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Neonatal Intestinal Obstruction 379

Assess the stage of ischaemia and derotate counterclockwise if Increasingly, laparoscopic techniques have been used to repair
the bowel seems viable. Inform the anaesthetist about the manoeuvre the above-mentioned conditions. A good alternative for Africa is the
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because there will be a flush of intravenous endotoxins. minimal approach described by Banieghbal and Beale, whereby access
Depending on the viability of the bowel, continue on to a Ladd’s is gained through the umbilicus. Such an approach leaves a virtually
procedure, in which an extensive mobilisation of the mesentry is performed. unrecognisable scar.
Removal of the appendix is controversial and a surgical choice.
General Postoperative Care
Jejunoileal atresia Modern supportive care in the intensive care unit (ICU) with continu-
Surgery for jejunoileal atresia involves resection of the most dis- ing fluid resuscitation, parenteral nutrition, and respiratory support
tended proximal bowel and primary anastomosis. A diverting ostomy have been the bases for the increased survival rate. In countries where
is avoided if possible. As with surgery for duodenal atresia, resection parenteral nutrition is not available, transanastomotic tubes have been
or tapering of the proximal dilated segment is occasionally necessary tried with indefinite success for the purpose of early feeding. This
to limit the dysmotility that occurs in grossly dilated bowel. The ileo- postoperative management will make all the difference to the survival
caecal valve is preserved if possible because this prevents egress of of children in Africa.
bacteria from the colon into the small intestine with resultant bacterial Two weeks after anorectoplasty, serial anal dilatations should start
overgrowth and malabsorption. by using anal dilators of increasing size. Within Africa, the child
Meconium ileus should be kept hospitalised until the mother is comfortable with
Calcification on AXR (see Figure 61.2) indicates that an intestinal per- digital dilatations.
foration occurred in utero and spontaneously sealed; if not, the extruded In all of these conditions, the neonatologist and paediatric surgeon
meconium is walled off by adjacent intestine to form pseudocysts. must work together in a coordinated fashion, allowing the diagnosis
These babies have meconium peritonitis, and their appearance is to be quickly established and therapy to be rapidly implemented.
unmistakable; these are babies who are born with (as opposed to those In conditions of the intestine that are known to be associated
who develop) a distended, erythematous abdomen. with systemic disease, such as duodenal atresia (trisomy 21) and
A laparotomy is undertaken with drainage of the meconium meconium ileus (cystic fibrosis), appropriate consultation should
pseudocyst and identification of the site of the perforation, which is be obtained early, and the continued involvement of appropriate
converted to an enterostomy. specialists may be warranted long after the baby has recovered from
In uncomplicated meconium ileus, an enterostomy with irrigation of the initial hospitalisation.
the bowel contents may successfully loosen the meconium and permit Postoperative Complications
its evacuation and facilitate the closure of the enterostomy over a t-tube. Postoperative complications pertain to factors of
Postoperatively, after a contrast study shows distal patency, the t-tube
can be removed for the controlled fistula to close without further need of • total parenteral nutrition (cholestasis and hyperalimentation hepatitis);
surgery. Rarely, some patients might need an ostomy for diversion and • central venous access (pneumo/hemothorax, catheter embolus); and
access for proximal and distal irrigation with N-acetyl cysteine.
• catheter sepsis.
Hirschsprung’s disease Postoperative Stricture and/or Adhesions
The treatment of Hirschsprung’s disease is primarily surgical, except in
Anastomotic stricture is a complication after surgery. Postoperative
instances of enterocolitis.
adhesions can occur after any laparotomy. They may be caused by
Patients with HD are treated with a colostomy near the transition zone
peritonitis from leaking anastomosis. A recent study of 1,541 children
(level of beginning of dilatation). If histological leveling is not possible
who had intestinal surgery showed an adhesion rate of almost 10% in
in emergency cases, a right transverse diverting colostomy is safe. It is
the operative site and a rate of approximately 5% elsewhere.
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sometimes difficult to visualise the transition zone in a neonate.
A pull-through procedure is performed after the child is feeding and Decreased Gut Motility
gaining weight or at least 6 weeks after enterocolitis. Poor motility is often observed following repair of atresias. Chronic
Different procedures have been described as one- or two-stage dilatation of the intestine proximal to the obstruction may alter normal
procedures and are increasingly performed at a younger age. peristalsis across that segment of bowel, even after the obstruction has
The most recent innovations include minimally invasive techniques, been relieved.
such as the transanal pull-through using laparoscopy in cases in which the Malabsorption
transition zone is not located in the distal sigmoid colon.
Short gut syndrome results when the length of intestine that remains
Imperforate anus postoperatively cannot sustain normal absorption of nutrients. The nor-
Low lesions with fistulous connections to the perianal skin can be mal length of the small bowel in a term infant is approximately 250 cm.
repaired primarily by anoplasty. The estimated minimum jejunoileal length for sufficient bowel function
If the fistula runs from the rectum to the vagina or urethra or urinary in a term infant is around 75 cm. Resection of more than 60% of the
bladder, the imperforate anus is classified as high, and the infant should small bowel or resection that removes crucial anatomic segments, such
undergo a colostomy. as the ileocaecal valve, predisposes to malabsorption.
Definitive repair of the imperforate anus is classically performed by Bacterial overgrowth may contribute to malabsorption and
posterior sagittal anorectoplasty, in which the rectum is situated within subsequent failure to thrive. Probiotics have been shown in some
the striated muscle complex and anal sphincter. studies to normalise bowel flora and improve outcomes. Bowel-
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The laparoscopic pull-through using three ports has become a lengthening procedures and hormonal bowel manipulation may
favoured procedure for high anorectal malformations. help wean the patient with short gut syndrome from dependence on
parenteral nutrition.