Scope and feasibility of operating on the neonatal intensive care unit: 312 cases in 10 years.

PURPOSE: To report the scope, feasibility and learning experience of operating on neonates on the neonatal intensive care unit (NICU). METHODS: (1) Review of all NICU operations performed by general neonatal surgeons over 10 years; (2) 6-month prospective comparison of procedures performed in NICU or operating room; (3) structured interviews with five surgeons with 1-13 years experience of operating on NICU. RESULTS: 312 operations were performed in 249 infants. Median birth weight was 1,494 g (range 415-4,365), gestational age 29 weeks (22-42), and age at operation 25 days (0-163). Nearly half (147) were laparotomy for acute abdominal pathology in preterm, very low birth-weight infants There were no surgical adverse events related to location of surgery. Surgeon satisfaction with operating on NICU for this population was high (5/5). Several factors contribute to making this process a success. CONCLUSIONS: This is the largest reported series of general neonatal surgical procedures performed on NICU. Operating on NICU is feasible and safe, and a full range of neonatal operations can be performed. It removes risks associated with neonatal transfer and is likely to reduce physiological instability. We recommend this approach for all ventilated neonates and urge neonatal surgeons to operate at the cotside of unstable infants.

Meconium obstruction of prematurity.

Meconium obstruction of prematurity is an entity primarily affecting very low birthweight or extremely low birthweight babies causing low intestinal obstruction. Its presence may at best delay establishment of enteral feeding and compromise nutrition and at worst lead to mechanical obstruction requiring surgery or to intestinal perforation. There are considerable challenges in the recognition, diagnosis and management of this condition. Awareness of the disease and understanding of its pathogenesis may lead to early detection of affected babies and allow proactive measures to decrease the associated morbidity and mortality.

Trans-anastomotic tubes reduce the need for central venous access and parenteral nutrition in infants with congenital duodenal obstruction.

PURPOSE: To determine the effect of trans-anastomotic tube (TAT) feeding on outcome following repair of congenital duodenal obstruction (CDO). METHODS: Retrospective comparative study of all infants with CDO over 10 years. Data are median (range). Mann-Whitney U test and Fisher's exact test were used. RESULTS: Of 55 infants with CDO (48 atresia, 7 stenosis), 17 were managed with a TAT, 38 without. Enteral feeds were commenced earlier in infants with a TAT compared to those without (TAT 2 days post-repair [1-4] vs. no-TAT 3 days post-repair [1-7]; p = 0.006). Infants with a TAT achieved full enteral feeds significantly sooner than those without (TAT 6 days post-repair [2-12] vs. no-TAT 9 days post-repair [3-36]; p = 0.005). Significantly fewer infants in the TAT group required central venous catheter (CVC) placement and parenteral nutrition (PN) than in the no-TAT group (TAT 2/17 vs. no-TAT 28/38, p < 0.0001). There were six CVC-related complications (5 infections, 1 PN extravasation) and four TATs became displaced and were removed before achieving full enteral feeds. One infant with a TAT with trisomy 21 and undiagnosed Hirschsprung disease developed an anastomotic leak and jejunal perforation requiring re-operation. CONCLUSIONS: A TAT significantly shortens time to full enteral feeds in infants with CDO significantly reducing the need for central venous access and PN.

Recurrent neonatal gastro-intestinal problems after spontaneous intestinal perforation.

To identify intestinal complications during the neonatal period following spontaneous isolated intestinal perforation (SIP). A retrospective case notes review was undertaken of all patients with a diagnosis of SIP, confirmed at laparotomy or post-mortem, admitted between January 2000 and January 2005. Patients with confirmed gastric perforation were excluded as were patients with proven necrotising enterocolitis (NEC) or suspected, but not confirmed, SIP. Seventeen patients, median gestation 27 weeks and median birth weight 780 g, were treated by drain alone (1), drain and later laparotomy (4) or primary laparotomy (12). Eight patients required enterostomy formation at primary laparotomy (1 jejunostomy, 1 colostomy and 6 ileostomy). Five babies died in the neonatal period and three later in the first year. Nine patients (53%) had ten subsequent episodes of intestinal pathology requiring surgical intervention between 5 and 136 days later comprising early recurrent isolated perforation (2), NEC (3), milk curd obstruction with or without perforation (3) and adhesion obstruction (2). Secondary surgery involved laparotomy in eight patients, five of whom required formation or re-formation of a stoma, and palliative drain insertion in one patient. Recurrent intestinal pathology requiring surgical intervention during the neonatal period occurred in 53% of babies with SIP. Surgeons and neonatologists should be aware that this group of patients are prone to further intestinal pathology.