Primary Anastomosis Versus Stoma for Surgical Necrotizing Enterocolitis in US Children's Hospitals

INTRODUCTION

Multiple studies have documented the safety of intestinal anastomosis after resection for necrotizing enterocolitis (NEC). We sought to evaluate a large population of infants with surgical NEC and assess outcomes after primary anastomosis versus enterostomy.

METHODS

The Pediatric Health Information System database was used to identify infants with Bell Stage 3 NEC who underwent an intestinal resection for acute disease between 2016 and 2021. Demographics and preoperative physiology were assessed, and nutritional, infectious, and surgical outcomes were analyzed.

RESULTS

Two hundred twenty-two infants at 38 children's hospitals were included. Thirty-five (15.8%) were managed with a primary anastomosis. Among infants who underwent a resection within 10 d of their first operative intervention and survived for at least 3 d, a primary anastomosis was used in 26 (13.7%). These patients were older but had similar weight and physiological status at the time of resection as those managed with an enterostomy. The incidence of wound and infectious complications, duration of parenteral nutrition and length of stay were similar after anastomosis or enterostomy.

CONCLUSIONS

In a large, geographically heterogenous population of infants with NEC, only 15.8% were managed with a primary anastomosis after intestinal resection. Survivors who underwent resection within 10 d were demographically and physiologically comparable to those who underwent enterostomy and had similar surgical outcomes. While there are clearly indications for enterostomy in some infants with NEC, these data confirm the conclusions of smaller, single-center studies that a primary anastomosis should be considered more frequently.

Complete Resection of Necrotic Bowel Improves Survival in NEC Without Compromising Enteral Autonomy

AIMS

Controversy persists regarding operative strategy for necrotising enterocolitis (NEC). Some surgeons advocate resecting all necrotic bowel, whilst others defunction with a stoma, leaving diseased bowel in situ to preserve bowel length. We reviewed our institutional experience of both approaches.

METHODS

Neonates undergoing laparotomy for NEC May 2015-2019 were identified. Data extracted from electronic records included: demographics, neonatal Sequential Organ Failure Assessment (nSOFA) score at surgery, operative findings, and procedure performed. Neonates were assigned to two groups according to operative strategy: complete resection of necrotic bowel (CR) or necrotic bowel left in situ (LIS). Primary outcome was survival, and secondary outcome was enteral autonomy. Outcomes were compared between groups.

RESULTS

Fifty neonates were identified. Six were excluded: 4 with NEC totalis and 2 with no visible necrosis or histological confirmation of NEC. Of the 44 remaining neonates, 27 were in the CR group and 17 in the LIS group. 32 neonates survived to discharge (73%). On univariate analysis, survival was associated with lower nSOFA score (P = 0.003), complete resection of necrotic bowel (OR 9.0, 95% CI [1.94-41.65]), and being born outside the surgical centre (OR 5.11 [1.23-21.28]). On Cox regression multivariate analysis, complete resection was still strongly associated with survival (OR 4.87 [1.51-15.70]). 28 of the 32 survivors (88%) achieved enteral autonomy. There was no association between operative approach and enteral autonomy (P = 0.373), or time to achieve this.

CONCLUSION

Complete resection of necrotic bowel during surgery for NEC significantly improves likelihood of surviving without negatively impacting remaining bowel function.

LEVEL OF EVIDENCE

III.

[Analysis of clinical characteristics and risk factors of postoperative complications in infants with early-onset necrotizing enterocolitis after enterostomy]

Objective: To investigate the clinical characteristics of children with early-onset necrotizing enterocolitis (NEC) undergoing enterostomy and analyze the risk factors for postoperative complications. Methods: Retrospective analysis was conducted on the clinical data (perinatal conditions, clinical characteristics, clinical outcomes, etc.) of NEC patients who underwent enterostomy at Beijing Children's Hospital from May 2016 to May 2023. The patients were divided into two groups based on the age of onset: an early-onset enterostomy group (<14 days) and a late-onset enterostomy group (≥14 days). Furthermore, the children with NEC were categorized into complication group and non-complication group based on whether there were complications after enterostomy. The differences in clinical data between these groups were analyzed, and the clinical characteristics of children with early-onset NEC and enterostomy were summarized. Multivariate logistic regression model was employed to analyze the risk factors for postoperative complications in NEC children with enterostomy. Results: A total of 68 cases were enrolled, including 43 cases in the early-onset enterostomy group [26 males and 17 females, aged (6.5±3.0) days] and 25 cases in the late-onset enterostomy group [15 males and 10 females, aged (21.0±3.0) days]. There were 28 cases (17 males and 11 females), age [M (Q1, Q3)] 9 (5, 14) days in the complication group and 33 cases (22 males and 11 females), aged of 14 (6, 21) days in the non-complication group. Compared to the late-onset enterostomy group, the early-onset enterostomy group had significantly higher rates of intraventricular hemorrhage [30.2% (13/43) vs 8.0% (2/25)], hemodynamically significant patent ductus arteriosus [37.2% (16/43) vs 12.0% (3/25)], mechanical ventilation≥72 hours after birth [39.5% (17/43) vs 16.0% (4/25)], stage Ⅲ NEC [(69.8% (30/43) vs 40.0% (10/25)], extensive NEC [27.9% (12/43) vs 8.0% (2/25)], and short-term postoperative complications [56.8% (21/37) vs 29.2% (7/24)] (all P<0.05).Multivariate logistic regression model analysis revealed that residual length of proximal small intestine was a protective factor for postoperative complications after enterostomy in NEC infants (OR=0.764, 95%CI: 0.648-0.901, P=0.001), but stage Ⅲ NEC was a risk factor (OR=1.042, 95%CI: 1.004-5.585, P=0.017). Conclusions: The incidence of postoperative complications is high, and the prognosis is poor in children with early-onset NEC enterostomy. The residual length of proximal enterostomy is a protective factor for postoperative complications of NEC enterostomy, but stage Ⅲ NEC is a risk factor.

Umbilical cord milking in nonvigorous infants: a cluster-randomized crossover trial

BACKGROUND

Delayed cord clamping and umbilical cord milking provide placental transfusion to vigorous newborns. Delayed cord clamping in nonvigorous newborns may not be provided owing to a perceived need for immediate resuscitation. Umbilical cord milking is an alternative, as it can be performed more quickly than delayed cord clamping and may confer similar benefits.

OBJECTIVE

We hypothesized that umbilical cord milking would reduce admission to the neonatal intensive care unit compared with early cord clamping in nonvigorous newborns born between 35 and 42 weeks' gestation.

STUDY DESIGN

This was a pragmatic cluster-randomized crossover trial of infants born at 35 to 42 weeks' gestation in 10 medical centers in 3 countries between January 2019 and May 2021. The centers were randomized to umbilical cord milking or early cord clamping for approximately 1 year and then crossed over for an additional year or until the required number of consented subjects was reached. Waiver of consent as obtained in all centers to implement the intervention. Infants were eligible if nonvigorous at birth (poor tone, pale color, or lack of breathing in the first 15 seconds after birth) and were assigned to umbilical cord milking or early cord clamping according to their birth hospital randomization assignment. The baseline characteristics and outcomes were collected following deferred informed consent. The primary outcome was admission to the neonatal intensive care unit for predefined criteria. The main safety outcome was hypoxic-ischemic encephalopathy. Data were analyzed by the intention-to-treat concept.

RESULTS

Among 16,234 screened newborns, 1780 were eligible (905 umbilical cord milking, 875 early cord clamping), and 1730 had primary outcome data for analysis (97% of eligible; 872 umbilical cord milking, 858 early cord clamping) either via informed consent (606 umbilical cord milking, 601 early cord clamping) or waiver of informed consent (266 umbilical cord milking, 257 early cord clamping). The difference in the frequency of neonatal intensive care unit admission using predefined criteria between the umbilical cord milking (23%) and early cord clamping (28%) groups did not reach statistical significance (modeled odds ratio, 0.69; 95% confidence interval, 0.41-1.14). Umbilical cord milking was associated with predefined secondary outcomes, including higher hemoglobin (modeled mean difference between umbilical cord milking and early cord clamping groups 0.68 g/dL, 95% confidence interval, 0.31-1.05), lower odds of abnormal 1-minute Apgar scores (Apgar ≤3, 30% vs 34%, crude odds ratio, 0.72; 95% confidence interval, 0.56-0.92); cardiorespiratory support at delivery (61% vs 71%, modeled odds ratio, 0.57; 95% confidence interval, 0.33-0.99), and therapeutic hypothermia (3% vs 4%, crude odds ratio, 0.57; 95% confidence interval, 0.33-0.99). Moderate-to-severe hypoxic-ischemic encephalopathy was significantly less common with umbilical cord milking (1% vs 3%, crude odds ratio, 0.48; 95% confidence interval, 0.24-0.96). No significant differences were observed for normal saline bolus, phototherapy, abnormal 5-minute Apgar scores (Apgar ≤6, 15.7% vs 18.8%, crude odds ratio, 0.81; 95% confidence interval, 0.62-1.06), or a serious adverse event composite of death before discharge.

CONCLUSION

Among nonvigorous infants born at 35 to 42 weeks' gestation, umbilical cord milking did not reduce neonatal intensive care unit admission for predefined criteria. However, infants in the umbilical cord milking arm had higher hemoglobin, received less delivery room cardiorespiratory support, had a lower incidence of moderate-to-severe hypoxic-ischemic encephalopathy, and received less therapeutic hypothermia. These data may provide the first randomized controlled trial evidence that umbilical cord milking in nonvigorous infants is feasible, safe and, superior to early cord clamping.

Imaging manifestations of neonatal necrotizing enterocolitis to predict timing of surgery

BACKGROUND

To find the predictor of optimal surgical timing for neonatal necrotizing enterocolitis (NEC) patients by analyzing the risk factors of conservative treatment and surgical therapy.

METHODS

Data were collected from 184 NEC patients (Surgery, n=41; conservative treatment, n=143) between the years 2015 and 2019. Data were analyzed by univariate analysis, and multivariate binary logistic regression analysis.

RESULTS

Univariate analysis showed that statistically significant differences between the surgery and conservative treatment groups. The results of multivariate Logistic regression analysis indicated intestinal wall thickening by B-ultrasound and gestational age were independent factors to predict early surgical indications of NEC (p < 0.05). The true positive rate, false positive rate, true negative rate and false negative rate in the diagnosis of necrotic bowel perforation guided by DAAS (Duke abdominal X-ray score) ≥7 and MD7 (seven clinical metrics of metabolic derangement) ≥3 were 12.8%, 0.0%, 100.0% and 87.2%, respectively.

CONCLUSIONS

In summary, the ultrasound examination in NEC children showing thickening intestinal wall and poor intestinal peristalsis indicated for early operation.

The Congenital Heart Disease Brain: Prenatal Considerations for Perioperative Neurocritical Care

Altered brain development has been highlighted as an important contributor to adverse neurodevelopmental outcomes in children with congenital heart disease. Abnormalities begin prenatally and include micro- and macrostructural disturbances that lead to an altered trajectory of brain growth throughout gestation. Recent progress in fetal imaging has improved understanding of the neurobiological mechanisms and risk factors for impaired fetal brain development. The impact of the prenatal environment on postnatal neurological care has also gained increased focus. This review summarizes current data on the timing and pattern of altered prenatal brain development in congenital heart disease, the potential mechanisms of these abnormalities, and the association with perioperative neurological complications.

Tracheostomy in Infants in the Neonatal Intensive Care Unit

Approximately half of all pediatric tracheostomies are performed in infants younger than 1 year. Most tracheostomies in patients in the NICU are performed in cases of chronic respiratory failure requiring prolonged mechanical ventilation or upper airway obstruction. With improvements in ventilation and management of long-term intubation, indications for tracheostomy and perioperative management in this population continue to evolve. Evidence-based protocols to guide routine postoperative care, prevent and manage tracheostomy emergencies including accidental decannulation and tube obstruction, and attempt elective decannulation are sparse. Clinician awareness of safe tracheostomy practices and larger, prospective studies in infants are needed to improve clinical care of this vulnerable population.

Predictors of Mortality among Neonates with Congenital Diaphragmatic Hernia: Experience from an Inborn Unselected Cohort in India

OBJECTIVE

To evaluate the clinical profile and predictors of mortality in neonates with congenital diaphragmatic hernia (CDH).

METHODS

Demographic and clinical parameters of neonates with congenital diaphragmatic heria (n=37) between January 2014 and October, 2017 were reviewed, and compared among those who survived or expired in hospital.

RESULTS

Median (range) gestation and birthweight were 38 (37-39) weeks and 2496 (2044-2889) g, respectively. Persistent pulmonary hypertension (PPHN) was documented in 19 (51%) neonates and 10 (27%) had associated malformations. Surgery could be performed in 18 (49%), overall mortality was 60%. On univariate analysis, low Apgar scores, presence of malformations, PPHN, need for higher initial peak inspiratory pressure/high frequency ventilation, and requirement of a patch for closure were associated with increased mortality. On multivariate analysis, PPHN remained the only significant risk factor [adjusted RR 3.74 (95% CI 1.45-9.68)].

CONCLUSIONS

The survival of infants with CDH is low, and PPHN is an important predictor of mortality.

Primary Segmental Intestinal Volvulus in a Neonate

Primary segmental intestinal volvulus is a rare disease with an aggressive clinical course. Early diagnosis and prompt management prevents life-threatening necrosis and perforation. A 1-day-old newborn girl with this disorder is reported to emphasize the presentation, imaging findings and management.

Neonates living with enterostomy following necrotising enterocolitis are at high risk of becoming severely underweight

Necrotising enterocolitis (NEC) is often managed with a temporary enterostomy. Neonates with enterostomy are at risk of growth retardation during critical neurodevelopment. We examined their growth using z-score. We identified all patients with enterostomy from NEC in two neonatal surgical units (NSU) during January 2012-December 2016. Weight-for-age z-score was calculated at birth, stoma formation and closure, noting severely underweight as z < - 3. We compared those kept in NSU until stoma closure with those discharged to local units or home (LU/H) with a stoma. A total of 74 patients were included. By stoma closure, 66 (89%) had deteriorated in z-score with 31 (42%) being severely underweight. There was no difference in z-score at stoma closure between NSU and LU/H despite babies sent to LU/H having a more distal stoma, higher birth weight and gestational age. Babies in LU/H spent a much shorter period on parenteral nutrition while living with their stoma for longer, many needing readmission.Conclusion: Growth failure is a common and severe problem in babies living with enterostomy following NEC. z-score allowed growth trajectory to be accounted for in nutrition prescription and timing of stoma closure. Care during this period should be focused on minimising harm.What is Known:• Necrotising enterocolitis (NEC) is a life-threatening condition affecting predominately premature and very low birth weight neonates. Emergency treatment with temporary enterostomy often leads to growth failure.• There is no consensus on the optimal timing for stoma reversal, hence prolonging impact on growth during crucial developmental periods. Both malnutrition and surgical NEC are independently associated with poor neurodevelopment outcome.What is New:• Our study found growth in 89% of babies deteriorated while living with a stoma, with 42% having a weight-for-age z-score < - 3, meeting the WHO criteria of being severely underweight, despite judicial use of parenteral nutrition. Applying z-score to weight measurements will allow growth trajectory to be accounted for in clinical decisions, including nutrition prescription (both enteral and parenteral), and guide timing of stoma closure.• Surgeons who target stoma closure at a certain weight risk waiting for an indefinite period of time, during which babies' growth may falter.

Predictors for surgical intervention and surgical outcomes in neonates with cystic fibrosis

BACKGROUND/PURPOSE

To identify prenatal and perinatal predictors of surgery and describe surgical findings/outcomes of neonates with Meconium Ileus (MI) secondary to Cystic Fibrosis (CF).

METHODS

Potential risk factors (prenatal bowel echogenicity, CF genotype, birthweight, prematurity and sex) for MI and surgery were examined in a retrospective cohort of neonates with CF presenting to a tertiary center between 1997 and 2015. Following univariable analysis, predictors of MI and surgery were determined using multivariable logistic regression. For surgical patients, detailed operative findings and outcomes were examined.

RESULTS

MI was diagnosed in 26/120 (21.7%) neonates with CF and 19/26 (73.0%) required surgery. Prematurity was significantly associated with increased risk of MI and operative intervention (p-value 0.022 and p-value 0.016 respectively); lower birthweight was associated with operative intervention (p-value 0.039); genotype and echogenic bowel were associated with neither. Surgical data were available for 17/19 patients; median age at surgery was 2 days (IQR1-3), 4/17 had an atresia and 6/17 received an ostomy. Median NICU and hospital stays were 34.5 and 70 days while median time on TPN and time to ostomy reversal were 28.5 and 97 days, respectively.

CONCLUSIONS

In patients with CF, prematurity and lower birthweight were identified as risk factors for meconium ileus and need for surgery. Specific genotypes and echogenic bowel were not predictors of either.

LEVEL OF EVIDENCE

Level III.

Diagnosis and treatment of 34 cases of congenital tracheobronchial cartilage remnants of esophagus

PURPOSE

To describe the diagnosis and treatment of 34 cases of congenital tracheobronchial cartilage remnants of esophagus.

METHODS

The diagnosis and treatment of 34 cases of congenital tracheobronchial cartilage remnants of esophagus were analyzed retrospectively in our hospital.

RESULTS

Congenital tracheobronchial cartilage remnants of esophagus could be specifically diagnosed by clinical situation and esophageal barium meal examination. The anterior wall of the esophagus was cut longitudinally with the posterior wall of the esophagus preserved. And the cartilage was removed and the open anterior wall of the esophagus was sutured horizontally with full layer. In our study, 34 patients who underwent the operation had a satisfactory outcome. However, one patient underwent submucosal cartilage stripping, which resulted in a complication involving fistulae from the esophagus to the abdominal cavity that were healed after gastrostomy and nutritional support.

CONCLUSION

Congenital tracheobronchial cartilage remnants of esophagus caused symptoms when the infants were started on adjunct foods. Vomiting the food without gastric fluid and bile was the leading clinical manifestation. Distinguishing signs on esophageal barium contrast could be used as preoperative diagnosis evidence. Surgically removing the cartilage and horizontally suturing the esophagus provides a reliable outcome.

LEVEL OF EVIDENCE

Level IV.

TYPE OF STUDY

Retrospective study.

Outcome Analysis of Neonates following Laparotomy for Acute Abdomen: A Prospective Study

Background Low and middle-income countries (LMIC) bear the majority of the global pediatric surgical burden. Despite increasing volume of pediatric surgeries being performed in LMIC, outcomes of these surgeries in low and middle-income countries remain unknown due to lack of robust data. Objective The objective of our study was to collect data on and evaluate neonatal surgical outcomes at a tertiary level center in India. Method The surgical outcomes data of all neonates undergoing laparotomy between February 15, 2015 and October 14, 2015, at Sir Ganga Ram Hospital, New Delhi, India was collected prospectively. Descriptive statistics were used to determine the rates of various postoperative outcomes. Result A total of 37 neonatal surgeries were performed during the study period. The mean age of the neonates on the day of surgery was 7 days (range: 1-30 days). Most of the neonates (72.9%, n=27) were males. About 40% (n=15) of the neonates were preterm and 15 (40.5%) of them were small for gestational age. In our study, 10 neonates (28.6%) needed ventilation for 48 hours or less after surgery and 5 neonates (13.5%) were kept Nil per Oral (NPO) postoperatively for more than 10 days. Out of 37 neonates, 4 (10.80%) developed a surgical site infection and 8 neonates (21.6%) had postoperative sepsis. The in-hospital mortality rate among neonates undergoing laparotomy during the study period was 8.1 deaths per 100 neonates. Conclusion Co-ordination of care among pediatric surgeons, neonatologists, nursing and anesthesia team is required for optimal surgical outcome.

Bowel ultrasound for predicting surgical management of necrotizing enterocolitis: a systematic review and meta-analysis

BACKGROUND

Necrotizing enterocolitis (NEC) is a devastating inflammatory disease of the intestinal tract that represents a significant source of morbidity and mortality in preterm infants. Imaging of the abdomen is valuable for timely diagnosis and close monitoring of disease progression in NEC. Bowel ultrasound (US) is increasingly being recognized as an important imaging tool for evaluating NEC that provides additional detail than plain abdominal radiographs.

OBJECTIVE

To identify bowel US findings associated with surgical management or death in infants with NEC.

MATERIALS AND METHODS

We searched Embase, PubMed, and the Cumulative Index to Nursing and Allied Health Literature for studies investigating the association between bowel US findings and surgical management or death in NEC. Selected articles were evaluated for quality of study methodology using the Newcastle-Ottawa Scale, and aggregate statistics for odds ratio (OR) and 95% confidence interval were calculated.

RESULTS

Of 521 articles reviewed, 11 articles comprising 748 infants were evaluated for quality. Nine of the studies were retrospective and from single-center experiences. Pooled analysis showed that focal fluid collections (OR 17.9, 3.1-103.3), complex ascites (OR 11.3, 4.2-30.0), absent peristalsis (OR 10.7, 1.7-69.0), pneumoperitoneum (OR 9.6, 1.7-56.3), bowel wall echogenicity (OR 8.6, 3.4-21.5), bowel wall thinning (OR 7.11.6-32.3), absent perfusion (OR 7.0, 2.1-23.8), bowel wall thickening (OR 3.9, 2.4-6.1) and dilated bowel (OR 3.5, 1.8-6.8) were associated with surgery or death in NEC. In contrast, portal venous gas (OR 3.0, 0.8-10.6), pneumatosis intestinalis (OR 2.1, 0.9-5.1), increased bowel perfusion (OR 2.6, 0.6-11.1) and simple ascites (OR 0.54, 0.1-2.5) were not associated with surgery or death.

CONCLUSION

This meta-analysis identified several bowel US findings that are associated and not associated with surgery or death in NEC. Bowel US may be useful for early identification of high-risk infants with NEC who may benefit from more aggressive treatment, including surgery. Future studies are needed to determine whether the addition of bowel US in NEC evaluation would improve outcomes.

Bloodless Repair for a 3.6 Kilogram Transposition of the Great Arteries with Jehovah's Witness Faith

Achieving pediatric cardiac surgery using cardiopulmonary bypass (CPB) without allogeneic blood transfusion is challenging. There are many clinical and economic factors that point to the importance of avoiding blood transfusions. In some instances, honoring patients or parents beliefs may be the reason for avoiding blood transfusions. For example, patients or parents of the Jehovah's Witness faith refuse blood transfusion based on their religious beliefs. Over the last decade, our institution has seen a steady increase in our pediatric Jehovah's Witness patient population. Caring for these patients have allowed us to develop specific protocols that enable us to safely provide bloodless CPB in all of our patient populations. The success of such an approach to minimize the need for blood transfusions should not start in the operating room; it must include the preoperative period and the postoperative care by the critical care team in the cardiac intensive care unit (CICU). A multidisciplinary team approach has to be in place with clear communication between the cardiologist, anesthesiologist, cardiac surgeon, perfusionist, and the cardiac intensivist. We present a case of a 7 day old male (3.6 kg) with a preoperative diagnosis of Transposition of the Great Arteries and intact ventricular septum who underwent an arterial switch procedure without the transfusion of any blood products throughout his entire hospital stay.

Sutureless enterostomy for extremely low birth weight infants

OBJECTIVE

In recent years, improved survival rates of extremely low birth weight infants (ELBWIs) have led to an increasing number of enterostomy performed for those with meconium obstruction of prematurity (MOP)^1,2, spontaneous intestinal perforation (SIP)^3,4. To prevent serious stoma-related complications such as stoma side perforation, prolapse, fall and surgical site infection, we introduce our new "sutureless enterostomy" technique.

METHODS

We present the procedures in detail. We reviewed the medical records of twelve patients who underwent "sutureless enterostomy" in our neonatal intensive care unit from 2007 to 2013. Patient attributes, surgery-related items, stoma-related complications and outcomes were investigated.

RESULTS

Mean birth weight was 671±158g (mean±S.D.). Six cases of MOP, three cases of SIP and three cases of NEC were diagnosed. Mean operative time was 75±35min (mean±S.D.) None of them presented any of early stoma-related complications (necrosis, fall, and surgical site infection). However the parastomal hernia occurred in one patient as late complication. Three deaths occurred postoperatively as a result of exacerbations of their conditions.

CONCLUSIONS

Based on our preliminary observations, our new "sutureless enterostomy" was done safely and reduced the risk of stoma-related complications. It may be an ideal procedure for the ELBWI with MOP or SIP.

PATTERN AND OUTCOME OF NEONATAL SURGICAL CASES AT TIKUR ANBESSA UNIVERSITY TEACHING HOSPITAL, ADDIS ABABA, ETHIOPIA

INTRODUCTION

The survival of neonates with surgical conditions has greatly improved in developed countries, but still remains poor in developing countries. Available evidence suggests that this is due to several challenges encountered in neonates requiring surgical care. The aim of this study was to determine causes and outcomes of neonatal surgical admissions.

PATIENTS AND METHODS

retrospective review of medical records of neonates who were admitted and treated at Tikur Anbessa Hospital between January1, 2010 and December 31, 2014. Data were analyzed using descriptive statistics and association between variables measured using regression analysis on SPSS version 16 statistical software.

RESULTS

There were a total of 652 surgical neonatal admissions during the study period of which 396 were males, 252 females and 4 with indeterminate genitalia. The male to female ratio was 1.6:1. Majority of the cases 562 (86.2%) had congenital malformation. Lesions of the gastrointestinal tract 282(43.3%), mainly Anorectal malformations followed by abdominal wall defects. Two-third (66.6%) of the cases were surgically managed. Nearly onequarter of them died. The proportion who died ranged from 0.03% for Hirschsprung’s disease to 73.2% for esophageal atresia. The immediate causes of death among these series of neonates were ascribed to septic shock and respiratory failure.

CONCLUSION

Neonatal surgical admission is common in the Hospital. The overall number of deaths in this series of neonatal surgical cases was high. The type of principal diagnosis and the age of the neonates at admission were significantly associated with outcome. Creating awareness about neonatal surgical conditions may help to improve the current poor result.

[Neonatal surgical emergencies at the Bukavu Provincial General Reference Hospital in Democratic Republic of Congo]

INTRODUCTION

This study aims to determine the prevalence of neonatal surgical emergencies and their epidemiology.

METHODS

This retrospective cohort study reports 30 cases whose data were collected in the Department of Surgery at the Bukavu Provincial General Reference Hospital over a period of 3 years, from January 2010 to December 2013.

RESULTS

Neonatal surgical emergencies account for 1.31% of surgical pathologies in general. The most frequent age of patients during medical consultation was less than 8 days. Male prevalence was noted with sex-ratio 3/2. The most frequent pathologies were gastrointestinal tract emergencies (43.3%) followed by neurological emergencies (40%). 80% of newborns underwent surgery. Mortality rate was 43.3%.

CONCLUSION

Neonatal surgical pathologies occur in our midst. Clinicians should be on alert and implement prenatal diagnostic programs and proper neonatal care management in order to save the lives of these children.

A Modified EXIT-to-ECMO with Optional Reservoir Circuit for Use during an EXIT Procedure Requiring Thoracic Surgery

A 34 year old mother with a history of polyhydraminos and premature rupture of membranes presented for an ex utero intrapartum treatment (EXIT) procedure to deliver her 34 week gestation fetus. The fetus had been diagnosed with a large cervical mass which significantly extended into the right chest. The mass compressed and deviated the airway and major neck vessels posteriorly. Imaging also revealed possible tumor involvement with the superior vena cava and right atrium. The plan was for potential extracorporeal membrane oxygenation (ECMO) during the EXIT procedure (EXIT-to-ECMO) and the potential for traditional cardiopulmonary bypass (CPB) for mediastinal tumor resection. A Modified EXIT-To-ECMO with Optional Reservoir (METEOR) circuit was devised to satisfy both therapies. A fetal airway could not be established during the EXIT procedure and so the EXIT-to-ECMO strategy was utilized. The fetus was then delivered and transferred to an adjoining operating room (OR). Traditional cardiopulmonary bypass with a cardiotomy venous reservoir (CVR) was utilized during the establishment of an airway, tumor biopsy and partial resection. The patient was eventually transitioned to our institution's standard ECMO circuit and then transferred to the intensive care unit. The patient was weaned from ECMO on day of life (DOL) eight and had a successful tumor resection on DOL 11. The patient required hospitalization for numerous interventions including cardiac surgery at 4 months of age. She was discharged to home at 5 months of age.

Hairy Polyp of the Nasopharynx Arising from the Eustachian Tube

Hairy polyps of the nasopharynx display characteristic radiological imaging findings, including the presence of fat in the polypoid mass. Furthermore, diagnostic imaging is useful for delineating the site of origin of these lesions, which can facilitate surgical planning. For instance hairy polyps that arise from the right Eustachian tube can be amputated via a trans-nasal approach with endoscopy, but may necessitate a two stage approach in order to avoid injury to critical structures, such as the internal carotid artery. On histology, hairy polyps comprise an outer keratinizing squamous epithelium with adnexal tissue, including hair follicles, and central fibroadipose and cartilaginous tissue. These features are exemplified in this sine qua non radiology-pathology correlation article.

Advances in the Surgical Treatment of Gastroschisis

Gastroschisis (GS) is a structural defect of the anterior abdominal wall, usually diagnosed antenatally, that occurs with a frequency of approximately 4 per 10,000 pregnancies. Babies born with GS require neonatal intensive care and surgical management of the abdominal wall defect soon after birth. Although contemporary survival rates for GS are over 90%, these babies are at risk for significant morbidity, and require 4 to 6 weeks of costly, resource-intensive care in specialized neonatal units. Much consideration has been given to how best to treat the abdominal wall defect of GS. The traditional approach, necessitated by a need to establish enteral feeding as quickly as possible, consists of early postnatal visceral reduction and sutured abdominal closure. Advances in neonatal nutritional support have enabled the development of surgical approaches, which permit gradual visceral reduction and delayed abdominal closure. In cases where early visceral reduction cannot be achieved, delayed closure enabled by the initial placement of a prosthetic silo has been a live-saving alternative. The development of preformed silos has simplified their use and led to an interest in treating all cases with a delayed closure philosophy. Most recently, a sutureless technique of abdominal closure has been reported, which has the benefit of avoiding general anesthesia and offers other outcome improvements over sutured closure of the defect. The debate over primary closure versus silo placement and delayed closure continues to receive much attention. The goal of this article is to review historical aspects of gastroschisis closure, and then focus on current surgical techniques, including the innovative sutureless closure, with an analysis of the comparative clinical effectiveness of these approaches to treatment of the abdominal wall defect in GS.

Retroperitoneal immature teratoma

Retroperitoneal immature teratoma is a rare tumor in the newborn infant with only a few instances reported in several case series.(1,2,3) We report a case of retroperitoneal immature teratoma presenting unusually on day one of life with severe abdominal distension and respiratory failure.

The eponymous Dr James Marion Sims MD, LLD (1813-1883)

Dr James Marion Sims was born in 1813 in Lancaster County, South Carolina. It was while pioneering numerous surgical procedures in Alabama that in 1849 he achieved the outstanding landmark in medical history of successfully, and consistently, repairing vesicovaginal fistulae. Sims soon developed a reputation as a fine surgeon, with new operations and techniques, using novel surgical instruments and his innovative approaches frequently published. Moving to New York City in 1853, he further established hospitals devoted entirely to women's health. Sims was controversial, with flamboyant descriptions of self-confident success, yet they were tempered with sober reflection of failure and loss. Today we remain with the Sims speculum and Sims position, eponymous tributes to his accomplishments as the 'Father of Gynaecology'.

An Acute Complication of Ventriculoperitoneal Shunt with Bladder Perforation and Extrusion through the Urethra in a Newborn: Case Report and Review of the Literature

Ventriculoperitoneal shunt (VPS) surgery is a standard procedure for the management of hydrocephalus. Bladder perforation is an extremely rare complication of VPS surgery. Herein, we present for the first time an acute complication of VPS with bladder perforation and extrusion through the urethra in a newborn. We also reviewed the complication of VPS with bladder perforation as reported in the literature.

Fasciocutaneous Flap Reconstruction after Repair of Meningomyelocele: Technique and Outcome

AIMS

The objectives of this study are to describe our technique in meningomyelocele (MMC) repair, analyzing the results and complications, as well as to study the effect of delay in operation on the complication rate.

PATIENTS AND METHODS

Between March 1997 and October 2012, 48 patients with MMC were treated at Jordan University Hospital by a combined neurosurgical and plastic surgical team. Patients underwent neurosurgical repair of the neural elements and soft tissue reconstruction using local fasciocutaneous flaps. The patients were further divided into two subgroups (local or referrals from other hospitals).

RESULTS

Of all patients, 8 (16.6%) had postoperative complications. When the complication rate was compared between the two groups, in the first group, who had early repair, only 2 out of 19 patients had complications (10.5%), while in the second group, with delayed operation, 6 out of 29 patients developed complications (20.7%). The follow-up of all patients showed that the soft tissue cover maintained good durability with no skin breakdown.

CONCLUSION

We recommend early MMC repair using this rather simple method to provide a reliable soft tissue coverage. A combined approach by a neurosurgical and plastic surgical team in the management of this challenging neonatal emergency is appreciated.

Laparoscopic repair of duodenal atresia in a low birth weight neonate

The small volume of the infant abdomen limits the application of laparoscopic procedures. We successfully repaired a duodenal atresia in a 2-kg female infant using a standard diamond-shaped anastomosis and intracorporeal suturing and knot-tying techniques. Anesthesia and positive pressure ventilation assured adequate gas exchange during pneumoperitoneum during the procedure.

[The accessibility of high-tech medical care of newborns with surgical pathology in conditions of Far North]

The actual stage of development of public health rendering of specialized medical care is based on principles of generality, accessibility, addressness, qualitativeness, and effectiveness. However, the problem of rendering specialized medical care to population is one of most critical targets in district centers and requires immediate solution. The main mean of resolving this problem is re-hospitalization of patient in more large-scale medical institutions. The rendering of high-tech medical care, surgery care included, to newborns in the Republic of Sakha (Yakutia) is possible only in conditions of metropolitan health institutions i.e. medical institutions of third level. Annually, almost half of newborns with surgical pathology is transported from central district hospital. The organization of reanimation counseling center, maintenance of remote monitoring of newborns and development of telemedicine and means of sanitary aviation play main role in supporting accessibility of high-tech medical care in conditions of this region.

Under pressure: a contribution to the pathogenesis of acquired ileal atresia

An acquired ileal atresia is a rare occurrence. A 3-week-old neonate is presented, who developed postnatally a type 2 ileal atresia and an ileal stenosis within a pre-existing internal hernia secondary to an adhesion band. The literature reports a total of eight cases (4 females) with acquired ileal atresia in babies ranging in age from 3 weeks to 2 years (median 4 months). Mechanical forces (eg, adhesion band, intussusception and volvulus) onto the intestine are most frequently (75%) implicated as the primary event. The distal ileum is most often affected and a type 3A atresia is identified in six of eight (75%) cases.

Gastric perforation in the newborn

BACKGROUND

Gastric perforation in neonates is an uncommon condition. It could be spontaneous but a contributing cause should be sought.

AIM

To review our experience of treating 8 neonates with gastric perforation over the past 20 years.

METHODS

We reviewed the records of all newborns admitted to our hospital between 1990 and 2010 with regard to gender, age at admission, contributing factors, associated anomalies, site of perforation, type of operation, and outcome.

RESULTS

Of the eight neonates, five were female and three male. The average weight was 2130 g. Four babies were premature. Three infants were ventilated for respiratory difficulty. Five patients had associated anomalies. Perforation occurred in the lesser curvature in 4, at the greater curvature in 3, and at the anterior antrum surface in 1. All patients were treated with gastrorrhaphy. Four neonates required additional gastrostomy. Mortality was 75% (6 infants).

CONCLUSION

Active perinatal management, early treatment of primary pathologies, and protection of the stomach against distension in neonates at risk are essential in the management of neonatal gastric perforation.

Endoscopic neurosurgery in preterm and term newborn infants--a feasibility report

OBJECTIVE

Neuroendoscopic procedures became essential in neurosurgical treatment of disturbed cerebrospinal fluid dynamics. While a vast number of papers report on the neuroendoscopic experience for adults and children, no series so far reported on techniques and indications for neonate infants. We present our experience for the feasibility of neuroendoscopic procedures in preterm and term newborn infants.

METHODS

All preterm and term infants who underwent an endoscopic neurosurgical intervention prior to the 28th day after the previously estimated date of delivery were identified by retrospective review. Surgical procedures and techniques, complications, and further follow-up data are reported.

RESULTS

During the study period, 14 infants (median age at surgery, 36+(2)/7 weeks of gestation) underwent 20 endoscopic procedures. The performed procedures included endoscopic septostomy (n = 3), endoscopic shunt placement for multiloculated hydrocephalus (n = 4), endoscopic transaqueductal stenting for isolated fourth ventricle (n = 3), and endoscopic lavage for ventriculitis (n = 4) or for intraventricular hemorrhage (n = 6). No severe complications were seen, while two patients necessitating unexpected interventions during further follow-up (10 %).

CONCLUSIONS

Despite the fragility of preterm and term newborn infants, neuroendoscopic procedures may play an important role in the treatment of disturbed cerebrospinal fluid (CSF) dynamics also in this patient population. The neuroendoscopic approach may be curative in conditions like isolated lateral ventricle, may facilitate simplified and effective CSF diversion in multiloculated hydrocephalus or isolated fourth ventricle, and may be beneficial in the course of ventriculitis and intraventricular hemorrhage. Further studies must verify our experience with a bigger cohort of patients and on a multicenter basis.

Maternal morbidity and reproductive outcomes related to fetal surgery

PURPOSE

The purpose of this manuscript was to examine the maternal morbidity and reproductive outcomes following maternal-fetal surgery with an emphasis on the EXIT procedure.

METHODS

The medical records of all women who underwent an ex-utero intrapartum treatment (EXIT) procedure or mid-gestation open maternal fetal surgery (OMFS) at our center from December 2001 to December 2011 were reviewed retrospectively. Future reproductive outcomes were obtained via telephone questionnaire.

RESULTS

Thirty-three women underwent maternal-fetal surgery. Twenty-six had EXIT, and seven had OMFS. The questionnaire response was 82% (27/33). Eighty-one percent (17/21) of the EXIT cohort desired future pregnancy. All who attempted (13/13) were successful. The majority (85%) conceived spontaneously and within 2.5 years on average. In the OMFS group, 40% experienced complications. One had uterine dehiscence, and another had uterine rupture requiring urgent delivery at 36 weeks. In subsequent pregnancies, 20% of OMFS cases were complicated by uterine rupture, and 8% of EXIT patients had uterine dehiscence. All had good maternal-fetal outcome.

CONCLUSION

Future reproductive capacity and complication rates in subsequent pregnancies following EXIT procedure are similar to those seen in the general population. In contrast, mid-gestation OMFS remains associated with relatively morbid complications. This evidence can help guide in counseling expectant mothers who are faced with the challenge of considering fetal surgery.

[Predicting outcome in necrotizing enterocolitis with the score for neonatal acute physiology: a retrospective study of 62 cases]

OBJECTIVE

To explore the value of the score for neonatal acute physiology (score for neonatal acute physiology, SNAP) in predicting outcome and risk of surgery of necrotizing enterocolitis (NEC).

METHOD

A total of 62 NEC patients in neonatal intensive care unit (NICU) of Zhejiang University Children's Hospital were reviewed from October 2001 to October 2011. All the patients were classified into surgery group and non-surgery group according to whether the patient had the surgical intervention. Also the patients were divided into death group and alive group according to the outcome. Data on gestational age at birth, gender, birth weight, early clinical manifestations, treatment and prognosis of all patients were collected. SNAP-II and score for neonatal acute physiology and perinatal extension II (SNAPPE-II) were calculated on the day of diagnosis.

RESULT

Abdominal distension, which was seen in 91.9% of the cases, was the commonest early clinical manifestation. The next was residual and bloody stool. SNAP-II and SNAPPE-II score in surgery group (26.5,26.5) were higher than that of the non-surgery group (13.0, 13.0,P = 0.002, 0.006). And the same scores in death group (29.0,32.0) were higher than those in the alive group (8.0, 8.0) (P = 0.000, 0.000). Measuring the scores as a predictor of surgery, the area under ROC curve for SNAP-II was 0.745, and was 0.714 for SNAPPE-II. The area under ROC curve for SNAP-II was 0.916, and was 0.929 for SNAPPE-II.The best positive point of SNAP-II and SNAPPE-II for predicting surgery was 22 and 28. The best positive point of SNAP-II and SNAPPE-II for predicting death was 18.5 and 22.

CONCLUSION

The SNAP-II and SNAPPE-II score may be used to predict the prognosis and the risk of surgery in the NEC patients. The scores are also good predictors of mortality in the early period when NEC occurs.

[Imaging assessment of neonatal necrotizing enterocolitis]

OBJECTIVE

To improve the understanding of recognizing and diagnosis of neonatal necrotizing enterocolitis (NEC), imaging assessment of neonates with NEC was analyzed retrospectively.

METHOD

Data of 211 cases of NEC were retrospectively collected from the Department of Neonatology, Children's Hospital of Chongqing Medical University between Jan.1(st) 2006-Dec.31(st) 2011.

RESULT

Analysis of abdominal X-ray of 211 cases showed that there were 40 cases (19.0%) who had no changes on each X-ray, 47 cases (22.3%) had improvement and 23 cases (10.9%) became worse. In the group of no changes, positive rate with good prognosis was 97.5% and with poor prognosis, it was 2.5%. In the group of improvement, positive rate with good prognosis was 97.9%, and the contrary was 2.1%. Positive rate with good prognosis was 56.5%, and the contrary was 43.5% in worse group. Chi-square analysis of the three groups showed χ(2) = 31.742, P < 0.01. Comparison of detection rate of pneumoperitoneum on abdominal X-ray (16.0%, 12/75) and Doppler US (1.3%, 1/75), χ(2) = 10.191, P < 0.05, portal pneumatosis on abdominal X-ray(1.3%, 1/75) versus Doppler US (12.0%,9/75), χ(2) = 6.857, P < 0.05. Surgical timing mostly corresponded to pneumoperitoneum (OR = 19.543) and intestinal obstruction (OR = 19.527) of abdominal X-ray. The logistic regression equation is y = -2.915-1.588x1+2.972x4+2.973x7 + 1.711x9 (χ(2) = 101.705, P < 0.01).

CONCLUSION

Abdominal X-ray is the most important method of diagnosis of NEC, the group of deterioration of abdominal X-ray has obvious bad prognosis differ from no change group and better group. Comparison with abdominal X-ray and Doppler US, the former in pneumoperitoneum positive rate was higher than the latter, at the same time, portal pneumatosis on Doppler US is more sensitive to abdominal X-ray, the value of two imaging assessments both supplement each other. Surgical timing mostly corresponds to pneumoperitoneum and intestinal obstruction.

[Central neuroaxial blocade and metabolic stress-answer in a newborn and babies in surgical diseases]

Investigation of markers of humoral stress was conducted in 25 babies (the main group), in whom a central neuroaxial blocade was performed while doing various surgical interventions. In a control group there were included 20 babies, in whom a standard atharalgesia was applied. The best efficacy was achieved while anesthesia using central neuroaxial blocade.

[Prenatal diagnosis and evolution of patent urachus]

Prenatal ultrasonographic features of patent urachus consist in anechoic proximal cord cyst communicating with the bladder associated with large umbilicus. Distinction should be made with omphalocele and bladder extrophy. Spontaneous evolution leads to rupture during mid-trimester and bladder protrusion. Karyotyping is not mandatory in isolated typical cases. Early postnatal surgery is usually required.

[Influence of selected factors on the treatment and prognosis in newborns with gastroschisis on the basis of own experience]

AIM

The purpose of the study was to evaluate the influence of selected prognostic factors for postoperative course and prognosis in newborns with gastroschisis.

MATERIAL AND METHODS

A study of all newborns with gastroschisis treated between 2000-2010 in the Clinic of Surgery of Children and Adolescents, Institute of Mother and Child was performed. Data collected from medical documentation included the following: presence or lack of prenatal diagnosis, mode of delivery, gestational age (below or above 37 weeks), birth weight, necessity on transportation from provincial hospitals or transfer within Institute, condition of the bowel (good - little fibrinous inflammation or bad - massive inflammatory peel, necrosis, perforation, atresia), interval between delivery and operation, kind of surgery (primary repair, silo closure), complication requiring secondary operation, period of ventilatory support (PVS), time needed to achieve full enteral feeding (FEF), total length of hospital stay (TH), number and cause of death. Selected information obtained from the data of the patients were separated into two periods of time: 2000-2005 and 2006-2010 for better evaluation of the influence of individual factors on the efficiency of treatment and prognosis. Multivariate logistic regression was used to investigate the association between selected risk factors and end points (PVS,FEF,TH). Statistical analyses were performed using Stata v.10 (College Station, TX, Stata Corporation LP 2007).

RESULTS

During the study period 32 newborns with gastroschisis were treated. Prenatal diagnosis was made in 22 patients (69%) and the mean age of diagnosis was 30.7 weeks. Cesarean section was performed in 25 cases and vaginal delivery occurred in 7 cases. The mean gestational age during delivery was 35.7 weeks, mean weight was 2430 g. Twenty one newborns were delivered before 37 week of gestation, eleven after 37 week. Fifteen patients were transported from provincial obstetrics hospitals, seventeen were transferred within the Institute (from the Obstetrics Clinic to Clinic of Pediatric Surgery). A good condition of the externalized bowel was found in 18, a bad condition in 14 patients (therein necrosis with perforation in 2, atresia in 2). Mean delivery - operation interval was 6.3 hours. The operation was performed till 3rd hour after birth in 12, over 3rd hour in 20 newborns. During the first surgical intervention primary closure was possible in 29 cases, silo was used in 3 patients. Five patients required more than one surgical intervention (2 patients after silo closure and 3 patients after primary repair). For patients who survived mean PVS was 4.6, mean time FEF was 24.7 days, TH was 34.5 days. Five patients died. The reasons for death were heart tamponade in 2 and complications in the course of sepsis in 3 patients. In the period 2006-2010 versus 2000-2005 number of prenatal diagnosis significantly increased (46% and 84% respectively), mean age at delivery decreased (38.6 and 35.3 respectively), period between delivery and operation shortened from 8.8 to 3.8 hours, more patients were operated on during first three hours after birth (7.6% and 58% respectively). The condition of the bowel was assessed similarly in both periods (bad condition 38% and 47% respectively). All deaths occurred in newborns treated in the years 2000-2005. Multivariate logistic regression showed there was one independent risk factor that influenced the two end points: the period of respiratory support and the length of hospital stay, i. e. the delivery - operation interval. Patients with delivery - operation interval over 3 hours after birth had a significantly higher risk of long-standing ventilatory support or death (OR=12.4, 95%CI {1.7, 89.3}, p=0.013) and a significantly higher risk of longer total hospital stay or death (OR=12.7, 95%CI {1.7, 97.0}, p=0.014). None of the factors analyzed had statistical significance with respect to the length of time needed to achieve full enteral feeding.

CONCLUSION

The main independent risk factor having influence on the course of treatment and prognosis was the delivery - operation interval. Early repair of gastroschisis makes primary closure easier and shortens the post-operative course. Newborns with gastroschisis despite progress in prenatal diagnostics, neonatal intensive care and surgical methods remains a serious therapeutic problem requiring multidisciplinary care and long-standing hospital stay.

Dog ear graft for closure of the large skin defects in meningomyelocele surgery

The closure of large skin defects is one of the challenging problems in plastic surgery and neurosurgery. Different reconstructive surgical techniques can be used for closing large skin defects. We report a technique for closing the large skin defects after the surgical repair of meningomyeloceles.

[Does the regional health care organization impact the outcome of infants born with congenital diaphragmatic hernia?]

INTRODUCTION

Congenital diaphragmatic hernia (CDH) is a serious pathology that requires optimal management in very specialized health centers. French medical care organization is regionally based. Hence, evaluating local practices may help deliver clear information to parents before delivery. The aim of this study was to analyze the neonatal characteristics and the postnatal outcome of infants affected with CDH, treated within two different French perinatal health care networks.

PATIENTS AND METHODS

Retrospective cohort study of infants with CDH, cared for in the Lorraine perinatal health care network (Réseau Périnatal Lorrain [RPL]) or at Édouard-Herriot Hospital (HEH) in Lyon, between 1997 and 2007.

RESULTS

One hundred and twenty-seven newborns were included, 44 in the RPL and 83 in Lyon. Prenatal diagnosis of CDH was similar in RPL and at HEH; 47.7% of infants with CDH died in RPL vs 36.1% in HEH (P=0.2). Surgery delayed for more than 24h was more frequent in RPL (68.6% vs 31.7%; P<0.001), with a postoperative mortality rate of 31.4% vs 15.9%; P=0.08. In RPL, specialized medical follow-up was rare (33.3% vs 100%; P<0.001), while psychomotor retardation was more frequent (33.3% vs 5.7%; P=0.002).

CONCLUSION

This study brings to light the diversity of care and outcome for infants affected with CDH in two French perinatal health care networks. These results may help improve both centers' practices. In Lorraine for instance, the follow-up of these vulnerable children can be improved.

Cogenital intrapericardial herniation of liver

Intrapericardial herniation of liver is a rare form of diaphragmatic hernia. We report a 30-hour old baby with right congenital anterior diaphragmatic hernia masquerading as congenital pneumonia with cardiomegaly. It is prudent to consider congenial anterior diaphragmatic hernia in any newborn with unexplained respiratory distress, cardiomegaly and pericardial effusion.

[Mortality of neonatal surgical emergencies at the Gynecology-Obstetric and Pediatric hospital of Yaounde, Cameroon]

From July 2005 to November 2009, 38 neonates with surgical emergencies died in the neonatal unit of the Gyneco Obstetric and Pediatric Hospital Yaounde. The mortality rate of these emergencies was 43.1%, and those within the age group of 1 to 7 days were the most affected with a sex ratio of 1.2. The mean delay before consultation was 3.7 days. Half of the neonates had a birth weight of less than 2,500 g and 7 cases (18.4%) were premature. A medicalised ambulance was used for transfer to our unit in only half of the neonates. The main disorders were those affecting the digestive tract in 42.1% of our series. In 50% of our cases, there were associated malformations and 28 cases (73.7%) did not undergo surgery. Malnutrition and infection were the main complications in 60% of the cases. The authors discuss this deplorable situation and suggest recommendations for improvement.

[Assessment of pain sensitivity in neonates with surgical pathology]

Definition of pain in newborns with surgical pathology in the traditional way (change the child's behavior, skin color, heart rate, mean arterial pressure, body temperature, blood gas parameters) is subjective. The "Med-Storm" pain stress detector, manufactured by "Med-Storm Innovation AS" (Norway) allows the quantification of pain during and after surgery in infants. For a small sample, specificity was 76%, sensitivity--89%. Important indicator was the peak skin conductance. The change in the area under the curve was less often, but indicated the need of analgesia dose change.

[Postoperative analgesia of newborns using local anesthetic administered through wound irrigation catheter of permanent action]

The analysis of publications is devoted to the application of skin conductance monitoring in anesthesiology and intensive care. Rates of skin conductance (baseline values, the amplitude and frequency of the waves) are closely linked with the state of the sympathic nervous system. According to their dynamics it is possible to judge on the pain and stress in patients with whom the contact is difficult: newborns, infants, patients of all age groups during general anesthesia and in critical condition. According to published data monitoring skin conductance showed itself as a sensitive and promising method to identify and determine the severity of pain in all age groups, approaching by its characteristics the theses of the pain assessment perfect tool.