肠折叠术在肠闭锁手术中的应用

目的 评价肠折叠术在肠闭锁手术中的应用效果.方法 回顾分析2005年4月至2009年4月南京医科大学附属南京儿童医院收治的68例肠闭锁患儿术前、术中和术后恢复过程的临床资料,比较手术方法、胎龄、出生体重、伴发疾病、手术年龄和时间、住院时间、全静脉营养持续时间、肠功能恢复时间(术后经口喂养时间、术后经口喂养达40ml/3 h的时间)、生长发育以及是否需再手术等方面的差异.结果 根据手术方法将患儿分为二组,38例在切除闭锁盲端肠吻合基础上加肠折叠术(折叠组),30例行扩张段斜行切除肠成形术(对照组);二组在胎龄、出生体重、伴发疾病、手术年龄上差异无统计学意义;折叠组手术时间(1.21±0.24)h、住院时间(12.2±2.5)d比对照组(1.77±0.31)h、(17.3±3.2)d显著减少(P＜0.05);折叠组术后经口喂养时间、术后经口喂养达40ml/3 h的时间和全静脉营养持续时间分别是(8±2.3)d、(13.1±1.9)d、(8.3±1.8)d,均比对照组(12.9±1.7)d、(18.7±1.1)d、(13.6±2.5)d显著缩短(P＜0.05);术后半年内折叠组有1例因粘连性肠梗阻需再次手术,对照组共有6例术后半年内再次手术,其中术后功能性肠梗阻3例、吻合口漏2例、粘连性肠梗阻1例,比折叠组显著增加.术后平均随访时间为2.7年(6个月至5年),二组生长发育达到正常标准,差异无统计学意义.结论 肠闭锁手术时在肠吻合基础上加肠折叠术,方法简单,创伤小,并发症少,有助于保留肠管吸收面积和促进肠功能恢复,可以作为预防肠闭锁扩张肠管功能性梗阻的一种有效选择方法.

Abstract：

Objective To evaluate the efficacy of bowel plication as a part the surgical treatment of intestinal atresia (IA) in childrea Methods Between April 2005 and April 2009,68 neonates with IA underwent surgical treatment in this center. According to the surgical procedures the patients underwent, the 68 neonates were divided into bowel plication group and control group. The 38 children underwent bowel plication after atretic segments resection and primary anastomosis. The 30 children of the control group underwent tapering enteroplasty after atretic segments resection. Data including operation procedures,ages,birth weight,concomitant diseases,age at surgery, length of hospital stay, length of total parenteral nutrition (TPN),postoperative intestinal function recovery (the time of the first oral feeding and the oral feeding volume reached 40 ml/kg/3h),growth and development,complications and reoperations were retrospectively analyzed. Results No differences of ages, birth weight, age at operation, and concomitant diseases were found between the two groups. The time of operation and hospital stay of the bowel plication group were significantly shorter than those of the control group [(1.21±0.24)h,(12.2±2.5)d vs. (1. 77 ± 0. 31)h, (17. 3 ± 3. 2)d,P＜0. 010]. The time of the first oral feeding, the time when oral feeding volume reached 40 ml/kg/3h,and TPN length of the bowel plication group were also shorter than those of control group [(8 ± 2. 3)d, (13. 1 ± 1. 9)d, (8. 3 ± 1.8)d vs (12. 9 ±1. 7)d,(18. 7 ± 1. l)d,(13. 6 ± 2. 5)d,P＜0. 05]. In the bowel plication group, 1 (2. 6%) underwent reoperation for adhesive intestinal obstruction half a year after the initial surgery. However,in the control group,6 (20%) included 3 underwent reoperation for intestinal obstruction,2 for anastomotic leakage and 1 for adhesive intestinal obstruction. The patients were followed up for an average period of 2. 7 years (6 months-5 years). All infants thrived. Conclusions The additional bowel plication after atretic segment resection and primary anastomosis improves the clinical outcomes for children with intestinal atresia.     

Surgery for necrotising enterocolitis: primary anastomosis or enterostomy?

The ideal surgical management of neonates with necrotising enterocolitis (NEC) is still a matter of debate. The purpose of this study was to compare the results of bowel resection with primary anastomosis with the results of bowel resection with enterostomy. Sixty-three neonates with NEC had a bowel resection in the acute phase of the disease in the period between February 1990 and March 2001. Thirty-four of them (54%) underwent resection of the bowel with primary anastomosis (Group A), and 29 (46%) had resection with enterostomy (Group B). Group A had a lower gestational age and lower birth weight. Mortality, complication rate, and postoperative weight gain were not significantly different between the groups. However, Group B had a significantly longer primary hospital stay (80±49 days versus 58±31 days, P<0.04) and needed a 2nd hospital stay for restoring gastrointestinal continuity. For both reasons, it can be argued that primary anastomosis is superior to enterostomy after resection.     

Excision duodenoplasty: a new technique for congenital duodenal obstruction

Slow anastomotic function is a common problem in the management of congenital duodenal obstruction. We describe a simple technique of excision duodenoplasty (ED) that results in a fixed open anastomosis, which facilitates early commencement of feeds and discharge from hospital. A retrospective case-note review (1981–2000) was undertaken to compare the results of ED with side-to-side duodenoplasty (SSD) and diamond-shaped anastomosis (DD). The outcome measures were days to commencement of feeds, duration of total parenteral nutrition (TPN), and length of hospital stay. In ED a 1.0 to 1.5-cm elleptical segment of dilated duodenum is excised. A longitudinal incision is made in the smaller distal duodenum. A side-to-side one-layer anastomosis is performed. The wall of the proximal duodenal stump is thick, and excision of the ellipse keeps the anastomosis open by preventing apposition of the opposing walls. This facilitates good drainage across the anastomosis. The time to onset of feeding was longer after SSD (median 7 days) compared to ED (5 days) and DD (5 days). The total duration of TPN was also longer for SSD (9 days) in comparison to ED (7 days) and DD (7 days). Although the duration of hospital stay was more for SSD (18 days) than ED (13 days) and DD (16 days), this difference was not statistically significant. The ED technique thus gives an equally good result as DD and a better result than SSD. It is simple to perform and to teach. Accepted: 26 February 2001     

T-tube ileostomy for intestinal perforation in extremely low birth weight neonates

To evaluate the results of use of T-tube ileostomy in selected cases of intestinal perforation in extremely low birth weight (ELBW) neonates. The records of 288 ELBW neonates treated at author’s institution, from 1998 to 2003 were retrospectively reviewed to identify neonates operated for intestinal perforation with T-tube placement. T-tube was inserted into the bowel through the site of perforation or proximally to the perforated gut via separate stab incision. T-tubes were used in five ELBW neonates (BW 600–900 g, gestational age 25–27 weeks) with intestinal perforation, in four of them at the time of primary surgery and in one neonate 8 days after primary anastomosis. All patients survived and there were no serious complications related to the T-tube insertion. Median duration of T-tube placement was 4 weeks (range 3–8 weeks), full enteral feeding after T-tube insertion was achieved in 4 weeks (range 1–6 weeks). All sites of T-tube insertion closed spontaneously. T-tube ileostomy is an effective and safe technique for treatment of selected cases of intestinal perforation in ELBW neonates. With respect to the hypoperistalsis of immature bowel, we recommend the use of T-tube in all cases of isolated intestinal perforation in ELWB neonates.     

Neonatal outcome of gastroschisis and exomphalos: a 10-year review

OBJECTIVE: To study neonatal outcomes associated with gastroschisis and exomphalos in a regional neonatal unit. METHODS: A retrospective (1988-97) data analysis to study the effect of the type of defect/surgery, mode/place of delivery and associated anomalies on time to start and reach full feeds, duration of total parental nutrition (TPN) support and total hospital stay. Exact bivariate test procedures were used for data analysis. RESULTS: Twenty-one cases of gastroschisis (17 inborn) and five cases (four inborn) of exomphalos were identified. Of these, 23.8% cases of gastroschisis and 60% of cases of exomphalos had associated gut anomalies. The survival rates for gastroschisis and exomphalos were 91 and 100%, respectively. The median time to start and reach full enteral feeds in outborn neonates was longer than in inborn neonates (9 vs 25 days, respectively, P = 0.01; and 16 vs 49 days, respectively, P = 0.01), as was the duration of TPN support (14 vs 42 days, respectively; P = 0.02). Neonates with gastroschisis had significant delays in starting and reaching full feeds compared with neonates with exomphalos (median 13 vs 4.5 days, respectively, P = 0.03; and 24 vs 8, respectively, P = 0.02) and they required prolonged support with TPN (median 23 vs 6 days, respectively; P= 0.01). Antenatal detection was significantly more frequent in inborn compared with outborn neonates (100 vs 67%, respectively; P = 0.03). The severity of associated gut anomalies and the delivery to surgery interval did not differ significantly to explain the increased morbidity in outborn neonates. Outcome was not significantly different after analysis by type of surgery and mode of delivery. CONCLUSIONS: Increased morbidity in outborn neonates may be related to factors such as temperature, care, hydration status, care of the defect and vascular compromise of prolapsed gut during prolonged transportation.     

Intestinal atresia

Intestinal atresia accounts for about one third of all cases of neonatal intestinal obstruction. The survival rate has improved to 90% in most of the series with the operative mortality being <1%. The survival rate improves with distal atresias. An increased mortality is observed in multiple atresias (57%), apple peel atresia (71%), and when atresia is associated with meconium ileus (65%), meconium peritonitis (50%) and gastroschisis (66%). Although appearance of echogenic bowel on prenatal ultrasonography is suggestive of GI, it is confirmed in only 27% cases. Prenatal ultrasonography is more reliable in detection of dudenal atresia than more distal lesions. Short bowel syndrome is the major impediment in the management of jejunoileal atresia. Although total parenteral nutrition (TPN) is the main adjunctive treatment, it delays intestinal adaptation and may cause cholestasia and subsequent liver damage. Graduated enteric feedings, use of growth hormone, glutamine and modifed diets containing low fat, complex carbohydrates and protein supplements have been used in a adults with short bowel syndrome to successfully diminish TPN requirements and enhance nutrient absorption in nearly half of the patients. Utilization of growth factors to facilitate intestinal adaptation and advances in small bowel transplant may improve the long-term outcomes in future.     

Meconium ileus secondary to cystic fibrosis The East London experience

Meconium ileus (MI) affects 15% of neonates with cystic fibrosis (CF). The authors reviewed the management and outcome of 51 neonates presenting to a single institution between 1976 and 1995 with MI secondary to CF. Clinical presentation included abdominal distension (96%), bilious vomiting (49%), and delayed passage of meconium (36%). A family history of CF was present in 4 cases (8%). Twenty-three neonates presented with MI and evidence of volvulus, atresia, or perforation (complicated MI). Of these, 16 underwent stoma formation, 1 appendicectomy, and 6 resection with primary anastomosis. Twenty-eight neonates presented with uncomplicated MI. Of these, 11 were managed non-operatively by Gastrografin enema (10) or enteral N-acetylcysteine (1). The remainder required stoma formation (15) or bowel resection with primary anastomosis (2). Early postoperative complications occurred in 2 neonates (4%). In this hospital the 1-year survival for this condition has increased from 49% (1953–1970) to 98% (1976–1995) irrespective of the surgical procedure performed or the presence of volvulus, atresia, or perforation. In our experience, bowel resection with primary anastomosis is as safe as stoma formation and is associated with a reduced length of initial hospital stay. Accepted: 23 October 1997     

Laparoscopy-assisted surgery for neonatal intestinal atresia and stenosis: a report of 35 cases

Purpose

Jejunal?Cileal atresias are the most common causes of intestinal occlusion in neonatal period. Treatment is classically performed by a right upper quadrant transverse laparotomy. Our study aimed to present our initial experience of intestinal atresia in newborn treated with laparoscopic assisted approach.

Methods

Overall 35 small intestinal atresias, which occurred in infants from September 2009 to July 2012 in our hospital, were treated by laparoscopy-assisted procedure. After carefully inspecting through laparoscope by a multi-port or single-site approach, these were definitely diagnosed. The anastomosis of intestinal atresia was manually performed after exteriorization of the bowel via the umbilical port site incision.

Results

There were no conversions to an open procedure and no intraoperative various complications. The incision of umbilical port was about 2?C2.5?cm. The post-operative course was uneventful.

Conclusion

Laparoscopy-assisted procedure could be safely accomplished in neonates with intestinal atresia. Comparing to open surgery, parents were extremely satisfied with the cosmetic results. The early experience suggests that the outcomes are excellent.     

Gastroschisis: early enteral feeds may improve outcome

OBJECTIVE: Population-based retrospective review of gastroschisis from 1986 to 1996. METHODS: This was a retrospective review of gastroschisis. Seventy cases were identified from the Birth Defects Registry of Western Australia (WA). Hospital medical records of live-born cases were reviewed. RESULTS: The live-born incidence of gastroschisis in WA was 2.1 per 10,000 live births for the period 1986-96. The incidence in mothers aged less than 20 years was 8.3-fold that of women aged over 30 years (P < 0.0001). The incidence rate for the period 1995-96 was over twice the rate for 1986-88. Age at first enteral feed was significantly related with length of hospital stay and duration of total parental nutrition (TPN). Each day delay in commencing enteral feed was associated with an increase in hospital stay of 1.05 days and an increase in TPN duration of 1.06 days. The method of delivery of the infant, age at repair, length of anaesthetic time, duration of postoperative paralysis and gestational age was not associated with length of stay or TPN duration. The data were divided into two cohorts: (i) 1986-90; and (ii) 1991-96. There was a statistically significant reduction in hospital stay from a geometric mean of 45.7 (1986-90) to 22.9 days (1991-96). CONCLUSIONS: Gastroschisis has a favourable outlook, with 89.7% survival of live births. Over the 10 year period studied, there has been a reduction in length of hospital stay and duration of TPN. The age at which the infant is first fed enteral feeds appears to be important in affecting the length of hospital stay and the duration of TPN, with delays associated with a longer hospital stay and longer TPN duration.     

Risk stratification in gastroschisis: can prenatal evaluation or early postnatal factors predict outcome?

Purpose  The prenatal or postnatal factors that predict complex gastroschisis in patients (atresia, volvulus, necrotic bowel and bowel perforation) remain controversial. We evaluated the prognostic value of prenatal ultrasonographic parameters and early postnatal factors in predicting clinical outcomes. Methods  We analyzed maternal and neonatal records of 46 gastroschisis patients treated from 1998 to 2007. Information regarding demographics, prenatal ultrasound data when available, intrapartum and postnatal course was abstracted from medical records. Outcome variables included survival, ventilator days, TPN days, time to full enteral feeds, complications and length of stay. Univariate or multivariate analysis was used, with P < 0.05 considered as significant. Result  A total of 75% of complex patients were categorized within 1 week of life. Interestingly, prenatal bowel dilation (>17 mm) and thickness (>3 mm) did not correlate with outcome or risk stratification into simple versus complex (P < 0.05). Complex patients had increased morbidity compared to simple patients (sepsis 58 versus 18%; P = 0.021, NEC 42 versus 9%; P = 0.020, short bowel syndrome 58 versus 3%; P = 0.0001, ventilator days 24 versus 10; P = 0.021; TPN days 178 versus 38; P = 0.0001 and days to full feeds 171 versus 31; P = 0.0001; and length of stay 90 versus 39 days, P = 0.0001). Conclusions  Prenatal bowel wall dilation and/or thickness did not predict complex patients or adverse outcome. Complex gastroschisis patients can be identified postnatally and have substantial morbidity.     

Congenital jejunoileal and colonic atresia

Jejunoileal and colonic atresias are a common cause of neonatal intestinal obstruction. Authors present the aetiology, types of atresias, clinical symptoms, diagnostics, surgical treatment, problems of postoperative management and prognosis in the newborns with congenital intestinal atresia. In the years 1992-2000, in the Department of Paediatric Surgery and in the Department of Pathology and Intensive Care of Newborn at the National Research Institute of Mother and Child in Warsaw, 539 newborns were surgically treated (congenital anomalies of gastrointestinal tract, genito-urinary system, central nervous system, defects of abdominal wall and diaphragm). In 21 patients jejunoileal or colonic atresia were confirmed. On the base of the course of treatment the authors analyse prognostic factors: prematurity, certain types of atresia, additional pathology accompanying intestinal defect, necessesity of re-section of the long part of the bowel or multiple anastomosis. Diagnostic and treatment problems in three patients with short bowel syndrome needed additional discussion.     

Multiple gastrointestinal atresias

Three neonates with numerous mucosal septal atresias that occluded the intestinal lumen, commencing at the prepyloric region and ending at the rectum, are reported. The clinical and pathological features are presented and an attempt is made to offer a concept for the pathogenesis of multiple gastrointestinal atresias.     

Glucagon-like peptide 2 enhances maltase-glucoamylase and sucrase-isomaltase gene expression and activity in parenterally fed premature neonatal piglets

Exogenous glucagon-like peptide 2 (GLP-2) mimics the stimulatory effect of enteral nutrition on intestinal mucosal growth in preterm neonatal pigs. Little is known about its effects on small intestinal function. In this study, we investigated whether the trophic actions of GLP-2 and enteral nutrition are paralleled by effects on small intestinal function. Cesarean-delivered piglets (92% of gestation) were given either a parenteral nutrient infusion [total parenteral nutrition (TPN), n = 7], TPN + human GLP-2 (25 nmol/kg/d, n = 8), or enteral nutrition (ENT, n = 6) for 6 d. Gene expression (mRNA) and activities of lactase phlorizin hydrolase (LPH), maltase-glucoamylase (MGA), sucrase-isomaltase (SI), aminopeptidase N (ApN), and A (ApA) and dipeptidyl peptidase IV (DPP IV) were measured. Both GLP-2 and enteral nutrition increased mucosal weight (+30-40%, p < 0.05) relative to TPN. GLP-2 stimulated jejunal MGA and SI mRNA abundance and activity levels but did not change LPH in parenterally fed pigs (p < 0.05). Enteral nutrition decreased jejunal LPH and MGA mRNA abundance and activity and increased ileal ApN, ApA, and DPP IV activities relative to TPN (p < 0.05). We conclude that GLP-2 and enteral nutrition exert different effects on intestinal enzyme function despite similar effects on intestinal growth. In addition, the effects of GLP-2 on intestinal function in these parenterally fed, premature neonatal pigs differed from those previously reported for similarly fed term neonates.     

Outcomes of exomphalos: an institutional experience

Objective  Abdominal wall defects, particularly exomphalos, in newborn infants are associated with significant morbidity and mortality. The objective of the present study was to review the outcomes of neonates with exomphalos in our neonatal intensive care unit during the last 12 years. Study design  In this retrospective study 52 neonates with exomphalos were identified from 1996 to 2007. Exomphalos were stratified by the type of defect [exomphalos minor versus major (major defined as defect size more than 5 cm and/or liver in the sac)] [1]. Clinical data, demographic data, and outcome measures of mortality, length of stay (LOS), duration of mechanical ventilation and age at full enteral feeds were studied. Associated anomalies were compared between the two groups. Results  Of the 52 neonates, 1 was transferred back to referring hospital after surgical repair of the defect and was not analyzed. Exomphalos minor accounted for 24 cases and exomphalos major in 27 cases. Mortality was higher in infants with exomphalos major (n = 9, 33%) compared to infants with exomphalos minor (n = 2, 8%). The median LOS (10 vs. 47 days, P = 0.023), median age at full enteral feeds (5 vs. 23 days, P = 0.004) and median duration of mechanical ventilation (7 vs. 23 days, P = 0.001) were shorter for exomphalos minor compared to exomphalos major. Bacteremia was present in 4 (15%) of neonates with exomphalos major. Syndromic associations were present in 8 neonates (33%) with exomphalos minor compared to 2 neonates (7%) with exomphalos major. Beckwith Wiedemann syndrome was most frequently noted in neonates with syndromic exomphalos minor. Trisomy 13 was the only chromosomal abnormality in the entire cohort (1/51 = 2%) and was seen in a single neonate (1/27 = 3.7%) with exomphalos major. Non-syndromic anomalies were seen in 12 (50%) and 14 neonates (52%) with the minor and major defects, respectively. Only four neonates with exomphalos minor (16%) and ten neonates with exomphalos major (37%) had no associated anomalies. Pulmonary hypoplasia and pulmonary hypertension were identified on either lung biopsy or autopsy (n = 5) as causes of mortality. Conclusion  Neonates with exomphalos minor have better survival, decreased LOS, time to full enteral feeds and shorter duration of mechanical ventilation. Syndromic associations were more common in exomphalos minor. Respiratory failure was the major cause of mortality in infants with exomphalos major.     

Blood flow parameters of the superior mesenteric artery as an early predictor of intestinal dysmotility in preterm infants

Background Blood flow parameters in the superior mesenteric artery (SMA) change with vasoconstriction or vasodilatation of the intestinal vascular bed. In cases of severe growth retardation as a result of haemodynamic disturbances, the blood flow changes persist into postnatal life.Objective To assess early changes of Doppler sonographic blood flow parameters in the SMA for prediction of later intestinal motility disturbances in preterm infants and tolerance of enteral feeding during the first week of life.Materials and methods Doppler sonographic blood flow parameters in the SMA were measured on the first day of life and the following 5 days in 478 neonates with a birth weight below 1,500 g. According to the Doppler results, the neonates were divided into two groups—those with pathological parameters and those with normal blood flow parameters. Correlations between blood flow parameters, the development of intestinal dysmotility and the tolerated amount of enteral feeding were calculated.Results Pathological blood flow parameters were observed in 148 neonates (group 1) and normal blood flow parameters in 330 neonates (group 2). Intestinal motility disturbance occurred in 125 neonates (83%) of group 1 and 47 neonates (15%) of group 2. Neonates in group 2 tolerated significantly more feed by the fifth day of life than neonates in group 1. Postnatal adaptation did not differ between the two groups, although the majority of neonates with intestinal dysmotility were small for gestational age. The predictive value of blood flow parameters for prediction of intestinal motility revealed high sensitivity and specificity by the first postnatal day, 2 or 3 days before development of clinical signs of intestinal dysmotility. There was a strong negative correlation between pathological pulsatility index on day 1 and the quantity of tolerated enteral feeding on day 5.Conclusions Pathological blood flow parameters in the SMA can predict problems of intestinal motility and tolerance of enteral feeding. With the early detection of these problems a prompt start of adequate therapy to avoid complications is possible.     

The Santulli enterostomy in necrotising enterocolitis

An ideal operation for necrotising enterocolitis (NEC) would be quick and reliable, remove all nonviable bowel, minimise the loss of intestinal length, permit early restoration of intestinal continuity, and minimise the need for secondary operations. No operation currently meets all these needs. In this study we review our experience with the Santulli enterostomy in NEC. From 1992 to 1998, 19 patients (16 males, three females) underwent a Santulli enterostomy for Bell grade III NEC. The median gestational age at birth (GA) was 26 weeks (range 23–30), and the median birth weight 755 g (range 600–1095). The median patient age at operation was 10 days (range 3–59), and the median operative time was 55 min (range 25–90). Sixteen (84%) patients survived. Complications included leakage of the Santulli anastomosis in four cases, stomal necrosis in two cases, additional intestinal necrosis in two cases, leakage of a concurrent intra-abdominal anastomosis in two cases, and intestinal obstruction in four cases. Twelve patients underwent relaparotomy. Enteral feeding was started at a median of 5 days postoperatively (range 2–9), with full oral feeding possible at a median of 21 days (range 10–128). The median time until closure of the enterostomy was 48 days and the median hospital stay 87 days (range 19–197). After stomal closure, obstructive symptoms necessitated a new Santulli enterostomy in two patients and a revision of the anastomosis in one patient. Santulli enterostomy can be used to treat NEC even in very small premature babies. It enables rapid recovery of intestinal continuity and early stomal closure. However, the operation is technically demanding and carries significant morbidity.     

Frequency and Indications for Tracheostomy and Gastrostomy After Congenital Heart Surgery

Patients undergoing congenital heart surgery may occasionally require additional surgical procedures in the form of tracheostomy and gastrostomy. These procedures are often performed in an attempt to diminish hospital morbidity and length of stay. We reviewed the Web-based medical records of all patients undergoing congenital heart surgery at Miami Children’s Hospital from February 2002 through August 2007. Patients who were deemed preterm and had undergone closure of a patent ductus arteriosis were eliminated. The records of all other patients were queried for the terms gastrostomy, g-tube, Nissan, fundal plication, tracheostomy, or tracheotomy. Patients’ medical records in which these terms appeared in any portion were completely reviewed. There were 1660 congenital heart operations performed in the study period. There were 592 operations performed on patients whose age ranged from 1 month to 1 year and 441 neonatal operations. Mortality was 2%. Median postoperative stay was 8 days (range, 1–191 days), 12 days for neonates (range, 3–142 days), and 19 days for neonates undergoing RACHS-1 category 6 operations (range, 4–142 days). Tracheostomies were performed in four patients (0.2%). Gastrostomies were performed on eight patients (0.4%), representing 0.8% of patients <1 year of age, 1.4% of neonates, and 2.4% of patients undergoing RACHS-1 category 6 operations. The rate of patients undergoing either tracheostomy or gastrostomy after congenital heart surgery at our institution was quite low. Avoidance of either of these two procedures was achieved without increased morbidity or length of stay. The rate at which these procedures need to be performed may reflect the magnitude of the patients’ lifetime trauma related to their underlying condition and acute and total surgical experiences.     

Glucagon-like peptide 2 stimulates intestinal nutrient absorption in parenterally fed newborn pigs

OBJECTIVES: Parenteral nutrition is a critically important intervention for children with intestinal dysfunctions. However, total parenteral nutrition (TPN) with no enteral feeding is associated with small intestine atrophy and malabsorption, which complicate the transition to enteral nutrition. The objective of the present study was to evaluate the therapeutic potential of the intestinotrophic peptide glucagon-like peptide 2 (GLP-2), which reduces TPN-associated atrophy and maintains nutrient absorption in adult rats, for preventing nutrient malabsorption in neonates receiving TPN. METHODS: Term pigs obtained by cesarean delivery received from birth TPN alone (TPN; n = 7) or TPN with GLP-2 (25 nmol . kg(-1) . d(-1); GLP-2; n = 8) or were fed sow milk enterally (n = 7). The small intestine was removed on postnatal day 6 to measure morphological responses and absorption of glucose, leucine, lysine and proline by intact tissues and brush border membrane vesicles and to quantify the abundances of mRNA and protein for enterocyte glucose transporters (SGLT-1 and GLUT2). RESULTS: Relative to TPN alone, administration of GLP-2 resulted in small intestines that were larger (P < 0.01), had greater abundances of mRNA and protein for SGLT-1, but not for GLUT2, and had higher capacities to absorb nutrients (P < 0.01). Moreover, the intestines of GLP-2 pigs were comparable in size and absorptive capacities with those of pigs fed sow milk enterally. CONCLUSIONS: Providing GLP-2 to neonates receiving TPN prevents small intestine atrophy, results in small intestine absorptive capacities that are comparable to when nutrients are provided enterally and may accelerate the transition from TPN to enteral nutrition.     

早期微量喂养对危重症新生儿胃肠道动力的影响

目的　在接受机械通气的新生儿中进行早期微量喂养 ,观察其对新生儿胃肠道动力的影响。方法　收集 1998年 9月至 1999年 2月间 ,机械通气的 13例患儿 ,分早期喂养组 (6例 )和常规喂养组 (7例 )。早期微量喂养组平均在生后 2 .5d开始开奶 (每 2小时 2ml/kg) ,常规喂养组为生后13 .6d ,两组均在生后第 3天开始静脉营养。当两组患儿病情稳定后 ,进行放射性核素胃食管显像和血胃泌素、胃动素测定。结果　早期微量喂养组的胃排空率 (32 .6± 12 .2 ) %快于常规喂养组 (16 .0± 5 .5 ) %、到达全量肠内营养时间为 (17.5± 8.0 )d对 (34.9± 17.7)d以及拔胃管时间 (12 .2± 8.3)d对 (31± 11.2 )d均明显缩短 (P <0 .0 5 ) ,但两组在反流指数、血胃泌素、胃动素水平、恢复出生体重时间以及住院天数等方面差异不明显。结论　早期微量喂养能促进胃肠动力成熟 ,缩短到达全量肠内营养的时间并早日建立经口喂养 ,减少喂养困难的发生。     

Erythromycin as a prokinetic agent in preterm neonates: a systematic review

BACKGROUND: It often takes several days or even weeks to establish full enteral feeds (FEFs) in preterm, especially extremely low birthweight neonates because of feed intolerance related to gastrointestinal hypomotility. Clinical trials of erythromycin as a prokinetic agent in preterm neonates have reported conflicting results. AIM: To systematically review the efficacy and safety of erythromycin as a prokinetic agent in preterm neonates. METHODS: Only randomised controlled trials in preterm neonates (gestation < or = 37 weeks) were considered eligible for inclusion. The primary outcome was the time to reach FEFs of 150 ml/kg/day. The secondary outcomes included the incidence of erythromycin related adverse effects such as diarrhoea, cardiac arrhythmias, and hypertrophic pyloric stenosis. No restrictions were applied on the dose (low: 3-12 mg/kg/day; antimicrobial: > or = 12 mg/kg/6-8 hours) and route (oral or intravenous) and mode (prophylactic or rescue) of administration. The standard methodology for systematic reviews was followed. A subgroup analysis was pre-planned based on the dose and mode of drug administration. RESULTS: Seven trials (three prophylaxis, four rescue) with various doses, routes and modes of administration, and durations of erythromycin treatment and different results were found to be eligible for inclusion in the analysis. Meta-analysis could not be performed, as specific data were either inadequate or not available. CONCLUSION: The conflicting trial results may be explained by differences in dose and route and mode of administration of erythromycin and in gastrointestinal motor responses in the presence of different feeding conditions-for example, fasting v fed state, intermittent v continuous feeds. Gestational and postnatal ages during erythromycin treatment are also important.