Laparoscopic Management of Small Bowel Obstruction in Children

Laparoscopy or laparotomy for adhesive bowel obstruction in children: a systematic review and meta-analysis

PURPOSE

Adhesive small bowel obstruction (ASBO) is one of the most important cause of postoperative morbidity in children who underwent abdominal surgery. Laparoscopic management for ASBO in pediatric patients has been reported. However, its safety and efficacy has not been evaluated in details. The aim of this study is to compare the outcomes of laparoscopy and laparotomy for the treatment of ASBO in children.

METHODS

A systematic review and meta-analysis were performed following the Cochrane Handbook for systematic reviews of intervention and the preferred reporting item for systematic reviews and meta-analysis (PRISMA) and a protocol registered in PROSPERO (CRD42017067914). The primary outcome was the number of intraoperative and postoperative complications. The secondary outcome was length of hospital stay. The risk of bias in non-randomized studies of interventions (ROBINS-I) tool was used to assess the risk of bias. Quality of evidence was summarized using the grades of recommendation, assessment, development and evaluation (GRADE) approach.

RESULTS

We identified three observational studies and no randomized controlled trials. The meta-analysis was done only for the primary outcome. Complications were significantly fewer after laparoscopy compared to laparotomy (Odds ratio = 0.51; 95% CI 0.40-0.66; p < 0.01; I ²: 0%). The overall risk of bias was considered serious.

CONCLUSIONS

Our results, based on observational studies, indicate that laparoscopy for ASBO was associated with less postoperative complications compared to conventional laparotomy. However, the quality of evidence is very low. A well-controlled study is needed to assess the efficacy of laparoscopy for pediatric patients with ASBO.

Segmental volvulus in the neonate: A particular clinical entity

BACKGROUND

Complete intestinal volvulus is mainly related to congenital anomalies of the so-called intestinal malrotation, whereas segmental volvulus appears as a distinct entity, mostly observed during the perinatal period. Because these two situations are still lumped together, the aim of this study was to describe the particular condition of neonatal segmental volvulus.

STUDY DESIGN

We analyzed the circumstances of diagnosis and management of 17 consecutives neonates operated for segmental volvulus more than a 10-year period in a single institution. During the same period, 19 cases of neonatal complete midgut volvulus were operated.

RESULTS

Prenatal US exam anomalies were observed in 16/17 (94%) of segmental volvulus, significantly more frequently than in complete volvulus (p=0.003). Intestinal malposition was described peroperatively in all cases of complete volvulus, but also in 4/17 segmental volvulus (23%). Intestinal resection was performed in 88% of segmental volvulus when only one extensive intestinal necrosis was observed in complete volvulus. Parenteral nutrition was required in all patients with segmental volvulus with a median duration of 50days (range 5-251).

CONCLUSION

Segmental volvulus occurs mainly prenatally and leads to fetal ultrasound anomalies. This situation, despite a limited length of intestinal loss, is associated to significant postnatal morbidity.

TYPE OF THE STUDY

Treatment study.

LEVEL OF EVIDENCE

Level IV.

Role of laparoscopy in the prevention and in the treatment of adhesions

The formation of adhesions after abdominal surgery can lead to increased morbidity in children, increases the incidence of readmission, and may pose a significant challenge to subsequent surgical care over their lifetime. As the pathophysiology of peritoneal adhesion formation has been better understood, preventive strategies that minimize surgical trauma and contamination have been sought. Laparoscopy, over the past few decades, has become an increasingly utilized approach for many pediatric surgical problems and intuitively should have an advantage over open surgery in reducing adhesion formation. In this review, we examine the utility of laparoscopy in both the prevention and the treatment of intraabdominal adhesive disease in children.

Laparoscopy for small bowel obstruction in children--an update

INTRODUCTION

We evaluated the current role of minimally invasive surgery (MIS) in children with small bowel obstruction (SBO) at our institution.

SUBJECTS AND METHODS

A retrospective review of patients undergoing MIS for acute SBO was performed from 2008 to 2013. The study population was compared with a historical control including patients from 2001 to 2008.

RESULTS

There were 71 patients who met inclusion criteria; 35 were male, and 36 were female. Sixty-two children underwent laparoscopy for their first episode of SBO, and 12 underwent laparoscopy for recurrent SBO, accounting for 74 episodes of SBO managed with MIS. The most common etiology of SBO was adhesions (n=40). Laparoscopy and laparoscopic-assisted procedures were associated with shorter nasogastric tube decompression (1.4±2 days [P<.001] and 1.5±2.7 days [P=.002], respectively) and time to regular diet (3.9±4 days [P=.002] and 4.6±2.8 days [P=.024], respectively) compared with those converted to laparotomy (5.1±4.9 days of nasogastric tube decompressions and 8±4.7 days to regular diet). There was no difference in postoperative morbidity comparing laparoscopy (11%), laparoscopic-assisted (5%), and laparoscopic converted to open procedures (18%) (P=.48).

CONCLUSIONS

Laparoscopy continues to be a safe diagnostic and therapeutic tool in the management of pediatric SBO.

Congenital membrane causing duodenal obstruction and malpositioning of the descending colon

A congenital membrane without intestinal malrotation is a rare cause of duodenal obstruction. Here we present an 11-year-old girl who had suffered from intermittent abdominal cramping pain and vomiting for more than 5 years. The image studies, including a plain abdomen roentgenogram and sonogram, showed no definite diagnosis. The upper gastrointestinal series and small bowel series showed the contrast was static over the third portion of the duodenum and the descending colon pulled up toward the epigastric area. Laparoscopic exploration revealed a congenital membrane extending from the right-side paraduodenal peritoneum through the third portion of the duodenum to the descending colon, which had caused obstruction of the third portion of the duodenum and malpositioning of the descending colon. To the best of our knowledge, this is the first case report in the literature where a congenital membrane caused both duodenal obstruction and malpositioning of the descending colon.

Evaluation of intestinal viability using 3-charge coupled device image enhancement technology in a pediatric laparoscopic appendectomy model

BACKGROUND

Intraoperative laparoscopic determination of intestinal viability is currently limited to subjective visible cues. Adjunctive modalities are neither widely available nor practical. Three-charge coupled device (3-CCD) imaging directly correlates the amount of light detected by CCDs to tissue oxygenation. We hypothesize that application of 3-CCD image enhancement detects bowel ischemia in a pediatric laparoscopic appendectomy model.

METHODS

We recorded 10 laparoscopic appendectomies for appendicitis. Offline analysis involved selecting regions of interest (ROIs) in the appendix, adjacent colon, and nonappendiceal fat and calculating mean intensity values in selected images before and after division of the mesoappendix. The colon was used as a control, and the intensity values were normalized to fat.

RESULTS

As an indicator of decreased perfusion, the mean appendix ROI intensity values decreased over time (R(2) = 0.92) compared with the colon mean ROI intensity values, which remained stable. There was a statistically significant difference between fat-normalized intensity values for ischemic and nonischemic appendix after 1 minute.

CONCLUSION

We have demonstrated proof of principle for the determination of bowel ischemia using 3-CCD image enhancement. By quantitatively identifying areas of ischemia, this technique has the potential to significantly change the management of ischemic bowel in the future.