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Bethell GS, Jones IH, Battersby C, Knight M, Hall NJ. Methods of identifying surgical Necrotizing Enterocolitis-a systematic review and meta-analysis. Pediatr Res 2024:10.1038/s41390-024-03292-3. [PMID: 38849483 DOI: 10.1038/s41390-024-03292-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/02/2024] [Accepted: 05/15/2024] [Indexed: 06/09/2024]
Abstract
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.
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Affiliation(s)
- George S Bethell
- University Surgical Unit, Faculty of Medicine, University of Southampton, Southampton, UK
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Ian H Jones
- Department of Paediatric Surgery and Urology, Birmingham Children's Hospital, Birmingham, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Marian Knight
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Nigel J Hall
- University Surgical Unit, Faculty of Medicine, University of Southampton, Southampton, UK.
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK.
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2
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Zani A. Invited commentary on Montalva L, et al.: Early laparoscopic-assisted surgery is associated with decreased post-operative inflammation and intestinal strictures in infants with necrotizing enterocolitis. J Pediatr Surg 2023; 58:715. [PMID: 36690573 DOI: 10.1016/j.jpedsurg.2022.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 11/13/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Augusto Zani
- Neonatal and Pediatric Surgeon, Division of General and Thoracic Surgery, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada.
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3
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Montalva L, Incerti F, Qoshe L, Haffreingue A, Marsac L, Frérot A, Peycelon M, Biran V, Bonnard A. Early laparoscopic-assisted surgery is associated with decreased post-operative inflammation and intestinal strictures in infants with necrotizing enterocolitis. J Pediatr Surg 2023; 58:708-714. [PMID: 36585304 DOI: 10.1016/j.jpedsurg.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 10/12/2022] [Accepted: 11/13/2022] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Louise Montalva
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France.
| | - Filippo Incerti
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France
| | - Livia Qoshe
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; Princeton Internships in Civic Service, Princeton University, Princeton, NJ, USA
| | - Aurore Haffreingue
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Lucile Marsac
- Department of Pediatric Anesthesia, Intensive Care and Pain Management, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alice Frérot
- Neonatal Intensive Care Unit, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Matthieu Peycelon
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France
| | - Valérie Biran
- Neonatal Intensive Care Unit, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Arnaud Bonnard
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France
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4
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Montalva L, Bonnard A. Reply to Letter to the Editor by Bethell and Hall. J Pediatr Surg 2023:S0022-3468(23)00167-7. [PMID: 36931939 DOI: 10.1016/j.jpedsurg.2023.02.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023]
Affiliation(s)
- Louise Montalva
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France.
| | - Arnaud Bonnard
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France
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Zula DJ, Houlton AY, Nataraja RM, Pacilli M. Preduodenal Portal Vein Associated With Intestinal Malrotation and Jejunal Atresia. Cureus 2021; 13:e16467. [PMID: 34422496 PMCID: PMC8370843 DOI: 10.7759/cureus.16467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2021] [Indexed: 12/02/2022] Open
Abstract
Preduodenal portal vein (PDPV) is a rare congenital anomaly commonly associated with other gastrointestinal abnormalities. We report the case of a female neonate with a PDPV, intestinal malrotation and jejunal atresia. This is the second account of this association reported in the literature. The previously reported case underwent a gastroduodenostomy to correct the presumed duodenal obstruction caused by the PDPV. In our case, the PDPV was not corrected and the child remains well and asymptomatic. We propose that in this rare association, the PDPV is not a cause of obstruction and does not need correction.
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Affiliation(s)
- David J Zula
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, AUS
| | - Adelene Y Houlton
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, AUS
| | - Ramesh M Nataraja
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, AUS
| | - Maurizio Pacilli
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, AUS
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Moschino L, Duci M, Fascetti Leon F, Bonadies L, Priante E, Baraldi E, Verlato G. Optimizing Nutritional Strategies to Prevent Necrotizing Enterocolitis and Growth Failure after Bowel Resection. Nutrients 2021; 13:nu13020340. [PMID: 33498880 PMCID: PMC7910892 DOI: 10.3390/nu13020340] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 02/07/2023] Open
Abstract
Necrotizing enterocolitis (NEC), the first cause of short bowel syndrome (SBS) in the neonate, is a serious neonatal gastrointestinal disease with an incidence of up to 11% in preterm newborns less than 1500 g of birth weight. The rate of severe NEC requiring surgery remains high, and it is estimated between 20–50%. Newborns who develop SBS need prolonged parenteral nutrition (PN), experience nutrient deficiency, failure to thrive and are at risk of neurodevelopmental impairment. Prevention of NEC is therefore mandatory to avoid SBS and its associated morbidities. In this regard, nutritional practices seem to play a key role in early life. Individualized medical and surgical therapies, as well as intestinal rehabilitation programs, are fundamental in the achievement of enteral autonomy in infants with acquired SBS. In this descriptive review, we describe the most recent evidence on nutritional practices to prevent NEC, the available tools to early detect it, the surgical management to limit bowel resection and the best nutrition to sustain growth and intestinal function.
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MESH Headings
- Enterocolitis, Necrotizing/complications
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/prevention & control
- Enterocolitis, Necrotizing/surgery
- Failure to Thrive/prevention & control
- Humans
- Infant
- Infant Nutritional Physiological Phenomena
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/prevention & control
- Infant, Premature, Diseases/surgery
- Intestines/surgery
- Short Bowel Syndrome/etiology
- Short Bowel Syndrome/prevention & control
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Affiliation(s)
- Laura Moschino
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Miriam Duci
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Francesco Fascetti Leon
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Luca Bonadies
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Elena Priante
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Giovanna Verlato
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
- Correspondence: ; Tel.: +39-0498211428
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7
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Knudsen KBK, Thorup J, Thymann T, Strandby R, Nerup N, Achiam MP, Lauritsen T, Svendsen LB, Buelund L, Sangild PT, Ifaoui IBR. Laparoscopy to Assist Surgical Decisions Related to Necrotizing Enterocolitis in Preterm Neonates. J Laparoendosc Adv Surg Tech A 2019; 30:64-69. [PMID: 31874058 DOI: 10.1089/lap.2018.0180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Kristine Bach Korsholm Knudsen
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Pediatric Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Section for Comparative Pediatrics and Nutrition, IVH, University of Copenhagen, Copenhagen, Denmark
| | - Jorgen Thorup
- Department of Pediatric Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Thymann
- Section for Comparative Pediatrics and Nutrition, IVH, University of Copenhagen, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rune Strandby
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nikolaj Nerup
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Michael Patrick Achiam
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Torsten Lauritsen
- Department of Anesthesiology, The Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lars Bo Svendsen
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lene Buelund
- Section of Diagnostic Imaging, Department of Veterinary Clinical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Per Torp Sangild
- Section for Comparative Pediatrics and Nutrition, IVH, University of Copenhagen, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Inge Botker Rasmussen Ifaoui
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Pediatric Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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8
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Abstract
Necrotizing enterocolitis occurs in 14% of infants less than 1000 g. Preoperative management varies widely, and the only absolute indication for surgery is pneumoperitoneum. Multiple biomarkers and scoring systems are under investigation, but clinical practice is still largely driven by surgeon judgment. Outcomes in panintestinal disease are poor, and multiple creative approaches are used to preserve bowel length. Overall, recovery is complicated in the short and long term. Major sequelae are stricture, short gut syndrome, and neurodevelopmental impairment. Resolving controversies in surgical necrotizing enterocolitis care requires multicenter collaboration for centralized data and tissue repositories, benchmarking, and carrying out prospective randomized controlled trials.
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Affiliation(s)
- Benjamin D Carr
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, SPC 4211, Ann Arbor, MI 48108, USA
| | - Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, SPC 4211, Ann Arbor, MI 48108, USA.
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9
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Abstract
Neonatal surgery is recognized as an independent discipline in general surgery, requiring the expertise of pediatric surgeons to optimize outcomes in infants with surgical conditions. Survival following neonatal surgery has improved dramatically in the past 60 years. Improvements in pediatric surgical outcomes are in part attributable to improved understanding of neonatal physiology, specialized pediatric anesthesia, neonatal critical care including sophisticated cardiopulmonary support, utilization of parenteral nutrition and adjustments in fluid management, refinement of surgical technique, and advances in surgical technology including minimally invasive options. Nevertheless, short and long-term complications following neonatal surgery continue to have profound and sometimes lasting effects on individual patients, families, and society.
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Affiliation(s)
- Mauricio A Escobar
- Pediatric Surgery, Mary Bridge Children׳s Hospital, PO Box 5299, MS: 311-W3-SUR, 311 South, Tacoma, Washington 98415-0299.
| | - Michael G Caty
- Section of Pediatric Surgery, Department of Surgery, Yale-New Haven Children׳s Hospital, New Haven, Connecticut
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10
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Abstract
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.
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11
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Abstract
Necrotizing enterocolitis is a devastating intestinal disease that affects ~5% of preterm neonates. Despite advancements in neonatal care, mortality remains high (30–50%) and controversy still persists with regards to the most appropriate management of neonates with necrotizing enterocolitis. Herein, we review some controversial aspects regarding the epidemiology, imaging, medical and surgical management of necrotizing enterocolitis and we describe new emerging strategies for prevention and treatment.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Agostino Pierro
- Division of General and Thoracic Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Canada
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12
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Lacher M, Kuebler JF, Dingemann J, Ure BM. Minimal invasive surgery in the newborn: current status and evidence. Semin Pediatr Surg 2014; 23:249-56. [PMID: 25459008 DOI: 10.1053/j.sempedsurg.2014.09.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The evolution of minimally invasive surgery (MIS) in the newborn has been delayed due to the limited working space and the unique physiology. With the development of smaller instruments and advanced surgical skills, many of the initial obstacles have been overcome. MIS is currently used in specialized centers around the world with excellent feasibility. Obvious advantages include better cosmesis, less trauma, and better postoperative musculoskeletal function, in particular after thoracic procedures. However, the aim of academic studies has shifted from proving feasibility to a critical evaluation of outcome. Prospective randomized trials and high-level evidence for the benefit of endoscopic surgery are still scarce. Questions to be answered in the upcoming years will therefore include both advantages and potential disadvantages of MIS, especially in neonates. This review summarizes recent developments of MIS in neonates and the evidence for its use.
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Affiliation(s)
- Martin Lacher
- Center of Pediatric Surgery, Hannover Medical School, Carl Neuberg St. 1, Hannover 30625, Germany.
| | - Joachim F Kuebler
- Center of Pediatric Surgery, Hannover Medical School, Carl Neuberg St. 1, Hannover 30625, Germany
| | - Jens Dingemann
- Center of Pediatric Surgery, Hannover Medical School, Carl Neuberg St. 1, Hannover 30625, Germany
| | - Benno M Ure
- Center of Pediatric Surgery, Hannover Medical School, Carl Neuberg St. 1, Hannover 30625, Germany
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13
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Muchantef K, Epelman M, Darge K, Kirpalani H, Laje P, Anupindi SA. Sonographic and radiographic imaging features of the neonate with necrotizing enterocolitis: correlating findings with outcomes. Pediatr Radiol 2013; 43:1444-52. [PMID: 23771727 DOI: 10.1007/s00247-013-2725-y] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 03/29/2013] [Accepted: 04/19/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Abdominal radiography is the reference standard in imaging neonates with necrotizing enterocolitis (NEC); however, ultrasound of the abdomen including bowel may be of value in this setting. OBJECTIVE To correlate sonographic and radiographic findings with patient outcomes in NEC. MATERIALS AND METHODS We reviewed sonographic and radiographic exams, as well as clinical, pathological and laboratory records. Ultrasound images were reviewed for free intraperitoneal gas, peritoneal fluid, pneumatosis intestinalis, portal gas, bowel vascularity, bowel wall thickness and echogenicity, peristalsis and the presence of dilated bowel with anechoic contents. Contemporaneously acquired radiographs were reviewed for intraperitoneal gas, pneumatosis intestinalis, portal gas, the sentinel loop sign and gas pattern. Patients were categorized into two groups based on clinical outcome. RESULTS Forty-four neonates receiving 55 sonograms were included. Focal fluid collections, echogenic free fluid, increased bowel wall echogenicity and increased bowel wall thickness were statistically significant in predicting an unfavorable outcome. Other features approached significance in predicting poor outcomes: free peritoneal gas, pneumatosis intestinalis, aperistalsis, bowel wall thinning and absent bowel perfusion. Anechoic free peritoneal fluid predicted a good outcome. The sentinel loop sign on radiographs predicted an unfavorable outcome. CONCLUSIONS Abdominal sonography and radiography in patients with NEC can help prognosticate the outcome.
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Affiliation(s)
- Karl Muchantef
- Department of Radiology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA,
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14
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What Role Does Laparoscopy Play in the Diagnosis and Immediate Treatment of Infants with Necrotizing Enterocolitis? J Laparoendosc Adv Surg Tech A 2013; 23:397-401. [DOI: 10.1089/lap.2012.0482] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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15
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Athalye-Jape G, More K, Patole S. Progress in the field of necrotising enterocolitis – year 2012. J Matern Fetal Neonatal Med 2012; 26:625-32. [DOI: 10.3109/14767058.2012.746296] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Malakounides G, John M, Rex D, Mulhall J, Nandi B, Mukhtar Z. Laparoscopic surgery for acute neonatal appendicitis. Pediatr Surg Int 2011; 27:1245-8. [PMID: 21877240 DOI: 10.1007/s00383-011-2972-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2011] [Indexed: 11/25/2022]
Abstract
We present the first two cases of acute neonatal appendicitis operated on through the laparoscopic approach. Acute neonatal appendicitis is uncommon and rarely considered by clinicians when assessing the neonatal acute abdomen. Our two cases demonstrate the potential value of diagnostic laparoscopy in the acute neonatal abdomen that poses a diagnostic dilemma. Furthermore, technical modifications of well-established laparoscopic techniques in the older child enable its use in neonates as a therapeutic tool.
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Abstract
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.
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Abhyankar A, Mukhtar Z. Laparoscopy-assisted surgery for neonatal intestinal atresia: single-center experience(*). Asian J Endosc Surg 2011; 4:90-3. [PMID: 22776229 DOI: 10.1111/j.1758-5910.2011.00075.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Neonatal intestinal atresia surgery requires careful assessment of bowel patency, resection of the affected bowel and a diligent anastomosis. Traditional anastomosis with sutures via a laparoscopic approach would lengthen the surgical time. Various minimally invasive techniques have been reported for neonatal surgery. Our technique offers improved benefits of laparoscopy while observing good principles of surgery. MATERIALS AND SURGICAL TECHNIQUE Using a three-port approach to aid careful laparoscopic inspection of the bowel, we performed laparoscopy-assisted neonatal intestinal atresia repair in three term neonates with no cardiorespiratory compromise. Anastomosis was manually performed after exteriorzation of the bowel via the umbilical port site without any extension of the original port-site incision. There were no complications or conversions to open approach. DISCUSSION Our technique is an improvement over previously reported limited/umbilical laparotomy approaches and blends the benefits of laparoscopy and open surgery most effectively. Careful bowel inspection and assessment of patency could be safely and systematically performed laparoscopically with limited exteriorization of the bowel for rapid hand-sewn anastomosis and without compromising bowel viability. A multicenter randomized trial will be useful to compare the open laparotomy approach with our technique.
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Affiliation(s)
- A Abhyankar
- Consultant Pediatric Surgeon/Urologist, University Hospital of Wales, Cardiff, UK.
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Laparoscopic localization and microlaparotomy for focal isolated perforation in necrotizing enterocolitis: an alternative approach to a challenging problem. J Pediatr Surg 2011; 46:424-7. [PMID: 21292104 DOI: 10.1016/j.jpedsurg.2010.11.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2010] [Revised: 11/21/2010] [Accepted: 11/22/2010] [Indexed: 11/24/2022]
Abstract
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.
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Necrotizing enterocolitis: early conventional and fluorescein laparoscopic assessment. J Pediatr Surg 2011; 46:348-51. [PMID: 21292086 DOI: 10.1016/j.jpedsurg.2010.11.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 11/04/2010] [Indexed: 11/22/2022]
Abstract
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.
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Abstract
Minimally invasive surgery (MIS) has significantly improved the field of surgery, with benefits including shorter operating time, improved recovery time, minimizing stress and pain due to smaller incisions, and even improving mortality. MIS procedures, including their indications, impact, limitations, and possible future evolution in neonates and infants, are discussed in this article.
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Affiliation(s)
- Tiffany Lin
- DeBakey Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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Abstract
The aim of this study was to assess the feasibility of complex minimally invasive surgery in neonates (and infants <5 kg). A systematic search of databases was performed. Inguinal herniotomy and pyloromyotomy were specifically excluded. Various operations were assessed for operative times, conversion rates, complications and centres performing the procedures. From 479 abstracts, 50 papers were identified describing 1,215 patients. Common operations performed were fundoplication (n = 473), operations for ovarian pathology (n = 151) and oesophageal atresia repair (n = 123). Other not-so-common operations included Kasai procedure (n = 61), Ladd's procedure (n = 55), bowel atresia surgery (n = 45) and congenital diaphragmatic hernia repair (n = 41). Mean operation times varied from 43 min for fundoplication to 209 min for Kasai procedure, with other operation times falling in between the two extremes. Likewise, conversion rates varied from 0.2% for fundoplication to 15% for congenital diaphragmatic hernia, with other conversion rates falling in between. Complications ranged from 0 to 67%. About 70-94% of the cases were performed in six pioneering centres. Fundoplication and operations for ovarian pathology have low complication and conversion rates and appear to be well suited to the average-trained paediatric laparoscopic surgeon. More complex procedures are feasible and safe, but technically demanding and need further expertise.
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Nam SH, Kim DY, Kim SC, Kim IK. The Experience of Surgical Treatment of Necrotizing Enterocolitis. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2009. [DOI: 10.4174/jkss.2009.76.4.246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- So-Hyun Nam
- Department of Pediatric Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae-Yeon Kim
- Department of Pediatric Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong-Chul Kim
- Department of Pediatric Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In-Koo Kim
- Department of Pediatric Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Guner YS, Chokshi N, Petrosyan M, Upperman JS, Ford HR, Grikscheit TC. Necrotizing enterocolitis--bench to bedside: novel and emerging strategies. Semin Pediatr Surg 2008; 17:255-65. [PMID: 19019294 DOI: 10.1053/j.sempedsurg.2008.07.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Necrotizing enterocolitis (NEC) is a devastating illness that predominantly affects premature neonates. The mortality associated with this disease has changed very little during the last two decades. Neonates with NEC fall into two categories: those who respond to medical management alone and those who require surgical treatment. The disease distribution may be focal, multifocal, or panintestinal. Surgical treatment should therefore be based on disease presentation. Recent studies have added significant insight into our understanding of the pathogenesis of NEC. Several groups have shown that upregulation of nitric oxide plays an integral role in the development of epithelial injury in NEC. As a result, some treatment strategies have been aimed at abrogating the toxic effects of nitric oxide. In addition, several investigators have reported the cytoprotective effect of epidermal growth factor, which is found in high levels in breast milk, on the intestinal epithelium. Thus, fortification of infant formula with specific growth factors could soon become a preferred strategy to accelerate intestinal maturation in the premature neonate to prevent the development of NEC. One of the most devastating complications of NEC is the development of short bowel syndrome (SBS). The current treatment of SBS involves intestinal lengthening procedures or bowel transplantation. A novel emerging method for treating SBS involves the use of tissue-engineered intestine. In laboratory animals, tissue-engineered small intestine has been shown to be successful in treating intestinal failure. This article examines recent data regarding surgical treatment options for NEC as well as emerging treatment modalities.
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Affiliation(s)
- Yigit S Guner
- Department of Surgery, Childrens Hospital Los Angeles, and the Keck School of Medicine, University of Southern California, Los Angeles, California 90027, USA
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Blejter J, Millan F, Gimenez J, Martinez A, Giambini D. Intestinal stenting in preterm, very-low-birth-weight infants with necrotizing enterocolitis and multiple perforations. J Pediatr Surg 2008; 43:1358-60. [PMID: 18639696 DOI: 10.1016/j.jpedsurg.2008.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2007] [Revised: 02/01/2008] [Accepted: 02/04/2008] [Indexed: 10/21/2022]
Abstract
We present 2 cases of necrotizing enterocolitis with multiple intestinal perforations or areas of segmental bowel necrosis in preterm, very-low-birth-weight infants. We reviewed their charts and researched the related literature. We used SILASTIC (Silmag, Argentina) intestinal stents to avoid multiple formal bowel anastomosis or stomas and longer resections, and to reduce operative time. In the first case, we externalized the stent through the first and last perforation; and in the second, through a proximal jejunostomy and the orifice left after an appendectomy. This method was useful in avoiding short bowel syndrome in both infants, and they were discharged successfully. They are currently 31/2 and 2 years old, respectively, eating without any restriction and with mild developmental delays. Treatment of preterm infants with multiple bowel perforations or areas of bowel necrosis requires a maximal effort to preserve as much intestinal length as possible. Use of the SILASTIC stent technique provides a good treatment variant in selected cases to preserve bowel length, reduce operative time, and avoid short bowel syndrome.
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Affiliation(s)
- Javier Blejter
- Pediatric Surgery Service, Pedro de Elizalde Hospital, Buenos Aires, Argentina.
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Patole S. Prevention and treatment of necrotising enterocolitis in preterm neonates. Early Hum Dev 2007; 83:635-42. [PMID: 17826009 DOI: 10.1016/j.earlhumdev.2007.07.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Accepted: 07/30/2007] [Indexed: 01/10/2023]
Abstract
Prevention and treatment of NEC has become an area of priority for research due to the increasing number of preterm survivors at risk, and the significant mortality and morbidity related to the illness. Probiotic supplementation appears to be a promising option for primary prevention of NEC but further large trials are necessary for documenting their safety in terms of sepsis as well as long-term neurodevelopmental outcomes and immune function. As new frontiers including immunomodulating agents like pentoxifylline continue to be explored, the impact of well-established simple strategies like antenatal glucocorticoid therapy, and early and preferential use of breast milk must not be forgotten. Clinical research on manifestations of ileus of prematurity, and feeding in the presence of common risk factors such as IUGR is needed. Safety of minimal enteral feeds in terms of NEC and benefits of standardised feeding regimens need to be confirmed. Association of common clinical practices such as red cell transfusions, H2 receptor blockade, and thickening of feeds with NEC warrants attention. An approach utilising a package of potentially better practices seems to be the most appropriate strategy for the prevention and treatment of NEC.
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Affiliation(s)
- Sanjay Patole
- Department of Neonatal Paediatrics, KEM Hospital for Women, Perth, Australia.
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Tan HL, Tantoco JG, Ee MZ. The role of diagnostic laparoscopy in micropremmies with suspected necrotizing enterocolitis. Surg Endosc 2006; 21:485-7. [PMID: 17103277 DOI: 10.1007/s00464-006-9030-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Revised: 04/04/2006] [Accepted: 04/27/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND The timely diagnosis of perforations or dead gut can be extremely difficult in micropremmies with necrotizing enterocolitis. A negative laparotomy is just as detrimental as failure to recognize early perforation in this group of patients. We have been exploring the role of microlaparoscopy using a needlescope to determine if this modality is feasible and useful in the surgical management of these patients. We report our technique and initial experience with needlescopic diagnosis. METHODS Four patients (weight >500 to <1000 g) with abdominal distension and clinical sepsis not responsive to aggressive medical treatment were included in this study. None had radiologic evidence of pneumatosis or perforation. There was no absolute surgical indication for laparotomy except for strong suspicion of a surgical cause. Needlescopic diagnosis was performed in all these patients. RESULTS There was no evidence of perforation or bile in the abdominal cavity in one patient. This patient improved on medical management, avoiding a laparotomy. The rest had bile or fibrin in the abdominal fluid with a localized perforation, and in each case we performed a microlaparotomy directly over the site of perforation to create a stoma. CONCLUSIONS Needlescopic diagnosis is feasible and appears to be safe, even in critically ill micropremmies less than 1000 g. The technique can provide useful information for surgical decision-making and allows for precise placement of a microlaparotomy incision over the site of perforation, thus minimizing the trauma from open surgery in this special group of patients. We are currently expanding its role in patients with overt perforations to determine if we can limit the extent of surgical exploration without compromising the adequacy of surgical management.
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MESH Headings
- Abdominal Cavity/pathology
- Abdominal Cavity/surgery
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/pathology
- Enterocolitis, Necrotizing/surgery
- Humans
- Infant, Extremely Low Birth Weight
- Infant, Newborn
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/pathology
- Infant, Premature, Diseases/surgery
- Laparoscopy/methods
- Treatment Outcome
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Affiliation(s)
- H L Tan
- Department of Paediatrics, The University of Adelaide, Adelaide, South Australia, Australia.
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Abstract
Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in neonates. The disease affects mainly premature neonates. The pathogenesis is still unknown but predisposing factors are prematurity, formula feeding and sepsis. The disease can lead to gangrene and intestinal perforation requiring surgery. The options for surgery are between primary peritoneal drainage or laparotomy. However, the optimum choice between peritoneal drainage and laparotomy remains controversial, particularly in low-birth-weight infants (<1000 g). Peritoneal drainage offers temporary decompression, drainage and stabilization of patients whilst awaiting surgery, or in patients too unstable to be able to tolerate surgery or anaesthesia. Those weighing >1000 g who have no associated morbidities and are clinically stable are preferentially treated by primary laparotomy. The principal surgical objectives of laparotomy in acute NEC are to control sepsis and removal of gangrenous bowel preserving as much bowel length as possible. The surgical options at laparotomy include resection with enterostomy, resection with primary anastomosis, proximal jejunostomy and "clip and drop" technique. The option exercised is influenced by the clinical status of the patient and the extent of the disease.
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Affiliation(s)
- Agostino Pierro
- Department of Paediatric Surgery, The Institute of Child Health and Great Ormond Street Hospital for Children NHS Trust, University College London, Guilford Street, London WC1N 1EH, UK.
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