The role of diagnostic laparoscopy in micropremmies with suspected necrotizing enterocolitis

Methods of identifying surgical Necrotizing Enterocolitis-a systematic review and meta-analysis

BACKGROUND

Current data suggests potential benefit of earlier surgery for necrotizing enterocolitis (NEC) however this requires accurate prognostication early in the disease course. This study aims to identify and determine the effectiveness of previously reported methods or tests for the identification of surgical NEC.

METHODS

Systematic review and meta-analysis with registration on PROSPERO including articles describing a method of identifying surgical NEC. Outcomes of interest were effectiveness and repeatability of index test.

RESULTS

Of the 190 full-text articles screened, 90 studies were included which contained 114 methods of identifying surgical NEC in 9546 infants. Of these methods, 44 were a scoring system, 37 a single biomarker, 24 an imaging method, and 9 an invasive method. Sensitivity and specificity ranged from 12.8-100% to 13-100%, respectively. Some methods (9.6%) provided insufficient methods for repeatability within clinical practice or research. Meta-analyses were possible for only 2 methods, the metabolic derangement 7 score and abdominal ultrasound.

CONCLUSIONS

A range of methods for identifying surgical NEC have been identified with varying overall performance and uncertainties about reproducibility and superiority of any method. External validation in large multicentre datasets should allow direct comparison of accuracy and prospective study should evaluate impact on clinical outcomes.

IMPACT

Earlier identification of need for surgery in necrotizing enterocolitis (NEC) has the potential to improve the unfavourable outcomes in this condition. As such, many methods have been developed and reported to allow earlier identification of surgical NEC. This study is the first synthesis of the literature which identifies previously reported methods and the effectiveness of these. Many methods, including scoring systems and biomarkers, appear effective for prognostication in NEC and external validation is now required in multicentre datasets prior to clinical utility.

Early laparoscopic-assisted surgery is associated with decreased post-operative inflammation and intestinal strictures in infants with necrotizing enterocolitis

INTRODUCTION

In 2015, a protocol including early laparoscopy-assisted surgery in the treatment of necrotizing enterocolitis (NEC) was implemented at our institution. Carbon dioxide insufflation during laparoscopy may have an anti-inflammatory effect. We aimed to compare post-operative outcome after early laparoscopy-assisted surgery and classical laparotomy for NEC.

MATERIAL AND METHODS

Charts of premature infants undergoing surgery for NEC (2012-2021) were reviewed. Cases operated by early laparoscopy-assisted surgery (2015-2021) were compared to infants operated for NEC between 2012 and 2015 (laparotomy-NEC). Outcomes were post-operative CRP, need for reintervention, mortality, and the occurrence of post-NEC intestinal strictures. CRP was measured on the day of surgery (POD-0), 2 days (POD-2), and 7 days after surgery (POD-7). Data were compared using contingency tables for categorical variables and Student t-test or Mann-Whitney test for continuous variables.

RESULTS

Infants with NEC operated by early laparoscopy (n = 48) and laparotomy (n = 29) were similar in terms of perforation (60% vs 58%, p = 0.99) and POD-0 CRP (139 vs 124 mg/L, p = 0.94). Delay between first signs of NEC and surgery was shorter in the laparoscopy group (3 vs 6 days, p = 0.004). Early laparoscopy was associated with a lower CRP on POD-2 (108 vs 170, p = 0.005) and POD-7 (37 vs 68, p = 0.002), as well as a lower rate of post-operative intestinal stricture (34% vs 61%, p = 0.04).

CONCLUSIONS

In addition to being safe and feasible in premature infants, early laparoscopic-assisted surgery was associated with decreased NEC-related post-operative inflammation and strictures. A prospective, randomized study is needed in order to evaluate short and long-term effects of laparoscopy in infants with NEC.

LEVEL OF EVIDENCE

Level III.

Diagnostic challenges in postoperative intra-abdominal sepsis in critically ill patients: When to reoperate?

The present paper was done to review common diagnostic techniques used to help surgeons find the most suitable way to diagnose postoperative intra-abdominal sepsis (IAS). The topic was searched on MEDLINE, Embase, and Cochrane Library databases. Collected articles were classified and checked for their quality. Findings of selected research were included in this study and analyzed to find the best diagnostic method for intra-abdominal sepsis. IAS presents severe morbidity and mortality, and its early diagnosis can improve the outcome. Currently, there is no consensus among surgeons on a single diagnostic modality that should be used while deciding reoperation in patients with postoperative IAS. Though it has a high sensitivity for abdominal infections, computed tomography has limited applications due to mobility and time constraints. Diagnostic laparoscopy is a safe process that produces usable images, and can be used at the bedside. Diagnostic peritoneal lavage (DPL) has high sensitivity, and the patients testing positive through DPL can be subjected to exploratory laparotomy, depending on severity. Abdominal Reoperation Predictive Index (ARPI) is the only index reported as an aid for this purpose. Serial intra-abdominal pressure measurement has also emerged as a potential diagnostic tool. A proper selection of diagnostic modality is expected to improve the outcome in IAS, which presents high mortality risk and a limited time frame.

Case Report: A Rare Condition of Abdominal Pain: Chemotherapy Induced Portal Vein Pneumatosis Mimicking the Bowel Necrosis

Portal vein pneumatosis is the presence of air in the portal venous system, which is one of the classic radiologic features of bowel ischemia or necrosis. However, there are several other morbidities that can have portal vein pneumatosis as a complication. This is a case of a 44-year-old man who suffered from severe abdominal pain after chemotherapy for soft tissue sarcoma of his left hip. The physical signs, laboratory findings, as well as the portal venous pneumatosis sign of the CT scan strongly indicated the probability of bowel necrosis and subjected the treatment decision of the patient finally to laparotomy. However, nothing abnormal except a segment of swollen small intestine was detected. Caution should be kept in mind when encountering a patient with suspected bowel necrosis following chemotherapy since several chemotherapeutic agents could cause portal vein pneumatosis. Diagnostic laparoscopy might be a better option for such cases.

Laparoscopy to Assist Surgical Decisions Related to Necrotizing Enterocolitis in Preterm Neonates

Aim of the Study: Necrotizing enterocolitis (NEC) is a devastating intestinal disease that mainly affects preterm infants. Despite advancements in neonatal care, mortality of NEC remains high and controversies exist regarding the most appropriate time for surgical intervention and challenging of diagnosing NEC. Using a pig model of NEC, we aimed to examine if laparoscopy is feasible for diagnosis of NEC. Methods: Preterm caesarean-delivered piglets (n = 42) were fed with increasing amounts of infant formula up to 5 days to induce NEC. On days 3-5, we examined the intestine by laparoscopy under general anesthesia. The bowel was examined by tilting the pigs from supine position to the left and right side. Macroscopic NEC lesions were identified and graded according to a macroscopic scoring system, then a laparotomy was performed to rule out any organ injury and missed NEC lesions. Results: Visible NEC lesions (scores 4-6) were found in 26% (11/42) of the piglets. A positive predictive value of 100% was found for laparoscopy as a diagnostic marker of NEC in both colon and the small intestine. One piglet had a higher NEC score in the small intestine found at laparotomy, than at laparoscopy, resulting in a sensitivity of 67%, and a specificity of 100% for the small intestine. Conversely, both the sensitivity and specificity for colon was 100%. Acceptable levels of agreement was found, with minimal proportional bias in both colon and the small intestine for laparoscopy and laparotomy. Ultrasound examination had a lower sensitivity of 67% and specificity of 63%. All piglets were respiratory and circulatory stable during the procedure. Conclusions: In preterm piglets, laparoscopy is a feasible tool to diagnose NEC with a high positive predictive value and a high specificity.

Early postoperative outcomes of surgery for intestinal perforation in NEC based on intestinal location of disease

Current surgical strategies for necrotizing enterocolitis (NEC) include primary drainage, resection with enterostomies, and primary anastomosis. There is considerable controversy regarding the preferable surgical management of NEC. We sought to investigate whether the surgical outcomes of newborns with NEC undergoing exploratory laparotomy differed according to the location of the disease site.A total of 204 patients with NEC following laparotomy between July 2007 and May 2017 were retrospectively reviewed. Clinical outcomes, including mortality, neonatal intensive care unit (NICU) length of stay and complications, were evaluated based on the type of surgical operation.Enterostomy creation or primary anastomosis was performed in 98 patients, and 106 cases underwent laparotomy and simple drainage because of panintestinal involvement with near total intestinal compromise or no perforation. The ileum was the most commonly affected location (n = 170, 83.3%). Patients who had undergone a simple drainage procedure experienced less blood loss (P = .023) and a shorter procedure time (P = .061), although no statistical significance was attained. Infants with bowel anastomosis or ostomy had significantly shorter times to beginning enteral feeds (P = .023) and times on mechanical ventilation (P = .011) compared with infants who had undergone drainage (Student's t test). The mean NICU length of stay (P = .088) was longer for the patients with drainage, although the difference did not attain significant. No difference in the overall mortality rate was detected between the 2 groups (P = .10).The postoperative outcomes in newborns undergoing laparotomy were associated with the surgical type, which was determined by disease location in the bowel.

A Wandering Abdominal Mass in a Neonate: An Enteric Duplication Cyst Mimicking an Ovarian Cyst

Enteric duplication cysts are rare congenital anomalies that are prenatally diagnosed through antenatal ultrasonography (US). In female patients, however, attention must be paid since these formations might be confused with ovarian cysts. Herein, we present a case of a low birth weight female infant with an enteric duplication cyst. A cystic lesion was detected in the right abdomen of the fetus on antenatal US and magnetic resonance imaging (MRI). Serial US and MRI examinations performed after birth showed a single cyst that wandered from side to side in the abdomen; the initial diagnosis was thought to be an ovarian cyst. During laparotomy, however, it was found to be an enteric duplication cyst with volvulus. To our knowledge, there has been no report of an enteric duplication cyst presenting as a wandering abdominal mass. Our experience indicates that early intervention is necessary for patients who have a wandering abdominal mass to avoid complications and urgent surgery, whether it is an ovarian cyst or an enteric duplication cyst.

The Role of Laparoscopy in the Acute Neonatal Abdomen

Introduction.The surgical treatment of the acute neonatal abdomen still poses a challenge in pediatric surgery. Various underlying etiologies require different surgical procedures. Until today the role of laparoscopy in the surgical treatment of the acute neonatal abdomen is controversial. The aim of this study was to analyze our experiences with laparoscopy and to perform a review of the literature. Methods. Retrospective, single-institution study including all term and preterm neonates initially undergoing laparoscopy due to an acute abdomen. Results. Altogether, 17 neonates presenting with an acute neonatal abdomen initially underwent laparoscopy. Unnecessary laparotomy could be avoided in 9 of 17 (53%) neonates. After diagnostic laparoscopy, 2 patients did not require any further surgical intervention. Eight neonates presented midgut atresia intraoperatively, 5 of them underwent laparoscopic-assisted correction. Successful laparoscopic derotation of an acute volvulus (n = 1) and laparoscopic appendectomy (n = 1) could be performed. Conversion to open surgery was necessary in 8 neonates (47%) due to creation of a stoma (n = 5), multiple intestinal bands causing poor visualization (n = 2), and bowel necrosis (n = 1). Conclusions. Laparoscopy is a useful diagnostic tool to evaluate the need for further surgical intervention in the acute neonatal abdomen and enables immediate surgical treatment of acute volvulus, appendicitis, or intestinal atresia. In case of conversion to laparotomy, precise localization of the incision is guaranteed. Minimization of the surgical trauma and avoidance of unnecessary laparotomy are the most important benefits of the minimal-invasive approach for the critically ill neonate.

Minimally invasive surgery in the neonate

The advent of minimally invasive surgical techniques in the neonate has been delayed due to the limited working space and the unique physiology of the newborn. In the last decade, with the introduction of new instruments and techniques, many of the initial problems have been solved making minimally invasive surgery feasible for a variety of indications in the neonate and a favored approach in specialized centers around the world. Although an increasing number of reports document the feasibility of this exciting technique, data demonstrating its benefit compared to conventional surgery is limited. This review focuses on recent developments in minimally invasive surgery in neonates and the evidence for its use.

Microlaparoscopic hernia repair in children: initial experiences

INTRODUCTION

This study reports the authors' experience with the exclusive use of 2-mm instrument sets and small diameter scopes in 100 children undergoing microlaparoscopic herniorrhaphy.

METHOD

This prospective study was designed as a pilot feasibility study; all data related to patients and procedures were prospectively collected. A pneumoperitoneum was established, and 1.7 to 2 mm 0° or 30° scopes were introduced for visualization. Exclusively 2-mm instruments were used.

RESULTS

This study included 100 children (aged 15 days to 11 years, median age 2.3 years) undergoing microlaparoscopic hernia repair. A total of 140 hernias were treated. The average operative time for the microlaparoscopically experienced surgeon was 16 minutes for bilateral inguinal hernia and 12 minutes for unilateral hernias. All procedures were completed microlaparoscopically. Hernia recurrence was observed in 2 patients.

CONCLUSION

Based on the authors' early experience, it is found that microlaparoscopic hernia repair in children seems to be a safe and feasible procedure.

Laparoscopic localization and microlaparotomy for focal isolated perforation in necrotizing enterocolitis: an alternative approach to a challenging problem

BACKGROUND

Necrotizing enterocolitis has a wide clinical spectrum of manifestation. We report a novel method of managing focal isolated perforation in necrotizing enterocolitis by using diagnostic laparoscopy to localize the site of perforation and by making a microincision over the perforation to perform exteriorization or limited resection and primary anastomosis.

METHODS

We included low-birth weight infants presenting with sudden clinical deterioration and pneumoperitoneum. Patients with gross abdominal wall signs were excluded on the probability that they had extensive disease. Diagnostic laparoscopy was performed using a 3.5-mm trocar and 1.9-mm telescope. A 1-cm incision was made over the site of perforation, and local surgical debridement was performed.

RESULTS

There were 3 extremely low-birth weight patients (580, 700, and 780 g) and 1 larger infant (1.6 kg). In all cases, an isolated perforation was detected. None had widespread disease. The 3 smaller infants had exteriorization and enterostomies. The larger patient had resection and primary anastomosis. All patients recovered uneventfully.

CONCLUSION

Diagnostic laparoscopy can be safely performed in extremely low-birth weight infants. It allows precise identification of the site of perforation to perform a limited microlaparotomy at this site, significantly reducing the surgical trauma of extensive bowel handling. We report a novel method of managing this vexing problem.

Necrotizing enterocolitis: early conventional and fluorescein laparoscopic assessment

AIM

The clinical and radiological diagnosis of necrotizing enterocolitis (NEC) can be difficult. When radiological evidence is present, severity and complications, such as perforation and full-thickness necrosis, often may not be obvious. This study aims to establish early signs of full-thickness necrosis or perforation by using standard and fluorescein laparoscopy before clinical deterioration of patients occurs.

PATIENTS AND METHODS

Thirteen patients with preoperative presumed clinical and/or radiological diagnosis of NEC underwent laparoscopy. A 4.7-mm umbilical or left upper quadrant camera port was inserted by using the open method. The abdominal cavity was inspected for bowel ischemia, fibrin, adhesion formation, and presence of free intestinal contents. If necessary, one or two 3-mm working ports were inserted for manipulation of bowel.

RESULTS

Median age of 13 patients was 17 (3-38) days. Their median weight was 1160 (910-2415) g. The first 5 infants had standard laparoscopy only, with the next 8 having fluorescein-aided assessment added to the laparoscopy. Standard laparoscopy identified perforation in 5 patients and gangrenous bowel in 2. One patient was found to have chyle ascites, and 1 patient had no abnormal findings on laparoscopy. Fluorescein identified gangrenous bowel in 3 additional patients. Laparotomy and necessary surgical intervention were performed in all 10 patients with positive laparoscopy findings. Eleven patients survived and were doing well at a median of 9 (range, 6-39) months of follow-up.

CONCLUSION

Laparoscopy helps to improve assessment of patients with a diagnosis of NEC. It allows for early identification of perforation and necrosis. Where ischemia is suspected, fluorescein laparoscopy may have an added benefit in identifying necrotic segments.

Feasibility of microlaparoscopy for surgical procedures of advanced complexity in children

Abstract Purpose: We conducted a prospective study to determine the value and the feasibility of the microlaparoscopic approach for surgical procedures of advanced complexity in children. We report our experience with these small instruments. We also report the preliminary results of a recently developed 2.4 mm prototype scope, specifically developed for the present study.

METHODS AND PATIENTS

This study includes 15 children (aged two weeks to 11 years; median, 2.8 years). Eighteen procedures with advanced complexity were carried out: Nissen fundoplication, thoracoscopic congenital diaphragmatic hernia repair in a newborn, hiatoplasty with repair of an upside-down-stomach, laparoscopically assisted pull-through for Hirschsprung's disease in a newborn, laparoscopic transperitoneal pyeloplasty and laparoscopy for acute abdominal illness.

RESULTS

No complications occurred due to the exclusive use of 2 mm instruments. All microlaparoscopy procedures were performed successfully except one fundoplication that was converted to an open procedure due to anatomical deformities. The average operative times for the 5 mm and 2 mm groups were similar compared across a similar age and type-of-intervention population.

CONCLUSION

The microlaparoscopic approach for surgical procedures of advanced complexity in pediatric surgery is feasible, safe, and effective in conditions where they are indicated and are practical in terms of the surgeon's experience and the facilities. The advantages of microlaparoscopy are obvious: minimum access trauma, "nearly scarless" healing, less risk of damage to abdominal organs, the possibility of fewer adhesions and less postoperative pain. We suggest the further consideration of the use of the microlaparoscope for advanced laparoscopic procedures in children.

Pneumatosis intestinalis and portal venous gas without bowel ischemia in a patient treated with irinotecan and cisplatin

Pneumatosis intestinalis and gas within the portal venous system are findings predictive of bowel ischemia. The etiologies of these alarming radiographic signs are diverse and not all causes require emergent surgical intervention. The combination of pneumatosis intestinalis, portal venous gas, and acidosis typically portends bowel ischemia and inevitable necrosis. This case report is the first description of benign pneumatosis and portal venous gas secondary to irinotecan and cisplatin.