Cause Of Neonatal Intestinal Obstruction Research Articles

Neonatal Surgery: Demand and Survival Both are Increasing: Eight Years Experience in Dhaka Medical College Hospital, Bangladesh

Purpose: In order to achieve the Millennium Development Goal (MDG) 4 target of a two-thirds reduction in under-five mortality from 1990 to 2015, major reductions are going to be required in neonatal mortality. Congenital anomalies have become the fourth cause of neonatal deaths and most of these are curable. Dhaka Medical College Hospital is the largest public hospital of the country and serving the poor and lower middle class people where surgery and medical facilities are mostly free of cost. This study was done to see the types of neonatal surgical patients admitted in this hospital and their management out come with limited facilities and find out the ways to improve the scenario to contribute in achieving the MDG.Materials & Methods: This was a retrospective study done over a period of 8 years from July 2001 to June 2009 and carried out in the Department of Pediatric Surgery, Dhaka Medical College Hospital, Dhaka. A total of 650 neonates were admitted during this period and it was the 17.99% of total number of 3612 pediatric surgical admission upto12 years of age. Data was collected from hospital records and analyzed retrospectively.Results: Out of these 650 neonates 533(80%) were admitted for Neonatal Intestinal Obstruction (NIO) and omphalocele were 59 (9.07%), ectopia vesicae are 14 (2.15% ), posterior urethral valves (PUV) were 19 (2.92%), gastroschisis were 7 (1.07%) , congenital diaphragmatic hernia (CDH) were 16 (2.46%),Tracheo-oesophageal fistula 1 (0.15%), and Conjoint twin 1 (0.15%). The most common cause of NIO was anorectal malformation (ARM) and 194 (66.43%) patients have high variety and 98(33.56%) patients have low variety ARM. Next was Hirschsprung disease and 137 (21.07%) neonates presented with this. Thirty-Five (5.38%) patients presented with septicemia and 40 (6.15%) presented with intestinal atresia, 20 (3.07%) neonates had meconium ileus and 9 (1.38%) patients presented with volvulus neonatorum. Five hundred and Fifty-nine patients (86.00%) were managed surgically. Out of 650 patients, 69 died, so mortality was 10.61% and before surgery 2.76% and after surgery was 7.84%.Conclusion: Pediatric surgeons by their skill and teamwork greatly improved the neonatal surgical service and contributing significantly in reducing infant mortality rate and to achieve MDG 4. But to improve further, neonatal intensive care unit (NICU) and other support systems are essential as well as support from UNICEF and World Health Organization (WHO) to include pediatric surgery and surgeons in their activities especially in developing countries. Due to socio-political and economic reasons of the developing countries the roll of pediatric surgeons are multidimensional.DOI: http://dx.doi.org/10.3329/jpsb.v1i1.19463

Neonatal intestinal obstruction : patterns, problems and outcome

Neonatal intestinal obstruction is the most common surgical emergency in newborn. Ideally neonatal surgery should be done in an organized neonatal surgical unit. This study was done mostly in general surgical setup in Khulna without any facility of NICU and TPN. The aim of this study was to detect the patterns of neonatal intestinal obstruction and to find out the problems and outcome of surgical treatment. This retrospective study was done between January 2008 and December 2010, in Khulna Medical College Hospital, Khulna Shishu Hospital and a private clinic in Khulna. A total of 205 neonates with intestinal obstruction were treated surgically. Babies of both sexes up to 28 days of age were included in this study. Common causes of neonatal intestinal obstruction were anorectal malformation (ARM), intestinal atresia, Hirschsprung's disease (HD), meconium ileus and malrotation of midgut. Male-female ratio was 1.6:1 and about 13% was premature. Out of 205 neonates, there were ARM-73, HD-47, meconium ileus-38, intestinal atresia-29, malrotation-13 and others-5. Total 172 (84%) survived. Those were ARM (94%), Hirschsprung's disease (91%), meconium ileus (79%), intestinal atresia (55%), malrotation of gut (85%) and others (40%). Overall mortality after initial surgical treatment was 16%. Prognosis of surgical treatment depends on early intervention, expert anaesthesia, associated anomaly and complication, gentle handling of delicate tissue and intensive postoperative management. Medical practitioners were the first attending physician in most instances. So both physicians and surgeons have a contributing role in reducing mortality. DOI: http://dx.doi.org/10.3329/bmjk.v45i1-2.13638 Bang Med J (Khulna) 2012; 45 : 6-10

Different varieties of colonic atresia in a series of 13 patients

Purpose The aim of this study was to review our experience in the management and outcome of colonic atresia, either isolated or associated with anorectal anomalies. Methods A total of 13 neonates with colonic atresia were operated upon in the Pediatric Surgery Unit of Zagazig University Hospital between August 2004 and April 2010. Complete data including age, sex, clinical findings, diagnostic procedure, associated anomalies, preoperative management, intraoperative findings, operative procedures, postoperative course, and outcome were reported for each patient. Results Colonic atresia was found in 13 patients, including nine boys (69.2%) and four girls (30.8%). It was located in the ascending colon in four (30.8%) patients, in the transverse colon in three (23%), and in the sigmoid colon in four (30.8%). The other two (15.4%) patients had colonic atresias extending to the small bowel. Two patients had associated anorectal anomalies. Type III colonic atresia was observed in six patients (46.2%), type II in three (23%), and type I in four patients (30.8%). The treatment included resection and primary anastomosis in seven patients (53.8%) and diverting colostomy in six (46.2%). Two patients died: one because of severe neonatal sepsis and the other because of severe cardiac anomalies. One patient developed anastomotic leakage and another had anastomotic dysfunction. Conclusion Colonic atresia is an uncommon cause of neonatal intestinal obstruction. The combination of colonic atresia and anorectal anomalies should be taken into consideration. Proper postoperative care and management of postoperative complications improve the outcome. Keywords : anorectal anomalies, atresia, colon

Segmental ileal dilatation: an unsuspected cause of neonatal intestinal obstruction

Segmental ileal dilatation: an unsuspected cause of neonatal intestinal obstruction

Jejunal stricture from compression by fallopian tube associated with autoamputation of an ovarian cyst: An unusual cause of neonatal intestinal obstruction

Jejunal stricture from compression by fallopian tube associated with autoamputation of an ovarian cyst: An unusual cause of neonatal intestinal obstruction

Surgical treatment of neonatal intestinal malformations

Oesophageal atresia (OA) is a congenital anomaly with an interruption of the oesophageal continuity with or without tracheo-oesophageal fistula (TOF). Type IIIB is the most common (85%) and shows hypersalivation post partum followed by recurrent attacks of suffocation as a consequence of recurrent aspirations. A nasogastric tube cannot be passed and radiodiagnostic investigations visualize the blind-ending upper oesophageal pouch. Surgical management includes the closure of the TOF and primary anastomoses of the blind ends. In case of a long gap, narrowing and delayed primary repair can be performed. Prognosis and survival are related to birthweight and to associated major cardiac defects. In patients with congenital duodenal atresia (DA), the complete interruption of the bowel continuity can be diagnosed antenatally by sonography and post partum by plain abdominal radiographs, showing the classic ‘double bubble’ sign. The obstruction can be due to an intraluminal web, complete separation of the duodenal ends, or caused by an extraluminal pancreas annulare or Ladd bands seen in the case of malrotation. Infants show bilious vomiting after birth and consecutive metabolic alkalosis. The surgical method to bypass the obstruction is a duodenoduodenostomy. Mortality rate is < 5%. Jejunoileal atresia (JIA) is a common cause of neonatal intestinal obstruction. More than 90% of patients have a single atresia. In the case of multiple atresias, most of the children are born prematurely with low birthweight. JIAs can be suspected prenatally via sonography. Main symptoms are bilious vomiting, a distended abdomen and signs of life-threatening sepsis in the case of bowel perforation. Surgical treatment has the aim of reconstructing bowel continuity and saving as much bowel length as possible to avoid the complications of short bowel syndrome and malabsorptive syndromes. Anorectal malformations (ARMs) comprise not only defects of the lowest part of the intestinal tract but also of the urinary and genital tract. In minor low types, the rectum and its fistula open into the perineal region and primary surgical repair by posterior sagittal approach is performed. In higher, more complex types, meconium passes into the male urethra or bladder or into the female vagina. In these cases, a colostomy and staged repair has to be performed. Complex types of ARM have a poorer outcome regarding bowel and urinary control.

Jejuno-ileal atresia: A 2-year preliminary study on presentation and outcome

Intestinal atresia is a common cause of neonatal intestinal obstruction. Jejuno-ileum is the commonest site of intestinal atresia. Reports on Jejunoileal atresia in developing countries are still few. The purpose of this study is to determine the presentation and management outcomes of neonates with Jejunoileal atresia treated in our hospital. Detailed data on all babies that presented and were treated within the study period (November2008-November, 2010) were kept and analyzed. A management protocol was put up and maintained. A total of 9 babies (7males and 2 females) were treated. They were aged 2 hours to 13 days. Their weight ranged from 1.7kg to 3.3kg. Apart from one baby which presented within 2hrs with prenatal ultrasound diagnosis, others had bilious vomiting from the first day of birth, abdominal distension and delayed or absent passage of meconium. Even though symptoms developed on the first day of birth, presentation to the surgical unit was delayed 72hours and beyond in most patients.Type I atresia is commonest (no=4).There is associated gut malrotation in 2 babies. Five babies had complications which included surgical site infection, sepsis, prolonged vomiting post operatively, aspiration, rupture of dilated proximal segment after membrane excision, entero-cutaneous fistula and malnutrition. Three babies died giving a mortality of 33.3%. Mortality is commoner in types IIIb and IV. Mortality is higher in complex atresia which most times will require neonatal intensive care and parenteral nutrition facilities. These are still lacking in our institution. Providing these facilities will further improve outcome.

Type 1 Bland Sutton colonic atresia complicated by fetalis hydrops in a premature neonate

Colonic atresia (CA) is an unusual cause of neonatal intestinal obstruction where a section of the colon has failed to form, leading to blockage or absence. A premature baby was delivered at 32 weeks of gestation via caesarian section following fetal distress. She was grossly oedematous and diagnosed with severe fetalis hydrops secondary to anaemia. She was resuscitated and stabilized. On the sixth day of life, the neonate's abdomen became severely distended with billous vomiting and failure to pass meconium. We suspected intestinal obstruction and performed an omnipaque enema which revealed dilated small bowel loops and a bowel atresia. Exploratory laparotomy confirmed a Type 1 Bland Sutton CA with mucosal web. An end colostomy was successfully performed and uneventful. In our case report, we describe a rare occurrence of postnatally diagnosed CA, complicated by fetalis hydrops and anaemia.

Management of jejunoileal atresias: an experience at eastern Nepal

BackgroundIntestinal atresia is a common cause of neonatal intestinal obstruction, and management of this disease in limited setup of a developing country is very difficult.MethodsThis study is a retrospective study of patients with jejunoileal atresias and their postoperative outcome in a teaching hospital in eastern Nepal over a 5-year period.ResultsThere were 28 children (19 boys and 9 girls). 11 children (39.28%) had jejunal atresia and 17 (60.71%) had ileal atresia. Eight (28.5%) patients died, 6 were jejunal atresia (54.5%) and 2 were ileal atresia (11.7%). The most common cause of death was sepsis which occurred in 7 out of 8 cases (87.5%). The risk factors for mortality identified were leucopenia, neutropenia, delay in surgery, location of atresia and type of atresia. Jejunal atresia tended to have a higher mortality than ileal atresia, and severe types of atresia (type IIIb and IV) were more often associated with mortality than other types of atresia. The significant differences between jejunal and ileal atresia were the increased duration between presentation and surgery, longer postoperative and total hospital stay, presence of more severe atresias and an increased risk of mortality in case of jejunal atresias.ConclusionThe prognosis for this disease have definitely changed in the last few decades in developed countries but in our environment, problems like late presentation and diagnosis, lack of availability of good neonatal intensive care units and parenteral nutritional support still prevail.

The Experience of Operative Management in Jejunoileal Atresia

Purpose: Intestinal atresia is a common cause of neonatal intestinal obstruction. Recently, the survival rate has been increasing from development of prenatal diagnosis, total parenteral nutrition (TPN) and neonatal intensive care. We evaluated the complication rate and cause of mortality after operative management for jejunoileal atresia. Methods: We reviewed 62 patients (36 males, 26 females) with jejuno-ileal atresia who underwent operation from 1998 to 2007. Results: There were 37 patients with jejunal atresia and 25 with ileal atresia. The average gestational age was 256±16.6 days and birth weight was 2,824±620 g. Prenatal diagnosis was performed in 45 patients (72.6%) around gestational age 27 weeks. Within 2nd day after birth, 44 patients (71%) underwent operation. Half of the jejunoileal atresia was type Ⅲa and type Ⅰ was in 8, type Ⅱ was in 3, type Ⅲb was in 12, and type Ⅳ was in 8. The operative treatment was resection & anastomosis in 59 patients and enterotomy & web excision in 3. They started feeding at 12.4±11.5 days after operation on average. The average duration of TPN was 26.7±23.5 days, and the incidence of cholestasis was 30.6%. Hospital days averaged 36.8±26 days. Early complication occurred in 14 patients (intestinal obstruction in 5, sepsis in 4, wound problem in 3, anastomosis leakage in 1, and intraabdominal abscess in 1). Late complication occurred in 7 patients (anastomosis stricture in 4 and intestinal obstruction in 3). There was only one case of mortality due to short bowel syndrome after re-operation for adhesive ileus. Conclusion: The operation for intestinal atresia was successful and aggressive management contributed to a low mortality rate.

Neonatal small left colon syndrome in the offspring of diabetic mothers—an analysis of 105 children

Background and Aim Neonatal small left colon syndrome (NSLCS) is considered a rare cause of neonatal intestinal obstruction, with few documented cases in the English literature. Maternal diabetes has been reported in 40% to 50% of the published cases of NSLCS. Currently, the incidence of maternal diabetes is increasing, but there has been no study to ascertain the incidence and significance of NSLCS in this population. This review aims to assess the current significance of NSLCS and its association with maternal diabetes. Materials and Method This was a retrospective review of 105 offspring of diabetic mothers who were admitted during the period 2004 to 2008 to our neonatal unit with special emphasis on associated NSLCS. Results There were 6 cases of intestinal obstruction in this group of 105 children. Five children, including a pair of twins, had classic features of NSLCS as demonstrated in the contrast enema with an abrupt transition at the splenic flexure and a narrow left colon. Conservative treatment was successful in all, negating the need for further invasive investigation. The sixth child had rectosigmoid Hirschprung disease. During the study period, there were no other cases of NSLCS in the nondiabetic population. Conclusion Neonatal small left colon syndrome is the most common cause of intestinal obstruction in offspring of diabetic mothers. Neonatal small left colon syndrome can be confidently diagnosed in this population based on the classic clinical and radiologic findings. The incidence of NSLCS can be expected to increase as the incidence of maternal diabetes increases.

Etiology and Treatment Outcome of Neona tal Intestinal Obstruction in a Tertiary Hospital

A prospective study was conducted on 54 cases of neonatal intestinal obstruction, admitted in Paediatric surgery department of Rajshahi Medical College Hospital during the period from January 2008 to December 2008, a period of 12 months. The objective of the study was to find out etiological aspect and outcome of admitted patient with neonatal intestinal obstruction. The patient constituted 33.7% of total neonatal admission in Paediatric surgery department during the study period. The male: female ratio was 1.4:1 with age ranging from 1 to 28 days. Birth weight of most of the patients was above 2 kg. Most of the patients came from poor and average family. Patients from poor family are slightly ahead. Plain x-ray abdomen was done in all cases in our study. Contrast radiography performed in selected cases. Ultrasound scan done to in selective case to rule out IHPS. No rectal biopsy was taken in case of suspected Hirschsprung's disease. The causes of neonatal intestinal obstruction were in order of frequency-Hirschsprung's disease (45.2%), Intestinal atresia (24.5%), malrotation (9.4%), bands &amp; adhesion (5.6%), meconium ileus (5.6%), volvulus neonatarum (5.6%), meconium plug syndrome (1.8%), unknown (3.7%). 50 patients were treated operatively. 28.3% cases developed complications. Most of the complications were related to colostomy and sepsis. Overall mortality was 20.8%. Mortality was maximum in intestinal atresia. Every patient was advised to come for follow up at the time of discharge but most of the people did not report. In the study only 17 (32.1%) patient came for follow up as per advice.TAJ 2009; 22(1): 198-203

Neonatal intestinal obstruction in Zaria, Nigeria.

To study the aetiology, morbidity and mortality of neonatal intestinal obstruction. A retrospective study. Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. One hundred and fifty one neonates (< or = 28 days) undergoing surgery for mechanical intestinal obstruction. The male/female ratio was 3:1 and median age at presentation was four days (range five hours-28 days). Anorectal malformation was the commonest cause, 104 (68.9%), 86.5% of which were high anomalies and 13.5% low; the median age at presentation was three days. Fifty two per cent of colostomies for the high anomalies were performed using general anaesthesia and 48% local anaesthetic, but there was an increasing use of local anaesthesia over the years. Hirschsprung's disease accounted for 11 (7.3%) of the cases, representing 20% of all patients presenting with Hirschsprung's disease to this hospital; the median age was six days and in two patients the caecum and sigmoid colon respectively had perforated; nine patients had colostomy, one caecostomy and one ileostomy (total colonic aganglionosis). Eleven (7.3%) patients had incarcerated or strangulated ingunial hernia (ten) and congenital ventral hernia (one); the hernias were repaired in all patients and three required intestinal resection for gangrene, two of which had ipsilateral testicular gangrene, necessitating orchidectomy. Intestinal atresia was the fourth common cause of obstruction ten (6.7%), eight of which were jejunoileal atresias and two duodenal and the median age was seven days; one atresia was associated with Hirschsprung's disease and had ileostomy, all other jejunoileal atresias were resected and duodenoduodenostomy was performed for the duodenal atresias. Other less common causes of neonatal intestinal obstruction were incarcerated exomphalos, malrotation, hypertrophic pyloric stenosis, annular pancreas, and idiopathic ileal volvulus and meconium ileus respectively. Postoperative complications occurred in sixteen of 95 patients (16.8%) including colostomy or ileostomy complications 11, wound infection three and anastomotic dehiscence (two). The overall mortality was 21.1%, 70% from overwhelming infection and 30% respiratory embarrassment; the mortality from the various conditions were Hirschsprung's disease 43%, intestinal atresia 40%, incarcerated exomphalos 40%, anorectal malformation 18.5% and the only patient with volvulus died. The morbidity and mortality of neonatal intestinal obstruction in this hospital has improved over previous years due largely to meticulous resuscitation before surgery but the problems of late presentation and poor neonatal intensive care facilities persist. The findings are at variance with those in developed countries.

Determinants of mortality in neonatal intestinal obstruction in Ile Ife, Nigeria

Neonatal intestinal obstruction (NIO) is a common cause of mortality. This study determined the causes of mortality in patients with NIO at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile Ife. Records of all cases of NIO managed at OAUTHC between January 1996 and December 2005 were retrospectively reviewed and the possible factors that may result in mortality were analysed. Sixty-three neonates with intestinal obstruction were managed, representing 24.3% of the neonatal admissions during the study period. Forty-two were males and 21 were females (M:F = 2:1). The majority (71.4%) of the patients presented within the first week of life. Anorectal malformation constituted 57.1% of the causes of NIO. Other causes included Hirschsprung's disease, duodenal atresia, intestinal malrotation with midgut volvulus and jejunal atresia. There were 18 deaths, with a mortality rate of 28.6%. Reoperation, postoperative bleeding and peroperative sepsis were significant determinants of mortality. NIO is associated with significant mortality in our centre. Repeat surgery, postoperative bleeding and sepsis were the significant factors that contributed to mortality in NIO.

Jejunal atresia associated with idiopathic ileal perforation

Jejunoileal atresia is one of the common causes of neonatal intestinal obstruction. Intestinal perforation with meconium peritonitis in the neonatal period, which carries a high mortality rate, is also common. The association of jejunal atresia with idiopathic ileal perforation is very rare.

PS02 ATRESIA OF THE JEJUNUM AND ILEUM: THE DISTINCTION

Purpose Atresia of the jejunum and ileum is one of the major causes of neonatal intestinal obstruction. Most affected newborn infants present with bilious emesis and abdominal distention. Traditionally, jejunal and ileal atresia have been grouped together as jejunoileal atresia. From our observation and experience, we found many differences regarding clinical features and outcome between these two groups. The purpose of this study is to elucidate the difference between jejunal and ileal atresia.Methodology A retrospective analysis of patients diagnosed with jejunal or ileal atresia during 1991–2005 was carried out.Results There were 68 patients with jejunal atresia and 56 with ileal atresia. The mean birth weight and gestational age of patients with jejunal atresia were significantly lower than those with ileal atresia. Antenatal perforation occurred more frequently in ileal atresia. Postoperative course was more prolonged and mortality was higher in jejunal atresia. Prolonged ileus and anastomotic dysfunction requiring long‐term parenteral nutrition were the major causes of complications leading to death.Conclusion There were many differences between patients with jejunal atresia and those with ileal atresia. The more compliant jejunal wall allows massive dilatation upon obstruction with subsequent loss of peristaltic activity, thus poorer outcome in comparison with ileal obstruction. We suggest that atresia of the jejunum and ileum be considered distinctly.

Laparoscopic Duhamel Procedure: Management of 55 Cases

Introduction: Hirschprung disease (HD) is a common cause of neonatal intestinal obstruction and chronic constipation. Advances in instrumentation and in laparoscopic experience have made laparoscopic correction possible in recent years.Methods: Medical records of children who underwent a laparoscopic Duhamel (LD) procedure from February 1995 to June 2002 in our institution were reviewed. Operative technique was always the same, using 4 ports (5, 5, 10, and 12 mm) and wall suspension. We recorded birth weight, clinical features, age and weight at procedure, morbidity, and followup.Results: Fifty-five children, 46 boys and 9 girls, with a median birth weight of 3046 g, were operated on. They ranged in age from 25 days to 8 years (mean, 13 months). Four cases of enterocolitis and 16 cases of sepsis necessitated 20 colostomies and 5 ileostomies (total colonic aganglionosis). Average operative time was 140 minutes (range, 100–330 minutes). Four conversions were necessary. There were no deaths. There was 1 anas...

Intestinal atresia: management problems in a developing country.

Over a 13-year period, 24 children with intestinal atresia were managed at the Jos University Teaching Hospital, Jos, Nigeria. Intestinal atresia ranks as the second most common cause of neonatal intestinal obstruction (after anorectal malformation) in our hospital. Five children had duodenal obstruction (two atresia, two duodenal webs, one annular pancreas), 17 had jejunoileal atresia, and two had colonic atresia. Fourteen were boys, and 10 were girls (M:F: 1.17:1). The median age at presentation to the surgeon was 6 days (range: 1 day-12 years). The most common presenting features were bilious vomiting and abdominal distension. Six patients did not pass meconium within the first 24 h of birth. The median weight at presentation was 2.6 kg (range: 1.1 kg-5.0 kg). Seven patients (four with jejunoileal atresia and three with duodenal obstruction) had associated congenital anomalies. Diagnostic investigation was plain abdominal x-ray, showing double-bubble gas shadows in duodenal atresia and varying degrees of air-fluid levels in jejunoileal and colonic atresias. An upper gastrointestinal series was done in three patients and a barium enema in one. Retrocolic duodenojejunostomy was done for all patients with duodenal atresia and annular pancreas, duodenotomy and web excision for those with duodenal webs, and resection with end-to-end anastomosis for those with jejunoileal atresia. One child with atresia involving the whole ileum and the colon had a jejunorectal anastomosis, while the other child with colonic atresia had caecostomy followed later by ileorectal anastomosis. Ten neonates died, giving a mortality rate of 41.7%. Mortality from intestinal atresia is still high in our environment, due mainly to lack of neonatal intensive care facilities.

Double Intestinal Atresia in Imperforate Anus: A Diagnostic Conundrum for Paediatric Surgeons

Anal atresia, i.e. imperforate anus, is not an infrequently seen congenital anomaly with an average worldwide incidence of 1:5,000 live births.1 Congenital jejunoileal obstruction caused by atresia or stenosis is also a relatively common cause of neonatal intestinal obstruction, with an incidence of 1:400 to 1:1,500 live births.2,3 In contrast, colonic atresia is a rare cause of intestinal obstruction in neonates, with an incidence of about 1:20,000 live births.4 Most neonates with imperforate anus have one or more abnormalities that affect other systems. However, only two of 172 patients with imperforate anus were reported to have an intestinal atresia below the duodenum,5 and only two of 246 patients had an absent colon.3 It is thus extremely rare to see a patient with an imperforate anus and concurrent ileal stenosis and colonic atresia, as described by Asabe and Nagasaki in this issue of the Asian Journal of Surgery.6 The aetiology of intestinal or colonic atresia is not clearly understood. The current consensus is that there is an in utero mesenteric vascular catastrophe, such as volvulus, intussusception, incarceration, or strangulation secondary to hernias, and embolic or thrombotic events,7 which results in ischaemia and absorption of the necrotic bowel segment. The cause of imperforate anus is regarded as an event in the abnormal embryological development that results from defects in the shape of the dorsal (posterior) cloaca and an absence of the dorsal cloacal membrane.8 The lack of relationship between the causes of intestinal atresia and imperforate anus may, thus, explain the rarity of their co-existence. The level of rectal atresia in imperforate anus has traditionally been assessed by an invertogram, as in the reported case.6 In our institute, we rarely use the invertogram for the diagnosis of congenital anorectal malformation. Instead, magnetic resonance imaging (MRI) of the pelvis in these patients is

Swenson revisited: a one-stage, transanal pull-through procedure for Hirschsprung’s disease

Background: Hirschsprung’s disease is a common cause of neonatal intestinal obstruction. A variety of operations have been used to treat this neurogenic form of bowel obstruction. This report describes an experience with a 1-stage abdominal and transanal pull-through operation in 15 patients with rectosigmoid disease. Methods: Fifteen infants with Hirschsprung’s disease included 11 boys and 4 girls. Median age at diagnosis was 3 days, and median age of operation was 30 days. Diagnosis was confirmed by rectal biopsy. Biopsies to confirm the transition zone were performed intraabdominally through a left lower quadrent incision. A Swenson pull-through was performed via transanal dissection. Results: There were no instances of anastomotic leaks, wound infections or postoperative bowel obstructions. All patients survived. Two had postoperative enterocolitis. Twelve of 15 patients did well and had 2–3 bowel motions per day. One with Down’s syndrome had enterocolitis and required a colostomy. Two were lost to follow up. Conclusions: A one-stage transanal pull-through procedure in infancy is a safe alternative to staged procedures for Hirschsprung’s disease.