Vol 10, No 3 (2020)

The rationale for dislocation of interregional specialized surgical care centers for children in the Russian Federation
Rozinov V.M., Morozov D.A., Rumyantsev S.A., Vaganov N.N., Petlakh V.I., Afaunov M.V.

Introduction. In Russia, there is a need to reorganize the system of providing specialized surgical care to children, primarily in emergency and urgent care and in remote, sparsely populated, and hard-to-reach areas. This need is evidenced by the significant persisting disparities in the mortality rate in the country’s various regions.

Purpose of the study. This study aims to provide multifactorial substantiation of the expediency, profile, and location of specialized (surgical) interregional centers (MRC), including high-tech, medical care for children, by the priority profiles of activity, about medical organizations of the federal districts (FD) of Russia.

Materials and methods. The study design included a two-level (regional and federal) system of professional expertise and justification in terms of the profile, location, and area of responsibility of the MRC in the federal district of the country. At the regional level, Delphi technology was implemented with a mathematical and statistical analysis of 103 expert opinions from 85 constituent entities of Russia, the result of which activities priority profiles were substantiated (“newborn surgery,” “neurosurgery,” “thoracic surgery,” “oncology,” “combustiology”) and patient routing preferences. At the second stage of the work, with the involvement of federal experts, the SWOT analysis technology was implemented as a universal method of strategic planning, with the justification of the location and number of MRCs in individual FD of the country, about specific medical organizations where they are based. For an objective (quantitative) assessment of the provision of the Federal District of Russia with the MRC of specialized medical care for children according to the established profiles of activity, we have proposed a calculated indicator — the “regional contingency coefficient” (CRC), representing the ratio of two uniformly calculated values — the number of MRCs and regions in a particular Federal District, or the country as a whole.

Results. The consolidated position of federal experts regarding the location of the MRC was formulated according to the established profiles of activity about FD and specific medical organizations in the Russian Federation constituent entities. The cattle in the profile of the activity of “neonatal surgery” was 0.14, and about “neurosurgery,” “thoracic surgery,” and “oncology,” respectively, 0.12, 0.11, and 0.11 for Russia as a whole. The lowest (0.09) cattle in the country characterized the situation with the “combustiology” profile. In the overwhelming majority (76.0%), the location of the MRC is tied to the administrative centers of the Federal District or cities of federal significance. Among the 50 MRCs of all priority profiles, 43 (86%) were potentially designated by experts based on multidisciplinary pediatric medical organizations.

Discussion. The effectiveness of the MRC functioning is due to the organization of medical and evacuation support for children with diseases and injuries. The development of consultative and resuscitation centers in the primary hospital structure is promising. Its functionality, along with remote counseling, treatment, and evacuation activities, includes monitoring the condition of sick and affected children at the place of primary hospitalization. An alternative is a presence on the clinical base of the MRC of a structural unit or a branch of the regional center for emergency medical care and disaster medicine.

Conclusion. Overcoming the inequality in the availability and quality of medical care for children in certain FD and regions of Russia is necessary to reorganize the current system of staged medical care. Optimal logistics of medical and evacuation support for specialized patients and injured people include the MRC as a collector for children in need of specialized care, including high-tech medical care, with the implementation of the predominant principle of “evacuation of oneself.”

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(3):263-274
Gastroenteroanastomosis using NOTES-technologies — results of an experimental study
Smirnov A.А., Chernov A.V., Kargabaeva A.B., Konkina N.V., Baranova N.A., Rasputin A.A., Ochirov C.B., Cheremnov V.S., Kozlov Y.A.

Introduction. Transluminal endoscopic surgery performed through natural orifices can reduce the incidence of complications associated with the surgical procedure and the incidence of postoperative complications. The purpose of this study was to determine the feasibility of performing an experimental gastroenteroanastomosis in a live pig model using NOTES.

Materials and methods. The experimental study was performed on living laboratory models — pigs weighing from 25 to 30 kg. The study’s preliminary phase allowed working out the technique using two animals removed from the experiment after its successful completion. The final phase included the implementation of gastrojejunoanastomosis in six animals with subsequent observation. In three animals, the procedure was performed with laparoscopic assistance using a single-channel video gastroscope. In the other three animals, it was performed without laparoscopy using a two-channel video gastroscope. Antibiotic therapy continued for seven days after surgery. The surviving animals were removed from the experiment after four weeks. Patency of the anastomosis was confirmed by repeated endoscopy and histological analysis of tissues.

Results. All procedures were completed successfully in six animals (three males and three females). The formation of anastomosis required an average of 133.3 ± 43.8 minutes (range, 80–200 minutes). In one animal, bleeding during gastric wall incision was recorded and was stopped by electrocoagulation. One animal died because of an anastomotic leak and peritonitis, confirmed by autopsy. In the five surviving animals, repeated endoscopy demonstrated fully passable anastomoses covered by the mucosa.

Conclusion. Gastrojejunal anastomosis using NOTES technology is technically possible but requires additional study.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(3):275-283
Choice of anesthetic support components for children during MRI procedures
Anastasov A.G., Ovcharenko O.V., Nazin D.O., Tomashkevych B.A., Mikhaylichenko Y.V.

Introduction. An MRI-scan in early childhood requires anesthesia to create complete immobility of the patient due to the high incidence of artifacts with an MRI duration of 40 to 60 minutes. The purpose of the work is to select the components of anesthetic support in children from one month to three years old with MRI.

Materials and methods. The object of the study was 33 patients aged one month to three years with congenital and acquired brain pathology. Anesthetic management — intravenous general anesthesia without mechanical ventilation. Anesthesia in 11 (33.3%) patients of group 1 — midazolam 0.5% 0.3 mg/kg, in 12 (36.4%) patients of group 2 — midazolam 0.5% at a dose of 0.3 mg/kg + ketamine 5% 1.5 mg/kg, and in 10 (30.3%) patients of group 3 — midazolam 0.5% at a dose of 0.3 mg/kg + propofol 2 mg/kg.

Results. Group 1 patients achieved a sedation level on the RASS scale of –2.2 ± 0.1 points with preservation of sound and tactile sensitivity, spontaneous involuntary movements limbs in 72.7% of cases. Group 2 patients had a lack of motor activity, consciousness - an assessment on the RASS scale — –4.6 ± 0.4 points, BIS — 59.4 ± 1%, increased in blood pressure by 7.3%, and normal without depression of respiratory function. Group 3 patients required careful titration of each subsequent dose, constant monitoring of breathing and hemodynamics, and, if necessary, maintaining adequate ventilation during the induction stage.

Conclusion. The most rational components for anesthesia support in young children during MRI scanning are midazolam solutions at a dose of 0.3 mg/kg and ketamine at 1.5/kg.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(3):285-292
Treatment of children with skin and soft tissue defects of distal phalanges of the fingers
Berezutskii S.N., Pinigin A.G.

Introduction. This article discusses the relevance of performing organ-preserving operations for traumatic skin and soft tissue defects in children. The author analyzes the traditional types of skin grafting procedures and their application in children. From the authors' point of view, the most acceptable skin grafting method is a displaced island flap on a neurovascular pedicle with direct blood flow.

Materials and methods. The operating technique of lifting a displaced island flap on a neurovascular pedicle with direct blood flow is shown. The features of its implementation, the number of children, and their distribution by groups are shown. From 2016 to 2019, 15 children with traumatic defects of the distal phalanges of the fingers were operated on in the microsurgical Department of the Khabarovsk KKB No. 2 using a displaced neurovascular island flap on the leg with “direct” blood flow. The children ranged in age from four to 14 years. The number of children and the frequency of damage to the right and left hands was approximately the same.

Results. Positive results of using this technique in the Department of Microsurgery of KKB No. 2 are presented. In all cases, it was possible to close the existing defects with the primary closure of the donor defect simultaneously; Sensitivity was preserved in all operated children, and movements in the finger joints were almost complete.

Discussion. This flap method has undeniable advantages, although it is quite time-consuming and requires microsurgical skills, techniques, and appropriate equipment. The proposed skin grafting results are encouraging and satisfying for both doctors and children with parents.

Conclusions. The authors recommend this skin grafting method for traumatic defects of the distal phalanges of the fingers in children.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(3):293-298
Anesthesia for surgery in a patient with Knist's dysplasia for severe scoliotic deformity
Smirnov I.V., Rojtberg G.E., Tsypin L.E., Lazarev V.V.

Kniest dysplasia is a disease that is inherited in an autosomal dominant manner. It manifests itself as dwarfism, scoliotic deformity of the spine, impaired joint mobility, muscle weakness, visual impairment, and sensorineural deafness. As a result of disproportionate trunk shortening, lumbar hyperlordosis and kyphoscoliosis develop, leading to internal organs (respiratory, cardiovascular system) disorders, disability, and reduced life expectancy.

A case of surgical treatment of a patient with Kniest dysplasia for severe kyphoscoliotic spinal deformity is described. Posterior corrective cross-rod transpediculocorporal screw spondylodesis T3-L5 with bone autoplasty was performed. While planning anesthesia, difficult tracheal intubation was evaluated on the LEMON scale of 7 points high-risk. While performing tracheal intubation, endoscopic techniques were used: videolaryngoscope, intubation bronchoscope, enabling success. Management of intraoperative blood loss was conducted by a complex of measures: laying the patient in the prone position with the release of the abdominal cavity, normothermia, intraoperative hemodilution of azlactone-balanced polyionic solutions to achieve the target hematocrit in the range of 24%–26%, and controlled hypotension with blood pressure decreased by 30% from the original hardware blood reinfusion during surgery. Also, on the first postoperative day, fusing tranexamic acid, correcting anemia and deficiency of blood coagulation factors donor components contributed to the success.

Discussion. When planning surgery and anesthesia, it is necessary to consider the risk of developing malignant hyperthermia, predicting difficult intubation, and complying with the algorithm to ensure airway patency and prevent massive intraoperative blood loss. With a comprehensive approach to patient management, it is possible to achieve rapid rehabilitation and discharge for outpatient treatment. Surgical treatment for rapidly progressing severe kyphoscoliathical spinal deformity can change the quality and duration of life in patients with Kniest syndrome.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(3):299-308
Ectopia of the pancreas in the loop of the small intestine in an 8-y-o child
Sharipov A.M., Giesov K.A., Zaripov H.Z., Sayfulloev I.D., Sayfulloev I.D., Guriev K.C., Sodikov N.D.

Ectopia of the pancreas in children is a rare congenital malformation in which normal pancreatic tissue develops in other organs, without communication with the main gland in the wall of the stomach, intestines, liver, gallbladder, Meckel's diverticulum, and the spleen. In this article, the authors cite a rare case of ectopia of the pancreas in the loop of the small intestine, which led to the development of intestinal obstruction. Girl B., eight years old, was admitted to the hospital on an emergency basis with paroxysmal abdominal pain. There was no nausea or vomiting. A contrast study of the gastrointestinal tract with barium sulfate was performed, which revealed a violation of the evacuation of the contrast medium. A laparoscopy was performed with the clinic for low intestinal obstruction. Revision of the intestine revealed a tumor-like formation measuring 6× 4 cm at 60 cm from the ileocecal angle. A minilaporotomy was performed, a 10 cm section of the ileum was resected, bearing a tumor-like formation with an end-to-end anastomosis. The postoperative period is favorable. The girl was discharged from the hospital on the eighth postoperative day. On histological examination, pancreatic tissue was found in the wall of the small intestine, with duct ectasia. At the follow-up examination after one year. the patient had no complaints with normal growth and development. This clinical observation demonstrates the nonspecificity of the clinical picture and the difficulty of diagnosing pancreatic ectopia, and the advantages of minimally invasive interventions that allow diagnosing a rare pathology and its timely adequate correction.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(3):309-313
Esophageal atresia: predicting outcomes and decreasing mortality
Mukhametshin R.F., Toropov N.V., Kabdrakhmanova O.T.

This literature review is devoted to the problem of predicting in-hospital mortality in newborns with esophageal atresia (EA). According to epidemiological study data, in developed countries, the mortality rate in newborns with EA ranges from 9% to 11% over the past 20 years. Three classifications were developed, Waterston 1962, Montreal 1993, and Spitz 1994, to assess the prognostic significance of risk factors. They considered birth weight, the presence of concomitant congenital malformations and pneumonia, and the need for mechanical ventilation. The choice of a model for predicting outcomes depends on the level of health care and other factors, such as prematurity, low birth weight, late diagnosis, and infectious complications. These factors have a greater impact on patient survival in developing countries than in developed ones, where insurmountable risk factors come out on top: combined congenital malformations and very low birth weight. Also, the magnitude of diastasis between segments of the esophagus creates difficulties in choosing surgical tactics and managing such patients in the postoperative period. In addition, the management of such patients in the intensive care unit, both preoperatively and postoperatively, has a significant impact on the outcome. The literature review underlined "pain points" in the treatment of newborns with EA in regions with different levels of medical care, the consideration of which will allow the achievement of better results.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(3):315-326
Esophageal atresia — state of the art (review of literature on the PUBMED base)
Rothenberg S., Kozlov Y.А.

Esophageal atresia is fundamentally important in pediatric surgery, as its treatment results create an accurate portrait of the standards of surgical care, which is provided by any medical institution. Cameron Haight performed the first successful reconstruction of the esophagus’ malformation relatively recently — just over 70 years ago. Advances in neonatal surgery, technology and advances in neonatal intensive care have dramatically improved treatment outcomes for this disease. Current mortality from this developmental abnormality has become minimal, despite its frequent association with other malformations. A revolutionary approach to the treatment of esophageal atresia was developed by Steven Rothenberg in 1999, the pioneer and legend of pediatric minimally invasive surgery. In 1999, he revolutionized esophageal anastomosis by thoracoscopy. The innovative concept of the minimally invasive approach ensured minimal trauma to patients, thereby providing the possibility of rapid postoperative recovery of patients and reducing the length of their surgical hospital stay. This literature review raises the main controversy in the surgical treatment of esophageal atresia in the 21st century. Emphasis is placed on the study of the role of minimally invasive surgery and the treatment of concomitant abnormalities associated with gastroesophageal reflux and tracheomalacia. As part of the study, a description of all the latest technologies, advances in technical and scientific terms, solutions, exceptional experience, and competence in developing and implementing minimally invasive operations in young children. These developments changed the direction of pediatric surgery and improved the quality of surgical care for children with congenital malformation of the esophagus and how they were performed.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(3):327-338
Diagnosis and treatment of infants with severe hydronephrosis (literature review)
Sergeeva S.V.

Introduction. An assessment of the effectiveness of antenatal diagnosis and postnatal management of infants and infants with grade IV hydronephrosis was performed based on the analysis of domestic and foreign literature.

Literature review. In the literature analysis, we used the databases СlinicalKey, Web of Science, Cyberleninka, PubMed, and Medline. The search was not limited by the publication date; instead, the search’s emphasis was placed on publications of the last 10 years.

Classification. Several classification systems have been developed to assess the severity of hydronephrosis in infants. However, none of them describes the degree of expansion of the PCS and the functional state of the renal parenchyma. This work shows the stages of embryogenesis of the obstruction of the pyelourethral segment.

Diagnosis. The issues of antenatal diagnostics and prognostically significant outcome criteria for an intrauterine malformation of the fetal urinary system are considered. The main diagnostic methods in the postnatal period are described.

Morphological changes. Variants of pathomorphological changes in the renal parenchyma, the pelvic wall, and ureter in prolonged obstruction conditions are described. The role and variability of the number of Cajal interstitial cells in the pelvic wall and ureter in hydronephrosis have been analyzed.

Treatment. Particular attention is paid to nephroprotective therapy and surgical treatment tactics of the defect. Questions regarding the timing and choice of treatment methods, the need and duration of preliminary urine diversion in infants and children with grade IV hydronephrosis remain open.

Conclusion. Analysis of the world literature shows that there is no single protocol for intrauterine diagnosis and postnatal management of children with grade IV hydronephrosis. The functional state of the parenchyma is possible only with a comprehensive examination to assess the degree of hydronephrosis. Improving antenatal and postnatal diagnostics, therapeutic and surgical treatment of children with severe hydronephrosis should be based on a doctor’s cooperation, a specialist in ultrasound diagnostics, a nephrologist, and a pediatric surgeon.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(3):339-352
Study design guidelines
Sereda A.P., Andrianova M.A.

Complying with certain requirements or, more precisely, following the guidelines for the design of a scientific publication helps to make it not only more comprehensible for reviewers and readers, but actually enhances the quality of work. For example, even if some aspects in design logic were fulfilled but not described, other researchers doing meta-analysis may wrongly but for a good reason downgrade such publication and exclude it from the analysis. understanding of the guidelines for study design ensures not only the proper description of the results but the initial planning of work. The CARE guidelines were established for reporting of clinical cases, STROBE — for reporting observational studies (cohort and case-control studies), CONSORT — for reporting randomized studies (these guidelines are often used also for other comparative and case series studies), STARD — for reporting diagnostic studies, and PRISMa — for reporting of systematic reviews and meta-analyses. The present paper describes the key aspects of those guidelines and provides templates for graphic display of study design in form of flow charts. evidently, we should not forget that each study is unique and there is always a place for a reasonable compromise between “requirements” and the real logic of the research in place.

The article is the reprint published with the permission of the copyright holder. Original article: Sereda AP, Andrianova MA. Study Design Guidelines. Traumatology and Orthopedics of Russia. 2019;25(3):165-184. doi: 10.21823/2311-2905-2019-25-3-165-184

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(3):353-368
Sixth All-Russian congress with international participation “Medical care in trauma. New in organization and technology. The role of the national public professional organization of traumatologists in the healthcare system of the Russian Federation”
Petlakh V.I.

Information from the upcoming congress of orthopedic traumatologists.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(3):369-370
To the 90th anniversary of the founder of pediatric anesthesiology-reseanimatology Victor A. Mikhelson
Lekmanov A.U.

A description of the professional activities and merits of the founder of the school of pediatric anesthesiologists-resuscitators of Russia, Professor Victor A. Mikhelson, for his 90th birthday.

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care. 2020;10(3):371-373

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