Review of Surgical options in Simple Meconium Ileus

Dr. Almumtin, Ahmed

Introduction

• Isolated versus part of an entity.• Simple and Complicated types.

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

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.

Clinically and Gross description

• Presentation:• Abd. distension

96%• bilious vomiting

50%• delayed passage of

meconium.

Differential Diagnosis

Radiographically• Plain X-rays:

• Unevenly dilated loops of bowel • Variable presence of air-fluid levels • Bubbles of gas.

• Contrast enema:• Microcolon.

Treatment

• Non-Operative.• Operative.

Non-Operative treatment

• Volume resuscitation.• Gastric decompression• Respiratory support if needed.• empirical antibiotics.• Hyperosmolar enema washout

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

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%

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

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.

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.

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.

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

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.

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)

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.

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

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

Thank You