Ileostomy in extremely low birth weight and premature neonates
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(2) ILEOSTOMY IN ELBW AND PREMATURE NEONATES. Material and methods. extremely low birth weight (ELBW) or premature neonates. There were 24 neonates (73%) with more extensive intestinal involvement (necrotizing enterocolitis, NEC), 4 (12%) with meconium peritonitis and 5 (15%) with complicated meconium ileus. In 4 cases of meconium ileus (12%) we found ileale atresia: particularly in one baby there was an intestinal atresia with pseudocisty; in another baby there was an intestinal stenosis and the perforation was covered by omentum. Eight patients (24%) were excluded from the study: 3 of them died before the reestablishment of bowel continuity, due to complications unrelated to illness or surgery, with respiratory distress syndrome and renal insufficiency; 2 had cystic fibrosis, associated with meconium ileus, and the operation was perfomed after four-six weeks, because the meconium had not completely passed by the end (despite the perfomance enemas according to “Noblett technique”); and 3 suffering from hydrocephalus and underwent ventriculoperitoneal shunt. In all patients an ileostomy with a skin bridge and resection of the necrotic or perforated intestine was perfomed. The ileostomy was perfomed between 2 and 15 days of life and the weight was between 600 and 1800 grams. The post-operative bowel function was in III days average; patients with meconium ileus started an oral feeding on III or IV postoperative day; patients with NEC started an oral feeding on XXI or XXV postoperative day. Thirteen patients (39%) developed complications prior of closure ileostomy. In 7 (21%) patients the complications were related to the ileostomy: 2 patient had a fistula on the base of ileostomy, 1 developed a peristomal hernia, 3 a prolapse and 1 an ileo-ileal intussusception, which involved the proximal stoma. In 2 patients (6%) was found cholestasis for total parenteral nutrition (TPN) and in the other 4 patient (12%) we found reccurent NEC with another intestinal perforation. We decided to anticipate the stoma closure in all patients with complications about ileostomy; on the contrary, in patient with recurrent NEC, we. IN C ER O V P A Y R M IG E H DI T C ® A. A prospective study was done in the Section of Pediatric Surgery of the Department of Pediatrics, Obstetrics and Reproductive Medicine of Siena University from July 2000 to Aprile 2011. We perfomed a temporary ileostomy with a skin bridge (Figure 1) and resection of the necrotic intestine in all patients, regardless of the etiology of intestinal perforation. An end to end ileoileal and end to side ileo-colic anastomosis were performed after variable periods. In some cases we performed, before the re-establishment of bowel continuity, another operation for recurrent desease. The data collected included the patient’s birth weight and the gestational age, the weight and age at the ileostomy and at the anastomosis, the presence / absence of intestinal atresia, the morbidity and mortality at short-and long-term follow-up at 3, 6, 12, 24 and 36 months. The association of possible risk factors for intestinal canalization was evaluated through analysis monovariate and thereafter for the significant variables identified through multivariate analysis. Results. Thirty-three neonates, 14 males (42%) and 19 females (58%), operated for intestinal perforation were identified. They were. M. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.. FERRARA. Figure 1.—Temporary ileostomy with a skin bridge (intraoperative findings).. 412. MINERVA PEDIATRICA. August 2013.
(3) FERRARA. peritonitis, to increase energies of the patient (with TPN and antibiotico-therapy), to develop the endocrine system and intestinal mucose. Operative strategy should be based on clinical manifestations and the patient’s general conditions. These fragile patients have considerably limited reserves of energy, immunologic reactivity, circulation, and respiratory regulation and there is even less chance to correct one’s decisions than with somewhat heavier babies. In the situation of extreme immaturity, any additional problem carries a great risk.1 According to the Literature, the optimal treatment for intestinal perforation in ELBW infants remains controversial.2, 3, 7 Some authors report that there is not a difference in outcomes between different surgical management, for example between the primary anastomosis or establishment temporarily enterostomy, in a newborn with intestinal perforation.6, 8-10 Other authors prefer to perform an enterostomy when there is severe abdominal distension, intestinal adhesions or bowel alterations and when the children have got a clear correlation between with the typical clinic characteristics and plain radiographic of pneumoperitoneum and the extent of intestinal damage.1, 4, 7, 11-13 The primary anastomosis is usually a valid surgical option for stable infant with. IN C ER O V P A Y R M IG E H DI T C ® A. performed a new laparotomy resecting the necrotic bowel and performing a new ileostomy. We did not have any other complication (such as leak anastomosis). The stoma closure was perfomed between 20 and 110 days after the ileostomy performation, and the weight was between 1200 and 2700 grams. The bowel function was between III and XII post-operative days. We did not find any complications in long-term follow-up. All patients are fine, with regular growth, nutrition, diuresis and bowel function. No patient required surgery for bowel lengthening or tranplantation and currently no child required partial parental nutrition. A multivariate logistic analysis of all paramaters, carried out on 25 patients, shows that the delay recovery of bowel function is strictly dependent on the presence of “meconium ileus”. In fact, patients with meconium ileus gain rcovery of bowel function 4 days or more the others (OR=8,0; P=0.0455) (Table I). Discussion. Regardless of etiology intestinal perforation is a devastating complication for these babies. Clinical management decisions should be precocious and quick to treat the Table I.—Description of variables. Parameters. Sex. M. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.. ILEOSTOMY IN ELBW AND PREMATURE NEONATES. Underlying disease Iileae atresia. Ileostomy complications Ileostomy weight Gestational age Birth weight. Type. M F Meconial Desease Not Meconial Des. Yes No Yes No < 1kg >1 kg ≤29 week >29 week <1kg >1 kg. Quantity. 11 (44%) 14 7 (28%) 18 4 (16%) 21 9 (36%) 16 10 (40%) 15 16 (64%) 9 11 (44%) 14. Age to ileostomy Duration ileostomy. Vol. 65 - No. 4. MINERVA PEDIATRICA. Median. Min. Max. 1050. 600. 1800. 29. 25. 35. 8 60. 2 20. 15 110. 413.
(4) ILEOSTOMY IN ELBW AND PREMATURE NEONATES. saline, and where possible with the patient’s own feces, of bowel downstream of ileostomy, in the weeks preceding the intervention of ostomy closure. In our opinion this should rehabilitate the intestinal lumen and reactivate the intestinal peristalsis. We excluded eight patients because their presence in our study could distort the results of intestinal function: indeed 3 babies died before ricanalization; 2 babies had cystic fibrosis which aggravate their clinical conditions; and 3 of them presented ventriculoperitoneal shunt which could be responsable of a condition of ascitis.. IN C ER O V P A Y R M IG E H DI T C ® A. localized intestinal damage/perforation.8, 14 The primary anastomosis is not an effective and safe technique in extremely low birth weight (ELBW) infant because they usually have got some poor general condition and there are many possibilities for anastomosis complications (anastomotic leak, anastomotic stricture, intestinal stricture, infection, etc.).6 The poor general condition was judged on basis of state of shock, such as thready pulse, tachycardia, and tachypnea, fever, need of oxygen supplementation, and requirement of inotropic support. Temporary ileostomy with stoma closure at second stage is an acceptable option in the surgical management of ELBW neonates with diffuse intestinal damage/perforation (necrotizing enterocolitis, and complicated meconium ileus).3, 5, 12 With a simpler and better management of neonates and a more rapid healing of the intestine suffering (due to its non-use with ileostomy) observed in our group of patients, we recommend the use of temporary ileostomy in all cases of neonates intestinal perforation. In this case we need to intervene with a second stage for ostomy closure, when the clinical condition of the patient is optimal. If there are some complications about ileostomy, as described in our series (peristomal hernia, fistula of the stoma, prolapse and intussusception), it is possible the intestinal stoma closure before the planned time, without damaging the child. At long-term follow-up we found no patients needed patial or total parental nutrition, and no patient required an intestinal lengthening. In terms of motality rate, excluding the 3 patients died of respiratory distress, we found no other patient death for NEC related complications. Moreover, the conducted statistical analysis allows us to detect that if there are not complications, surgical or medical, outcomes of patients depend mainly on their disease. In our opinion this is due to the characteristics of failure or delay in passed of meconium: 1) concretion of meconium in the ileum; 2) colon unused. For this reason we are use to begin the washing with. M. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.. FERRARA. 414. Conclusions. In conclusion, given the limitations of this study, it appears that temporary ileostomy is an effective and safe primary repair technique in ELWB or premature children with acute abdomen (NEC or complicated meconium ileus). This technique permits the surgeon to manage the child very well and the bowel to rest and to get well. Moreover the rate of mortality and morbility is very low. Riassunto. Ileostomia in prematuri e neonati con peso alla nascita estremamente basso Obiettivo. La creazione di un’ileostomia è un opzione chirurgica per il trattamento delle patologie intestinale neonatale, come l’enterocolite necrotizzante (NEC) e la patologia meconiale in prematuri e neonati con peso alla nascita estremamente basso (ELBW). Metodi. Uno studio prospettico fu condotto tra luglio 2000 e aprile 2011, prendendo in esame tutti i casi di addome acuto nei neonati prematuri. Fu confezionata un’ileostomia temporanea con ponte cutaneo, previa resezione dell’intestino necrotico. Un’anastomosi intestinale fu realizzata successivamente e furono presi in esame vari fattori che avrebbero potuto influenzare la ripresa della funzionalità intestinale. Uno studio statistico fu condotto attraverso l’analisi dei dati e l’utilizzo di monovariate multiple. Risultati. Furono sottoposti ad intervento chirurgico per perforazione intestinale 33 pazienti, 14 maschi e 19 femmine. In 24 neonati fu diagnosticata NEC, in 4 peritonite meconiale e in 5 ileo da. MINERVA PEDIATRICA. August 2013.
(5) FERRARA. 5. Vanamo K, Rintala R, Lindahl H. The Santulli enterostomy in necrotising enterocolitis. Pediatr Surg Int 2004;20:692-4. 6. Singh M, Owen A, Gull S, Morabito A, Bianchi A. Surgery for intestinal perforation in preterm neonates: anastomosis vs stoma. J Pediatr Surg 2006;41:7259. 7. Blakely ML, Tyson JE, Lally KP, McDonald S, Stoll BJ, Stevenson DK et al. Laparotomy versus peritoneal drainage for necrotizing enterocolitis or isolated intestinal perforation in extremely low birth weight infants: outcomes through 18 mounth adjusted age. Pediatrics 2006;117:e680-687. 8. Fasoli L, Turi RA, Spitz L, Kiely EM, Drake D, Pierro A. Necrotizing enterocolitis: extent of disease and surgical treatment. J Pediatr Surg 1999;34:1096-9. 9. Hall NJ, Curry J, Drake DP, Spitz L, Kiely EM, Pierro A. Resection and primary anastomosis is a valid surgical option for infants with necrotizing enterocolitis who weigh less than 1000 g. Arch Surg 2005;140:114951. 10. Ade-Ajayi N, Kiely E, Drake D, Wheeler R, Spitz L. Resection and primary anastomosis in necrotizing enterocolitis. J R Soc Med 1996;89:385-8. 11. Messina M, Ferrucci F, Garzi A, Meucci D, Buonocore G. A rare case of neonatal ileo-cecal valve stenosis due to coverei iliac perforation. Biol Neonate 2003;83:69-72. 12. Weber TR, Tracy TF Jr, Silen ML, Powell MA. Enterostomy and its closure in newborns. Arch Surg 1995;130:534-537. 13. Nam SH, Kim SC, Kim DY, Kim AR, Kim KS, Pi SY et al. Experience with meconium peritonitis. J Pediatr Surg 2007;42:1822-5. 14. Pumberger W, Mayr M, Kohlhauser C, Weninger M. Spontaneous localized intestinal perforation in verylow-birth-weight infants: a distinct clinical entity different from necrotizing enterocolitis. J Am Coll Surg 2002;195:796-803.. IN C ER O V P A Y R M IG E H DI T C ® A. meconio complicato. In 4 casi di ileo da meconio fu riscontrata un’atresia ileale. 8 pazienti furono esclusi dallo studio: 3 decessi, 2 con fibrosi cistica, 3 con idrocefalo. 13 pazienti svilupparono complicanze: 7 collegate all’ileostomia, 2 colestasi e 4 NEC ricorrente. Nei pazienti con patologia meconiale la funzionalità intestinale riprese con 4 o più giorni di ritardo rispetto agli altri (O.R. = 8,0; p=0.0455). Conclusioni. Nella nostra esperienza, il confezionamento di un’ileostomia per il trattamento di un addome acuto nei prematuri o nei neonati con peso estremamente basso permette un’ottima gestione del bambino, con l’esclusione dell’intestino malato si favorisce una guarigione più rapida con un basso tasso di mortalità e morbilità. Parole chiave: Ileostomia - Enterocolite necrotizzante - Neonato prematuro.. References. 1. Rygl M, Pycha K, Stranak Z, Skaba R, Brabec R, Cunat V et al. T-tube ileostomy for intestinal perforation in extremely low birth weight neonates. Pediatr Surg Int 2007;23:685-8. 2. Cass DL, Brandt ML, Patel DL, Nuchtern JG, Minifee PK, Wesson DE. Peritoneal drainage as definitive treatment for neonates with isolated intestinal perforation. J Pediatr Surg 2000;35:1531-6. 3. Chwals WJ, Blakely ML, Cheng A, Neville HL, Jaksic T, Cox CS Jr et al. Surgery-associated complications in necrotizing enterocolitis: a multiinstitutional study. J Pediatr Surg 2001;36:1722-4. 4. Tam AL, Camberos A, Applebaum H. Surgical decision making in necrotizing enterocolitis and focal intestinal perforation: predictive value of radiologic findings. J Pediatr Surg 2002;37:1688-91.. Received on October 20, 2011. Accepted for publication on November 16, 2012.. M. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.. ILEOSTOMY IN ELBW AND PREMATURE NEONATES. Vol. 65 - No. 4. MINERVA PEDIATRICA. 415.
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