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PubMed2002

MRI of the fetal gastrointestinal tract.

OBJECTIVE: To determine the MRI patterns of the gastrointestinal (GI) tract in normal fetuses and some GI tract abnormalities. MATERIALS AND METHODS: A retrospective (1996-1998) and prospective (1999-2000) study of 48 fetal abdominal MRI scans was performed between 23 and 38 weeks of gestation. T1-weighted (T1-W) fast gradient-echo (Flash 2D) and T2-weighted (T2-W) HASTE sequences were obtained on a 1.5-T unit, in frontal and sagittal planes, after maternal premedication. Fresh meconium was also studied. RESULTS: Normal patterns (40 cases): the rectum was seen in all cases and exhibited meconium-like high signal on T1-W images and low signal on T2-W images. It was close to the bladder whatever the fetal gender with its cul-de-sac being at least 10 mm below the bladder neck. The large bowel had a same signal; the distal colon was demonstrated more frequently than the proximal colon. The small bowel was transiently hyperintense on TI-W images early in gestation and then hyperintense on T2-W images. Normal measurements were obtained. GI tract abnormalities (eight cases): cysts close to normal bowel ( n=2), atresias ( n=5; microcolon, dilated small bowel with abnormal signal, one with a meconium cyst) and a cloacal malformation with midgut malrotation ( n=1; abnormal liquid signal in the rectum separated from the bladder wall and colon located on the left side). CONCLUSIONS: MRI provided complete visualisation of the fetal GI tract, showed specific signal intensities, identified the level of an obstruction, detected a microcolon, and demonstrated communication between urinary and GI tracts. It shows great potential.

Cloaca↗
PubMed1995

The natural history of meconium peritonitis diagnosed in utero.

The authors reviewed their experience with meconium peritonitis (MP) diagnosed in utero to define criteria for prenatal and postnatal management. Prenatal diagnosis was made by identifying abdominal calcification on serial ultrasound examinations in nine fetuses, between 18 and 37 weeks' gestation. Cases without associated bowel abnormalities were considered "simple MP" and those with bowel abnormalities were considered "complex MP." Five cases of simple MP were identified at 18, 23, 30, 34, and 37 weeks' gestation. These five fetuses were delivered at term and had normal abdominal examinations. Abdominal radiographs were obtained in three showing normal bowel gas patterns, and abdominal calcifications in only two. All five patients were fed uneventfully. Four cases of complex MP were identified at 26, 26, 31, and 31 weeks' gestation. All four fetuses had dilated loops of bowel. Two of the four had meconium cysts, one of which was associated with ascites and the other with polyhydramnios. Shortly after birth both infants with meconium cysts required ileal resection and ileostomy for ileal atresia and ileal perforation, respectively. The remaining two infants had no evidence of dilated bowel, meconium cyst, or ascites on postnatal radiograph and were fed uneventfully. These data suggest that only 22% of fetuses with a prenatal diagnosis of MP develop complications that require postnatal operation. Gestational age at diagnosis does not correlate with postnatal outcome. Fetuses with complex MP are at increased risk for postnatal bowel obstruction and perforation.

Ascites↗
PubMed2003

J. H. Louw Memorial Lecture. Outreach, origins and a hedgehog.

Professor J. H. Louw is honoured in this lecture for the major contribution he made to the development of paediatric surgery in South Africa as a specialty in its own right. Although he is perhaps best known internationally for his contribution to our understanding of the aetiology of small-bowel atresias, it may be that his greatest legacy lies in those he taught, many of whom are in the audience. He was a man who demanded the highest standards, both of himself and of his colleagues, and despite many other leadership roles and responsibilities in surgery generally, always considered that his first responsibility was to paediatric surgery. It may be fitting, therefore, that this lecture deals with two aspects that were dear to Professor Louw, namely the provision of specialist care for children with surgical conditions, and recent research into the causes of congenital structural abnormalities.

Adolescent↗
PubMed1997

Meconium ileus: a ten-year review of thirty-six patients.

Of 36 neonates with meconium ileus secondary to cystic fibrosis treated over a 10-year period, twenty-one (58%) had simple uncomplicated disease while fifteen (42%) had complications which included perforation (5), volvulus (6) and atresia (5). Gastrografin enema was employed in 20 infants with relief of obstruction in 8 (40%). Operative procedures consisted of resection and primary anastomosis in seventeen patients, stomas were fashioned in six, three had an enterotomy with irrigation only and two had Bishop-Koop enterostomy. Post-operative complications developed in 5 (18%) of these 28 patients. The overall survival rate was 97%. The one death occurred in an infant with short bowel syndrome, patent ductus arteriosus, hydrocephalus and pulmonary damage. There were eight additional patients who had meconium obstruction in the absence of cystic fibrosis.

Cystic Fibrosis↗
PubMed1997

Gastroschisis: a radiological and clinical review.

A retrospective clinico-radiological review was undertaken of 66 consecutive cases of gastroschisis managed at our institution between August 1982 and February 1993. The condition's morbidity and mortality were reviewed, as were its radiological features and their impact upon management. All patients underwent surgery in the first 24 h of life, and the overall survival rate was 92 %. The finding of bowel atresia at operation was associated with a particularly poor outcome, with only two out of five infants surviving. A minority of infants developed serious complications including necrotizing enterocolitis, short-bowel syndrome, persistent small-bowel dysfunction and cholestatic jaundice. Investigation by plain films, contrast studies and ultrasound examinations was necessary and helpful in these patients. Plain film radiography commonly revealed bowel-wall thickening and luminal dilatation, frequently accompanied by generalised abdominal distension. Small-bowel enema was considered to be superior to the conventional follow-through in distinguishing mechanical from functional obstruction in infants with persistent bowel dilatation.

Abdominal Muscles↗
PubMed1997

T-tubes in the management of meconium ileus.

Fifteen cases of meconium ileus (MI) were treated between 1986 and 1995; 7 responded to conservative treatment. Eight were operated upon, and comprise the study group. Six of the operated babies had no complications; 1 had meconium peritonitis with a pseudocyst and small-bowel atresia, and 1 had a volvulus of a small-bowel segment with necrosis. In all 8 cases a T-tube (TT) was left via an enterotomy; in the complicated cases the enterotomy was pre-anastomotic. The obstruction was relieved in all the babies, without any stoma or bowel resection in the uncomplicated cases. Two complications occurred: 1 patient died of respiratory failure 1 month following surgery and another required a relaparotomy for lysis of adhesions. We conclude that TT ileostomy is an effective and safe procedure for uncomplicated cases of MI that do not respond to conservative therapy, as well as for complicated cases that need an anastomosis.

Cause of Death↗
PubMed2004

The effect of antenatal diagnosis on the management of small bowel atresia.

The aim of this study was to determine whether babies with small bowel atresia (SBA) diagnosed antenatally followed a different course from those diagnosed postnatally. We reviewed the records of neonates admitted to a single institution between 1985 and 2000 with a diagnosis of SBA. Thirty-nine neonates presented with SBA, with antenatal diagnosis (AND) being made in 12 (31%). There was no difference between the AND and postnatal diagnosis (PND) groups in terms of gestational age at birth, but the AND group had a lower mean birth weight. The babies in the AND group were operated on more quickly than those in the PND group. Ten out of 12 (83%) AND patients required parenteral nutrition compared with 12 out of 27 (44%) in the PND group, and the AND group had a significantly longer mean length of stay and spent a longer time on parenteral nutrition than the PND group.

Female↗
PubMed2006

Prenatal counselling of small bowel atresia: watch the fluid!

OBJECTIVE: To evaluate polyhydramnios as a sign of extreme disproportion of atretic segments in small bowel atresia (SBA). METHODS: Twenty-eight patients with a prenatal diagnosis (PD) of SBA undergoing neonatal surgical treatment were reviewed retrospectively. Parameters recorded were gestational age, birth weight, surgical procedure, rate of complications, parenteral nutrition (PN) days and length of stay (LOS). Patients were divided into two groups: Group A with delayed anastomosis and Group B with direct anastomosis. RESULTS: Seventeen subjects were in Group A while 11 were in Group B. The two groups did not differ with regard to gestational age at diagnosis, birth weight and obstetrical management. Polyhydramnios was present in both Group A (64.7%) and Group B (9%) (p < 0.05). Patients in Group A needed a longer period on PN, had a longer LOS and exhibited significantly higher rates of complication. CONCLUSION: In the absence of other malformations, association of dilated bowel loops and polyhydramnios is highly predictive of severe SBA, which can in no instance be amenable to one-stage reconstruction. Because of its consequences on postnatal treatment, such information should be conveyed to the prospective parents at the time of counselling.

Counseling↗
PubMedDate not supplied

Contemporary management of meconium ileus.

Meconium ileus was noted as an early manifestation of cystic fibrosis in 60 neonates between 1972 and 1991. There were 20 girls and 40 boys. A family history of cystic fibrosis was present in six children. Twenty-five neonates had uncomplicated meconium ileus due to inspissated meconium within the terminal ileum. Thirty-five neonates presented with 56 complications of meconium ileus, including volvulus (n = 22), atresia (n = 20), perforation (n = 6), and giant cystic meconium peritonitis (n = 8). Clinical presentation included abdominal distension, bilious vomiting, and failure to pass meconium. In two recent cases, prenatal ultrasonography detected a mass with proximal bowel distension indicative of cystic meconium peritonitis. Mechanical bowel obstruction in the other neonates was diagnosed from plain abdominal radiographs and barium enema. Ten patients with uncomplicated meconium ileus were successfully treated with a diatrizoate meglumine (Gastrografin) enema. The remaining 15 patients required a laparotomy, with 9 treated by bowel resection and enterostomy and 6 recent cases managed with enterotomy and irrigation. Complicated cases were managed by bowel resection and anastomosis (n = 15) or enterostomy (n = 20). Survival at 1 year was 92% in patients with uncomplicated meconium ileus and 89% for those with complicated meconium ileus. The therapy of choice for uncomplicated meconium ileus is nonoperative Gastrografin enema, with enterotomy and irrigation reserved for enema failures. Complicated cases require exploration and, in the absence of giant cystic meconium peritonitis, are usually amenable to bowel resection and primary anastomosis.

Anastomosis, Surgical↗
PubMed1993

Respiratory gas exchange in response to fat-free parenteral nutrition: a comparison after thoracic or abdominal surgery in newborn infants.

Thoracic surgery is known to cause a postoperative respiratory failure because of the mechanical problems following chest wall disruption and/or diaphragmatic dysfunction. This study was to verify whether the fat-free intravenous nutritional support of neonates who underwent thoracic surgery could lead to a CO2 production exceeding the patients' respiratory reserves. Respiratory gas exchange and alveolar ventilation were obtained by indirect calorimetry and continuous recordings of transcutaneous PO2 and PCO2. These noninvasive measurements were compared at the same age of 7 +/- 1 days between a group of 7 newborn infants (mean +/- SEM: 3.09 +/- 0.14 kg, 39 +/- 1 weeks) after thoracic surgery versus a group of 8 newborn infants (2.88 +/- 0.17 kg, 37 +/- 1 weeks) after abdominal surgery. The intravenous macronutrient support was the same between both groups: 14 g/kg/d of glucose, 2 g/kg/d of amino acids, 250 kJ/kg/d of energy. One week after surgery, the global metabolic rate (195 kJ/kg/d) was not increased, and comparable between both groups. We documented that early after thoracic surgery, the ventilatory compensation required to handle the CO2 production (6.7 +/- 0.2 mL/kg/min) associated with a positive energy balance (45 +/- 8 kJ/kg/d) was effective.

Esophageal Atresia↗