Operative Management of Meconium Ileus With Needle Injection of N-Acetylcysteine

The operative management of meconium ileus in infants often includes enterotomy or appendectomy with N-acetylcysteine (NAC) instillation. Some have adopted an approach whereby NAC is instead injected directly into the meconium-bearing ileum at multiple sites with a small-gauge needle. We hypothesized that this technique would facilitate the mobilization of meconium without an enterotomy or even appendectomy.

A retrospective study of neonates who underwent operative management of meconium ileus at 6 hospitals in the United States and Australia between 2010 and 2021 was conducted. Outcomes after NAC instillation at multiple sites with a 27G needle injection versus enterotomy or the appendiceal stump were assessed. The primary outcomes were operative duration and time to full enteral feedings.

Inclusion criteria were met in 52 patients and 9 (17.3%) underwent needle injection of NAC. Meconium was evacuated via the appendiceal stump (33%) or colon and passed via rectum (67%) in all patients in whom NAC was injected via a needle but in only 4 (9%) of those who were administered NAC via an enterotomy. Time to first stool, first enteral feeding, goal enteral feedings, and postoperative length of stay did not differ based on the operative approach. The median operative time in the needle injection group was significantly shorter (90 versus 133 min, P = 0.009).

Needle injection of NAC appears to be safe and effective in clearing inspissated meconium in neonates who required operative management. It obviated the need for enteral violation in the majority of cases and resulted in reduced operative time.