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A new method of intestinal salvage for severe small bowel ischemia
M McCullagh1, D C Garvie, E H Dykes
1Children's Hospital Lewisham, London, England.
Insights
A novel surgical technique salvaged an infant with extensive small bowel infarction, preserving viable tissue to create a neojejunum. Early enteral feeding led to significant small bowel elongation and avoided long-term parenteral nutrition complications.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Neonatal Medicine
Background:
- Short bowel syndrome (SBS) poses significant morbidity and mortality risks, directly correlated with remaining small bowel length and parenteral nutrition duration.
- Gastroschisis with extensive small bowel ischemia presents a critical neonatal surgical challenge.
Observation:
- An infant with gastroschisis experienced extensive small bowel infarction due to volvulus at delivery.
- A second-look laparotomy revealed only 13 cm of viable terminal ileum and salvageable portions of proximal jejunum/ileum.
Findings:
- A new technique created a 12 cm neojejunum by longitudinally anastomosing divided viable jejunal segments.
- The infant tolerated full enteral feeding by day 47, and the neojejunum was later excised.
- The remaining small bowel elongated to 30 cm, enabling successful enteral autonomy.
Implications:
- This salvage technique offers a potential strategy to improve outcomes in neonates with extensive small bowel loss.
- Early enteral feeding initiation is crucial for promoting intestinal adaptation and minimizing complications associated with total parenteral nutrition in SBS.
- Preservation of viable mucosal surfaces, even in compromised bowel, can facilitate intestinal rehabilitation.
Abstract:
The morbidity and mortality in short bowel syndrome are directly related to the length of the remaining small bowel and to the duration of total parenteral nutrition. We describe the successful salvage of an infant with extensive small bowel infarction for whom a new technique was used to preserve all viable mucosal surfaces. The infant, with gastroschisis, was found to have a tight volvulus of the extruded bowel and extensive small bowel ischemia at the time of delivery. Forty-eight hours after reduction of the volvulus and abdominal decompression, a second-look laparotomy was performed. Although only the terminal 13 cm of ileum was completely viable, 25% of the circumference of a further 23 cm of proximal jejunum/ileum was considered salvageable. After debridement of the dead tissue, the remaining gutter of jejunum was divided at its midpoint, and the two halves were anastomosed longitudinally to provide a "neojejunum" of 12 cm in length, which was anastomosed between the duodenum and terminal ileum. Full enteral feeding was tolerated from day 47. Although the neojejunum was excised on day 149, after becoming dilated and atonic, by that time the remaining small bowel had elongated to 30 cm. Because of the early institution of full enteral feeding, there were no long-term complications related to total parenteral nutrition.