Diagnostic value of the microcolon using ultrasonography in small bowel atresia.

BACKGROUND: Microcolon helps diagnose small bowel atresia (SBA) using contrast enema. However, there are no ultrasonography (US) microcolon criteria for diagnosing SBA. Therefore, this study aimed to evaluate colon accuracy and other characteristics for diagnosing SBA by US, using surgical or clinical information as the reference standard. METHODS: US was performed on 46 neonates aged ≤ 7 days old. In the study group (n = 15), neonates with SBA were confirmed following surgery. In the study group without SBA (n = 15), neonates with other gastrointestinal problems besides SBA were confirmed by surgical or clinical follow-up. Sixteen neonates without gastrointestinal problems were classified as the control group. The colonic diameter was measured, and colonic gas was sought and observed. Statistical analysis was performed to compare US parameters between the study group and other two groups. The optimal cut-off value of the colonic diameter for SBA diagnosis was obtained using receiver operating characteristic analysis. RESULTS: Colonic diameters (0.5 cm) in the study group (interquartile ranges [IQR], 0.5-0.6 cm) was significantly smaller than that in the group without SBA (0.9 cm; IQR, 0.8-1.2 cm) (P < 0.001) and in the control group (1.2 cm; IQR, 0.8-1.35 cm) (P < 0.001). Optimum cut-off value for diagnosing SBA was 0.65 cm (sensitivity, 90.3%; specificity, 86.7%; accuracy, 89.1%) for the colonic diameter. Combining microcolon and gas-negativity showed the best performance in SBA diagnosis using US, with increased accuracy (91.3%). CONCLUSION: A colon < 0.65 cm in diameter should be called a microcolon; combining US with gas-negativity is an essential diagnostic basis for SBA.

Incidence of late severe intestinal complications after bowel atresia/stenosis.

BACKGROUND: To determine the incidence and risk factors for late severe intestinal complications after surgical repair for intra-abdominal congenital intestinal atresia/stenosis. METHODS: We included 51 patients who underwent surgical repair for congenital intestinal atresia/stenosis. Late severe intestinal complications included adhesive ileus, incisional hernia, or volvulus. Whether surgical intervention was urgent or not was recorded. The location of the atresia/stenosis was classified into two groups: atresia/stenosis located at the oral or anal side from the Treitz ligament. The type of atresia/stenosis was classified as low-risk types (type I, mucosal web/II, fibrous cord/IIIa, mesenteric gap defect) and high-risk types (IIIb, apple peel/IV, multiple atresia). We compared the incidence of late intestinal complications between the location of intestinal atresia/stenosis at the oral and anal side of Treitz ligament, and between low- and high-risk types of atresia/stenosis using Fisher's exact test. RESULTS: Eight (15.7%) had late intestinal complications, all of which occurred in patients with intestinal atresia/stenosis located on the anal side of the ligament of Treitz. Urgent surgical intervention was needed in four cases. There was a significant difference in the location of atresia/stenosis (with vs. without late intestinal complications at oral/anal side of the Treitz ligament: 0/8 vs. 24/19; P = 0.005) and the type of intestinal atresia/stenosis (with vs. without that accompanying low-/high-risk type: 5/3 vs. 41/2; P = 0.023). CONCLUSIONS: Physicians should consider the presence of intestinal complications that require surgical intervention in patients undergoing surgical reconstruction for jejunal and ileal atresia/stenosis with abdominal symptoms.

Treatment of jejunoileal atresia by primary anastomosis or enterostomy: Double the operations, double the risk of complications.

PURPOSE: No study has evaluated complication rates of the combined operations needed for temporary Enterostomy compared to primary anastomosis in the treatment of Jejunoileal Atresia. Therefore the aim of this study is: 1) to compare the occurrence of severe postoperative complications (defined as Clavien-Dindo ≥III within 30 days) and 2) to compare the occurrence of different short- and long-term complications following treatment for Jejunoileal atresia either by primary anastomosis or the combined Enterostomy procedures. METHODS: All consecutive neonates treated for Jejunoileal Atresias between January 1998 and February 2021 at our tertiary academic centres were retrospectively included. Perioperative characteristics and severity of postoperative complications (Clavien-Dindo) were extracted and evaluated, using chi-squared statistics, following each operation per treatment. RESULTS: Eighty patients were included of whom 48 (60%) received a primary anastomosis and 32 (40%) an Enterostomy. Perioperative baseline characteristics were comparable, apart from significantly more patients with a gastroschisis and significantly less patients with jejunum atresia in the Enterostomy group. Our results showed that 1) significantly (p ≤ 0.01) more CD ≥III occur following treatment by Enterostomy. 2) Both short-term (surgical site infection, wound dehiscence) and long-term (short bowel syndrome, adhesive bowel obstruction) complications occurred significantly more in those treated by Enterostomy. We showed no significant difference in anastomotic leakage/stenosis and mortality rates between both treatment strategies. CONCLUSION: Although perioperative factors might necessitate an Enterostomy, we advise a low threshold for performing a primary anastomosis when in doubt, taking into account the double risk of major complications found in patients treated with a temporary Enterostomy.

New sonographic feature (C-sign) to improve the prenatal accuracy of jejunal atresia.

OBJECTIVES: To describe a new sonographic feature of the C-sign for prenatal diagnosis of jejunal atresia and evaluate its role in prenatal jejunal atresia, particularly preceding bowel dilatation and polyhydramnios. METHODS: This was a retrospective study from a tertiary maternal hospital. Patients with prenatal sonographic examination and confirmed small bowel atresia postdelivery were included. All sonographic images were reviewed by two senior sonographers. Comparison of sonographic images between prenatal jejunal and ileal atresia using the C-sign resembles the shape of the entire duodenum and other traditional sonographic features. The control group without bowel atresia was assessed for the presence of the C-sign. RESULTS: The C-sign and combined bowel dilatation with polyhydramnios were more frequent in jejunal atresia than ileal atresia, but the C-sign can be used to detect jejunal atresia earlier. The C-sign can be more likely to diagnose jejunal atresia in persisting bowel dilatation and polyhydramnios. The C-sign was not reported in any of the control fetuses. CONCLUSION: The C-sign is a new sonographic feature that can be used to improve the prenatal accuracy and early detection of jejunal atresia. However, further prospective validation is needed.

Laparoscopic Management of Congenital Intestinal Obstruction: Duodenal Atresia and Small Bowel Atresia.

Background: Congenital intestinal obstruction occurs in ∼1:2000 live births. Congenital duodenal atresia and duodenal stenosis are frequent causes of intestinal obstruction and occur in 1 per 5000-10,000 live births. Today, duodeno-duodeno anastomosis is still the treatment of choice, and it can be performed safely by minimally invasive surgery, although duodenojejunal anastomosis is surgically simpler and has equal results. Jejunum-ileal atresia or stenosis is a major cause of neonatal intestinal obstruction; its prevalence is 1:330-1:1500 live births. Nowadays, the ability of laparoscopic assisted identification of the atresia and repair by only exteriorization of the small bowel through the umbilicus makes this technique safe and feasible in almost every new born. Methods: This article will describe the operative technique of laparoscopic management of congenital duodenal and small bowel obstruction. Results: For congenital duodenal atresia patients, mortality rate is less than 5% and the majority are secondary to associated comorbidities. There is a low rate of anastomotic leaks, anastomotic stricture, delayed gastric emptying, and bacterial overgrowth. For small bowel atresia patients, complications include anastomotic leak, adhesions, small bowel obstruction, and short bowel syndrome in less than 5% of the patients. The rate of re-operations due to small bowel obstruction in laparoscopic assisted repair patients is less compared with laparotomy patients. Conclusions: Minimally invasive surgery for duodenal and small bowel atresia is safe and feasible and reduces the complications of open surgical procedures.

Novel insights into the histology of jejunoileal atresia and its therapeutic implications.

AIM: To study the histology of resected specimens of jejunoileal atresia (JIA) and to explore its probable therapeutic implications. METHODS: Biopsies were taken from the resected specimens of 32 patients of JIA. Sections were taken at the atretic ends and successively at every 5 cm in resected proximal bowel. They were stained for light microscopy and immunohistochemistry for CD117 (Interstitial cell of Cajal), α smooth muscle antibody (SMA), neuron filament protein (NFP) and calretinin. Histological findings on light microscopy and immune reactivity intensity for NFP, calretinin and α-SMA were recorded. Time taken to achieve full enteral nutrition (FEN; defined as attainment of oral feeds at 100 ml/kg/day without any intravenous fluid supplementation) was recorded and correlated with CD117 count by non-parametric Spearman rank correlation coefficient. RESULTS: Light microscopy failed to detect any abnormality in majority (n = 27, 84%) of JIA specimens. Mucosal ulceration (7.8%), submucosal inflammatory cells (8%), focal muscle thinning (2.5%), decreased ganglion cells and nerve fibers (3.8%) were noted on light microscopy. However all of them had normal α SMA, calretinin and NFP immunoreactivity. Mean ICC counts at proximal and distal atretic segment were 6.56 ±â€¯3.79 and 8.37 ±â€¯3.21 per HPF respectively. Serial sections in proximal dilated segment did not reveal any definite or well demarcated increase in ICC counts. CD117 counts at the proximal cut end of atresia was less than 6 per high power field (hpf) in 15 patients (46.8%) while at the site of anastomosis a count of more than 6/hpf was observed in 73% patients. There was no direct correlation of ICC counts with attainment of FEN. CONCLUSION: Absence of major morphological abnormalities in the proximal dilated bowel contradicts the findings of earlier studies on histology of JIA in smaller cohorts. Our observations reiterate that bowel plication rather than massive bowel resection should be the preferred management in babies with JIA. LEVEL OF EVIDENCE: Prognosis study (Level II).

Prenatal diagnosis of midgut volvulus with jejunal atresia by ultrasonography.

Prenatal midgut volvulus is difficult to diagnose, and it is particularly difficult to evaluate the degree of rotation, which may be related to prognosis. We present a rare case of prenatal midgut volvulus with a 720° rotation around the superior mesenteric artery diagnosed based on ultrasonography, and jejunal atresia was noted at the same time. This condition was supported by prenatal magnetic resonance imaging and the subsequent postnatal operation. To the best of our knowledge, there is no previous literature describing similar ultrasound findings in the prenatal period. Recognition of the color Doppler ultrasound imaging findings can help elucidate the relationship among the twisted vessels of midgut volvulus during the prenatal examination.

A Rare Cause of Chronic Life Threatening Bleeding in a Girl: The Ulcerated Blind Loops.

Ulceration in a blind loop can lead to massive gastrointestinal tract (GIT) bleeding. A 13-year old girl presented with symptomatic melena requiring repeated blood transfusion since childhood. She was an operated case of small bowel atresia in neonatal life. Her upper and lower gastrointestinal endoscopies were normal. Operation showed presence of multiple ulcers in two blind loops (parts of previous side to side anastomosis) and at the anastomotic site. She underwent resection and end-to-end anastomosis of the small bowel leading to complete resolution of melena and anemia.

Prenatal diagnosis of gastric and small bowel atresia: a case series and review of the literature.

OBJECTIVE: To describe seven cases of gastrointestinal tract (GIT) obstructions and to report a skewed review of the literature. METHODS: We performed a search of our permanent perinatal database about cases with prenatal ultrasound and MRI diagnosis of gastrointestinal tract obstructions between 2006 and 2013. All cases were followed until hospital discharge and pre-natal diagnosis were confirmed by fetal MRI, postnatal imaging and/or intra-operative findings. Maternal age, parity, gestational age at diagnosis, ultrasound findings, gestational age at delivery, Apgar scores at 1 and 5 min and postnatal outcome have been recorded. RESULTS: We identified seven cases of gastric and small bowel atresia. Karyotype was normal in six cases and abnormal in one co-twin [46,XY dup (20) (qq13.1q13.3)dn] of a dichorionic-diamniotic pregnancy. The mean ± SD for maternal age, gestational age at diagnosis, gestational at delivery, birth weight and Apgar scores at 1 and 5 min were 30.8 ± 4.8 years, 29.8 ± 3.7 weeks, 2507.5 ± 727.5 g and 5.6 ± 2.1, 7.6 ± 1.6, respectively. All fetuses' undergone surgical procedures in the postnatal period and all of them were discharged live from the hospital. CONCLUSION: Prompted antenatal detection of gastrointestinal tract obstruction using ultrasound proved to be diagnostic in all cases. Fetal MRI aid was a useful complementary diagnostic investigation. Correct pre-natal diagnosis allows adequate counseling, delivery planning and management care by a multidisciplinary team.

Outcomes in infants with prenatally diagnosed gastroschisis and planned preterm delivery.

BACKGROUND: The timing and mode of delivery of pregnancies with prenatally diagnosed gastroschisis remains controversial. AIM: To evaluate the outcome of patients with gastroschisis managed during two time periods: 2006-2009 and 2010-2014, with planned elective cesarean delivery at 37 versus 35 gestational weeks (gw). A secondary aim was to analyze the outcome in relation to the gestational age at birth. MATERIAL AND METHODS: Retrospective review of all cases with gastroschisis managed at our institution between 2006 and 2014. RESULTS: Fifty-two patients were identified, 24 during the initial period, and 28 during the second. There were a significantly higher number of emergency cesarean deliveries in the first period. There were no differences between groups with regard to the use of preformed silo, need of parenteral nutrition or length of hospital stay. When analyzing the outcome in relation to the gw the patients actually were born, we observed that patients delivered between 35 and 36.9 gw were primary closed in 88.5% of cases, with shorter time on mechanical ventilation, parenteral nutrition and hospital stay. CONCLUSION: Planned caesarian section at 35 completed gestational weeks for fetuses with prenatally diagnosed gastroschisis is safe. We observe the best outcome for patients born between 35 and 36.9 gw.

Near total jejuno-ileal atresia: a management challenge.

A 2-day-old female neonate with the clinical picture of proximal small bowel atresia, on exploration, turned out to have intestinal atresia of a rare variety, i.e., a near-total jejuno-ileal atresia. The baby had total small bowel length of less than 10 cm. She survived for 3 months on enteral feeding after end-to-back duodeno-ileal anastomosis and thereafter succumbed to septicemia. The case is presented for it's extreme rarity and consideration of this extreme form of small bowel atresia as an offshoot of the existing classifications of jejuno-ileal atresia since it has dismal prognosis and presents as a management challenge even today.

Changes of smooth muscle contractile filaments in small bowel atresia.

AIM: To investigate morphological changes of intestinal smooth muscle contractile fibres in small bowel atresia patients. METHODS: Resected small bowel specimens from small bowel atresia patients (n = 12) were divided into three sections (proximal, atretic and distal). Standard histology hematoxylin-eosin staining and enzyme immunohistochemistry was performed to visualize smooth muscle contractile markers α-smooth muscle actin (SMA) and desmin using conventional paraffin sections of the proximal and distal bowel. Small bowel from age-matched patients (n = 2) undergoing Meckel's diverticulum resection served as controls. RESULTS: The smooth muscle coat in the proximal bowel of small bowel atresia patients was thickened compared with control tissue, but the distal bowel was unchanged. Expression of smooth muscle contractile fibres SMA and desmin within the proximal bowel was slightly reduced compared with the distal bowel and control tissue. There were no major differences in the architecture of the smooth muscle within the proximal bowel and the distal bowel. The proximal and distal bowel in small bowel atresia patients revealed only minimal differences regarding smooth muscle morphology and the presence of smooth muscle contractile filament markers. CONCLUSION: Changes in smooth muscle contractile filaments do not appear to play a major role in postoperative motility disorders in small bowel atresia.

Meconium Peritonitis: 15 Cases Studies

PURPOSE: Meconium peritonitis is a form of aseptic, chemical peritonitis that results from a perforation of the gut during the intrauterine or perinatal period. The rarity of the disease resulted in few survivors up to the 1950's. However, the constantly increasing survival rate has followed an aggressive surgical management, along with a more thorough understanding of the etiological and pathological variations likely to be encountered. This study was performed to analyze our past 10 years' experience with meconium peritonitis. METHODS: The hospital records of 15 patients treated between January 1991 to December 2000 were retrospectively reviewed. RESULTS: The male to female sex ratio was 2:1, and the age at surgery varied from at the time of birth to 48 days. The clinical manifestations included marked abdominal distension (13 cases), respiratory distress (8 cases), billous vomiting (5 cases) and scrotal swelling (1 case). Radiological findings included air-fluid level (7 cases), calcification (4 cases) and pneumoperitoneum (3 cases). The prenatal ultrasonography demonstrated dilated loops of bowel, septated fetal ascites and calcification. The leading cause of perforation was small bowel atresia (8 cases). A primary end-to-end anastomosis was performed in 10 cases. Generalized type (8 cases) was the most common finding of meconium peritonitis. 86% of patients survived without long-term complications. CONCLUSION: Early recognition and proper management offer the greatest opportunity for survival in cases of meconium peritonitis.