Trends in Neonatal Intestinal Obstruction in a Developing Country

Abstract

Dr. Ekenze and colleagues are to be congratulated for an honest report on an important condition, neonatal intestinal obstruction. Outcomes in many developing countries are poor for neonatal bowel obstruction but are rarely published so candidly. I want to elaborate on the complex and multiple factors that continue to dog all Third World pediatric surgeons attempting to achieve results comparable to those of developed countries. The desired goal of a healthy survivor of neonatal intestinal obstruction requires the coordinated interaction of medical, nursing, and rehabilitative specialties in an organized team. Although certain critical components may exist, there are stark deficiencies in other areas, such as infection control, nutritional therapy, and stoma and wound care. These disciplines, critical to the postsurgical management of a neonate after abdominal surgery, are usually not available. Few dedicated pediatric hospitals exist in developing countries, and some have been closed because of financial nonsustainability. Access to good quality neonatal intensive care is widely accepted as the most important factor contributing to the improvement in neonatal surgical outcomes over the last three decades. Access to intensive care cannot be taken for granted in Africa. Even where such units do exist, they are characterized by 100% bed occupancy, hopelessly low staff allocation for the severity of illness of their patients, and the need to keep hospital stays to a minimum and triage for only the sickest of the sick. This precludes many patients’ access to such units and forces surgeons to operate on compromised neonates without access to a specialized postoperative care facility. For many of these conditions, the slow establishment of intestinal passage during the recovery period mandates the use of parenteral feeding. Its unavailability to the cohort of patients in the study under consideration here undoubtedly placed them at a significant survival disadvantage. The authors do not state whether transanastomotic feeding tubes were used, but our experience with their use is not favorable. In challenging patients with prolonged intestinal dysfunction, long-term intravenous nutrition carries a prohibitive mortality rate due mainly to nosocomial sepsis. Survival to a stage where a patient would be eligible for intestinal transplantation, even if this were available, is rare. In Africa, antenatal ultrasonography is a privilege afforded to only a small number of women in large urban areas, and most conditions are therefore diagnosed only after birth. At my institution, 23,000 babies are born annually. Systematic postnatal examination of every ostensibly healthy newborn by a physician is no longer performed. Nurse-to-patient ratios in postnatal care areas permit only damage control care mandated by urgent symptoms; care when symptoms present; and neonates with proximal varieties of intestinal obstruction frequently do not display dramatic signs of the obstruction. (Often the only symptom is bilious vomiting, and this may be attributed incorrectly to conditions such as gastroesophageal reflux or sepsis.) The authors do not include esophageal atresia among the causes of obstruction, but the record for late presentation for this condition (with complete esophageal obstruction) at our institution is 22 days of life. Presentation to the pediatric surgeon with severe dehydration and metabolic imbalance on the fourth to tenth day of life is the norm rather than the exception. In many areas, the medical expertise to diagnose or suspect the condition G. Pitcher (&) Department of Paediatric Surgery, Chris Hani Baragwanath Hospital, Soweto, Johannesburg, South Africa e-mail: Pitchmax@icon.co.za