Contemporary management of meconium ileus

Abstract

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.

Recent Change in Management Pattern of Meconium Ileus at Dhaka Shishu Hospital

“…The predominant complications of MI were volvulus, gangrene, perforation and atresia seen in both groups. Delphin et al, Rescorla et al and Karimi et al reported similar findings 7,8,12 . Significant differences were found between the types surgical procedures in both groups in this study.…”

“…Intra peritoneal leakage was found more in Bishop Koop procedure followed by T tube ileostomy. Delpin et al and Karimi et al mentioned higher risk of leakage in Bishop Koop procedure 8,12 . In Bishop Koop procedure intestinal contents passes into distal bowel, thus more fluid & nutrients are absorbed.…”

“…Here, intra peritoneal leakages were few and complications were negligible. After first description by Harberge et al, several author described T tube ileostomy as a safe and effective procedure for simple MI 8,10,11 . Samiul H et al also found results of T tube ileostomy is better than BishopKoop procedure in simple MI 15 .…”

“…Success rate of non-operative management of simple MI is about 60 to 70% of newborns and current short-term operative survival rates of 70 to 100% are reported 7 . Options for surgical management of MI include resection of dilated ileum with primary anastomosis, Bishop-Koop ileostomy, Santulli procedure or Mikulicz procedure, T tube ileostomy 1,2,8,9 Bishop-Koop procedure, Santulli procedure and Mikulicz procedure are extensive operation, associated with gut reduction. Though Bishop-Koop procedure allows function of distal bowel and stoma output is minimum, Mikulicz procedure associated with high output stoma, failure to thrive, sepsis, recurrent hospital admission and higher mortality.…”

“…T-tube ileostomy includes enterotomy, evacuation of thick meconium and placement of T-tube for post-operative irrigation 8,9 . This procedure do not require gut resection and there is no intraperitoneal anastomosis.…”