Membrane resection and Heineke-Mikulicz jejunoplasty for the management of Type-I jejunal atresia: a case series

Fung A.C., Lee M.K., Lui M.P., Lip L.Y., Chung P.H., Wong K.K.

We aimed to compare the outcomes of primary anastomosis (PA) and enterostomy as treatments for intestinal atresia in neonates to identify the factors influencing the choice of modality. We conducted a retrospective single-centre analysis of all neonates with intestinal atresia between 2000 and 2020 and measured the clinical outcomes. We performed logistic regression to identify factors that influenced the choice of surgical approach. Of 62 intestinal atresia neonates, 71% received PA. There were no significant differences in gestation, gender, age at operation, birth weight, or body weight at operation between the PA and enterostomy groups. PA reoperation was not required for 78% of patients, and the PA group had shorter hospital stays. Complications, operative time, duration on parenteral nutrition, time to full enteral feeding were comparable in both groups. Upon multivariate regression analysis, surgeons favoured PA in proximal atresia [Odds ratio (OR) 38.5, 95% Confidence Interval (CI) 2.558–579] while enterostomy in smaller body size [OR 2.75, CI 0.538–14.02] and lower Apgar score [OR 1.1, CI 0.07–17.8]. Subgroup analysis in these patient groups demonstrated comparable outcomes with both surgical approaches. Both surgical approaches achieved comparable outcomes, but PA was associated with short hospital stays and the avoidance of stoma-related complications, and reoperation was generally not required. This surgical approach was suitable for patients with proximal atresia, but enterostomy remained a sensible choice for patients with smaller body sizes and lower Apgar scores.

Morris G., Kennedy A.

The small intestine is a complex organ system that is vital to the life of the individual. There are several congenital anomalies that occur and present most commonly in infancy; however, some may not present until adulthood. Most congenital anomalies of the small intestine will present with obstructive symptoms, whereas some may present with vomiting, abdominal pain, and/or gastrointestinal bleeding. Various radiologic procedures can aid in the diagnosis of these lesions that vary depending on the particular anomaly. The congenital anomalies of the small intestine discussed include Meckel diverticulum, duodenal web, duodenal atresia, jejunoileal atresia, and intestinal duplications.

Eeftinck Schattenkerk L.D., Backes M., de Jonge W.J., van Heurn E.L., Derikx J.P.

AbstractPurposeNo study has evaluated complication rates of the combined operations needed for temporary Enterostomy compared to primary anastomosis in the treatment of Jejunoileal Atresia. Therefore the aim of this study is: 1) to compare the occurrence of severe postoperative complications (defined as Clavien-Dindo ≥III within 30 days) and 2) to compare the occurrence of different short- and long-term complications following treatment for Jejunoileal atresia either by primary anastomosis or the combined Enterostomy procedures.MethodsAll consecutive neonates treated for Jejunoileal Atresias between January 1998 and February 2021 at our tertiary academic centres were retrospectively included. Perioperative characteristics and severity of postoperative complications (Clavien-Dindo) were extracted and evaluated, using chi-squared statistics, following each operation per treatment.ResultsEighty patients were included of whom 48 (60%) received a primary anastomosis and 32 (40%) an Enterostomy. Perioperative baseline characteristics were comparable, apart from significantly more patients with a gastroschisis and significantly less patients with jejunum atresia in the Enterostomy group. Our results showed that 1) significantly (p ≤ 0.01) more CD ≥III occur following treatment by Enterostomy. 2) Both short-term (surgical site infection, wound dehiscence) and long-term (short bowel syndrome, adhesive bowel obstruction) complications occurred significantly more in those treated by Enterostomy. We showed no significant difference in anastomotic leakage/stenosis and mortality rates between both treatment strategies.ConclusionAlthough perioperative factors might necessitate an Enterostomy, we advise a low threshold for performing a primary anastomosis when in doubt, taking into account the double risk of major complications found in patients treated with a temporary Enterostomy.

Yang S., Wang M., Shen C.

Tsamis A., Pocivavsek L., Vorp D.A.

Crohn’s disease is a challenging inflammatory process with a propensity for focal gastro-intestinal tract inflammation and stricture. Surgically, Crohn’s is often treated with resection. However, a subtype of diffuse disease with multiple strictures is treated by strictureplasty procedures in hope of avoiding short-gut syndrome. Prior work by Pocivavsek et al. defined the geometry of a Heineke–Mikulicz strictureplasty. Here, we bring this analysis one step closer to clinical and biological relevance by calculating the mechanical stresses and strains that the strictureplasty deformation generates on a model intestinal wall. The small bowel is simulated as a linearly elastic isotropic deformable cylindrical shell using finite element modeling. Data show a divergence in elastic response between the anti-mesenteric and mesenteric halves. The anti-mesenteric surface shows a bending dominated elastic response that correlates with the prior purely geometric analysis. However, the mesenteric half is not a neutral bystander during strictureplasty formation, as geometric arguments predict. Strong in-plane stretching strains develop in a rim around the image of the transverse closure, which may impact local perfusion and serve as sites of disease recurrence. Lastly, nearly all the deformation energy is stored in the central vertex stitch, placing this part at highest risk of dehiscence. This study enhances our understanding of mechanical response in complex nonlinear cylindrical geometries like the surgically manipulated intestinal tract. The developed framework serves as a platform for future addition of more complex clinically relevant parameters to our model, including real tissue properties, anisotropy, blood supply modeling, and patient deriver anatomic factors.

Vinocur D.N., Lee E.Y., Eisenberg R.L.

Anal atresia and anorectal malformations I ntestinal obstructions are the most common surgical emergencies in the neonatal period. Early and accurate diagnosis of intestinal obstruction is paramount for proper patient management. For evaluation and diagnosis, intestinal obstruction in neonates can be divided into either high or low obstruction on the basis of the number of dilated bowel loops present on the initial abdominal radiographs. Although three or fewer dilated bowel loops are typically seen with high intestinal obstruction, more than three are generally seen with low intestinal obstruction in neonates. High intestinal obstructions are defined as occurring proximal to the ileum, resulting in various combinations of gastric, duodenal, and jejunal dilatation according to the level of obstruction (Table 1). In contrast, low intestinal obstructions involve the distal ileum or colon and typically result in diffuse dilatation of multiple small-bowel loops (Table 1). Although neonates with classic radiographic findings of high intestinal obstruction, such as duodenal atresia, may directly undergo surgery without any additional imaging, an upper gastrointestinal series is typically performed for further evaluation. Similarly, an enema examination is used for further investigation of low intestinal obstruction in neonates.

Baker M.L., Williams R.N., Nightingale J.M.

Patients with a high-output stoma (HOS) (> 2000 ml/day) suffer from dehydration, hypomagnesaemia and under-nutrition. This study aimed to determine the incidence, aetiology and outcome of HOS.The number of stomas fashioned between 2002 and 2006 was determined. An early HOS was defined as occurring in hospital within 3 weeks of stoma formation and a late HOS was defined as occurring after discharge.Six-hundred and eighty seven stomas were fashioned (456 ileostomy/jejunostomy and 231 colostomy). An early HOS occurred in 75 (16%) ileostomies/jejunostomies. Formation of a jejunostomy (defined as having less than 200 cm remaining of proximal small bowel; n = 20) and intra-abdominal sepsis? obstruction (n = 14) were the commonest causes identified for early HOS. It was possible to stop parenteral infusions in 53 (71%) patients treated with oral hypotonic fluid restriction, glucose-saline solution and anti diarrhoeal medication. In 46 (61%) patients, the HOS resolved and no drug treatment was needed, 20 (27%) patients continued treatment, six (8%) of whom went home and continued to receive parenteral or subcutaneous saline, and nine died. Twenty-six patients had late HOS. Eleven were admitted with renal impairment and four had intermittent small-bowel obstruction. Eight patients were given long-term subcutaneous or parenteral saline and two also received parenteral nutrition. All had hypomagnesaemia.Early high output from an ileostomy is common and although 49% resolved spontaneously, 51% needed ongoing medical treatment, usually because of a short small-bowel remnant.

Burjonrappa S., Crete E., Bouchard S.

To describe the outcomes of 130 intestinal atresias between 1982 and 2007. Records were analyzed for location, demographics, prenatal diagnosis, birth weight, associated anomalies, surgery, establishment of oral intake, re-interventions and mortality. Statistical analyses were performed using Fisher test and ANOVA. There were 59 duodenal (30 male), 63 jejuno-ileal (34 male) and 8 colonic atresias (3 male). Prenatal diagnosis was established in 27 (46%) duodenal (DA), 26 (41%) jejuno-ileal (JIA) and 1 (12.5%) colonic atresias (CA). The mean birth weights, 2,380.5 g (SD 988) DA, 2,814 g (SD 755) JIA and 3,153 g (SD 527) CA were significantly different (p = 0.011). The mean gestational ages were 36, 37 and 37 weeks in DA, JIA and CA, respectively (p-NS). Associated congenital anomalies were seen in 41 (76%) DA, 32 (52%) JIA and 3 (38%) CA (p = 0.08, NS). The median time to full oral feeds after surgery was 18 days in DA, 20 days in JIA and 15.6 days in CA, respectively (p > 0.05). Eight patients with DA and nine patients with JIA underwent repeat surgery for adhesive obstruction. Adhesive bowel obstruction was most common in the first year after surgery in both groups (15/17). Gastroschisis was seen in six (10%) of JIA and three (35%) of CA. Two patients in the JIA group underwent bowel lengthening. Patients with gastroschisis and those with associated anomalies needed prolonged duration of TPN after JIA correction. There was no mortality in the duodenal atresia and colonic atresia groups. Six patients in the JIA group died, three of severe atresias coupled with multiple anomalies and three of cholestasis and sepsis. Distal atresias are difficult to diagnose antenatally. Proximal atresias have a significantly lower birth weight than distal atresias. Associated anomaly screening is important in all atresias.

Yamataka A., Koga H., Shimotakahara A., Kobayashi H., Lane G.J., Miyano T.

In high jejunal atresia (HJA), discrepancy between the diameters of the proximal and distal jejunum can often be significant and cause major anastomotic complications. We developed 2 novel procedures to enhance conventional jejuno-jejunostomy (JJ): bilateral side-plication during JJ (BSP): plication of both lateral aspects of the dilated proximal jejunum, and jejunal plication before JJ (pre-P): plication of the jejunum proximal to the planned JJ site along the anti-mesenteric line. We used BSP in a neonate with a membranous stenosis 5 cm distal to the duodeno-jejunal flexure, and pre-P in 2 neonates, both with HJA and hugely dilated proximal jejunum. By using BSP, the jejunum could be plicated symmetrically near the closed jejunotomy, allowing the caliber change at the closed jejunotomy to be smooth without any kinking. If simple anti-mesenteric plication had been performed instead, proximal-to-distal kinking caused by closing the jejunotomy site transversely after the membrane was excised could have worsened. By using pre-P, the caliber change across the JJ could be made smooth and symmetric. If plication had been performed along the anti-mesenteric line after completing the JJ, the proximal jejunum near the JJ would have become asymmetrical causing the JJ to become kinked. Postoperatively, there were no JJ-related complications, and all subjects are well after a mean follow-up period of 3.0 years. Our novel procedures are simple and appear to enhance JJ by controlling kinking at the JJ site.

Sweeney B., Surana R., Puri P.

Duodenal atresia is associated with a higher incidence of associated congenital malformations than jejunoileal atresia, supporting the hypothesis that the duodenal obstruction occurs early in fetal life. In this study, the authors analyzed the incidence of major associated malformations in jejunal atresia (JA) and ileal atresia (IA) to determine if there is a positive correlation between the proximity of the intestinal atresia and the association of other major anomalies.Records of all patients with jejunoileal atresias treated at the authors' institution between 1980 and 1997 were examined.There were 83 patients with jejunoileal atresias, 38 with JA, and 45 with IA. Sixteen (42%) of the JA patients had an associated major congenital malformation, whereas only 1 (2%) of the IA patients had an associated malformation. A single atresia was found in 18 (47%) of JA patients and 41 (91%) of IA patients. Twenty (53%) of the JA patients had either multiple or apple-peel atresia. Thirteen patients (16%) died, 11 with JA, and 2 with IA. Of the 11 patients with JA who died, 6 had multiple atresias, 4 had cystic fibrosis, and 1 had small bowel volvulus.The higher incidence of associated major congenital extraintestinal malformations in JA compared with IA patients suggests that some cases of JA may arise from a malformative process.

Kling K., Applebaum H., Dunn J., Buchmiller T., Atkinson J.

After reconstruction of jejunal atresias at the ligament of Treitz, many patients do not respond to simple tapering and anastomosis requiring repetitive operations because of dysfunction of dilated proximal bowel. A new operative approach using lateral duodenectomy and duodenojejunostomy (LDAD) is reported.Three infants with atresias within 10 cm of the ligament of Treitz were treated with LDAD, and their records are reviewed retrospectively. The entire duodenum is visualized after creating a malrotation; this is followed by opening the dilated duodenum and resecting dilated proximal jejunum. The resection is extended proximally, incorporating the lateral duodenal incision, excising the lateral duodenal wall, and preserving the ampulla. The residual duodenum is fashioned into a tube and anastomosed to the spatulated distal jejunum.Three infants underwent this procedure over a 4-year period. Two had undergone tapering enteroplasties previously but were unable to tolerate oral feedings; 1 infant had LDAD primarily. All were ultimately successfully managed by LDAD and were feeding within 14 days. Follow-up is from 14 to 49 months.Although experience is limited to 3 patients, the prompt return of intestinal function with LDAD may justify primary use of this more radical procedure in difficult-to-treat proximal atresias.

Kimble R.M., Harding J., Kolbe A.

A wide variety of additional congenital anomalies occur in babies born with a gut atresia or stenosis. The specific pattern of anomalies depends on the location of the atresia. The serious nature of many of them makes perioperative diagnosis imperative. Eighty-six babies born with pure oesophageal atresia (OA), duodenal atresia (DA) or stenosis, or jejuno-ileal atresia (JIA) have been studied. These, combined with over 2,000 cases in the literature, have been used to develop a protocol to optimally investigate babies with gut atresia for associated anomalies. The authors recommend routinely obtaining anterio-posterior and lateral chest and abdominal radiographs for babies with pure OA, DA and intestinal atresia, making sure the entire spine can be visualised. Cardiac and renal ultrasonography (US) should be routine in all babies with pure OA or DA. A micturating cystourethrogram should be done in those babies with abnormal urinary tract US or an associated anorectal anomaly. A sweat test should be obtained in babies with JIA, and a rectal biopsy should be taken in babies with the combination of Down's syndrome and DA to exclude Hirschsprung's disease.

Martin L.W., Zerella J.T.

An experience with 59 infants with jejunal and ileal atresia is presented along with a proposed classification based on a combination of morphology and clinical characteristics. It would appear that the characteristics of each type are sufficiently distinct as to render this worthwhile classification.