SMALL INTESTINAL FISTULAS IN CHILDREN

SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 86 SMALL INTESTINAL FISTULAS IN CHILDREN N.N. Nazarov Tashkent State Medical University https://doi.org/10.5281/zenodo.17451738 Abstract. The article systematizes clinical manifestations of diseases, information on auxiliary diagnostic methods and surgical tactics. For the purpose of forming all of intestinal stoma in our observations is divided into the following groups: temporary stoma formed to fully turn off the segment of the colon in emergency status of the child (in 29 patients with 70.7%); intestinal stoma as a stage correction of congenital malformations (in 7 patients – 17.1%); decompressive stoma with paralytic intestinal obstruction (5 patients – 12.2%). Indications, type and level of formation of a temporary intestinal stoma in children are determined by the specifics of the underlying disease and the option of subsequent reconstructive surgery. Despite the inevitability of the development of parastomal complications, in most cases, with the right surgical technique, it is possible to prevent their occurrence. Keywords: congenital malformations and acquired diseases of the abdominal organs, small bowel fistulas, complications of intestinal stomas, children. Introduction Intestinal anastomosis in neonates with discrepancies in the diameter of the afferent and efferent segments of the intestine, as well as in conditions of peritonitis, is almost always subject to the risk of its failure [1,3]. Postoperative paresis, intraintestinal hypertension, permeability of toxins and virulent microbial flora in the area of the anastomotic suture strip, as well as high endogenous intoxication in combination with hemodynamic disturbances impede normal healing of the sutured intestinal wound [6-7,14]. Mortality in emergency bowel resection in children remains at the level of 11-32.1%, and does not tend to decrease, which leaves open the question of surgical tactics in emergency situations [1,8-9,11-12]. Various types of ostomy surgeries have been used in children for over fifty years; however, many issues remain unresolved and continue to cause controversy among surgeons treating this group of patients. Specifically, preoperative examination algorithms have not been developed, nor have clear indications been established for the placement of various types of temporary enterostomy in children, depending on gastrointestinal pathology, the child's general condition, and premorbid background [1,4-5,7,13]. Intestinal stoma can cause both early and late postoperative complications [2,10,14]. No connection has been established between these complications and errors in determining the extent of resection of the altered intestinal fragment during removal. Issues regarding postoperative management of patients with intestinal fistulas remain unresolved [1,13]. Reconstructive interventions present challenges: the incidence of postoperative complications during stoma closure in children under 3 years of age ranges from 10 to 40%, while in newborns it reaches 66% [4,11,13-14]. The timing and methods of reconstructive surgeries, as well as their impact on the development of postoperative complications, are controversial. When deciding on the timing and method of intestinal stoma closure, along with the patient's general condition, the condition of the afferent and efferent segments of the intestine is fundamental. This SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 87 requires a search for the most informative and objective methods for assessing intestinal condition at the stages of surgical treatment [1-2,7-8,11,14]. Clearly, effective treatment of children with congenital and acquired abdominal diseases requiring bowel resection requires the development of a rational treatment strategy. This strategy should be based on criteria that clearly define the standardization of the appropriate surgical intervention, postoperative management, and subsequent delayed rehabilitation [2,10]. Purpose of the study. To improve treatment outcomes for children with congenital and acquired surgical diseases of the small intestine by optimizing methods for forming artificial intestinal fistulas, predicting the postoperative course, and treating and preventing complications. Materials and methods of research. From 2017 to 2019, 41 children with various malformations, gastrointestinal tract (GIT) diseases, and their complications, which led to the formation of preventive intestinal stomas, were examined and treated at the clinical sites of the Department of Hospital Pediatric Surgery of the Tashkent Pediatric Medical Institute. Of these, 6 (14.6%) had malformations of the gastrointestinal tract; 35 (85.4%) had acquired diseases of the abdominal organs. The age of the patients ranged from 3 months to 14 years. Among the patients, boys predominated - 22 (53.7%), while girls accounted for 19 (46.3%). Along with a thorough collection of anamnesis, objective and laboratory research methods, the following instrumental diagnostic methods were used: irrigography, passage of barium suspension through the gastrointestinal tract, gastrointestinal endoscopy and MSCT. According to the purpose of formation, all intestinal stomas in our observations are divided into the following groups: a) temporary stomas formed for the purpose of complete exclusion of a segment of the intestine in an emergency condition of a child (29-70.7%); b) intestinal stomas as a stage of correction of a congenital malformation (7-17.1%); c) decompressive stomas in paralytic intestinal obstruction (5-12.2%). Results and their discussion. Indications for the formation of a temporary artificial intestinal fistula were: impossibility of creating a direct anastomosis; during resection of a section of intestine under conditions of peritonitis of various etiologies; in low congenital intestinal obstruction, when there is a significant difference in the diameters of the afferent and efferent intestinal loops; in progressive necrotizing enterocolitis (NEC), when the abdominal cavity is compromised, and the intestine is affected over a large area and in order to preserve its maximum length, it is necessary to resect a section of intestine along the border of conditional viability; in case of intestinal trauma; the need to eliminate obstruction without resection of a section of intestine; to reduce intoxication and prepare the child for reconstructive surgery for a developmental defect of the gastrointestinal tract. Artificial intestinal fistulas were used in emergency surgery to stabilize the patient's condition by quickly restoring gastrointestinal flow, thereby reducing endotoxemia, relieving inflammation, and unclogging the interintestinal anastomosis. In elective surgery, intestinal stomas were used to prepare a child for major plastic surgery to ensure a favorable surgical and postoperative course. We observed 2 children (4.9%) with congenital low intestinal obstruction, 1 with traumatic intestinal injury (2.4%), 2 with Hirschsprung's disease (4.9%), 3 with Meckel's diverticulum of the ileum (7.3%), 10 with acute inflammatory diseases of the abdominal organs (24.4%), and 23 with NEC (56.1%). All patients discussed in the study received staged treatment. In addition to the underlying disease, 21 (51.2%) patients had one or more malformations: gastrointestinal tract anomaly – 3 (14.3%); congenital heart defect – 4 (19.0%); elongation of the colon – 5 (23.8%); urinary system – 1 (4.8%); various somatic diseases – 8 (38.1%). In 2 children, SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 88 the severity of the condition at the time of surgery was aggravated by necrosis, intestinal perforation, peritonitis, and in 6 children, pneumonia. The goal of preoperative preparation was to achieve good bowel movement, suppress pathogenic microflora, correct water-salt, protein, and vitamin metabolism disorders, and reduce chronic intoxication. The extent of preparation depended on the clinical stage of the disease, the severity of secondary changes, and pain. The duration of preparation for low intestinal obstruction, NEC, intestinal perforation, and peritonitis ranged from 2 to 4 hours. Closure times for temporary intestinal stomas ranged from 1 to 6 months and were determined by the nature of the pathology, provided that the inflammatory process in the abdominal cavity had subsided, the child's condition had stabilized, gastrointestinal motility had been restored, and correction of the congenital malformation had been completed. Stomas at the jejunal level required early closure due to high intestinal loss. Before stoma closure, the following complications were observed: weight loss - 13 (31.7%), adhesive intestinal obstruction - 5 (12.2%), intestinal evagination 4 (9.8%). Complications from the intestinal stoma: bleeding - 1 (2.4%); superficial suppuration (failure of the enterocutaneous suture) - 1 (2.4%); stoma retraction - 1 (2.4%); stenosis - 2 (4.8%). All operated patients with low congenital intestinal obstruction were diagnosed with peritonitis of varying severity, with intestinal perforation and associated changes in the abdominal organs. Only a thorough intraoperative examination of the entire intestine allows us to determine the presence of anomalies or the nature of the underlying pathology, which facilitates the selection of an appropriate surgical strategy and adequate completion of the operation. Two children underwent emergency surgery within 4 to 6 hours of admission to the surgical hospital; abdominal exploration revealed ileal atresia. Palliative surgeries were performed on both patients: a singlebarrel ileostomy for one, and a double-barrel ileostomy for the other. Children with small intestinal fistulas underwent elective surgery 1.5-2 months after the primary surgery. Two operated patients underwent radical end-to-end ileo-ileoanastomosis. We used temporary artificial intestinal fistula placement as the first stage of surgical correction in the treatment of two children with Hirschsprung's disease. Progressive necrotizing enterocolitis was the reason for the ostomy. Rectosigmoidal variants of Hirschsprung's disease were observed in two children. The choice of surgical approach and intestinal transection site were determined based on radiographic examination results. In two patients, a lateral approach in the right iliac fossa was used for stoma placement due to a clearly visible transition zone. In patients with total colonic enterocolitis, an end enterostomy was performed on the unaffected portion of the small intestine. The positive effect of intestinal stoma includes not only restoration of intestinal passage but also reduction of intoxication. Children with a history of Hirschsprung's disease and stoma placement underwent elective surgery 3-6 months after the initial surgery. In 14 children with peritonitis, during the initial intervention and when complications developed, resection of a section of the intestine was performed with the formation of preventive intestinal stomas. The most common cause of intestinal fistula removal was intussusception with necrosis – 7 (50.0%) children, destructive forms of diverticulitis – 2 (14.3%) children, traumatic intestinal injury – 1 (7.1%) child. Adhesive intestinal obstruction with intestinal necrosis was the reason for stoma placement in 4 (28.6%) cases, intestinal perforation – in 2 cases, nonspecific ulcerative colitis and obstructive intestinal obstruction – in 1 case. Types of intestinal fistulas formed in children after resection of a section of intestine under conditions of peritonitis: single-barrel enterostomy – 1 (7.1%); double enterostomy – 8 (57.2%); suspension – 5 (35.7%). We used double enterostomy in 8 children. The indications for this SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 89 surgical option were: destructive forms of Meckel's diverticulum in 2 patients and complicated ileococcal intussusception in 6 patients. A total of 7 patients underwent surgical treatment. The indications for surgical treatment were the following: clinical signs of peritonitis; small-intestinal intussusception (diagnosed by ultrasound); failure of conservative treatment. The following forms of intestinal intussusception were verified during surgery: small-intestinal – in 2 patients (28.6%); ileocolic – in 5 patients (71.4%). All 14 patients underwent surgical treatment: end-to-end ileo-ileoanastomosis – in 9 (64.3%); ileoascendoanastomosis – in 5 (35.7%). We observed 23 patients (boys – 10; girls – 13) with progressive NEC grades III-a and IIIb (classification of Walsh, Kliegman, 1986). NEC was detected in the small intestine in 19 patients (82.6%) and in the colon in 4 patients (17.4%). Pathological changes were present in both the small and colon in 7 cases. Multiple perforations were detected in 21 patients (91.3%), and single perforations were found in 2 patients (8.7%). Surgeries in children with progressive NEC involved resection of the affected bowel and creation of single or double artificial intestinal fistulas. Ostomy options largely depended on the level and extent of the necrotic process. For children with complicated NEC, the following types of artificial intestinal fistulas were used during the initial surgery: single-barrel enterostomy (6); double enterostomy (13); and suspension enterostomy (4). A single-stem fistula, depending on the level of resection, was used as a small bowel fistula in 6 children. The advantage of this technique is the relative simplicity of the procedure. Complications arise in the postoperative period and are related to the need to compensate for significant chyme losses with massive intravenous infusions. A double-stem fistula is more appropriate, which we used in 13 patients. Bringing the distal portion of the intestine to the anterior abdominal wall allows, by introducing water, nutritional mixtures, and collected intestinal chyme into the stoma, to virtually restore natural gastrointestinal passage, thereby better preparing the child for reconstructive surgery. The introduction of an enterostomy in patients with necrotizing enterocolitis allows for the rapid restoration of passage through the gastrointestinal tract to the stoma, which relieves inflammation and reduces the level of endogenous intoxication. In all patients, the intestinal anastomosis was created using the "end-to-end" or "end-to-side" principle, with the afferent or efferent intestinal loop brought out to the anterior abdominal wall (a compression suture was used in one case). An important factor that should determine the management strategy for this group of patients is the fact that, when treating patients with NEC, in order to preserve as much intestinal length as possible, the resection level often passes through conditionally viable tissue. In one of 23 children, suture failure was observed during intestinal anastomosis formation, requiring repeated reconstructive interventions. The following types of small intestinal stomas were imposed in the patients: single-barrel – 9 (22.0%), double-barrel – 22 (53.7%), suspension – 10 (24.3%). In 22 (53.7%) cases, stoma formation was performed after preliminary resection of small intestinal sections, in 19 (46.3%) cases without its resection. In 3 patients (7.3%), the stoma was imposed within the jejunum, in 33 (80.4%) - within the ileum. Among them, in 7 cases, the stoma was imposed at a distance of 1520 cm from Baugin's valve. In the postoperative period, complications were observed in one patient in the form of anastomotic failure, adhesive intestinal obstruction – 5 (12.2%), repeated stoma – 2 (4.8%). Summarizing the analysis of treatment for children over one year of age, it can be noted that during bowel resection in the setting of peritonitis, the indications for the formation SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 90 of terminal intestinal fistulas expanded during the initial stages of surgery. This saved lives, but complicated the postoperative care of these patients. Rehabilitation of children with enterostomies began immediately after the intestinal fistula was repaired. Once the small bowel stoma, especially the high one, was functional, standard ostomy bags were used to protect the surrounding tissues from chyme, care for the stoma, and track losses, with two-piece Coloplast systems being preferred. Thus, despite the high importance of creating stomas in the clinical practice of a surgeon, a number of controversial and unresolved issues remain that require a further constructive approach from both the surgical community and the patient - the stoma carrier and his parents. Conclusion An integrated assessment of the severity of the child's condition, based on clinical and laboratory data, intraoperative changes, and premorbid background, allows for the reasonable determination of indications for the formation of temporary artificial intestinal fistulas. Indications, type and level of formation of a temporary intestinal stoma in children are determined by the specifics of the underlying disease and the option of subsequent reconstructive surgery. 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