Vol 13, No 2 (2023)

BACKGROUND: Surgical treatment of pancreatic cysts is one of the most difficult procedures in pediatric surgery. In children with pancreatic cysts, the issues of differential diagnosis and determining the connection of the cyst cavity with the main pancreatic duct remain problematic. Recent publications have focused on the use of endoscopic ultrasonography in pediatric practice to visualize the parenchyma and the ductal system of the pancreas with high accuracy.

AIM: This work aimed to study the results of treatment of children with cystic formations of the pancreas using modern radiation diagnostic methods and minimally invasive surgical technologies.

MATERIALS AND METHODS: Analysis was conducted on the results of treatment of 66 patients consisting of 30 boys (45.5%) and 36 girls (54.5%) aged 6 months to 18 years (average age of 10.9 ± 5.2 years) with extraparenchymatous and intraparenchymatous pancreatic cysts.

RESULTS: Multispiral computed tomography (Se 90%, Sp 91%, and Ac 91%; p < 0.05) and magnetic resonance imaging (Se 96%, Sp 94%, Ac 95%; p < 0.05) are the most informative for the differential diagnosis of intra- and extraparenchymatous pancreatic cysts. For thin-walled extraparenchymatous cysts up to 6 cm in size, conservative therapy is effective in the early period of the disease. External (42.4%) and internal (51.3%) drainage of cysts can be performed when the existence of pancreatic pseudocysts is prolonged (more than 2 months). Indications for simultaneous longitudinal pancreaticoejunostomy may occur in 9.5% of patients. Excision of the pseudocyst with pancreatic resection may be required in 4.7% of cases. For intraparenchymatous cysts, 33.3% of cases require the enucleation of cystic formation, 25% require the distal splenoserving resection of the pancreas, 25% require the central resection of the pancreas with the imposition of distal pancreatoejunoanastomosis, and 12.5% require pylori-preserving pancreatoduodenal resection. Approximately 70.8% of surgical interventions on the pancreas in children can be performed by laparoscopic access with a conversion rate in 12.5% of cases.

CONCLUSIONS: The choice of surgical intervention in children with pancreatic cysts is determined by the etiology, cyst size, localization, connection with the main pancreatic duct, and degree of involvement of the parenchyma in the tumor process. Most operations on the pancreas may be performed using minimally invasive approaches.

BACKGROUND: Although the principles of postoperative multimodal analgesia have been discussed in several articles, this issue remains insufficiently studied in pediatric cardiac surgery.

AIM: To increase the effectiveness of postoperative analgosedation in children after heart surgery by combining intravenous dexmedetomidine and paracetamol.

MATERIALS AND METHODS: Prospective, nonrandomized, controlled study (n = 65, 2–4 yr). Elective heart surgeries were performed in children with congenital heart defects, such as ventricular and/or interatrial septal defect and tetralogy of Fallot, under cardiopulmonary bypass and general anesthesia. Patients were divided into two groups according to the type of postoperative analgesia: group 1, main (n = 35): 30 min after surgery, infusion of dexmedetomidine with a loading dose of 1.0 μg/kg/h or 10 min, then infusion of 0.8 μg/kg/h during the day against the background of planned analgesia with paracetamol (15 mg/kg, intravenously) 2 h after surgery and then every 8 h during the day; group 2, comparisons (n = 30), 0.3 mg/kg — morphine, intramuscularly. The effectiveness of postoperative analgosedation in children was analyzed using the Richmond scale and FLACC + hemodynamics, acid-base balance, blood gases, cortisol, glucose, and blood lactate.

RESULTS: Sufficient stabilization of the main hemodynamics and respiratory indicators confirmed the adequacy of postoperative analgosedation in group 1 patients. There was a −14% drop in heart rate, specific peripheral resistance, and mean arterial pressure. There was no respiratory depression observed, and the decrease in blood pressure and heart rate was hemodynamically modest. Postoperative stability of blood lactate, glucose, and cortisol levels demonstrated the absence of major metabolic diseases and emotional and physical stress in the main group of children. The transfer of 74.3% of the first group's patients to the specialized department 42.3 ± 5.5 h after the procedure decreased costs and strain on the intensive care unit staff.

CONCLUSIONS: Dexmedetomidine combined with paracetamol provides an adequate level of sedation, suppresses extubation irritations, prevents psychomotor agitation, and provides sufficient analgesia.

Chronic intestinal failure is a pathogenetic component in children with short bowel syndrome. Short bowel syndrome limits the patient's capacity to socialize fully, the bad prognosis of the child's physical and spiritual development, and the patient's family's organizational and material issues. The severity of the problem is aggravated by the limited prospects for surgical treatment of patients, including transplantology, the imperfection of the legal framework for health care, particularly in terms of parenteral nutrition at home, and the supply of expensive drugs, consumables, and equipment to children with short bowel syndrome under state guarantees. Developing an equivalent of glucagon-like peptide-2 (GLP-2), a drug teduglutide representing the endogenous intestinal growth factor and intestinal adaptation, created an additional therapeutic possibility for individuals with short bowel syndrome. There are no data in Russian academic literature on the efficacy and safety of teduglutide in pediatric practice.

This study aims to conduct a systematic search and critical analysis of publications on the effectiveness and safety of using teduglutide in children with short bowel syndrome.

Publications from the PubMed, Scopus, and eLibrary databases, as well as scientific journals, were examined from 2012 to 2022. The articles were reviewed in English and Russian. Seven hundred seventy publications on using teduglutide in experimental and clinical practice were found; 94 sources matched the keywords; and eight articles were selected according to the PRISMA criteria. The risks of confounding bias were assessed using the ROBINS-I tool. Most patients received the therapeutic impact of teduglutide, and 8.4%–64.7% of patients achieved enteral autonomy. The drug's dose was 0.05 mg/kg/day. Without a therapeutic effect, the time limits for the inappropriate use of teduglutide ranged from 6 months to 1 yr. There is no causal relationship between taking teduglutide and undesirable reactions to treatment. The review of publications revealed an insufficient evidence foundation for the efficacy of teduglutide due to a lack of control groups in most studies, a small sample size, and errors in data methodology. Despite the encouraging preliminary results of individual studies, the problem of a shortage of randomized controlled tests of teduglutide remains.

Every year, new medical equipment is introduced to surgeons to improve the techniques of surgical interventions and reduce the risk of postoperative complications. One of these methods is hydrosurgery.

This study aimed to analyze medical literature on the experience of using hydrosurgical units in various branches of modern surgical practice, provide information on their effectiveness, and evaluate their main advantages, disadvantages, and prospects for use in pediatric surgery.

Publication search and information analysis were carried out using the databases PubMed, eLibrary, Web of science, and Cyberleninca. The following search phrases were used: “hydrosurgery,” “water jet devices,” “hydrosurgery,” “water jet hydrodissection,” “HybridKnife,” “Erbejet,” “VersaJet,” “water-jetdevices,” and “water-jetdebridement.” For the literature review, only sources in Russian and English published from 2015 to 2022 were selected. The experience of using hydrosurgical units in adult and pediatric surgical practices was considered. According to the specified search parameters, we analyzed 54 articles, 38 of which were included in the literature review. The remaining 16 articles were excluded due to the small sample of patients and incomplete stages of the study.

RESULTS: The results indicated the significant effectiveness and versatility of hydrosurgical methods. The fixed advantages of their use in the modern practice of a surgeon largely prevailed over their disadvantages, allowing their potential application in surgical interventions of varying degrees of complexity. Hydrosurgical technologies in pediatric practice were used in combustiology, treatment of wounds, skin neoplasms, and destructive pneumonia.

CONCLUSIONS: In conclusion, hydrosurgical methods are one of the effective modern surgical approaches to the treatment of patients with various pathologies. An in-depth study of this method in pediatric surgery is warranted.

Congenital hyperinsulinism is a severe disease that causes irreversible damage to the cerebral cortex. This article presents a clinical observation of successful surgical treatment for a child with an extremely rare form of hyperinsulinism accompanied by two foci in the opposite ends of the pancreas. The child was in extremely critical condition from birth due to recurrent hypoglycemia and was diagnosed with hyperinsulinism at the age of two weeks. Specific therapy with diazoxide and octreotide was initiated but proven to be ineffective (parenteral glucose administration was still needed, and octreotide only provided partial results). When the child was one month old, positron emission tomography-computed tomography with 18F-DOPA was performed and revealed the focal hyperfixation of the radiopharmaceutical in the tail and head of the pancreas. This finding indicated the presence of two pathological foci or a focus in the tail and the physiological accumulation of the radiopharmaceutical in the head. At the age of one month and 20 days, the child underwent laparoscopic revision of the pancreas to visualize a focus in the tail that was confirmed by express biopsy. The resection of the tail (15%) was performed with confirmation of clear resection margins. During further revision, a focus was detected in the head. Resection was again performed with histological confirmation of complete resection. On the 12^th day after the operation, the child was discharged without therapy with clinical recovery. The child is currently being monitored (for over six months), growing and developing according to age. A fasting test was performed, and the recurrence of hyperinsulinism was ruled out. This article presents a detailed description of the clinical and radiological examination results, the patient’s history, the surgical techniques, and the intervention results. As part of the discussion, a literature review on the behavior of laparoscopic resections of the pancreas in children with congenital hyperinsulinism was carried out.

Perineal groove is a congenital anal anomaly. This skin defect appears next to the anal opening, similar to a cleft, and is covered by a mucous membrane. The anomaly often occurs in girls. Grooves can be detected in patients with normally formed anus or as part of an anorectal malformation with a perineal fistula or anal stenosis. Perineal groove is a congenital anal anomaly.

This work aimed to provide information for specialists about this congenital developmental anomaly. In our clinic, five girls were observed and diagnosed with perineal groove quite early in their lives (from one to three months of age). Only one required surgical treatment because she had an anorectal malformation with a perineal fistula. In one case, bougienage of the anus was prescribed because stenosis was detected in a timely manner. For the three girls with a normally formed anus, surgery or other types of treatment were not indicated. In other clinics, either long-term courses of conservative local therapy were prescribed for “anal fissure” or “folds in the anus” or a diagnosis of anorectal defect was made with indications for surgery. This study also analyzed current publications on the diagnosis and treatment of congenital perineal sulcus.

Basing on their own experience in the diagnosis and treatment of children with hematogenous osteomyelitis and their study of domestic and foreign sources, the authors came to the conclusion that in all classifications available, consensus is lacking on the origin, course, form, stage, phase, outcome, and consequences of hematogenous osteomyelitis in children. This realization prompted us to revise the classification of hematogenous osteomyelitis in children.

The proposed new classification of hematogenous osteomyelitis in children was developed by amending the existing ones. It consists of 10 headings: etiology, origin, course, form, stages, localization, morphological form, complications, outcome, and consequences. Along the course, hematogenous osteomyelitis was divided into acute, subacute, and atypical forms. In addition to the allocation of “subacute” hematogenous osteomyelitis, a separate section gives a brief description of the features of its course and clinical manifestations. Hematogenous osteomyelitis of bones forming joints and hematogenous osteomyelitis of mixed bones (spine) were added to the “Localization” section, and apophyseal localization was added to osteomyelitis of tubular bones. In the “Outcome” section in the “Recovery” section, four subsections were highlighted.

We submit this classification for discussion and await opinions and suggestions from pediatric surgeons on improving the classification of hematogenous osteomyelitis in children.

The Symposium of Pediatric Surgeons of Russia, “Intestinal Anastomoses in Children,” was conducted in Volgograd on April 26, 2023, with around 180 doctors in attendance. Thirty papers were presented and discussed, and 41 articles were published in the proceedings of the symposium. According to the results of a systemic analysis of a questionnaire poll of major pediatric surgeons in 75 regions of Russia, 4,558 surgeries on intestinal anastomosis formation were performed in 2021–2022, including 1,735 operations in newborn children (36%); their share in general pediatric surgery was less than 0.6%, and it was more than 18.6% in neonatal surgeons. The number of intestinal anastomoses formed during laparoscopic procedures increased (4.4%). Pediatric surgeons equally often used double-row nodal intestinal sutures (33.3%), single-row continuous sutures (34.6%), and different types of sutures (33.3%). A T-shaped anastomosis was performed in cases of necrotizing enterocolitis where there was a significant difference in the diameters of the intestine's inflow and outflow channels. The clip-and-drop technique was used to treat neonates with multifocal necroses. Interintestinal anastomoses were favored over enterostomies in numerous segmental resections. For duodenal obstruction, duodeno-duodenal, and duodeno-jejunal anastomoses were performed. In children with Crohn's disease and choledochal cysts, most specialists prefer operations with stapling devices. Creating a magnetic interintestinal anastomosis lowers the risk of postoperative complications and facilitates the postoperative period. Clinical observations after laparoscopic surgeries accounted for a significant proportion of complications (66%). Anastomosis failure was three times more common in planned small intestinal in older children than in emergency surgeries (1.2 and 0.4%, respectively).

The modern stage of development of intestinal anastomosis formation techniques in children is characterized by good results, the expansion of indications for intestinal anastomosis in conditions of compromised colon or peritonitis, and the introduction of laparoscopic techniques and mechanical stapling devices with slightly poorer results.

After almost three years of the pandemic, in November 2022, pediatric surgeons came together in Moscow for the traditional Forum at the Izmailovo Hotel. The program of the plenary session of the forum included the presentation of the annual prize named after S.D. Ternovsky “For a great contribution to the development of domestic pediatric surgery”, which was awarded to Professor V.A. Novozhilov. Within the framework of the plenary session, a report dedicated to the 100^th anniversary of the birth of Girey Alievich Bairov was also presented. The topic of neonatal surgery was actively discussed both in the plenary report of Professor D.A. Morozov “Surgery of newborns in the Russian Federation”, and in the discussion format of the schools of pediatric surgeons in Moscow and St. Petersburg. Video session “How I do it”. A workshop was held for the main children’s, which touched upon the unresolved issues of the specialty, in particular the problem of providing surgical care to children by general surgeons. The extensive program of the three days of the forum included symposiums, round tables and master classes on topical issues of pediatric surgery. The forum was attended by 1,706 specialists from 14 countries. The audience of participants has significantly expanded due to remote broadcasting, the duration of which was 43.5 hours. On the final day of the Forum, a traditional competition of research papers for young scientists took place.

The VIII Forum of Pediatric Surgeons of Russia was a large-scale event covering the actual problems of our specialty. Presented reports and discussions showed directions for further scientific development and introduction of advanced medical technologies into practice.

The paper describes the professional activities and merits of the pediatric surgeon Vladimir G. Bairov, in celebration of his anniversary.

Information about the life path of the founder of domestic anesthesiology and resuscitation, Professor Anatoly P. Zilber.

Information about the untimely deceased pediatric surgeon, doctor of medical sciences, Evgeny Ya. Gatkin.