1
|
Montalva L, Incerti F, Qoshe L, Haffreingue A, Marsac L, Frérot A, Peycelon M, Biran V, Bonnard A. Early laparoscopic-assisted surgery is associated with decreased post-operative inflammation and intestinal strictures in infants with necrotizing enterocolitis. J Pediatr Surg 2023; 58:708-714. [PMID: 36585304 DOI: 10.1016/j.jpedsurg.2022.11.007] [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: 07/23/2022] [Revised: 10/12/2022] [Accepted: 11/13/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION In 2015, a protocol including early laparoscopy-assisted surgery in the treatment of necrotizing enterocolitis (NEC) was implemented at our institution. Carbon dioxide insufflation during laparoscopy may have an anti-inflammatory effect. We aimed to compare post-operative outcome after early laparoscopy-assisted surgery and classical laparotomy for NEC. MATERIAL AND METHODS Charts of premature infants undergoing surgery for NEC (2012-2021) were reviewed. Cases operated by early laparoscopy-assisted surgery (2015-2021) were compared to infants operated for NEC between 2012 and 2015 (laparotomy-NEC). Outcomes were post-operative CRP, need for reintervention, mortality, and the occurrence of post-NEC intestinal strictures. CRP was measured on the day of surgery (POD-0), 2 days (POD-2), and 7 days after surgery (POD-7). Data were compared using contingency tables for categorical variables and Student t-test or Mann-Whitney test for continuous variables. RESULTS Infants with NEC operated by early laparoscopy (n = 48) and laparotomy (n = 29) were similar in terms of perforation (60% vs 58%, p = 0.99) and POD-0 CRP (139 vs 124 mg/L, p = 0.94). Delay between first signs of NEC and surgery was shorter in the laparoscopy group (3 vs 6 days, p = 0.004). Early laparoscopy was associated with a lower CRP on POD-2 (108 vs 170, p = 0.005) and POD-7 (37 vs 68, p = 0.002), as well as a lower rate of post-operative intestinal stricture (34% vs 61%, p = 0.04). CONCLUSIONS In addition to being safe and feasible in premature infants, early laparoscopic-assisted surgery was associated with decreased NEC-related post-operative inflammation and strictures. A prospective, randomized study is needed in order to evaluate short and long-term effects of laparoscopy in infants with NEC. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Louise Montalva
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France.
| | - Filippo Incerti
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France
| | - Livia Qoshe
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; Princeton Internships in Civic Service, Princeton University, Princeton, NJ, USA
| | - Aurore Haffreingue
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Lucile Marsac
- Department of Pediatric Anesthesia, Intensive Care and Pain Management, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alice Frérot
- Neonatal Intensive Care Unit, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Matthieu Peycelon
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France
| | - Valérie Biran
- Neonatal Intensive Care Unit, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Arnaud Bonnard
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France
| |
Collapse
|
2
|
Abstract
Neonatal appendicitis is a rare disease with a high mortality rate. Appendicitis is difficult to diagnose in neonatal and infant populations because it mimics other more common conditions in these age groups. Furthermore, signs and symptoms of appendicitis are often nonspecific in nonverbal patients and a high index of suspicion is necessary to initiate the appropriate diagnostic work-up. The keys to successful management of appendicitis in infants include keeping the diagnosis on the differential in the setting of unexplained intra-abdominal sepsis, following a diagnostic algorithm in the work-up of infant abdominal pathology, and performing appendectomy once the diagnosis is confirmed.
Collapse
Affiliation(s)
- Christina M Bence
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, 999 North 92nd Street, Suite CCC320, Milwaukee, WI 53226, USA.
| | - John C Densmore
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, 999 North 92nd Street, Suite CCC320, Milwaukee, WI 53226, USA
| |
Collapse
|
3
|
Knudsen KBK, Thorup J, Thymann T, Strandby R, Nerup N, Achiam MP, Lauritsen T, Svendsen LB, Buelund L, Sangild PT, Ifaoui IBR. Laparoscopy to Assist Surgical Decisions Related to Necrotizing Enterocolitis in Preterm Neonates. J Laparoendosc Adv Surg Tech A 2019; 30:64-69. [PMID: 31874058 DOI: 10.1089/lap.2018.0180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Aim of the Study: Necrotizing enterocolitis (NEC) is a devastating intestinal disease that mainly affects preterm infants. Despite advancements in neonatal care, mortality of NEC remains high and controversies exist regarding the most appropriate time for surgical intervention and challenging of diagnosing NEC. Using a pig model of NEC, we aimed to examine if laparoscopy is feasible for diagnosis of NEC. Methods: Preterm caesarean-delivered piglets (n = 42) were fed with increasing amounts of infant formula up to 5 days to induce NEC. On days 3-5, we examined the intestine by laparoscopy under general anesthesia. The bowel was examined by tilting the pigs from supine position to the left and right side. Macroscopic NEC lesions were identified and graded according to a macroscopic scoring system, then a laparotomy was performed to rule out any organ injury and missed NEC lesions. Results: Visible NEC lesions (scores 4-6) were found in 26% (11/42) of the piglets. A positive predictive value of 100% was found for laparoscopy as a diagnostic marker of NEC in both colon and the small intestine. One piglet had a higher NEC score in the small intestine found at laparotomy, than at laparoscopy, resulting in a sensitivity of 67%, and a specificity of 100% for the small intestine. Conversely, both the sensitivity and specificity for colon was 100%. Acceptable levels of agreement was found, with minimal proportional bias in both colon and the small intestine for laparoscopy and laparotomy. Ultrasound examination had a lower sensitivity of 67% and specificity of 63%. All piglets were respiratory and circulatory stable during the procedure. Conclusions: In preterm piglets, laparoscopy is a feasible tool to diagnose NEC with a high positive predictive value and a high specificity.
Collapse
Affiliation(s)
- Kristine Bach Korsholm Knudsen
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Pediatric Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Section for Comparative Pediatrics and Nutrition, IVH, University of Copenhagen, Copenhagen, Denmark
| | - Jorgen Thorup
- Department of Pediatric Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Thymann
- Section for Comparative Pediatrics and Nutrition, IVH, University of Copenhagen, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rune Strandby
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nikolaj Nerup
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Michael Patrick Achiam
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Torsten Lauritsen
- Department of Anesthesiology, The Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lars Bo Svendsen
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lene Buelund
- Section of Diagnostic Imaging, Department of Veterinary Clinical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Per Torp Sangild
- Section for Comparative Pediatrics and Nutrition, IVH, University of Copenhagen, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Inge Botker Rasmussen Ifaoui
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Pediatric Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
4
|
Chia-Yu Chang P, Fu YW, Hsu YJ, Huang H, Wei CH. Transumbilical minilaparotomy in low-birthweight newborns for complicated conditions. Pediatr Neonatol 2019; 60:318-323. [PMID: 30145106 DOI: 10.1016/j.pedneo.2018.07.014] [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: 02/07/2018] [Accepted: 07/27/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND The purpose of this study is to examine the outcome of transumbilical minilaparotomy for infants and compare the results between normal birthweight (NBW) and low birthweight (LBW). METHODS Between July 2010 and March 2017, infants who underwent abdominal surgery through transumbilical minilaparotomy were enrolled. Medical records were retrospectively reviewed. Patients were divided into two groups, NBW and LBW. Complexity was defined as complicated conditions other than intestinal atresia and malrotation. RESULTS Totally, 16 patients were included. The diagnosis included intestinal atresia (n = 3), meconium peritonitis (n = 4), bowel infarction/necrosis (n = 4), spontaneous intestinal perforation (n = 2), segmental volvulus and necrosis (n = 1), necrotizing enterocolitis (n = 1), and malrotation (n = 1). The median gestational age and body weight were 32 (24-40) weeks and 1731 (560-4200) grams respectively. The median age at operation was 3 (1-41) days. The surgical procedure included primary repair of the intestine (n = 14), ileostomy (n = 1) and Ladd's procedure (n = 1). Postoperative complications included anastomotic leakage (n = 2), adhesion ileus (n = 1), and missed rectal atresia (n = 1). There was one mortality due to extremely low birthweight and poor lung maturation. Re-operation was required in 3 patients for anastomotic leakage (n = 2) and missed rectal atresia (n = 1). Mean birthweight was 2932 ± 97 and 1263 ± 667 g in NBW (n = 5) and LBW (n = 11), respectively (p < 0.01). Complexity rate was 40% and 90.9%, respectively (p = 0.034). The mean operation time was 139.4 ± 65.8 and 124.3 ± 46.1 min, respectively (p = 0.60). The complicated rate and reoperation rate were similar. CONCLUSIONS Transumbilical minilaparotomy is technically feasible and an alternative option of minimally invasive surgery for LBW infants and complex conditions.
Collapse
Affiliation(s)
- Paul Chia-Yu Chang
- Division of Pediatric Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan; School of Medicine, Mackay Medical College, New Taipei City, Taiwan
| | - Yu-Wei Fu
- Department of Pediatric Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Yao-Jen Hsu
- Department of Pediatric Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Hsuan Huang
- Division of Pediatric Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chin-Hung Wei
- Division of Pediatric Surgery, Department of Surgery, Shuang Ho Hospital, New Taipei City, Taiwan; School of Medicine, Taipei Medical University, Taipei, Taiwan.
| |
Collapse
|
5
|
Alemayehu H, Sola R, Le NH, Juang D, Aguayo P, Fraser JD, St. Peter SD. Abdominal Exploration in Neonates Using Transumbilical Exposure Compared with Transverse Laparotomies. J Laparoendosc Adv Surg Tech A 2018; 28:751-754. [DOI: 10.1089/lap.2017.0301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Hanna Alemayehu
- Department of Surgery, The Children's Mercy Hospital, Kansas City, Missouri
| | - Richard Sola
- Department of Surgery, The Children's Mercy Hospital, Kansas City, Missouri
| | - Nhatrang H. Le
- Department of Surgery, The Children's Mercy Hospital, Kansas City, Missouri
| | - David Juang
- Department of Surgery, The Children's Mercy Hospital, Kansas City, Missouri
| | - Pablo Aguayo
- Department of Surgery, The Children's Mercy Hospital, Kansas City, Missouri
| | - Jason D. Fraser
- Department of Surgery, The Children's Mercy Hospital, Kansas City, Missouri
| | - Shawn D. St. Peter
- Department of Surgery, The Children's Mercy Hospital, Kansas City, Missouri
| |
Collapse
|