Arch Dis Child: first published as 10.1136/adc.38.198.103 on 1 April 1963. Downloaded from Arch. Dis. Childh., 1963, 38, 103. PROGNOSIS AFTER RESECTION OF SMALL BOWEL IN THE NEWBORN* BY VALENTINE A. J. SWAIN, ALEXANDER PEONIDES and WINIFRED F. YOUNG From the Queen Elizabeth Hospitalfor Children, London This report concerns the results in a series of 1912). Kremen et al. (1954) have shown that children who have had a resection of small bowel preservation of the ileocaecal valve is essential in for obstruction in the neonatal period. The preventing severe intestinal hurry in animals that recovery rate after this procedure has improved, have lost most of their ileum. Where stagnation particularly at special centres, but the presence of of the bowel contents occurs following entero- multiple abnormalities such as cardiovascular anastomosis, malabsorption, anaemia and other disorders and prematurity increases the risk of features of the 'blind loop' syndrome may be operation. The first few days of the post-operative expected, due to vitamin and mineral deficiencies. period are often hazardous after complete obstruc- The anaemia is usually of macrocytic and hyper- tion from atresia (single or multiple), due largely to chromic type. This alimentary dysfunction is disparity in the size of the anastomosed bowel above attributed to abnormal growth of bacteria within and below the obstruction. The distended and the stagnant loop, extending to the proximal small hypertrophied proximal gut, sometimes containing intestine. It has been produced experimentally in viscid meconium, contrasts with the collapsed distal animals (Badenoch, 1958; Card, 1959). After copyright. bowel which never having functioned is small in resection of the intestine, therefore, the outcome diameter. The excision of dilated bowel above the depends not only on the amount and type of bowel obstruction, advocated by Gross (1953), Nixon remaining, but also on the function of the stoma (1955) and others, has helped the recovery of such at the site of the anastomosis. Short-circuiting cases, but where the whole of the proximal gut is by-pass procedure should be avoided and the risk distended in high jejunal obstruction, its excision is of a stenotic junction lessened by modifications of often not possible, and recovery of intestinal technique, such as the use of single layer junction function may be greatly delayed. with interrupted absorbable sutures. http://adc.bmj.com/ Massive resections may be necessary in volvulus Small intestinal sequelae are often difficult to intestinalis neonatorum or mesenteric vascular diagnose, but straight abdominal radiographs, and thrombosis. Animal experiments (Flint, 1912) and pictures taken after giving an opaque medium where studies after massive resections in adults (Haymond, indicated, may detect a persistent dilated loop of 1935) indicate that at least half of the intestine can bowel. Conservative treatment with modification be removed with recovcry. Preservation of the of diet and antibiotics is worth trying, but if it fails ileum is more important than the jejunum for excision of the offending loop may be necessary. absorption in general (Kremen, Linner and Nelson, In summary, babies who have had a short length of on October 1, 2021 by guest. Protected 1954; Benson, 1955), and absorption of vitamin B12 bowel resected can be expected to recover and in particular (Booth and Mollin, 1957; 1959) is develop well, whereas large resections may lead to dependent on the distal small bowel. After malnutrition from malabsorption. This may show resection of a moderate length of bowel, dysfunction itself by retarded growth, signs of mineral and with intestinal hurry may persist for several weeks, vitamin deficiencies or, if the lower ileum is missing, but ultimately the bowel functions normally (Booth, by specific defects such as macrocytic anaemia. Evans, Menzies and Street, 1959). This recovery Both at the beginning and at follow-up examina- may be due to compensatory hypertrophy of intes- tions, co-operation between the paediatric surgeon tinal villi, as shown in animal experiments (Flint, and physician is clearly essential in treating these cases, in order to detect alimentary sequelae and constitutional disturbances and so avoid retarded * A paper read at a meeting of the British Association of Paediatric Surgeons in London, September 1962. development whenever possible. 103 Arch Dis Child: first published as 10.1136/adc.38.198.103 on 1 April 1963. Downloaded from 104 ARCHIVES OF DISEASE IN CHILDHOOD Present Study Two of those suffering from cystic fibrosis of the Between 1953 and 1960 42 newborn babies were pancreas, who were making good early progress, admitted to the Queen Elizabeth Hospital with succumbed to pulmonary complications, one at small bowel obstruction; 18 patients required 6 weeks and the other at 4 months of age. Each resection of the small bowel and the present study had had resection of about 50 cm. of ileunr, and the concerns only these. At the time of operation first had had a Ramstedt operation for pyloric 16 were aged between 1 and 6 days; the other two stenosis. were 12 and 28 days, the obstruction being complete Since it can be supposed that full recovery of in all except the last. Diagnosis of intestinal alimentary function depends upon the extent of a obstruction rested upon the clinical findings sup- resection, the course of four patients from whom ported by the radiological appearances of the abdo- 45-67 cm. of small gut were removed has been men on a straight film taken erect. Before opera- compared with that of seven who lost 5-30 cm. tion each patient was given an intravenous infusion Recovery in seven was uneventful, but in four (three to correct deficits of water and electrolytes from of the first and one of the second group) it was vomiting, from pooling of fluid in the gut proximal complicated early after the operation. One had to the obstruction and from starvation. These diarrhoea from intestinal hurry, and three had infusions were continued to replace deficits during complications due to dilatation of a loop proximal the period of post-operative ileus and to provide to the site of anastomosis. All failed to thrive, maintenance requirements of water, electrolytes three became anaemic and A.D., the patient with and some calories as glucose, until oral feeding intestinal hurry, became dehydrated from gross could be resumed. The plan for assessing the electrolyte depletion. He had had excision of the requirements for such treatment was based on longest piece of the bowel in this series. J.B., with clinical, laboratory and balance data described and alimentary dysfunction following a long resection, discussed elsewhere (Young, McIntosh, Swain and had, and probably still has, recurring partial Levin, 1959). obstruction in the region of the anastomosis, but Table 1 shows the site, cause of obstruction and the dilatation of bowel in two others (J.L., J.C.) results in this series of 18 patients. Among the only persisted for two or three months. L.D., copyright. 13 infants surviving the post-operative period, three with good early progress, developed alimentary with meconium ileus had cystic fibrosis of the symptoms and anaemia years later. At 6 years of pancreas, and one with a jejuno-ileal septumwas age a 'blind loop syndrome' was diagnosed and the a mongol. The birth weight of each exceeded loop resected with recovery of normal bowel 5 lb. (2- 26 kg.) which may have contributed to function thereafter. These five cases are described recovery. in detail. Table 2 shows the findings in the five who died Present Review during the post-operative period. Two were pre- http://adc.bmj.com/ mature infants weighing less than 4 lb. (1-81 kg.) Of the 11 surviving patients, nine, whose ages at birth, one of whom was grossly dehydrated range from 3 to 8 years, have been re-examined for before operation at the age of 6 days, and the other alimentary sequelae and nutritional state. Each required a massive resection. One of the others has been examined also for anaemia, hypoprotein- who weighed less than 5 lb. (2 26 kg.) at birth also aemia, rickets and retardation of skeletal age and had persistent ileus. In the remaining two obstruc- for steatorrhoea by analysis of a three-day collection tion was due to inspissated meconium which was not of stools, except in the patient with cystic fibrosis amenable to surgical treatment. of the pancreas. on October 1, 2021 by guest. Protected Fig. 1 shows that, except for J.B.'s height and Progress A.W.'s weight (each of which is above the 3rd Table 3 is a summary of the course in the 11 percentile), both the height and the weight of each infants who survived. Three of those surviving the child are above the 10th percentile, and above the post-operative period underwent a second operation 50th percentile in five children. The skeletal age for closure of an ileostomy and two to overcome of all except A.W. is also within the normal range. the initial obstruction, one of which then had the None of the children has anaemia, hypoproteinaemia ileostomy closed at a third operation. One had a or rickets, but J.B. and L.D. who have a recent Ramstedt operation for hypertrophic pyloric stenosis history of malabsorption had been given iron at an older age, and another developed intestinal during a preceding period. obstruction due to adhesions, at the age of 11 weeks, The fat excretion has been estimated in four of which was relieved by a further operation. the five children who had had complications and in Arch Dis Child: first published as 10.1136/adc.38.198.103 on 1 April 1963. Downloaded from PROGNOSIS AFTER SMALL BOWEL RESECTION IN NEWBORN 105 TABLE I SITE AND CAUSE OF SMALL BOWEL OBSTRUCTION IN 18 NEWBORNS Results Deaths Site Cause Number Surviving Post-operative In Period Post-operative Later Period Septum-Incomolete .