Meconium peritonitis in Nigerian Children

Value of prenatal diagnosis of meconium peritonitis: Comparison of outcomes of prenatal and postnatal diagnosis

Advancements in diagnostic modalities have improved the diagnosis of meconium peritonitis (MP) both in utero and ex utero. This study aimed to determine the efficacy of prompt prenatal and postnatal diagnoses of MP on the postnatal outcomes of these patients.We conducted a retrospective chart review of neonates with MP admitted to the Mackay Memorial Hospital Systems from 2005 to 2016. The prenatal diagnoses, postnatal presentations, surgical indications, operative methods, types of MP, operative findings, associated anomalies, morbidities, patient outcomes, and survival rates were analyzed. Morbidities included postoperative adhesion ileus, bacteremia, and short bowel syndrome. We also performed subgroup analyses of the morbidity and survival rates of prenatally versus postnatally diagnosed patients, as well as inborn versus outborn neonates.Thirty-seven neonates with MP were enrolled. Of this number, 24 (64.9%) were diagnosed prenatally. Twenty-two (59.5%) were born preterm. The most common prenatal sonographic findings included fetal ascites followed by dilated bowel loops. Abdominal distention was the most frequent postnatal symptom. Thirty-four (91.9%) neonates underwent surgery, whereas 3 were managed conservatively. Volvulus of the gastrointestinal tract was the most frequent anatomic anomaly. The total morbidity and survival rates were 37.8% and 91.9%, respectively. The morbidity and survival rates did not differ significantly between prenatally and postnatally diagnosed patients (37.5% vs 33.3%, P = 1.00; 91.7% vs 92.3%, P = 1.00, respectively). Inborn and outborn patients did not differ in terms of morbidity and survival rates (27.3% vs 53.3%, P = .17; 100% vs 80.0%, P = .06, respectively).Although not statistically significant, inborn MP neonates had higher survival rates when compared with outborn MP neonates. Prompt postnatal management at tertiary centers seemed crucial.

Scrotal abscess: Varied etiology, associations, and management

Aim:

To report a series of scrotal abscess, a rare problem, their etiology, and management.

Materials and Methods:

A retrospective study of children who presented with scrotal abscess between January 2010 and March 2015, analyzed with respect to clinical features, pathophysiology of spread and management.

Results:

Eight infants and a 3-year-old phenotypically male child presented with scrotal abscess as a result of abdominal pathologies which included mixed gonadal dysgenesis (MGD) [1]; three anorectal malformations with ectopic ureter [1], urethral stricture [1], and neurogenic bladder [1]; meconium peritonitis with meconium periorchitis [2], ileal atresia [1], and intra-abdominal abscess [1]; posturethroplasty for Y urethral duplication with metal stenosis [1] and idiopathic pyocele [1]. Transmission of the organism had varied routes include fallopian tube [1], urethra ejaculatory reflux [4], hematogenous [2], and the patent process of vaginalis [2]. Two of the nine required extensive evaluation for further management. Treating the predisposing pathology resolved scrotal abscesses in eight of nine patients, one of whom, required vasectomy additionally. Idiopathic pyocele responded to needle aspiration and antibiotics.

Conclusion:

Scrotal abscess needs a high index of suspicion for predisposing pathology, especially in infants. Laparoscopy is safe and effective in the management of the MGD and ectopic ureter.

Challenges of management and outcome of neonatal surgery in Africa: a systematic review

BACKGROUND

Disparity still exists in the outcome of neonatal surgery between high-income countries and low-income and middle-income countries. This study reviews publications on neonatal surgery in Africa over 20 years with a focus on challenges of management, trends in outcome, and potential interventions to improve outcome.

METHODS

We did a literature review by searching PubMed and African Index Medicus for original articles published in any language between January 1995 and September 2014. A data extraction sheet was used to collect information, including type of study, demographics, number of cases, outcome, challenges, and suggestions to improve outcome.

RESULTS

A total of 51 studies from 11 countries met the inclusion criteria. The 16 studies in the first 10 years (1995-2004; group A) were compared with the 35 in the last 10 years (2005-2014; group B). Nigeria (n = 32; 62.7 %), South Africa (n = 7; 13.7 %), Tanzania (n = 2; 3.9 %), and Tunisia (n = 2; 3.9 %) were the predominant sources of the publications, which were retrospective in 38 (74.5 %) studies and prospective in 13 (25.5 %) studies. The mean sample size of the studies was 95.1 (range 5-640). Overall, 4849 neonates were studied, with median age of 6 days (range 1-30 days). Common neonatal conditions reported were intestinal atresia in 28 (54.9 %) studies, abdominal wall defects in 27 (52.9 %), anorectal malformations 25 in (49.0 %), and Hirschsprung's disease, necrotising enterocolitis, and volvulus neonatorum in 23 (45.1 %) each. Mortality was lowest (<3 %) in spina bifida and facial cleft procedures, and highest (>50 %) in emergency neonatal surgeries involving bowel perforation, bowel resection, congenital diaphragmatic hernia, oesophageal atresia, and ruptured omphalocele or gastroschisis. Overall average mortality rate was higher in group A than group B (36.9 vs 29.1 %; p < 0.001), and varied between the groups for some conditions. The major documented challenges were delayed presentation and inadequate facilities in 39 (76.5 %) studies, dearth of trained support personnel in 32 (62.7 %), and absence of neonatal intensive care in 29 (56.9 %). The challenges varied from country to country but did not differ in the two groups.

CONCLUSION

Improvement has been achieved in outcomes of neonatal surgery in Africa in the past two decades, although several of the studies reviewed are retrospective and poorly designed. Cost effective adaptations for neonatal intensive care, improved health-care funding, coordinated neonatal surgical care via regional centres, and collaboration with international partners are potential interventions that could help to address the challenges and further improve outcome.

Radiographic signs of gastrointestinal perforation in children: A pictorial review

Plain abdominal radiographs remain an important aid for clinicians in the diagnosis of gastrointestinal perforation, especially in neonates and very sick children where clinical features of peritonitis may not be as prominent. Suggestive radiographic features are not always very obvious, especially when taken in the supine position and may lead to delayed or missed diagnosis. Through a pictorial review of plain radiographs, this article highlights a number of documented features of gastrointestinal perforation on X-ray in the paediatric setting, which increases the accuracy of diagnosis.

Does meconium peritonitis pseudo-cyst obstruct labour?

Meconium peritonitis pseudo-cyst is very rare. Its perinatal management is controversial and can be associated with increased fetomaternal morbidity and mortality. A 34-week gestation infant with large meconium peritonitis pseudo-cyst, detected by intrapartum fetal ultrasound study, had abnormally increased ratio of fetal abdominal circumference to head circumference. Intrapartum aspiration of the pseudo-cyst was performed and was followed by a smooth vaginal delivery. The postnatal course of the baby showed that early laparotomy was essential for stabilisation of the infant's general condition.

Peritonitis in children: our experience in Benin City, Nigeria

BACKGROUND

Peritonitis is a surgical emergency of variable etiology with a high mortality rate, particularly in children. This paper reports our experience with the epidemiology and outcome of management of childhood peritonitis in an African setting.

PATIENTS AND METHODS

Consecutive children with peritonitis managed over six years (2004-2009) at the University of Benin Teaching Hospital, Nigeria, were included in this prospective experience after approval by the local Ethics Committee.

RESULTS

Of the 721 children aged between one day and 18 years (mean 5 ± 4.2 years), comprising 415 males and 306 females (male/female ratio 1.4:1) who were managed for gastrointestinal disease, 182 (25.2%) developed peritonitis, 179 (98.4%) preoperatively and three (1.6%) postoperatively. Secondary bacterial peritonitis most often followed complicated appendicitis (120; 65.9%), intussusception (13; 7.1%), volvulus (5; 2.7%), and intestinal atresia (4; 2.2%). Peritonitis was generalized in all children younger than 11 years but less so after that age, and the outcome was poorest in neonatal infants, who accounted for 14 (63.6%) of the 18 peritonitis-related deaths (p < 0.0001). All the children had thorough peritoneal irrigation and lavage that included the insertion of drains in cases of localized peritonitis. The choice of antibiotics and additional surgical options that included bowel resection and anastomosis, stoma creation, and closure of perforation depended on the primary pathology and bacteriology findings. The duration of hospitalization was increased to between seven days in older children with localized peritonitis and 25 days in neonatal infants with generalized peritonitis compared with 3-5 days in children with similar pathology who did not have peritonitis (p < 0.0001).

CONCLUSION

Peritonitis was severe and generalized in younger children, especially neonatal infants, who accounted for the majority of the deaths recorded. Early referral of children, particularly neonatal infants, having gastrointestinal complaints for surgical consultation and prompt surgical management is recommended to prevent peritonitis and to improve the outcome of children with the disease.