Jejunoileal Atresia Research Articles

A Pilot Study on Histopathology of the Jejunoileal Atresia-Can it Be Used as a Guide to Determine the Length of Adequate Resection?

Introduction:Some studies reported that there is abnormality in the histopathology of atretic bowel in jejunoileal atresia (JIA). We have made an attempt to assess sequential histopathologic changes in the resected atretic segment.Material and methods:The histopathology of the resected segment was evaluated at 1, 3, 5, 7, 9, and 11 cm from atretic end (Sections A to F, respectively). The ratio of inner and outer muscle layer (measured by NIS-Element D software) was calculated at every section. Immunohistochemistry for α-smooth muscle actin (α-SMA) was also done. The findings were compared with control.Results:In control set (n = 5), the ratio of inner and outer muscle layer was 1.03. In patients with JIA, the ratio was 0.68 to 0.9 at section A. This ratio varied at various sections in all specimens. In section F, this ratio was 0.95 to 1.09, which is close to control ratio. There were no specific findings related to α-SMA staining.Conclusions:It appears that the bowel proximal to the atresia is abnormal for a varied length. It may be a possibility that this abnormality is present at least up to about 10 cm proximal to atresia. Adequate resection is important for optimal outcome.

Outcome of Management of Neonatal Intestinal Obstruction at a Tertiary Center in Nigeria.

Background:Intestinal obstruction in a newborn remains a significant emergency in pediatric surgery. Clinical presentation is often subtle with sudden deterioration of their clinical states. Clinical outcome in the developing countries is poor owing to a variety of factors.Objective:The objective of this study is to identify the factors affecting the management outcome in our environment.Patients and Methods:Data on clinical presentation, management, and outcome of all neonates managed for intestinal obstruction over a 13-year period at a tertiary center in Nigeria were retrospectively reviewed. Analysis of factors affecting the management outcome was also performed.Results:One hundred and seventeen neonates comprising 85 (72.7%) boys and 32 (27.3%) girls were managed for intestinal obstruction. The age at presentation ranged from 0 to 29 days, with a mean of 6.86 ± 8.4 days. Seventy-five (64.1%) patients presented within a week of onset of symptoms and 42 (35.9%) patients later. Eighty-five patients (72.6%) presented with symptoms from birth. The most common causes of intestinal obstruction included anorectal malformation in 62 (53%) neonates and Hirschsprung's disease in 16 (13.7%) neonates. Other causes included obstructed inguinoscrotal hernias, duodenal atresia, jejunoileal atresia, malrotation, and annular pancreas. Eleven patients died with a mortality rate of 9.4%. The age at presentation (P = 0.001) and the presence of postoperative complications (P = 0.009) were significantly related to the duration of hospital stay. Furthermore, the presence of postoperative complications (P = 0.012) was significantly associated with postoperative mortality.Conclusion:Early presentation and postoperative complications significantly affected the morbidity and mortality associated with the management of neonates with intestinal obstruction.

Fish consumption in early pregnancy and congenital gastrointestinal tract atresia in the Japan Environment and Children’s Study

Current evidence suggests that the aetiology of congenital gastrointestinal (GI) tract atresia is multifactorial, and not based solely on genetic factors. However, there are no established modifiable risk factors for congenital GI tract atresia. We used data from a Japanese nationwide birth cohort study launched in 2011, and examined whether fish consumption in early pregnancy was associated with congenital GI tract atresia. We analysed data of 89 495 women (mean age at delivery=31·2 years) who delivered singleton live births without chromosomal anomalies. Based on the results of the FFQ, we estimated the daily intake of fish and n-3 PUFA consumption in early pregnancy. We defined a composite outcome (oesophageal atresia, duodenal atresia, jejunoileal atresia and/or anorectal malformation) as congenital GI tract atresia. In this population, median fish intake was 31·9 g/d, and seventy-four cases of congenital GI tract atresia were identified. Fish consumption in early pregnancy was inversely associated with the composite outcome (multivariable-adjusted OR for the high v. low consumption category=0·5, 95 % CI 0·3, 1·0). For all the specific types of atresia, decreased OR were observed in the high consumption category, although not statistically significant. Reduced atresia occurrence was observed even beyond the US Food and Drug Administration's recommended consumption of no more than 340 g/week. Also, n-3 PUFA-rich fish and n-3 PUFA consumptions tended to be inversely associated with atresia. Fish consumption in early pregnancy may be a preventive factor for congenital GI tract atresia.

Multiple Jejunoileal Atresia and Stenosis with Duplication Cyst in a Newborn

Jejunoileal atresia is a congenital anomaly that is characterized clinically by bilious vomiting and abdominal dis-tension. It has been associated with various other anomalies but its association with mesenteric cyst is rare. We are presenting a patient with antenatally diagnosed duplication cyst with multiple jejunoileal atresia and stenosis with possible etiology behind such an association.

Is the Bishop–Koop procedure useful in severe jejunoileal atresia?

PurposeThe aim of this study was to report our experience using the Bishop–Koop procedure for the treatment of various surgical problems of jejunoileal atresia including luminal discrepancy, complex meconium peritonitis, type IIIb and type IV atresia which we defined as severe jejunoileal atresia. MethodsThis retrospective study was performed on the patients with severe jejunoileal atresia who underwent Bishop–Koop procedure at a tertiary center in China over a five year of period. The mortality, complication rate, nutrition status and the risk factors for postoperative adverse outcomes were explored. ResultsA total of 41 neonates underwent the Bishop–Koop procedure. The median duration of the hospital stay and total parenteral nutrition and the point at which oral feeding was initiated postoperatively were 24 days (95% CI =18.99–29.01), 13 days (95% CI = 9.03–16.97) and 11 days (95% CI = 10.17–11.83) respectively. The mortality rate was 7.32% (3/41). The complication rate was 41.4% (17/41) including anastomotic leak, intestinal obstruction, high output stoma and cholestasis. The weight for age Z-score at stoma closure was restored to normal levels (−0.86, 95% confidence interval (CI) = −1.44, −0.28). The main factor associated with adverse outcomes in severe jejunoileal atresia was premature delivery (odds ratio (OR) = 4.44, 95% CI = 1.06–18.67). ConclusionsBishop–Koop procedure appears to be a technically efficient method for severe jejunoileal atresia, although larger studies are needed to compare Bishop–Koop procedure and other operation techniques. Type of studyTherapeutic. Level of evidenceLevel IV.

Presentation and outcome of treatment of jejunoileal atresia in Nigeria.

Background:Intestinal atresia is a common cause of neonatal intestinal obstruction. Previous reports from Nigeria have indicated a high mortality rate. This is a report of current outcome review from one tertiary center.Patients and Methods:A retrospective analysis of infants managed for jejunoileal atresia in 10 years (2005–2014). The information retrieved from patients’ records was analyzed using SPSS 17.Results:There were 38 patients (19 boys and 19 girls) aged 1–28 days (median 4 days). Twenty-four patients (63.2%) presented after 48 h of life. Twenty-five (65.8%) had jejunal atresia and 13 (34.2%) had ileal atresia. Six patients had associated anomalies. The most common atresia was type III (39.5%, 15 patients). Twenty-eight (73.7%) patients had a resection of the atresia and anastomosis and others had enterostomies. Total parenteral nutrition and neonatal intensive care support were not available during the period of the study. Bowel function was established within 1 week and 27 (71.1%) patients commenced oral feeding. Twenty-six (68.4%) patients had postoperative complications resulting in prolonged hospital stay of 2–44 days (median = 13). Mortality was 34.2% (13 patients). Factors that significantly affected mortality were intestinal necrosis at presentation, postoperative complications, and severe malnutrition.Conclusion:Intestinal atresia is still associated with unacceptably high morbidity and mortality, due to late presentation, and lack neonatal intensive care services and parenteral nutritional support. Efforts need to be intensified to address these factors to improve outcome.

Bilious vomiting in the newborn

Bilious vomiting in a newborn is a sign of bowel obstruction and can present with or without abdominal distention. The more proximal the obstruction is, the less distended the abdomen will be. A thorough physical exam followed by plain abdominal films often gives the diagnosis. Dilated loops of bowel or air fluid levels suggest the diagnosis of obstruction. Upper gastrointestinal or contrast enema study is often necessary to make a diagnosis. The causes of bilious vomiting in the newborn are duodenal, jejunoileal, and colonic atresias, meconium ileus, meconium plug, hypoplastic left colon, necrotizing enterocolitis, Hirschsprung disease and malrotation with midgut volvulus. The latter represents a neonatal emergency and prompt diagnosis and treatment are necessary to prevent rapid bowel necrosis.

Transanastomotic feeding jejunostomy with nasogastric aspiration in case of jejuno-ileal atresia for early feeding and better out come: Five year experience

Transanastomotic feeding jejunostomy with nasogastric aspiration in case of jejuno-ileal atresia for early feeding and better out come: Five year experience

Neonatal intestinal obstruction associated with situs inversus totalis: two case reports and a review of the literature

BackgroundThe association of neonatal intestinal obstruction with situs inversus totalis is extremely rare with only few cases reported in the literature to date. This association poses dilemmas in management. We present two such cases (of Indian origin), and briefly discuss the pertinent literature and measures to prevent unfavorable outcome.Case presentationCase 1: a 1-month-old preterm (1300 g) male neonate belonging to Hindu (Indian) ethnicity presented with recurrent bile-stained vomiting, non-passage of stools and epigastric fullness. A babygram and upper gastrointestinal contrast studies revealed situs inversus and suggested proximal jejunal obstruction with midgut volvulus. Exploration confirmed situs inversus totalis along with reverse rotation and midgut volvulus. There was a small gangrenous area in the proximal jejunal loop. A Ladd’s procedure, resection of the gangrenous jejunal loop, and jejunojejunal anastomosis was performed. Note was made of the unusual appearance of the intestines suggestive either of fibrous or fatty infiltration. Postoperatively, our patient developed septicemia and died.Case 2: a 4-day-old female neonate belonging to Hindu (Indian) ethnicity, small (1320 g) for gestation, presented with history of non-passage of meconium since birth, refusal to accept feeds, and episodes of recurrent bilious vomiting with abdominal distension. A plain radiogram revealed situs inversus and proximal jejunal obstruction. Ultrasonography of her abdomen revealed renal dysplastic changes in both her kidneys. Laparotomy confirmed multiple jejunoileal atresias with situs inversus totalis. Resection anastomoses was performed for multiple atresias. Our patient passed a few pellets of meconium stools postoperatively; feeds were started gradually on the sixth day. Our patient gradually developed oliguria and renal failure, followed by respiratory distress and generalized edema requiring ventilatory support. She died later due to multiorgan failure.ConclusionsClinicians should have high index of suspicion for malrotation with midgut volvulus or intestinal atresias in neonates of situs inversus presenting with bilious vomiting. The surgical treatment should follow the same surgical principles. In situs inversus, because of transposition of viscera, midgut volvulus may occur in an anticlockwise direction, hence derotation is performed clockwise. Prognosis was poor in our series because of low birth weight, late presentation, presence of gangrenous locus in the small bowel and development of septicemia in our first case and multiorgan fibrosis/dysplasia in our second case. Early diagnosis and timely referral is paramount for favorable outcome.

Role of ultrasound in diagnosis of fetal congenital abdominal anomalies: One year prospective study

Introduction: Congenital anomalies are important cause of perinatal and infant mortality, and are contributor to childhood morbidity. Fetal congenital abdominal anomalies are one of the most common anomalies. Ultrasound screening of fetus helps to identify these anomalies as early as possible in antenatal period and thus provides information for proper decisions during pregnancy. Aim: To find out the incidence of congenital abdominal anomalies affecting fetus and to study the outcome in patients with fetal congenital abdominal anomalies by following them postnatally. Material and Methods: Prospective, Observational and Non-interventional study. Ultrasound screening of 5761 fetuses were performed. Pregnancies, with ultrasound findings of fetal congenital abdominal anomalies with or without other associated anomalies, were followed up. Postnatal confirmation of anomalies were carried out by clinical examination/ imaging procedures / autopsy. Results: Incidence of fetal congenital abdominal anomalies was 5.56 per 1000 births. Among the fetal congenital abdominal anomalies, fetal urinary tract anomalies were the most common with an incidence of 4.69 per 1000 births. Incidence of Omphalocele, Gastroschisis and Jejunoileal atresia were 5.2, 1.7 and 1.7 per 10,000 births respectively. Concordance between antenatal and postnatal diagnosis was 90.63%. Conclusion: Antenatal ultrasound examination should be performed for all pregnant women to diagnose congenital anomalies. Prenatal diagnosis of congenital anomalies provides information for proper decisions during pregnancy, fetal intervention if available and appropriate treatment perinatally, thus improves perinatal and long term outcomes.

Enteral reduction and oblique anastomosis

Background: Jejunoileal atresias are major causes of neonatal intestinal obstruction, and various surgical techniques were described for their treatment. Resection and/or tapering of the proximal dilated pouch and end-toend or end-to-back enteral anastomosis are the most commonly used techniques. Either of these techniques, however, has shortcomings such as loss of bowel length, kink obstruction, and anastomotic leak due to anastomotic line mismatch. Objective: The aim of this study was to describe an alternative surgical technique for bowel atresia repair, enteral reduction and oblique anastomosis. Patients and methods: The technique involves reduction of the dilated bowel diameter by removing an elliptical fullthickness part of the anterior wall of the proximal dilated pouch and oblique anastomosis of the resultant window with a longitudinally incised posterior wall of the distal bowel. Results: This technique was used in seven successive neonates, four female and three male, in 1 year. Their ages at operation ranged between 2 and 30 days (median 3 days). Six neonates recovered well. Enteral feeds were tolerated in 7–10 days and the length of hospital stay ranged between 15 and 36 days. One baby, who underwent surgical repair at the age of 30 days, died following severe sepsis and anastomotic leak. Conclusion: Enteral reduction and oblique anastomosis is an easy and safe alternative to current surgical techniques used for the treatment of small intestinal atresia. No bowel resection is required while proximal bowel tapering is achieved. Keywords: oblique anastomosis, small bowel atresia, tapering

Cystic meconium peritonitis with jejunoileal atresia: Is it associated with unfavorable outcome?

AIMTo compare the outcome between patients with jejunoileal atresia (JIA) associated with cystic meconium peritonitis (CMP) and patients with isolated JIA (JIA without CMP).METHODSA retrospective study was conducted for all neonates with JIA operated in our institute from January 2005 to January 2016. Demographics including the gestation age, sex, birth weight, age at operation, the presence of associated syndrome was recorded. Clinical outcome including the type of operation performed, operative time, the need for reoperation and mortality were studied. The demographics and the outcome between the 2 groups were compared.RESULTSDuring the study period, 53 neonates had JIA underwent operation in our institute. Seventeen neonates (32%) were associated with CMP. There was no statistical difference on the demographics in the two groups. Patients with CMP had earlier operation than patients with isolated JIA (mean 1.4 d vs 3 d, P = 0.038). Primary anastomosis was performed in 16 patients (94%) with CMP and 30 patients (83%) with isolated JIA (P = 0.269). Patients with CMP had longer operation (mean 190 min vs 154 min, P = 0.004). There were no statistical difference the need for reoperation (3 vs 6, P = 0.606) and mortality (2 vs 1, P = 0.269) between the two groups.CONCLUSIONPrimary intestinal anastomosis can be performed in 94% of patients with JIA associated with CMP. Although patients with CMP had longer operative time, the mortality and reoperation rates were low and were comparable to patients with isolated JIA.

Early Reoperations after Primary Repair of Jejunoileal Atresia in Newborns.

Aim: To review nine-year experience in managing jejuno-ileal atresia (JIA) by primary resection and anastomosis and identify factors associated with reoperations.Methods: From April 2006 to May 2015, all consecutive neonates who underwent bowel resection and primary anastomosis for JIA were analyzed retrospectively. Patients with temporary enterostomy were excluded. Patient demographics, types of atresia, surgical techniques, need for reoperations, and long-term outcomes were investigated. Results: A total of forty-three neonates were included, in which nineteen (44.2%) of them were preterm and fourteen (32.6%) were of low birth weight. Thirteen patients (30.2%) had jejunal atresia whereas thirty patients (69.8%) had ileal atresia. Volvulus, intussusception and meconium peritonitis were noted in 12, 8, and13 patients, respectively. Eight patients (18.6%) had short bowel syndrome after operation. Ten patients (23.3%) required reoperations from 18 days to 4 months after the initial surgery due to anastomotic stricture (n=1), adhesive intestinal obstruction (n=1), small bowel perforation (n=2) and functional obstruction (n=6). Prematurity and low birth weight were associated with functional obstruction leading to reoperation (p=0.04 and 0.01 respectively). The overall long-term survival was 97.7%. All surviving patients achieved enteral autonomy and catch-up growth at a median follow-up of 4.7 years.Conclusion: Long-term survival of JIA after primary resection and anastomosis are excellent. However, patients have substantial risk of early reoperations to tackle intraabdominal complications.

Intestinal Atresia: Experience at a Busy Center of North-West India.

Objective: To evaluate the presentation, management, complications and outcome of intestinal atresia (IA) managed at our center over a period of 1 year. Materials and methods: Records of patients of IA admitted in our center from January 2015 to December 2015 were retrospectively analyzed. Demographic data, antenatal history, presenting complaints, location (duodenal, jejunoileal, colonic) of atresia, surgery performed and peri-operative complications were noted. Results: Total 78 cases of IA were included in the analyses. Mean age and weight at the time of presentation was 5.8 days (range 0-50), and 1.9 kg (range 1.1-3.2), respectively. IA included duodenal atresia [DA (32)], jejuno-ileal atresia [JIA (40)], colonic atresia [CA (3)] and atresia at multiple-location (sites) in 3 cases. Ninety percent of patients underwent surgery within 5 to 20 hours of admission. All cases of DA except one underwent Kimura's diamond shaped duodeno-duodenostomy. One case with perforated duodenal web underwent duodenotomy with excision of web. Seven patients with JIA and CA required primary stoma, while rest were managed by excision of dilated proximal segment and primary anastomosis. Complications included anastomotic leak in 5, proximal perforation in 2, functional obstruction in 7, aspiration pneumonitis in 3, and wound infection in 6 patients. Mean hospital stay for survivors was 11 days. Overall survival was 63%. Conclusion: Late presentation, overcrowding in intensive care unit, septicemia, functional obstruction and anastomotic leak are the causes of poor outcome in our series. Early diagnosis, some modification in surgical technique, use of total parenteral nutrition and adequate investigations for other congenital anomalies may improve the outcome.

Alimentary Tract Atresias associated with Anorectal Malformations: 10 Years' Experience.

Anorectal malformation (ARM) is one of the most common congenital anomaly that requires emergency surgery in the neonatal period. ARMs are frequently associated with other life threatening congenital anomalies. Commonly associated anomalies are genito-urinary, cardiovascular, gastro-intestinal, skeletal and spinal. Alimentary tract anomalies are frequently masked by the intestinal obstruction produced by the anorectal atresia. This retrospective study was carried out to find out the incidence of associated alimentary tract atresias with ARM. In our series, out of 785 cases of high ARM, 14 cases had associated esophageal atresia (1.8%), followed by 7 cases of duodenal atresia (0.89%), and followed by pyloric atresia, jejuno-ileal atresia and colonic atresia.

Modified Gut Anastomotic Technique in Type III and Type IV Jejunoileal Atresias.

Background: Type III and IV jejunoileal atresias are associated with loss of significant length of the gut and can lead to short gut syndrome if further resection of proximal dilated gut is done. We modified the anastomotic technique so that proximal dilated segment of the gut is not resected as to prevent short gut syndrome. Material and Methods: Medical Record of patients of Type III and IV jejuno-ileal atresias managed with modified anastomotic technique in our center during 5-years was reviewed. Results: Fifteen patients were managed with our modified technique. There were no anastomotic leak observed and there was 6% mortality seen in our modified technique. Conclusion: We found less mortality and morbidity in our technique compared to recommended techniques described in literature.

Use of T-Tube Enterostomy in Neonatal Gastro-intestinal Surgery.

Aim: To evaluate the results of the use of the T-tube ileostomy in neonatal intestinal surgery cases. Materials and Methods: A retrospective review of sixty two neonates underwent intestinal obstruction surgery by using T-tube ileostomy was conducted between January 1990 and January 2013.The pathologies of the intestinal obstruction were; thirty four of jejunoileal atresia cases, thirteen case meconium ileus, eight cases perforated necrotizing enterocolitis (NEC), three cases meconium peritonitis, three cases with bowel resection due to intestinal volvulus, and one case of gastroschisis. Results: Mean duration of T-tube placement was 13 days (range9–20days) and the sites of T-tube insertion closed spontaneously in 2 days (range 1-4 days). The mean duration for starting oral intake postoperatively in these patients was 9 days (6-16 days). All patients well tolerated the procedure and there were no serious complications related to the T-tube insertion. However, four patients died due to other reasons like sepsis, respiratory failure and prematurity. Conclusion: T-tube enterostomy is an effective and safe technique for treatment of selected cases of neonatal intestinal surgery. It showed less morbidity and mortality rates than the conventional stoma. Therefore, it is considered a helpful approach in cases where there is danger of hypoperistaltic dilated bowel proximal to the anastomosis.

Review of 31 cases of neonatal gastrointestinal perforations

Background: Despite the recently improved neonatal intensive management, gastrointestinal perforation during the neonatal period is still a major challenge for pediatric surgeons.Objective: To review the effects of different clinical and operative parameters on the mortality of neonatal intestinal perforations.Patients and Methods: A retrospective study was done to 31 cases of neonatal intestinal perforation at the neonatal intensive care unit of Basrah children speciality hospital during the past four and half years (July 2011 to December 2015). Information regarding the age, sex, gestational age, birth weight, clinical examination, x-rays value in diagnosis, causes and sites of perforations, types of operative procedures, and their effects on prognosis are all studied.Results: Males were affected more than females (a ratio of 3.4: 1); birth weight has a significant association with the prognosis (P-value of 0.045). Hirschsprung`s disease was the commonest cause for perforation (29%), followed by necrotizing enterocolitis and jejunoileal atresia (16.1%, each). Idiopathic perforations constituted only 12.9%. Ileum was the commonest site of perforation (58.1%), followed by cecum (16.1%). Stoma creation was the commonest operative procedure performed. Other procedures like, primary anastomosis, and primary peritoneal drainage followed by laparotomy were also used. This study revealed high mortality rate (45.2%). Complications like sepsis, anastomotic leaks, or burst abdomen carried a high risk of death.Conclusions: High mortality rate is encountered, especially for necrotizing enterocolitis. In contrast to other study, Hirschsprung`s disease is the commonest cause of perforation rather than necrotizing enterocolitis. Radiology has a relatively good accuracy in the diagnosis of intestinal perforations, although some cases were discovered intra-operatively. In this series, prompt accurate treatment with stoma creation harbored the best prognostic results; furthermore no benefits obtained from primary peritoneal drainage.

Gastroschisis with Concomitant Jejuno-Ileal Atresia Complicated by Jejunal Perforation.

Gastroschisis is an isolated structural anomaly rarely associated with other life-threatening anomalies. The most common associated gastrointestinal anomalies are intestinal atresia, Meckel's diverticulum and intestinal duplications. Intestinal atresia occurs in 10-15% of gastroschisis cases. [1] We herein report a case of gastroschisis with concomitant type III b jejuno-ileal atresia with perforation of the proximal dilated segment of jejunum with congenital short bowel successfully treated by primary anastomosis and primary abdominal closure.

Gastroschisis with Concomitant Jejuno-Ileal Atresia Complicated by Jejunal Perforation

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