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Chugh PV, Nes E, Culbreath K, Keefe G, Edwards EM, Morrow KA, Ehret D, Soll RF, Modi BP, Horbar JD, Jaksic T. Comparing Healthcare Needs in Extremely Low Birth Weight Infants With NEC and Spontaneous Intestinal Perforation. J Pediatr Surg 2024:S0022-3468(24)00157-X. [PMID: 38561308 DOI: 10.1016/j.jpedsurg.2024.03.006] [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: 11/29/2023] [Revised: 02/21/2024] [Accepted: 03/10/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) affect 6-8% of extremely low birth weight (ELBW) infants. SIP has lower mortality than NEC, but with similar short-term morbidity in length of stay, growth failure, and supplemental oxygen requirements. Comparative long-term neurodevelopmental outcomes have not been clarified. METHODS Data were prospectively collected from 59 North American neonatal units, regarding ELBW infants (401-1000 g or 22-27 weeks gestational age) born between 2011 and 2018 and evaluated again at 16-26 months corrected age. Outcomes were collected from infants with laparotomy-confirmed NEC, laparotomy-confirmed SIP, and those without NEC or SIP. The primary outcome was severe neurodevelopmental disability. Secondary outcomes were weight <10th percentile, medical readmission, post-discharge surgery and medical support at home. Adjusted risk ratios (ARR) were calculated. RESULTS Of 13,673 ELBW infants, 6391 (47%) were followed including 93 of 232 (40%) with NEC and 100 of 235 (42%) with SIP. There were no statistically significant differences in adjusted risk of any outcomes when directly comparing NEC to SIP (ARR 2.35; 95% CI 0.89, 6.26). However, infants with NEC had greater risk of severe neurodevelopmental disability (ARR 1.43; 1.09-1.86), rehospitalization (ARR 1.46; 1.17-1.82), and post-discharge surgery (ARR 1.82; 1.48-2.23) compared to infants without NEC or SIP. Infants with SIP only had greater risk of post-discharge surgery (ARR 1.64; 1.34-2.00) compared to infants without NEC or SIP. CONCLUSIONS ELBW infants with NEC had significantly increased risk of severe neurodevelopmental disability and post-discharge healthcare needs, consistent with prior literature. We now know infants with SIP also have increased healthcare needs. LEVELS OF EVIDENCE Level II.
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Affiliation(s)
- Priyanka V Chugh
- Boston Children's Hospital, Department of Surgery, Boston, MA, USA
| | - Emily Nes
- Boston Children's Hospital, Department of Surgery, Boston, MA, USA
| | | | - Gregory Keefe
- Boston Children's Hospital, Department of Surgery, Boston, MA, USA
| | - Erika M Edwards
- University of Vermont, Department of Mathematics and Statistics, Burlington, VT, USA; Vermont Oxford Network, Burlington, VT, USA
| | | | - Danielle Ehret
- Vermont Oxford Network, Burlington, VT, USA; University of Vermont Larner College of Medicine and University of Vermont Medical Center, Burlington, VT, USA
| | - Roger F Soll
- Vermont Oxford Network, Burlington, VT, USA; University of Vermont Larner College of Medicine and University of Vermont Medical Center, Burlington, VT, USA
| | - Biren P Modi
- Boston Children's Hospital, Department of Surgery, Boston, MA, USA
| | - Jeffrey D Horbar
- Vermont Oxford Network, Burlington, VT, USA; University of Vermont Larner College of Medicine and University of Vermont Medical Center, Burlington, VT, USA
| | - Tom Jaksic
- Boston Children's Hospital, Department of Surgery, Boston, MA, USA.
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Laje P. Abdominal Surgical Emergencies in Neonates. Neoreviews 2023; 24:e97-e106. [PMID: 36720694 DOI: 10.1542/neo.24-2-e97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Abdominal surgical emergencies are relatively common in neonates. Some of them are related to congenital diseases such as intestinal atresia and intestinal malrotation, whereas some are entirely postnatal conditions such as necrotizing enterocolitis and gastric perforation. While there is a wide range of clinical severity for these conditions, outcomes are most favorable with prompt identification and expeditious treatment. In this review, we describe the most common neonatal abdominal surgical emergencies, highlight the signs that can help with early detection, and explain the approach to diagnosis and management.
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Affiliation(s)
- Pablo Laje
- Division of General, Thoracic, and Fetal Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
- Children's Hospital of Philadelphia, Philadelphia, PA
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Olaloye O, Eke C, Jolteus A, Konnikova L. Single cell analysis via mass cytometry of spontaneous intestinal perforation reveals alterations in small intestinal innate and adaptive mucosal immunity. Front Immunol 2023; 14:995558. [PMID: 36825028 PMCID: PMC9941693 DOI: 10.3389/fimmu.2023.995558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 01/18/2023] [Indexed: 02/10/2023] Open
Abstract
Introduction Spontaneous intestinal perforation (SIP) is a poorly understood severe gastrointestinal complications of prematurity which is poorly understood. Extremely premature infants born prior to 28 weeks' gestation develop a localized perforation of the terminal ileum during the first week of life and therapy involves surgery and cessation of enteral feeds. Little is known regardj g the impact of mucosal immune dysfunction on disease pathogenesis. Methods We performed mass cytometry time of flight (CyTOF) of small intestinal mucosa of patients with SIP (Gestational age (GA) 24 - 27 weeks, n=8) compared to patients who had surgery for non-SIP conditions (neonatal (GA >36 weeks, n=5 ) and fetal intestine from elective terminations (GA 18-21 weeks, n=4). CyTOF analysis after stimulation of T cells with PMA/Ionomycin was also performed. Results We noted changes in innate and adaptive mucosal immunity in SIP. SIP mucosa had an expansion of ckit+ neutrophils, an influx of naïve CD4 and CD8 T cells and a reduction of effector memory T cells. SIP T cells were characterized by reduced CCR6 and CXCR3 expression and increased interferon gamma expression after stimulation. Discussion These findings suggest that previously unrecognized immune dysregulation is associated with SIP and should be explored in future studies.
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Affiliation(s)
- Oluwabunmi Olaloye
- Department of Pediatrics, Yale University, New Haven, CT, United States
- Division of Neonatal and Perinatal Medicine Yale University, New Haven, CT, United States
| | - Chino Eke
- Department of Pediatrics, Yale University, New Haven, CT, United States
| | - Abigail Jolteus
- Department of Pediatrics, Yale University, New Haven, CT, United States
| | - Liza Konnikova
- Department of Pediatrics, Yale University, New Haven, CT, United States
- Division of Neonatal and Perinatal Medicine Yale University, New Haven, CT, United States
- Department of Obstetrics, Gynecology, and Reproductive Sciences, New Haven, CT, United States
- Program in Human and Translational Immunology, Yale University, New Haven, CT, United States
- *Correspondence: Liza Konnikova,
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Onken F, Senne M, Königsrainer A, Wichmann D. Classification und Treatment Algorithm of Small Bowel Perforations Based on a Ten-Year Retrospective Analysis. J Clin Med 2022; 11:jcm11195748. [PMID: 36233616 PMCID: PMC9572575 DOI: 10.3390/jcm11195748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/19/2022] [Accepted: 09/24/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Small bowel perforations are a rare diagnosis compared with esophageal, gastric, and colonic perforations. However, small bowel perforations can be fatal if left untreated. A classification of small bowel perforations or treatment recommendations do not exist to date. Methods: A retrospective, monocentric, code-related data analysis of patients with small bowel perforations was performed for the period of 2010 to 2019. Results: Over a 10-year period, 267 cases of small bowel perforation in 257 patients (50.2% male and 49.8% female; mean age of 60.28 years) were documented. Perforation’s localization was 5% duodenal, 38% jejunal, 39% ileal, and 18% undocumented. Eight etiologies were differentiated: iatrogenic (41.9%), ischemic (20.6%), malignant (18.9%), inflammatory (8.2%), diverticula-associated (4.5%), traumatic (4.5%), foreign-body-associated (1.9%), and cryptical (1.5%) perforations. Operative treatment combined with antibiotics was the most commonly used therapeutic approach (94.3%). The mortality rate was 14.23%, with highest rate for patients with ischemic perforations. Discussion: An algorithm for diagnostic and therapeutic steps was established. Furthermore, it was found that small bowel perforations are rare events with poor outcomes. Time to diagnosis and grade of underlying disease are the most essential parameters to predict perforation-associated complications.
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Affiliation(s)
- Flurina Onken
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
- Department of Anesthesia and Intensive Care Medicine, University Hospital of Tübingen, Hoppe-Seyler-Str.3, 72076 Tübingen, Germany
| | - Moritz Senne
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
- Correspondence: ; Tel.: +49-7071-2968165
| | - Alfred Königsrainer
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
| | - Dörte Wichmann
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
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