Annals of Pediatric Surgery Vol 5, No 1, January 2009, PP 31-35 Original Article Different Surgical Techniques in Management of Small Intestinal Atresia in High Risk Neonates Almoutaz A. Eltayeb Pediatric Surgical Unit, Assiut University Hospital, Faculty of Medicine, Assiut University, Egypt Background/purpose: Intestinal atresia constitutes one of the most common causes of neonatal intestinal obstruction. Many techniques have been described for surgical correction of intestinal atresia such as Mikulicz double barrel ileostomy, Bishop-koop, Santulli and primary resection with end to end anastomosis. The aim of this work was to assess the different surgical modalities in management of intestinal atresia especially in high risk neonates attempting to improve the morbidity and mortality rates in such patients. Patients and methods: During the period from January 2005 to January 2008, 32 neonates (20 males and 12 females) suspected to have intestinal atresia were referred to Assiut University Hospitals. All neonates presented with bilious vomiting and failure of passage of meconium. The 32 cases were classified according to the surgical technique into three groups: Group A included 12 patients who were treated with primary resection/ anastomosis or enterotomy with excision of the membrane (in type I atresia). Group B included 10 patients, who undergone Bishop-koop technique, and Group C included 10 patients who were treated with Santulli technique. Results: In this study intestinal leak and delayed intestinal transit (DIT) were significant complication among group A and contributed more to septicaemia and dessiminated intravscular coagulopathy (DIC). The overall mortality were 11 cases; 6 cases from group A, 2 cases from group B and 3 cases from group C. The improvement in group B and C was attributed to the low pressure anastomosis performed with less leakage problems. The early start of oral feeding and shorter duration of TPN usage in group B and C in relation to group A helped in reducing the bacterial overgrowth in the gut and decreasing the sepsis rate. Also the total duration of hospital stay was shorter in group B and C in comparison to group A. Conclusions: Using Bishop-koop and Santulli techniques in the current study has improved the survival of these patients and minimized the post operative complications. Key words: Small intestinal atresia, surgical techniques. I INTRODUCTION Intestinal atresia constitutes one of the most common causes of neonatal intestinal obstruction. It is a serious congenital anomaly that affects approximately 1: 5000 live births. 1 The apple peel type constitutes 10% of all small bowel atresia which was first reported by Santulli and Blanc in 1961. 2 An ischemic insult to the developing midgut at some stage during fetal development is widely accepted to result in jejunoileal atresia. 3 Many techniques have been described for surgical correction of intestinal atresia such as Mikulicz double barrel ileostomy, Bishop-koop, Santulli and primary resection with end to end anastomosis. The current practice is to perform primary end to end anastomosis after excision of the dilated bowel. However, there are certain situations that this may carry the risk of anastomotic leakage or non function due to discrepancy in the bowel size between the proximal Correspondence to: Al Moutaz A. El Tayeb, MD. Pediatric Surgery Unit, Department of Surgery, Faculty of Medicine, Assuit University, E mail almoutazeltayeb@hotmail.com
Eltayeb A. and distal ends or sepsis caused by bacterial overgrowth in the proximal dilated atonic loop, perforations, doubtful bowel viability and healing problems. 4,5 The aim of this work was to assess the different surgical modalities in management of intestinal atresia in high risk neonates attempting to improve the morbidity and mortality rates in such patients. PATIENTS AND METHODS During the period from January 2005 to January 2008, 32 neonates (20 males and 12 females) with intestinal atresia were admitted to neonatal intensive care unit at Assiut University Hospital. Eighteen were full term newborn with mean gestational age of 38 ± 1.23 weeks and mean birth weight of 3.1±0.35 Kg. The remaining 14 were preterm newborn with mean gestational age of 33± 1.28 weeks and mean birth weight of 2.28 ± 0.13Kg. Ten neonates were presented 1 to 2 days after birth, 15 were presented at the age of 3-7 days and 7 were presented after 1 week and up to 22 days of age. Full detailed history and clinical examination were done to identify any risk factors and to detect any associated anomalies. All neonates presented with bilious vomiting and failure of passage of meconium. Twenty four neonates had moderate to marked abdominal distension. X- ray films were done and showed distended intestinal loops with multiple air fluid levels in 28 neonates. Six cases showed clinical and laboratory findings of neonatal sepsis as lethargy, poor suckling, skin mottling, thrombocytopenia and positive C- reactive protein test (CRP). All cases received the initial medical resuscitation in the form of IV fluids, nasogastric suction and vitamin K injection.. IV antibiotics in the form of third generation cephalosporin (100 mg/kg/day) with metronidazole (7.5 mg/kg/8 hours) were given to all cases. Surgical techniques: The 32 cases were classified according to the surgical technique into three groups: Group A: included 12 patients who were treated with primary resection/ anastomosis or enterotomy with excision of the membrane (in type I atresia); Group B: included 10 patients, who undergone Bishop-koop technique, and Group C: included 10 patients who were treated with Santulli technique. the selection of the techniques was determined according to the site, type of atresia, and the coexisting risk factors. Exploration was done through right upper transverse abdominal incision. Limited resection of the dilated proximal loop was performed in group A with primary anastomosis in 7 cases (using 5/0 polyglycolic acid absorbable suturing material as single layer (Fig 5). While in the remaining 5 cases with type I atresia just enterotomy and excision of the membrane was done. In Bishop-koop technique (10 cases) the distal loop was taken out to as a stoma with end to side anastomosis between proximal loop and the anti mesenteric border of the distal loop (fig 6). In Santulli technique (10 cases) the reverse was done where the proximal loop was taken out to the surface with end to side anastomosis between the distal and the anti mesenteric border of the proximal loop. Statistical analysis was done using SPSS version 11 (Chicago, USA). Comparing means between the three groups was done using ANOVA test. RESULTS The total number of deaths was 11 cases; 6 cases from group A, 2 cases from group B and 3 cases from group C. the site and type of atresia in each group is shown in Table1 and Table 2. The causes of mortality were sepsis and DIC in 7 cases, anastomotic leakage in 2 cases, anastomotic dysfunction in 2 cases, NEC in one case and short bowel syndrome in one case. Other postoperative complications were encountered in 7 cases; minimal wound infection in 4 cases who were managed conservatively, complete burst abdomen in one case and incisional hernia in 2 cases. Re-operation was needed for those survived cases from group B and C to restore continuity of GIT after 3 months. The follow up period was 6 to 12 months. The cases attended the follow up showed normal growth curve findings. There was no significant difference between group B & C regarding the start of oral feeding, duration of TPN and duration of hospital stay. There was a significant difference between group A and the other two groups (B&C) regarding the start of oral feeding and duration of TPN but no significant differences in duration of hospital sta (Table 3) Annals of Pediatric Surgery 32
Eltayeb A. Fig 1. Type I: Mucosal atresia with intact muscularis. Fig 2. Type II: the atretic ends are separated by a fibrous band. Fig 3. Type IILa: atretic ends are separated by a V-shaped gap defect. Fig 4. Type IIIb: Apple peel deformity of the distal atretic segment Fig 5. Primary resection/ anastomosis Fig 6. Santulli and Blanc technique 33 Vol 5, No 1, January 2009
Eltayeb A. Table I Anatomical site of atresia in the different groups: Site of atresia. Group A Group B Group C Jejunal 9 7 2 Ileal 3 3 8 Total 12 10 10 Table II Types of atresia in different groups: Type of atresia Group A Group B Group C Type I 5 - - Type II 5 6 2 Type III a 2 3 3 Type III b - 1 3 Type IV - - 2 Total 12 10 10 Table III Characteristics of patients and the frequency of complications encountered in the different groups: Group A(n=12) B(n=10) C(n=10) Starting of oral feeding (days) Duration of TPN(days). Anastomotic leakage. Delayed intestinal transit 9 ( ± 1.33) 4 (±0.67) 4 ( ±1.22) 10 (± 3.65) 5 (± 2.16) 5 (± 2.04) 2 0 0 2 0 0 NEC 1 0 0 Septicaemia and DIC Short bowel syndrome. 3 2 2 0 0 1 Wound infection. 1 1 2 Burst abdomen. 0 0 1 Incisional hernia. 1 0 1 Duration of hospital stay (days) 15 ( ± 5.40) 12 ( ± 1.70) 12 ( ±2.46) Mortality 6 2 3 DISCUSSION The choice of a specific surgical technique for the treatments of intestinal atresia depends on the pathological type of atresia (type I, II, III a, III b, IV) and the presence of associated malrotation, volvulus or meconium peritonitis. 6 Harry Bishop and Everett Koop in 1957 7 described an end to side anastomosis of the small intestine where the atretic small distal portion is directed out. Santulli and Blanc took the reversed way in 1961 8. The enterostomy has the advantage that it allows deflation of dilated proximal bowel and in the same time it allows the intestinal contents to pass gradually through the distal unused bowel (low pressure anastomosis). Thus the distal bowel gradually dilates and functions, also it allows early feeding which reduces the needs for parenteral nutrition with its hazards. The disadvantages of enterostomies, that further surgery is required to close the stoma, skin excoriation and leakage from the stoma which may aggravates the nutritional status. 6 Masumoto et al, 1999 9 showed that hypoplasia of the intramural nerves and pacemaker cells was seen predominantly in the proximal segments of intestinal atresia, and that these changes in the proximal segment may contribute to postoperative intestinal dysmotility. The dilated proximal bowel in patients with intestinal atresia might also be responsible for disturbed intestinal transit (DIT) during the postoperative period. 10 Moreover, the decrease in intraluminal pressure, which was induced as a physiological consequence of dilated bowel, also might be involved in DIT because of the importance of the pressure gradient for transportation of luminal contents. 11 Various treatment methods were described to avoid occurrence of DIT. Nixon in 1955 11 resected the dilated bowel and showed an improved in the survival rate. In 1973, Howard and Othersen 12 described a tapering jejunoplasty, and observed the return of peristalsis in the tapered jejunum radiographically. In1983, de Lorimier and Harrison 13 reported another operation involving folding in and plicating the antimesenteric portion of the dilated bowel instead of resection. Although the most effective method might be resection of the dilated bowel, it is possible that massive resection may induce short bowel syndrome. Tapering jejunoplasty and bowel plication (BP) seems to avoid this problem. The advantages of BP that it is minimally invasive surgery for neonates and if added to the remaining Annals of Pediatric Surgery 34
dilated bowel after the resection or tapering jejunoplasty might be the method of choice to avoid massive resection. 10 It was reported that the mortality rates from intestinal atresia have dropped from 70% in 1961to 20% after 1970. 14 Today 80-90% of these cases complete their first post operative year. These results are related to the early diagnosis and development of reliable operative equipments and techniques as well as to improvement in intensive care management and parenteral nutrition. 4 The overall mortality in our study was (34.4%), with slight increase in group A (50%) compared to both group B and C (20% and 30%). This high mortality was attributed mainly to delayed presentation, septicaemia and DIC and short bowel syndrome. In this study, intestinal leak and DIT were significant complication among group A and contributed more to septicaemia and DIC. The improvement in group B and C in this study was attributed to the low pressure anastomosis performed with less leakage problems. The early start of oral feeding and shorter duration of TPN usage in group B and C in relation to group A helped in reducing the bacterial overgrowth in the gut and so the sepsis rate. Also the total duration of hospital stay was shorter in group B and C in relation to group A but with no significant statistical difference. CONCLUSION The results of the current study showed that the use of stoma (Bishop-koop or Santulli techniques) have an important role in the management of intestinal atresia. Using these techniques has improved the survival of these patients and minimized the postoperative complications. Also, early diagnosis and referral are important. However we need more efforts to improve our intensive care and parenteral nutrition to achieve a better outcome. REFERENCES Eltayeb A. 1- Waldhausen J.H. and Sawin R.S: Improved long-term outcome for patients with jejunoileal apple peel atresia. J Pediatr Surg 32:1307-1309, 1997 2- Sato S., Nishijima E., Muraji T.,et al: Jejunoileal atresia: A 27-year experience. J Pediatr Surg. 33:1633-1635, 1998 3- Nixon H.H. and Tawes R.: Etiology and treatment of small intestinal atresia: Analysis of a series of 127 jejunoileal atresias and comparison with 62 duodenal atresias. Surgery 69:41-51, 1970 4- Wit J., Sellin S., Degenhardt P., Scholz and Mau H.: Is Bishop- Koop anastomosis still modern in the treatment of newborn? Chirurg. 71:307-310, 2000 5- Kumaran N. and Shankar K.R.: Trends in the management and outcome of jejuno-ileal atresia. Eur J Pediatr Surg 12:163-167, 2002 6- Kaddah S.N.: High risk intestinal atresia: A comparative study between primary anastomosis and Bishop-Koop technique. The Gaz. Egypt. Paed.51:93-99, 2003 7- Bishop H.C. and Koop C.E.: Management of meconium ileus resection, Roux-en-y- anastomosis and ileostomy irrigation with pancreatic enzymes. Ann Surg 145:410, 1957 8- Santulli T.V. and Blanc W.A.: Congenital atresia of the intestine. Pathogenesis and treatment. Ann Surg. 154:939, 1961 9- Masumoto K, Suita S, Nada O, et al: Abnormality of enteric neurons, intestinal pacemaker cells and smooth muscle in human intestinal atresia. J Pediatr Surg 34:1463-1468, 1999 10- Takahashi A., Suzuki N., Ikeda H., et al: Results of bowel plication in addition to primary anastomosis in patients with jejunal atresia. J.Pediatr.Surg.36:1752-1756, 2001 11- Nixon HH: Intestinal obstruction in the newborn. Arch. Dis. Child 30:13-22, 1955 12- Howard ER. And Othersen H.B.: proximal jejunoplasty in the treatment of jejunal atresia. J Pediatr Surg 8:685-690, 1973 13- De Lorimier AA. And Harrison MR.: Intestinal plication in the treatment of atresia. J Pediatr Surg 18:734-737, 1983 14- Festen S., Brevoord J.C.D., Goldhoorn G.A., Festen C., Hazebroek F.W.J., Van Heurn L.W.E., de Langen Z.J., Van Der Zee D.C. and Aronson D.C. : Excellent long-term outcome for survivors of apple peel atresia. J Pediatr Surg 37:61-65, 2002 35 Vol 5, No 1, January 2009