Meconium ileus surgical management
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Mangament, Surgical and non Surgical management of meconium ileus
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Meconium ileus surgical management
- 1. Review of Surgical options in Simple Meconium Ileus Dr. Almumtin, Ahmed
- 2. Introduction • Isolated versus part of an entity. • Simple and Complicated types.
- 3. Incidence and pathogenesis • 9-33% of all intestinal obstruction. • 1:25000 newborns. • 3rd case of neonatal small bowel obstruction. • prenatal detection. • association with congenital anomalies
- 4. Genuine associations • Cystic fibrosis and meconium ileus. • Meconium ileus and the premature infants. • Meconium with lower carbs, high proteins, and albumin. • CFTR gene, approx 1000 mutations.
- 5. Clinically and Gross description • Presentation: • Abd. distension 96% • bilious vomiting 50% • delayed passage of meconium.
- 7. Radiographically • Plain X-rays: • Unevenly dilated loops of bowel • Variable presence of air-fluid levels • Bubbles of gas. • Contrast enema: • Microcolon.
- 9. Non-Operative treatment • Volume resuscitation. • Gastric decompression • Respiratory support if needed. • empirical antibiotics. • Hyperosmolar enema washout
- 10. Hyperosmolar Enema • Aims for hydration and softening of meconium mass. • Careful resuscitation, hydration, appropriate electrolytes repletion and maintenance of normothermia. • Must be performed under fluoroscopic control. • slow infusion to the rectum. Meconium pellets usually will pass in the next 24-48 hours. • Warm saline enemas with 1% N-acetylcysteine is of help
- 11. Hyperosmolar Enema • after successful evacuation, 5 ml of 10% N- acetylcysteine is given through NGT Q6 hours. • Consider pancreatic enzymes if suspecting CF. • Success rate range 63-83%
- 12. Operative Management • Indications: • Inadequate meconium evacuation or complications of contrast enema. • failure of hyperosmolar enema to promote passage of meconium in 24-48 hours. • if associated with intestinal atresia
- 13. Principles • Manual evacuation. • Entrotomy, intraoperative saline irrigation, mechanical separation of pellets from bowel wall. • 2% or 4% N- acetylcysteine or 50% hyperosmolar solution instillation can be helpful.
- 14. Principles • Resection of the extremely dilated proximal segment (in order to avoid size discrepancy) anastomosis. • Complication is leak. • The other option; resection, with creation of stoma.
- 15. Techniques • Mikulicz Double barrel enterostomy. • Advantages: • Less operative time. • Risk of leak is avoided. • Solubilizing agents can then be administered in distal and proximal loops. • Disadvantages: • Potential high stoma output and fluid losses. • long resections can result in short bowel • the need for another surgery to restore continuity in later time.
- 16. Techniques • Distal chimney enterostomy (Bishop- Koop procedure ) • resection with anastomosis between the end of the proximal segment and the side of the distal segment of bowel approximately 4 cm from the opening of the distal segment • The distal end is brought out as the ileostomy • This technique allows for normal gastrointestinal transit while providing a means for management of the distal obstruction through the ileostomy should it occur
- 18. Techniques • Proximal chimney enterostomy (Santulli) • Distal limb end is anastomosed to the side of proximal limb • enhanced proximal irrigation and decompression. • no need for evacuation at the time of surgery • risk of high output stoma, and consequent electrolyte disturbance and dehydration.
- 19. Techniques • Primary resection and anastomosis • resection of the obstructed segment. • irrigation of remaining pellets in the distal bowel. • ileocolic anastomosis. • disadvantages: • Anastomosis complications. • resection of additional bowel (terminal ilium containing pellets with the dilated segment of ileum)
- 20. Post-operative management • Resuscitation, maintenance fluids. • Replacement of fluid losses ( through NGT or ileostomy) • 2 or 4% N-acetylcystein via NGT or ileostomy. • Workup of Cystic fibrosis. • Keeping the placed stoma in mind for future closure.
- 21. Nutrition Support • As bowel function resumes, oral feeding can start with breast milk or infant formula. • Supplemental pancreatic enzymes and vitamin. • those with long post-surgical course might require enteral feeds or TPN. • watch for TPN associated cholestasis. • Glutamine-enriched formulas to the distal bowel maybe tried to enhance bowel growth
- 22. References • Pediatric Surgery Diagnosis and Management, Prem Puri, Michael Holwarth • Ashcraft’s pediatric surgery, 5th edition. • Pediatric Surgery (Springer Surgery Atlas Series). • Operative pediatric suregry, Lewis Spitz, Arnold G Coran. 7th edition
- 23. Thank You
Editor's Notes
- Simple: terminal ileum is filled with firm concretions, small in diameter, and mold around the inspissated lumps of meconium. proximal dilated bowel. distally, disused colon (microcolon) Complicated: usually present dramatically, immediately after birth. some will develop symptoms within 24 hours of birth. Signs of meconium peritonitis ( Abd distension, tenderness, abdominal wall erythema), clinical evidence of sepsis. intraperitoneal calcifications on abdominal X-rays. complications include: perforation, meconium peritonitis, volvolus and atresia
- meconium ileus is one of the most common causes of intestinal obstruction in the newborn. Meconium ileus is always associated with CF. can be the earliest clinical manifestation of CF ( 16% of patients with CF will present as meconium ileus)
- 16% of CF patients will present with meconium ileus, and 80-90% of meconium ileum cases have CF. Meconium ileus is the earliest clinical manifestation of cystic fibrosis (CF) and occurs in 8–10% of patients with CF at birth CF: autosomal recessive, 4-5%, occurs 1:3000 live births yearly. Mutations in the Cystic fibrosis transmembrane regulator encoding for chloride channel, results in reduced clearance of secretions.
- soap-bubble (the “Singleton’s sign”) or ground-glass appearance is due to a dense meconium mixed with air, typical of the distal ileum: this picture is usually located in the mid- abdomen or in the right iliac fossa
- Stomas placed in the course of surgical management should be closed as soon as possible (4 to 6 weeks) to help avoid prolonged problems with fluid, electrolyte, nutritional losses, and choles- tatic jaundice.