Intestinal atresia: an end-to-end linear anastomotic technique

The role of preserved bowel and mesentery fixation in apple-peel intestinal atresia

Objective

This study explored the feasibility of mesoplasty with end-to-side anastomosis in the treatment of different apple-peel mesenteric defects with high jejunal atresia.

Methods

A retrospective analysis was performed on 42 premature infants admitted to the hospital between 2014 and 2021. Prenatal ultrasound scans revealed bowel dilatation. The patients experienced vomiting after birth and produced white or no meconium. Plain radiography showed double or triple bubble signs and the patients underwent emergency laparotomy. High jejunal atresia with different apple-peel atresia appearance was discovered intraoperatively, involving mobilization of the ileocecal region. Patients received end-to-side anastomosis between the enlarged blind pouch and atretic bowel, as well as mesoplasty. A jejunal feeding tube was placed trans-nasally. Patients were discharged after achieving full enteral feeding. We also reviewed the literature on the subject.

Results

Three patients died and 39 survived. The discharged patients were followed up for 12 months, and none showed post-operative complications such as intestinal obstruction, malnutrition, or chronic diarrhea. All surviving patients reached the expected height and weight for children of the same age.

Conclusion

For cases of high jejunal atresia with apple-peel intestinal atresia, mesoplasty may be a good option to avoid postoperative volvulus.

T-tube enterostomy in the management of apple-peel atresia: A case series from a single center

BACKGROUND AND OBJECTIVE

Although complex atresias, such as apple-peel and multiple atresias, comprise a smaller percentage, they are usually associated with a higher incidence of postoperative complications and mortality rate. Contrary to simple atresias where the surgical technique of choice usually entails bowel resection and anastomosis with or without enteroplasty, managing apple-peel atresia remains more sophisticated. Decompressive and functionalizing stomas are sometimes mandatory to overcome problems such as increased wall thickness and the wide disparity among the anastomotic ends. Few reports discussed using tube enterostomy in the management of apple-peel atresia; nonetheless, no previous prospective studies were conducted to discuss its efficacy on a larger population. In this study, we are describing our experience using this technique on 12 patients suffering from apple-peel atresia in our center.

METHODS

A prospective study was conducted from June 2015 to May 2020, where all children who were found to have apple-peel atresia were included in the study. T-tube was placed through an enterotomy through the dilated proximal bowel, around 10 cm before the anastomotic line, and was kept in place using a double suture (Stamm technique) before closing the anterior face of the anastomosis. The short distal limb of the T-tube was oriented toward the anastomotic line, while the long proximal limb was directed proximally. After finishing the anastomosis, the T-tube was delivered outside the abdominal wall, anchoring the enterostomy along with the proximal dilated jejunum against the anterior abdominal wall.

RESULTS

A total of 12 cases were encountered throughout the period of study. The mean age at operation was 4 days and the mean birth weight was 2700 g. The mean time for starting oral feeding postoperatively and T-tube removal was 8 and 10.5 days, respectively. Cases were discharged after a mean of 22 days. As regards morbidity and mortality, a single case developed skin excoriations at the site of tube insertion and was managed conservatively using topical ointments and another case died from overwhelming sepsis 3 days after the operation.

CONCLUSION

T-tube enteroplasty is a safe and feasible option in the surgical management of apple-peel atresia. The main strength of our study is its prospective nature and that it includes apple-peel atresia cases only. However, the main limitation is that a larger sample is needed.

Long-term surgical outcomes of apple-peel atresia

PURPOSE

The purpose of this study was to investigate (i) postoperative course of apple-peel atresia (APA), (ii) long-term follow-up of APA children, and (iii) risk factors for poor prognosis.

METHODS

We conducted a retrospective review of 39 APA neonates treated at our institution between 2008 and 2017. Patient characteristics, operative details, postoperative course, long-term outcomes, and prognostic factors were analyzed.

RESULTS

Of the 39 APA neonates, 30 (76.9%) were born preterm, and 20 (51.3%) were diagnosed prenatally. All patients underwent primary anastomosis within the first week after birth: 10 laparoscopic-assisted (25.6%) and 29 open (74.4%). Postoperative complications occurred in 28 patients (71.8%), of which 20 (71.4%) developed cholestasis. Survival at hospital discharge was 94.9%. Median parenteral nutrition period was 59 days. Reoperation was required in 7 children (17.9%) owing to anastomotic obstruction (n = 3) and adhesive intestinal obstruction (n = 4). 32 children (82.1%) were followed up for an average of 5.7 years, of which 23 children (71.9%) showed normal growth and development. APA patients with low birth weight and associated anomalies had significantly worse outcomes.

CONCLUSION

Most of the patients with apple-peel atresia have excellent long-term outcomes, though initial postoperative complications are common. Low birth weight and the presence of associated anomalies are independent prognostic factors in APA.

TYPE OF STUDY

Prognosis study (case series).

LEVEL OF EVIDENCE

Level IV.

Intestinal flow after anastomotic operations in neonates

Stagnation of contents at the anastomotic site for intestinal flows after anastomotic operation is a critical issue in neonates. Although various anastomosis methods have been developed, in the clinical field, poor passage at the anastomotic site in cases of jejunal atresia is still observed. A CFD study was carried out to clarify the reasons for the stagnation and to find favorable anastomosis methods from a fluid dynamical point of view. Direct numerical simulations were performed using OpenFOAM. The boundaries of the computational domain were peristaltically moved to reproduce flow. The results reveal that the peristaltic motion on the distal side dominates the flow and that on the proximal side has a negligible influence. In particular, the contents do not pass the anastomotic site when the peristaltic motion on the distal side is not active. The flow rate as a measure of the driving force of the flow on the proximal side is large when the amplitude of the peristaltic motion is large and the diameter is small. It was also found that anastomosis methods do not affect flow resistance.

The impact of body weight on stapled anastomosis in pediatric patients

PURPOSE

The purpose of this study is to clarify the impact of body weight on outcomes of stapled anastomosis in pediatric patients.

METHODS

A total of 253 pediatric patients who underwent intestinal anastomosis were classified according to body weight (<3.5 kg: light group, ≥3.5 kg: heavy group), and clinical outcomes of stapled and hand-sewn anastomoses were compared.

RESULTS

The light and heavy groups included 77 (stapled: n = 13, hand-sewn: n = 64) and 176 (stapled: n = 58, hand-sewn: n = 118) patients, respectively. In both groups, stapled anastomosis was associated with reduced time to initial oral feeding (light group: 4 vs. 7 days, p = 0.006; heavy group: 3 vs. 5 days, p < 0.001) and full feeding (light group: 12 vs. 16 days, p = 0.026; heavy group: 7 vs. 9 days, p = 0.001), whereas its complication rate was not significantly different from that of hand-sewn anastomosis (light group: 30.8 vs. 12.5%, p = 0.112; heavy group: 3.4 vs. 2.5%, p = 0.665). In patients who underwent stapled anastomosis, the complication rate was significantly higher in the light group (30.8 vs. 3.4%, p = 0.009), with two cases of volvulus related to anastomotic dilatation.

CONCLUSIONS

Stapled anastomosis is an effective procedure facilitating prompt oral feeding. However, the risk of complications, including volvulus related to anastomotic dilatation, should be considered among patients weighing <3.5 kg.

LEVEL OF EVIDENCE

III.

Modified Gut Anastomotic Technique in Type III and Type IV Jejunoileal Atresias

BACKGROUND

Type III and IV jejunoileal atresias are associated with loss of significant length of the gut and can lead to short gut syndrome if further resection of proximal dilated gut is done. We modified the anastomotic technique so that proximal dilated segment of the gut is not resected as to prevent short gut syndrome.

MATERIAL AND METHODS

Medical Record of patients of Type III and IV jejuno-ileal atresias managed with modified anastomotic technique in our center during 5-years was reviewed.

RESULTS

Fifteen patients were managed with our modified technique. There were no anastomotic leak observed and there was 6% mortality seen in our modified technique.

CONCLUSION

We found less mortality and morbidity in our technique compared to recommended techniques described in literature.

Stapled intestinal anastomosis is a simple and reliable method for management of intestinal caliber discrepancy in children

PURPOSE

Popularity of minimally invasive surgeries has led to the development of stapled intestinal anastomosis for adults. The advanced instruments used in this technique are getting suitable with the small intestinal lumens of neonates and infants. We reviewed and compared the intraoperative and postoperative results of stapled and hand-sewn anastomoses in children.

METHODS

The operative data of children who underwent stapled and hand-sewn anastomoses between March 2005 and December 2011 were collected and analyzed retrospectively. Furthermore, we compared patients who underwent anastomoses for colostomy closure of anorectal malformation (4 stapled, 9 hand-sewn) and those who underwent anastomoses for treatment of ileal atresia (3 stapled, 11 hand-sewn).

RESULTS

In the 47 patients who underwent stapled anastomosis, no intraoperative complications were observed and postoperative complications included wound infection (n = 3), delayed gastric emptying (n = 1), and ileus (n = 1). No complications suggesting anastomotic dilatation were identified. It was observed that patients who underwent stapled anastomosis for colostomy takedown with caliber discrepancy had significantly shorter surgery time than those who underwent hand-sewn anastomosis.

CONCLUSION

Our results suggest that stapled anastomosis is safe and effective for various surgical diseases in neonates, infants, and children.

Management of jejunoileal atresias: an experience at eastern Nepal

BACKGROUND

Intestinal atresia is a common cause of neonatal intestinal obstruction, and management of this disease in limited setup of a developing country is very difficult.

METHODS

This study is a retrospective study of patients with jejunoileal atresias and their postoperative outcome in a teaching hospital in eastern Nepal over a 5-year period.

RESULTS

There were 28 children (19 boys and 9 girls). 11 children (39.28%) had jejunal atresia and 17 (60.71%) had ileal atresia. Eight (28.5%) patients died, 6 were jejunal atresia (54.5%) and 2 were ileal atresia (11.7%). The most common cause of death was sepsis which occurred in 7 out of 8 cases (87.5%). The risk factors for mortality identified were leucopenia, neutropenia, delay in surgery, location of atresia and type of atresia. Jejunal atresia tended to have a higher mortality than ileal atresia, and severe types of atresia (type IIIb and IV) were more often associated with mortality than other types of atresia. The significant differences between jejunal and ileal atresia were the increased duration between presentation and surgery, longer postoperative and total hospital stay, presence of more severe atresias and an increased risk of mortality in case of jejunal atresias.

CONCLUSION

The prognosis for this disease have definitely changed in the last few decades in developed countries but in our environment, problems like late presentation and diagnosis, lack of availability of good neonatal intensive care units and parenteral nutritional support still prevail.

Concavo-convex oblique anastomosis technique for jejuno ileal atresia

Aim:

To evaluate the role of end-to-end oblique bowel anastomosis in bowel atresia.

Methods:

End-to-end oblique anastomosis was done in 25 neonates of bowel atresia and the results were compared with traditional method of end to back anastomosis in 25 cases.

Results:

We found less mortality and morbidity (5%) in our technique as compared to end to back technique (20%).

Conclusions:

We recommend this technique, as anastomosis is wide with less angulations, flow of effluent is linear, and there is less force exerted over post-anastomotic side wall.

Novel procedures for enhancing high jejunal atresia repair: bilateral side-plication and plication before anastomosis

In high jejunal atresia (HJA), discrepancy between the diameters of the proximal and distal jejunum can often be significant and cause major anastomotic complications. We developed 2 novel procedures to enhance conventional jejuno-jejunostomy (JJ): bilateral side-plication during JJ (BSP): plication of both lateral aspects of the dilated proximal jejunum, and jejunal plication before JJ (pre-P): plication of the jejunum proximal to the planned JJ site along the anti-mesenteric line. We used BSP in a neonate with a membranous stenosis 5 cm distal to the duodeno-jejunal flexure, and pre-P in 2 neonates, both with HJA and hugely dilated proximal jejunum. By using BSP, the jejunum could be plicated symmetrically near the closed jejunotomy, allowing the caliber change at the closed jejunotomy to be smooth without any kinking. If simple anti-mesenteric plication had been performed instead, proximal-to-distal kinking caused by closing the jejunotomy site transversely after the membrane was excised could have worsened. By using pre-P, the caliber change across the JJ could be made smooth and symmetric. If plication had been performed along the anti-mesenteric line after completing the JJ, the proximal jejunum near the JJ would have become asymmetrical causing the JJ to become kinked. Postoperatively, there were no JJ-related complications, and all subjects are well after a mean follow-up period of 3.0 years. Our novel procedures are simple and appear to enhance JJ by controlling kinking at the JJ site.