Trends in the Management and Outcome of Jejuno-Ileal Atresia

Abstract

The aim of this study was to evaluate contemporary patterns of presentation and trends in the management and outcome of newborn infants with jejuno-ileal atresia at a regional paediatric surgical centre in the United Kingdom. The hospital neonatal surgical registry was used to identify patients with jejuno-ileal atresia (n = 83) admitted between 1976 - 1998, excluding those associated with gastroschisis. The clinical records were reviewed and antenatal information, patient demographics, associated anomalies, operative treatment, post-operative management and outcomes were analysed in three time periods to identify trends in management and survival: Group 1 1976 - 1982 (n = 32), Group 2 1983 - 1990 (n = 21), and Group 3 1991 - 1998 (n = 30). Overall survival was 90 %. The number of patients with associated anomalies were Group 1, 10 (31 %); Group 2, 7 (33 %); and Group 3, 11 (37 %). Cystic fibrosis was encountered in 4 (13 %), 1 (5 %) and 4 (13 %) patients, respectively. Resection with primary anastomosis was the definitive management in most of patients: Group 1, 25 (78 %); Group 2, 17 (81 %); and Group 3, 27 (90 %). Initial stoma followed by delayed primary anastomosis was performed in 14 infants; eight patients had divided stomas while 6 had Bishop-Koop stoma. Tapering was used in 10 patients (12 %) with proximal jejuno-ileal atresia. Parenteral nutrition was increasingly utilised over the three time periods studied. There were no deaths in Group 3 compared to 6 deaths in Group 1 and 2 in Group 2 (P = 0.02). Most of the deaths were due to overwhelming sepsis. Mortality did not correlate significantly with the TYPE of atresia, presence of associated anomalies or the need for long-term total parenteral nutrition. The overall complication rate in survivors was 18 %. In the infants undergoing Bishop-Koop operation the complication rate was 50 %. This study has shown a significant reduction in mortality from jejuno-ileal atresia, which may be attributed primarily to advances in perioperative management, including parenteral nutrition. Generous resection of the atretic segment with primary anastomosis is more frequently employed in preference to initial stoma formation. Cystic fibrosis remains an important co-morbid condition that must be excluded promptly in all newborns.

Treatment strategies in the management of jejunoileal and colonic atresia

“…This reduction in mortality has largely been due to better understanding of etiologic factors, recognition that the dilated bowel proximal to the atretic segment was dysfunctional leading to modifications in surgical procedures, improved anastomotic technique and suture material, improvement in various aspects of neonatal care and anesthesia, as well as the development of total parenteral nutrition (TPN). [7,8] However, in developing countries like ours, the results are still not satisfactory. [9][10][11] Reported mortality rates following surgery for JIA, range from 41% [11] to 68%.…”

“…[7,8,20] Use of TPN is especially useful in patients with type IIIb atresia, type IV atresia, or in cases with short-bowel syndrome. [17] In the absence of availability of TPN, early restoration of oral or some form of enteral feeding becomes essential.…”

“…[3] However, over the last 2 decades or more, most reports from developed countries describe survival rates approximating or greater than 90%, for patients with jejunoileal atresia (JIA). [4][5][6][7] Prognosis in cases of colonic atresia (CA) is also usually excellent. This reduction in mortality has largely been due to better understanding of etiologic factors, recognition that the dilated bowel proximal to the atretic segment was dysfunctional leading to modifications in surgical procedures, improved anastomotic technique and suture material, improvement in various aspects of neonatal care and anesthesia, as well as the development of total parenteral nutrition (TPN).…”

Bishop Koop Method in the Management of Multiple Intestinal Atresia.

“…The significant disparity in the size of intestinal ends, the increased wall thickness and the intestinal dysmotility with decreased peristalsis are important anatomical features to be considered by the surgeon before the operation. These conditions may force the surgeon to create a proximal stoma, despite the increased morbidity and mortality of this procedure [7] ; [8].…”

Intestinal Atresia: A Four-Year Review of Cases in Ikeja-Lagos

“…The pattern of presentation, management and outcome vary with the site of the obstruction and the presence of associated congenital anomalies. In recent times, the management has improved due to advancement in neonatal intensive care, improved preoperative resuscitation, anaesthesia and operating techniques as well as the use of total parenteral nutrition (TPN) 1,2 . However, the combination of late presentation and lack of neonatal intensive care facilities and TPN have continued to contribute to poor outcome in the developing world 3,4 .…”