Intestinal Atresia: Experience at a Busy Center of North-West India

Management and Outcomes of Intestinal Atresia - A Single Institution Experience From 1947 to 2019

AIM OF THE STUDY

We aimed to evaluate disease characteristics, associated malformations and surgical outcomes of congenital intestinal atresia.

METHODS

We identified all patients with jejunoileal (JIA) or colonic atresia (CA) treated at the Helsinki University Children's hospital during 1947-2019 and collected clinical data retrospectively from archived and electronic medical records.

RESULTS

Of the 180 included patients, 156 had JIA and 24 CA. Overall survival improved markedly from 34% during 1947-1977 to 93% during 1978-2019. Rate of primary anastomosis (81% in JIA, 21% in CA) remained unchanged while early surgical complications decreased (32% vs 18%, P = 0.04) and prematurity rate increased (21% vs 45%, P = 0.002) among JIA patients over time. Around half of patients had associated, mostly gastrointestinal malformations which occurred comparably in JIA and CA. During 1978-2019, 20 (21%) JIA patients, but none of CA patients, developed short bowel syndrome. Presence of type 3b atresia (n = 16) or gastroschisis (n = 14), but not the extent of intestinal resection or surgical complications, was associated with development of short bowel syndrome without decreasing survival. Shorter primary bowel resection without tapering surgery in JIA predisposed to repeated resections due to obstructive symptoms, and prolonged duration of parenteral nutrition.

CONCLUSION

Survival of patients with JIA and CA has improved remarkably over time and is currently high despite frequent prematurity and associated malformations. In patients with JIA, apple peel atresia and gastroschisis predisposed to short bowel syndrome without jeopardizing high survival rates.

LEVEL OF EVIDENCE

IV.

Importance of Prenatal Diagnosis of Ileal Atresia in Gestational Diabetes Cases

BACKGROUND Maldevelopment of the fetal bowel can result in the rare condition of intestinal atresia, which results in congenital bowel obstruction. This report describes a case of prenatal diagnosis of fetal ileal atresia at 22 weeks' gestation. CASE REPORT Here, we present a 24-year old woman who was 22 weeks into her first pregnancy when she underwent routine fetal ultrasound. She was diagnosed with gestational diabetes mellitus. Her body mass index was normal and she had normal weight gain. The ultrasonographic examination performed revealed a hyperechoic bowel and a small dilatation of the bowel. The couple was counselled for possible intestinal atresia and its postnatal implications. At 33 weeks of gestation, polyhydramnios appeared, and the intestinal distension was much more pronounced, with hyperechoic debris in the intestinal lumen (succus-entericus). After birth, surgery was performed and we concluded the patient had type II atresia, which was surgically treated. CONCLUSIONS This report has highlighted the importance of antenatal ultrasound in detecting fetal abnormalities, and has shown that rare conditions such as intestinal atresia can be accurately diagnosed and successfully managed. Surgical correction, if implemented promptly after stabilizing the general condition, can have a relatively good prognosis. Coexisting fetal ileal atresia and gestational diabetes mellitus are rare occurrences, which can make each condition even more difficult to treat.

Type IIIb jejunal atresia treated surgically with two end-to-end anastomoses

A term newborn presented after birth with abdominal distension and vomiting in a developing country in Asia. Ultrasonography suggested intestinal obstruction and abdominal X-ray showed a 'double-bubble' sign suggestive of intestinal atresia. The newborn was diagnosed with early-onset neonatal sepsis secondary to intestinal obstruction and transferred to the neonatal intensive care unit. Surgery was performed and type IIIb jejunal atresia was found. Type IIIa/b jejunal atresia is associated with high incidence of poor outcome in lower socioeconomic countries. The affected intestinal segment and a distal serosal tear were resected and two end-to-end anastomoses formed. Oral feeding commenced on day 13 postoperatively. The patient was discharged on day 20 with adequate nutritional status. At follow-up, the patient continued to thrive. An operation involving resection of two different segments of bowel repaired with two end-to-end anastomoses in a neonate had a successful outcome for the patient.

Jejunoileal atresia: a case-series of 63 neonates and risk factors to mortality

Introduction

Jejunoileal atresia (JIA) among neonates is still a condition which has huge morbidity and mortality, particularly in the developing world. We share a case series of JIA in context of their presentation, management, and outcome.

Materials and methods

This study was conducted at Children’s Hospital and Institute of Child Health, Lahore, over 1 year. We included all patients presenting with JIA, and their demographic details, presentation, investigations, treatment strategies, and the outcome were noted at a pre-designed proforma. All data were analyzed using SPSS version 26.

Results

A total of 63 neonates with JIA were included. Most of them (79.4%) presented after 48 h of life, and the mean age at presentation was 5.68 ± 4.75 days. There were 37 male patients (58.7%), and 51 (81%) were full-term. The most common presenting complaint was not being able to pass meconium (88.9%). Type III atresia was the most common subtype (41.3%). Most of them underwent resection without tapering. The mean hospital stay was 12.81 ± 6.53, and it was significantly longer among those who underwent re-exploration (P = 0.034). Twenty-three patients (36.5%) expired within 6 months of follow-up. The only significant factor for mortality was the presence of short bowel syndrome (P = 0.030). All other demographic and management factors did not alter the mortality rate.

Conclusion

Management of surgical neonates is a difficult job in developing countries with limited resources. There is a high mortality rate of neonates following JIA surgeries, and surgeons in these countries must fight on many fronts to improve the outcome.

Clinical Profile, Outcomes and Predictors of Mortality in Neonates Operated for Gastrointestinal Anomalies in a Tertiary Neonatal Care Unit- An Observational Study

Background

Gastrointestinal (GI) malformations have varied short-term and long-term outcomes reported across various neonatal units in India.

Methods

This descriptive study was done to study the clinical profile, outcomes and predictors of mortality in neonates operated for congenital GI malformations in a tertiary neonatal care unit in South India between years 2011 and 2020. Details were collected by retrospective review of the case sheets.

Results

Total of 68 neonates were included with esophageal atresia (EA) in 10, infantile hypertrophic pyloric stenosis (IHPS) in 9, duodenal atresia (DA) in 10, ileal atresia in 8, jejunal atresia in 5, anorectal malformations (ARM) in 11, meconium ileus/peritonitis in 9, malrotation in 2, and Hirschsprung's disease (HD) in 4. Antenatal diagnosis was highest in DA (80%). Associated anomalies were maximum in EA (50%), the most common being vertebral, anal atresia, cardiac defects, tracheoesophageal fistula, renal and radial abnormalities, and limb abnormalities association (VACTERL). Overall mortality was 15%. IHPS, DA, Malrotation, HD and ARM had 100 % survival while ileal atresia had the least survival (38%). Gestational age <32 weeks (odds ratio [OR] 12.77 [1.96, 82.89]) and outborn babies (OR 5.55 [1.01, 30.33]) were significant predictors of mortality in babies operated for small intestinal anomalies. None of the surviving infants were moderately or severely underweight at follow-up.

Conclusion

Overall survival of surgically correctable GI anomalies is good. Among the predictors for mortality, modifiable factors such as in-utero referral of antenatally diagnosed congenital anomalies need attention. One-fifth had associated anomalies highlighting the need to actively look for the same. Although these neonates are vulnerable for growth failure, they had optimal growth on follow-up possibly due to standardized total parenteral nutritional policy during neonatal intensive care unit stay.

How can we improve perinatal care in isolated multiple intestinal atresia? A retrospective study with a 30-year literature review

INTRODUCTION

Multiple intestinal atresia (MIA) is a rare cause of neonatal intestinal obstruction. To provide an overview of the current prenatal, surgical, and nutritional management of MIA, we report our experience and a literature review of papers published after 1990.

METHODS

All cases of isolated MIA (non-hereditary, not associated with apple-peel syndrome or gastroschisis) treated at our institution between 2005 and 2016 were reviewed and compared with cases found in the literature.

RESULTS

Seven patients were prenatally suspected of having intestinal obstruction and were postnatally diagnosed with MIA, with a mean 1.7 (1-2) resections-anastomoses (RA) and 6 (1-10) strictureplasties performed, resulting in a mean resected bowel length of 15.1cm (15-25 cm). Median time to full oral feed was 46 days (14-626 days). All patients were alive and none had orality disorder after a mean follow-up of 3.1 years (0.2-8.1 years). Three surgical strategies were found in the literature review: multiple RA (68%, 34/50) including Santulli's technique in four of 34 (12%) and anastomoses over a transanastomotic tube (32%, 16/50), with a 98% survival rate, and short-bowel syndrome for only two patients.

CONCLUSION

Bowel-sparing surgery and appropriate medical management are key to ensuring a favorable nutritional and gastrointestinal outcome and a good prognosis. Prenatal assessment and standardization of the surgical course of treatment remain challenging.

An Atypical Variant of Apple Peel Atresia: Reporting a Rare Case

Apple peel intestinal atresia is a rare congenital malformation. It consists of a proximal jejunum ending in a blind pouch and distal small bowel wrapped around its vascular supply in a spiral fashion. A combination of type IIIb jejunoileal atresia (apple peel atresia) and type IV (multiple intestinal atresias) is a rare entity. The diagnosis and management of such complicated cases is a challenge, especially in resource-limited settings. We report a case of a four-day-old female who presented to the neonatal intensive care unit with complaints of vomiting, yellow discoloration of the skin, and failure to pass meconium since birth. The baby was born preterm (34 weeks) via spontaneous vaginal delivery. The physical examination concluded a jaundiced and dehydrated child with a soft, non-tender abdomen and absent gut sounds. X-ray abdomen showed two air-fluid areas in the left hypochondrium. The upper gastrointestinal gastrografin study revealed that contrast opacified the third part of the duodenum and no contrast was observed beyond it. On exploratory laparotomy, proximal jejunal atresia with four distal atresias in apple peel fashion and a viable 20 cm of small bowel was observed. The apple peel segments were supplied by mesenteric vessels. Unfortunately, our patient expired despite all supportive measures. The case highlights the significance of the prenatal and early postnatal diagnosis of such a complex combination of intestinal atresias for adequate and timely management.

Risk Factors for Surgical Site Infection in Neonates: A Systematic Review of the Literature and Meta-Analysis

Purpose: Surgical site infections (SSI) contribute to postoperative morbidity and mortality in children. Our aim was to evaluate the prevalence and identify risk factors for SSI in neonates. Methods: Using a defined strategy, three investigators searched articles on neonatal SSI published since 2000. Studies on neonates and/or patients admitted to neonatal intensive care unit following cervical/thoracic/abdominal surgery were included. Risk factors were identified from comparative studies. Meta-analysis was conducted according to PRISMA guidelines using RevMan 5.3. Data are (mean ± SD) prevalence. Results: Systematic review-of 885 abstracts screened, 48 studies (27,760 neonates) were included. The incidence of SSI was 5.6% (1,564 patients). SSI was more frequent in males (61.8%), premature babies (77.4%), and following gastrointestinal surgery (95.4%). Meta-analysis-10 comparative studies (16,442 neonates; 946 SSI 5.7%) showed that predictive factors for SSI development were gestational age, birth weight, age at surgery, length of surgical procedure, number of procedure per patient, length of preoperative hospital stay, and preoperative sepsis. Conversely, preoperative antibiotic use was not significantly associated with development of SSI. Conclusions: Younger neonates and those undergoing abdominal procedures are at higher risk for SSI. Given the lack of evidence-based literature, prospective studies may help determine the risk factors for SSI in neonates.