Effecting factors of the mortality and morbidity in the jejunoileal obstruction.

Öz

Objective: Jejunoileal atresia and meconium ileus are seen common among major causes of intestinal obstructions of the newborns requiring emergency surgical treatment. The aim of this study is determined effecting factors of the mortality and morbidity in the jejunoileal obstruction in newborns.

Material and Method: This study is designed as a retrospectively from all records of the neonates with jejunoileal obstructions hospitalised in between January 2004 and January 2013.

Results:  44 newborns were opertated due jejunoileal obstruction during the 9 years period. 34 of them were intestinal atresia (77,2%), the others had meconium ileus. Prenatal diagnosis was suggestive of intestinal obstruction in 15 fetuses (44%). %41of 34 intestinal atresia was premature.

At the time of surgery,  34 (77,2%) of the jejunoileal atresias were classified 6(17,6%) as type I(mucosal), 8(23,5 %) as type II(atretic fibrous cord), 5(14,2 %) as type IIIa(V-shaped mesenteric defect), 11(24,4%) as type IIIb("apple peel" atresia), and 4(11,8%) as type IV(multiple atresias). Other findings in operation had included  malrotation in 9(20,4%), meconium peritonitis in 1(2,9%), Meckel diverticulum in 1(2,9%), and intrauterine intussusception in 1(2,9%).

Operative management included resection of the atresia with primary bowel anastomosis in 28 neonates (82,3%), temporary ostomy in 2(5,8%), with intestinal resection in 30(88,1% of those), enterotomy with web excision in 1(2,9%). Ladd procedure was performed in those neonates with malrotation 9(20,4%) and Meckel diverticulectomy was performed in 1 neonate, and incidental appendectomy was performed in 4 neonates (11,6%). Following resection, 1 patients (2,9%) had resultant short-bowel syndrome.

Mortality for neonates with with jejunoileal atresia was 7 cases (20,5%). Ten neonates (22,7 %) had cystic fibrosis documented by sweat chloride determinations. The long-term survival rate for children with jejunoileal atresia, 79,5%; and with meconium ileus 90%. 

Conclusion: In neonates with jejunoileal obstruction short bowel syndrome and cystic fibrosis increases morbidity and mortality. TPN and growth hormone support, effective use of antibiotics, intensive care conditions improve, and the improvement of nursing care in patients reduces mortality and morbidity in the postoperative period of patients with meconium ileus with/without jejunoileal atresia and ultrashort-bowel syndrome.

Anahtar Kelimeler

• jejunum; ileum; atresia, cystic fibrozis, short bowel syndrome, total parenteral nutrition, meconium; ileusjejunum; ileum; atresia; cystic fibrosis; short bowel syndrome; total parenteral nutrition; meconium; ileus; surgery

Jejunoileal obstrüksiyonlarda mortalite ve morbiditeyi etkileyen faktörler.

Öz

Amaç: Yenidoğanlarda acil cerrahi tedavi gerektiren barsak obstruksiyonlarının başlıca sebebi jejunoileal atreziler ve mekonyum ileuslarıdır. Bu çalışmanın amacı yenidoğanların jejunoileal obstruksiyonlarında mortalite ve morbitideyi etkileyen faktörleri ortaya koymaktır.

Gereç ve Yöntem: Ocak 2004 - Aralık 2012 yılları arasında jejunoileal obstruksiyon nedeniyle opere edilen yenidoğanların tüm dosya kayıtları mortalite ve morbidite açısından retrospektif olarak değerlendirildi.

Bulgular: 9 yıllık süre boyunca opere edilen intestinal obstruksiyonlu 44 olgunun 34’ü(%77,2) jejunoileal atrezi, 10’u mekonyum ileusu olup jejunoileal atrezilerin %41’i prematüre idi. Atrezili olguların 2’si(%5,8) gastroşizis ve 1’i(%2,9) Meckel invajinasyonu ile birlikteydi. 17 olguda (%38,6) prenatal tanı konulmuştu. Mekonyum ileuslu olguların 2’sinin (%20) ve JİA’li olguların 15’inin (%44) prenatal tanısı vardı.

Ameliyatta 34 jejunoileal atrezili olgudan(%77,2); 6’sının Tip 1(%17,6), 8’inin Tip 2(%23,5), 5’inin Tip 3A(%14,2), 11’inin Tip 3B(%24,4), 4’ünün Tip 4(%11,8) olduğu saptandı. Ayrıca 9’unda (%20,4) malrotasyon, 1’inde (2,9) Meckel divertikülü, 1’inde (%2,9) intrauterin invajinasyon, 1’inde (%2,9) mekonyum peritoniti mevcuttu.

28 olguya(%82,3) primer rezeksiyon anastomoz, 2’sine(%5,8) ostomi, birine enterotomi-web eksizyonu yapılmıştı. Malrotasyon olan 9 olguya(%20,4) ayrıca Ladd prosedürü, 4 olguya(%11,6) appendektomi yapılmıştı. Rezeksiyonu takiben bir olguda kısa barsak sendromu gelişti. 19 olguda(%43) total parenteral nutrisyon yapıldı. Jejunoileal atrezi olgularının %79,5’i, mekonyum ileus olgularının %90’ı yaşadı.

Sonuç: Jejunoileal obstruksiyonlu yenidoğanlarda kistik fibrozis ve kısa barsak sendromu morbiditeyi ve mortaliteyi arttırmaktadır. Postoperatif dönemde kısa barsak sendromu gelişen olgularda TPN ve büyüme hormonu desteği, antibiotiklerin etkin kullanılması, yoğun bakım şartlarının iyileşmesi ve hemşirelik bakımının iyileşmesi jejunoileal atrezili olgularda mortalite ve morbiditeyi azaltmaktadır.

Anahtar Kelimeler

• jejunum; ileum; atrezi; kistik fibroz; kısa barsak sendromu; total parenteral beslenme; mekonyum; ileus; cerrahi; çocuk

Kaynakça

1. Martin LW, Zeralla JT. Jejunoileal atresia; a proposed classification. J Pediatr Surg 1976;11:399-403.
2. Casaccia G, Trucchi A, Nohom A, Aite L. The impact of cystic fibrozis on neonatal intestinal obstruction: the need for prenatl/neonatal screening. Pediatr Surg Int 2003;19:75-8.
3. Andersen DH, Hodges RG. Celiac syndrome; genetics of cystic fibrosis of the pancreas, with a consideration of etiology. Am J Dis Child 1946;72:62-80.
4. Bobadilla JL, Macek M Jr, Fine JP, Farrell PM. Cystic fibrosis: a worldwide analysis of CFTR mutations - correlation with incidence data and application to screening. Hum Mutat 2002;19:575-606.
5. Başoğlu N, Sancı M, Başoğlu Ö, Tınar Ş. İzole Segmental Dilatasyon Nedeniyle Antenatal İntestinal Obstruksiyon Bulgusu. Perinatoloji Dergisi 2001;9: 261-3.
6. Langer JC, Adzick NS, Filly RA, Golbus MS, deLorimier AA, Harrison MR. Gastrointestinal tract obstruction in the fetus. Arch Surg 1989;124:1183-267.
7. Haller JA, Tepas JJ, Pickard LR: Intestinal atresia: Current concepts of pathogenes, pathophysiology and operative manegment. Am Surg 1983;49:385-91.
8. Miraglia R, Catalano P, Maruzzelli L. Balloon dilatation of postoperative small bowel anastomotik stricture in an infant with apple peel intestinal atresia after serial transvers enteroplasty and jejunoileal anastomozis. J Pediatr Surg 2010;45:E25-E28

9. Stollman TH, de Blaauw I, Marc H.W, Wijyen A. Decreased mortalty but increase morbidity in neonates with jejunoileal atresia ; a study of 114 cases over a 34- year period. J Pediatr Surg 2009;44:217-21.
10. Hiroaki B, Hori T, Amagai T. The Etiologic Role of Intrauterine Volvulus and Intussusception in Jejunoileal Atresia. J Pediatr Surg 2004;39:1812-4.
11. Lima M, Ruggeri G, Domini M, Gargano T, Landuzzi V, Sciutti R. Evolution of the surgical management of bowel atresia in newborn: Laparascopically assisted treatment. Pediatr Med Chir 2009;31:215-9.