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Bonasso PC, Dassinger MS, Mehl SC, Gokun Y, Gowen MS, Burford JM, Smith SD. Timing of enterostomy closure for neonatal isolated intestinal perforation. J Pediatr Surg 2020; 55:1535-1541. [PMID: 31954555 DOI: 10.1016/j.jpedsurg.2019.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 12/01/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE No consensus guidelines exist for timing of enterostomy closure in neonatal isolated intestinal perforation (IIP). This study evaluated neonates with IIP closed during the initial admission (A1) versus a separate admission (A2) comparing total length of stay and total hospital cost. METHODS Using 2012 to 2017 Pediatric Health information System (PHIS) data, 359 neonates with IIP were identified who underwent enterostomy creation and enterostomy closure. Two hundred sixty-five neonates (A1) underwent enterostomy creation and enterostomy closure during the same admission. Ninety-four neonates (A2) underwent enterostomy creation at initial admission and enterostomy closure during subsequent admission. For the A2 neonates, total hospital length of stay was calculated as the sum of hospital days for both admissions. A1 neonates were matched to A2 neonates in a 1:1 ratio using propensity score matching. Multivariate models were used to compare the two matched pair groups for length of stay and cost comparisons. RESULTS Prior to matching, the basic demographics of our study population included a median birthweight of 960 g, mean gestational age of 29.5 weeks, and average age at admission of 4 days. Eighty-seven pairs of neonates with IIP were identified during the matching process. Neonates in A2 had 91% shorter total hospital length of stay compared to A1 neonates (HR: 1.91; 95% CI for HR: 1.44-2.53; p < .0001). The median length of stay for A1 was 95 days (95% CI: 78-102 days) versus A2 length of stay of 67 days (95% CI: 56-76 days). Adjusting for the same covariates, A2 neonates had a 22% reduction in the average total cost compared A1 neonates (RR: 0.78; 95% CI for RR: 0.64-0.95; p-value = 0.014). The average total costs were $245,742.28 for A2 neonates vs. $315,052.21 for A1 neonates (p < 0.001). CONCLUSION Neonates with IIP have a 28 day shorter hospital length of stay, $75,000 or 24% lower total hospital costs, and a 22 day shorter post-operative course following enterostomy closure when enterostomy creation and closure is performed on separate admissions. TYPE OF STUDY Prognosis Study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Patrick C Bonasso
- Division of Pediatric Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - M Sidney Dassinger
- Division of Pediatric Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Steven C Mehl
- Division of Pediatric Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Yevgeniya Gokun
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Marie S Gowen
- Division of Pediatric Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeffrey M Burford
- Division of Pediatric Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Samuel D Smith
- Division of Pediatric Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Abstract
Progress in our understanding of the pathophysiology, prevention and treatment of necrotizing enterocolitis (NEC) has been hampered for many reasons. Included among these is the fact that what we are calling "NEC" is likely to represent different disease processes, which need to be delineated before evaluating individual pathogenic mechanisms and attempting to develop predictive and diagnostic biomarkers. Treatment is also likely to be hampered because not all of the different entities called "NEC" will respond to the same regimen. In this review, some of these entities will be discussed in more detail, with suggestions for refining our approach toward improving methods for their diagnosis, prevention and treatment.
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Affiliation(s)
- Josef Neu
- Pediatrics/Neonatology, University of Florida, Gainesville, Florida, USA,
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3
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Triki W, Lahmidi MA, Baraket O, Itaim A, Hamida SB, Bacar A, Bouchoucha S. Recurrent Spontaneous Colonic Perforation in a 10- years-old Child. Indian J Pediatr 2019; 86:562. [PMID: 30756290 DOI: 10.1007/s12098-019-02897-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/04/2019] [Indexed: 11/21/2022]
Affiliation(s)
- Wissem Triki
- Department of Surgery, Habib Bougatfa Hospital Bizerte, Bizerte, Tunisia.
| | | | - Oussema Baraket
- Department of Surgery, Habib Bougatfa Hospital Bizerte, Bizerte, Tunisia
| | - Ahmed Itaim
- Department of Surgery, Habib Bougatfa Hospital Bizerte, Bizerte, Tunisia
| | - Sonia Ben Hamida
- Departement of Gastroenterology, Habib Bougatfa Hospital Bizerte, Bizerte, Tunisia
| | - Abdelmajid Bacar
- Department of Surgery, Habib Bougatfa Hospital Bizerte, Bizerte, Tunisia
| | - Sami Bouchoucha
- Department of Surgery, Habib Bougatfa Hospital Bizerte, Bizerte, Tunisia
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Kim SH, Cho YH, Kim HY. Spontaneous Perforation of Colon in Previously Healthy Infants and Children: Its Clinical Implication. Pediatr Gastroenterol Hepatol Nutr 2016; 19:193-198. [PMID: 27738601 PMCID: PMC5061661 DOI: 10.5223/pghn.2016.19.3.193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 03/28/2016] [Accepted: 05/12/2016] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Spontaneous colon perforations are usually encountered as necrotizing enterocolitis in the neonatal period, but occur rarely in infants and children without pathological conditions. This study was conducted to describe its clinical implication beyond the neonatal period. METHODS Cases of spontaneous colon perforation confirmed after the operation were reviewed retrospectively and the clinicopathological characteristics were analyzed. Clinical data were compared according to the presence of pneumoperitoneum as initial findings. RESULTS Eleven patients were included in the study period and showed a history of hospitalization before transfer due to management for fever, respiratory or gastrointestinal problems. Six patients showed a sudden onset of abdominal distention and only seven patients showed a pneumoperitoneum as initial radiologic findings, however there were no significant clinicopathological differences. Perforation was found evenly in all segments of the colon, most commonly at the sigmoid colon in four cases. There were no specific pathologic or serologic causes of perforation. CONCLUSION When previously healthy infants and children manifest a sustained fever with a sudden onset of abdominal distention during management for fever associated with respiratory or gastrointestinal problems, there is a great likelihood of colon perforation with no pathological condition. Prompt surgical management as timely decision-making is necessary in order to achieve a good progress.
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Affiliation(s)
- Soo-Hong Kim
- Department of Pediatric Surgery, Pusan National University Children's Hospital, Yangsan, Korea
| | - Yong-Hoon Cho
- Department of Pediatric Surgery, Pusan National University Children's Hospital, Yangsan, Korea
| | - Hae-Young Kim
- Department of Pediatric Surgery, Pusan National University Children's Hospital, Yangsan, Korea
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5
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Nishizaki N, Maiguma A, Obinata K, Okazaki T, Shimizu T. Localized intestinal perforations as a potential complication of brain hypothermic therapy for perinatal asphyxia. J Matern Fetal Neonatal Med 2015; 29:2537-9. [PMID: 26445344 DOI: 10.3109/14767058.2015.1094048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Brain hypothermic therapy (BHT) is becoming a frequently used standard of care for perinatal asphyxia. Although cardiovascular side effects, coagulation disorders, renal impairment, electrolyte abnormalities, impaired liver function, opportunistic infections, and skin lesions are well-known adverse effects of BHT in newborns, little information is available on the clinical features of intestinal perforation-related BHT. We herein report a case of therapeutic brain cooling for perinatal asphyxia complicated by localized intestinal perforation. In practice, the neonatologist should be aware that intestinal perforation in an infant with perinatal asphyxia is possible, particularly following BHT.
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Affiliation(s)
| | | | | | - Tadaharu Okazaki
- b Department of Pediatric Surgery , Juntendo University Urayasu Hospital , Chiba , Japan , and
| | - Toshiaki Shimizu
- c Department of Pediatrics , Juntendo University School of Medicine , Tokyo , Japan
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6
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McAdams RM, Ledbetter DJ. Focal intestinal perforation in late preterm and term neonates with hypoxic ischemic encephalopathy. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2015. [DOI: 10.1016/j.epsc.2015.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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7
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Fisher JG, Jones BA, Gutierrez IM, Hull MA, Kang KH, Kenny M, Zurakowski D, Modi BP, Horbar JD, Jaksic T. Mortality associated with laparotomy-confirmed neonatal spontaneous intestinal perforation: a prospective 5-year multicenter analysis. J Pediatr Surg 2014; 49:1215-9. [PMID: 25092079 DOI: 10.1016/j.jpedsurg.2013.11.051] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 11/05/2013] [Accepted: 11/06/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Spontaneous intestinal perforation (SIP) has been recognized as a distinct disease entity. This study sought to quantify mortality associated with laparotomy-confirmed SIP and to compare it to mortality of laparotomy-confirmed necrotizing enterocolitis (NEC). METHODS Data were prospectively collected on 177,618 very-low-birth-weight (VLBW, 401-1500g) neonates born between January 2006 and December 2010 admitted to US hospitals participating in the Vermont Oxford Network (VON). SIP was defined at laparotomy as a focal perforation of the intestine without features suggestive of NEC or other intestinal abnormalities. The primary outcome was in-hospital mortality. RESULTS At laparotomy, 2036 (1.1%) neonates were diagnosed with SIP and 4076 (2.3%) with NEC. Neonates with laparotomy-confirmed SIP had higher mortality (19%) than infants without NEC or SIP (5%, P=0.003). However, laparotomy-confirmed SIP patients had significantly lower mortality than those with confirmed NEC (38%, P<0.0001). Mortality in both NEC and SIP groups decreased with increasing birth weight and mortality was significantly higher for NEC than SIP in each birth weight category. Indomethacin and steroid exposure were more frequent in the SIP cohort than the other two groups (P<0.001). CONCLUSIONS In VLBW infants, the presence of laparotomy-confirmed SIP increases mortality significantly. However, laparotomy-confirmed NEC mortality was double that of SIP. This relationship is evident regardless of birth weight. The variant mortality of laparotomy-confirmed SIP versus laparotomy-confirmed NEC highlights the importance of differentiating between these two diseases both for clinical and research purposes.
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Affiliation(s)
- Jeremy G Fisher
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, GA, USA; Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, GA, USA
| | - Brian A Jones
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, GA, USA; Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, GA, USA
| | - Ivan M Gutierrez
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, GA, USA; Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, GA, USA
| | - Melissa A Hull
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, GA, USA; Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, GA, USA
| | - Kuang Horng Kang
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, GA, USA; Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, GA, USA
| | | | - David Zurakowski
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, GA, USA
| | - Biren P Modi
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, GA, USA; Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, GA, USA
| | | | - Tom Jaksic
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, GA, USA; Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, GA, USA.
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8
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Das PC, Rai R, Lobo GJ. Jejunal atresia associated with idiopathic ileal perforation. J Indian Assoc Pediatr Surg 2011; 13:88-9. [PMID: 20011479 PMCID: PMC2788440 DOI: 10.4103/0971-9261.43039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Jejunoileal atresia is one of the common causes of neonatal intestinal obstruction. Intestinal perforation with meconium peritonitis in the neonatal period, which carries a high mortality rate, is also common. The association of jejunal atresia with idiopathic ileal perforation is very rare.
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Affiliation(s)
- P C Das
- Department of Pediatric Surgery, Fr. Muller Medical College and Hospital, Mangalore, Karnataka, India
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9
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Abstract
So much is unknown about SIP-its etiology, pathophysiology, best treatment modality, and outcome. Yet the incidence of SIP is increasing as more VLBW infants are surviving and since SIP has been identified as a separate disease from NEC. Because many cases present with an insidious onset, it is imperative that practitioners review all x-rays with SIP in mind. Although SIP is a relatively rare occurrence in the NICU, its potential to increase morbidity and mortality in premature infants warrants further research to improve outcomes.
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10
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Drewett MS, Burge DM. Recurrent neonatal gastro-intestinal problems after spontaneous intestinal perforation. Pediatr Surg Int 2007; 23:1081-4. [PMID: 17828407 DOI: 10.1007/s00383-007-1999-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2007] [Indexed: 10/22/2022]
Abstract
To identify intestinal complications during the neonatal period following spontaneous isolated intestinal perforation (SIP). A retrospective case notes review was undertaken of all patients with a diagnosis of SIP, confirmed at laparotomy or post-mortem, admitted between January 2000 and January 2005. Patients with confirmed gastric perforation were excluded as were patients with proven necrotising enterocolitis (NEC) or suspected, but not confirmed, SIP. Seventeen patients, median gestation 27 weeks and median birth weight 780 g, were treated by drain alone (1), drain and later laparotomy (4) or primary laparotomy (12). Eight patients required enterostomy formation at primary laparotomy (1 jejunostomy, 1 colostomy and 6 ileostomy). Five babies died in the neonatal period and three later in the first year. Nine patients (53%) had ten subsequent episodes of intestinal pathology requiring surgical intervention between 5 and 136 days later comprising early recurrent isolated perforation (2), NEC (3), milk curd obstruction with or without perforation (3) and adhesion obstruction (2). Secondary surgery involved laparotomy in eight patients, five of whom required formation or re-formation of a stoma, and palliative drain insertion in one patient. Recurrent intestinal pathology requiring surgical intervention during the neonatal period occurred in 53% of babies with SIP. Surgeons and neonatologists should be aware that this group of patients are prone to further intestinal pathology.
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Affiliation(s)
- M S Drewett
- Department of Neonatal Medicine and Surgery, Princess Anne Hospital, Coxford Road, Southampton SO16 5YA, UK.
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11
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[Pseudo-"isolated" intestinal perforation in a very low birth weight infant: exceptional presentation of Hirschsprung's disease]. Arch Pediatr 2006; 13:1320-2. [PMID: 16919428 DOI: 10.1016/j.arcped.2006.06.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2005] [Accepted: 06/26/2006] [Indexed: 10/24/2022]
Abstract
Intestinal perforations in preterm newborn are characterized with high morbidity and mortality rates. They often are associated with necrotizing enterocolitis and seldom correspond to idiopathic spontaneous intestinal perforation. Perforations upstream of an intestinal organic obstruction (atresia), or of a functionnal obstruction (meconium-ileus, Hirschsprung disease) have been considered to be rare in preterm newborns. We report a case of caecal perforation with a pneumoperitoneum which occurred at 5 days of life, in a 28-week gestational age infant, that was treated by cecostomy. There were no signs of necrotizing enterocolitis. At 43 days of life, the preoperative contrast enema study revealed a left colon transition zone, suggesting a Hirschsprung disease, which was confirmed by rectal biopsies. Transanal pull-through was performed. There were no postoperative complication. This case demonstrates that an isolated intestinal perforation in very preterm newborn can reveal a Hirschsprung disease, especially if it occurs in the caecum.
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12
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Paquette L, Friedlich P, Ramanathan R, Seri I. Concurrent use of indomethacin and dexamethasone increases the risk of spontaneous intestinal perforation in very low birth weight neonates. J Perinatol 2006; 26:486-92. [PMID: 16791261 DOI: 10.1038/sj.jp.7211548] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Dexamethasone or indomethacin predisposes very low birth weight (VLBW) neonates to spontaneous intestinal perforation (SIP). However, no study has specifically investigated the role of the concurrent use of indomethacin and dexamethasone in SIP. OBJECTIVE To test whether the concurrent use of indomethacin and dexamethasone increases the risk of SIP. METHODS In this single center, retrospective, 2:1 matched, case-control study, the odds of SIP were assessed using univariate and multivariate logistic regression analysis in < or =14-day old VLBW infants. RESULTS Sixteen VLBW infants with SIP were matched to 32 controls by birth weight. After adjusting for clinically relevant variables, patients who received > or =3 doses of indomethacin for ductal closure or intraventricular hemorrhage prophylaxis and > or =3 doses of low-dose dexamethasone (0.3 mg/kg cumulative dose over 3 days) for refractory hypotension during the first postnatal week, were 9.6 times more likely to develop SIP [95% CI 1.22, 75.71]. CONCLUSIONS The combined use of indomethacin and dexamethasone increases the risk of SIP in VLBW neonates.
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Affiliation(s)
- L Paquette
- USC Division of Neonatal Medicine, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA.
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13
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Abstract
PURPOSE Gastrointestinal perforation is a catastrophic condition in neonates, especially in premature neonates. Although perforation is commonly observed in the small intestine during the neonatal period, perforation of the colon is a rare condition. This study analyzed the clinical findings and results of perforation of the colon in neonates. METHODS Between 1989 and 2004, 8 neonates were treated for spontaneous perforation of the colon at our institute. These patients were retrospectively reviewed. RESULTS Gestational ages ranged from 36 to 41 weeks. Seven patients weighed above 2500 g, whereas one patient weighed 1800 g at birth. Perforations developed within 7 days after birth in 6 patients and before birth in two. Associated bowel diseases included rectosigmoid type of Hirschsprung's disease in two patients, immature ganglia in one, imperforate anus in one, colonic atresia in one, and necrotizing enterocolitis in one. An obvious cause was not identified in the remaining two. Six patients without definite anatomic obstructions, such as imperforate anus or colonic atresia, required evaluations for suspected Hirschsprung's disease. All 8 patients underwent colostomy and recovered from peritonitis. Seven survived, but one died of sudden infant death syndrome. CONCLUSIONS In this study, perforation of the colon during the neonatal period mostly occurred in term or near-term neonates and carried a good prognosis. During management, it was important to identify Hirschsprung's and its allied disorders as a cause of perforation.
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Affiliation(s)
- Hiroaki Komuro
- Department of Pediatric Surgery, Graduate School of Comprehensive Human Sciences and University Hospital, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan.
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Abstract
Gastrointestinal perforations have been reported occasionally in neonates. The authors describe a 9-month-old girl with mosaic trisomy 8 on home breath-stacking therapy who presented with an acute abdomen. A large perforation in the first portion of the duodenum was found as well as an incidental annular pancreas. Despite occupying approximately half of the circumference of the lumen, the perforation was able to be closed primarily without complications. Several etiologies have been suggested for intestinal perforations. This report hypothesizes the possible involvement of breath stacking in conjunction with partial obstruction by an annular pancreas.
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Affiliation(s)
- Prabo Dwight
- Queen's University School of Medicine, Kingston, Ontario, Canada
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15
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Sajja SBS, Middlesworth W, Niazi M, Schein M, Gerst PH. Duodenal atresia associated with proximal jejunal perforations: a case report and review of the literature. J Pediatr Surg 2003; 38:1396-8. [PMID: 14523829 DOI: 10.1016/s0022-3468(03)00405-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Duodenal atresia is associated with Down's syndrome, malrotation, and congenital cardiac defects. Idiopathic intestinal perforations in a newborn, which are not associated with necrotizing enterocolitis (NEC), have been described. The authors report on a full-term neonate who had multiple perforations of the proximal jejunum distal to duodenal atresia. To the best of the authors knowledge, the combination of idiopathic intestinal perforation and duodenal atresia has not been reported previously.
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Affiliation(s)
- Sai B S Sajja
- Department of Surgery, Bronx-Lebanon Hospital Centre, Bronx, NY 10457, USA
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16
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Hwang H, Murphy JJ, Gow KW, Magee JF, Bekhit E, Jamieson D. Are localized intestinal perforations distinct from necrotizing enterocolitis? J Pediatr Surg 2003; 38:763-7. [PMID: 12720189 DOI: 10.1016/jpsu.2003.50162] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND/PURPOSE Localized intestinal perforation (LP) is thought to be a distinct entity when compared with perforation associated with necrotizing enterocolitis (NEC). Studies have indicated that LP is more amenable to percutaneous drainage and associated with a better outcome. We sought to determine whether LP and NEC could be distinguished based on clinical parameters alone. METHODS A retrospective review of 40 neonates with gastrointestinal perforations between January 1990 and May 1998 was performed. All had undergone laparotomy and had histologic specimens available for evaluation. RESULTS Twenty-one neonates had necrotizing enterocolitis (NEC), and 19 had localized perforation (LP) based on histologic criteria. More neonates with LP were exposed to prenatal indomethacin (37% v 5%; P <.05), received intravenous dexamethasone (42% v 10%; P <.05), had umbilical artery catheters (63% v 14%; P <.05), and had a higher white blood cell (WBC) count (27.1 +/- 23.1 v 14.3 +/- 11.5; P <.05). More neonates with NEC had pneumatosis intestinalis (47% v 11%; P <.05). No significant differences existed in enteral feeding (16% LP v 38% NEC) or overall mortality rate (37% LP v 38% NEC). No statistical differences in the timing of perforation or clinical presentation were found. CONCLUSIONS NEC and LP are difficult to distinguish based on clinical parameters alone. The authors did find associations between LP and prenatal indomethacin, intravenous dexamethasone, umbilical artery catheters, and a higher WBC count. Mortality rate and clinical outcome were nearly identical in both groups. Pneumatosis intestinalis, thought to be pathognomonic for NEC, was seen on abdominal radiograph in 2 babies with histologically proven LP.
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Affiliation(s)
- Hamish Hwang
- Departments of Pediatric Surgery, Pathology, and Radiology, British Columbia's Children's Hospital, Vancouver, British Columbia, Canada
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Okuyama H, Kubota A, Oue T, Kuroda S, Ikegami R, Kamiyama M. A comparison of the clinical presentation and outcome of focal intestinal perforation and necrotizing enterocolitis in very-low-birth-weight neonates. Pediatr Surg Int 2002; 18:704-6. [PMID: 12598969 DOI: 10.1007/s00383-002-0839-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/15/2002] [Indexed: 10/25/2022]
Abstract
There is controversy about the identity of focal intestinal perforation (FIP) and necrotizing enterocolitis (NEC). To elucidate the difference between them, we reviewed their clinical presentations. Over the last 20 years, 39 very-low-birth-weight (VLBW) neonates, including 21 extremely-low-birth-weight neonates, underwent a laparotomy for intestinal perforation without mechanical causes. Nineteen patients had typical findings of NEC, and 8 had FIP. FIP is defined as isolated intestinal perforation without gross necrosis. In FIP, the gestational age was significantly lower than in NEC (23.8 +/- 1.8 vs 27.0 +/- 2.5 weeks, P < 0.01). The birth weight (BW) of FIP patients was lower than that of NEC infants (635 +/- 134 vs 883 +/- 256 g, P < 0.05). The incidence of coexistent respiratory distress syndrome (RDS) was higher in FIP compared to NEC (88% vs 37%, P < 0.05). The age at onset was younger in FIP than NEC (7.3 +/- 2.7 vs 14.4 +/- 7.9 days, P < 0.05). All patients except 1 had the sites of perforation exteriorized. There was a trend toward higher survival in FIP compared to NEC (88% vs 58%, P = 0.136). Our data clearly show differences in BW, gestational age, and association of RDS between FIP and NEC. Based on our data, prematurity and RDS appear to be the major etiologic factors of FIP. The present series supports the fact that FIP is a definite clinical entity.
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Affiliation(s)
- Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
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Tam AL, Camberos A, Applebaum H. Surgical decision making in necrotizing enterocolitis and focal intestinal perforation: predictive value of radiologic findings. J Pediatr Surg 2002; 37:1688-91. [PMID: 12483631 DOI: 10.1053/jpsu.2002.36696] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/PURPOSE Given the current controversy over the appropriate surgical management (peritoneal drainage versus exploratory laparotomy) of advanced necrotizing enterocolitis and focal intestinal perforation, the authors examined the predictive value of radiologic findings. METHODS The medical records of 80 infants undergoing exploratory laparotomy for presumed advanced necrotizing enterocolitis (NEC) or focal intestinal perforation (FIP) were reviewed. Radiologic criteria were evaluated as predictors of NEC (pneumatosis intestinalis, portal venous gas) or perforation (free air, gasless abdomen). The standard epidemiologic measures were calculated for each criterion. RESULTS For pneumatosis intestinalis, the sensitivity was 44% (n = 27) and specificity, 100% (n = 19). For portal venous gas, the sensitivity was 13% (n = 8) and specificity, 100% (n = 19). The sensitivity and specificity calculated for free air was 52% (n = 23) and 92% (n = 33), respectively. The sensitivity and specificity calculated for a gasless abdomen was 32% (n = 14) and 92% (n = 33), respectively. CONCLUSIONS While demonstrating high specificity, the radiologic signs traditionally associated with NEC and FIP have unexpectedly low sensitivities. Although positive radiologic findings are of great predictive value, negative radiologic findings acquired while determining the need for and specific type of surgical intervention in suspected NEC or FIP must be interpreted with extreme caution.
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Affiliation(s)
- Alda L Tam
- Department of Surgery, Kaiser Permanente Medical Center, Los Angeles, CA 90027, USA
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Cass DL, Brandt ML, Patel DL, Nuchtern JG, Minifee PK, Wesson DE. Peritoneal drainage as definitive treatment for neonates with isolated intestinal perforation. J Pediatr Surg 2000; 35:1531-6. [PMID: 11083416 DOI: 10.1053/jpsu.2000.18299] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/PURPOSE To better define the indications for peritoneal drainage (PD) in premature babies with intestinal perforation, the authors reviewed their experience with this procedure in a tertiary neonatal intensive care setting. METHODS The charts of all neonates who underwent PD as initial treatment for intestinal perforation between 1996 and 1999 were reviewed. Those patients with pneumatosis intestinalis on abdominal radiograph had perforated necrotizing enterocolitis (NEC) diagnosed; whereas, those infants with no pneumatosis had isolated intestinal perforation diagnosed. The clinical characteristics and outcomes of these 2 groups were compared. RESULTS Twenty-one premature neonates had primary PD between 1996 and 1999, 10 for isolated intestinal perforation and 11 for perforated NEC. Patients with isolated intestinal perforation had lower birth weights (708 v 949 g; P < .05), were less likely to have started feedings (30% v 91%, P < .05), and the perforation developed at an earlier age (10.6 v 28.0 d, P < .05) compared with the patients who had perforated NEC. Only 2 of 10 infants with isolated perforation required subsequent laparotomy (at 10 weeks for stricture and 12 weeks for a persistent fistula). For these patients, the long-term survival rate was 90%. In contrast, 8 of 11 infants with perforated NEC required laparotomy, and although the 30-day survival rate was 64%, the long-term survival rate was only 27%. CONCLUSIONS Peritoneal drainage provides successful and definitive treatment for most premature babies with isolated intestinal perforation. For neonates with perforation caused by NEC, peritoneal drainage may provide temporary stabilization, but most of these infants require subsequent laparotomy, and few survive.
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Affiliation(s)
- D L Cass
- Department of Surgery, Texas Children 's Hospital and the Baylor College of Medicine, Houston, 77030-2399, USA
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Mallet EC, Robillard PY, Randrianaly H, Boumahni B, Edmar A, Mariette JB, Fagot E. [Spontaneous neonatal gastric perforation]. Arch Pediatr 2000; 7:94-5. [PMID: 10668094 DOI: 10.1016/s0929-693x(00)88926-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
This article reviews the radiology of necrotizing entercolitis (NEC), with an emphasis on the sensitivity and specificity of the typical plain film findings. An approach to radiologic diagnosis is suggested. The more recently described entity of perforation without NEC also is described.
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MESH Headings
- Acute Disease
- Enterocolitis, Necrotizing/complications
- Enterocolitis, Necrotizing/diagnostic imaging
- Enterocolitis, Necrotizing/etiology
- Enterocolitis, Necrotizing/therapy
- Humans
- Infant, Newborn
- Infant, Premature, Diseases/diagnostic imaging
- Infant, Premature, Diseases/etiology
- Infant, Premature, Diseases/therapy
- Radiography
- Risk Factors
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Affiliation(s)
- C Buonomo
- Children's Hospital, Boston, Massachusetts, USA
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Shorter NA, Liu JY, Mooney DP, Harmon BJ. Indomethacin-associated bowel perforations: a study of possible risk factors. J Pediatr Surg 1999; 34:442-4. [PMID: 10211650 DOI: 10.1016/s0022-3468(99)90495-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The association between indomethacin administration and bowel perforation in premature infants is well known. The goal of this study was to examine possible risk factors for this complication. METHODS Fifteen cases of indomethacin-associated bowel perforation occurred from 1993 to 1996. All had a birth weight < or = 1,100 g. These patients were compared with a control group of 51 infants who were cared for contemporaneously, had birth weights < or = 1,100 g and received indomethacin. RESULTS Survival rate in the control group was 96%. For the group with perforations, it was 53%. Two types of perforation were seen, one occurring in the setting of necrotizing enterocolitis, and the other, a simple perforation in an otherwise normal-appearing bowel. For the latter group, the survival rate was 86%, and, when possible, primary repair was the procedure of choice. Use of aminophylline was greater in the control group. Otherwise, there were no significant differences between the two groups in any of the variables observed. However, when the simple perforations were observed separately, these patients had, on average, received indomethacin at a younger age than the controls (P < .05). The clustering of perforation cases from May through August suggests an infectious agent might be involved. CONCLUSIONS Earlier administration of indomethacin correlates with an increased risk of focal perforation. It is unclear, however, whether the risk factor is the drug itself or the earlier need for it. Aminophylline use was somewhat more in the control group, but this is not likely to reflect a protective role for that drug. The possible involvement of an infectious agent should be considered.
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Affiliation(s)
- N A Shorter
- Department of Surgery, Children's Hospital at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA
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23
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Abstract
There are few reports of gastrocolic fistula in infancy. Our observations on the clinical course of this condition are presented. The diagnostic possibilities and surgical procedure are discussed.
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Affiliation(s)
- J Hager
- Department of Pediatric Surgery, I. University Hospital for Surgery, Innsbruck, Austria
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25
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Izraeli S, Freud E, Mor C, Litwin A, Zer M, Merlob P. Neonatal intestinal perforation due to congenital defects in the intestinal muscularis. Eur J Pediatr 1992; 151:300-3. [PMID: 1499584 DOI: 10.1007/bf02072234] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Congenital defect of the muscular layer of the small intestine is a rare cause of spontaneous bowel perforation in premature infants. During the last 12 years we have observed four similar cases. We describe the most recent one, a premature infant who developed two abdominal events. On her 2nd day of life, spontaneous perforation of the distal ileum due to focal absence of the muscular layer occurred. Several weeks later she developed the typical clinical and histological picture of necrotizing enterocolitis. The clinical and histological characteristics of the two different conditions are compared, and the 24 cases reported in the literature are discussed. We conclude that focal absence of intestinal musculature may be not such a rare entity as is commonly believed.
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Affiliation(s)
- S Izraeli
- Department of Neonatology, Beilinson Medical Centre, Petach Tiqva, Israel
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26
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Abstract
During the last decade neonatal surgical results have improved considerably. Except for infants born with serious congenital heart disease, diaphragmatic hernia or exomphalos, postoperative mortality rates for infants with single anomalies have fallen to the region of 10%. This dramatic success story has been marred by a corresponding increase in the number of individuals with several anomalies entering late childhood with severe chronic handicaps. During the remainder of this century much effort will be expended in devising programmes of investigation which will attempt to predict which individuals will have a poor long-term prognosis. Such programmes will necessitate very close liaison between obstetricians, radiologists, neonatologists, local paediatricians, paediatric surgeons, general practitioners and parents. Very urgent surgery is necessary for the best results in infants with gastroschisis, intestinal volvulus and irreducible inguinal hernia, but for most other conditions there have been recent trends away from very urgent surgery to operation during daylight hours within the ensuing 24 h. Surgery within a few hours of presentation is necessary for intussusception and for early acute appendicitis, but perforated appendicitis should be treated by aggressive fluid replacement and intravenous antibiotics and surgery should be contemplated only in the rare cases of continued deterioration.
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Sharma AK, Prabhakar G, Agarwal LD, Sharma CS, Sharma SC, Haldiya KN. Spontaneous duodenal perforation in neonates. Indian J Pediatr 1991; 58:383-5. [PMID: 1937655 DOI: 10.1007/bf02754976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- A K Sharma
- Department of Pediatric Surgery, S.P.M. Child Health Institute, S.M.S. Medical College, Jaipur
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Weinberg G, Kleinhaus S, Boley SJ. Idiopathic intestinal perforations in the newborn: an increasingly common entity. J Pediatr Surg 1989; 24:1007-8. [PMID: 2809944 DOI: 10.1016/s0022-3468(89)80203-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Between 1982 and 1987 seven neonates ranging in age from 24 hours to 1 week were treated for idiopathic intestinal perforations at the Montefiore Medical Center, Albert Einstein College of Medicine. Four of the infants were born prematurely; three were full term. Five were being treated in an intensive care nursery when the perforation was diagnosed. All infants whose perforations were due to necrotizing enterocolitis, appendicitis, Hirschsprung's disease, meconium ileus, intestinal atresias, or drug therapy are excluded from the series. None of the infants had associated anomalies. The sites of the perforations were as follows: two in the jejunum, two in the ileum, one in the cecum, and two in the transverse colon. Six of the perforations were on the antimesenteric aspect of the bowel; one was on the mesenteric aspect. The sizes of the perforations ranged from pinhole to 1 cm in diameter. All the infants did well. Pathologic examination of the resected specimens failed to reveal an etiology for the perforations. There were no cases of duplication or muscular hypoplasia. We believe the etiology of this condition may be ischemic necrosis, secondary to a localized vascular accident in the wall of the affected viscus, but we do not have a good explanation for the upsurge in cases we are seeing.
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Affiliation(s)
- G Weinberg
- Division of Pediatric Surgery, Montefiore Medical Center, New York, NY
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