Intestinal obstruction in a premature baby: Endoscopic diagnosis and management by minimal access surgery.

Neonatal intestinal obstruction is the most common surgical emergency in a newborn. Although, large numbers of newborns are operated in our country, limited published literature is available on advances in diagnosis, and management of this problem with outcome analysis in newborns. We report a premature (32 weeks) newborn who developed acute onset symptoms of small bowel obstruction in 3(rd)week of life, and discuss the approach to diagnosis and management with the minimal access surgery and successful outcome.

INTRODUCTION

Neonatal intestinal obstruction is the most common surgical emergency in newborn. Although, several centers have been doing neonatal surgery, very few have reported their experience and outcome from our country.[12] The majority of neonatal intestinal obstruction present soon after birth in the first few days. The differential diagnosis of babies presenting in the 3rd or 4th week of life with small bowel obstruction is limited to few conditions that is malrotation and volvulus, Hirschsprung’s disease, intestinal obstruction secondary to necrotizing enterocolitis (NEC), Meckel’s diverticulum (MD) with vitello-intestinal band etc. The minimal access surgery (MAS) has been used in neonates for a few years at western centers, but has not been reported as yet from any developing country. We have used this technique for a premature baby with acute intestinal obstruction and successful outcome.

CASE REPORT

A premature girl was delivered by emergency lower segment caesarian section at 32 weeks due to absent diastolic blood flow on antenatal Doppler ultrasound. She was managed in level one nursery and was discharged 2 weeks later on breast feed at 1.8 kg. One week later, she developed irritability and refusal to feed with passage of blood and mucus per rectum with progressive abdominal distension. She was brought back to nursery where she was further found to have tenderness in the right lower abdomen. A plain X-ray revealed dilated small bowel loops [Figure 1]. She was observed for 12 h with nasogastric aspiration and intravenous antibiotics with no relief in symptoms. An ultrasound examination demonstrated dilated bowel loops with abrupt transition and collapsed bowel distally confirming intestinal obstruction. Contrast enema was normal and the upper gastrointestinal contrast study using the Gastrograffin revealed dilated small bowel loops and contrast not passing beyond distal ileum in delayed films. We decided to explore the baby by minimally invasive approach.

Figure 1

X-ray abdomen demonstrating dilated small bowel loops not responding to conservative management

The baby was placed prone in neutral position and under general anesthesia; the camera port was placed at the umbilicus by open technique. Pneumoperitoneum was created with intra-abdominal pressure at 5 mmHg. Two 5 mm ports were placed at the right and the left iliac fossa in midclavicular line. Respiratory and cardiovascular function were monitored closely by heart rate, noninvasive blood pressure, arterial oxygen saturation by pulse oxymetery, end tidal CO2, respiratory frequency, tidal volume, and peak/mean airway pressures. Laparoscopic examination revealed dilated loops of bowel extending up to distal small bowel with no peritoneal contamination. Appendix was located and found to be normal and terminal small bowel adjoining ileo-cecal junction was collapsed. The collapsed bowel was followed proximally to reveal a tight band compressing the bowel around, which the bowel had twisted with devitalized bowel close to the area of obstruction. This band was divided and followed to the bowel revealing band originating from MD. This segment of the bowel was exteriorized from the umbilical port and extracorporeal bowel resection and anastomosis performed [Figure 2]. The total duration for which pneumoperitoneum was required was approximately 15 min. The CO2 flow rate was maintained at 2 L/min. The intraoperative and perioperative period was uneventful; she recovered well after surgery and went on to full breast feeds by the end of the week.

Figure 2

Laparoscopic localization, division of vitello-intestinal band, relieve of intestinal obstruction and exteriorization of Meckel’s diverticulum bearing segment of small bowel through the umbilical port

Pathological examination of the diverticulum demonstrated lining of small bowel mucosa with normal villous pattern. No heterotopic mucosa was identified within the diverticulum. The baby has since been discharged without any complication, no visible scar on the abdomen, and thriving well.

DISCUSSION

Neonatal intestinal obstruction in the 3rd week of life, in a newborn leaves the possibility of bowel atresia’s behind, leaving few possibilities, which can be approached and managed by the MAS effectively.[3] Since the baby was otherwise well with no associated features of sepsis, NEC was an unlikely possibility. Hence, our first differential pre-operative diagnosis in this patient was small bowel obstruction due to vitello-intestinal duct pathology and a small bowel intussussception as a distant second. Both present with features of small bowel obstruction and can have associated lower gastrointestinal bleeding. Since both have focal small bowel pathology, MAS was chosen as the procedure of choice to go forward with an investigation for etiological diagnosis and treatment in this baby as reported by other authors earlier.[4]

MD usually appears as a pouch 3-6 cm in length that arises from the antimesentric border of the ileum at variable lengths from the ileocecal junction. It results from failure of the complete obliteration of the embryonic vitelline or the omphalomesentric duct, which occurs by the 5th week of gestation when the placenta replaces the yolk sac as the source of nutrition for the developing fetus.[5] Although, complications occur more commonly in children, symptomatic MD is extremely rare in neonatal population and reported to account for lesser than 20% of all pediatric cases.[6] In the neonates, it has been reported to present with perforation, intussussception, segmental ileal dilatation, and ileal volvulus.[78] The mechanism of obstruction include enlargement of the small bowel around a fibrous band attached to the umbilicus, entrapment of the intestinal loop within the mesodiverticular band (persistent vitelline arteries), intussussception with a free diverticulum acting as a lead point, volvulus around the umbilical band or stenosis secondary to chronic diverticulitis or incarceration of the inguinal/femoral hernias by the presence of MD in their sacs. MD presents a diagnostic as well as a therapeutic challenge. A high index of suspicion is necessary for prompt diagnosis and treatment. MD should be kept in mind as a cause of acute abdomen in neonates and children. Delay in diagnosis may lead to significant morbidity or mortality particularly in neonates because progression of diverticulitis and obstruction to perforation, generalized sepsis, or massive hemorrhage with hypovolemic shock can occur rapidly in these neonates. The diagnostic modalities including technetium-99m pertechnetate scintigraphy, which has been a popular investigation for this condition may be effective only in 60-80% of all cases.[9]

MAS in newborns are far more demanding than pediatric age group due to obvious reasons as explained in our previous publication.[10] We have restricted the current usage of MAS to a limited population where it is of definite benefit and does not change the eventual outcome compared to established standards of care in our hospital. Neonatal laparoscopy has been conducted in the past for confirming diagnosis of and treatment of a range of conditions in the neonatal age group including conditions such as bowel atresia, malrotation, NEC, Hirschsprung’s disease etc.[11] However, we could not come across any publication from our country on use of MAS in premature baby for diagnosis and treatment of focal small bowel pathology. This elegant approach is bound to emerge as the procedure of choice for this condition in days to come.

CONCLUSION

MD is a rare cause of intestinal obstruction, should be kept as a differential diagnosis even in a neonate, particularly if obstruction develops in an otherwise well baby. The benefits of MAS can be extended to newborns in selected cases, without compromising safety as shown in this case reported.