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    A comprehensive analysis of 51 neonates with congenitalintestinal atresia

    Hayrettin Ozturk,MD,Hulya Ozturk, MD, Senol Gedik,MD,Hatun Duran,MD,Abdurrahman Onen,MD.

    Intestinal atresia is one of the major causes ofneonatal intestinal obstruction.1During the past2 decades a better understanding of the etiology andimprovement in anesthesiology and perioperativecare have led to a significant improvement insurvival.2-4 Although favorable outcome has beenachieved in developed countries, with resultant high

    survival,5-7

    mortality still remains high in developingcountries.8,9Te aim of this study was to evaluatecontemporary patterns of presentation and trendsin the management and outcome of 51 newborninfants with intestinal atresia.

    Methods. We retrospectively reviewed 51 casesof intestinal atresia between January 1983 andFebruary 2003. Clinical data included antenatalhistory, age, gender, weight, presenting symptomsand signs, diagnostic procedures, location andtype of atresia, associated abnormalities, surgicaltreatment, associated problems, morbidity,mortality and plans of treatment (first 10 years andsecond 10 years). Te type of jejunoileal atresia wasdetermined according to Grosfelds classification.1Te type of duodenal atresia was determinedaccording to Gray and Skandalakiss classification.10

    Antenatal diagnosis was made in 5 neonates(9.8%) on the basis of polyhydramnios and dilatedloops of bowel observed on antenatal ultrasoundscans. Plain abdominal x-ray was carried out inall 51 children. It showed a double gas shadow induodenal atresia, and the other plain films showedvarying degrees of multiple air-fluid levels. Lower

    and upper gastrointestinal (GI) contrast studiesaided diagnostic suspicion of intestinal atresia. Anupper GI series was carried out in 3 patients whoshowed proximal jejunal atresia, and one patient

    with colonic atresia had a barium enema, whichshowed a blind-ended descending colon. Each ofthe neonates received intravenous 10% dextrose insaline, nasogastric tube decompression, and urethralcatheter insertion. Resuscitation was modifiedaccording to biochemistry results. riple antibiotics

    1050

    ABSTRACT

    Objective: o determine contemporary patterns ofpresentation and trends in the management and outcome of51 newborn infants with intestinal atresia.

    Methods: We retrospectively reviewed 51 cases of intestinal

    atresia between January 1983 and February 2003. Clinicaldata included antenatal history, age, gender, weight, presentingsymptoms and signs, diagnostic procedures, location andtype of atresia, associated abnormalities, surgical treatment,associated problems, morbidity, mortality and plans oftreatment.

    Results:wenty children had duodenal obstruction, 24 hadjejunoileal atresia, and 7 had colonic atresia. Approximatelyone-fourth of patients associated with duodenal atresia hadpreterm delivery and all patients with jejunoileal and colonicatresia were full term. Clinical features such as vomiting,abdominal distention, delayed meconium passage and

    jaundice were more frequent in jejunoileal atresia patients.

    Other associated organ anomalies particularly Downssyndrome were more frequent in duodenal atresia patients. Aduodeno-duodenostomy was preferred in most of the patients

    with duodenal atresia and annular pancreas; duodenotomyand web excision for those with duodenal webs; and resection

    with end-to-end anastomosis for those with jejunoileal atresia.In all patients with colonic atresia, colostomy procedure wasperformed as the first step of surgery.

    Conclusion: Experienced neonatal care and prompt totalparenteral nutrition by placing central line during surgerymay improve the outcome of such patients.

    Saudi Med J 2007; Vol. 28 (7): 1050-1054From the Department of Pediatric Surgery (Ozturk H), Abant Izzet BaysalUniversity, Medical School, Department of Pediatric Surgery (Ozturk H), IzzzetBaysal Obstetrics and Children Hospital, Bolu, Department of Pediatric Surgery(Gedik), Diyarbakir Children Hospital, and the Department of Pediatric Surgery(Duran, Onen), Dicle University, Medical School, Diyarbakir, Turkey.

    Received 1st October 2006. Accepted 11th February 2007.

    Address correspondence and reprint request to: Dr. Hayrettin Ozturk, Departmentof Pediatric Surgery, Abant Izzet Baysal University, Medical School, 14280 Bolu,Turkey. Tel. +90 (374) 2534656 Ext. 3220. Fax: +90 (412) 2488440.

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    Intestinal atresia management and outcome ...Ozturk et al

    and total parenteral nutrition were given. Ampicillin,gentamicin and clindamycin were the antibiotic ofchoice in the majority of patients. Surgery was thenperformed through an upper transverse abdominalincision.

    Statistical analysis. Data were entered andanalyzed on a personal computer using Statistical

    Package for Social Sciences Version 10.0. Comparativeanalysis for the first 10 years and second 10 years interms of morality, morbidity: Fischers exact test. Dataare reported as the mean SD, and P value of less than0.05 was considered statistically significant.

    Results. Demographic data. Te maindemographic data of patients associated with duodenal,

    jejunoileal, and colonic atresia are summarized inTables 1 and 2. Approximately one-fourth of patientsassociated with duodenal atresia had preterm delivery,all patients with jejunoileal and colonic atresia were fullterm. Clinical features such as vomiting, abdominaldistention, delayed meconium passage and jaundice

    were more frequent in jejunoileal atresia patients.Other associated organ anomalies particularly Downssyndrome were more frequent in duodenal atresiapatients.

    Surgical findings.A duodeno-duodenostomy waspreferred in 13 patients. Te patients with duodenalatresia had side-to-side retrocolic duodenojejunostomy

    in 3 patients, and a Ladds procedure was performedfor the 3 patients who had malrotation. Te childrenwith duodenal web had duodenotomy and excisionof the web. Te children with annular pancreas hadduodenoduodenostomy. In addition, the 3 patientsassociated with anal atresia underwent sigmoid loopcolostomy. Tey are diagnosed prior to surgery. Nineneonates had jejunal atresia, 2 had multiple atresiasalong to jejunum and ileum, and the remaining 15had ileal atresia. Tree patients with jejunoileal atresiaadditionally had malrotation of the midgut. Operativetreatment included wide proximal resection with end-to-end anastomosis in 16 neonates (9 with jejunalatresia, 7 with ileal atresia) and proximal resection

    Table 1 -Te demographics of patients with duodenal atresia (n=20).

    Patient variables No. of patients with

    duodenal atresia

    Median age (days, (range)

    Gender (male/female)

    Weight at presentation (kg, range)

    Preterm newborn

    Clinical features

    Vomiting

    Abdominal distension

    Delayed meconium passage

    Jaundice

    Hospitalization (days, range)

    Type of duodenal obstruction

    ype I

    ype II

    ype III

    Annular pancreas

    Type of associated anomalies

    Anal atresiaMeckels diverticulum

    Malrotation

    Down syndrome

    Jejunal atresia

    Colonic atresia

    Cardiac anomaly

    Undescended testis

    Extremity anomalies

    3.7 (1-12)

    11/9

    2.1 (1.3-3.1)

    5

    20

    -

    -

    -

    11.5 (1-23)

    3

    4

    10

    3

    32

    2

    5

    1

    1

    2

    1

    1

    Table 2 -Te demographics of patients with jejunoileal and colocnicatresia (n=31).

    Patient variables No. of patientswith jejunoilealatresia (n=24)

    No. of patientswith jejunoileal

    atresia (n=7)

    Median age (days, (range)Gender (male/female)Weight at presentation (kg, range)Preterm newbornClinical features

    VomitingAbdominal distensionDelayed meconium passageJaundice

    Hospitalization (days, range)Type of duodenal obstruction

    ype I

    ype II

    ype IIIaype IIIbype IV

    Type of associated anomaliesAnal atresiaMeckels diverticulum

    MalrotationDowns syndromeJejunal atresiaColonic atresiaCardiac anomalyUndescended testisExtremity anomaliesCleft lipHypospadiasBifid scrotumRenal agenesisAnnular pancreas

    4 (1-15)13/11

    2.3 (1.3-3.5)-

    2123176

    9.6 (2-20)

    4

    5

    1122

    -1

    3-

    2-112---

    3.6 (3-12)3/4

    2.9 (2.5-3.5)-

    575-

    9.4 (5-24)

    2 (1 hepatic,1 splenic flexure)5 (3 sigmoid, 2transverse colon

    ---

    --

    1-

    ------11

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    Saudi Med J 2007; Vol. 28 (7) www.smj.org.sa

    with antimesenteric tapering enteroplasty and end-to-end anastomosis in 6 (4 with jejunal atresia, 2 withileal atresia). Four neonates had a trans anastomotictube for early enteral feeding. Te 2 neonates withmultiple atresia had multiple resection with end-to-end anastomosis. A Ladds procedure was added in 3neonates with malrotation. All patients received total

    parenteral nutrition (PN). Postoperative oral feedingtolerance time was differed between 7 and 20 days.Colostomy procedure was performed in all these

    patients as the first step of surgery. Te type of colostomyperformed was sigmoid loop in 2 patients, transverseloop in 3, and sigmoid diverting in 2 patients. Colonicanastomosis was performed 4-8 weeks after the firstoperations.

    Outcome. Te clinical features of complicated casesare summarized in Tables 3 and 4. Of the 20 duodenalatresia patients, 9 (45%) developed postoperativecomplications, while 7 (35%) died. Of the 24 jejunoilealatresia patients, 9 (46%) developed postoperativecomplications, while 8 (33%) died. No morbidity ormortality was observed in colonic atresia patients. Te

    comparison of plans of treatment. For all patients,the postoperative complication and mortality rate wasdecreased in the last 10 years compared to previous 10years (p

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    Intestinal atresia management and outcome ...Ozturk et al

    of 5,000 newborns.11 With improved neonatal careand the introduction of safe anesthesia and refinedsurgical techniques, survival has risen from

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    6. Grosfeld JL, Ballantine VN, Shoemaker R. Operativemanagement of intestinal atresia and stenosis based onpathologic findings.J Pediatr Surg1979; 14: 368-375.

    7. Dillon PWA, Cilley RE. Newborn surgical emergencies:gastrointestinal anomalies and abdominal wall defects. PediatrClin North Am1993; 40: 1289-1314.

    8. Ameh EA, Nmadu P. Intestinal atresia and stenosis: aretrospective analysis of presentation, morbidity and mortalityin Zaria, Nigeria. West Afr J Med2000; 19: 39-42.

    9. Barrack SM, Kyambi JM, Ndungu J, Wachira N, Anangwe G,Safwat S. Intestinal atresia and stenosis as seen and treated atKenyatta National Hospital, Nairobi. East Afr Med J1993; 70:558-564.

    10. Stauffer Urs G, Schwoebel M. Jejunoileal atresia and stenosis.In: Welch KJ, Randolph JG, Ravitch MM, editors. Pediatricsurgery. 5th ed. St. Louis: Mosby Publication 1998. p. 1133,1143

    11. Buyse ML. Intestinal atresia and stenosis. In: Buyse ML. BirthDefects Encyclopedia. Cambridge (MA): Blackwell ScientificPublications; 1990. p. 993-994.

    12. Kumaran N, Shankar KR, Lloyd DA, Losty PD. rends in themanagement and outcome of jejuno-ileal atresia. Eur J PediatrSurg2002; 12: 163-167.

    13. Puri P, Fujimoto . New observations on the pathogenesis ofmultiple intestinal atresias.J Pediatr Surg1988; 23: 221-225.

    14. eja K, Schnatterly P, Shaw A. Multiple intestinal atresias:pathology and pathogenesis. J Pediatr Surg 1981; 16:194-199.

    15. Dillon PWA, Cilley RE Newborn surgical emergencies:gastrointestinal anomalies and abdominal wall defects. PediatrClin North Am 1993; 40: 1289-1314.

    16. Haler JA, epas JJ, Pickard LR, Shermeta DW. Intestinal atresia:current concepts of pathogenesis, pathophysiology and operativemanagement.Am Surg1983; 49: 385-391.

    17. Dalla Vecchia LK, Grosfeld JL, West KW, Rescorla FJ, SchererLR, Engum SA Intestinal atresia and stenosis: a 25-yearexperience with 277 cases.Arch Surg1998; 133: 490-496.

    18. Khen N, Jaubert F, Sauvat F, et al. Group for the Study ofIntestinal Atresia. Fetal intestinal obstruction induces alterationof enteric nervous system development in human intestinalatresia. Pediatr Res2004; 56: 975-980.

    19. Karnak I, Ciftci AO, Senocak ME, anyel FC, BuyukpamukcuN. Colonic atresia: surgical management and outcome. PediatrSurg Int2001; 17: 631-635.

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