Antenatal counselling of congenital surgical anomalies: A decade of experience in a local tertiary centre

Management, Outcome, Risk, and Expectation Classification for Structural Fetal Anomalies to Aid Antenatal Counseling: A Systematic Review

The aim of this study was to propose Management, Outcome, Risk, and Expectation (MORE) as a risk based stratification to aid in antenatal parental counseling and decision making through a systematic review of published literature. A Preferred Reporting Items for Systematic Reviews and Meta Analyses compliant systematic review was conducted to include articles that covered antenatal counseling of pediatric surgical conditions. The following information was solicited for each anomaly: primary organ syste*-m of involvement, single or multi system anomaly, natural history of the disease, standard management of the anomaly, need for antenatal intervention, and whether the anomaly requires any alteration in the obstetric management. Twenty two studies were identified fulfilling the inclusion criteria, between 1993 and 2023. Only two studies were found to have GRADE A recommendation and Level I evidence. Most of the studies were review articles/ survey, and 6 studies were found to be retrospective observational studies. Based on the analysis of the solicited information, the anomalies were stratified into a group subsequently maturing them into a simplified MORE classification scheme which stressed the importance of Management (10, 45.45%), Outcome (9, 40.90%), Risk (9, 40.90%), and Expectation (10, 45.45%) categories during antenatal counseling. MORE classification of fetal structural anomalies is a simple but comprehensive framework to assist the physicians and other medical personnel antenatal parental counseling and decision making.

Open Versus Thoracoscopic Repair of Congenital Diaphragmatic Hernia: A 19-Year Review in a Tertiary Referral Centre in Hong Kong

BACKGROUND

Congenital diaphragmatic hernia (CDH) is a developmental defect that causes herniation of abdominal organs into the thoracic cavity with significant morbidity. Thoracoscopic repair of CDH is an increasingly prevalent yet controversial surgical technique, with limited long-term outcome data in the Asian region. The aim of this study was to compare open laparotomy versus thoracoscopic repair of CDH in paediatric patients in a major tertiary referral centre in Asia.

METHODS

We performed a retrospective analysis of neonatal patients who had open laparotomy or thoracoscopic repair for CDH in our institution between July 2002 and November 2021. Demographic data, perioperative parameters, recurrence rates and surgical complications were analysed.

RESULTS

64 patients were identified, with 54 left sided CDH cases. 33 patients had a prenatal diagnosis and 35 patients received minimally invasive surgical repair. There was no significant difference between open and minimally invasive repair in recurrence rate (13 % vs 17 %, P = 0.713), time to recurrence (184 ± 449 days vs 81 ± 383 days, P = 0.502), or median length of ICU stay (11 ± 14 days vs 13 ± 15 days, P = 0.343), respectively. Gastrointestinal complications occurred in 7 % of neonates in the open group and none in the thoracoscopic group. Median follow-up time was 9.5 years.

CONCLUSIONS

This study is a large congenital diaphragmatic hernia series in Asia, with long term follow-up demonstrating no significant difference in recurrence rate, time to recurrence or median length of ICU stay between open and minimally invasive repair, suggesting thoracoscopic approach is a non-inferior surgical option with avoidance of gastrointestinal complications compared to open repair.

LEVEL OF EVIDENCE: 3

TYPE OF STUDY

Retrospective Cohort Study.

Does COVID-19 Infection during Pregnancy Increase the Appearance of Congenital Gastrointestinal Malformations in Neonates?

BACKGROUND

COVID-19 was an infection that was capable of bringing the entire world to a standstill position within a period of days to months. Despite the advancements in the medical sector, the contagion was difficult to control and costed the lives of millions of people worldwide. Many short- and long-term effects are witnessed even to date in people that contracted the disease. Pregnant females had to suffer not only the devastating effects of the virus, but also the psycho-social impact of the lockdown. The impact of COVID-19 infection during pregnancy causing decreased antenatal care or hypoxemic episodes due to severe respiratory distress and whether it could lead to the appearance of congenital gastrointestinal malformation in neonates is still unclear. The aim of our study was to analyze if COVID-19 infection during pregnancy could increase the incidence of gastric malformations in neonates born from these women.

MATERIALS AND METHODS

We sifted the files of all neonates admitted into our hospital between January 2022 and December 2022, and based on inclusion and exclusion criteria, we included the cases having gastrointestinal congenital malformations during the COVID-19 pandemic. We performed a single-center, retrospective, observational descriptive study. We further divided the patients based on the anatomical location of the malformation. We also took down details of the evolution of pregnancy and whether the mother had contracted a SARS-CoV-2 infection during the pregnancy. Details regarding the Apgar score, days of intensive care admission, sex, and nutrition were the key findings studied.

RESULTS

A total of 47 neonates were found to have digestive anomalies, among which, based on the anatomical locations, the number of malformation cases found at the level of the esophagus were 15, while 16 occurred at the level of the pylorus; we found 12 cases of malformation of the duodenum, and four cases had malformation of the rectum. Out of these 47 neonates, 38.3% were females and 61.7% were males. A total of 58% were preemies, among which 9% had intra-uterine growth retardation (IUGR), and 42% were full-term newborns, among which 4% had intra-uterine growth retardation (IUGR). A total of 45% of the births were primiparous pregnancies and 55% were from multiparous females. A total of 14 mothers were found to have tested positive for COVID-19 during the course of pregnancy (p-value = 0.23); many had mild symptoms but were not tested.

CONCLUSIONS

COVID-19 can affect the wellbeing of the pregnant female and their fetus. Larger studies can help gain extensive knowledge as to whether COVID-19 also has the potential to result in congenital gastrointestinal anomalies in children born from COVID-19 positive mothers. In our study, only a few infants born with this pathology were found to be born from COVID-19 positive mothers. Hence, it is difficult to conclude or exclude a direct correlation between the infection and the congenital malformations.

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.

Meconium peritonitis: A 22-year review in a tertiary referral center

BACKGROUND

Meconium peritonitis (MP) is a sterile, chemical peritonitis resulting from in-utero fetal bowel perforation. Severe cases may lead to serious morbidities and mortalities.

OBJECTIVE

To review the common antenatal ultrasound abnormalities associated with MP, and identify radiological and clinical prognostic factors.

MATERIALS AND METHODS

Retrospective review of all neonates with MP from January 1997 to December 2019 treated in our hospital was performed. Antenatal ultrasound findings, clinical presentations and outcomes were analyzed.

RESULTS

Thirty-five neonates (17 males, 18 females) were included in the study. Thirty-two (91.4%) attended antenatal screening, and 27 (84.4%) of them had abnormalities identified on antenatal ultrasound. The most common abnormality was polyhydramnios (43.8%). Nineteen (54.3%) patients were inborn. Twenty (57.1%) patients were born prematurely. Laparotomy was required in 85.7% of patients. The median time to laparotomy was shorter in the inborn group [1 day (0-9 days) vs 4 days (2-34 days), p = 0.001], but the duration of post-operative hospital stay was comparable [71 days (16-423 days) vs 73.5 days (23-231 days)]. However, such duration was found to be significantly longer in the pre-term group when compared to full-term [58.5 days (16-89 days) vs 85 (21-423 days), p = 0.01]. The most common pathology was small bowel atresia and there were two mortalities.

CONCLUSION

Due to the advancement in prenatal detection, pediatric anesthesia, intensive care and surgical techniques, the morbidity and mortality of MP has much decreased. Effective multi-disciplinary antenatal counseling facilitated the perinatal management of MP and resulted in comparable prognosis and outcome in inborn and outborn neonates.