Bilious vomiting in the newborn

Bilious (dark green) vomiting in the newborn is a surgical emergency as the underlying diagnosis may be volvulus of the entire midgut secondary to malrotation. This diagnosis is time critical as, untreated, volvulus will lead to midgut necrosis, resulting in short gut syndrome or death. While a range of other diagnoses are possible, transfer to a paediatric surgical centre should be undertaken urgently so that malrotation/volvulus can be excluded or treated. This review focuses on the causes, investigation and management of proximal bowel obstruction in the neonate that present primarily with bilious vomiting.     

Bilious vomiting in the newborn

Bilious (dark green) vomiting in the newborn is a surgical emergency as the underlying diagnosis may be volvulus of the entire midgut secondary to malrotation. This diagnosis is time-critical because if untreated, volvulus will lead to midgut necrosis resulting in short gut syndrome or death. While a range of other diagnoses are possible, transfer to a paediatric surgical centre should be undertaken promptly so that malrotation volvulus can be excluded or treated. This review focuses on the causes, investigation, and management of proximal bowel obstruction in the neonate that present primarily with bilious vomiting.     

Primary volvulus of the small intestine in infants

Primary small bowel volvulus which no definite cause can be detected surgically is rare. In this paper, we present five cases of primary small bowel volvulus and discuss the clinical features including etiology.     

Mesenteric cystic lymphangioma presented with small bowel volvulus

A 62‐year‐old man presented with small bowel obstruction due to volvulus that was caused by mesenteric cystic lymphangioma. Preoperative diagnosis of this rare benign pathology of the lymphatic system is almost impossible. Complete surgical removal is the treatment of choice.     

Experience with the Duodenal Switch Operation in the Presence of Intestinal Malrotation

The presence of intestinal malrotation (IM) may pose unexpected problems during bariatric operations. We reviewed the records of patients with IM undergoing bariatric operations at our institution over the last 5 years. Three patients underwent four procedures. These included an open duodenal switch, an attempted laparoscopic gastric bypass with open duodenal switch as a second-stage procedure, and lastly a laparoscopic robot-assisted duodenal switch. All patients have had good outcomes. The key anatomic principles of a tension-free duodeno-enterostomy and maintaining appropriate orientation at the distal enteroenterostomy are emphasized.     

Delayed presentation of familial intestinal malrotation with volvulus in two adult siblings

Intestinal malrotation is an uncommon cause of abdominal pain and normally presents during infancy. Familial cases of malrotation are extremely rare in the absence of other congenital malformations. We present the case of a 22-year-old woman with undiagnosed chronic abdominal pain and her previously well 16-year-old brother who presented within 18 months of each other with acute midgut volvulus secondary to intestinal malrotation. Clinicians should be aware of this rare but serious cause of abdominal pain.     

Recurrent intestinal volvulus in midgut malrotation causing acute bowel obstruction: A case report

Intestinal malrotation occurs when there is a disruption in the normal embryological development of the bowel. The majority of patients present with clinical features in childhood, though rarely a first presentation can take place in adulthood. Recurrent bowel obstruction in patients with previous abdominal operation for midgut malrotation is mostly due to adhesions but very few reported cases have been due to recurrent volvulus. We present the case of a 22-year-old gentleman who had laparotomy in childhood for small bowel volvulus and then presented with acute bowel obstruction. Preoperative computerised tomography scan showed small bowel obstruction and features in keeping with midgut malrotation. Emergency laparotomy findings confirmed midgut malrotation with absent appendix, abnormal location of caecum, ascending colon and small bowel. In addition, there were small bowel volvulus and a segment of terminal ileal stricture. Limited right hemicolectomy was performed with excellent postoperative recovery. This case is presented to illustrate a rare occurrence and raise an awareness of the possibility of dreadful recurrent volvulus even several years following an initial Ladd’s procedure for midgut malrotation. Therefore, one will need to exercise a high index of suspicion and this becomes very crucial in order to ensure prompt surgical intervention and thereby preventing an attendant bowel ischaemia with its associated high fatality.     

Bile duct duplication as a cause of distal bowel gas in neonatal duodenal obstruction

Purpose

The aim of this study is to investigate the clinical characteristics of cases of duodenal atresia (DA) which present with bowel gas distal to a typical double-bubble sign through an anomalous bile duct conduit.

Methods

Medical records of 57 neonates with duodenal obstruction (atresia or stenosis), presenting with a double-bubble sign and treated at our institute from 1978 to 2010, were retrospectively reviewed.

Results

Thirteen (23%) of 57 neonates presented with bowel gas distal to the double-bubble sign. Passage of gas through the duodenal stenosis may have occurred in 3 cases, whereas in 9 cases, gas may have bypassed the atresia through an anomalous bifurcated bile duct termination and through the pancreatic duct from the accessory to the main pancreatic duct in one case. A preoperative upper gastrointestinal series was performed in 9 cases, and an anomalous bifurcated bile duct conduit was demonstrated in 5 cases. Severe and prolonged cholestasis necessitating evaluation for biliary atresia was found in 2 patients with anomalous bile duct anatomy.

Conclusions

Neonatal DA presenting with distal bowel gas via an anomalous bifurcated bile duct conduit is more common than initially thought and occurs more frequently than duodenal stenosis. These patients might be at risk for cholestasis, possibly owing to duodeno-biliary reflux through the ampulla.     

Multiple intestinal atresias associated with angiodysplasia in a newborn

This is a report describing the association of multiple small bowel atresias with multifocal angiodysplasia of the intestinal wall in a newborn. To the authors' knowledge, such association has never been reported.     

Laparoscopic duodenoduodenostomy in the neonate

Background

Minimally invasive procedures are performed in neonates for an ever-expanding list of congenital anomalies. The laparoscopic repair of duodenal atresia and stenosis in the neonate is one such indication.

Method

We report our experience with the laparoscopic duodenoduodenostomy for duodenal atresia and stenosis in the neonate over the past 4 years. A retrospective chart review was conducted on all cases of duodenal atresia and stenosis diagnosed at our center between January 2004 and January 2008.

Results

Seventeen neonates underwent laparoscopic duodenoduodenostomy successfully during the period. Patient weight at surgery ranged from 1.35 to 3.75 kg. Most were operated on within the first week of life. Many had associated anomalies. There were no conversions to an open procedure, no intraoperative complications, and no anastomotic leaks observed. Time to full feeds averaged 12 days.

Conclusions

Laparoscopic duodenoduodenostomy in the neonate can be safely and successfully performed with excellent short-term outcome.     

Duodenal atresia associated with proximal jejunal perforations: a case report and review of the literature

Duodenal atresia is associated with Down’s syndrome, malrotation, and congenital cardiac defects. Idiopathic intestinal perforations in a newborn, which are not associated with necrotizing enterocolitis (NEC), have been described. The authors report on a full-term neonate who had multiple perforations of the proximal jejunum distal to duodenal atresia. To the best of the authors knowledge, the combination of idiopathic intestinal perforation and duodenal atresia has not been reported previously.     

����С��Ťת������ϵ�̽��

目的 研究提高成人小肠扭转早期诊断率的方法。方法 回顾分析过去１０年经手术证实的成人小肠扭转８３例。结果 首要病因是 腹腔粘连,占５！％,发病年龄６０岁以上者占５７％,９５％的病例有绞窄性肠阻的临床表现;腹部平片诊断率低（１４．５％）。结论提高早期诊断率首先要注重临床症状与体征;不能盲目依赖腹部平片,应特别重视术后粘连引起小肠扭转的诊断。     

Different types of intestinal atresia in identical twins

The authors present a previously unreported association of different types of intestinal atresia in identical low-birth-weight twins. Both babies were affected by duodenal atresia, associated in the first case with a complete mucosal duodenal membrane and in the second one with an “apple-peel” jejunal atresia. These occurrences may suggest that they were either the consequence of linkage of 2 genes or a pleiotropic expression of a single gene responsible for such rare conditions.     

Laparoscopy-assisted surgery for prenatally diagnosed small bowel atresia: simple, safe, and virtually scar free

Purpose

The aim of this study was to describe a new technique for the surgical management of prenatally diagnosed small bowel atresia.

Methods

Under general anesthesia, a 5-mm trocar was inserted using an open technique through an intraumbilical incision. The proximal atretic bowel end was identified using laparoscopy and mobilized toward the umbilicus using an additional 3-mm trocar inserted in the left lower quadrant. The umbilical trocar then was removed, and a ring retractor was inserted into the trocar site and used to expand the wound to deliver both atretic bowel ends. The bowel was repaired and returned to the abdomen through the umbilical wound. The umbilical fascia and skin were closed conventionally.

Results

Three patients were reviewed. Two had minimal abdominal distension, and the atretic bowel ends could be identified easily; laparoscopy-assisted surgery was successful. The third case had significant dilatation, and laparotomy was required. Postoperatively, there was minimal abdominal scarring, and the umbilicus was normal in appearance.

Conclusions

Although this experience is limited to 3 patients, this technique is simple, safe, and virtually scar free and can be applied for the treatment of neonates with prenatally diagnosed small bowel atresia, especially if there is minimal abdominal distension at birth.     

Congenital duodenal atresia associated with a separate duodenal diaphragm.

A case of a complete duodenal diaphragm associated with a separate duodenal atresia is described. This association has not been previously reported.