Prolonged feeding difficulties after surgical correction of intestinal atresia: a 13-year experience

Does prenatal diagnosis of meconium peritonitis have the better recovery? A single-center over 10 years of experience

OBJECTIVE

To evaluate whether infants with prenatal diagnosis of meconium peritonitis (MP) have a poorer prognosis.

METHODS

A retrospective analysis of data from infants treated with surgery from January 2008 to December 2020 was conducted. The patients were divided into prenatal diagnosis group and postnatal diagnosis group based on the timing of diagnosis. The intraoperative and postoperative parameters of the two groups of patients were compared.

RESULTS

A total of 71 cases of MP were included in the study, with 48 cases in the prenatal diagnosis group and 23 cases in the postnatal diagnosis group. The comparison of preoperative indicators between the two groups of patients showed no statistically significant differences in baseline (p > 0.05). Intraoperative indicators, including blood loss, anastomosis, retained intestinal tube length and excised intestinal tube length, showed no statistically significant differences between the two groups (p > 0.05). However, the postnatal diagnosis group had a significantly shorter operation time than the prenatal diagnosis group (p < 0.05). Postoperative indicators, including fasting time, albumin usage, complications, and abandonment or mortality rates, show no difference (p > 0.05). Nevertheless, the postnatal diagnosis group exhibited significantly shorter hospital stay and time to first bowel movement compared to the prenatal diagnosis group (p < 0.05).

CONCLUSION

Prenatal diagnosis of meconium peritonitis is associated with increased surgical complexity, prolonged hospital stay, and delayed recovery of intestinal function. However, there is no evidence of higher mortality or more complications compared to infants diagnosed postnatally, and there is no significant difference in long-term prognosis.

Antimesenteric sleeve tapering enteroplasty with end-to-end anastomosis versus primary end-to-side anastomosis for the management of jejunal/ileal atresia

BACKGROUND/OBJECTIVE

Small bowel atresia commonly causes neonatal intestinal obstructions. Technical problems are associated with the surgical management of atresia using primary end-to-end anastomosis. Furthermore, the significantly dilated proximal loop may be associated with the stasis of intestinal fluid, thus increasing pressure on the anastomosis and prolonging fasting time before initiation of oral intake. This study aimed to perform antimesenteric tapering of the proximal loop using a linear stapler to reduce its diameter and facilitate anastomosis with the distal loop.

METHODS

This retrospective study included 57 neonates diagnosed with jejunoileal atresia. They were categorised into two groups: Group A (n = 29), which included neonates treated using antimesenteric sleeve enteroplasty tapering using a linear stapler and Group B (n = 28), which included neonates treated at the primary end of the proximal loop to the side of the distal loop anastomosis.

RESULTS

The mean operative time was 122.5 min in group A vs. 118 min in group B, and the mean duration to reach full oral intake was 17 days in group A vs. 20.2 days in group B (p = 0.03). The mean length of hospital stay was 25 and 35 days in groups A and B, respectively (p = 0.042).

CONCLUSION

Tapering the proximal dilated bowel loop to achieve anastomosis with the distal loop improved the transient time, reduced stasis and its associated translocation and colonisation, and allowed for early initiation and maintenance of oral intake. All these parameters shortened the overall length of hospital stay.

Primary anastomosis is the preferred surgical approach for proximal intestinal atresia: a retrospective 20-year analysis

PURPOSE

We aimed to compare the outcomes of primary anastomosis (PA) and enterostomy as treatments for intestinal atresia in neonates to identify the factors influencing the choice of modality.

METHODS

We conducted a retrospective single-centre analysis of all neonates with intestinal atresia between 2000 and 2020 and measured the clinical outcomes. We performed logistic regression to identify factors that influenced the choice of surgical approach.

RESULTS

Of 62 intestinal atresia neonates, 71% received PA. There were no significant differences in gestation, gender, age at operation, birth weight, or body weight at operation between the PA and enterostomy groups. PA reoperation was not required for 78% of patients, and the PA group had shorter hospital stays. Complications, operative time, duration on parenteral nutrition, time to full enteral feeding were comparable in both groups. Upon multivariate regression analysis, surgeons favoured PA in proximal atresia [Odds ratio (OR) 38.5, 95% Confidence Interval (CI) 2.558-579] while enterostomy in smaller body size [OR 2.75, CI 0.538-14.02] and lower Apgar score [OR 1.1, CI 0.07-17.8]. Subgroup analysis in these patient groups demonstrated comparable outcomes with both surgical approaches.

CONCLUSION

Both surgical approaches achieved comparable outcomes, but PA was associated with short hospital stays and the avoidance of stoma-related complications, and reoperation was generally not required. This surgical approach was suitable for patients with proximal atresia, but enterostomy remained a sensible choice for patients with smaller body sizes and lower Apgar scores.

Minimizing Enterostomy Complication in Neonates, Lessons Learnt from Three European Tertiary Centres

INTRODUCTION

Stoma formation in neonates is often a life-saving procedure across a variety of conditions but is still associated with significant morbidity. Tube stoma technique was originally described for short bowel patients, but in selected cases of neonates this approach could prevent the incidence of stoma-related complications. The aim of the study was to evaluate the safety and utility of tube stomas as an alternative to conventional enterostomy in the neonatal population.

MATERIAL AND METHODS

A retrospective multicentre analysis of neonates undergoing emergency laparotomy and tube stoma formation between 2005 and 2017 was performed. Tube stoma complications were analysed. The investigation focused on stricture, skin lesion, enteric fistula and prolapse.

RESULTS

Thirty-seven neonates underwent tube stoma fashioning during the study period. Tube-stoma complications were limited to three patients (8.1%), with two children (5.4%) requiring additional stoma surgery during the first 30 days because of an enterocutaneous fistula, and one child (2.7%) for bowel stenosis.

CONCLUSIONS

In select neonates, such as those with proximal enteric stomas, the tube stoma avoids some of the commonly encountered complications (prolapse, skin excoriation). Further prospective studies are needed to validate these findings in order for us to recommend this technique as superior.

A rare case of jejunal atresia

Introduction

Intestinal atresia more common in the small bowel, apart from large intestine. Jejunal atresia characterized by complete occlusion of the intestinal lumen, is a rare congenital anomaly occurring in 1 in 12,000 live births.

Importance

The jejunal atresia can be single or multiple occurring anywhere from the ligament of Treitz to the jejuno-ileal junction, requiring immediate surgical attention to prevent mortality and morbidity among these neonates.

Case presentation

A rare case of jejunal atresia in neonate and its management has been discussed here.

Clinical discussion

Surgical excision of the involved bowel and end to end anastomosis of the normal bowel is definitive treatment.

Conclusion

The morbidity associated with post-operative hypo persistaltic bowel can be minimised by adding oral prokinetics in controlled manner.

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The jejunal atresia can be single or multiple occurring anywhere from the ligament of Treitz to the jejuno-ileal junction.

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Because of the range of the mobility of jejunum and ileum, as well as due to their anatomy of the vascular arcade their potential for compression and volvulus is high, hence vascular ischemia.

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Type IV jejunal atresia comprising of multiple atretic segments of jejunum. Only few cases have been reported so far

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Patients with jejunoileal atresia usually have prolonged ileus after surgical correction for upto 3to 4 weeks.depending on total parenteral nutrition for long time.

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to reduce this intestinal hypomotility, prokinetics have been suggested like neostigmine and erythromycin apart from excisional tapering of the proximal hypoperistaltic jejunum.

How can we improve perinatal care in isolated multiple intestinal atresia? A retrospective study with a 30-year literature review

INTRODUCTION

Multiple intestinal atresia (MIA) is a rare cause of neonatal intestinal obstruction. To provide an overview of the current prenatal, surgical, and nutritional management of MIA, we report our experience and a literature review of papers published after 1990.

METHODS

All cases of isolated MIA (non-hereditary, not associated with apple-peel syndrome or gastroschisis) treated at our institution between 2005 and 2016 were reviewed and compared with cases found in the literature.

RESULTS

Seven patients were prenatally suspected of having intestinal obstruction and were postnatally diagnosed with MIA, with a mean 1.7 (1-2) resections-anastomoses (RA) and 6 (1-10) strictureplasties performed, resulting in a mean resected bowel length of 15.1cm (15-25 cm). Median time to full oral feed was 46 days (14-626 days). All patients were alive and none had orality disorder after a mean follow-up of 3.1 years (0.2-8.1 years). Three surgical strategies were found in the literature review: multiple RA (68%, 34/50) including Santulli's technique in four of 34 (12%) and anastomoses over a transanastomotic tube (32%, 16/50), with a 98% survival rate, and short-bowel syndrome for only two patients.

CONCLUSION

Bowel-sparing surgery and appropriate medical management are key to ensuring a favorable nutritional and gastrointestinal outcome and a good prognosis. Prenatal assessment and standardization of the surgical course of treatment remain challenging.

Sex differences in surgically correctable congenital anomalies: A systematic review

PURPOSE

This study aims to compare the prevalence and outcomes of surgically correctable congenital anomalies between sexes.

METHODS

Upon registration on PROSPERO (CRD42019120165), a librarian aided in conducting a systematic review using PRISMA guidelines. The five largest relevant studies were included for each anomaly. Cumulative prevalence differences and confidence intervals were calculated, and the Cochran-Mantel-Haenszel test was performed.

RESULTS

Of 42,722 identified studies, 68 were included in our analysis. All included anomalies had greater than 1000 patients except duodenal atresia (n = 787) and intestinal duplication (n = 148). Males had a significantly higher prevalence than females in 10/14 anomalies (Hirschsprung's disease, omphalomesenteric duct, congenital diaphragmatic hernia, anorectal malformation, malrotation, esophageal atresia, congenital pulmonary airway malformation, intestinal atresia, omphalocele, and gastroschisis; p < 0.001). There was no difference in the prevalence of duodenal atresia or intestinal duplication between sexes (p = 0.88 and 0.65, respectively). Females had a significantly higher prevalence of biliary anomalies (atresia and choledochal cyst).

CONCLUSION

Our study indicates that males have higher prevalence rates of most congenital anomalies. Further investigations are required to illuminate the embryology underlying this sex distribution and whether sex influences outcomes.

TYPE OF STUDY

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Prognostic study, level II.

New simple low-cost surgical approach to complex jejuno-ileal atresia

We report our experience of staged operations in the surgical treatment of complex jejuno-ileal atresia. Our study examined transgastric deflation of the proximal segment and feeding jejunostomy through the distal segment as a first stage followed by a definitive restoration of continuity secondarily at a tertiary centre over a period of three years. A cohort of 21 cases were studied. None suffered with intestinal perforation or volvulus. Tube plugging was seen in three patients who were relieved by flushing. Tube replacement was not required. One patient developed necrotising enterocolitis and died. Sepsis was seen in three. The age at the second operation was 56.2 ± 6.6 days. There was no complication after this second procedure. We therefore recommend this staged management for complex jejuno-ileal atresia, but suggest further studies.

Long-term surgical outcomes of apple-peel atresia

PURPOSE

The purpose of this study was to investigate (i) postoperative course of apple-peel atresia (APA), (ii) long-term follow-up of APA children, and (iii) risk factors for poor prognosis.

METHODS

We conducted a retrospective review of 39 APA neonates treated at our institution between 2008 and 2017. Patient characteristics, operative details, postoperative course, long-term outcomes, and prognostic factors were analyzed.

RESULTS

Of the 39 APA neonates, 30 (76.9%) were born preterm, and 20 (51.3%) were diagnosed prenatally. All patients underwent primary anastomosis within the first week after birth: 10 laparoscopic-assisted (25.6%) and 29 open (74.4%). Postoperative complications occurred in 28 patients (71.8%), of which 20 (71.4%) developed cholestasis. Survival at hospital discharge was 94.9%. Median parenteral nutrition period was 59 days. Reoperation was required in 7 children (17.9%) owing to anastomotic obstruction (n = 3) and adhesive intestinal obstruction (n = 4). 32 children (82.1%) were followed up for an average of 5.7 years, of which 23 children (71.9%) showed normal growth and development. APA patients with low birth weight and associated anomalies had significantly worse outcomes.

CONCLUSION

Most of the patients with apple-peel atresia have excellent long-term outcomes, though initial postoperative complications are common. Low birth weight and the presence of associated anomalies are independent prognostic factors in APA.

TYPE OF STUDY

Prognosis study (case series).

LEVEL OF EVIDENCE

Level IV.

Comparison of outcomes following three surgical techniques for patients with severe jejunoileal atresia

Background

Severe jejunoileal atresia is associated with prolonged parenteral nutrition, higher mortality and secondary surgery. However, the ideal surgical management of this condition remains controversial. This study aimed to compare the outcomes of patients with severe jejunoileal atresia treated by three different procedures.

Methods

From January 2007 to December 2016, 105 neonates with severe jejunoileal atresia were retrospectively reviewed. Of these, 42 patients (40.0%) underwent the Bishop–Koop procedure (BK group), 49 (46.7%) underwent primary anastomosis (PA group) and 14 (13.3%) underwent Mikulicz double-barreled ileostomy (DB group). Demographics, treatment and outcomes including mortality, morbidity and nutrition status were reviewed and were compared among the three groups.

Results

The total mortality rate was 6.7%, showing no statistical difference among the three groups (P = 0.164). The BK group had the lowest post-operative complication rate (33.3% vs 65.3% for the PA group and 71.4% for the DB group, P = 0.003) and re-operation rate (4.8% vs 38.8% for the PA group and 14.3% for the DB group, P < 0.001). Compared with the BK group, the PA group showed a positive correlation with the complication rate and re-operation rate, with an odds ratio of 4.15 [95% confidence interval (CI): 1.57, 10.96] and 12.78 (95% CI: 2.58, 63.29), respectively. The DB group showed a positive correlation with the complication rate when compared with the BK group, with an odds ratio of 7.73 (95% CI: 1.67, 35.72). The weight-for-age Z-score at stoma closure was –1.22 (95% CI: –1.91, –0.54) in the BK group and –2.84 (95% CI: –4.28, –1.40) in the DB group (P = 0.039).

Conclusions

The Bishop–Koop procedure for severe jejunoileal atresia had a low complication rate and re-operation rate, and the nutrition status at stoma closure was superior to double-barreled enterostomy. The Bishop–Koop procedure seems to be an appropriate choice for severe jejunoileal atresia.

A new variant of type III jejunoileal atresia

Jejunoileal atresia (JIA) is a congenital defect that can result in significant loss of bowel length. The traditional classification of JIA was first proposed by Grosfeld and includes 4 subtypes. Among these, type IIIB, or apple-peel atresia, is characterized by a proximal atretic jejunum and a distal segment of spiraled bowel that terminates at the cecum. Owing to this anatomy, patients with type IIIB JIA are at increased risk for short bowel syndrome and intestinal failure. In this report, we described the case of a neonate with a prenatal diagnosis of JIA. At exploration, she was initially found to have a type IIIB atresia. However, instead of terminating at the cecum, the distal spiraled segment was followed by 75 cm of normal small bowel and mesentery. Surgical correction proceeded with minimal resection and primary anastomosis. She recovered well from this procedure, tolerated full enteral nutrition by mouth, and displayed good weight gain at outpatient follow-up. Owing to the unique anatomy of the gastrointestinal tract in this case report, we propose the addition of a new class of JIA, type IIIC, to better reflect its prognostication and surgical management.

Probiotic research in neonates with congenital gastrointestinal surgical conditions - Now is the time

Neonates with congenital gastrointestinal surgical conditions (CGISC) receive parenteral nutrition, get exposed to multiple courses of antibiotics, undergo invasive procedures, and are nursed in intensive care units. They do not receive early enteral feeding and have limited opportunities for skin to skin contact with their mothers. Many of these infants receive gastric acid suppression therapies. All these factors increase the risk of gut dysbiosis in these infants. Gut dysbiosis is known to be associated with increased risk of infections and other morbidities in ICU patients. Experimental studies have shown that probiotics inhibit gut colonization with pathogenic bacteria, enhance gut barrier function, facilitate colonization with healthy commensals, protect from enteropathogenic infection through production of acetate, reduce antimicrobial resistance, enhance innate immunity, and increase the maturation of the enteric nervous system and promote gut peristalsis. Through these mechanisms, probiotics have the potential to decrease the risk of sepsis and inflammation, improve feed tolerance and minimise cholestasis in neonates with CGISC. Among preterm non-surgical infants, evidence from more than 35 RCTs and multiple observational studies have shown probiotics to be safe and beneficial. A RCT in neonates (N=24) with gastroschisis found that probiotic supplementation partially attenuated gut dysbiosis. Two ongoing RCTs (total N=168) in neonates with gastrointestinal surgical conditions are expected to provide feasibility data to enable the conduct of large RCTs. Rigorous quality assurance of the probiotic product, ongoing microbial surveillance and clinical vigilance are warranted while conducting such RCTs.

Is the Bishop-Koop procedure useful in severe jejunoileal atresia?

PURPOSE

The aim of this study was to report our experience using the Bishop-Koop procedure for the treatment of various surgical problems of jejunoileal atresia including luminal discrepancy, complex meconium peritonitis, type IIIb and type IV atresia which we defined as severe jejunoileal atresia.

METHODS

This retrospective study was performed on the patients with severe jejunoileal atresia who underwent Bishop-Koop procedure at a tertiary center in China over a five year of period. The mortality, complication rate, nutrition status and the risk factors for postoperative adverse outcomes were explored.

RESULTS

A total of 41 neonates underwent the Bishop-Koop procedure. The median duration of the hospital stay and total parenteral nutrition and the point at which oral feeding was initiated postoperatively were 24 days (95% CI =18.99-29.01), 13 days (95% CI = 9.03-16.97) and 11 days (95% CI = 10.17-11.83) respectively. The mortality rate was 7.32% (3/41). The complication rate was 41.4% (17/41) including anastomotic leak, intestinal obstruction, high output stoma and cholestasis. The weight for age Z-score at stoma closure was restored to normal levels (-0.86, 95% confidence interval (CI) = -1.44, -0.28). The main factor associated with adverse outcomes in severe jejunoileal atresia was premature delivery (odds ratio (OR) = 4.44, 95% CI = 1.06-18.67).

CONCLUSIONS

Bishop-Koop procedure appears to be a technically efficient method for severe jejunoileal atresia, although larger studies are needed to compare Bishop-Koop procedure and other operation techniques.

TYPE OF STUDY

Therapeutic.

LEVEL OF EVIDENCE

Level IV.

Meconium Peritonitis: A Case Study

Meconium peritonitis is a sterile chemical peritonitis preceded by bowel perforation, resulting in meconium leakage and subsequent inflammatory cascade within the peritoneal cavity. The presentation can range from simple failure of the neonate to pass meconium to complications such as persistent pulmonary hypertension, lung hypoplasia, and systemic inflammatory syndrome. The purpose of this article is to review a case of meconium peritonitis while considering its etiology, diagnosis, management, and multidisciplinary team care.

Cystic meconium peritonitis with jejunoileal atresia: Is it associated with unfavorable outcome?

AIM

To compare the outcome between patients with jejunoileal atresia (JIA) associated with cystic meconium peritonitis (CMP) and patients with isolated JIA (JIA without CMP).

METHODS

A retrospective study was conducted for all neonates with JIA operated in our institute from January 2005 to January 2016. Demographics including the gestation age, sex, birth weight, age at operation, the presence of associated syndrome was recorded. Clinical outcome including the type of operation performed, operative time, the need for reoperation and mortality were studied. The demographics and the outcome between the 2 groups were compared.

RESULTS

During the study period, 53 neonates had JIA underwent operation in our institute. Seventeen neonates (32%) were associated with CMP. There was no statistical difference on the demographics in the two groups. Patients with CMP had earlier operation than patients with isolated JIA (mean 1.4 d vs 3 d, P = 0.038). Primary anastomosis was performed in 16 patients (94%) with CMP and 30 patients (83%) with isolated JIA (P = 0.269). Patients with CMP had longer operation (mean 190 min vs 154 min, P = 0.004). There were no statistical difference the need for reoperation (3 vs 6, P = 0.606) and mortality (2 vs 1, P = 0.269) between the two groups.

CONCLUSION

Primary intestinal anastomosis can be performed in 94% of patients with JIA associated with CMP. Although patients with CMP had longer operative time, the mortality and reoperation rates were low and were comparable to patients with isolated JIA.

Complications in neonatal surgery

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.

Small Bowel Congenital Anomalies: a Review and Update

The small intestine is a complex organ system that is vital to the life of the individual. There are a number of congenital anomalies that occur and present most commonly in infancy; however, some may not present until adulthood. Most congenital anomalies of the small intestine will present with obstructive symptoms while some may present with vomiting, abdominal pain, and/or gastrointestinal bleeding. Various radiologic procedures can aid in the diagnosis of these lesions that vary depending on the particular anomaly. Definitive therapy for these congenial anomalies is surgical, and in some cases, surgery needs to be performed urgently. The overall prognosis of congenital anomalies of the small intestine is very good and has improved with improved medical management and the advent of newer surgical modalities. The congenital anomalies of the small intestine reviewed in this article include malrotation, Meckel's diverticulum, duodenal web, duodenal atresia, jejunoileal atresia, and duplications.

Surgical management and autologous intestinal reconstruction in short bowel syndrome

Short bowel syndrome (SBS) is a serious condition with considerable morbidity and mortality. When treatment with parenteral nutrition fails and life-threatening complications occur, autologous intestinal reconstruction (AIR) should be considered before intestinal transplantation (ITx). Single or combined ITx should be reserved for patients with severe liver disease and as last resort in the treatment of SBS. Longitudinal intestinal lengthening and tailoring (LILT) has proven its value in AIR, but its availability depends on the expertise of the surgeons. Serial transverse enteroplasty (STEP) has similar success rates as LILT and fewer patients progress to ITx. STEP is also applicable at small bowel dilatation in ultra-short bowel syndrome. The scope may be widened when duodenal dilatation can be treated as well. Spiral intestinal lengthening and tailoring (SILT) is a promising alternative. More research is needed to confirm these findings. Therefore we suggest an international data registry for all intestinal lengthening procedures.

Natural Language Processing for Cohort Discovery in a Discharge Prediction Model for the Neonatal ICU

OBJECTIVES

Discharging patients from the Neonatal Intensive Care Unit (NICU) can be delayed for non-medical reasons including the procurement of home medical equipment, parental education, and the need for children's services. We previously created a model to identify patients that will be medically ready for discharge in the subsequent 2-10 days. In this study we use Natural Language Processing to improve upon that model and discern why the model performed poorly on certain patients.

METHODS

We retrospectively examined the text of the Assessment and Plan section from daily progress notes of 4,693 patients (103,206 patient-days) from the NICU of a large, academic children's hospital. A matrix was constructed using words from NICU notes (single words and bigrams) to train a supervised machine learning algorithm to determine the most important words differentiating poorly performing patients compared to well performing patients in our original discharge prediction model.

RESULTS

NLP using a bag of words (BOW) analysis revealed several cohorts that performed poorly in our original model. These included patients with surgical diagnoses, pulmonary hypertension, retinopathy of prematurity, and psychosocial issues.

DISCUSSION

The BOW approach aided in cohort discovery and will allow further refinement of our original discharge model prediction. Adequately identifying patients discharged home on g-tube feeds alone could improve the AUC of our original model by 0.02. Additionally, this approach identified social issues as a major cause for delayed discharge.

CONCLUSION

A BOW analysis provides a method to improve and refine our NICU discharge prediction model and could potentially avoid over 900 (0.9%) hospital days.