Meconium ileus surgical management
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Transcript of Meconium ileus surgical management
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Review of Surgical options in Simple Meconium Ileus
Dr. Almumtin, Ahmed
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Introduction
• Isolated versus part of an entity.• Simple and Complicated types.
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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
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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.
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Clinically and Gross description
• Presentation:• Abd. distension
96%• bilious vomiting
50%• delayed passage of
meconium.
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Differential Diagnosis
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Radiographically• Plain X-rays:
• Unevenly dilated loops of bowel • Variable presence of air-fluid levels • Bubbles of gas.
• Contrast enema:• Microcolon.
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Treatment
• Non-Operative.• Operative.
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Non-Operative treatment
• Volume resuscitation.• Gastric decompression• Respiratory support if needed.• empirical antibiotics.• Hyperosmolar enema washout
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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
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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%
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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
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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.
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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.
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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.
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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
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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.
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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)
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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.
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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
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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
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Thank You