af44\dbch\af31505\loch\f44 
arge the lumen . Regardless of the approach, from the right or from the left, or other technical variations, the recurrent laryngeal and phrenic nerves must be identified and protected. Flex\-
ible endoscopic observation of the trachea during these maneuver\hich\af44\dbch\af31505\loch\f44 s\hich\af44\dbch\af31505\loch\f44  can corroborate relief of the compression.
\par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 TRACHEOMALACIA
\par \hich\af44\dbch\af31505\loch\f44 Often tracheomalacia is produced by the constant pres\-\hich\af44\dbch\af31505\loch\f44 
sure of a cardiovascular structure. Thus, it is almost always necessary to suspend the offending vessel and utilize its attachments to the trachea to expand the tra- cheal lumen. Occasionally, tracheomalacia can be pri\-
mary in nature and there is no obvio\hich\af44\dbch\af31505\loch\f44 u\hich\af44\dbch\af31505\loch\f44 s compression. In these cases, suspension of the large mediastinal ves\-sels may enlarge the tracheal lumen.}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 18-21}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
 Interestingly in the United Kingdom (Scotland), guidelines have been promulgated for the use of thoracoscopic aor- topexy to treat severe prima\hich\af44\dbch\af31505\loch\f44 ry tracheomalacia.}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 22}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
 The National Health Service believed that these guidelines were necessary because individual surgeons would operate infrequently on infants and children who are good candidates for operative correction.
\par \hich\af44\dbch\af31505\loch\f44 INFLAMMATORY OBSTRUCTIONS
\par \hich\af44\dbch\af31505\loch\f44 Viral \hich\af44\dbch\af31505\loch\f44 laryngotracheitis (croup), bacterial or membranous tracheitis, and epiglottitis are inflammatory condi\-
tions that may require surgical intervention. The acute inflammatory airway process may progress rapidly to a life-threatening obstruction and require e\hich\af44\dbch\af31505\loch\f44 m\hich\af44\dbch\af31505\loch\f44 
ergency tracheostomy. However, in all cases of inflammatory obstruction, endotracheal intubation before trache- ostomy is advisable, if at all possible. It is important to distinguish croup and bacterial tracheitis from epiglottitis because the treatments
\hich\af44\dbch\af31505\loch\f44  \hich\af44\dbch\af31505\loch\f44 are quite different .
\par }\pard \ltrpar\qj \fi360\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
Children with epiglottitis characteristically toler\-ate endotracheal intubation without airway injury because the inflammation and edema are supraglot- tic and not circumferential. They do, however, present more risks of intubation fa
\hich\af44\dbch\af31505\loch\f44 ilure because of the severe edema of the epiglottis. Some hospitals have strict pro\-tocols requiring diagnostic laryngoscopy in the operat\-
ing room with anesthesia standby for suspected cases of epiglottitis because an emergency tracheostomy is occasional\hich\af44\dbch\af31505\loch\f44 l\hich\af44\dbch\af31505\loch\f44 
y necessary. Conversely, with viral or bacterial laryngotracheitis, the inflammatory pro\-cess involves the entire circumference of the airway and prolonged intubation may lead to permanent scarring.
\par \hich\af44\dbch\af31505\loch\f44 Croup characteristically occurs during viral seasons in c\hich\af44\dbch\af31505\loch\f44 
hildren age 3 months to 3 years. Children in whom the classic "croupy" cough develops frequently have a history of an antecedent respiratory infection, usu\-ally with a high fever.}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 24}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
 Bacterial tracheitis, a nonviral infectious disease, is seen with fever an\hich\af44\dbch\af31505\loch\f44 d rapid devel\-
opment of upper airway obstruction, characterized by copious mucopurulent secretions. Epiglottitis typically affects children who are age 2 to 6 years and have sore throat and dysphagia. Consequently, speech may be slurred and drooling of sa
\hich\af44\dbch\af31505\loch\f44 l\hich\af44\dbch\af31505\loch\f44 iva is prominent. Lat\-eral radiographs of the neck may show an edematous epiglottis.
\par \hich\af44\dbch\af31505\loch\f44 Fortunately, most of these inflammatory processes are now controlled with antibiotics and respiratory care without surgical intervention. Treatment includes oxygen with in\hich\af44\dbch\af31505\loch\f44 
creased humidification and inhala\-tion of racemic epinephrine. Endotracheal intubation is well tolerated in epiglottitis and usually causes no further injury while antibiotic therapy produces reso\-
lution of the epiglottic edema. However, in cases of viral\hich\af44\dbch\af31505\loch\f44  \hich\af44\dbch\af31505\loch\f44 
or bacterial tracheitis, even brief (24-48 hours) intubation may cause ulceration in a trachea that is already acutely inflamed and swollen. Therefore, it may be best to use endotracheal intubation to estab\-
lish a definitive diagnosis. If resolution does \hich\af44\dbch\af31505\loch\f44 n\hich\af44\dbch\af31505\loch\f44 ot occur within 48 to 72 hours, a temporary tracheostomy may be advisable.
\par \hich\af44\dbch\af31505\loch\f44 The decreasing incidence of epiglottitis is probably due to the increasing use of immunization against Hae\-mophilus influenzae type b, the most common causative organism. Other infe\hich\af44\dbch\af31505\loch\f44 
ctious organisms, however, may produce the typical epiglottic swelling. Intu\-bation is usually not necessary for more than 24 to 48 hours until antibiotics can control the infection. Croup also is now more easily treated without intu\-
bation with racemic e\hich\af44\dbch\af31505\loch\f44 p\hich\af44\dbch\af31505\loch\f44 inephrine inhalation combined with administration of dexamethasone, 0.6 mg/kg, either orally, intramuscularly, or intravenously.
\par \hich\af44\dbch\af31505\loch\f44 Regardless of the cause of the inflammatory pro\-cess, rapid obstruction of the airway can occur in a small child. The surgeon m\hich\af44\dbch\af31505\loch\f44 
ust be prepared to work with the anesthesiologist and pediatrician to establish an airway by endotracheal intubation, bronchoscopy, or tracheostomy.
\par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 TRACHEOSTOMY
\par \hich\af44\dbch\af31505\loch\f44 Our experience has been that tracheostomy with a lin\-ear tracheal incision through the second,\hich\af44\dbch\af31505\loch\f44  third, and, possibly, fourth rings without excising any of the ante\-
rior wall of the trachea is the preferred technique in children. Cruciate incisions should not be used because the flaps created may be inverted and narrow the lumen. However, some surge\hich\af44\dbch\af31505\loch\f44 o\hich\af44\dbch\af31505\loch\f44 
ns continue to espouse a technique called Starplasty. Cruciate incisions in the skin and the anterior tracheal wall are sutured together to produce a permanent ostomy. This technique should be reserved for permanent tracheostomy because operative closure 
\hich\af44\dbch\af31505\loch\f44 i\hich\af44\dbch\af31505\loch\f44 s necessary when a tracheostomy tube is no longer needed.
\par }\pard \ltrpar\qj \fi360\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
Tracheostomy is best performed with an endotracheal tube in place so that the airway is controlled. A transverse incision made in the lower neck is deep\-ened to allow lateral retraction of the strap\hich\af44\dbch\af31505\loch\f44 
 muscles after the midline is opened. This dissection is then car\-
ried down to the trachea. In small children, palpation of the ridges of the tracheal cartilages is frequently more valuable than visualization for determining the appropriate level of trach\hich\af44\dbch\af31505\loch\f44 e
\hich\af44\dbch\af31505\loch\f44 otomy. The incision in the trachea is made below the thyroid isthmus, no higher than the second ring. The tracheostomy tube specifi\-
cations are illustrated in Table 21-3. Traction sutures of polypropylene, left long and labeled "Left" and "Right," allow e\hich\af44\dbch\af31505\loch\f44 a\hich\af44\dbch\af31505\loch\f44 sier reintubation in the event of acci\-
dental dislodgement within the first week. If the tra- cheostomy has been in place for longer than 2 weeks, bronchoscopy can be helpful during decannulation.
\par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
A large granuloma frequently develops at the superior rim o\hich\af44\dbch\af31505\loch\f44 f the tracheostomy stoma and may need endoscopic excision.
\par \hich\af44\dbch\af31505\loch\f44 TRACHEAL REPAIR Congenital Stenosis
\par \hich\af44\dbch\af31505\loch\f44 Most congenital obstructions have a cartilaginous base but also have a fibrous tissue component. As men\-tioned earlier, many congenital stenotic lesions in the a\hich\af44\dbch\af31505\loch\f44 
irway are asymptomatic until an acute event such as an injury, acute tracheal inflammation, or endo- tracheal intubation. At that point, the constriction of the airway becomes symptomatic. Complete tracheal rings may first be suspected when the child requ
\hich\af44\dbch\af31505\loch\f44 i\hich\af44\dbch\af31505\loch\f44 res an anesthetic and an endotracheal tube meets a tra- cheal obstruction.
\par }\pard \ltrpar\qj \fi360\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
For treatment of long-segment obstruction from complete tracheal rings, we have devised a procedure in which either the KTP or CO}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\sub\langnp1058\insrsid1786095 
\hich\af44\dbch\af31505\loch\f44 2}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44  laser is used to divide each complete cartilaginou\hich\af44\dbch\af31505\loch\f44 
s ring in the posterior mid\-line.}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 41}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44  With an endoscopic balloon, the trachea is grad\-
ually dilated as the rigid bronchoscope is advanced. When all complete rings have been divided, a tube is inserted to serve as a stent. If long-term stenting is required, a\hich\af44\dbch\af31505\loch\f44 
 T-tube is used (see later). If this procedure is done carefully without forceful dilation, no air leak should occur because the esophagus posteriorly fills the gap in the posterior tracheal wall. With a short seg\-
ment of complete rings, resection and ana\hich\af44\dbch\af31505\loch\f44 s\hich\af44\dbch\af31505\loch\f44 
tomosis has been accepted as effective therapy, but few surgeons have a large experience with this technique. Other groups have used resection for long and short lesions but are now considering slide tracheoplasty. An improvement on standard resection pro
\hich\af44\dbch\af31505\loch\f44 c\hich\af44\dbch\af31505\loch\f44 
edures, slide tracheoplasty allows reconstruction without tension. The narrowed segment is transected in its midportion, and the remaining stenotic segments are incised. One end of the trachea is opened in the pos\-
terior midline, and the other is incised \hich\af44\dbch\af31505\loch\f44 i\hich\af44\dbch\af31505\loch\f44 n the anterior midline. Long-term evaluation has been satisfactory.}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44  }{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
The diameter of the resulting anastomosis is broad enough to avoid airway narrowing.
\par \hich\af44\dbch\af31505\loch\f44 Some surgeons have compared laryngotracheal reconstruction with cricotracheal resection and at\-tempted \hich\af44\dbch\af31505\loch\f44 
to categorize the indications for each pro- cedure. The surgical therapy for these patients continues to evolve, as evidenced by a recent review of 50 patients treated for congenital tracheal stenosis at a single institution over an 18-year span (1982 - 2
0\hich\af44\dbch\af31505\loch\f44 00).}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44  }{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Although the operation originally preferred was peri- cardial tracheoplasty, four procedures were com\-
pared: pericardial-patch tracheoplasty (28 patients), tracheal autograft (12 patients), tracheal resection (8 patients), and slide tracheoplasty (2 p\hich\af44\dbch\af31505\loch\f44 
atients). These authors concluded that their operation of choice for short segments would be resection. Resection with tracheal autograft was preferred for long-segment ste\-noses (more than eight rings). In this latter proce\-
dure, the stenotic trachea is \hich\af44\dbch\af31505\loch\f44 i\hich\af44\dbch\af31505\loch\f44 
ncised anteriorly and the midportion is excised. A primary anastomosis is made posteriorly, and the anterior defect is closed with a free autograft fashioned from the excised trachea. Others have used human cadaver tracheal allografts for recon- struction
.\hich\af44\dbch\af31505\loch\f44  The ideal surgical treatment for congeni\-tal tracheal stenosis has not yet been devised.
\par \hich\af44\dbch\af31505\loch\f44 Anterior cricoid split is a procedure that is useful in treating moderate subglottic stenosis in neonates and young infants. Infants selected for the anterior cri- co\hich\af44\dbch\af31505\loch\f44 
id split procedure should weigh more than 1500 g and require assisted ventilation or inspired oxygen of more than 35%. They should also not be in cardiac failure. This technique is illustrated in Figure 21-15.}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44  }{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
Proper selection of patients for anterior cric\hich\af44\dbch\af31505\loch\f44 
oid split is crucial. After anterior cricoid split, those infants who can be successfully extubated have excellent long-term outcomes, whereas those who continue to need intubation will require tracheostomy.
\par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Open Laryngotracheoplasty
\par \hich\af44\dbch\af31505\loch\f44 Many variations exist \hich\af44\dbch\af31505\loch\f44 in the operative techniques of procedures available for tracheal reconstruction for a scarred and stenotic trachea. First, an open pro\-
cedure can be done with or without cardiopulmo- nary bypass. Recently, there has been a tendency to avoid bypass and use\hich\af44\dbch\af31505\loch\f44  \hich\af44\dbch\af31505\loch\f44 
only endotracheal anesthesia. Second, the repair can be performed with or without an augmentation graft. The grafts may include tra- cheal autografts, costal cartilage, cartilage from other sites such as thyroid or alar cartilage, autologous or allogeneic
\hich\af44\dbch\af31505\loch\f44  \hich\af44\dbch\af31505\loch\f44 pericardium, skin, and tracheal allografts. Third, a stent may be used to maintain the lumen and can remain in place for hours, days, months, or years.
\par }\pard \ltrpar\qj \fi360\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 When open laryngotracheoplasty is performed with
\-out a cartilage graft, it is essentially a cricoid spli\hich\af44\dbch\af31505\loch\f44 t or the expansion of the lumen with the use of a castellated
\par \hich\af44\dbch\af31505\loch\f44 The classic cartilage laryngotracheoplasty utilizes a cartilage graft. An omental flap may help a long cartilaginous graft survive. The cartilage is inserted anteriorly after incising the stenot
\hich\af44\dbch\af31505\loch\f44 
ic seg- ment. Cartilage inserts also can be placed posteriorly and laterally in sites where the stenotic cricoid is incised. Ciliated mucosa has been found on the surface of a mature costal cartilage graft if the perichondrium faces the airway lumen. Anot
\hich\af44\dbch\af31505\loch\f44 h\hich\af44\dbch\af31505\loch\f44 er option is resection and pri\-mary anastomosis. The stenotic portion of the trachea is excised, and an end-to-end anastomosis is performed.
\par \hich\af44\dbch\af31505\loch\f44 A slide tracheoplasty uses autologous trachea by dividing the trachea in the midportion of the stenotic segment. Th\hich\af44\dbch\af31505\loch\f44 
e upper and lower portions of the stenosis are incised in the midline, one anteriorly and the other posteriorly, and the anastomosis is then performed.}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 
\hich\af44\dbch\af31505\loch\f44  }{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
Another option for repair of tracheal stenosis is by anterior incision and closure of the defect with pe\hich\af44\dbch\af31505\loch\f44 
ricardium. All pericardial patch operations are done on cardiopulmonary bypass. However, experience at some centers has not been as good because of com\-
plications secondary to patch collapse. The original proponents of pericardial patching have now report\hich\af44\dbch\af31505\loch\f44 e\hich\af44\dbch\af31505\loch\f44 
d improved results with a free tracheal autograft in which the excised stenotic segment is flattened and used as a free anterior autograft to expand the lumen at the anastomosis.
\par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 CONGENITAL BRONCHOPULMONARY MALFORMATIONS
\par \hich\af44\dbch\af31505\loch\f44 A variety of developmental abnormal\hich\af44\dbch\af31505\loch\f44 ities of the tra\-
cheobronchial tree and pulmonary parenchyma are found in the newborn. Some of these have a genetic basis and produce widespread physiologic ab\-normalities. Many of these, such as surfactant protein deficiency, alveolar capillary dysplasia,
\hich\af44\dbch\af31505\loch\f44  and general\-
ized pulmonary hypoplasia, are newly described and are not in the traditional scope of care of the pediatric surgeon. Thus, they are not addressed in this chapter. In this chapter, the more focal anatomic abnormali\-ties of the foregut and its
\hich\af44\dbch\af31505\loch\f44  \hich\af44\dbch\af31505\loch\f44 
anlagen, traditionally termed bronchopulmonary malformations (BPMs), are covered. Although these lesions have been recognized for years and grouped as related for discussion purposes, no uni\-
form pathologic or embryologic reason exists for this clustering.\hich\af44\dbch\af31505\loch\f44  Rather, this grouping remains appropriate to facilitate an understanding of the common clinical presentation and management of BPMs.
\par }\pard \ltrpar\qj \fi360\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
With the advent of near-routine prenatal ultraso- nography, a great deal has been learned about the nat\-ural history and pathophysiology of BPMs. Currently, ultrasound findings are altering many of the con\-
ventional beliefs and understanding of these lesi\hich\af44\dbch\af31505\loch\f44 o\hich\af44\dbch\af31505\loch\f44 ns. Moreover, prenatal identification and a more accu\-
rate depiction of their natural history have given rise to advanced fetal interventions. The lessons learned from prenatal ultrasonography have also affected the postnatal management of cystic lung les\hich\af44\dbch\af31505\loch\f44 i
\hich\af44\dbch\af31505\loch\f44 
ons, because previously unrecognized and likely clinically silent malformations are being detected with ever greater frequency. Still, despite these advances, BPMs defy a common embryologic classification and, as a whole, their pathophysiology remains var
\hich\af44\dbch\af31505\loch\f44 i\hich\af44\dbch\af31505\loch\f44 ed.
\par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 EMBRYOLOGY AND CLASSIFICATION
\par \hich\af44\dbch\af31505\loch\f44 The traditional understanding is that the tracheo- bronchial tree and proximal gastrointestinal tract arise from a common foregut anlagen. At the end of the third week of gestation, the laryngotracheal groove or diverticul
\hich\af44\dbch\af31505\loch\f44 um can be seen in the caudal end of the
\par \hich\af44\dbch\af31505\loch\f44 embryonic foregut. This groove arises as a ventral enlargement of the foregut and then grows caudad to form the primordium of the trachea and lung bud. This outgrowth of endoderm is ventral and in parallel with the m
\hich\af44\dbch\af31505\loch\f44 
ore dorsal portion of the foregut or future esophagus. Next, the lateral walls of the foregut, now called longitudinal ridges, begin to approximate in the midline, forming the tracheoesophageal septum. The separation of the dorsal esophagus and the more v
\hich\af44\dbch\af31505\loch\f44 e\hich\af44\dbch\af31505\loch\f44 
ntral tracheobronchial tree is thought to be caused by this tracheoesophageal septum and is complete by the sixth week of gestation. If this process fails or is incomplete, congenital defects affecting the trachea, conducting airways, or esophagus may res
\hich\af44\dbch\af31505\loch\f44 u\hich\af44\dbch\af31505\loch\f44 lt.
\par }\pard \ltrpar\qj \fi360\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
Some now question this traditional embryologic description.}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 4}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44  Several lines of evidence tend to refute these long-held beliefs. With the use of scanning elec\-\hich\af44\dbch\af31505\loch\f44 
tronic microscopy at various stages of development, findings in chick embryos have described a paired caudal "lung bud" diverticulum with no identifiable tracheal primordium.}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 4}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44  Even more elusive is the devel
\-opmental program of the lung primordia after sepa\hich\af44\dbch\af31505\loch\f44 ra\-tion from the foregut anlagen, which occurs between 6 and 16 weeks' gestation. Current advances in molecu\-
lar biologic techniques, including conditional mutants and transgenic mice, have allowed a more in-depth investigation and understanding of the mo\hich\af44\dbch\af31505\loch\f44 l\hich\af44\dbch\af31505\loch\f44 ecular reg\-
ulators of airway and pulmonary parenchymal devel\-opment. In more generalized terms, the epithelium of the trachea, bronchi, and alveoli originate from endoderm, whereas muscle and cartilage originate from mesoderm.}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 2}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44  Subsequent epithelial mesenc
\hich\af44\dbch\af31505\loch\f44 hymal interactions result in the changes of branching mor\-phogenesis and yield site-specific specialized epithelia for air conduction and gas exchange. Studies in mice have established non-overlapping cell lineages of con
\-ducting airways (trachea and bron\hich\af44\dbch\af31505\loch\f44 c\hich\af44\dbch\af31505\loch\f44 hi) as being distinct from those of peripheral airways (bronchioles, acini, and alveoli), well before formation of the definitive lung buds.}{
\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 78}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 
\hich\af44\dbch\af31505\loch\f44  Similarly, studies in knockout mice and conditional mutants have revealed the involvement of many of the secreted\hich\af44\dbch\af31505\loch\f44 
 protein morphogens involved in organogenesis throughout mammalian development, such as members of the BMP, FGF, Hhh, and Wnt families.
\par \hich\af44\dbch\af31505\loch\f44 Knowledge of this embryology serves to elucidate the reasons for the frequent consideration of the close relation betwee\hich\af44\dbch\af31505\loch\f44 n anomalies of the proximal gastroin\-
testinal tract and pulmonary system. Congenital BPMs comprise a broad spectrum of clinical lesions from both systems, including esophageal duplications, cystic lung lesions, and anomalies of solid pulmonary paren\-chyma\hich\af44\dbch\af31505\loch\f44  
\hich\af44\dbch\af31505\loch\f44 with abnormal vascular supply. Classification of congenital BPMs therefore is not easy from either a morphologic or an embryologic standpoint. A sim\-
plified listing of BPMs by anatomic location becomes the most useful classification system for the clinici\hich\af44\dbch\af31505\loch\f44 a\hich\af44\dbch\af31505\loch\f44 n charged with managing the myriad presentations and diagnoses.
\par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 POSTNATAL MANAGEMENT
\par \hich\af44\dbch\af31505\loch\f44 Several fetal anomalies can be confused with CPAMs and BPSs.}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 3}{\rtlch\fcs1 \af44\afs24 
\ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44  Chief among these are CDHs, broncho- genic and enteric cysts, mediastinal cystic teratomas, congenital lobar \hich\af44\dbch\af31505\loch\f44 
emphysema (CLE), and bronchial
\par \hich\af44\dbch\af31505\loch\f44 atresia.}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 31-34}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 
\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
 Smaller lesions may be asymptomatic at birth. Before the increased use of prenatal ultrasonog- raphy, many of these lesions went unnoticed, even on perinatal chest radiography. Current practice is to obtain comp\hich\af44\dbch\af31505\loch\f44 
uted tomography (CT) of the chest either before discharge or in the first several weeks of life. Planned elective resection of asymptomatic CPAMs and BPSs is recommended, given the accumulating evidence for the risks of either infection or occult malignan
\hich\af44\dbch\af31505\loch\f44 t\hich\af44\dbch\af31505\loch\f44  trans\-formation.}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 3,35-38}{\rtlch\fcs1 \af44\afs24 
\ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44  However, this remains debatable and practice patterns are still evolving for the small asymp\-
tomatic lesions. Moderate-sized lesions may cause some respiratory embarrassment at birth, either from hyper\-inflation or from the seconda\hich\af44\dbch\af31505\loch\f44 
ry mass effects on normal lung. The traditional postnatal management of planned delivery with multidisciplinary neonatal evaluation, stabilization, and eventual excision has produced an excellent overall prognosis. On rare occasions when severe perinatal 
\hich\af44\dbch\af31505\loch\f44 r\hich\af44\dbch\af31505\loch\f44 espiratory distress is anticipated, a strategy using ECMO has been described.}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 
\hich\af44\dbch\af31505\loch\f44 1315}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 
\par \hich\af44\dbch\af31505\loch\f44 BRONCHOPULMONARY SEQUESTRATION
\par \hich\af44\dbch\af31505\loch\f44 Sequestrations should be distinguishable from CPAMs by their pathologic, radiologic, and clinical characteristics. A pulmonary sequestration is\hich\af44\dbch\af31505\loch\f44 
 classically described as a cystic mass of nonfunctioning lung parenchyma that lacks a demonstrable connection to the tracheobronchial tree. In addition, this sequestered mass of lung tissue receives its blood supply anomalously from the systemic circulat
\hich\af44\dbch\af31505\loch\f44 i\hich\af44\dbch\af31505\loch\f44 on. However, as with many of these lesions, exceptions are common, with a wide variety of arterial supply and venous drainage com\-
binations being described. Because of the anomalous blood supply, many believe the true embryologic derivation of these lesio\hich\af44\dbch\af31505\loch\f44 n\hich\af44\dbch\af31505\loch\f44 s should classify them as vas\-
cular anomalies. However, because the majority of the clinical symptoms are respiratory, we continue to clas\-sify these as lung lesions. Sequestrations are largely solid lesions. Pathologically, these lesions demonstrate pare
\hich\af44\dbch\af31505\loch\f44 n\hich\af44\dbch\af31505\loch\f44 chymal maldevelopment, reflected as microcys- tic abnormalities similar to type II microcystic CPAMs.
\par }\pard \ltrpar\qj \fi360\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
Sequestrations are typically classified as either intralobar or extralobar. If the lesion is contained within the same investing pleura as nor\-mal lung, i\hich\af44\dbch\af31505\loch\f44 
t is intralobar. Extralobar lesions are found outside the investing parietal pleura of adjacent nor\-
mal lung. Intralobar sequestrations are usually found in the lower lobe basilar segments and are more common in the patient's left hemithorax. Extralobar l\hich\af44\dbch\af31505\loch\f44 e\hich\af44\dbch\af31505\loch\f44 
sions have a more variable occurrence pattern. However, their typical location is also basilar, below the more normally formed lung. Extralobar lesions also have been found in the upper thorax, below the diaphragm in the upper abdomen, throughout the medi
\hich\af44\dbch\af31505\loch\f44 a\hich\af44\dbch\af31505\loch\f44 
stinum, and within the pericardium. Many sequestrations are asymptomatic. Given the lack of communication to the tracheobronchial tree, infectious complications most likely develop from hematogenous seeding. Extralobar sequestrations are frequently identi
\hich\af44\dbch\af31505\loch\f44 f\hich\af44\dbch\af31505\loch\f44 
ied as an incidental finding, with approximately 15% occurring below the diaphragm and, not infrequently, in association with a left-sided CDH. The radiographic findings for either intralobar or extralobar sequestrations are usually that of an opacified s
\hich\af44\dbch\af31505\loch\f44 o\hich\af44\dbch\af31505\loch\f44 
lid lung mass or a cystic parenchymal lesion with an air-fluid level secondary to infection. Intralobar BPS accounts for the majority of lesions overall, yet extralobar lesions are more likely to have other associated anomalies in as many as 50% to 65% of
\hich\af44\dbch\af31505\loch\f44  \hich\af44\dbch\af31505\loch\f44 
cases. The most commonly recognized anomalies associated with BPS, in addition to CDH, include diaphragmatic eventration and other foregut malformations such as tracheoesophageal fistula and esophageal duplication.
\par \hich\af44\dbch\af31505\loch\f44 Historically, angiography was performed t\hich\af44\dbch\af31505\loch\f44 o confirm the anomalous systemic blood supply and to help in planning surgical management. Currently, the hall\-
mark anomalous vascular supply can be identified by Doppler ultrasonography, CT, or MR angiography or a combination of these modalities. Typical\hich\af44\dbch\af31505\loch\f44 l\hich\af44\dbch\af31505\loch\f44 
y, a single large feeding vessel arising from the abdominal aorta is. This vessel can be typically found within a pedicle or stalk. However, not infrequently, more than one major vessel is found to supply the sequestration. The venous anatomy may be even 
\hich\af44\dbch\af31505\loch\f44 m\hich\af44\dbch\af31505\loch\f44 ore variable, with systemic, bronchial, and azygous system involvement. If a bronchus is found within the pedicle, communication with the gastrointestinal tract should be sought.
\par }\pard \ltrpar\qj \fi720\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af44\afs24 \ltrch\fcs0 \b\f44\fs24\cf1\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Atresia of esophagus
\par }{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\cf1\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Development of esophagus in an embrionic period, violati\hich\af44\dbch\af31505\loch\f44 
on of processes of vacuolization at the solid stage of development of intestinal tube. Frequency of supervision of anomaly of development. VACTERL- association.
\par \hich\af44\dbch\af31505\loch\f44 Types of atresia of esophagus. Clinical symptoms: foamy excretions, excessive salivation, aspir\hich\af44\dbch\af31505\loch\f44 ation, asphyxia, respiratory disorders, respirator distress-syndrome, pneumonia.
\par \hich\af44\dbch\af31505\loch\f44 Tracheoesophageal fistulasin newborns with atresia and without atresia of esophagus.
\par \hich\af44\dbch\af31505\loch\f44 \hich\f44 Diagnostics: insertion of gastric tube, Elephant's test, X-ray with contrast catheter, p\'cd-\hich\af44\dbch\af31505\loch\f44 metry.
\par \hich\af44\dbch\af31505\loch\f44 
Preoperative preparation, its volume and duration. Operative treatment: retropleural access, mobilization of segments of esophagus, direct anastomosis with liquidation of fistula. Indications for multistage operations: esophagostomy, gastrostomy, pl
\hich\af44\dbch\af31505\loch\f44 astic operation on an esophagus with antireflux defence.
\par \hich\af44\dbch\af31505\loch\f44 Postoperative period, possible complications: pneumonia, insolvency of anastomosis, mediastinitis, pleurisy, pyopneumothorax, atelectssis, fistule recanalisation, stenosis of anastomosis. Proper tact
\hich\af44\dbch\af31505\loch\f44 ic at complications.
\par \hich\af44\dbch\af31505\loch\f44 Gastroesophageal reflux, conservative and operative medical treatment.
\par }{\rtlch\fcs1 \ab\af44\afs24 \ltrch\fcs0 \b\f44\fs24\cf1\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Diaphragmatic hernia
\par }{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\cf1\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
Development of diaphragm and origin of defects in a diaphragm. Classification of diaphragmatic hernia by Dolesky. Degree of hypoplasia of pulmo\hich\af44\dbch\af31505\loch\f44 nary tissue.
\par \hich\af44\dbch\af31505\loch\f44 Clinical symptoms: violation of breathing, disorders of digestion, cardiac  insufficiency,"asphictic obstruction " by Doletsky.
\par \hich\af44\dbch\af31505\loch\f44 Hernia of the esophagus (hiatus hernia) is followed with a sick syndrome, anaemia as a result of bleeding. At hernia of anterior\hich\af44\dbch\af31505\loch\f44  part of diaphragm there is a deformation of sternum, pain.

\par \hich\af44\dbch\af31505\loch\f44 Diagnostics of application of roentgenologic examination with the contrast material, ultrasound.
\par \hich\af44\dbch\af31505\loch\f44 Differential diagnostics: hemorrhagic syndrome, lobar emphysema, cysts of lungs, spontaneous pneump\hich\af44\dbch\af31505\loch\f44 thorax.
\par \hich\af44\dbch\af31505\loch\f44 Diaphragmatic  hernia and absolute indications to operative interference. Accesses: laparotomy, thoracotomy.
\par \hich\af44\dbch\af31505\loch\f44 Preoperative preparation during 12-32 hours till a stabilization of indexes of hemodynamics, blood gases and adequate diuresis.
\par \hich\af44\dbch\af31505\loch\f44 The volume \hich\af44\dbch\af31505\loch\f44 
of operation is determined by the type of anomaly of development: plastic of diaphragm, suturing of diaphragm, its fixation to a  muscular tissues or ribs, in case of diaphragmatic aplasia \hich\f44 \endash \loch\f44  synthetic transplontat.
\par \hich\af44\dbch\af31505\loch\f44 General mortality (14-30%) and its reason\hich\af44\dbch\af31505\loch\f44 s.
\par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 SURGICAL MANAGEMENT OF CONGENITAL PULMONARY }{
\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \scaps\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 airway}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 
\hich\af44\dbch\af31505\loch\f44  MALFORMATION AND BRONCHOPULMONARY SEQUESTRATION
\par \hich\af44\dbch\af31505\loch\f44 Although somewhat debatable, the finding of a CPAM or BPS, regardless of symptoms, is an indication for resection, given the risk of either infection or m\hich\af44\dbch\af31505\loch\f44 alig\-
nant transformation. In an asymptomatic newborn, the resection can be electively performed at 3 to 6 months of age. Both pleuropulmonary blastoma and bronchoalveolar carcinoma have been reported in infants, children, and adults with known CPAMs. The 
\hich\af44\dbch\af31505\loch\f44 p\hich\af44\dbch\af31505\loch\f44 reoperative chest CT can help in planning the operative approach. Traditionally, a lateral thora\-cotomy has been performed, depending on the loca\-
tion of the target lesion. Either a lobectomy, or less frequently, a segmentectomy allows complete removal of\hich\af44\dbch\af31505\loch\f44  \hich\af44\dbch\af31505\loch\f44 the majority of these lesions. For extralobar seques\-
trations, the preoperative imaging and localizing stud\-ies are even more important, given the possibility that some lesions are located below the diaphragm. Obvi\-ously, for extralobar lesions, a nonanat\hich\af44\dbch\af31505\loch\f44 o
\hich\af44\dbch\af31505\loch\f44 mic resection is possible and is facilitated by the stalk or pedicle-like nature of the feeding vessel.
\par }\pard \ltrpar\qj \fi360\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
Over the past decade, the thoracoscopic approach for resection of CPAMs and BPSs has been well described. The advantages of this approach include a redu\hich\af44\dbch\af31505\loch\f44 
ction in postoperative pain, decrease in hospital stay, improvement in cosmesis, and, importantly, the avoidance of morbidities (namely, musculoskeletal complications) associated with a thoracotomy. The first large series of thoracoscopic pulmonary proce
\-\hich\af44\dbch\af31505\loch\f44 d\hich\af44\dbch\af31505\loch\f44 ures in infants and children was reported in 2000.}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44  }{
\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 The vast majority of the 113 cases reported were pul\-
monary biopsies and wedge resections. Lobectomies were performed with a hybrid technique of directed thoracoscopy and mini-thoracotomy. This report pre\-\hich\af44\dbch\af31505\loch\f44 
dated many of the instruments that are currently used for hemostasis and tissue sealing. The Ligasure (Tyco, Inc., Norwalk, CT), for example, also can be used to seal neonatal lung parenchyma when an incom\-
plete fissure is encountered. Since this initial \hich\af44\dbch\af31505\loch\f44 r\hich\af44\dbch\af31505\loch\f44 
eview, numerous reports attesting to the safety and efficacy of the thoracoscopic technique in the management of BPS and CPAM have been published. In a recent report, 65 of the 97 patients underwent thora\-coscopic resection for either CPAM or BPS.}{
\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 53}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 
\hich\af44\dbch\af31505\loch\f44  All bu\hich\af44\dbch\af31505\loch\f44 t 4 of the 97 lobectomies performed were completed thoracoscopically. Three postoperative complications were described (pneumothorax, pneumonia, and per\-
sistent air leak). Postoperative hospitalization averaged 2.4 days in patients who underwent successfu\hich\af44\dbch\af31505\loch\f44 l\hich\af44\dbch\af31505\loch\f44  thora\-
coscopic surgery. In 2007, a two-surgeon experience was published detailing a series of 144 consecutive pediatric lobectomies, 112 of which were performed for CPAM/sequestrations. Lung abnormalities were diagnosed prenatally (by ultrasonography and
\hich\af44\dbch\af31505\loch\f44 /\hich\af44\dbch\af31505\loch\f44 or MRI) and postnatally (by CT). The majority of these resec\-
tions were lower lobectomies, which are technically less difficult than upper lobe resections. The median operating time was 125 minutes, and the median post\-operative hospitalization was 2.8 da\hich\af44\dbch\af31505\loch\f44 y
\hich\af44\dbch\af31505\loch\f44 s. Long-term fol\-low-up (1-10 years) has not revealed any problems with musculoskeletal deformity or weakness.
\par \hich\af44\dbch\af31505\loch\f44 With further evolution in the thoracoscopic tech\-nique, a broader range of lesions, such as bilateral dis\-ease and very large lesions, can be app\hich\af44\dbch\af31505\loch\f44 
roached. On the other hand, it may be best to stage bilateral cases to give the remaining normal lung a period of accommo\-
dation between elective resections. Currently, the main limiting factor for the thoracoscopic approach is the child whose condition i\hich\af44\dbch\af31505\loch\f44 s\hich\af44\dbch\af31505\loch\f44 
 unstable because of the mass effect, because the large size may eliminate the effec\-
tive working space needed for thoracoscopic resection. On occasion, intraoperative cyst rupture has provided the necessary working space for resection by minimal- access \hich\af44\dbch\af31505\loch\f44 t\hich\af44\dbch\af31505\loch\f44 
echniques. An exceedingly large lesion requir\-
ing pneumonectomy also will require additional plans for managing potential pulmonary hypertension or the temporary respiratory insufficiency that can result from pulmonary hypoplasia. ECMO may be useful as a \hich\af44\dbch\af31505\loch\f44 t
\hich\af44\dbch\af31505\loch\f44 emporizing measure in such cases.
\par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 EMPHYSEMATOUS LESIONS
\par \hich\af44\dbch\af31505\loch\f44 On occasion, CLE can be confused with a macrocystic CPAM. Radiographically, CLE appears as overdis\-tention involving one or more lobes .This is believed to be caused by a variant of bronchomalacia wit
\hich\af44\dbch\af31505\loch\f44 h a focal cartilaginous deficiency of the tracheo- bronchial tree, leading to regional airway collapse with expiration.}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 
\hich\af44\dbch\af31505\loch\f44 23}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
 With postnatal air exchange, air trapping behind a structurally inadequate conducting airway leads to these emphysematous changes. Oth\hich\af44\dbch\af31505\loch\f44 
er rare causes include extrinsic compression from anomalous pulmonary vessels or by a very large ductus arterio- sus . In the premature infant with significant respiratory distress syndrome, pulmonary interstitial emphysema, in its more chronic form, can 
\hich\af44\dbch\af31505\loch\f44 e\hich\af44\dbch\af31505\loch\f44 volve into a variant of CLE. One third of cases remain classified as idiopathic.
\par }\pard \ltrpar\qj \fi360\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
The clinical presentation of CLE can be as varied as its numerous causes. With massive lobar overdistention, compression of the normal lung and the mediastinum can cause respi\hich\af44\dbch\af31505\loch\f44 
ratory and cardiovascular collapse. In these cases, emergency thoracotomy is necessary as a lifesaving maneuver. In less dramatic presentations, progressive tachypnea and expansion lead to assisted ventilation and radio- graphic identification of the offe
\hich\af44\dbch\af31505\loch\f44 n\hich\af44\dbch\af31505\loch\f44 ding lesion. Plain chest radiographs and CT scans have been used both for diagnosis and for determining the appropriate\-ness of surgical resection and the boundaries of nor\-
mal lung. In most cases, resection of the abnormal lung allows re-expansion and co\hich\af44\dbch\af31505\loch\f44 m\hich\af44\dbch\af31505\loch\f44 pensatory growth of the normal lung. Expectant management is accept\-
able for the largely asymptomatic lesion. However, complete resolution of the radiographic findings is rare, and, for this reason, surgical resection is indi- cated. The aforementioned co\hich\af44\dbch\af31505\loch\f44 n\hich\af44\dbch\af31505\loch\f44 
cerns of retained secretions as a nidus for infection exist with CLE as for CPAMs.
\par \hich\af44\dbch\af31505\loch\f44 The acquired forms of emphysematous pulmo\-nary lesions generally are first seen in a more time- dependent fashion than are the lesions caused purely by congenital structural\hich\af44\dbch\af31505\loch\f44 
 defects. A history of chronic ventilation of a poorly compliant premature
\par \hich\af44\dbch\af31505\loch\f44 lung precedes the development of pulmonary intersti\-tial emphysema and its sequelae of lobar emphysema or parenchymal cysts. Many of these lesions will resolve spontaneously. Howeve\hich\af44\dbch\af31505\loch\f44 
r, if the mass effect produces some of the same clinical symptoms of com\-
pression of the normal lung and mediastinum, then surgical intervention is indicated. In the most chronic forms of CLE, operative therapy for cystic pulmonary lesions from prolonged \hich\af44\dbch\af31505\loch\f44 v\hich\af44\dbch\af31505\loch\f44 
entilator barotrauma can be quite difficult because little residual normal lung will be available for continued gas exchange.
\par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 LOBULATION ANOMALIES AND ISOMERISM
\par \hich\af44\dbch\af31505\loch\f44 Significant variations of lung anatomy occur with respect to the pattern of lung lobulation. Th\hich\af44\dbch\af31505\loch\f44 
e most common variability is an absent or incomplete fissure separating the anatomic lobes. Absent fissures occur in 30% of individuals, whereas incomplete fissures can be seen in more than half of the general population.}{\rtlch\fcs1 \af44\afs24 
\ltrch\fcs0 \f44\fs24\lang1058\langfe1033\super\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44  }{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
However, these variations do not i\hich\af44\dbch\af31505\loch\f44 
ndicate disordered lobulation and, as such, have no clinical significance, other than to the operating surgeon. True lobulation and segmentation abnormalities can result in extra lobes such as a cardiac lobe (division of the left lower lobe into two separ
\hich\af44\dbch\af31505\loch\f44 a\hich\af44\dbch\af31505\loch\f44 
te lobes) or supersegmentation of the lower lobes. The majority of these anomalies are without clinical relevance. Lobulation anomalies can occur with abnormal bronchial patterns as seen with accessory tracheal lobes with direct airway connection to the t
\hich\af44\dbch\af31505\loch\f44 r\hich\af44\dbch\af31505\loch\f44 achea.
\par }\pard \ltrpar\qj \fi360\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
The azygos lobe is a malformation usually of the right upper lobe that is caused by an aberrant azygos vein that is suspended by pleura and acts as a mes\-entery that produces the defect. These lesions also most likely are clinically silent. Reports 
\hich\af44\dbch\af31505\loch\f44 have men\-
tioned esophageal lung, also termed communicating bronchopulmonary foregut malformation, in which a tract is preserved between the respiratory and alimentary systems. These anomalies are almost always seen in association with esophageal atresia a
\hich\af44\dbch\af31505\loch\f44 n\hich\af44\dbch\af31505\loch\f44 d tracheal ste\-nosis or fistula.
\par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 PULMONARY AGENESIS, APLASIA, AND HYPOPLASIA
\par \hich\af44\dbch\af31505\loch\f44 Pulmonary agenesis is the complete failure of both airway and parenchymal development. Pulmonary aplasia is used to describe the incomplete develop\-ment of lung parenchyma supplie\hich\af44\dbch\af31505\loch\f44 
d by a rudimentary bronchus. Pulmonary hypoplasia is distinguished by a normal tracheobronchial tree and underdeveloped pulmonary parenchyma. Agenesis can occur either unilaterally or bilaterally. In the latter case this would be incompatible with life. I
\hich\af44\dbch\af31505\loch\f44 n\hich\af44\dbch\af31505\loch\f44  cases of unilateral agen\-
esis, frequently other associated severe developmental abnormalities are also found. Most commonly, these include the elements of the VACTERL syndrome. The etiology and embryonic pathophysiology of aplasia and agenesis remain lar
\hich\af44\dbch\af31505\loch\f44 g\hich\af44\dbch\af31505\loch\f44 ely unknown.
\par }\pard \ltrpar\qj \fi360\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 
Pulmonary hypoplasia is the most commonly encountered anomaly of underdeveloped lung paren\-chyma. There are a variety of known causes. The compressive effects of lung, mediastinal, or cardiac masses or herniated abdominal viscera, as seen with
\hich\af44\dbch\af31505\loch\f44  CDH, can result in arrested pulmonary parenchymal develop\-
ment. Other causes include the abnormal mechanical effects of fetal diaphragmatic excursion or fetal lung and amniotic fluid volume. Specifically, abnormal or absent fetal breathing or oligohydram\hich\af44\dbch\af31505\loch\f44 n
\hich\af44\dbch\af31505\loch\f44 ios, with or without renal dysgenesis or obstructive uropathy, can be causative of pulmonary hypoplasia.
\par \hich\af44\dbch\af31505\loch\f44 
The diagnosis and treatment of pulmonary hypo- plasia is dependent on the underlying etiology. For example, severe respiratory impairment can be seen with pulmonary hypoplasia from a CDH. In these cases, stabilization of the underlying physiologic impairm
\hich\af44\dbch\af31505\loch\f44 e\hich\af44\dbch\af31505\loch\f44 nt is the priority. In cases of aplasia or agen\-
esis, the chest radiographs may demonstrate opacification of the ipsilateral hemithorax and an ipsilateral mediastinal shift with volume loss. In addition, asym\-metry of the chest with obviously impaired res\hich\af44\dbch\af31505\loch\f44 p
\hich\af44\dbch\af31505\loch\f44 ira\-
tory movement of the affected side is seen. Treatment is initially directed at any associated anomalies, with particular focus on congenital cardiac lesions. If an operation is needed to remove a nonfunctioning lobe or lung, every effort is made to pr
\hich\af44\dbch\af31505\loch\f44 e\hich\af44\dbch\af31505\loch\f44 
serve functional parenchyma. In cases that render an empty hemitho- rax, consideration should be given to the intrathoracic placement of a tissue expander to prevent significant musculoskeletal disfigurement from the eventual mediastinal and skeletal shif
\hich\af44\dbch\af31505\loch\f44 t\hich\af44\dbch\af31505\loch\f44  toward the volume loss side.
\par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 MEDIASTINAL CYSTS
\par \hich\af44\dbch\af31505\loch\f44 As has been discussed, many of the commonly rec\-ognized congenital bronchial malformations, such as bronchial agenesis, atresia, or stenosis, produce parenchymal abnormalities that distinguish these lesions c
\hich\af44\dbch\af31505\loch\f44 linically. However, a subset of congenital mal\-
formations is unique to the bronchial tree and has been traditionally grouped under the nomenclature of bronchogenic cysts or foregut duplication cysts. As discussed earlier, the embryologic derivation of the\hich\af44\dbch\af31505\loch\f44 s
\hich\af44\dbch\af31505\loch\f44 
e from a common foregut anlagen, their occurrence in the chest, and their most frequent clinical symptoms make their inclusion appropriate in a discussion of BPMs. The nomenclature in common usage remains confusing. In general, the term foregut duplicatio
\hich\af44\dbch\af31505\loch\f44 n\hich\af44\dbch\af31505\loch\f44 
 cyst appropriately links these lesions embryologically as arising from a common developmental structure. When one considers their histologic architecture, these lesions can be divided into three subdivisions: (1) bronchogenic cysts, (2) enteric duplicati
\hich\af44\dbch\af31505\loch\f44 o\hich\af44\dbch\af31505\loch\f44 n cysts, and (3) neuroenteric cysts, all of which reveal their common endodermal origins.
\par }\pard \ltrpar\qj \fi360\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 \hich\af44\dbch\af31505\loch\f44 Bronchogenic cysts are lined by respiratory bron
\-chial epithelium, are mucus filled, and may contain cartilage in their walls. Enteric duplication cysts are lined by \hich\af44\dbch\af31505\loch\f44 intestinal epithelium (either esophageal or gastric) and may contain smooth muscle. Most com\-
monly, enteric cysts occur within the muscular wall of an otherwise intact esophagus without communication with the lumen. Neuroenteric cysts are the embryo- logi\hich\af44\dbch\af31505\loch\f44 c\hich\af44\dbch\af31505\loch\f44 
 exception, arising from a failure of separation of notochord and foregut. These lesions contain gastro\-intestinal mucosa with well-developed smooth mus\-
cle walls and communicate with the central nervous system (CNS), spinal cord, and perhaps dura. This a\hich\af44\dbch\af31505\loch\f44 s\hich\af44\dbch\af31505\loch\f44 
sociation explains their frequent coexistence with congenital vertebral defects, most commonly hemi- vertebrae. Neuroenteric cysts are, however, much rarer than either bronchogenic or enteric cysts.
\par \hich\af44\dbch\af31505\loch\f44 Foregut duplications must be considered in the differenti\hich\af44\dbch\af31505\loch\f44 
al diagnosis of a cystic mediastinal lesion. Bronchogenic cysts can be diagnosed prena- tally, perinatally, or in an older child. The lesion may be seen in the newborn with acute respiratory distress because a large lesion can compress adjacent normal lun
\hich\af44\dbch\af31505\loch\f44 g\hich\af44\dbch\af31505\loch\f44  tissue. They may be totally asymptomatic in an older child or may occur with infection in an occult lesion. Occasionally, the lesion is discovered inciden\-
tally on chest radiography performed for unrelated reasons. Further studies should include CT of th\hich\af44\dbch\af31505\loch\f44 e\hich\af44\dbch\af31505\loch\f44 
 chest to identify the lesion and its relation to surrounding structures. Mediastinal cysts also have been identi\-
fied on prenatal ultrasonography and are followed up perinatally with these same imaging modalities. Close scrutiny of the mediastinal struct\hich\af44\dbch\af31505\loch\f44 u\hich\af44\dbch\af31505\loch\f44 
res is indicated because all bronchogenic cysts, whether symptom\-
atic or not, should be excised, given their propensity for expansion, infection, and hemorrhage. Because bronchogenic cysts are most commonly discrete lesions, they can be successfully appro\hich\af44\dbch\af31505\loch\f44 a
\hich\af44\dbch\af31505\loch\f44 
ched thora- coscopically. Care must be taken to avoid injury to either the bronchial or esophageal wall, particularly when they share a common wall. The development of intracorporeal suturing techniques has enhanced our ability to excise these lesions end
\hich\af44\dbch\af31505\loch\f44 o\hich\af44\dbch\af31505\loch\f44 scopically. Previous infection makes their removal more difficult by either the open or thoracoscopic approach, given the fibro- vascular reaction that occurs surrounding infected lesions.

\par \hich\af44\dbch\af31505\loch\f44 Bronchogenic cysts also may occur within the pul\-monary parenchyma \hich\af44\dbch\af31505\loch\f44 separate from the hilar struc\-
tures. Peripheral bronchogenic cysts may be multiple, in which case they are more appropriately termed bronchiolar cysts or cystic bronchiectasis. The more peripheral bronchogenic or pulmonary cysts are lined by ciliated resp
\hich\af44\dbch\af31505\loch\f44 i\hich\af44\dbch\af31505\loch\f44 ratory epithelium and likely result from abnor\-
malities during the latter portion of the pseudoglandular stage of lung development, as contrasted to the more central lesions that are true foregut abnormalities. These lesions invariably communicate with th\hich\af44\dbch\af31505\loch\f44 e
\hich\af44\dbch\af31505\loch\f44  airway and often create obstruction of accompanying bronchi. Peripheral lesions may initially be seen early from the accumulation of mucus that leads to obstruc\-
tion, or they may be seen later as infected peripheral lesions. They may be confused with nec\hich\af44\dbch\af31505\loch\f44 r\hich\af44\dbch\af31505\loch\f44 otizing pneu\-
monia. Diagnostic evaluation almost always includes CT. The treatment is surgical resection, given the natu\-ral history of persistence with recurring symptoms. 
\par }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid2561007 {\rtlch\fcs1 \ab\af44\afs24 \ltrch\fcs0 \b\f44\fs24\lang1058\langfe1033\langnp1058\insrsid1786095 
\hich\af44\dbch\af31505\loch\f44 6.  }{\rtlch\fcs1 \af2\afs24 \ltrch\fcs0 \b\f2\fs24\insrsid2561007\charrsid2561007 \hich\af2\dbch\af31505\loch\f2 Main literature:}{\rtlch\fcs1 \af2\afs24 \ltrch\fcs0 \f2\fs24\insrsid2561007\charrsid2561007 
\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0 \ltrch\fcs0 \f2\cf1\lang1033\langfe1033\langnp1033\langfenp1033\insrsid2561007\charrsid2561007 \hich\af2\dbch\af31505\loch\f2 1.\tab}}\pard \ltrpar\ql \fi-360\li720\ri0\sl276\slmult1
\widctlpar\wrapdefault\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin720\itap0\pararsid2561007 {\rtlch\fcs1 \af2\afs24 \ltrch\fcs0 \f2\fs24\cf1\insrsid2561007\charrsid2561007 \hich\af2\dbch\af31505\loch\f2 Pediatric surgery: textbook /}{\rtlch\fcs1 
\af2\afs24 \ltrch\fcs0 \f2\fs24\cf19\highlight8\insrsid2561007\charrsid2561007  }{\rtlch\fcs1 \af2\afs24 \ltrch\fcs0 \f2\fs24\cf1\highlight8\insrsid2561007\charrsid2561007 \hich\af2\dbch\af31505\loch\f2 
Losev O.O., Melnychenko M.H., Dilanyan I.R., Samofalov D.O.; edited by Loseva O.O. \hich\f2 \endash \loch\f2  Odesa : ONMedU, 2011. \hich\f2 \emdash \loch\f2  224 pages
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\widctlpar\wrapdefault\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin720\itap0\pararsid2561007 {\rtlch\fcs1 \af2\afs24 \ltrch\fcs0 \f2\fs24\cf1\insrsid2561007\charrsid2561007 \hich\af2\dbch\af31505\loch\f2 \hich\f2 
Pediatric surgery (Textbook / Grif of the Ministry of Health of Ukraine / Odesa: ONMedU, 2019, 224 \'f1\loch\f2 .) Losev O.O., Melnychenko M.H., a\hich\af2\dbch\af31505\loch\f2 nd others, 7 people altogether
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Kryvchenya D. Y., Lysak S.V, Plotnikov O.M Surgical diseases in children. - Vinnytsya: New book, 2008. - 256 p.
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Pediatric surgery. / Edited by Sushka V.I. and co-authors // K. Health. - 2002. - 718 p.
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\hich\af2\dbch\af31505\loch\f2 ry. Tutorial. Part 2. Edited by Tolstanova O.K., Rybalchenko V.F., Danilova O.A. and others. Zhytomyr "POLISSYA". - 2016. - p. 225, 322-331
\par }\pard \ltrpar\qj \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid2561007 {\rtlch\fcs1 \af2\afs24 \ltrch\fcs0 \f2\fs24\insrsid2561007\charrsid2561007 
\par }{\rtlch\fcs1 \af2\afs24 \ltrch\fcs0 \b\f2\fs24\insrsid2561007\charrsid2561007 \hich\af2\dbch\af31505\loch\f2 Additional literature:
\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0 \ltrch\fcs0 \f2\cf1\lang1033\langfe1033\highlight8\langnp1033\langfenp1033\insrsid2561007\charrsid2561007 \hich\af2\dbch\af31505\loch\f2 6.\tab}}\pard \ltrpar\qj \fi-360\li720\ri0\sl276\slmult1
\widctlpar\wrapdefault\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin720\itap0\pararsid2561007 {\rtlch\fcs1 \af2\afs24 \ltrch\fcs0 \f2\fs24\cf1\highlight8\insrsid2561007\charrsid2561007 \hich\af2\dbch\af31505\loch\f2 
Emergency surgery of the abdominal cavity (standards of organization and professionally o\hich\af2\dbch\af31505\loch\f2 riented algorithms for medical care) / Edited by Fomina P.D., Usenko O.Y., Bereznytsky Y.S. - Kyiv: \hich\f2 \lquote \loch\f2 
Health of Ukraine\hich\f2 \rquote \loch\f2  Library, 2018. - 354 p.
\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0 \ltrch\fcs0 \f2\cf1\lang1033\langfe1033\highlight8\langnp1033\langfenp1033\insrsid2561007\charrsid2561007 \hich\af2\dbch\af31505\loch\f2 7.\tab}\hich\af2\dbch\af31505\loch\f2 
Age aspects of acute appendicitis in children and the key to its recognition. Tutorial. 2019. 260 p. Edited b\hich\af2\dbch\af31505\loch\f2 y Bodnar B.M., Ribalchenko V.F., Bodnar O.B., Melnichenko M.H., and others. Publish}{\rtlch\fcs1 \af2\afs24 
\ltrch\fcs0 \f2\fs24\highlight8\insrsid2561007\charrsid2561007 \hich\af2\dbch\af31505\loch\f2 ing}{\rtlch\fcs1 \af2\afs24 \ltrch\fcs0 \f2\fs24\cf1\highlight8\insrsid2561007\charrsid2561007 \hich\af2\dbch\af31505\loch\f2 . ISBN 978-966-697-828-1
\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0 \ltrch\fcs0 \f2\cf1\lang1033\langfe1033\highlight8\langnp1033\langfenp1033\insrsid2561007\charrsid2561007 \hich\af2\dbch\af31505\loch\f2 8.\tab}\hich\af2\dbch\af31505\loch\f2 
Nedelska S.M. Diseases of the hepatobiliary system and pancreas in children. Textbook for 6th-year students of a medical faculty, interns, ped\hich\af2\dbch\af31505\loch\f2 
iatricians, family doctors / Nedelska S.M., Mazur V.I., Shumna T.E.. - Zaporizhzhia: [ZDMU], 2017. - 113 p.
\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0 \ltrch\fcs0 \f2\cf1\lang1033\langfe1033\highlight8\langnp1033\langfenp1033\insrsid2561007\charrsid2561007 \hich\af2\dbch\af31505\loch\f2 9.\tab}\hich\af2\dbch\af31505\loch\f2 
Violation of defecation in children: constipation and encopresis: Textbook /  Rybalchenko V.F., Berezhnyy V.V. ,Konoplitsky V.S., and others; Edi\hich\af2\dbch\af31505\loch\f2 
ted by professor Rybalchenko V.F., Berezhnyy V.V., Konoplitsky V.S., Rusak P.S. - Kyiv: VIT-A-POL LLC, 2018. - 548 p .: illustrations
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Intestinal malrotation in children: from embryogenesis to consequences / Monograph. Edited by Pereyaslova A.A., Rybalc\hich\af2\dbch\af31505\loch\f2 henko V.F., Loseva O.O - K .: PE "INPOL LTM" Printing House "000000000", 2019. - 226 p: illustrations

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Intestinal obstruction in children: a textbook for students of the 5th year of medical faculties (specialties: "Medical business", "Pediatrics"). Spahi O.V., Barukhovych V.Y., Kokorkin O.D., Lyaturynska O.V., Pakholchuk O.P., Zaporozhchenko A.H. - Zaporiz
\hich\af2\dbch\af31505\loch\f2 h\hich\af2\dbch\af31505\loch\f2 zhia. -2015.- 75 p.
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\hich\af2\dbch\af31505\loch\f2 chokin O.V., Makarova M.O., Anikin I.O. Zaporizhzhia, 2013. 165 p.
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Bachurin V.I. Malformations of the genitourinary system as a cause of urological pathologies: teaching metho\hich\af2\dbch\af31505\loch\f2 
dology for independent work of fourth-year students in the specialty: 7.12010001 "Medical business", 7.12010002 "Pediatrics", 6.120102 "Laboratory diagnostics" / Bachurin V.I.. - Zaporizhzhia: ZSMU, 2017. - 86 p.
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Shmakov A.P. Workshop on pediatric surg\hich\af2\dbch\af31505\loch\f2 ery: manual / Shmakov A.P.- Vitebsk, VSMU, 2016 .-- 309 p.
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Makarov A.V. Examination of the respiratory organs in children. Training manual. Makarov A.V., Danilov O.A., Sokur P.P., Rybalchenko V.F., Yurchenko M.I. - C .: Business entity Kolyada O.P., 20\hich\af2\dbch\af31505\loch\f2 05. - 160 p.
\par }\pard \ltrpar\qj \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid2561007 {\rtlch\fcs1 \af2\afs24 \ltrch\fcs0 \f2\fs24\cf1\highlight8\insrsid2561007\charrsid2561007 
\par 
\par 
\par }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid2561007 {\rtlch\fcs1 \af2\afs24 \ltrch\fcs0 \f2\fs24\insrsid2561007\charrsid2561007 
\par }\pard \ltrpar\qj \li284\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin284\itap0\pararsid2561007 {\rtlch\fcs1 \af2\afs24 \ltrch\fcs0 \f2\fs24\insrsid1786095\charrsid2561007 
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