Risk factors for spontaneous localized intestinal perforation in the preterm infant

Neonatal Gastrointestinal Perforations: A 4-year Experience in a Single Centre

BACKGROUND

Gastrointestinal perforation (GIP) during the neonatal period is still a significant problem despite improved neonatal care. The study aimed to report on incidence, management, morbidity and mortality.

MATERIAL AND METHODS

Records of neonates with GIPs between October 2018 and November 2022 were retrospectively analysed.

RESULTS

There were 47 patients, 22 (46.8%) males and 25 (53.2%) females. The incidence of neonatal GIP was 0.39% amongst all newborns treated in the neonatal intensive care unit. The mean gestational age was 30.4 ± 4.5 (23-38) weeks, and the mean birth weight was 1493.08 ± 753 (580-2940) g. Of 47 neonates, 5 (10.6%) were full term and 42 (89.4%) were preterm. The mean age of surgery was 12.25 ± 9.89 (0-41) days. A laparotomy was performed in 43 (91.4%) of 47 neonates, while seven of the patients underwent surgical intervention after decompression by percutaneous drainage. Four patients were managed with peritoneal drainage alone due to poor general condition. The pathologies unrelated to necrotising enterocolitis (NEC) were the most common cause of GIPs (55.3%) and included spontaneous intestinal perforation (n = 18), stomach perforation (n = 4), segmental volvulus (n = 2), acute mesenteric ischaemia (n = 1) and meconium peritonitis (n = 1). Overall survival was 55.4%.

CONCLUSION

GIPs are one of the most significant causes of mortality in newborns. The most common cause of perforations is non-NEC entities and can be seen in the entire intestinal system from the stomach to the colon. Surgical exploration is still the primary management model.

Association between Abnormal Antenatal Doppler Characteristics and Gastrointestinal Outcomes in Preterm Infants

Antenatal Doppler disturbances are associated with fetal hypoxia and may induce a brain-sparing vascular redistribution at the expense of splanchnic circulation, possibly predisposing to gut complications. We aimed to compare several gastrointestinal outcomes among very-low-birthweight (VLBW) preterm infants with different antenatal Doppler features. VLBW infants born between 2010-2022 were retrospectively included and stratified into the following clusters based on antenatal Doppler characteristics: normal Doppler (controls); absent or reversed end-diastolic flow in the umbilical artery (UA-AREDF) alone or also in the ductus venosus (UA+DV-AREDF); and abnormal Doppler with or without brain-sparing redistribution. The following outcomes were evaluated: time to reach full enteral feeds (FEF), feeding intolerance (FI), necrotizing enterocolitis (NEC), and spontaneous intestinal perforation (SIP). Overall, 570 infants were included. Infants born following UA+DV-AREDF had significantly higher FI, NEC, and SIP rates and achieved FEF later compared to controls. Increased FI prevalence and a longer time to FEF compared to controls were also observed among UA-AREDF infants and in the presence of brain-sparing redistribution, which also increased NEC rates. Antenatal Doppler abnormalities exacerbate the gastrointestinal risks of preterm infants. Detailed knowledge of Doppler features can aid in identifying those at highest risk of intestinal complications who may benefit from tailored enteral feeding management.

Development of artificial neural networks for early prediction of intestinal perforation in preterm infants

Intestinal perforation (IP) in preterm infants is a life-threatening condition that may result in serious complications and increased mortality. Early Prediction of IP in infants is important, but challenging due to its multifactorial and complex nature of the disease. Thus, there are no reliable tools to predict IP in infants. In this study, we developed new machine learning (ML) models for predicting IP in very low birth weight (VLBW) infants and compared their performance to that of classic ML methods. We developed artificial neural networks (ANNs) using VLBW infant data from a nationwide cohort and prospective web-based registry. The new ANN models, which outperformed all other classic ML methods, showed an area under the receiver operating characteristic curve (AUROC) of 0.8832 for predicting IP associated with necrotizing enterocolitis (NEC-IP) and 0.8797 for spontaneous IP (SIP). We tested these algorithms using patient data from our institution, which were not included in the training dataset, and obtained an AUROC of 1.0000 for NEC-IP and 0.9364 for SIP. NEC-IP and SIP in VLBW infants can be predicted at an excellent performance level with these newly developed ML models. https://github.com/kdhRick2222/Early-Prediction-of-Intestinal-Perforation-in-Preterm-Infants.

Clinical Presentation and Multifactorial Pathogenesis of Necrotizing Enterocolitis in the Preterm Infant

BACKGROUND

Necrotizing enterocolitis (NEC) is a serious infection of the bowel wall induced by multiple pathological factors, which include inflammation and tissue invasion with bacteria known to cause severe infections. NEC is now understood to be several disease processes under one umbrella. The most common form occurs in premature infants and can exert significant impacts to preterm morbidity and mortality.

PURPOSE

This narrative review describes current knowledge of the clinical presentation and pathophysiology of NEC in premature infants.

METHODS/SEARCH STRATEGY

A review of literature was conducted using key words in PubMed and CINAHL with preference for years 2015 to 2020.

FINDINGS/RESULTS

Several converging and interrelated factors including characteristics of the premature intestinal mucosa, gut ischemia, dysregulation of the microbiome, enteral feeding, and genetics create an environment where NEC is more likely to occur.

IMPLICATIONS FOR PRACTICE

To recognize and diagnose NEC in preterm infants, an understanding of underlying factors that create an optimal environment for disease acquisition in premature infants is essential.

IMPLICATIONS FOR RESEARCH

Prevention of NEC remains the most important strategy for decreasing morbidity and mortality. Multiple areas of potential study exist for NEC pathophysiology including those that consider how the factors discussed in this review are interrelated and how each particular pathway can be optimized to prevent the onset of NEC.

Spontaneous intestinal perforation associated with premature twin infants

OBJECTIVE

Identify perinatal risk factors associated with SIPSTUDY DESIGN:This was a retrospective case-control study of SIP in infants born at ≤28 weeks of gestation and admitted between 1995 and 2016 at a tertiary care NICU. Infants with NEC or other GI abnormalities were excluded. Cases of SIP were matched with gestational age-matched controls with the closest birth date. Maternal, infant and birth related factors were evaluated using univariate analyses and significant factors were evaluated using multiple logistic regression.

RESULT

25 cases of SIP were matched with 25 controls. No maternal factors reached statistical significance. Being one of twins increased the odds of SIP 29-fold. Birth-order or weight-discrepancy in twin had no association of SIP within twin pairs.

CONCLUSION

Twins are at significantly higher risk for SIP. The association of SIP and twin gestation was independent of previously reported risk factors of perinatal indomethacin or magnesium sulfate and merits further study.

Long-term outcomes of very low birth weight infants with spontaneous intestinal perforation: A retrospective case-matched cohort study

BACKGROUND

Spontaneous intestinal perforation (SIP) is an intestinal complication that occurs in very ill preterms. We investigated whether SIP survivors have worse neurodevelopmental and gastrointestinal outcomes and a poorer quality of life than controls.

METHODS

A retrospective case-matched cohort study was performed involving infants treated for SIP in a NICU between August 1994 and April 2014. Controls and SIP patients were matched to gestational age, gender, and birth period. Medical records were reviewed. Telephone surveys were conducted to evaluate the medical condition, quality of life (PedsQL™ 4.0), neuropsychiatric and gastrointestinal outcome. McNemar's and Wilcoxon tests were performed, and generalized linear models were computed.

RESULTS

Forty-nine SIP patients were included. The percentages of children with multiple disabilities (40% vs. 17%, OR = 3.3) and requiring physiotherapy (86% vs. 60%, OR = 4.77) were higher in the SIP group than in the control group. Intraventricular hemorrhage (IVH) led to a worse neurodevelopmental outcome regardless of SIP (OR = 8.79 for disability), and female gender was a protective factor against disability (OR = 0.06). Reported quality of life and gastrointestinal comorbidities did not differ between the two groups.

CONCLUSION

SIP survivors tend to be at risk of multiple disabilities. IVH and female gender influence the neurodevelopmental outcome regardless of SIP.

LEVELS OF EVIDENCE

Level III: case-control study.

Isolated Ascites in a Monochorionic Twin after Fetoscopic Laser Ablation Is Not Necessarily Secondary to Recurrence or Anaemia: Bowel Complications in Twin-to-Twin Transfusion Syndrome after Fetoscopic Laser Ablation

BACKGROUND/PURPOSE

We report a case study of jejunal atresia and the results of a systematic literature review of all reported cases of bowel complications occurring after fetoscopic laser ablation (FLA) for the treatment of twin-to-twin transfusion syndrome (TTTS).

METHODS

A systematic literature review was performed of bowel complications after FLA for TTTS according to PRISMA guidelines.

RESULTS

There are 11 published cases of small bowel atresia, 5 cases of necrotising enterocolitis (NEC), and 2 cases with foetal bowel perforations. Recipient twins were more likely to be affected by small bowel atresia (7 recipient and 4 donor cases) and NEC (3 recipient and 2 donor twins). Prenatal ultrasonographic abnormalities were demonstrated in 7 out of 9 cases with bowel atresia and in both cases of bowel perforation. The overall survival rate for neonates with bowel complications after FLA is 72%, but is much lower for co-twins at 22%. The survival rates for jejunoileal atresia and NEC are 91 and 40%, respectively.

CONCLUSIONS

It is uncertain as to whether these bowel anomalies are due to bowel ischaemia associated with TTTS, the treatment with FLA, or a combination of both. Cases with prenatal abdominal ultrasonographic abnormalities after FLA should have close prenatal and postnatal assessment to detect bowel complications.

Jejunal perforation as an unusual presentation of total colonic aganglionosis in a neonate: A case report

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Untreated distal bowel obstruction eventually leads to perforation near the obstruction.

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Total colonic aganglionosis can present as a proximal jejunal perforation.

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Distal bowel should also be sought in cases of proximal bowel perforation.

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Appendiceal biopsy can be a reliable tool for suspecting total colonic aganglionosis.

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Multiple colon and rectal biopsies are necessary to diagnose total colonic aganglionosis.

Introduction

Neonatal intestinal perforation usually occurs at distal small bowel secondary to distal bowel obstruction. The aim of this report is to describe an unusual case of total colonic aganglionosis with an initial presentation of proximal jejunal perforation.

Presentation of case

A male newborn presented with jejunal perforation on the fifth day of life and was treated by laparoscopic primary repair. Abdominal distention persisted postoperatively, and radiological examination revealed an obstruction near the terminal ileum. Laparotomy showed a transition zone 30-cm proximal to the ileocecal valve, and diverting ileostomy and appendiceal biopsy was performed. Permanent section demonstrated the complete absence of ganglion cells in the appendix and total colonic aganglionosis was strongly suspected.

Discussion

Contrary to the classic teaching, proximal bowel perforation can occur in case of far distal obstruction, and careful distal evaluation would direct more appropriate surgical treatment option.

Conclusions

Total colonic aganglionosis can present as a proximal bowel perforation. Careful distal evaluation can provide diagnostic clues in cases of proximal intestinal perforation. Appendiceal biopsy is a reliable tool for evaluating suspected total colonic aganglionosis, but multiple colonic and rectal biopsies should be obtained to confirm the diagnosis.