Intestinal atresia: factors affecting survival

Eighty-four patients with congenital jejuno-ileal or colonic atresia treated at this hospital during the years 1961-86 were studied. There were 42 cases of jejunal atresia, seven cases of jejuno-ileal atresia, 33 cases of ileal atresia and two cases of colonic atresia. Multiple atresias occurred in 19 patients. During the first 15 years of the study the mortality rate was 56%. In the last 10 years it was 22%. Multivariate linear modelling techniques were used to determine the factors associated with a fatal outcome. In order of magnitude associations were found between death and year of treatment (P less than 0.01), the type of anastomosis performed to correct the atresis (P less than 0.05), the presence of other congenital abnormalities (P less than 0.01) and presence of a malrotation (P less than 0.02). The anastomoses associated with the highest mortality were those with a stoma. The mean length of bowel resected proximal to the anastomosis was 15 cm and the mean length resected distally 5 cm. Eleven patients had 60 cm or less of small bowel remaining after surgery and only three of these survived. The highest mortality rate can be expected in patients with other congenital abnormalities and those with a malrotation. A primary anastomosis without a stoma is recommended.

Efficacy of antibody NF2F11 staining in the investigation of severe long-standing constipation. A preliminary report

A retrospective study of 7 adult patients (6 with severe, long-standing constipation and 1 with chronic idiopathic intestinal pseudoobstruction) was carried out to test the diagnostic potential of the antineurofilament monoclonal antibody NF2F11. In 4 of the cases of constipation and in the 1 case of pseudoobstruction, paraffin sections of resected colon revealed an anomaly in that the axon bundles of both plexus systems remained unstained. This picture differed from that found in the control population. The results are discussed in relation to previous studies of congenital neurogenic abnormalities of the digestive tract in children.

Familial apple peel jejunal atresia: surgical, genetic, and radiographic aspects

Fifty-seven cases of apple peel jejunal atresia have been reported in the English literature. Patients with this anomaly have a high incidence of prematurity (70%), malrotation (54%), short gut syndrome (74%), multiple atresias (15%), complications (63%), and mortality (54%). Mortality has decreased from 63% to 47% since 1970. We report three new cases of apple peel jejunal atresia, including two from one family. Radiographic evidence of high small bowel obstruction and a malrotated microcolon on preoperative roentgenogram with barium enema should suggest this diagnosis. Five families, including ours, have been reported in which more than one child was affected, and it has been suggested that this disorder is transmitted by an autosomal recessive gene. However, the occurrence of conventional intestinal atresia in other siblings, the association with multiple atresias, and discordance in a set of apparently monozygotic twins indicate that there may be a more complex spectrum of genetic transmission. Subsequent siblings are at increased risk for apple peel atresia or related malformations. Prenatal ultrasound can facilitate early diagnosis and treatment.

Disaccharidase activities and intestinal absorption in infants with congenital intestinal obstruction

The results of studies on disaccharidase activities and on intestinal absorption in cases of complete and incomplete congenital small bowel obstruction are presented. Assays of the activities of maltase, isomaltase, sucrase, trehalase, and lactase have been performed on biopsy specimens taken at the time of surgery. In specimens taken from above the site of obstruction, the activities are reduced for all disaccharidases, and are particularly low for trehalase and lactase. There was no difference between the cases with complete and incomplete obstruction. Distal to a complete obstruction, trehalase and lactase were reduced, whereas in cases of incomplete obstruction, the activities of all disaccharidases were within what is considered normal in the reference material. Two months after surgery, the disaccharidase activities were found to be normal. One month after surgery, the absorption of glucose and vitamin A was markedly impaired in cases with complete obstruction, whereas that of D-xylose was not significantly reduced from normal. In cases with incomplete obstruction, the results did not differ from those found in normal infants. The fact that failure to thrive is common during the first months after birth in patients with congenital intestinal atresia, even when surgery is successful, may be explained by deficient intestinal absorption, particularly in patients with complete obstruction.

Duodenal duplication--3 new cases

Duplications can occur anywhere in the alimentary tract from mouth to anus. There may be multiple duplications in about 15% of cases. The most common site is in the distal ileum, in over 50% of cases. Duodenal duplications are rare, and occur in only 5-10% of the total in recent reviews (3, 5, 7). Three cases of this very uncommon abnormality are reported.

Histopathological investigation of duplications of the alimentary tract

Lack of information on the morbid anatomy of duplications of the alimentary tract stimulated an evaluation of patients with such duplications seen at the Sophia Children's Hospital, Rotterdam, from 1970 to 1984. There were 14 patients in all, involving 2 foregut, 6 midgut, and 4 hindgut duplications. Resected material of 12 of these patients has been investigated with particular emphasis on the presence of nervous tissue in these duplications. Routine histological as well as histochemical staining procedures have revealed nervous tissue in practically all duplications investigated. Considering the findings reported in the literature with reference to the earliest manifestation of nerve cells throughout the alimentary tract, the results demonstrate that duplications occur well before the 12th week of gestation.

[Hyperbilirubinemia in neonates associated with total parenteral nutrition]

Clinical studies on the pathogenesis of hyperbilirubinemia (HB) in neonates during total parenteral nutrition (TPN) were performed. From 1971 to 1982, 77 neonates underwent TPN for more than 2 weeks in our institutions. Forty-four of them (57.2%) developed HB during the first one month of life. Twenty eight of 32 patients (87.5%) with dominant infection developed hB, while only 16 of 45 (35.6%) without infection developed HB. Patients with any kind of obstructive intestinal diseases evoked HB more commonly than patients with other diseases. In addition, HB occurred more often in the patients receiving more than 110 kcal/kg/day than those receiving less than that. Gestational ages, birth weights, the duration of TPN and fasting periods had no significant influence on the occurrence of HB.

Microcolon of prematurity: a form of functional obstruction

Six premature infants (birth weights 920-1320 g) developed marked abdominal distension after birth, and contrast enema examination showed a microcolon. Four of the six were born to mothers with toxemia who received magnesium sulfate. Bilious emesis was absent in all six, despite marked distension and failure to pass meconium. None of the patients had aganglionosis or cystic fibrosis; five of six were followed without surgery and recovered spontaneously. The sixth had perforation 8 hr after contrast enema and required bowel diversion; this infant also survived. This appears to be an equivalent form in small premature infants of the "small-left-colon syndrome" seen in term infants. Surgery should be reserved for complications; it is not necessarily indicated by the finding of a microcolon in such patients.

Gastrointestinal tract anomalies: neonatal surgical problems

This report deals only with anomalies, treated after prenatal diagnosis, with which we have experience. Other malformations have been intentionally excluded. The neonatal management of duodenal atresia and jejunoileal atresia is briefly outlined. Our early results in 7 cases treated after antenatal diagnosis are compared with 81 cases treated without the benefit of antenatal diagnosis. Antenatal diagnosis appears to improve the outcome in these patients.

Congenital short small bowel with malrotation in a neonate

A 1-day-old male infant with congenital short small bowel was transferred to our hospital because of bilious vomiting and abdominal distension. An exploratory laparotomy performed at the age of 8 days revealed malrotation without any volvulus or stenosis of the small intestine, which was 45 cm long. There were no other anomalies except absence of the appendix. Postoperative nutritional support was by intravenous hyperalimentation and administration of elemental diet. However, parenteral nutrition was discontinued because of hyperbilirubinaemia. The patient died from marked emaciation at 2 months of age despite the administration of elemental diet. Therefore, careful total parenteral nutrition is the only management for successful therapy until the child's intestinal absorptive function develops.

[Intestinal abnormalities as a cause of ileus in the newborn infant]

Between 1971 and 1984 58 neonates were operated on because of bowel obstructing intestinal malformations. The most significant postoperative complications were cardiac insufficiency (7), mechanical bowel obstruction (5), sepsis (4), short bowel syndrome (3), respiratory insufficiency or pneumonia (3), anastomotic leak (2) or stenosis (1), bleeding (2), bowel infarction (1). Overall mortality: 15/58 (26%).

Newborn surgical emergencies of the gastrointestinal tract

Intestinal obstruction and necrotizing enterocolitis are two of the most common surgical emergencies of the gastrointestinal tract. This article reviews the signs and symptoms of these conditions and presents guidelines for their management.

[Left micro-colon syndrome and hypothyroidism]

We report a case of neonatal intestinal obstruction with left microcolon and congenital hypothyroidism. Total relief of symptoms was obtained after 45 days of treatment by L-thyroxine and enemas. Congenital hypothyroidism, frequently associated with motor disorders of the gastrointestinal tract in neonates, has not been previously reported in association with small left colon syndrome.

Congenital absence of small intestinal musculature (one case report)

Intestinal obstruction due to congenital absence of the small intestinal musculature in a neonate is presented. This report represents the seventh known case of this abnormality. In addition, in our case ectopic oesophageal mucosa and ectopic gastric mucosa is detected. The aetiology of this condition is unknown, and the diagnosis must simply depend on pathological examination of biopsy samples taken from appropriate regions. Unfortunately the regions of this disease have no continuity. Therefore, course of treatment cannot be established as the extent of the region cannot be correctly identified. To detect change of colour tone of the bowel may be helpful in the treatment of the disease.

Megacystis-microcolon-intestinal hypoperistalsis syndrome: a functional intestinal obstruction in the female newborn

A fatal case of the megacystis-microcolon syndrome in a newborn girl is presented and two previously unreported findings are discussed. The umbilical hernia is thought to represent a mechanically induced embryological defect, secondary to the expanding nonfunctional megacystis which appears to be the dominant component from an early stage. Hypertrophic changes of the large intestinal wall musculature, adjacent to dilated segments, may indicate an impaired propulsive activity in utero, as a result of defective neurotransmission. The latter is proposed as the common pathophysiological mechanism for both urinary and intestinal malfunction.

[Preoperative risk evaluation in juvenile ileus]

Preoperative risk calculation in children with bowel obstruction allows early therapeutic measures to improve prognosis. In a retrospective study the preoperative status was evaluated in 310 newborns and 127 children beyond the newborn period who had to be operated for bowel obstruction. Preoperative parameters were: age, birth weight (newborns), weight, body temperature, red and white blood count, electrolytes, urea-nitrogen, total serum protein, pH, PO2, PCO2 and base excess. These parameters were compared in surviving children and children who died postoperatively. In newborns a statistically significant difference between both groups was found for birth weight, rectal temperature, pH and total serum protein, whereas in children beyond the newborn age the same was true for age, weight and total serum protein. Besides well balanced electrolytes and good management of artificial respiration, total serum protein and in newborns additionally blood-pH and rectal temperature must be normalized preoperatively to reduce the risk in children with bowel obstruction.