T-tube ileostomy for meconium ileus: four decades of experience

A COMPARATIVE STUDY BETWEEN SANTULLI ILEOSTOMY AND LOOP ILEOSTOMY IN NEONATES WITH MECONIUM ILEUS

Background:

Meconium ileus is a common cause of intestinal obstruction in neonates that different surgical methods have been described for its management such as Santulli and loop ileostomy.

Aim:

To evaluate and compare clinical efficacy of Santulli and loop ileostomy in neonates with meconium ileus.

Methods:

In this retrospective study, 58 patients with meconium ileus were evaluated. After analyses of hospital records, 53 patients with completed hospital records were included. Demographic information, surgery parameters and postoperative complications were extracted from the hospital records or calling parents.

Results:

Skin excoriation (21.4% vs. 84%, p<0.001), ostomy prolapsed (0 vs. 28%, p=0.003), and surgical site infection (7.1% vs. 28%, p=0.044) was significantly lower in Santulli ileostomy group. Furthermore, ileostomy output in first week (70.53±15.11 ml vs. 144.6±19.99 ml, p<0.001) and in 4^th week (2.14±4.98 ml vs. 18.4±17.95 ml, p<0.001) was significantly lower in Santulli ileostomy group as compared to loop ileostomy group. Finally, hospital stay in Santulli ileostomy group was 12±2.34 and in loop ileostomy 14.24±1.47 days (p<0.001).

Conclusion:

Santulli ileostomy is better than loop ileostomy due to significant less frequency of surgical site infection, skin excoriation, prolapse of ostomy, ileostomy volume output and hospitalization time.

A comparative study between Santulli ileostomy and loop ileostomy in neonates with meconium ileus

Background:

Meconium ileus is a common cause of intestinal obstruction in neonates that different surgical methods have been described for its management such as Santulli and loop ileostomy.

Aim:

To evaluate and compare clinical efficacy of Santulli and loop ileostomy in neonates with meconium ileus.

Methods:

In this retrospective study, 58 patients with meconium ileus were evaluated. After analyses of hospital records, 53 patients with completed hospital records were included. Demographic information, surgery parameters and postoperative complications were extracted from the hospital records or calling parents.

Results:

Skin excoriation (21.4% vs. 84%, p<0.001), ostomy prolapsed (0 vs. 28%, p=0.003), and surgical site infection (7.1% vs. 28%, p=0.044) was significantly lower in Santulli ileostomy group. Furthermore, ileostomy output in first week (70.53±15.11 ml vs. 144.6±19.99 ml, p<0.001) and in 4^th week (2.14±4.98 ml vs. 18.4±17.95 ml, p<0.001) was significantly lower in Santulli ileostomy group as compared to loop ileostomy group. Finally, hospital stay in Santulli ileostomy group was 12±2.34 and in loop ileostomy 14.24±1.47 days (p<0.001).

Conclusion:

Santulli ileostomy is better than loop ileostomy due to significant less frequency of surgical site infection, skin excoriation, prolapse of ostomy, ileostomy volume output and hospitalization time.

Risk factors for adverse outcome in infancy in meconium ileus cystic fibrosis infants: A multicentre Italian study

BACKGROUND

Meconium ileus (MI) is a risk factor for poor outcomes in cystic fibrosis (CF) patients. The aim of this study was to identify the risk factors for poor 12-month clinical outcomes in MI-CF newborns.

METHODS

This retrospective, multicentre, observational study of MI-CF infants born 2009-2015 recorded their pre- and neonatal histories, intestinal occlusion treatments, post-surgical history, nutrition, CF diagnosis, and compared the patients with 12-month faltering growth or chronic Pseudomonas aeruginosa respiratory infection (cases) with the others (controls).

RESULTS

About 25% of the 85 patients enrolled by 13 Italian CF centres (24% premature, 18% of low birth weight) had prenatally diagnosed bowel obstruction, and 39% had complex MI. Seventy-one required surgery (the 33 with complex MI and 38 with simple MI), of whom 58 (82%) required post-surgical intensive care, including 25 (35%) needing ventilatory support. Forty-six (54%) were breastfed; exclusively parenteral nutrition was started in 52 (61%). Cholestasis was diagnosed in 21%. Thirty-one (37%) experienced negative outcomes: the only risk factors were prenatally diagnosed intestinal obstruction and a need for intensive care and oxygen therapy. The cases had significantly higher first blood immunoreactive trypsinogen (b-IRT) levels (P = .008). Logistic regression showed that the probability of having negative outcome is decreased in the absence of cholestasis (Odds Ratio = 0.125) and a need for intensive therapy (OR = 0.141), and increased by not having been breastfed (OR = 2.921).

CONCLUSIONS

High b-IRT levels, prenatally diagnosed intestinal obstruction, a severe post-surgical clinical picture and early liver disease are risk factors for negative outcomes. Breastfeeding may be protective.

Management Strategy of Meconium Ileus-Outcome Analysis

Background:

Meconium ileus (MI) is defined as an intestinal obstruction caused by the impaction of inspissated meconium in the terminal ileum. In this study, we have evaluated the nonoperative management of patients of simple MI without fluoroscopic support –an important requisite of the Noblett's criteria. Besides this, surgical management in cases of failed conservative management and complicated MI was also assessed.

Materials and Methods:

This was a retrospective observational study. Various clinical and radiological parameters were evaluated. Conservative management included the use of water-soluble contrast diatrizoate meglumine and diatrizoate sodium. In case of nonpassage of meconium in 24 h from first intervention, exploratory laparotomy with ileostomy was performed. All complicated MI underwent exploratory laparotomy with creation of stoma as and when needed.

Results:

The duration of this study was 6½ years. Twenty-five neonates of MI were admitted. Of these, 22 had simple MI and remaining three had complicated MI. Eighteen neonates responded to the conservative management. In four neonates, who did not respond, exploratory laparotomy was performed. All three neonates having complicated MI underwent exploratory laparotomy. One patient expired in follow-up.

Conclusion:

MI is an important neonatal emergency, which needed immediate attention of a pediatric surgeon. Proper evaluation of the patient, careful application of principals of conservative management, and timely surgical intervention may fetch satisfactory results.

Meconium Ileus

Cystic fibrosis is one of the most common inheritable traits in Caucasians. Meconium ileus and its potential complications are the most likely reasons that these patients will need surgical care. Surgical intervention is usually needed in the neonatal period but may also be required later in life. This article discusses the various ways cystic fibrosis can affect the gastrointestinal tract. Both the operative and nonoperative management of complicated and uncomplicated meconium ileus are discussed in the neonatal period as well as long-term issues, such as distal intestinal obstructive syndrome, fibrosing colonopathy, and rectal prolapse, all of which may be seen in older children and adults.

Comparison of T Tube Ileostomy and Bishop Koop Ileostomy for the Management of Uncomplicated Meconium Ileus

BACKGROUND

Meconium ileus is a common cause of neonatal intestinal obstruction. Various surgical procedures are in practice for uncomplicated meconium ileus. Bishop Koop ileostomy allows distal passage of gut content and uses the distal absorptive area. T tube ileostomy avoids the need for gut resection and formal closure of stoma. The aim of this prospective interventional study was to compare the outcome of T-tube ileostomy and Bishop Koop ileostomy for the treatment of uncomplicated meconium ileus.

MATERIALS AND METHODS

It was a prospective interventional study from January 2015 to December 2016. Patients were randomly assigned to the T-tube ileostomy group (group A) and Bishop Koop ileostomy group (group B). The patients were followed up for 6 weeks post-operatively. Surgical outcomes between the two groups were compared.

RESULTS

The age range of the patients was 1 to 7 days; majority of the patients were males. Mean operation time of group A (60.76±5.81 minutes) and group B (87.05±6.49 minutes) showed significant difference (p =0.0001). After operation, mean time to start bowel movements in group A (4.90±1.41days) and group B (6.53±2.58 days) showed significant difference (p= 0.020). Times to establish oral feeding, irrigation tube removal and postoperative complications showed no significant difference. All patients that survived in the group B required formal stoma closure, while in the group A stomas closed spontaneously. One patient in the group A had intraperitoneal leakage leading to mortality after second operation. Four patients had leakage in the group B; 2 of them died.

CONCLUSIONS

T-tube ileostomy was found as an effective and safe procedure for the management of uncomplicated meconium ileus.

Protection of low rectal anastomosis with a new tube ileostomy using a biofragmentable anastomosis ring: A retrospective study

A temporarily defunctioning stoma, while effective at reducing symptomatic anastomotic leakage after low anterior resection (LAR) of rectal cancer, and its subsequent closure, is associated with significant morbidity. Here, we devised a new tube ileostomy using a biofragmentable anastomosis ring (TIB) with no need for reversal.This is a retrospective cohort study. From June 2011 to March 2015, TIBs were performed on 31 consecutive patients with mid- or low-rectal cancer who underwent elective laparoscopic LARs. From January 2008 to May 2011, 25 similarly diseased patients underwent elective laparoscopic LARs and conventional loop ileostomy (LI) and were included as controls. All of the anastomotic sites were within 6 cm of the anal verge. Demographic, clinical feature, and operative data were recorded.The demographic features of both groups were similar. The TIB mean surgical duration was significantly lower than in the LI group (215 ± 28 vs 245 ± 54 min, P = 0.010). Because of readmission for stoma closure, the total hospital stay of the LI group was longer than that of the TIB group (38.1 ± 26.5 vs 19.1 ± 7.9 days, respectively, P = 0.002). Ileal content was completely diverted by TIB for 13.7 ± 2.1 (range, 10-19) days postoperatively. The drainage tube was removed on postoperative day 27.8 ± 6.9 (range, 20-44), and the mean continued duration of the discharge tract, before fistula healing, was 4.5 ± 1.9 (range, 2-10) days. Postoperative complications of the 2 modalities were not significant. In the TIB group, 1 rectovaginal fistula occurred 30 days postsurgery. In the LI group, 1 rectovaginal fistula occurred 3 months after stoma closure. Both complications were treated with transverse colostomy. No major TIB associated complications were observed in the present study.TIB is a safe, feasible, effective, but time-limited diversion technique, which may reduce symptomatic anastomosis leakage after LAR for rectal cancer.

Gastrointestinal surgery in cystic fibrosis: a 20-year review

OBJECTIVES

The purpose of this study was to evaluate outcomes of the surgical management for meconium ileus (MI) and Distal Intestinal Obstruction Syndrome (DIOS) in Cystic Fibrosis (CF).

METHODS

Children born between 1990 and 2010 were identified using a regional CF database. Retrospective case note analysis was performed. Outcome measures for MI were mortality, relaparotomy rate, length of stay (LOS), time on parental nutrition (TP), and time to full feeds (TFF). Outcome measures for DIOS were: age of onset, number of episodes, and need for laparotomy.

RESULTS

Seventy-five of 376 neonates presented with MI. Fifty-four (92%) required laparotomy. Contrast enema decompression was attempted in nineteen. There were no post-operative deaths. Thirty-nine (72%) neonates with MI were managed with stomas. LOS was longer in those managed with stomas (p=0.001) and in complex MI (p=0.002). Thirty-five patients were treated for DIOS. Twenty-five patients were managed with gastrograffin. Ten patients underwent surgical management of DIOS. Overall, MI did not predispose to later development of DIOS. There was a significantly greater incidence of laparotomy for DIOS in children who had MI.

CONCLUSION

The proportion of neonates with complex meconium ileus was high (49%) and may explain the infrequent utilisation of radiological decompression. Complex MI or management with stomas both significantly increase LOS. Re-laparotomy rate is high (22%) in MI irrespective of the type of management. DIOS is not a benign condition, particularly when the child has had previous abdominal surgery. Early referral to a surgical team is essential in these children.

Comparison between Tube Ileostomy and Loop Ileostomy as a Diversion Procedure

Aim. Loop ileostomy has high complication rates and causes much patient inconvenience. This study was performed to compare the outcome of tube versus loop ileostomy in management of ileal perforations. Patients and Methods. From July 2008 to July 2011, all patients with ileal perforation on laparotomy where a defunctioning proximal protective loop ileostomy was considered advisable were chosen for study. Patients were randomly assigned to undergo either tube ileostomy or classical loop ileostomy as the diversion procedure. Tube ileostomy was constructed in the fashion of feeding jejunostomy, with postoperative saline irrigation. Results. A total of 60 diversion procedures were performed over the period with 30 for each of tube and loop ileostomy. Typhoid and tuberculosis formed the most common etiology for ileal perforation. The complication rate of tube ileostomy was 33%. Main complications related to tube ileostomy were peritubal leak, tube blockage. In patients with loop, overall complications in 53% majority were peristomal skin irritation and wound infection following ileostomy closure. Two patients developed obstruction following ileostomy closure which needed reoperation. Conclusions. Tube ileostomy is effective and feasible as a diversion procedure and has reduced morbidity. It can be used as an alternative to loop ileostomy.

Issues in the management of simple and complex meconium ileus

INTRODUCTION

Various surgical methods are used to treat meconium ileus (MI), including resection with enterostomy (RES), primary anastomosis (RPA), and purse-string enterotomy with intra-operative lavage (PSI). The aim of this study is to discuss the surgical treatment of MI, based on our experience.

PATIENTS AND METHODS

Of the 41 MI patients treated at our institution between 1984 and 2007, 18 had simple MI and 23 had complex MI. These groups were analyzed according to treatment modality, concentrating on length of hospital stay, complications [peritonitis, septicemia, adhesive small bowel obstruction (ASBO), and malabsorption/diarrhea], need for additional surgical procedures, mortality.

RESULTS

Of the 18 patients with simple MI, 7 (39%) were successfully treated with diluted Gastrografin® enema. The remaining 11 patients were treated surgically: two underwent RPA, of whom one died; five had RES, of whom one developed ASBO; four underwent PSI, of whom two developed peritonitis. In the complex MI group, 14 patients underwent RPA, with peritonitis occurring in three (one died); nine underwent RES, of whom two developed ASBO.

CONCLUSION

In patients with simple MI, conservative treatment with diluted Gastrografin® enema is an effective initial treatment in our hands. In case of failure, RES is advisable. Patients with complex MI are candidates for RES. RPA and PSI seem to have higher complication rates.

Feasibility and outcome of proximal catheter ileostomy - a pilot study

BACKGROUND/AIM

Loop ileostomy has high complication rates and causes much patient inconvenience. This study was carried out to evaluate the feasibility and outcome of a proximal catheter ileostomy in place of loop ileostomy in patients treated by intestinal repair and/or resection-anastomosis.

DESIGN

Prospective study.

SETTING

J. N. Medical College Hospital, Aligarh Muslim University, Aligarh, India.

PATIENTS AND METHODS

From November 2006 to November 2009, in all patients treated surgically by primary repair and/or resection-anastomosis of small and/or large bowel, we constructed a catheter ileostomy when a defunctioning proximal protective loop ileostomy was considered advisable. Catheter ileostomy was constructed in the fashion of catheter jejunostomy, with postoperative saline irrigation.

RESULTS

Catheter ileostomy was performed in 20 patients in the 3-year period. The mean age of the subjects was 28.6 years and the male: female ratio was 1.86:1. Four patients died of septicemia and multiple organ failure unrelated to catheter ileostomy in the immediate postoperative period. Catheter ileostomy started functioning within 48 hours of the operation, and twice-daily irrigation was found sufficient in 81.25% of the surviving patients. Only one patient developed peritubal leak with mild skin excoriation that cleared within 5 days. Another patient with Koch's abdomen underwent conversion to loop colostomy on re-exploration for postoperative adhesive obstruction. There was no instance of intestinal leak. Ileostomy wounds closed spontaneously within 7-14 days of catheter removal, and none required formal closure. Hospital stay ranged from 12-35 days (mean: 23 days).

CONCLUSIONS

Catheter ileostomy is effective in protecting intestinal anastomosis/repair; there is minimal morbidity and no catheter-related leak/mortality, and we recommend the procedure.

T-tube ileostomy for intestinal perforation in extremely low birth weight neonates

To evaluate the results of use of T-tube ileostomy in selected cases of intestinal perforation in extremely low birth weight (ELBW) neonates. The records of 288 ELBW neonates treated at author's institution, from 1998 to 2003 were retrospectively reviewed to identify neonates operated for intestinal perforation with T-tube placement. T-tube was inserted into the bowel through the site of perforation or proximally to the perforated gut via separate stab incision. T-tubes were used in five ELBW neonates (BW 600-900 g, gestational age 25-27 weeks) with intestinal perforation, in four of them at the time of primary surgery and in one neonate 8 days after primary anastomosis. All patients survived and there were no serious complications related to the T-tube insertion. Median duration of T-tube placement was 4 weeks (range 3-8 weeks), full enteral feeding after T-tube insertion was achieved in 4 weeks (range 1-6 weeks). All sites of T-tube insertion closed spontaneously. T-tube ileostomy is an effective and safe technique for treatment of selected cases of intestinal perforation in ELBW neonates. With respect to the hypoperistalsis of immature bowel, we recommend the use of T-tube in all cases of isolated intestinal perforation in ELWB neonates.

Meconium Ileus–Is a Single Surgical Procedure Adequate?

Meconium ileus is one of the gastrointestinal manifestations of cystic fibrosis (CF), and affects 15% of neonates. The condition results from the accumulation of sticky inspissated meconium. Both nonoperative and operative therapies may be effective in relieving obstruction. The treatment of choice for uncomplicated meconium ileus is the use of enteral N-acetylcysteine or Gastrografin enemata. Once such therapy fails, surgery is indicated. A number of operative procedures are in use, including Bishop-Koop enterostomy, T-tube irrigation, resection and primary anastomosis, and enterotomy with irrigation and primary closure. During the period 1991-2003, five newborns required surgical intervention for uncomplicated meconium ileus. None responded to conservative management. All were males, including one set of twins. All underwent laparotomy, enterotomy, appendectomy, irrigation and closure of enterotomy. None required a second surgical procedure. CF was confirmed in all, and in each case, both parents were found to be genetic carriers of a mutational form of CF. A single surgical intervention is preferable in these patients, in view of the high rate of pulmonary involvement in CF patients. Enterotomy, irrigation and primary closure are the treatment of choice for uncomplicated meconium ileus.

Surgical management of pulmonary and gastrointestinal complications in children with cystic fibrosis

PURPOSE OF REVIEW

Cystic fibrosis is a common disorder, affecting as many as 1:2500 Caucasian live births. Despite improved medical management, disease-specific complications are common and are responsible for substantial morbidity and ultimately mortality. Both pulmonary and gastrointestinal complications of cystic fibrosis are well known; however, the complications requiring surgical intervention in the pediatric population are infrequent. We provide a detailed review of the cystic fibrosis-associated pulmonary and gastrointestinal complications and potential surgical options for management in children with cystic fibrosis.

RECENT FINDINGS

Recent operative approaches are described that include application of minimally invasive surgical techniques primarily for intrathoracic disease. Novel medical therapies are also presented. Finally an attempt is made to put in perspective those surgical care advances that have had a benefit on disease outcomes.

SUMMARY

This report will provide the physician caring for the child with cystic fibrosis an understanding of those disease complications that will require surgical consultation and potential operative intervention.

Transition of care between paediatric and adult gastroenterology. Cystic fibrosis

Advancement in treatment has resulted in a dramatic increase in life expectancy of patients with cystic fibrosis (CF) to well beyond 30 years of age in most centres. What was once a fatal genetic disease in childhood now sees over a third of its CF populations in adult clinics. The improved survival is multifactorial, but most attribute the reasons to more aggressive nutritional care along with better management of the gastrointestinal and pulmonary systems. Many of the nutritional and GI issues of paediatric patients remain similar when they become adults, except that there is the added psychosocial stress associated with this transition. This chapter aims to highlight the gastrointestinal and nutritional issues manifesting at the different stages of life from infancy to adulthood, and the recommended management.