Intestinal anastomoses in children: The draft decision of the Russian Symposium of Children surgeons (April 2023)

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INTRODUCTION

On April 26, 2023, the “Intestinal Anastomoses in Children” symposium of pediatric surgeons in Russia was held in Volgograd. The significance of this topic stems from the fact that numerous complex and unresolved issues remain in this challenging section of abdominal surgery. These issues are associated with the active introduction of laparoscopic surgery into medical practice, the necessity of prevention of intestinal anastomosis (IA) failure, and the choice of appropriate methods and techniques of their formation. The symposium’s agenda included a presentation of the results of the symposium, with 30 reports being delivered and a total of 41 articles published in the “Proceedings of the Symposium” [1]. More than 180 specialists participated in the symposium.

In preparation for the symposium, the Chief Pediatric Surgeon of the Russian Ministry of Health developed questionnaires containing inquiries about surgeries performed with IA formation. These questionnaires were then sent to the chief specialists of 75 subjects of the Russian Federation. A systematic analysis was conducted on the received questionnaires, which included data from 4,558 operations performed between 2021 and 2022. The issues of intestinal anastomosing technique in open and laparoscopic surgeries, peculiarities of its performance in various diseases, and pathologic conditions of abdominal cavity organs in children of different ages were considered. The analysis of complications encountered in various types of IA was performed.

After hearing and discussion of the reports, the draft decision of the symposium was adopted. Below is its text for familiarization of a wide range of specialists with further adjustment for inclusion in the federal clinical recommendations.

DEFINITION

IA formation is a surgical technique used to restore the integrity of the intestine, which has been compromised by the removal of a part of it, allowing the passage of contents through the digestive tract. It can be considered as an independent operation, as well as part of any intervention on the abdominal cavity organs. Anastomosis between two parts of the digestive tract is one of the most common operations in pediatric abdominal surgery. According to the analysis of the questionnaire survey of chief pediatric surgeons of Russia in 2023, the share of operations of IA formation in the practice of pediatric surgeons was no more than 0.6%, while in the practice of neonatal surgeons reported over 18.6%.

TYPES OF INTESTINAL ANASTOMOSES USED IN PEDIATRIC PRACTICE

There are various types of IA, including end-to-end, side-to-side, side-to-side, end-to-side, and side-to-side anastomoses. Among these, end-to-end anastomoses are the most commonly performed in pediatric practice.

The formation of intestinal anastomoses can be achieved using both manual techniques and stapling devices. It has been observed that there is an increase the number of CAs formed during laparoscopic surgeries (about 4.4% in the period 2022–2023). The choice of a specific variant of IA formation depends on the specific clinical situation, the expertise of the operating surgeon, and the availability of appropriate equipment.

The results obtained from a systematic analysis of data from the chief pediatric surgeons of 75 constituent entities of the Russian Federation, which includes the Donetsk People’s Republic and the Lugansk People’s Republic, in 2021–2022, revealed that pediatric surgeons almost equally often employed double-row knotted intestinal sutures (33.3%), single-row continuous sutures (34.6%), and other types of sutures (33.3%). The single-row knotted suture (10.6%) or their “original” suture type (5.3%) were less frequently preferred. A total of 4,558 IA operations were analyzed, including 1,735 in neonates (36%).

INTESTINAL ANASTOMOSES IN NECROTIZING ENTEROCOLITIS AND MESENTERIC THROMBOSIS

The standard surgical treatment for children diagnosed with necrotizing enterocolitis consists of resection of the altered intestinal area with the formation of intestinal stomas and subsequent formation of IA. During the first stage of surgical treatment, the affected intestinal area is resected, and with various types of stomas are removed, including double ileostomy, terminal ileostomy, colostomy, and jejunostomy. Subsequently, IA formation is performed: end-to-end anastomosis of the ileum, end of the ileum to the side of the large intestine, and T-anastomosis in case of a marked mismatch between the diameters of the leading and diverting parts of the intestine. The terms of anastomosis formation vary from 2.5 weeks to 4 months. Patients with T-shaped anastomosis undergo closure of the unloading stoma within 3–6 months.

In cases of peritonitis in newborns with necrotizing enterocolitis, it is possible to form small intestinal anastomoses. However, this approach is associated with a high risk of anastomosis failure in the early postoperative period. The final decision is made according to the specific clinical situation.

The clip-and-drop technique is used to treat neonates with multifocal necrosis of the intestinal tube. The first step in surgical treatment involves resection of obviously necrotic parts of the intestine. Potentially viable intestinal fragments are sutured tightly at both ends and immersed in the abdominal cavity. After stabilization of the patient’s condition in 72–120 h, a second operation is performed. This involves assessing the viability of the remaining intestinal fragments, resecting segments that are subjected to further necrosis, and applying interintestinal anastomoses. Segmental resection of necrotized intestine without removing intestinal stomas followed by delayed formation of interintestinal anastomoses may be the strategy of choice for surgical treatment of multifocal necrosis of the intestinal tube, allowing for maximum preservation of the remaining length of the intestine and achieving a good postoperative result.

DUODENAL AND SMALL INTESTINAL OBSTRUCTION

The cause of congenital duodenal obstruction can be attributed to malformations affecting the intestine itself (atresia, membrane, or stenosis) as well as abnormalities involving the organs and vessels surrounding the duodenum (ring-shaped pancreas, preadenal portal vein, or peritoneal tracts compressing the duodenum). Depending on the specific clinical situation, different types of anastomoses are used, namely, duodeno-duodenal and duodeno-jejunal. The Kimura method of diamond-shaped duodeno-duodenoanastomosis has gained significant popularity and is successfully performed using laparoscopic techniques.

At the same time, the introduction of laparoscopic technique of anastomosis formation requires appropriate training. According to the analysis of 2021–2022, as a result of duodenal obstruction treatment in 453 newborns, the majority recovered without complications (10 children died [2.2%] due to progression of combined pathology), anastomosis failure occurred in 9 (1.9%), and repeated anastomosis reconstructions were required in 13 patients (2.9%). Laparoscopic duodenal anastomoses were performed in 87 children (19.2%). In these patients, anastomosis failure occurred three times more often (6.8%), as well as the need for repeated anastomosis reconstructions (8%), and mortality increased to 4.6%.

The most common cause of congenital small intestinal obstruction is atresia. The preferred surgical procedure for this condition involves resection of the atresized part of the small intestine with direct or T-shaped anastomosis in case of a marked discrepancy between the diameters of the leading and diverting parts of the intestine. The greatest difficulties arise with multiple atresia of the small intestine. However, it is possible to form multiple anastomoses between non-atresized parts of the intestine.

HIRSCHSPRUNG’S DISEASE AND NEUROMUSCULAR DYSPLASIA OF THE COLON

The aim of surgery in Hirschsprung’s disease is to remove the aganglionic segment of the intestine. The scope of surgery is determined by the extent of this segment and can vary from rectal resection to total colectomy with the formation of colorectal and even ileorectal anastomosis. Along with classical operations for Hirschsprung’s disease, such as Soave, Duhamel, and Swenson operations, techniques of forming anastomoses with the rectum using stapling devices have recently been increasingly used.

CROHN’S DISEASE

Crohn’s disease (CD) is characterized by transmural lesions of the intestinal wall. In children, the aggressive course of the disease is often complicated by the development of intestinal strictures, fistulas, and infiltrates, requiring surgical treatment. While there is no single standard of anastomosis formation in children with CD, most specialists prefer hardware variants.

Depending on the level and extent of the lesion, various resections of the ileum and colon can be performed. The operations can be performed in one stage, involving resection of the affected part of the intestine with the primary formation of interintestinal anastomosis. Alternatively, a two-stage operation may be performed. In the first stage, a primary ileostomy is created to disconnect the colon. In the second stage, under the ileostomy cover, the colonic stricture is resected, and a circular anastomosis is performed using both manual technique of anastomosis creation and the use of stapling devices for this purpose. The ileostomy is removed once the disease is in remission.

CREATION OF INTERINTESTINAL ANASTOMOSES DURING ROUX-LOOP FORMATION IN CHILDREN WITH CHOLEDOCHAL CYSTS

The radical operation in children with choledochal cysts involves the excision of cystically altered extrahepatic bile ducts, cholecystectomy, and the formation of hepaticojejunoanastomosis with a disconnected loop along the small intestine. The variants of interintestinal anastomosis are different. Each of them has its own technical peculiarities and can be accompanied by the development of specific complications. After the stage of radical excision of the choledochal cyst, it is necessary to provide bile outflow by forming two anastomoses. The jejunum is crossed at a distance of 20–25 cm from the ligament of Treitz, and its distal loop is passed behind the colon into the subhepatic space, forming hepaticojejunoanastomosis end-to-end or end-to-side single-row suture. Then, the loop is disconnected according to Roux’s method by forming an end-to-side IA with a single-row suture between the driving loop of jejunum and the disconnected one at a distance of 30–40 cm from the hepaticojejunoanastomosis.

Extracorporeal or intracorporeal application of stapling devices can be the optimal option of interintestinal anastomosis in the formation of Roux loop during minimally invasive surgeries in children with choledochal cysts, which is accompanied by the least number of postoperative complications and allows to reduce the time of surgical intervention.

INTESTINAL ANASTOMOSES IN RECONSTRUCTIVE UROLOGY

The creation of an artificial bladder is a reconstructive operation that involves forming a low-pressure reservoir with sufficient capacity from a section of intestine. This procedure is accompanied by an interintestinal anastomosis to restore the continuity of the intestinal tract, uretero-intestinal anastomoses, and the creation of a percutaneous dry stoma for self-catheterization. Intestinal urinary derivation in pediatrics is used for adequate surgical correction in those patients with bladder exstrophy, cloaca, cloaca exstrophy, and epispadias, who have marked pathological changes in the lower urinary tract.

Typically, surgeries to create a heterotopic bladder follow the Mainz Pouch I technique, which involves forming a heterotopic bladder from the small intestine and creating a continent appendicostomy. Additional procedures may include the formation of continent efferent stomas using the modified Monti procedure and augmentation colocystoplasty with the formation of a continent efferent stoma, also following the modified Monti procedure.

MULTIPLE INTESTINAL ANASTOMOSES

In rare cases of intestinal pathology, segmental resection of different parts of the intestine is required and, accordingly, the simultaneous formation of more than two interintestinal anastomoses. Such situations often occur in patients who are at risk of developing postresection short bowel syndrome and chronic intestinal insufficiency. When performing surgical interventions in such patients, the following principles should be followed: precision technique in the application of interintestinal anastomoses; the most economical resection of the intestine during stoma isolation; the use of techniques for shoeing the driving section in case of a marked difference in the diameter of the compared intestinal sections; and preservation of any viable part of the intestine with a reasonable avoidance of enterostomies in favor of interintestinal anastomoses in patients with multiple intestinal stomas.

The preservation of intestinal length is the leading objective in this category of patients, and one-stage placement of more than two interintestinal anastomoses is not associated with a higher incidence of surgical complications. According to an analysis of the work of pediatric surgeons in Russia in 2021–2022, out of 310 newborns with primary anastomoses in conditions of segmental discongruence, the need for multiple small intestinal anastomoses arose in 77 patients (7.6% of all small intestinal anastomoses in newborns and 24% of patients with primary anastomoses).

INTERINTESTINAL MAGNETIC ANASTOMOSES

Interintestinal magnetic anastomosis in a double-barrel intestinal stoma is an alternative to surgical excision of the stoma and the formation of an IA to restore the passage of intestinal chyme in the disconnected intestinal section. This technique is commonly used in neonatal patients who have undergone necrotizing enetrocolitis, necrosis of the intestine at midgut ingestion. In older children, the formation of magnetic anastomoses is performed in case of intestinal obstruction, injuries of small, large, and rectum. On the 4th–7th day, a pair of permanent magnets is placed in the fistula holes. As the necrosis of the compressed intestinal tissue is necrotic, a lateral union in the form of interintestinal magnetic anastomosis is formed. The appearance of independent stools and a decrease in stoma discharge is an indicator of a functioning stoma. When closing a double-barrel stoma in 2–4 months, the integrity of the intestinal tube is restored with the preservation of the created interintestinal magnetic anastomosis, which allows to sharply reduce the risk of intestinal suture failure and start enteral nutrition early after surgery.

The two-stage surgical treatment method for patients operated for acute abdominal pathology with resection of the intestinal segment and creation of a magnetic interintestinal anastomosis allows to significantly reduce the risk of postoperative complications, facilitates the course of the postoperative period, and helps to avoid the development of dysbacteriosis in the disconnected intestine. In addition, reconstructive surgery is performed against the background of somatic well-being in the most favorable terms.

COMPLICATIONS IN THE FORMATION OF INTESTINAL ANASTOMOSES IN CHILDREN

IA failure is a major complication with severe and even fatal consequences. Nevertheless, such factors as suture row and interrupted suture do not affect the incidence of failure. The incidence of this complication is significantly higher during emergency interventions, in case of severe adhesions in the abdominal cavity, peritonitis, as well as when performing one-stage colorectal anastomosis. The incidence of failure is significantly higher in patients with concomitant congenital pathology.

According to the data of the chief pediatric surgeons of the Russian Federation regions, in 2021–2022, the failure of duodenal anastomoses in newborns amounted to 1.9%, repeated reconstructions were required in 2.9%. Lethality was 2.2%. IA formation in conditions of peritonitis, with compromised duodenum or disruption of its blood supply increased anastomosis failure up to 27.2%, the need for repeated reconstruction — up to 9%. Clinical observations of laparoscopic operations (66% of all duodenal anastomosis failures) accounted for a significant share in the structure of complications.

Lethality in the subgroup of 1,012 newborns with IA formation at the level of small intestine amounted to 3.75%. In 40% of cases, it occurred after stoma closure surgery, while in 31% of cases, it occurred after operations against the background of peritonitis or intestinal circulatory disorders. Repeated reconstruction of small intestinal anastomoses in newborns was required in 41 children (4%), with every second case occurring after stoma closure operations. Failure of small intestine anastomoses in newborns was detected in 2% of cases. In primary anastomosis formation (233), including multiple anastomoses (77), the failure rate was 2.1%. After stoma closure, the failure rate was 1.7%, and during operations in conditions of peritonitis or circulatory disorders of the intestinal wall, the failure rate was 2.9%.

The formation of small intestinal IA was performed in 2,097 older children. Analysis of planned operations on the small intestine in older children (closure of stomas, fistulas, including magnetic devices [594 patients, 28.3%]) showed that anastomosis failure occurred in 1.2% of cases, repeated reconstructions in 1.5% of cases, and the lethality rate was 1.3%.

At the same time, emergency intestinal resections were performed in 908 patients (43.2%) in cases of intestinal obstruction, intestinal perforations, trauma, inflammatory diseases, where frequent problems included peritonitis, intestinal viability, and adequacy of blood supply. The treatment results were better—anastomosis failure occurred in 0.4% of observations, repeated reconstructions in 1.3%, and a lethality rate of 0.3%.

When anastomoses were formed at the level of the colon, failure occurred in 2.2% of both newborns and older children. Indications for repeated reconstruction of anastomoses occurred in 0.74%–1.7% of cases. Eighty-five older children (13.4%) underwent emergency surgery for various perforations of the colon, complications of inflammatory and infectious diseases of the colon. In this subgroup, there were no anastomosis failures or fatal outcomes, and only two children (2.4%) required repeated reconstruction.

Out of 4,558 operations of IA formation (including 1,735 in newborns) in the period 2021–2022 in Russia, anastomosis failure was registered in 1.65% of observations, repeated reconstructions in 2.8%, with lethality rate of 1.52%.

CONCLUSION

Thus, the current stage of development of techniques for IA formation is characterized by good results, expansion of indications for IA in conditions of compromised intestine or peritonitis, and introduction of laparoscopic techniques and mechanical stapling devices with somewhat worse results.

ADDITIONAL INFORMATION

Messages to readers. You can send your comments and suggestions on the project to the Secretary of the Russian Association of Pediatric Surgeons Oleg S. Gorbachev at: raps@telemednet.ru

Authors’ contribution. Thereby, all authors made a substantial contribution to the conception of the study, acquisition, analysis, interpretation of data for the work, drafting and revising the article, final approval of the version to be published and agree to be accountable for all aspects of the study.

Funding source. This study was not supported by any external sources of funding.

Competing interests. The authors declare that they have no competing interests.

ДОПОЛНИТЕЛЬНЯ ИНФОРМАЦИЯ

Обращение к читателям. Свои замечания и предложения по проекту решения можно направлять секретарю Российской ассоциации детских хирургов Олегу Сергеевичу Горбачеву по адресу: raps@telemednet.ru

Вклад авторов. Все авторы внесли существенный вклад в разработку концепции, проведение исследования и подготовку статьи, прочли и одобрили финальную версию перед публикацией.

Источник финансирования. Авторы заявляют об отсутствии внешнего финансирования при проведении исследования.

Конфликт интересов. Авторы декларируют отсутствие явных и потенциальных конфликтов интересов, связанных с публикацией настоящей статьи.

About the authors

Mikhail A. Akselrov

Tyumen State Medical University

Email: akselerov@mail.ru
ORCID iD: 0000-0001-6814-8894
SPIN-code: 3127-9804

Dr. Sci. (Med.), Professor

Russian Federation, Tyumen

Elena Yu. Dyakonova

National Medical Research Center for Children’s Health

Email: dyakonova@nczd.ru
ORCID iD: 0000-0002-8563-6002
SPIN-code: 5709-3352

Dr. Sci. (Med.)

Russian Federation, Moscow

Svetlana A. Karavaeva

North-Western State Medical University named after I.I. Mechnikov

Email: swetl.karavaewa2015@yandex.ru
ORCID iD: 0000-0001-5884-9128
SPIN-code: 4224-5532

Dr. Sci. (Med.), Professor

Russian Federation, Saint Petersburg

Olga V. Karaseva

Clinical and Research Institute of Emergency Pediatric Surgery and Trauma

Email: karaseva.o@list.ru
ORCID iD: 0000-0001-9418-4418
SPIN-code: 7894-8369

Dr. Sci. (Med.), Professor

Russian Federation, Moscow

Semen L. Kovarskiy

N.I. Pirogov Russian National Research University

Email: sim3150@gmail.com
ORCID iD: 0000-0001-6310-7110
SPIN-code: 9308-5014

Dr. Sci. (Med.), Professor

Russian Federation, Moscow

Yuri A. Kozlov

Irkutsk State Medical Academy of Postgraduate Education

Email: yuriherz@hotmail.com
ORCID iD: 0000-0003-2313-897X
SPIN-code: 3682-0832

Dr. Sci. (Med.), Professor, Member of the Russian Academy of Sciences

Russian Federation, Irkutsk

Sergey V. Minaev

Stavropol State Medical University

Email: sminaev@yandex.ru
ORCID iD: 0000-0002-8405-6022
SPIN-code: 3113-6982

Dr. Sci. (Med.), Professor

Russian Federation, Stavropol

Olga G. Mokrushina

N.I. Pirogov Russian National Research University

Email: mokrushina@yandex.ru
ORCID iD: 0000-0003-4444-6103
SPIN-code: 5998-7470

Dr. Sci. (Med.), Professor

Russian Federation, Moscow

Dmitry A. Morozov

Yu.E. Veltishchev Research Clinical Institute of Pediatrics and Pediatric Surgery, N.I. Pirogov Russian National Research University

Email: damorozov@list.ru
ORCID iD: 0000-0002-1940-1395
SPIN-code: 8779-8960

MD, Dr. Sci. (Med.), Professor

Russian Federation, Moscow

Vladimir I. Petlakh

Yu.E. Veltishchev Research Clinical Institute of Pediatrics and Pediatric Surgery, N.I. Pirogov Russian National Research University

Email: vladimirip1@gmail.com
ORCID iD: 0000-0001-5403-313X
SPIN-code: 9100-6976
https://pedklin.ru/specialisty/petlakh-vladimir-ilich/

Dr. Sci. (Med.), chief researcher

Russian Federation, Moscow

Igor V. Poddoubny

A.I. Evdokimov Moscow State University of Medicine and Dentistry

Email: igorpoddoubnyi@yandex.ru
ORCID iD: 0000-0002-9077-6990
SPIN-code: 4340-8700

Dr. Sci. (Med.), Professor

Russian Federation, Moscow

Alexey V. Podkamenev

Saint Petersburg State Pediatric Medical University

Email: podkamenev@hotmail.com
ORCID iD: 0000-0001-6006-9112
SPIN-code: 7052-0205

Dr. Sci. (Med.), assistant professor

Russian Federation, Saint Petersburg

Alexandr Yu. Razumovskiy

N.I. Pirogov Russian National Research University

Email: 1595105@mail.ru
ORCID iD: 0000-0003-3511-0456
SPIN-code: 3600-4701

Dr. Sci. (Med.), Professor, Member of the Russian Academy of Sciences

Russian Federation, Moscow

Yury Yu. Sokolov

Russian Medical Academy of Continuous Professional Education

Email: sokolov-surg@yandex.ru
ORCID iD: 0000-0003-3831-768X
SPIN-code: 9674-1049

Dr. Sci. (Med.), Professor

Russian Federation, Moscow

Valeriya V. Kholostova

N.I. Pirogov Russian National Research University

Email: vkholostova@yandex.ru
ORCID iD: 0000-0002-3463-9799
SPIN-code: 7923-6493

Dr. Sci. (Med.), assistant professor

Russian Federation, Moscow

Natalya A. Tsap

Ural State Medical University

Author for correspondence.
Email: tsapna-ekat@rambler.ru
ORCID iD: 0000-0001-9050-3629
SPIN-code: 7466-8731

Dr. Sci. (Med.), Professor

Russian Federation, Yekaterinburg

References

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