Mortality in neonatal duodenal obstruction

Nutritional role of amniotic fluid: clues from infants with congenital obstruction of the digestive tract

AIMS

To investigate the role played by amniotic fluid in late fetal nutrition by analysis of infants born with digestive tract atresia.

METHODS

Birth weight (BW), gestational age and gender of infants born with oesophageal (OA), duodenal (DA), jejunal (JA) and ileal atresia (IA) were recorded and BW Z-scores compared. Infants with incomplete obstruction (stenosis), chromosomal or syndromic conditions and multiple congenital malformations were excluded. Term infants admitted with suspected postnatal intestinal obstruction in whom no congenital malformation was found were used as a control group.

RESULTS

A total of 584 infants were identified comprising 148 OA, 60 DA, 26 JA and 57 IA with 293 in the control group. Infants with OA and DA had statistically significantly lower BW Z-score than controls. However, BW Z-score for infants with more distal atresia (JA and IA) was similar to controls. When compared with infants with OA, BW Z-score for infants with more distal atresia was higher than that for OA. BW Z-score in infants with OA was significantly lower in those born at term compared with those born preterm (mean±SD -0.92±1.0 vs -0.48±0.87; p=0.01) with a significant negative correlation between BW Z-score and increasing gestational age (R²=0.12; p<0.0001). This effect of gestational age was not seen in other atresias.

CONCLUSION

These observations support the concept that reduced enteral absorption of amniotic fluid due to high digestive tract obstruction in utero reduces fetal growth. The effect is greater when the obstruction is more proximal and with advancing gestation.

Fetal duodenal obstructions: increased risk of prenatal sudden death

OBJECTIVES

The aim of this study was to describe the outcome of fetuses with duodenal obstruction diagnosed prenatally and to compare the outcome with the results of studies of newborns.

METHODS

All fetuses with a prenatal diagnosis of duodenal obstruction were registered and evaluated prospectively from January 1985 to December 2000.

RESULTS

Duodenal obstruction was found in 29 fetuses at a mean gestational age of 29+2 weeks. Polyhydramnios was found in 24 cases (83%). Six fetuses (21%) had trisomy 21. Associated anomalies, including trisomy 21, were found in 18 cases (62%). Four fetuses with normal karyotype died in utero at 31-35 gestational weeks. Two of them had associated anomalies, but the anomalies could not explain the prenatal deaths and the deaths occurred suddenly and unexpectedly. Three infants died postnatally; all three had associated anomalies. Four infants with normal karyotype had neurological impairment suggesting that they might have had intrauterine asphyxia.

CONCLUSIONS

The present study indicates that duodenal obstruction is a more serious condition than previously believed, with an increased risk of prenatal asphyxia and death, even when the karyotype is normal and no associated anomalies are present. We consider the possibility that it could be caused by bradycardia/asystole following vagal overactivity due to distension of the upper gastrointestinal tract.

Intrinsic duodenal obstruction: trends in management and outcome over 45 years (1951-1995) with relevance to prenatal counselling

OBJECTIVE

To investigate the incidence of associated anomalies and document changes and progress in the management and outcome of intrinsic duodenal obstruction (atresia or stenosis) in a large series over a long time period with a view to providing comprehensive data for prenatal counselling.

DESIGN

A retrospective casenote review.

SETTING

A quaternary referral centre for paediatric and neonatal surgery.

POPULATION

Two hundred and seventy-five infants born with duodenal obstruction between 1951 and 1995.

METHODS

For analysis of management and outcome data, the series was divided into three groups, each admitted over 15 year periods: Group A, 1951-1965; Group B, 1966-1980; Group C, 1981-1995.

MAIN OUTCOME MEASURES

Primary: associated anomalies, complication rates and survival. Secondary: age at diagnosis, duration of hospital stay.

RESULTS

There were 136 males and 139 females. Seventeen of 30 cases (57%) presenting between 1991 and 1995 were diagnosed prenatally on ultrasound scan. The median age at diagnosis for atresia was 3.5 days (Group A); 2.2 days (Group B) and 1.8 days (Group C). The median age at diagnosis for incomplete obstruction was five days. Associated anomalies included Down's syndrome (n = 82, 30%); Down's plus cardiac malformation (n = 38, 14%); isolated cardiac (n = 64, 23%); and gastrointestinal problems (n = 116, 42%). Overall complication rates fell from 51% (Group A) to 18% (Group C) and survival increased from 51% to 95% . Median hospital stay also decreased from 35 days to 18 days.

CONCLUSIONS

These data confirm a progressive improvement in the outcome of intrinsic duodenal obstruction over the past 45 years. It is important to note that they only relate to infants born with duodenal atresia and do not take into account possible 'hidden' mortality resulting from spontaneous abortion or termination.

Congenital duodenal obstruction

Over the period 1980-1989, 49 patients with congenital duodenal obstruction due to duodenal atresia, duodenal stenosis or annular pancreas were treated. There were three deaths, all related to associated severe congenital anomalies and none related to surgery for duodenal obstruction; 78 per cent of the patients had associated congenital anomalies which, in some instances, complicated their management. Prenatal diagnosis by ultrasonography was made in 18 per cent of the patients and these patients had operations relatively earlier.

Newborn duodenal atresia: an improving outlook

From 1973 through 1983, 20 newborns with congenital duodenal atresia were treated. These patients are compared with our previous series and with other published series. There were no fatalities among the 19 patients who underwent operation, an improvement from the 72 percent survival rate in our previous series. Fifty-five percent of the patients had associated congenital anomalies, which frequently complicated their management. The use of a transanastomotic jejunal feeding tube resulted in delayed oral feeding and prolonged hospitalization, and cannot be recommended.

Congenital duodenal obstruction. A review of 65 cases

We report our experience with 65 patients with congenital duodenal obstruction, 36 with intrinsic and 29 with extrinsic lesions. Seventeen patients had trisomy 21 syndrome. Eight pregnancies were complicated by polyhydramnios. The diagnostic features encountered, the operative procedures used, and the postoperative management regimes used are presented. Thirty-two of the 36 patients with intrinsic lesions and 28 of the 29 patients with extrinsic lesions survived. The data on the five patients who died emphasize the effect of multiple congenital anomalies and prematurity on survival. This review suggests that the surgical procedures available for treating patients with congenital duodenal obstruction are well established and yield predictably good results.

Extrinsic duodenal obstruction in infants and children

A series of 34 patients with extrinsic duodenal obstruction is described. The diagnosis and treatment are discussed. Five infants died and the findings are given. The remaining 29 have progressed normally.