Distinguishing outcomes of neonatal intestinal volvulus: Review of our experience over the last 20 years

Clinical management of intestinal malrotation in different age groups

PURPOSE

Intestinal malrotation, characterized by abnormal intestinal positioning, can lead to severe complications like volvulus and internal hernias, especially in neonates and children. Our aim was to evaluate the diagnostic methods, treatment results and postoperative follow-up of pediatric patients treated for intestinal malrotation.

METHODS

This retrospective study reviewed medical records of pediatric patients who underwent surgery for intestinal malrotation between January 2013 and January 2022. Data on demographics, symptoms, diagnostic approaches, surgical interventions, and postoperative outcomes were analyzed.

RESULTS

The study included 45 patients, with a male predominance (68.8%). Ages ranged from 1 day to 15 years, averaging 1.54 years. Presenting symptoms were acute abdomen (n = 21) and chronic abdominal pain with vomiting (n = 24). Diagnoses were established via physical exams and imaging, including upper gastrointestinal contrast studies and abdominal ultrasonography. All patients received the Ladd procedure, with some requiring necrotic bowel resection due to volvulus.

CONCLUSION

The diagnosis and management of pediatric intestinal malrotation present significant challenges due to its variable symptoms and potential for life-threatening complications. Early and accurate diagnosis, followed by appropriate surgical management, is crucial. This study emphasizes the importance of diligent postoperative follow-up to identify and mitigate complications, particularly in younger and severely affected patients.

Neonatal Intestinal Segmental Volvulus: What Are the Differences with Midgut Volvulus?

OBJECTIVE

 Intestinal volvulus in the neonate is a surgical emergency caused by either midgut volvulus (MV) with intestinal malrotation or less commonly, by segmental volvulus (SV) without intestinal malrotation. The aim of our study was to investigate if MV and SV can be differentiated by clinical course, intraoperative findings, and postoperative outcomes.

METHODS

 Using a defined search strategy, two investigators independently identified all studies comparing MV and SV in neonates. PRISMA guidelines were followed, and a meta-analysis was performed using RevMan 5.3.

RESULTS

 Of 1,026 abstracts screened, 104 full-text articles were analyzed, and 3 comparative studies were selected (112 patients). There were no differences in gestational age (37 vs. 36 weeks), birth weight (2,989 vs. 2,712 g), and age at presentation (6.9 vs. 3.8 days). SV was more commonly associated with abnormal findings on fetal ultrasound (US; 65 vs. 11.6%; p < 0.00001). Preoperatively, SV was more commonly associated with abdominal distension (32 vs. 77%; p < 0.05), whereas MV with a whirlpool sign on ultrasound (57 vs. 3%; p < 0.01). Bilious vomiting had similar incidence in both (88 ± 4% vs. 50 ± 5%). Intraoperatively, SV had a higher incidence of intestinal atresia (2 vs. 19%; p < 0.05) and need for bowel resection (13 vs. 91%; p < 0.00001). There were no differences in postoperative complications (13% MV vs. 14% SV), short bowel syndrome (15% MV vs. 0% SV; data available only from one study), and mortality (12% MV vs. 2% SV).

CONCLUSION

 Our study highlights the paucity of studies on SV in neonates. Nonetheless, our meta-analysis clearly indicates that SV is an entity on its own with distinct clinical features and intraoperative findings that are different from MV. SV should be considered as one of the differential diagnoses in all term and preterm babies with bilious vomiting after MV was ruled out-especially if abnormal fetal US and abdominal distension is present.

Prenatal Sonography in Suspected Proximal Gastrointestinal Obstructions: Diagnostic Accuracy and Neonatal Outcomes

BACKGROUND

The purpose of this study was to assess diagnostic accuracy and neonatal outcomes in fetuses with a suspected proximal gastrointestinal obstruction (GIO).

METHODS

After IRB approval, a retrospective chart review was conducted on prenatally suspected and/or postnatally confirmed cases of proximal GIO at a tertiary care facility (2012-2022). Maternal-fetal records were queried for presence of a double bubble ± polyhydramnios, and neonatal outcomes were assessed to calculate the diagnostic accuracy of fetal sonography.

RESULTS

Among 56 confirmed cases, the median birthweight and gestational age at birth were 2550 g [interquartile range (IQR) 2028-3012] and 37 weeks (IQR 34-38), respectively. There was one (2%) false-positive and three (6%) false-negatives by ultrasound. Double bubble had a sensitivity, specificity, positive predictive value, and negative predictive value for proximal GIO of 85%, 98%, 98%, and 83%, respectively. Pathologies included 49 (88%) with duodenal obstruction/annular pancreas, three (5%) with malrotation, and three (5%) with jejunal atresia. The median postoperative length of stay was 27 days (IQR 19-42). Cardiac anomalies were associated with significantly higher complications (45% vs 17%, p = 0.030).

CONCLUSIONS

In this contemporary series, fetal sonography has high diagnostic accuracy for detecting proximal gastrointestinal obstruction. These data are informative for pediatric surgeons in prenatal counseling and preoperative discussions with families.

LEVEL OF EVIDENCE

Diagnostic Study, Level III.

Causes of bloody stools in neonates: a case series report

BACKGROUND

Bloody stools in a neonate may stand for a spectrum of conditions ranging from benign to life-threatening. It is critical to detect the cases that have significant underlying pathology, especially those which require urgent surgical intervention. Previous studies always focused on one particular disease related to bloody stools in neonates, or the study only involved a small number of cases. This study aimed to investigate the common causes of bloody stools in neonates.

METHODS

This retrospective cohort study included the neonates admitted to our institution due to "bloody stools" over a 5-year period. We compared the differences among patients' characteristics, feeding choice, underlying diseases, and operation rate between preterm and term neonates.

RESULTS

A total of 300 patients were included, accounting for 1.1% of the total neonatal admissions. The overall rate of exclusive breastfeeding was 28.0%. The most common underlying causes for bloody stools were: cow's milk protein allergy (CMPA, 53.3%), swallowed blood syndrome (10.0%), viral enteritis (9.7%), necrotizing enterocolitis (NEC) > stage II (8.3%), non-specific enteritis (7.3%), and anal fissure (5.0%). The median [interquartile range (IQR)] onset age for bloody stools for all infants was 12 [3-22] days after birth. Preterm neonates had a lower rate of exclusive breastfeeding (P=0.844), higher incidence of NEC > stage II (P=0.014), later bloody stools onset age (P<0.001), and longer length of hospital stay than term neonates (P<0.001). For neonates with NEC, those with bottle-fed had an earlier onset age for bloody stools than those with breast-fed (P=0.027). Only 1.7% (n=5) required surgery (2 stage III NEC, 1 post-NEC stricture, and 2 volvuli). Survival at hospital discharge was 100%.

CONCLUSIONS

Bloody stools in neonates is generally a benign, self-limiting disorder, not related to surgical conditions. The overall operation rate among neonates with bloody stools was only 1.7%. CMPA and NEC were the most common underlying non-surgical and surgical diseases, respectively, for neonates with bloody stools. Feeding choice is related to bloody stools in neonates, policies and strategies to support breastfeeding should be strengthened in the future.

Nomogram for Estimating the Risks of Intestinal Ischemia and Necrosis in Neonates With Midgut Volvulus: A Retrospective Study

BACKGROUND

Delayed diagnosis and inaccurate judgment of the severity of the disease may be the principal reasons for the poor prognosis associated with neonatal midgut volvulus. We aimed to develop a nomogram model that timely assesses the risks of intestinal ischemia and necrosis in the neonate with midgut volvulus.

MATERIALS AND METHODS

We retrospectively analyzed the clinical data from neonates with midgut volvulus who were admitted to Guangzhou Women and Children's Medical Center from January 2009 to December 2019. Univariate and multivariate analyses were used to obtain independent factors to build a predictive model. The independent factors were used to develop the nomogram model.

RESULTS

Heart rate, mean arterial pressure, serum C-reactive protein, serum sodium, serum albumin, and pH levels were independent predictors for intestinal ischemia and necrosis in patients with midgut volvulus. The area under the receiver operating characteristic curve (AUC) of the predictive model was 0.985 (95% confidence interval, 0.966-0.999; P < 0.001). The sensitivity was 90.48%, and the specificity was 93.10%. A nomogram model was established using the six independent predictors, with a C-index of 0.859 and a favorable consistency between the predicted and actual intestinal ischemia and necrosis rates according to the internal validation.

CONCLUSION

The constructed nomogram model could be a superior tool for predicting intestinal ischemia and necrosis in neonates with midgut volvulus.