Improving the provision of surgical care to newborns with peritonitis

  • Authors: Dedov A.С.1
  • Affiliations:
    1. Воронежский государственный медицинский университет им. Н.Н. Бурденко
  • Issue: Vol 11, No 2 (2022): Materials of the XV International Surgical Forum "INNOVATIVE TECHNOLOGIES IN SURGERY"
  • Pages: 47-52
  • Section: Хирургические дисциплины
  • URL: https://new.vestnik-surgery.com/index.php/2415-7805/article/view/7286

Cite item

Abstract

Relevance: The most formidable problem in newborns and premature infants, leading to a fatal outcome, is peritonitis.

Objective: to study the tactics of treatment, preoperative preparation for the development of peritonitis in newborns and premature infants in order to improve it.

Methods: The study was conducted from 2012 to 2021 on the basis of the BUZ in VRCCH №1, in the department "Surgery of newborns".

All children underwent laboratory examination (general blood test, acid-base state, blood electrolytes), and abdominal X-rays.

Results: Over the past 10 years, 38 children with clinical manifestations of peritonitis have been in the hospital.

Gastrointestinal perforations were postnatal in most (92%) cases and were accompanied by fibrinous (31%), serous (31%) and fecal (38%) peritonitis.

The study revealed that necrotizing enterocolitis was the cause of perforating peritonitis in 65.7% of cases (IIIA - 48%, III B - 52%), in 10.5% of cases - atresia of the small intestine with perforation, short bowel syndrome with intestinal necrosis and gastroschisis occurred in 10.4% of cases. 8.1% of children had intestinal malrotation with necrosis. 5.2% of newborns had intrauterine fecal peritonitis and stomach rupture.

All children with perforations were operated on. The tactics of surgical intervention differed depending on the type and level of perforation, the length of the process and the condition of the newborn. Laparocentesis followed by peritoneal drainage was performed in 25.7% of children.

Conclusions: The most common cause of peritonitis in newborns is necrotic enterocolitis, which has the most unfavorable prognosis of treatment. The mortality rate of newborns with perforated peritonitis decreased from 40% to 5%.

Full Text

Relevance

One of the most severe and life-threatening diseases of the gastrointestinal tract in newborns are perforations of the stomach and intestines, the mortality rate of which reaches 42-79% [1]. The clinical course of gastrointestinal perforations in newborns is extremely severe, combined with syndromes of high intra-abdominal pressure and multiple organ failure [2].

Objective

To study the tactics of treatment, preoperative preparation for the development of peritonitis in newborns and premature infants in order to improve it.

Materials and methods

1. Research plan.
We conducted a retrospective analysis of the medical histories of children with perforative peritonitis hospitalized in the Department of Neonatal Surgery in the Department of VODKB No. 1. From 2012 to 2021, 38 children with clinical manifestations of peritonitis were in the hospital.
All children underwent laboratory examination (general blood test, acid-base state, blood electrolytes), and abdominal X-rays.

2. Conditions of the event.
The study was conducted on the basis of the BUZ IN VODKB No. 1, in the department "Surgery of newborns".

3. Duration of the study.
The study was conducted from September 2021 to January 2022.

4. Description of the medical intervention.
We conducted a retrospective study of medical histories. Preoperative preparation was a set of measures aimed at maintaining homeostasis, adequate diuresis and fighting infections.

5. The main outcome of the study.
The effectiveness of surgical intervention was assessed by the stabilization of vital signs and the frequency of relaparatomies. Mortality developed in 5.2% of cases.

6. Additional outcomes of the study.
Relaparatomy was performed in 12% of cases.

7. Methods of registering outcomes.
Statistical processing of the material was carried out on a personal computer using the Exel universal program package (2007).

8. Statistical analysis.
Principles of calculating the sample size:
The sample size was not calculated beforehand.

Methods of statistical data analysis:
Statistical data processing was carried out using the Statistica 10.0 program. The results are presented in the form of mathematical expectation M and its error (m). Quantitative indicators were compared according to the Student's test, provided its normal distribution. Qualitative indicators were compared according to the Mann-Whitney and chi-squared criteria.

Results

Objects (participants) of the study.

The objects of the study were medical records of patients, a database. Participants are newborn children.

The main results of the study.

Gastrointestinal perforations were postnatal in most (92%) cases and were accompanied by fibrinous (31%), serous (31%) and fecal (38%) peritonitis.The study revealed that necrotizing enterocolitis was the cause of perforating peritonitis in 65.7% of cases (IIIA - 48%, III B - 52%), and atresia of the small intestine with perforation in 10.5% of cases.
Short bowel syndrome with intestinal necrosis and gastroschisis occurred in 10.4% of cases.8.1% of children had intestinal malrotation with necrosis. 5.2% of newborns had intrauterine fecal peritonitis and stomach rupture.
Among all newborns with necrotizing enterocolitis, 7 were premature (28%). In 52% of children, the clinical picture of peritonitis appeared in the first week of life, most of whom (94%) had chronic intrauterine fetal hypoxia and intrauterine development delay.
Stage III of necrotic enterocolitis was observed in 48% of children. The remaining 52% of newborns were admitted to the IIIb stage of necrotic enterocolitis - the stage of perforated peritonitis. Perforations in most cases (in 75% of children) were localized in the ileum, less often (25% of children) — in the descending colon.
During the first week of life, children with intrauterine fecal peritonitis and spontaneous rupture of the stomach were hospitalized. Gastric rupture was observed in children with bronchopulmonary dysplasia and respiratory distress syndrome.
Newborns with type 3 and type 4 atresia of the small intestine were divided equally (50% of children each). Type 3 atresia was combined with abdominal adhesions and intestinal obstruction. 10% of children with atresia had multiple organ failure syndrome.

Additional research results.

All children with perforations were operated on. The tactics of surgical intervention differed depending on the type and level of perforation, the length of the process and the condition of the newborn.
Have been implemented:

  • Laparocentesis followed by peritoneal drainage - 25.7%;
  • Resection of the affected part of the intestine with the imposition of primary intestinal anastomosis - 11%;
  • Suturing of a perforated hole - 8%;
  • The imposition of intestinal stomas (one or more) - 55.3%.

Preoperative preparation included correction of CBS, blood electrolytes, stabilization of blood pressure, maintenance of diuresis of at least 2.0 ml/kg/hour, administration of broad-spectrum antibiotics, selection of adequate ventilation parameters, maintenance of body temperature at a normal level.
Postoperative mortality was 5.2%. Repalatoromy was performed in 13% of cases.
No adverse events were recorded.

Discussion

Summary of the main result of the study.

  1. The most common cause of peritonitis in newborns is necrotic enterocolitis;
  2. In 75% of cases, perforations were localized in the ileum, which is associated with inadequate enteral load, which causes ischemia in the distal small intestine;
  3. One of the main risk factors for spontaneous perforations is neonatal distress syndrome;
  4. Perforations in NEC have the most unfavorable prognosis of treatment than in other nosological units.

Limitations of the study

A small sample of medical histories of children (38 children).

Conclusion

One of the main pathologies in which there is a high mortality rate among newborns with surgical diseases is diffuse peritonitis. The most common cause is necrotic enterocolitis. In most cases, perforations were localized in the ileum, which is associated with inadequate enteral load, which causes ischemia in the distal small intestine. It is necessary to choose the right enteral (in particular protein) load for newborns, and especially premature babies. [3] It is planned to continue the study in order to study in detail the preoperative preparation with a possible change in its tactics.

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About the authors

Anton С. Dedov

Воронежский государственный медицинский университет им. Н.Н. Бурденко

Author for correspondence.
Email: anton.dedov.01@mail.ru
ORCID iD: 0000-0002-0321-1554
SPIN-code: 8722-3757
Russian Federation

References

  1. Писклаков А.В., Федоров Д.А., Новиков Б.М. Опыт лечения новорожденных с некротизирующим энтероколитом с учетом показателей внутрибрюшного давления. Дет хир 2015; 2: 27—29. (Pisklakov A.V., Fedorov D.A., Novikov B.M. Experience of treatment of newborns with necrotizing enterocolitis taking into account indicators of intraperitoneal pressure. Det Khir 2012; 2: 27—29.);
  2. Караваева С.А. Хирургическое лечение некротического энтероколита: Автореф. дис. д-ра мед. наук. Ст-Петербург 2002; 47. (Karavayeva S.A. Surgical treatment necrotizing enterocolitis: Avtoreferat Dis. d-ra med. nauk. St-Peterburg 2002; 47.);
  3. Zornoza M., Pelaez D., Romero R. et al. Role of peritoneal drainage in necrotizing enterocolitis in critical infants with extremely low birth weight. Cir Pediat 2011; 24: 3: 146—150.

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