Use of trans-anastomotic tubes in congenital duodenal obstruction.

AIM: Despite data to suggest benefit of trans- anastomotic tube (TAT) feeding in infants following repair of congenital duodenal obstruction (CDO), TAT usage is limited. We aimed to report a large series of infants with CDO treated with or without TAT in order to improve the evidence underlying this simple intervention. METHOD: Single centre retrospective review of all infants CDO over a 20-year period (January 1999 - November 2020, inclusive). Important outcomes were compared between infants treated with or without TAT. Data are median [IQR]. RESULTS: Ninety-six infants were included. A TAT was placed in 54 infants (56%). Median time to full enteral feed was significantly shorter in the TAT group (6 [5-8] days vs 10 [7.5-12], p <0.001). Time to first feed was shorter in the TAT group (2 [2-2.8] days vs 3 [2-5], p<0.001). Significantly fewer infants with a TAT placed received a central venous catheter (CVC, 15% vs 76%, p <0.001). Infants without a TAT received parenteral nutrition (PN) for longer (0 [0-0] vs 7 [0-11] days, p <0.001). There was no change in length of stay between TAT and no TAT group (16 [13-21.8] vs 15 [12-21.8] days, p = 0.722). Eight infants (15%) in the TAT group required a CVC and PN. One infant in the TAT group developed a perforation that required surgical management and nine infants in the non-TAT group had complications related to the CVC (21%), including one infant that required general anaesthetic for tunnelled central line placement (2.3%). CONCLUSION: In infants with CDO, TAT use was associated with earlier establishment of full enteral feeds, reduced need for CVC and PN and reduced complications. Further research should focus on the barriers to wider use of TAT by surgeons and neonatologists in infants with CDO.

Association Between Administration of Antacid Medication and Anastomotic Stricture Formation After Repair of Esophageal Atresia.

BACKGROUND: Anastomotic stricture is a significant cause of morbidity after repair of esophageal atresia (EA). Exposure to gastric acid has been postulated to contribute to stricture development and severity leading to prophylactic antacid use by some surgeons. We investigated the association between administration of antacid medication and the development of anastomotic strictures. METHODS: Retrospective case-note review of consecutive infants undergoing repair of EA with distal tracheoesophageal fistula (type C) between January 1994 and December 2014. Only infants who underwent primary esophageal anastomosis at initial surgical procedure were included. Stricture-related outcomes were compared initially for infants who received prophylactic antacid medication (PAAM) versus no prophylaxis, and the role of PAAM in stricture prevention was explored in a multivariate model. Outcomes were also compared for infants grouped by antacid use at any stage. RESULTS: One hundred fourteen infants were included. Sixteen infants received PAAM at surgeon preference. Of the remaining 98 infants, 44 subsequently received antacid as treatment for gastroesophageal reflux (GER) and 54 never received antacid medication. There was no statistically significant association between incidence of stricture in the first year (10 of 16 versus 41 of 98; P = 0.18) nor time to first stricture (median, 57 d [41-268] versus 102 d [43-320]; P = 0.89) and administration of PAAM. Similarly, there were no statistically significant associations between incidence of stricture, age at first stricture and number of dilatations, and administration of antacid medication either as prophylaxis nor when given as treatment for symptoms or signs of GER. CONCLUSIONS: These data do not support the hypothesis that PAAM reduces the incidence or severity of anastomotic stricture after repair of EA. Treatment with antacids may be best reserved for those with symptoms or signs of GER. Further prospective investigation of the role of antacid prophylaxis on stricture formation after EA repair is warranted.

Growth pattern of infants with gastroschisis in the neonatal period.

BACKGROUND/AIM: Early postnatal growth patterns may have significant long term health effects. Although preterm infants on parenteral nutrition (PN) exhibit poor growth, growth pattern of term or near-term infants requiring PN is not well reported. We aimed to investigate this in infants born with gastroschisis. METHODS: Retrospective review of all infants with gastroschisis requiring PN treated at a single centre over a 4 year period. Growth and clinical data were retrieved, and weight SDS scores for corrected gestational age calculated. Weight SDS (mean ± SD) were compared at clinically relevant timepoints and multi-level regression used to model growth trends over time. MAIN RESULTS: During the study period 61 infants with gastroschisis were treated; all were included. Infants were small for gestational age at birth for weight (SDS score -0.87 ± 0.85). Weight SDS decreased significantly during the first 10 days of age (mean decrease 0.81 ± 0.56; p < 0.0001) and between birth and discharge (mean decrease 0.81 ± 0.56; p < 0.0001). Despite tolerating full enteral feeds, weight SDS velocity was negative around the time of transition from parenteral to enteral feed. There was evidence of 'catch up' growth between 3 and 6 months of age. CONCLUSION: Despite nutritional support with PN, infants with gastroschisis demonstrate significant growth failure during the newborn period. Further efforts are required to understand the underlying mechanisms, improve nutritional support and to evaluate the long term consequences of postnatal growth failure in this population.

Nutritional role of amniotic fluid: clues from infants with congenital obstruction of the digestive tract.

AIMS: To investigate the role played by amniotic fluid in late fetal nutrition by analysis of infants born with digestive tract atresia. METHODS: Birth weight (BW), gestational age and gender of infants born with oesophageal (OA), duodenal (DA), jejunal (JA) and ileal atresia (IA) were recorded and BW Z-scores compared. Infants with incomplete obstruction (stenosis), chromosomal or syndromic conditions and multiple congenital malformations were excluded. Term infants admitted with suspected postnatal intestinal obstruction in whom no congenital malformation was found were used as a control group. RESULTS: A total of 584 infants were identified comprising 148 OA, 60 DA, 26 JA and 57 IA with 293 in the control group. Infants with OA and DA had statistically significantly lower BW Z-score than controls. However, BW Z-score for infants with more distal atresia (JA and IA) was similar to controls. When compared with infants with OA, BW Z-score for infants with more distal atresia was higher than that for OA. BW Z-score in infants with OA was significantly lower in those born at term compared with those born preterm (mean±SD -0.92±1.0 vs -0.48±0.87; p=0.01) with a significant negative correlation between BW Z-score and increasing gestational age (R2=0.12; p<0.0001). This effect of gestational age was not seen in other atresias. CONCLUSION: These observations support the concept that reduced enteral absorption of amniotic fluid due to high digestive tract obstruction in utero reduces fetal growth. The effect is greater when the obstruction is more proximal and with advancing gestation.

Emergency laparotomy in infants born at <26 weeks gestation: a neonatal network-based cohort study of frequency, surgical pathology and outcomes.

OBJECTIVE: Identify the proportion of infants born at <26 completed weeks' gestation who require emergency laparotomy, and review the surgical pathology, incidence of subsequent surgical procedures and outcome. DESIGN: Retrospective cohort review. SETTING: Tertiary neonatal surgical unit. PATIENTS: All infants born at <26 weeks' gestation in a neonatal network over an 8-year period. RESULTS: Of 381 infants, laparotomy was indicated in 61 (16%) and performed in 57. Surgical pathology encountered included spontaneous intestinal perforation (SIP) (28), necrotising enterocolitis (NEC) (14), volvulus without malrotation (1), strangulated inguinal hernia (1), milk curd obstruction (4), NEC stricture (1) and meconium obstruction of prematurity (2). No intestinal pathology was found in six. Four infants with indications for laparotomy and severe comorbidity had intensive care withdrawn without surgery. The most frequent procedure performed was resection with primary anastomosis. Nine infants (16%) required more than one laparotomy. Of the 16 infants who had stoma formation, eight had closure before discharge. Fifteen infants required surgical patent ductus arteriosus ligation following laparotomy, and 17 had laser therapy for retinopathy of prematurity. Overall 42 infants with indication for laparotomy (69%) survived to discharge. CONCLUSIONS: Nearly one in six infants born at <26 weeks required emergency laparotomy. The most frequent pathology encountered was SIP (49%), followed by NEC (25%). Over one-quarter required subsequent gastrointestinal surgery, with many also requiring cardiothoracic and ophthalmic procedures. These data are important for those caring for extremely preterm infants, the provision of information to parents and organisation of neonatal services.

Intrauterine death rate in gastroschisis following the introduction of an antenatal surveillance program: Retrospective observational study.

AIM: To investigate whether an antenatal surveillance protocol including ultrasound and cardiotocograph monitoring reduces intrauterine death (IUD) in cases of gastroschisis. Secondary outcomes included neonatal death rate, mode of delivery and rate of intervention before planned time of delivery. METHODS: This was a retrospective observational study of all women with antenatally diagnosed gastroschisis who were managed according to the surveillance program between 2002 and 2015 in a tertiary fetal medicine and pediatric surgical center covering the Wessex region of England. We reviewed and analyzed data from the Wessex Antenatally Detected Anomalies (WANDA) database as well as prospectively managed maternity, ultrasound and neonatal databases over the given time period. Case notes were reviewed when delivery was expedited. RESULTS: The IUD rate was 2.2%, a 58% reduction since the introduction of the surveillance protocol. Delivery was expedited in 35.4% of cases, and in 86% of these, delivery was by cesarean section. In women being induced as planned at 38 weeks, the vaginal delivery rate was 88%, and for those in spontaneous labor before 38 weeks it was 75%. CONCLUSIONS: An antenatal surveillance program appears to reduce the IUD in gastroschisis. In one-third of cases, delivery was indicated before the planned date of delivery. When expedited delivery was indicated, the chance of cesarean section was high.

The burden of excluding malrotation in term neonates with bile stained vomiting.

PURPOSE: To determine the number of term infants with bilious vomiting (BV) referred to a neonatal surgical centre for exclusion of malrotation by upper gastrointestinal contrast (UGI) examination. METHODS: Retrospective review of term (>37/40) neonates <28 days of age undergoing UGI for exclusion of malrotation between Jan 2010 and Dec 2014 in a neonatal network with 30,000 term deliveries annually. Only infants with BV in the absence of alternative clinical/radiological diagnosis were included. RESULTS: One hundred and sixty-six infants met the inclusion criteria. Fourteen (9 %) infants had malrotation diagnosed by UGI and confirmed at laparotomy. Only 1 of 110 infants referred at 0-2 days of age had positive UGI compared to 13 of 56 infants referred after this age (p < 0.01). An increase in referrals followed the death of an infant from midgut volvulus and as a result one in 500 term infants are currently being referred. CONCLUSION: Increasing awareness of the potential consequences of bilious vomiting appears to have resulted in increased referrals with no increase in detection of malrotation. Prospective studies are required to determine whether investigation of all infants with unexplained bilious vomiting is required and if it is possible to select cases for surgical referral.

Do infants with gastroschisis may have a high incidence of non-IgE-mediated cow's milk protein allergy?

BACKGROUND/PURPOSE: To determine the frequency and characteristics of suspected cow's milk protein allergy (CMPA) in infants with gastroschisis and response to change in milk. METHODS: A retrospective cohort study of 111 consecutive infants with gastroschisis. RESULTS: 64 episodes suggesting non-IgE-mediated CMPA occurred in 50 infants (45 %) at a median age of 44 days (9-186) and during the primary admission in 38 %. At the time of the episode the infant feed was breast milk (BM, n = 24), term formula (TF, n = 20) or extensively hydrolysed formula (EHF, n = 6). The feed was changed to EHF (34), amino acid formula (AAF) (14) or BM with maternal CMP-free diet (2). Partial or complete resolution of symptoms occurred in all. There was histological evidence of an allergic reaction to CMP in all four infants in whom tissue was available. Recurrent episodes occurred in 13/50 infants (26 %), 10 of whom were receiving EHF. There were no recurrent episodes in infants being fed with AAF. CONCLUSION: Features suggesting non-IgE-mediated CMPA appear common in infants with gastroschisis.

C-reactive protein (CRP) levels in babies with gastroschisis managed with preformed silos.

BACKGROUND/PURPOSE: The purpose of this study was to assess the degree of elevation of serum C-reactive protein (CRP) levels in infants with gastroschisis managed by placement of a preformed silo and subsequent nonoperative closure. METHODS: CRP measurements were collected prospectively in infants with gastroschisis undergoing preformed silo placement until defect closure. Infants requiring operative closure or surgical silo placement were excluded as were any infants with confirmed sepsis during the closure period. RESULTS: Data were available for 43 infants. Median CRP at birth was 8 mg/L (range 6 to 55) rising to 42 mg/L (range 35 to 68) at the time of closure. CONCLUSIONS: Elevation of serum CRP levels is to be expected in infants with gastroschisis managed with a preformed silo in the absence of infection. This data may be used to prevent unnecessary use of antibiotics in this group of patients.

Workload and costs associated with providing a neonatal surgery service.

AIM: To identify the workload related to provision of a neonatal surgical service in a UK neonatal network in order to inform local and national service commissioning. METHOD: Data relating to neonatal surgical admissions to a level 3 perinatal centre serving a network with 36,000 births per year collected prospectively over a 5-year period were analysed to identify annual activity. Daily dependency was assessed prospectively over a 6-month period and service costs calculated using existing local tariffs. Admissions from outside the network were excluded from analysis, and allowance was made for refused network admissions. RESULTS: On average 140 admissions required 2137 cot-days per year. At 80% occupancy, the service requires seven neonatal cots suggesting that there is a national requirement for one neonatal surgical cot per 5000 births. Intensive care, high care (HC) and special care accounted for 37%, 46% and 17% of cot-days, respectively. This equates to an annual service cost of £2m, about £250,000 per 5000 births. CONCLUSIONS: This assessment of the facilities and costs required to provide a neonatal surgical service in a level 3 perinatal centre in the UK may be used to inform network and national commissioning.

Staged reduction of gastroschisis using preformed silos: practicalities and problems.

PURPOSE: Previous single-center studies have reported favorable outcomes when preformed silos (PFS) are used for the staged reduction of gastroschisis. The aim of this study was to assess the frequency and nature of complications associated with PFS in a large population and provide an insight into the practicalities of their routine use. METHODS: A retrospective review was carried out of all cases of gastroschisis managed with PFS in 4 UK neonatal surgical units for a 6-year period. RESULTS: One hundred fifty infants were included, and 139 (92.7%) silos were applied at cot side (no sedation, n = 93). Median silo size was 4 cm, and time of application was 2.5 hours. Enlarging the defect by incision of fascia was required in 17 (11%). Defect closure was performed at a median of 4 days (0-47) with 93 (62%) being at cot side. Methods of closure were adhesive strips/dressings (n = 94), sutures (n = 48), and patch (n = 8). Discoloration of the viscera occurred in 16 (11%), managed successfully by simple methods (change of PFS, aspirating the stomach, or incision of the defect fascia) (n = 8), conversion to operative silo (n = 3), and operative reduction (n = 1). Four required bowel resection. Other complications included missed atresia (n = 5; 3.3%) and nectrotizing enterocolitis (n = 11; 7%). There were 5 deaths in the series (3.3%). CONCLUSIONS: Staged reduction of gastroschisis with PFS is simple, convenient, and safe. The low rates of associated complications and mortality appear favorable when compared to infants managed with more traditional techniques. We recommend that PFS should be used for the routine management of gastroschisis.

Late-onset volvulus without malrotation in preterm infants.

PURPOSE: The aim of the study was to report a new observation of late-onset volvulus without malrotation (VWM) in preterm infants. METHODS: The study used medical note review of infants with VWM identified at a single regional centre between 1996 and 2007. RESULTS: Ten patients were identified. Group 1 includes 4 patients (gestation, 28-38 weeks; median, 32) who presented within 4 days of age (range, 1-4; median, 3). Group 2 includes 6 patients (gestation, 25-33 weeks; median, 27), who presented later (range, 22-57 days; median, 45). Characteristics of group 2 patients included recurrent episodes of abdominal distension and bile vomiting (6/6), long-term continuous positive airway pressure requirement (5/6), and sudden, severe deterioration with acute abdominal signs (6/6). Small bowel volvulus was found at laparotomy requiring resection (30%-70% of total small bowel) and either primary anastomosis (4) or stoma formation (2). All babies survived. CONCLUSIONS: There appear to be 2 clinical groups with VWM-one presenting within the first few days of life and the other presenting after the first month of life associated with a specific clinical history. This latter group has not been described before.

Gastroschisis: the cost of an epidemic.

BACKGROUND: The rising incidence of gastroschisis has been highlighted by the Department of Health as a growing concern. As well as the health implications for the increasing number of affected infants, this increase in incidence will have an impact of the costs of health care. This study was undertaken to estimate the financial cost of treating this condition in one tertiary neonatal surgical center. METHODS: A retrospective analysis was performed of all patients admitted to a tertiary neonatal surgical center with gastroschisis from January 1996 to December 2005. The main outcome measures were incidence, length of hospital stay, and total cost for all patients each year. RESULTS: The incidence of gastroschisis has risen 3-fold in 10 years. The median cost per patient is relatively constant. A few patients with severe intestinal dysmotility require prolonged hospital stay. As the condition becomes more common, there are an increasing number of complex patients and thus an increase in annual costs, which is disproportionate to the increase in numbers of cases. We estimate that the annual cost to the National Health Service (NHS) of this condition in England and Wales has risen from pound3.6 million in 1996 to in excess of pound15 million in 2005. CONCLUSIONS: Urgent research is required into the etiology of gastroschisis and into the severe intestinal dysmotility that occurs in some complex patients.

The perinatal management of gastroschisis.

Gastroschisis is increasing in frequency and is becoming a common condition. It is now invariably detected antenatally and although the long-term outcome in the majority of cases is excellent, the existence of both fetal and postnatal complications has led to variations in practice to try to optimise outcome. This article reviews the evidence for some of these variations where such evidence exists and provides a contemporary view of best practice where it does not.

Meconium plug obstruction.

We reviewed the final diagnosis and incidence of bowel pathology in neonates presenting with large bowel obstruction that was relieved by the passage of meconium plugs. A retrospective case-note review was undertaken of all patients with a discharge diagnosis of meconium plug syndrome (MPS), meconium ileus (MI), Hirschsprung's disease (HD), or small left colon syndrome (SLCS) from January 1996 to April 2002. Of 21 patients with meconium plug obstruction, eight (38%) had HD, nine had MPS, four had SLCS, and none had MI. However, there was considerable clinical and radiological overlap between MPS and SLCS, suggesting that these terms are imprecise. We found a much higher incidence of HD in babies presenting with meconium plug obstruction than has previously been reported. Overlap between MPS and SLCS suggests that these are not specific diagnoses and that current terminology needs to be changed. All babies with meconium plug obstruction should have HD and cystic fibrosis (CF) excluded.