Intestinal obstruction in neonatal/pediatric surgery

Pediatric intestinal obstruction: analysis of etiologies and factors influencing short-term outcomes in Rwanda

Background

Intestinal obstruction is a common presentation in pediatric surgical emergencies and presents with different etiologies depending on country or region. Its morbidity and mortality are high in low-income and middle-income countries, with variable influencing factors. The aims of this study were to determine the etiologies, morbidity and mortality of pediatric intestinal obstruction and to assess the factors associated with the outcomes of these conditions in Rwanda.

Methods

This was a cross-sectional study conducted on pediatric patients with intestinal obstruction in two Rwandan university teaching hospitals. The patients were followed from admission until discharge, and we documented their basic characteristics, diagnosis, operative details and postoperative outcomes. Data were collected using data collection form and were electronically captured and analysed using SPSS software.

Results

A total of 65 patients were enrolled in this study. They were predominantly male (n=49, 75.4%), and the majority of patients (86.2%) were below age 6 years. Intussusception was the most common etiology (n=22, 33.8%). Other common etiologies were Hirschsprung's disease (n=13, 20%), incarcerated inguinal and umbilical hernias (n=6, 9.2%), intestinal worms' impaction (n=5, 7.7%) and adhesions (n=5, 7.7%). Mortality and morbidity were 9.2% and 39.7%, respectively. The most common complications were surgical site infection (n=6, 9.5%) and sepsis (n=6, 9.5%). Preoperative anemia (p=0.001), finding of gangrenous bowels (p=0.003) and bowel resection at the time of laparotomy (p=0.039) were factors associated with postoperative complications.

Conclusions

The etiologies of intestinal obstruction are variable and common in children below 6 years in Rwanda. The associated morbidly is high and is influenced by the preoperative anemia, finding of gangrenous bowels and bowel resection.

Importance of Second-Look Surgery in a Newborn Presenting With Early Malrotation

Intestinal malrotation refers to the abnormal positioning of the intestines due to a deviation from normal developmental stages. Volvulus is seen in 60%-70% of neonates diagnosed with intestinal malrotation. We are reporting a case of s six-day-old male who presented with multiple episodes of bilious vomiting and constipation and had malrotation of intestines with midgut volvulus. After a contrast upper GI study, the patient was taken for exploratory laparotomy, and extensive patches of an early stage of bowel ischemia were observed; resection was avoided at this stage. In the second-look surgery, all the gangrenous bowel loops were resected, and anastomosis was done.

Albumin haemoglobin index: A novel pre-operative marker for predicting mortality and hospital stay in patients under one-year undergoing gastrointestinal surgeries

AIM

The aim of this study was to evaluate the mortality and morbidity of infants <1 year of age with intestinal obstruction requiring surgical intervention and to investigate the factors affecting mortality and hospital length of stay in paediatric surgery, including albumin-haemoglobin index.

PATIENTS AND METHODS

The records of gastrointestinal paediatric surgeries in the past 10 years of patients who were <1-year-old at Baskent University Konya Hospital were obtained from the hospital and retrospectively studied. Patient characteristics, especially the relationship between albumin haemoglobin index (AHI) and hospital duration and mortality, were examined. According to the surgical areas, it also subjected this relationship to further analysed in subgroups.

RESULTS

There were 144 cases who fulfilled the inclusion criteria. Pre-operative serum AHI was analysed using receiver operating characteristics (ROC) curve analyzes. In the ROC analysis, AHI had a diagnostic value in predicting case discharge rates (area under the curve: 0.755, P = 0.001). When the cut-off point was set at 46.18, the sensitivity of the test was 57.5% and the sensitivity for predicting survival was 84%. In the logistic regression model to estimate survival, the odds ratio of AHI was 1.063 (confidence interval: 1.020-1.108, P = 0.004). In subgroup analyzes, AHI positively predicted survival in the NEC group and in the other group. In a linear regression model analysing the effect of AHI on hospital stay of length, AHI explained 10% of the variance in the hospital stay of length variable and significantly and negatively influenced the hospital length variable (β = -0.319, P = 0.05). In the linear regression model for subgroup analyzes, AHI significantly and negatively predicted hospital length of stay in the NEC and pyloric surgery groups, but positively predicted hospital length of stay in the perforation group.

CONCLUSION

The AHI can be used as a valuable marker to predict the likelihood of discharge and length of hospital stay in paediatric surgical cases <1-year-old.

Adams–Oliver syndrome, intestinal obstruction and heart defects: a case series of aplasia cutis congenita

Aplasia cutis congenita (ACC) is a rare congenital defect described by the absence of skin and occasionally subcutaneous tissues or bone. The management of ACC varies depending on the lesion size, location and associated abnormalities. Small lesions often heal spontaneously, whereas larger lesions are significant and usually associated with additional anomalies in other organs. This paper reports three cases, which describe large lesions of ACC, presented with other abnormalities (Adams–Oliver syndrome, intestinal obstruction and heart defect). Particular attention should be paid to the patient with large lesions of ACC to investigate more congenital anomalies.

Variations of intestinal malrotation in adults: A case report of midgut volvulus and literature review for the surgeon

Introduction

Intestinal malrotation is a rare congenital abnormality occurring in 0.2–1% of the population. Adult presentations comprise only 0.2–0.5% of all cases leading to diagnostic challenges and worse outcomes in adults. We present a rare case of chronic/intermittent midgut volvulus with unique anatomic findings in an adult with intestinal malrotation.

Presentation of case

An 18-year-old Caucasian male presented to a community hospital with abdominal pain, nausea, and vomiting. He underwent a CT scan demonstrating concern for small bowel volvulus and subsequently underwent a negative exploratory laparotomy. He was discharged post-operatively with no identified etiology for his presentation. He subsequently had multiple presentations to the ED with recurrent symptoms, review of imaging led to concern for duodenal volvulus resulting in transfer to a tertiary hepatobiliary centre. Repeat CT scan two weeks following initial presentation was consistent with intestinal malrotation with midgut volvulus. Bloodwork was unremarkable and physical exam demonstrated normal vital signs with a tender epigastrium. He underwent an exploratory laparotomy with Ladd's procedure. Intra-operative findings included a midgut volvulus and uniquely positioned Ladd's bands to the transverse colon. Post-operatively he tolerated oral intake and was discharged with three-month follow-up.

Discussion

Adults with intestinal malrotation suffer from delays in diagnosis and management. In contrast to the neonatal population, adults often present with vague, or chronic symptoms, which obscures the diagnosis.

Conclusion

The increased morbidity and mortality observed in adults with intestinal malrotation highlights the need for surgeons to appreciate the challenges associated with this diagnosis in the adult population to ensure early recognition and management.

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Intestinal malrotation is a rare but potentially lethal presentation in adults

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Rare variations in anatomic abnormalities as seen in this case lead to a range of clinical presentation in adults

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This case demonstrates radiographic and intra-operative findings of a chronic midgut volvulus in intestinal malrotation

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Delays in diagnosis and management of midgut volvulus in adults lead to increased morbidity and mortality

Current assessment of parental and health professional perception of the colour of neonatal vomiting: Results of a scoping survey

PURPOSE

To determine current perceptions of doctors, nurses and parents for the colour of a neonatal vomit which should prompt an urgent surgical review.

METHODS

A voluntary scoping survey of parents/guardians of patients and non-surgical healthcare professionals was conducted with respondents asked to choose from 8 different selections in a colour swatch from pale yellow to dark green. A control group consisted of 13 paediatric surgeons. Data were analysed using the paired t test, Fishers exact test. A p value of < 0.05 was considered to be significant.

RESULTS

365 participants responded: 36% (131/365) parents, 18% (64/365) nurses and 46% (166/365) doctors. 4/365 (1%) did not state their role. 343 participants completed all questions and responses were analysed using total responses for each question. 82% (121/148) of doctors and 78% (50/64) of nurses had more than 3 years of post-graduate experience. Overall, 63% (227/361) of participants (100% paediatric surgeons, 78% other doctors, 75% nurses/midwives & 30% parents) considered dark and light green vomits to be a sign of intestinal obstruction. 67% (242/361) of participants (100% paediatric surgeons, 72% other doctors, 56% nurses/midwives and 62% parents) believed dark and light green vomiting needed an urgent surgical referral. There were significant differences between the control group and other groups in terms of whether the neonate could wait until the next day for a review; nursing staff (p = 0.0002), postnatal/midwifery (p =  < 0.0001), emergency medicine (p = 0.04), general practice (p = 0.002), neonatal (p = 0.0001) and paediatricians (p = 0.005). Only the neonatologists (p = 0.04), nursing staff (p = 0.001) and postnatal/midwifery (p = 0.004) believed that the neonate could have safe observation.

CONCLUSION

Although the perception that green vomiting is potentially serious is acknowledged by the majority of healthcare professionals surveyed, there is still a requirement for more targeted educational practices in nursing, midwifery and medical staff.

Paediatric adhesive bowel obstruction: a systematic review

Adhesions following abdominal surgery remain a common cause of bowel obstruction. The incidence is between 1 and 12.6% in children who have had previous abdominal surgery. While conservative management is usually trialled in all patients (including children) suspected of having ASBO, the majority will require surgical intervention. New materials such as Seprafilm^® have been studied in the paediatric population, with promising results of its use in index abdominal surgeries to prevent the formation of adhesions. In this article, we conducted a systematic review to present an overview of the current knowledge on the incidence, aetiology, pathophysiology, clinical presentation, and management of ASBO.

Cystic Nontubular Jejunal Duplication Cyst Presenting As Acute Intestinal Obstruction: A Surgical Challenge

Enteric duplication cysts are rare congenital anomalies that present with a vague constellation of symptoms such as vomiting and abdominal distension. Of these, cystic nontubular jejunal duplication cysts comprise an exceedingly small subset. Here, we delineate the case of a two-month-old female baby who presented with symptoms suggestive of acute intestinal obstruction. Radiological workup divulged a cystic lesion, which was subsequently confirmed to be a cystic nontubular jejunal duplication cyst with extensive intestinal wall sharing. Surgical excision was planned but posed a remarkable surgical challenge due to intestinal wall sharing and the cyst's exceedingly fibrotic nature.

Neonatal Bowel Obstruction by Pseudolymphoma: A Case Report

Interstitial obstruction in newborn infants can be caused by several factors such as malrotation, meconium plug syndrome, meconium ileus, Hirschsprung's disease, atresia and stenosis. Neonates who have been diagnosed with an interstitial obstruction are in need of immediate treatment; otherwise, they can deteriorate rapidly. Surgery remains the mainstay of treatment in most cases. Pediatric gastrointestinal tumours are very rare, especially in newborn infants. Their management is usually different as compared to adults. We present the case of a newborn infant who was born with interstitial obstruction. At the 31 weeks scan, a significant dilation of the small bowel was observed and the diagnosis of interstitial obstruction was made. When born, the newborn was transferred to a specialised unit and underwent a laparotomy. The findings were consistent with a tumour causing the obstruction; the histology reported this tumour as benign lymphoid hyperplasia. Pseudolymphoma is a very rare cause of fetal interstitial obstruction, and it should be considered in the differential diagnosis.

A rare case of neonatal colonic obstruction caused by a solitary intestinal tumor

Background

Intestinal obstruction caused by a tumor is very rare in newborns, and the preoperative diagnosis is difficult. We herein report a rare case of neonatal colonic obstruction due to solitary intestinal myofibroma with characteristic findings on gastrografin enema and the surgical strategy.

Case presentation

A 4-day-old female infant presented to our neonatal intensive-care unit with abdominal distention and bilious vomiting after feeding. A gastrografin enema showed that the transverse colon near the hepatic flexure was not delineated at the oral side. When pressure was applied, a small amount of contrast material moved into the mouth in the form of threads. Microcolon was not observed, and stenosis of the transverse colon was found 9 cm from the Bauhin valve. Partial resection and end-to-end anastomosis were performed. A pathological examination of the resected specimen suggested gastrointestinal stromal tumor (GIST). After obtaining a second opinion, the histology and immunohistological markers were deemed characteristic of infantile myofibroma.

Conclusion

If string sign and a napkin ring appearance are found in a case of neonatal intestinal obstruction, surgery should be performed with a tumor in mind. In cases of neonatal intestinal obstruction caused by a tumor, the lesion should be resected with a sufficient surgical margin before the pathological examination.

Analysis of the predictors of surgical treatment and intestinal necrosis in children with intestinal obstruction

PURPOSE

To explore the surgical treatment and predictors of intestinal necrosis in children with intestinal obstruction through analyzing blood biochemical indicators, and to establish a predictive model and evaluate its predictive accuracy, sensitivity and specificity.

METHODS

The data of children with intestinal obstruction hospitalized in Jiangxi Provincial Children's Hospital from January 2014 to June 2019 were retrospectively analyzed.

RESULTS

Thirty-six substances in the blood of children with successful conservative management and those requiring surgical treatment were significantly different. The model composed of 7 variables, including age, white blood cell count, creatine kinase, troponin I, myoglobin, C-reactive protein and fibrinogen, can be used to predict the unsuccessful conservative management in children with intestinal obstruction, whom need further operation. The average prediction accuracy was 83.50%, the false positive rate was 16.67% (32/192), AUROC is 0.9160 (95% CI, 0.8930-0.9390), and the sensitivity and specificity were 83.20% and 92.70% respectively. A prediction model based on the white blood cell count, creatine kinase, troponin I and myoglobin could predict the occurrence of intestinal necrosis. The average prediction accuracy was 73.70%, false positive rate was 4.49% (15/334), AUROC was 0.7390 (95% CI, 0.6820-0.7960), and the sensitivity and specificity were 71.70% and 64.70%, respectively.

CONCLUSIONS

Combination of age, white blood cell count, creatine kinase, troponin I, myoglobin, C-reactive protein and fibrinogen can be used to predict whether the children with intestinal obstruction need surgical treatment or not. Leukocyte count, creatine kinase, troponin I and myoglobin are closely related to the condition of children with intestinal obstruction and can be used to predict whether intestinal necrosis occurs.

TYPE OF STUDY

Retrospective Study LEVELS OF EVIDENCE: Level I.

Jejuno-ileal atresia: its characteristics and peculiarities concerning apple peel atresia, focused on its treatment and outcomes as experienced in one of the leading South African academic centres

PURPOSE

Jejuno-ileal atresia remains the most common form of intestinal obstruction in the neonatal and infantile age group and has an incidence of 1:300 to 1:1500. Apple peel atresia (APA) is the rarest of the five described types. The morbidity and mortality of patients with APA managed at our institution are high, and we review our experience with this paper. We compared our outcomes with other developed and developing countries. In addition, we looked at factors that affect outcome and how we can change them.

METHODS

The study was a retrospective review of all patients treated with APA at IALCH between January 2002 and December 2010 and includes 34 patients.

RESULTS

The results revealed a mortality in excess of 70%. There were poor antenatal screening, a high rate of prematurity and often delays in transfer to our institution. Relaparotomy and sepsis rates were high.

CONCLUSION

This review represents a significant number of patients with APA from a single institution. Although survival rates have improved significantly over the years, APA remains a life-threatening malformation and results in significant morbidity and mortality in our setting.

A complicated case of bowel obstruction with sepsis and methamphetamine toxicity in a child with pica

In this report, a pediatric case of bowel obstruction with sepsis complicated by methamphetamine toxicity is described. The decedent, an eleven-year-old female with a clinical history of pica, was found unresponsive in her home and pronounced dead following unsuccessful resuscitative efforts. Radiologic imaging showed multiple radio-opaque foreign objects in the stomach and bowel. Autopsy revealed a green leafy substance, coins and other metallic items, folded paper, and plastic in her stomach and bowels. Postmortem iliac blood and urine tested positive for amphetamine and methamphetamine. While the decedent's medical history and autopsy findings provided evidence consistent with bowel obstruction with sepsis due to the ingestion of foreign materials, the high methamphetamine concentration was suggestive of concurrent methamphetamine toxicity. Unique complications associated with this case include the phenomenon that methamphetamine toxicity and bowel obstruction can present similarly in children and the reported opinion that accidental drug ingestion is uncommon in children over the age of five. This case emphasizes that the age range for suspected accidental drug ingestion should be expanded for those with pica, as these patients, despite being older, may not be able to differentiate between what they should and should not ingest. Furthermore, when treating a pediatric patient with pica that appears to present with bowel obstruction, unintentional drug ingestion should also be considered, particularly if there is a suspicion that the child lives in a household where drugs are abused, given the prospect that drug toxicity can present similarly.

Feeding Outcomes in Neonates With Trisomy 21 and Duodenal Atresia

BACKGROUND

Duodenal atresia (DA), a common cause of congenital duodenal obstruction, is associated with trisomy 21. The postoperative feeding issues are not well described in this population. We hypothesize that the combination of DA and trisomy 21 is associated with the need for postoperative enteral feeding access.

METHODS

A retrospective cohort of patients between 2010 and 2017 with the diagnosis of DA or duodenal stenosis was identified. Relevant prenatal and postnatal clinical data were abstracted. Univariate analyses were performed.

RESULTS

Forty-three patients were identified. Nineteen patients (44%) were diagnosed with trisomy 21. Eight patients (25% with trisomy 21) had gastrostomy placed at the time of DA repair. In the remaining patients (n = 35), 40% ultimately had a gastrostomy button placed. The indications for placement included poor oral skills (n = 8), aspiration (n = 5), and failure to thrive (n = 1). All these patients had trisomy 21, resulting in 82.4% of trisomy 21 patients having a gastrostomy. There was a significant association between trisomy 21 and placement of a gastrostomy button both during index admission (P = 0.003) and lifetime (P < 0.001). All trisomy 21 patients with congenital heart disease (n = 9) had a gastrostomy placed versus only five of eight trisomy 21 patients (62.5%) without structural heart disease (P = 0.006).

CONCLUSIONS

Our data suggest that a correlation exists between trisomy 21, structural congenital heart anomalies, DA, and the eventual need for gastrostomy. These data should inform operative planning for this patient population.

Should we look for Hirschsprung disease in all children with meconium plug syndrome?

BACKGROUND

Meconium plug syndrome (MPS) is associated with Hirschsprung disease (HD) in 13-38% of cases. This study sought to assess institutional variation in utilization of rectal biopsy in children with MPS and the likelihood of diagnosing HD in this population.

METHODS

Patients with MPS on contrast enema in the first 30 days of life from the Pediatric Health Information System database in 2016-2017 were included. Institutional rates of rectal biopsies performed during the initial admission were calculated and then used to predict institutional rates of early HD diagnoses using Poisson regression.

RESULTS

Of 373 newborns with MPS, 106 (28.4%) underwent early rectal biopsy, of whom 43 (40.5%) had HD. Fifty-seven (15.3%) were ultimately diagnosed with HD. Eight (14%) of these patients had a delayed diagnosis. HD rates between institutions did not differ significantly (range 0-50%, p=0.52), but usage of early rectal biopsy did (range 0-80%, p=0.03). Each additional early biopsy increased the early HD diagnosis rate by 35% (β=0.30, 95% CI 0.15-0.45, p<0.0001).

CONCLUSION

The incidence of HD is increased in children with MPS. There is significant hospital variability in the utilization of early rectal biopsy, and opportunity exists to standardize practice.

TYPE OF STUDY

Study of Diagnostic test Level of Evidence: Level III.

Chronic bowel obstruction from colonic stenosis in early infancy-A report of two cases

Bowel obstruction in early infancy may result from a variety of congenital anomalies involving parts of the small and large bowel. However, in infancy, chronic bowel obstructions from congenital or acquired stenosis of the colon are rare and can cause diagnostic quandary. We present two cases of an eleven-week old male and a nine-week old male with massive abdominal distension and features of chronic bowel obstruction dating from neonatal period. In the first case investigations were inconclusive and laparotomy revealed isolated stenosis of the ascending colon. In the second case colonic stenosis was suspected preoperatively and a barium enema done showed multiple colonic stenosis confirming our working diagnosis. The diagnostic dilemmas encountered in managing the first patient are discussed to highlight the need for high index of suspicion of this condition in infants with chronic constipation. The way experience in managing the first case influenced diagnosis of the second case is also highlighted.

Congenital obstructive bowel anomalies presenting after neonatal age

Background

Delayed presentation might affect the ultimate management of children with congenital bowel obstructive bowel anomalies (CBA). We evaluated the profile, challenges of treatment and outcome of CBA presenting after neonatal age.

Methods

We did a retrospective analysis of data of children with CBA presenting after neonatal age from January 2013 to November 2017. We used the Statistical Package for Social Sciences (SPSS) for data entry and analysis.

Results

There were 57 cases in total comprising of Hirschsprung's disease (HD; 37 cases), anorectal malformation (ARM; 15 cases), and duodeno-jejunal web (5 cases), with median age of 9 months (IQR 4 months — 2 years) on presentation. Overall, 52 (91.2%) patients had one or more complications on presentation. Definitive procedure did not differ from established operations, but only 9 (15.8%) had primary procedures and 48 (84.2%) cases required multi-stage treatment. After an average follow up period of 19.5 months (range: 1–45 months), 18 (31.6%) cases developed procedure-related complications and 3 (5.3%) had residual bowel dysfunction, but there was no mortality. The morbidity was limited to cases with HD and ARM.

Conclusion

In our setting, HD is the commonest bowel anomaly that presents after the neonatal age. The delayed presentation may predispose to complications and preclude single-stage treatment in some cases. Training of healthcare providers to improve recognition and early referral of these anomalies may lead to early diagnosis and minimize morbidity.

Neonatal anesthesia in low birth weight babies at Hospital Nacional Guido Valadares, Dili, Timor-Leste

Over a 6-month period, eight neonates weighing less than 3 kg were operated on at Hospital Nacional Guido Valadares, Dili, Timor-Leste. Each was operated on for an abdominal condition. There is no postoperative neonatal ventilation, neonatal inotropes, fluid warmers, or parenteral nutrition available at Hospital Nacional Guido Valadares. Medical air and nitrous oxide are unavailable. Oxygen from cylinders is the only gas available in theaters and on the wards. Generally equipment is problematic and not designed for neonates. Five of these infants perished in hospital perioperatively, representing an in-hospital mortality of 62%, another is presumed to have died following discharge, and two recovered well. This represents an estimated overall mortality rate of 75%. This is not surprising given the difficult circumstances in theater and the limited postoperative support services available. The resources and time deployed in operating on these small neonates is significant. As difficult as it may be surgical enthusiasm and the uncertainties surrounding prognostication should not displace practical and realistic assessment of the likely outcome of operating on very small babies in low resource facilities where perioperative support is limited. Future development in the Timor-Leste healthcare sector will hopefully provide an environment where improvements in outcome can be achieved.

A Newborn With Abdominal Pain

A previously healthy 3-week-old boy presented with 5 hours of marked fussiness, abdominal distention, and poor feeding. He was afebrile and well perfused. His examination was remarkable for localized abdominal tenderness and distention. He was referred to the emergency department in which an abdominal radiograph revealed gaseous distention of the bowel with a paucity of gas in the pelvis. Complete blood cell count and urinalysis were unremarkable. His ongoing fussiness and abnormal physical examination prompted consultation with surgery and radiology. Our combined efforts ultimately established an unexpected diagnosis.

Acute mechanical intestinal obstruction in children at zinder national hospital, Niger: Aetiologies and prognosis

BACKGROUND

To describe the aetiological and prognostic aspects of acute mechanical intestinal obstruction (AMIO) in children at Zinder National Hospital (Niger).

MATERIALS AND METHODS

This was a cross-sectional study on a period to January 2013-June 2015. The database included all children under 15 years of age with a surgical diagnosis of mechanical intestinal obstruction. P < 0.05 was considered statistically significant for analysis.

RESULTS

AMIOs represent 21.78% (n = 78) of child digestive surgical emergencies (n = 358). Median age was 12 months (range: 1 day-15 years). Fifteen (19.23%) were neonates and sixty children (76.92%) had ≤60 months. The sex ratio (male/female) was 2.8. The mean time from onset to presentation was 39.96 ± 36.22 h. Intussusception and strangulated hernias were the main causes of AMIO with, respectively, 43.59% (n = 34) and 29.48% (n = 23). Anorectal malformations represent 17.95% (n = 14) of cases of AMIO. Intestinal resection was made in 22.08% and colostomy in 19.23% of patients. The average length of hospital stay was 6.44 ± 4.30 days. The post-operative complications were recorded in 26 patients (33.33%), mostly surgical site infections. Overall mortality of AMIO was 15.38% (n = 12). It was higher in the neonates (33.33%) (P = 0.032). Deaths were associated with delay of admission (P = 0.0005) and waiting time for surgery (P = 0.019).

CONCLUSION

Intussusception and strangulated hernia are the most common cause of AMIO in children. Diagnostic and therapeutic delays, lack of paediatric intensive care and post-operative complications are prognostic factors.

Prenatal diagnosis and outcome of fetal gastrointestinal obstruction

INTRODUCTION

The purpose of this study was to evaluate the accuracy of prenatal diagnosis for fetuses with gastrointestinal (GI) obstruction with correlation to postnatal outcomes.

METHODS

Fetuses diagnosed with GI obstruction (excluding esophageal and duodenal) were reviewed for those evaluated between 2006 and 2016. Prenatal diagnosis and imaging studies were compared to postnatal findings. Outcomes evaluated included diagnostic accuracy, rate of other anomalies, neonatal length of stay, incidence of short bowel syndrome, and discharge with TPN or gastrostomy.

RESULTS

Forty-eight patients were diagnosed prenatally with obstruction. Six patients were excluded owing to incomplete records and follow-up. Twelve fetuses were diagnosed with ultrasound alone, and thirty-four with ultrasound and MRI. A diagnosis of obstruction was accurate in 88.1% (n=37/42) with a positive predictive value of 91.3%, while US with MRI had an accuracy of 84.4%. Associated anomalies were highest among fetuses with anorectal obstruction (90.1%), compared to large (50%) or small bowel obstruction (28%). Survival rate was lowest for anorectal obstruction (54.5%), compared to large or small bowel obstruction (100% for both).

CONCLUSION

Fetal MRI is an accurate modality in the diagnosis of fetal GI obstruction and can complement findings characterized by ultrasound. Fetuses with anorectal obstruction have a higher rate of associated anomalies and the lowest survival.

LEVEL OF EVIDENCE

IIb.

Non-classified type duodenal atresia: case report

Our aim is to present a case with initial diagnosis of non-classified type duodenal atresia operated in our clinic. A patient with prenatally suspected to be duodenal atresia was explored. At laparotomy type 3 duodenal atresia was found between 2^nd and 3^rd parts of duodenum. In addition, a web was detected distal to the atresic part. Duodenoduodenostomy together with web excision was performed. He had not any additional pathology. Although duodenal atresia is a very well known pathology by pediatric surgeons, though rarely a non-classified type duodenal atresia can be encountered. Possible presence of a second atresia should be kept in mind, proximal and distal segments of the duodenum and intestinal passage must be explored carefully for the presence of second atresic segment before performing duodenoduodenostomy.

Pyloric atresia in the neonate

Bowel obstruction is a common cause for admission into the NICU, but pyloric atresia (PA) is a very rare cause of bowel obstruction. This article illustrates the development of the fetal gastrointestinal tract, most specifically the stomach and pylorus. Pathophysiology, typing, and treatment of PA are also explored. Presented are two cases of PA that occurred in a Level III NICU one month apart. Management of this condition is surgical in nature. Long-term prognosis is usually excellent because this defect is often isolated.

Comparative Effectiveness of Imaging Modalities for the Diagnosis of Intestinal Obstruction in Neonates and Infants:: A Critically Appraised Topic

RATIONALE AND OBJECTIVES

The purpose of this study was to critically appraise and compare the diagnostic performance of imaging modalities that are used for the diagnosis of upper and lower gastrointestinal (GI) tract obstruction in neonates and infants.

METHODS

A focused clinical question was constructed and the literature was searched using the patient, intervention, comparison, outcome method comparing radiography, upper GI contrast study, and ultrasound in the detection of upper GI tract obstruction such as duodenal atresia and stenosis, jejunal and ileal atresia, and malrotation and volvulus. The same methods were used to compare radiography and contrast enema in the detection of lower GI tract obstruction such as meconium plug syndrome, meconium ileus, Hirschsprung disease, and imperforate anus. Retrieved articles were appraised and assigned a level of evidence based on the Oxford University Centre for Evidence-Based Medicine hierarchy of validity for diagnostic studies.

RESULTS

There were no sensitivities/specificities available for the imaging diagnosis of duodenal atresia or stenosis, jejunal or ileal atresias, meconium plug, and meconium ileus or for the use of cross-table lateral radiography for the diagnosis of rectal pouch distance from skin in imperforate anus. The retrieved sensitivity for the detection of malrotation on upper GI contrast study is 96%, and the sensitivity for the diagnosis of midgut volvulus on upper GI contrast study is 79%. The retrieved sensitivity and specificity for the detection of malrotation with volvulus on ultrasound were 89% and 92%, respectively. The retrieved sensitivity and specificity for the detection of Hirschsprung disease on contrast enema were 70% and 83%, respectively. The retrieved sensitivity of invertogram for the diagnosis of rectal pouch distance from skin in imperforate anus is 27%. The retrieved sensitivities of perineal ultrasound and colostography for the diagnosis of rectal pouch distance from skin in imperforate anus were 86% and 100%, respectively.

CONCLUSIONS

There is limited evidence for the imaging diagnosis of duodenal atresia and stenosis, jejunal and ileal atresias, meconium plug, meconium ileus, and imperforate anus, with recommended practice based mainly on low-quality evidence or expert opinion. The available evidence supports the use of upper GI contrast study for the diagnosis of malrotation and volvulus, with ultrasound as an adjunct to diagnosis. Contrast enema is useful in the investigation of suspected Hirschsprung disease, but a negative study does not outrule the condition. Colostography is the investigation of choice for the work-up of infants with complex anorectal malformations before definitive surgical repair.

Pediatric intestinal obstruction in Malawi: characteristics and outcomes

BACKGROUND

Intestinal obstruction (IO) is a common pediatric surgical emergency in sub-Saharan Africa with high morbidity and mortality, but little is known about its etiopathogenesis in Malawi.

METHODS

Retrospective analysis of patients seen from February 2012 to June 2014 at Kamuzu Central Hospital in Lilongwe, Malawi (n = 3,407). Pediatric patients with IO were analyzed (n = 130).

RESULTS

Overall, 57% of patients were male with a mean age of 3.5 ± 4.1 years. A total of 52% of patients underwent operative intervention. The overall mortality rate was 3%. Leading causes of IO were Hirschprung's 29%, anorectal malformation 18%, and intussusception 4%. Neonates and patients with congenital causes of IO underwent surgery less frequently than infants and/or children and patients with acquired causes, respectively. These groups also demonstrated increased number of days from admission to surgery.

CONCLUSIONS

Increasing pediatric-specific surgical education and/or training and expanding access to resources may improve mortality after IO in poor medical communities within sub-Saharan Africa.

Congenital Bands with Intestinal Malrotation after Propylthiouracil Exposure in Early Pregnancy

Exposure to propylthiouracil in early pregnancy may be associated with an increased risk of birth defects. But the spectrum of associated congenital anomalies is not yet well defined. While preliminary reports suggest that most cases of propylthiouracil-associated birth defects are restricted to the preauricular and urinary systems, careful consideration should be given to other possible manifestations of teratogenicity. We propose that congenital bands may potentially represent a rare yet serious complication of propylthiouracil exposure in early pregnancy, possibly arising from an early mesenteric developmental anomaly. We report a case of a 17-day-old girl that presented with acute small bowel obstruction associated with intestinal malrotation arising from several anomalous congenital bands. Her mother was treated for Graves' disease during pregnancy with first trimester exposure to propylthiouracil but remained clinically and biochemically euthyroid at conception and throughout the duration of pregnancy. This case suggests that the use of propylthiouracil in early pregnancy may be associated with congenital bands and intestinal malrotation. More reports are needed to further support this association.

Glutamine supplementation for young infants with severe gastrointestinal disease

BACKGROUND

Endogenous glutamine biosynthesis may be insufficient to meet the needs of people with severe gastrointestinal disease. Results from studies using experimental animal models of gastrointestinal disease have suggested that glutamine supplementation improves clinical outcomes. This review examines evidence on the effect of glutamine supplementation in young infants with severe gastrointestinal disease.

OBJECTIVES

To assess the effect of supplemental glutamine on mortality and morbidity in young infants with severe gastrointestinal disease.

SEARCH METHODS

We searcheed the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2014, Issue 8), MEDLINE, EMBASE, and CINAHL (from inception to September 2014), conference proceedings, and reference lists from previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared glutamine supplementation versus no glutamine supplementation in infants up to three months old (corrected for preterm birth if necessary) with severe gastrointestinal disease defined as a congenital or acquired gastrointestinal condition that is likely to necessitate providing parenteral nutrition for at least 24 hours.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and undertook data extraction independently. We analysed the treatment effects in the individual trials and reported the risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference for continuous data, with 95% confidence intervals (CI). We used a fixed-effect model in meta-analyses and explored the potential causes of heterogeneity in sensitivity analyses.

MAIN RESULTS

We found three trials in which a total of 274 infants participated. The trials were of good methodological quality but were too small to detect clinically important effects of glutamine supplementation. Meta-analyses did not reveal a statistically significant difference in the risk of death before hospital discharge (typical RR 0.79, 95% CI 0.19 to 3.20; typical RD -0.01, 95% CI -0.05 to 0.03) or in the rate of invasive infection (typical RR 1.37, 95% CI 0.89 to 2.11; typical RD 0.08, 95% CI -0.03 to 0.18]).

AUTHORS' CONCLUSIONS

The available data from randomised controlled trials do not suggest that glutamine supplementation has any important benefits for young infants with severe gastrointestinal disease.

Is routine preoperative screening echocardiogram indicated in all children with congenital duodenal obstruction?

INTRODUCTION

Congenital duodenal obstruction (DO) is frequently associated with congenital heart disease (CHD). Operative repair of DO is often postponed until an echocardiogram is completed, which may result in unnecessary delays. We aimed to identify and characterize CHD in children with DO to determine if appropriately selected patients could forego preoperative echocardiogram.

METHODS

A two-center retrospective review of all infants with DO undergoing operative repair with completed echocardiograms was included (2003-2011). Demographics, co-morbid conditions, clinical exam findings, radiologic imaging, and need for cardiac surgery were recorded.

RESULTS

67 children were identified. 47 (70.1%) had CHD on echocardiogram of which 19 (40.5%) had significant CHD. Children without clinical findings, abnormalities on physical examination, and/or abnormal chest x-ray were unlikely to have CHD; i.e., no asymptomatic child had significant CHD. Sensitivity and specificity of clinical findings, physical exam, and/or chest x-ray for significant CHD were 100% (95% CI 0.79-1.0) and 37.5% (95% CI 0.24-0.53), respectively, for major CHD and 87.2% (0.74-0.95) and 60% (0.36-0.80) for any CHD.

CONCLUSION

Careful clinical assessment, evaluation with pulse oximetry, and chest x-ray may be sufficient to exclude significant CHD in children with DO. Identifying children at low risk for cardiac lesions may prevent unnecessary delays to operative intervention and may limit medical expenses.

Intestinal obstruction in a premature baby: Endoscopic diagnosis and management by minimal access surgery

Neonatal intestinal obstruction is the most common surgical emergency in a newborn. Although, large numbers of newborns are operated in our country, limited published literature is available on advances in diagnosis, and management of this problem with outcome analysis in newborns. We report a premature (32 weeks) newborn who developed acute onset symptoms of small bowel obstruction in 3^rdweek of life, and discuss the approach to diagnosis and management with the minimal access surgery and successful outcome.

Extrinsic colonic obstruction by congenital fibrous band in an infant

The finding of a congenital fibrous band during laparotomy for intestinal obstruction is extremely rare. Preoperative diagnosis is challenging and no characteristic radiological findings have been described. We report the case of a premature baby in whom incomplete intestinal obstruction was due to a congenital band originating from the duodeno-jejunal flexure and extending across the ascending colon.

Giant cystic meconium peritonitis presenting in a neonate with classic radiographic eggshell calcifications and treated with an elective surgical approach: a case report

INTRODUCTION

Giant cystic meconium peritonitis is relatively rare. Patients often present with nonspecific physical findings such as distension and emesis. Plain abdominal films remain invaluable for identifying the characteristic calcifications seen with a meconium pseudocyst, and large eggshell calcifications are pathognomonic for the giant cystic subtype.

CASE PRESENTATION

We present classic plain X-ray findings and an intraoperative image of a premature low birth weight two-day-old Hispanic male baby treated for giant cystic meconium peritonitis with a staged procedure involving peritoneal drainage, ostomy creation and closure.

CONCLUSION

Pediatric surgeons have a range of potential therapeutic approaches for giant cystic meconium peritonitis. A delay of definitive surgical management in the setting of massive abdominal soiling is a safe and acceptable strategy if adequate temporizing drainage is performed in the early perinatal period.

Glutamine supplementation for young infants with severe gastrointestinal disease

BACKGROUND

Endogenous glutamine biosynthesis may be insufficient to meet the needs of people with severe gastrointestinal disease. Studies using experimental animal models and controlled trials in adult patients with severe gastrointestinal disease have suggested that glutamine supplementation improves clinical outcomes. This review examines evidence for the effect of glutamine supplementation in young infants with severe gastrointestinal disease.

OBJECTIVES

To assess the evidence from randomised controlled trials that providing supplemental glutamine reduces mortality and morbidity in young infants with severe gastrointestinal disease.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2012, Issue 1), MEDLINE, EMBASE, and CINAHL (to November 2011), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared glutamine supplementation versus no glutamine supplementation in infants up to three months old (corrected for preterm birth if necessary) with severe gastrointestinal disease defined as a congenital or acquired gastrointestinal condition that is likely to necessitate providing parenteral nutrition for at least 24 hours.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Review Group with separate evaluation of trial quality and data extraction by two review authors. We synthesised data using a fixed-effect model and reported typical risk ratio (RR), typical risk difference (RD), and weighted mean difference (WMD).

MAIN RESULTS

We found two trials in which a total of 100 infants participated. The trials were of good methodological quality but were too small to detect clinically important effects of glutamine supplementation. Meta-analysis did not reveal a statistically significant difference in the risk of death before hospital discharge (typical RR 1.57; 95% confidence interval (95% CI) 0.25 to 9.66; RD 0.02; 95% CI -0.06 to 0.10) or in the rate of invasive infection [typical RR 1.22; 95% CI 0.55 to 2.70; RD 0.04; 95% CI -0.12 to 0.20).

AUTHORS' CONCLUSIONS

The available data from randomised controlled trials are insufficient to determine whether glutamine supplementation has any important benefits for young infants with severe gastrointestinal disease.

Commonly encountered surgical problems in the fetus and neonate

Neonatal surgical care requires a current understanding of pre- and postnatal intervention for a myriad of congenital anomalies. This article includes an update of the recent information on commonly encountered fetal and neonatal surgical problems, highlighting specific areas of controversy and challenges in diagnosis. The authors hope that this article is useful for trainees and practitioners involved in any aspect of fetal and neonatal care.

Induction of early meconium evacuation promotes feeding tolerance in very low birth weight infants

BACKGROUND

A delay in reaching full enteral feeding is linked to poorer outcome in preterm neonates. Meconium retention has been viewed as a cause of bowel dysfunction in very low birth weight infants (VLBWI). Thus, adequate evacuation of meconium could help to promote feeding tolerance.

OBJECTIVES

Our goal was to determine the effect of the induction of early meconium evacuation on feeding tolerance in VLBWI.

METHODS

An observational study involving two subsequent periods was performed in inborn infants with birth weights of <1,500 g, before (control) and after (study) the induction of early meconium evacuation by routine glycerin enema. The total duration of these periods was from January 2003 to December 2005. To evaluate feeding tolerance, we measured time to achieve full enteral feeding. Complications such as sepsis and necrotizing enterocolitis were compared.

RESULTS

The study group achieved full enteral feeding significantly faster than the control group (hazard ratio (HR) = 2.9; 95% confidence interval (CI) = 1.8-4.8), and this effect was more definite in infants with a birth weight of <1,000 g (HR = 4.6; 95% CI = 1.9-11.1). The study group passed first meconium faster than the control group (median = 1.4 vs. 3.7 days; p < 0.001). Sepsis, especially as determined by positive culture in central venouscatheter, was significantly reduced in the study group (7.7 vs. 27.8%; p = 0.02).

CONCLUSIONS

The induction of early meconium evacuation had a significantly positive effect on feeding tolerance and sepsis prevention in VLBWI.

[Congenital anatomic gastrointestinal obstruction: prenatal diagnosis, morbidity and mortality]

OBJECTIVES

To describe the morbidity and mortality associated with congenital gastrointestinal obstruction, assess the usefulness of prenatal diagnosis, and analyze the results in relation to the site of obstruction.

PATIENTS AND METHODS

We performed a retrospective case series study of 148 patients in a 13-year period (1990-2003). Sites of obstruction was classified into three groups: I) gastric, duodenal or jejunal; II) ileal or colonic; III) anorectal.

RESULTS

There were 65 patients in group I, 38 in group II and 45 in group III. Surgery was performed in 137 patients. Trisomy was diagnosed in 15 patients, polymalformation syndrome in 16 patients, and cystic fibrosis in seven patients. More than one site of intestinal obstruction was found in 22 patients (15 %). Morbidity consisted of nosocomial sepsis in 32 %, necrotizing enterocolitis in 7 %, and short gut in 3.4 %. Prematurity (48 %) was associated with higher morbidity and mortality. Overall mortality was 14.2 %, mainly associated with other malformations and extraintestinal problems. When patients with other extraintestinal malformations were excluded, the highest mortality was found in group II (OR: 12.19; CI: 2.4-76.2). The overall sensitivity of prenatal diagnosis was 0.44 and the mean gestational age at diagnosis was 31.6 weeks (SD 5.2). According to the site of obstruction, sensitivity was 0.77 in group I, 0.39 in group II and 0.04 in group III. Prenatal diagnosis did not alter prognosis.

CONCLUSIONS

Morbidity and mortality were strongly influenced by extraintestinal problems. The most severe intestinal complications were midgut volvulus and necrotizing enterocolitis. Prenatal diagnosis was late and showed good sensitivity only in group I.

Understanding neonatal bowel obstruction: building knowledge to advance practice

Providing care to neonates with bowel obstruction requires a basic understanding of gastrointestinal (GI) anatomy and functional landmarks as well as knowledge of the pathophysiology associated with intestinal blockage. Early recognition and prompt diagnosis necessitate astute assessment of common presenting symptoms and accurate interpretation of diagnostic investigations. Initial medical management is focused primarily on gastric decompression and maintenance of fluid and electrolyte balance. This article describes features of the neonatal GI tract and discusses common causes of neonatal bowel obstruction.

Prenatal bowel dilatation and the subsequent postnatal management

The presence of dilated bowel loops antenatally suggests fetal bowel obstruction. Neonatal intestinal obstruction can have different variations in presentation depending on the level and extent of obstruction. Some of these conditions can be diagnosed antenatally. Antenatal detection of surgically correctable anomalies would ideally reduce perinatal morbidity and mortality by allowing a planned delivery with early resuscitation and prompt surgical intervention. Duodenal atresia is the most common intestinal atresia diagnosed in a fetus. Presently there are no significant abnormalities of the fetal gastrointestinal tract that benefit from fetal intervention. However a thorough understanding of the disease processes is necessary for diagnosis and treatment of intestinal obstruction. With advances in neonatal intensive care and management there has been a significant decrease in mortality rates of neonates with intestinal obstruction.

Pregnancy among patients with chronic myeloid leukemia treated with imatinib

PURPOSE

Imatinib has potential teratogenicity in animals, but the effect of exposure to imatinib during conception and pregnancy in humans is not known.

PATIENTS AND METHODS

The records of all patients with chronic myeloid leukemia (CML) treated with imatinib were reviewed. We report the experience on 19 pregnancies involving 18 patients (10 females and eight males) who conceived while receiving imatinib for the treatment of CML.

RESULTS

All female patients discontinued therapy immediately on recognition of pregnancy. Three pregnancies (involving two female patients and one male patient) ended in spontaneous abortion, and one patient had an elective abortion. All other pregnancies were uneventful. Two of the 16 babies had minor abnormalities at or shortly after birth (hypospadias in one baby and rotation of small intestine in one baby) that were surgically repaired. All babies have continued normal growth and development. Among female patients who interrupted therapy, five of nine in complete hematologic remission (CHR) at the time of treatment interruption eventually lost CHR, and six experienced an increase in Philadelphia chromosome-positive metaphases. At a median of 18 months after resuming therapy with imatinib, eight patients had a cytogenetic response (complete in three patients).

CONCLUSION

Although there is no evidence that a brief exposure to imatinib during conception and pregnancy adversely affects the developing fetus, most patients lose their response after treatment interruption. Patients receiving imatinib should be advised to practice adequate contraception.