The clip and drop back technique in the management of multifocal necrotizing enterocolitis: a single centre experience

AIM

The surgical management of multifocal necrotizing enterocolitis (NEC) remains a major challenge. The "clip-and-drop" strategy with a second-look laparotomy permits re-assessment of bowel viability after optimization, thus offering the potential of both improving survival and conserving bowel length. This study reviews the outcome of this strategy in a single regional center.

METHODS

Since 2000, NEC patients undergoing emergency laparotomy selectively underwent a "clip-and-drop" operation if there was peri-operative instability and/or multifocal disease with uncertain bowel viability. Bowel with full thickness gangrene was resected and bowel-ends were temporarily tied-off; a second-look definitive procedure was performed when the patient had stabilized. For this review, in-hospital and follow-up records were studied retrospectively for demographics, 30-day mortality and long-term outcome.

MAIN RESULTS

Between 2000 and 2010, 16 patients underwent a "clip-and-drop" operation. The mean post-conception age was 32.8 weeks (27.7-41.7 weeks) with a median body weight of 1.4 kg (0.76-4.4 kg) at first operation. Preoperative radiograph showed free gas in 43.8% and portal venous gas in 37.5% of patients. 2 patients did not survive to the second laparotomy. 14 patients received a second laparotomy, after a mean of 51 h (35-74 h). 2 patients were found to suffer from NEC totalis on the second laparotomy and died without further procedures. All other patients (n = 12) had stoma formation. 1 patient died 4 days after stoma formation. The 30-day mortality for NEC with the "clip-and-drop" strategy was 31.6% (5/16). Among the 11 survivors, 1 died from liver failure complicated by short bowel syndrome at 5 months post operation, 2 others died from respiratory complications of prematurity despite adequate gastrointestinal function. The median follow-up time for the 8 long-term survivors was 45 months (7-129 months). Their median time to achieving full feeds was 41 days (range 21-105 days) after the second operation.

CONCLUSION

The "clip-and-drop" strategy, when used in selected patients with multifocal NEC, may help bowel conservation in survivors.

Minimal access surgery for sigmoid volvulus in children

A 12-year-old boy presented with large-bowel obstruction due to sigmoid volvulus. Temporary relief was achieved with rectal tube decompression. Elective laparoscopic-assisted sigmoid colectomy was performed. Post-operative recovery was uneventful. The patient remained well with no recurrence after 4 years of follow-up. Laparoscopic-assisted sigmoid colectomy may be the procedure of choice for selected children with sigmoid volvulus.

Electrical stimulation and biofeedback exercise of pelvic floor muscle for children with faecal incontinence after surgery for anorectal malformation

We report our experience of electrical stimulation and biofeedback exercise of pelvic floor muscle for children with faecal incontinence after surgery for anorectal malformation (ARM). Electrical stimulation and biofeedback exercise of pelvic floor muscle were performed on children with post-operative faecal soiling following repair of intermediate or high type ARM. Children under the age of 5 years or with learning difficulties were excluded. They had 6 months supervised programme in the Department of Physiotherapy followed by 6 months home based programme. Bowel management including toilet training, dietary advice, medications and enemas were started before the pelvic floor muscle exercise and continued throughout the programme. Soiling frequency rank, Rintala continence score, sphincter muscle electromyography (EMG) and anorectal manometry were assessed before and after the programme. Wilcoxon signed rank test was performed for statistical analysis. From March 2001 to May 2006, 17 children were referred to the programme. Twelve patients (M:F = 10:2; age = 5-17 years) completed the programme. There was a trend of improvement in Rintala score at sixth month (p = 0.206) and at the end of programme (p = 0.061). Faecal soiling was significantly improved at sixth month (p = 0.01) and at the end of the programme (p = 0.004). Mean sphincter muscle EMG before treatment was 1.699 microV. Mean EMG at sixth month and after the programme was 3.308 microV (p = 0.034) and 3.309 microV (p = 0.002) respectively. After the programme, there was a mean increase in anal sphincter squeeze pressure of 29.9 mmHg (p = 0.007). Electrical stimulation and biofeedback exercise of pelvic floor muscle is an effective adjunct for the treatment of faecal incontinence in children following surgery for anorectal malformation.

Laparoscopic mobilization of testicular vessels: an adjunctive step in orchidopexy for impalpable and redo undescended testis in children

The testicular position after conventional inguinal orchidopexy for canalicular, "peeping" and redo undescended testes may not be satisfactory despite retroperitoneal dissection. Laparoscopy allows extensive mobilization of testicular vessels to gain additional length. We review our experience of using laparoscopic mobilization of testicular vessels (LMTV) in orchidopexy for these difficult undescended testes. From January 2003 to May 2004, LMTV was performed in 18 boys. The testicular vessels were mobilized from just proximal to the internal inguinal ring to the level of caecum and sigmoid colon respectively. Fifteen patients had clinically impalpable testes. Diagnostic laparoscopy revealed 13 "peeping" and 2 canalicular testes. LMTV was performed together with inguinal orchidopexy. There were three cases of redo orchidopexies because of unfavourable testicular position after previous surgery. LMTV was performed following inguinal dissection. The median follow-up period is 11.7 months. Sixteen testes are located at the base of scrotum, and two at mid-scrotum. The size is normal in 17 testes, whereas 1 testis is smaller than the contralateral one. LMTV is a safe and efficient adjunctive step in orchidopexy for impalpable and redo undescended testes.