Journal of Neonatal Surgery

Improvement of Broviac catheter-related outcomes after the implementation of a quality management system: A before-and-after prospective observational study

Manel Kammoun, Anouar Jarraya, Saloua Ammar, kamel Kolsi — Tue, 03 Jan 2023 00:00:00 -0500

Background: Because of the high rates of Broviac catheter complications, we started an urgent quality process to reduce this morbidity. The aim is to assess the efficiency of the main actions we have taken in enhancing our practice and improving Broviac outcomes.

Methods: We included all neonates and young infants requiring surgical central venous access using a Broviac tunneled catheter. We compared the catheters’ outcomes before and after the implementation of a quality program based on a nurse teaching program, patient selection, and catheter management multidisciplinary protocol. The significance threshold was set at p<0.05.

Results: We included 94 patients: 51 in the protocol group and 43 in the control group. The complication rate was reduced from 60.3% to 25.5% with p=0.001. The lifetime of the catheter was improved from 11.3 ± 4.3 days to 19.1 ± 9 days with p=0.007. The catheter infection was reduced from 65.3% to 46.1% with p≤0.001.

Conclusion: This quality improvement project shows the utility of a quality assurance program based on careful indications and patient selection, a nursing teaching program, and a multidisciplinary catheter management protocol, in reducing Broviac catheter-related morbidity.

Triple atresia: Staged repair

Meryem Unal, Muhammad Fadli Abdullah, Hazlina Mohd Khalid, Mughni Bahari — Tue, 03 Jan 2023 00:00:00 -0500

Poor outcomes in congenital short bowel syndrome with intestinal malrotation: Experience from a developing country

Tue, 04 Apr 2023 00:00:00 -0400

Re: Constrained evidence-based practice

Amit Trivedi, Nadia Badawi, Gordon Thomas — Tue, 25 Apr 2023 00:00:00 -0400

Fetal Lung Interstitial Tumor (FLIT): A case series

Tue, 03 Jan 2023 00:00:00 -0500

Background: Fetal Lung Interstitial Tumor (FLIT) is a rare benign lung tumor. There have been 18 cases of FLIT described in the literature. FLIT is characterized by a region of arrested lung development and must be differentiated from other congenital lung lesions with poorer prognoses.

Case Presentation: We report the first two known cases of FLIT in Australia and New Zealand. In both cases, the patients developed respiratory distress at birth requiring intubation. Imaging revealed solid lesions and echocardiography demonstrated pulmonary hypertension. The patients underwent surgical resection without any complications or recurrence.

Conclusion: FLIT is a rare benign congenital lung tumor that can be adequately managed with surgical resection.

Experience with endoluminal vacuum therapy in the management of esophageal anastomotic leakage in newborns with esophageal atresia: A case series

Fri, 03 Mar 2023 00:00:00 -0500

Background: The management of dehiscence of esophageal anastomosis is challenging and requires a multidisciplinary approach. Endoluminal vacuum therapy (EVT) has shown promising results.

Case Presentation: Herein we present the data of two cases with esophageal atresia who developed esophageal anastomotic leakage, during 2021-2022, and who underwent EVT. The first case had 60% dehiscence of the anastomosis, anastomotic leak repair was performed followed by esophageal EVT placement. In the second case, the dehiscence was limited to 10%, and only esophageal EVT was provided. Within four and six days of EVT, upper gastrointestinal endoscopy and fluoroscopy were performed which showed tissue proliferation in situ and the absence of contrast leakage. Both patients were able to resume oral tolerance on the 4th day.

Conclusion: Esophageal EVT has shown promising results in the management of esophageal anastomotic leakage in newborns with esophageal atresia.

Management of persistent air leak in Neonates: A case series

Sun, 28 May 2023 00:00:00 -0400

Background: Autologous blood patch pleurodesis (ABPP) has been used in adults as an efficient and safe technique to address persistent air leak (PAL). A fibrin glue patch is also an alternative, but its elevated cost and technique can limit its routine use. Evidence of their use in the pediatric population, specifically in the neonatal age is scant.

Case Presentation: We share our management experience in a series of 3 cases. The first 2 were treated exclusively with ABPP and showed clinical and radiographic improvement. The 3rd case, due to the persistence of the air leak, required extended thoracotomy and fibrin patch placement.

Conclusion: The use of ABPP as an alternative for the treatment of neonates with PAL is a safe and efficient technique. The procedure is replicable and can be done at the bedside at a low cost. A fibrin glue patch should be considered as an alternative option when ABPP fails to resolve the leak.

Intrauterine toes gangrene in a neonate

Fariba Hemmati, Hamide Barzegar — Sun, 14 May 2023 00:00:00 -0400

A case of Aphallia associated with neonatal intestinal obstruction

Omar Ajaj — Fri, 06 Jan 2023 00:00:00 -0500

Short Bowel Syndrome in neonates and early infancy

Shivani Dogra, Nitin James Peters, Ram Samujh — Sat, 14 Jan 2023 00:00:00 -0500

Short bowel syndrome (SBS) is the commonest cause of intestinal failure in neonates. SBS results from widespread damage to the small intestine, leading to loss of functional capacity of this organ. This is generally secondary to conditions like necrotizing enterocolitis, gastroschisis, intestinal atresia, and midgut volvulus. The small bowel usually adapts to this damage in due course of time. The clinician's role usually entails the management of parenteral nutrition and the fluid and electrolyte balance to tide over this phase. The management should be initiated as soon as the diagnosis is suspected, especially post-surgical resection of the bowel. This should comprise enteral nutrition, with proactive monitoring and supplementation of electrolytes and micronutrients. Intestinal lengthening procedures like the Serial transverse enteroplasty (STEP), and Longitudinal intestinal lengthening and tailoring (LILT) may be considered in infants, where medical therapy fails to correct the pathology. The intricate nature of the condition warrants a multi-disciplinary approach, involving clinicians, intensivists, and surgeons, which ensures the best neonatal outcomes, in terms of the survival rates in these babies.

Nucleated red blood cells as a potential biomarker for predicting spontaneous intestinal perforation in premature infants

Tue, 31 Jan 2023 00:00:00 -0500

Background: The specific etiology of spontaneous intestinal perforation (SIP) and necrotizing enterocolitis (NEC) remains elusive. Both can present acutely without antecedent signs and can be difficult to differentiate. Neonatal nucleated red blood cell (NRBC) counts are part of the routine admission and serial CBCs drawn on premature neonates. Elevated NRBC counts could represent relative intrauterine hypoxemia, a possible risk factor for the development of SIP or NEC.

Methods: We compared premature neonates with SIP to premature neonates with NEC and controls, matched gestational age (GA) and birth weight (BW). Kruskal-Wallis, Chi-Square, or Fisher's exact tests and univariate and multivariate nominal logistic regression models were used to estimate the association of baseline NRBC. Median times to SIP and NEC were calculated using the Kaplan-Meier method. All analyses were performed with SAS 9.4.

Results: Male sex (72.5%), lower GA [Median (Q1, Q3): 25.1 (23.8, 28)], and lower BW [Median (Q1, Q3): 690 g (585, 1072)] had the highest incidence of SIP compared to NEC or controls. Increased baseline NRBC was associated with lower odds of developing NEC compared to controls [Median (Q1, Q3): 9 (5, 29) vs 19 (10, 51); OR (CI) 0.70 (0.55, 0.89), p-value = 0.0033]. Increased baseline NRBC was associated with higher odds of developing SIP compared to NEC [Median (Q1, Q3): 9 (5, 29) vs 19 (10, 51); OR (CI) 1.61 (1.18, 2.20) p-value = 0.0027]. There were no significant differences between intrauterine growth restriction (IUGR), maternal hypertension, chorioamnionitis, multiple births, or depressed APGAR scores in all three groups. NRBC for SIP neonates remained significantly higher at the day of life (DOL) 1-3 compared to other groups [Median (Q1, Q3): 23 (6, 93), p-value = 0.0020]. The percentage of patients with NRBC >4, remained elevated for patients with SIP as late as week three (p = 0.0023).

Conclusion: ELBW, male sex, and elevated baseline NRBC were significantly associated with the risk of developing SIP compared to NEC or controls. NRBC remained significantly elevated on DOL 1-3, compared to NEC or controls. Between the groups, there were no significant differences in perinatal stressors.

Factors associated with cholestasis after surgery for congenital duodenal atresia

Yosuke Minami, Kazuaki Takiguchi, Hirofumi Shimizu, Hideaki Tanaka — Thu, 23 Mar 2023 00:00:00 -0400

Background: This study assessed the characteristics of neonates with duodenal atresia (DA) who developed transient postoperative cholestasis which resolved spontaneously, without identifiable congenital anomalies or surgical complications, and identified potential risk factors for cholestasis.

Methods: Neonates with DA who underwent surgery at our institution between January 2009 and July 2022 were retrospectively reviewed. Demographic factors, intraoperative findings, placement of a trans-anastomotic tube (TAT), and postoperative outcomes were compared between patients who developed cholestasis (conjugated hyperbilirubinemia >2.0 mg/dL) after surgery (Group A) and those who did not (Group B). This report is a retrospective cohort study and complies with the STROBE statement.

Results: Among 19 neonates with DA, 6 (31.6%) developed cholestasis after surgery, with the highest direct bilirubin value being 4.3 (2.4-6.5) mg/dL (median, [range]) on postoperative day 14.5 (2-23) that persisted for 67 (47-116) days until spontaneous resolution. Neonates in Group A had a significantly younger gestational age (36.6 vs. 38.0 weeks) (median) (p=0.038), a higher rate of Down syndrome (66.7 vs. 15.4%) (p=0.046), a higher rate of TAT placement (66.7 vs. 15.4%) (p=0.046), and longer administration of total parenteral nutrition (15.5 vs. 7.0 days) (p=0.027) than those in Group B.

Conclusion: Transient cholestasis after surgery for DA seemed to be associated with prematurity, Down syndrome, parenteral nutrition, and TAT placement.

Epidemiology of congenital diaphragmatic hernia, esophageal atresia, and gastroschisis in South Brazil

Wed, 12 Apr 2023 00:00:00 -0400

Background: Birth defects remain a major contributor to infant mortality and lifelong disabilities. The epidemiology of congenital abnormalities varies around the world and little information is available from Latin America.

Methods: This is an epidemiological, descriptive, cross-sectional study with data from the Department of Informatics of the Unified Health System (DATASUS) on Congenital diaphragmatic hernia (CDH), esophageal atresia (EA) and gastroschisis (GS) in South Brazil from 2009 to 2019.

Results: The incidence of CDH is 0.93 cases, while EA is 0.47 and GS is 2.87, all per 10,000 live births. There is an association between all the malformations and premature birth, cesarean delivery, low birth weight, and low Apgar scores. Both EA and GS are associated with maternal age, EA with older, and GS with younger mothers. While EA is associated with multiple pregnancies, GS is associated with fewer years of maternal formal education, single parenting, and a lower number of prenatal consultations. CDH is associated with the male sex and black ethnicity.

Conclusion: This large population-based study estimates the prevalence and demographic factors associated with CDH, EA, and GS, and extends the limited descriptive epidemiologic information available.

Constrained evidence-based practice

Laraib Amjad Dudrah, Muhammad Bilal Mirza — Tue, 03 Jan 2023 00:00:00 -0500

Spontaneous perforation of Meckel’s diverticulum causing a partial small bowel obstruction: A case report

Mon, 09 Jan 2023 00:00:00 -0500

Background: Meckel’s diverticulum is a common congenital malformation in young children. Perforation of Meckel’s diverticulum in a neonate is a rarity and poses diagnostic and management challenges.

Case Presentation: This patient is a former 26 5/7 week estimated gestational age infant who presented at 41 weeks corrected gestational age with abdominal distension and was discovered to have a perforated Meckel’s diverticulum that presented as a partial small bowel obstruction. Resection of the involved bowel and ileo-ileal anastomosis was performed.

Conclusion: Small bowel obstructions should be considered as a potential presentation of a perforated Meckel’s diverticulum.

Management of massive air leak with persistent pneumothorax and pneumoperitoneum in a 1.2kg preterm neonate: A case report

Heerani Woodun, Jeremy Thomas, Dushyant Batra, Nia Fraser — Tue, 10 Jan 2023 00:00:00 -0500

Background: Pneumothorax is a life-threatening condition with potential iatrogenic causes which can extend to pneumomediastinum and pneumoperitoneum. Risk factors of spontaneous pneumothorax include prematurity, low birth weight, low APGAR scores, and cesarean-section delivery.

Case Presentation: A 1255 grams preterm boy (Twin-2) was born at 28+3 weeks of gestation by emergency lower segment cesarean section. He showed signs of respiratory distress after uncomplicated endotracheal tube insertion which was required due to apneic episodes during continuous positive airway pressure ventilation. Recurring tube thoracocentesis and high-frequency oscillatory ventilation (HFOV) treated persistent right-sided pneumothorax and nonsurgical pneumoperitoneum, with improvement on day 10, gradual removal of five chest drains by day 19, and extubation on day 24. Transillumination and chest radiography were the main diagnostic investigations. Laryngotracheobronchoscopy on day 16 identified erythema and possible old injury at the carina. He was also treated for hypotension, suspected sepsis, and pulmonary hypertension and was discharged home on day 66.

Conclusion: Identifying pneumothorax promptly is essential to reduce morbidity and mortality. Management is patient-specific and includes needle and tube thoracocentesis and often, mechanical ventilation. Our case demonstrates the challenges of managing a massive air leak in a premature newborn, who with adequate tube thoracocentesis and HFOV, successfully recovered from presumed iatrogenic persistent pneumothorax and pneumoperitoneum.

Two-stage surgical management of horseshoe lung associated with congenital pulmonary airway malformation in a neonate: A case report

Fri, 21 Apr 2023 00:00:00 -0400

Background: Horseshoe lung is a rare congenital malformation, and even rarer is its association with congenital pulmonary airway malformations.

Case Presentation: We report a case of horseshoe lung associated with congenital pulmonary airway malformation (Stocker type 2) who underwent surgical management in two stages. The patient had a right posterolateral thoracotomy with lower right lobectomy at 14 days of life, followed by a left posterolateral thoracotomy with lower left lobectomy at 7 months of age. He is doing fine after both surgeries and follow-up visits are ongoing.

Conclusion: The treatment of horseshoe lung should be individualized, surgical management is an effective option and the two-stage approach in neonates would reduce the risk of the simultaneous bilateral procedure.