Vol 13, No 3 (2023)

Information from the editor-in-chief on the inclusion of the journal “Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care” in the international SCOPUS database.

BACKGROUND: In pediatric surgery, intestinal anastomosis is a standard and responsible operative method used for all age groups. Although advancements in medical technology have significantly changed and expanded the range of surgical interventions, many questions remain, including the safety of intestinal anastomosis in newborns with significant segment discordance, the use of laparoscopic intestinal sutures, the use of mechanical stitching devices, and intestinal anastomosis in peritonitis.

AIM: To determine current problems and future directions in the field of intestinal anastomosis in children in the Russian Federation.

MATERIALS AND METHODS: The study is based on data from 4,558 intestinal anastomosis operations, including 1,735 in newborns, provided by the chief pediatric surgeons of 75 constituent entities of the Russian Federation during 2021–2022, including the Donetsk and Lugansk People’s Republics. Based on a questionnaire, the data were summarized and statistically processed.

RESULTS: The study reports on the results of intestinal anastomosis in children in the Russian Federation across various segments of the intestine and age groups. The risks of failure and re-reconstruction significantly increased when duodenal anastomosis was performed laparoscopically and in settings of peritonitis or a compromised intestinal wall (p < 0.05). Conversely, the use of laparoscopy and suturing devices in older children for small intestine anastomosis was carried out practically without complications. However, it was performed twice as often in emergencies and against the background of combined problems. In general, the results of small bowel anastomosis under poor conditions were statistically insignificant from intestinal anastomosis with stoma closure (p > 0.05). The data revealed that colon surgery, repeated reconstructions, duodenal anastomoses, and small intestine anastomoses in newborns with poor blood flow to the intestinal wall posed the highest risks of anastomotic failure. Small and large intestine surgery in newborns has the highest mortality rate, particularly with peritonitis and circulatory disorders.

CONCLUSIONS: Thus at the current stage of development, intestinal anastomosis in the Russian Federation is characterized by good results, the expansion of indications for anastomosis in conditions of compromised intestine or peritonitis, and the use of laparoscopic techniques and mechanical staplers.

BACKGROUND: Anorectal abnormalities occur in 1:1,500 to 1:5,000 live births. There is still no agreement on the best surgical procedure for treating some types of anorectal abnormalities in males. Anorectoplasty could be performed using the posterior sagittal approach and using laparoscopic techniques.

AIM: To assess the risk of postoperative complications and determine their specificity in males with anorectal malformations, depending on the surgery approach.

MATERIALS AND METHODS: A single-center retrospective cohort study was performed. Male patients with anorectal malformations who had surgical correction of anorectal malformation by posterior sagittal (group I) or laparoscopic-assisted anorectoplasty (group II) at the age of up to 1 yr at the N.F. Filatov Children’s City Clinical Hospital from 2008 to 2022. Postoperative and intraoperative problems and the number of surgical interventions that had to be redone to correct issues were noted.

RESULTS: Of the 33 patients in group I, 18 (55%) had anorectal malformations with bulbar fistula, 12 (36%) had anorectal malformations without fistula, and three (9%) had a prostatic fistula. Group II included 99 patients, with 53 (54%) having anorectal malformations with prostatic fistula, 30 (30%) having anorectal malformations with bulbar fistula, nine (9%) having anorectal malformations with bladder neck fistula, and seven (7%) having anorectal malformations without a fistula. The incidence of intraoperative and postoperative complications was statistically significantly higher in children after posterior sagittal anorectoplasty than laparoscopic-assisted anorectoplasty: I, 19 (58%) versus II, 33 (33%); p = 0.014. The number of redo surgical interventions to correct complications did not differ significantly between the studied groups: I, 8 (24%) versus II, 26 (26%); p = 0.819. The incidence of urethral damage was identified with posterior sagittal anorectoplasty compared with laparoscopic-assisted anorectoplasty: I, 4 (12%) versus II, 0 (0%); p < 0.001. We found no differences in postoperative complications between laparoscopic-assisted and posterior sagittal anorectoplasty.

CONCLUSIONS: The results define laparoscopic-assisted anorectoplasty as a viable and promising method that does not have specific postoperative complications if it is technically correctly performed. It is necessary to develop clear criteria for rectum mobilization and the volume of rectourethral fistula dissection during laparoscopic-assisted surgery to reduce the risks of postoperative problems and repeat surgery.

BACKGROUND: There have been an increasing number of publications in recent years demonstrating the efficiency and safety of ultrasound imaging techniques in anesthesiology and intensive care, which reduce the risk of complications during invasive manipulation and detecting life-threatening conditions at the earliest stage; however, practical implementation of these techniques is associated with significant difficulties, which served as the basis for this research.

AIM: To estimate the adherence of experts in pediatric anesthesiology and intensive care departments to using ultrasound imaging techniques in clinical practice.

MATERIALS AND METHODS: A voluntary, anonymous questionnaire study of pediatric intensive care unit heads in 65 Russian Federation regions was conducted.

RESULTS: Responses were obtained from 32 (38.4%) respondents. In 30% of cases, the work experience of specialists in the pediatric intensive care unit was around 5–10 yr, and there was no relationship between the introduction of ultrasound imaging techniques into the departments’ routine practice and the work experience of the specialists. All the professionals who participated in the study had access to an ultrasound scanner 24 h per day, 7 days a week. When measuring adherence to the use of ultrasound imaging techniques in providing venous access, five (15%) hospitals did not utilize them at all, whereas four (12.5%) medical institutions used them 100% of the time. The average frequency of main vein catheterization using ultrasonic imaging techniques is 49 ± 35.5%. Ultrasonography is used to examine cardiac systolic function by 26 (81) respondents and it is routine in 50% of patients who require continuous catecholamine infusion. The Teicholz method (56% of the time) is used to assess systolic cardiac function; the Simpson method was used in 34% of cases. Ultrasound imaging to assess pulmonary status is used by 56% of responders. It is only used routinely in 28% of patients who require controlled mechanical ventilation. Ultrasound imaging is used in 47% of cases to examine the status of breathing volume. In 72% of instances, ultrasonography is used to assess cerebral perfusion and diagnose intracranial hypertension syndrome. Ultrasound-imaging methods are used by 56% of responders for screening diagnoses of life-threatening disorders in children with polytrauma, and in 44% of cases, it is a routine assessment. Fifty-seven percent of respondents believe that ultrasound diagnostic techniques are highly effective, and 71% believe that their use is safe for patients.

In recent years, ultrasound elastography has been introduced into clinical practice. Because of the low availability of this equipment and the short period of operation, professionals are unaware of the technology’s potential. Based on the findings of a systematic review of published scientific studies, this study aims to determine the diagnostic use of ultrasound elastography in patients with surgical diseases and injuries. PubMed, Google Scholar, eLibrary, and other information databases were searched for publications in Pediatric Surgery, Russian Bulletin of Pediatric Surgery, Anesthesiology and Intensive Care, Pediatric Surgery, and SonoAce Ultrasound from 2016 to 2022. The total number of sources in the sample is 7,040. The analysis comprised 32 papers that met the PRISMA criteria. The findings are divided into “surgical diseases” and “injuries”. The works on space-occupying formations predominated among the “surgical diseases” (27 publications). A single study was related to vascular problems and ectopic pregnancy, and three articles corresponded to the criteria of “injury”. The method’s specificity was confirmed in the interquartile interval [Q₁ 77 – Q₃ 95], Me 88.1, with sensitivity in the interval [Q₁ 81 – Q₃ 94], Me 85.5. The advantages of elastography have been established in terms of the specificity of the method in identifying predictors of rotator cuff rupture, amounting to 96.7% and 61.2%–62.5%, respectively, when compared with the B-mode. In pancreatic cysts, elastography had a specificity of 75.0% but only 40.0% in B-mode. The advantage of elastography (84.0%) over grayscale studies (69.0%) in metastatic lymph node lesions was established. Elastography is 15% more effective than standard ultrasonography in treating supraspinatus tendon injury. Elastography raised the specificity of prostate cancer diagnosis from 45.0% to 89.0%.

Artificial intelligence technologies are increasingly being applied in a variety of medical disciplines. After reviewing 278 publications from 1985 to 2023, 99 articles were selected from the databases elibrary, PubMed, Medline, WoS, Nature, Springer, and Wiley J Database to present the main approaches and a modern picture of the application of artificial intelligence methods and technologies in pediatric surgery and intensive care. The article examines many facets of artificial intelligence systems for medical uses, namely, computer decision support systems or supporting the surgeon throughout the surgical intervention procedure. Computer analysis of 3D visualization and 3D anatomical modeling of images obtained from computed tomography and magnetic resonance imaging investigations can be used to plan operations. Because of the possibilities of sufficiently accurate 3D models and methods for organs and pathological processes, various methodologies and software tools for preoperative planning and intraoperative support of surgical intervention have been developed. Computer (technical) vision analyzes high-quality medical images and interprets them in multimodal three-dimensional images for computer diagnoses and operations under visual control, including augmented reality methods. Robotic surgery involves manipulators, including remotely controlled ones, and intellectualized complexes that independently perform specific actions of the “second assistant surgeon”. In intensive care, artificial intelligence technologies are being investigated to merge data from bedside monitors and other information about patients’ conditions to identify critical situations and control mechanical ventilation. Simultaneously, several obstacles impede the adoption of artificial intelligence in surgery. The nature and standardization of the initial data required for their integration, taking into consideration atypical cases, the possibility of bias in the sample used, and the transparency of the decision-making process in machine learning models are examples. The explanation of solutions presented in machine learning models and the transition to full-fledged validation of the systems being built define the prospects for developing and using artificial intelligence systems.

Acute paraproctitis and pararectal fistulas are common diseases in infants and adolescents. To date, discussions are ongoing about whether to use conservative or surgical treatment options, their implementation, and the use of antibiotics during the perioperative period. The study is based on a literature review of treating children with this pathology. The databases in Russian eLibrary.ru and English Medline, Web of Science, and PubMed were searched for literature sources. The following keywords were entered into the search: “acute paraproctitis”, “pararectal fistulas”, “fistulotomy”, and “fistulectomy.” There were 155 papers discovered, 51 of which were congruent with the purpose of our study and were evaluated. According to the data presented in the literature review, pararectal fistula is the outcome of acute paraproctitis in 20%–85% of cases. The cause of acute paraproctitis and pararectal fistulas in children is unknown. Imaging methods that allow you to identify all the hidden passages and characterize the relationship between the fistula and the anal sphincter play an important role in diagnosing pararectal fistulas. Cellular technologies are being used as a conservative treatment with established approaches. Incision and drainage are the preferred surgical procedures in treating acute paraproctitis, and fistulotomy is used in pararectal fistulas. Stem cell therapy is described as a promising treatment. Relapses of paraproctitis and/or the establishment of pararectal fistulas occur at a rate ranging from 0% to 85%. Such a large range may be related to the nature of the treatment and how fistulas are classified as relapses or complications. The recurrence of abscesses and anal fistulas is closely related to the type of surgical intervention. If the channel of the anal fistula is not identified and not dissected, the risk of recurrence is relatively high. Based on the findings of the data analysis, it is possible to infer that there is currently no single procedure for treating children with acute paraproctitis and pararectal fistulas. This explains the importance of performing randomized prospective studies to determine the best treatment strategies for children with this pathology.

The number of cases of traumatic pancreatic damage in children has increased by 1%–2% over the last several decades, which is related to an increase in car accidents and the popularity of outdoor sports (cycling and scooter). A 9-year-old boy was admitted to Children’s City Clinical Hospital after being injured in a bicycle fall. The boy complained of pain in the upper abdomen and around the wound on the anterior abdominal wall when he was admitted. The victim was conscious during the examination, the abdomen was not bloated, soft, or uncomfortable on probing in the higher portions, and peritoneal symptoms were negative. An ultrasound examination of the abdominal organs revealed symptoms of pancreatic injury, including the creation of a hematoma up to 58 mL in size. The general blood test found leukocytosis (12.75 · 10⁹/L) and an increase in amylase up to 1,664 U/L. Following preoperative preparation, a diagnostic laparoscopy was conducted, which included opening and draining the omental sac, as well as cleanliness and drainage of the abdominal cavity. The patient was given antimicrobial, hemostatic, infusion therapy, pancreatic secretion inhibitors, and food nutrition following the procedure. During the dynamics of the ultrasound examination, a pseudocyst of the pancreas with a volume of up to 22 mL was noted. The situation improved with treatment, the amylase indices reduced (271 U/L), and the child was discharged home 44 days a day. After 4.5 months, the cyst increased to 320 mL; therefore, during planned hospitalization, a laparotomy was performed with the imposition of pancreatocystojejunoanastomosis on the Roux-enabled loop. The postoperative time was uneventful, and the child was released from the hospital on the 14^th day. The diagnosis was confirmed through laparoscopy, and the omental sac and abdominal cavity were sterilized before drainage. Constant monitoring of the ultrasound image of the pancreatoduodenal zone and the dynamics of amylase markers allowed for the identification and evaluation of posttraumatic changes in the pancreas. An increase in the volume of the pseudocyst served as an indication for the imposition of pancreatocystojejunoanastomosis on the Roux-en-Y loop.

The paper describes the professional activities and merits of the pediatric surgeon Yuri F. Isakov.