BOWEL OBSTRUCTION LONG TERM OUTCOMES

In general, most infants with bowel obstruction who are expeditiously identified and treated have an excellent outcome. Survival usually depends on comorbidities, such as degree of prematurity, associated cardiac anomalies, and the presence of peritonitis or bowel compromise at the time of surgery. The survival rate for duodenal atresia is greater than 90%. Long-term survival in patients with volvulus and jejunoileal atresia depends upon the amount of bowel remaining after resection, but an 80-90% survival rate is expected. The rate of leaking anastomoses following repair of newborns with jejunoileal atresia is approximately 15%.

Total parenteral nutrition and better methods for central IV access have greatly improved outcomes for neonates who undergo surgery for bowel obstruction. Often, bowel function is not established for a prolonged interval postoperatively. While total parenteral nutrition can support an infant through this period, both long- and short-term complications are observed. Short-term complications from parenteral nutrition include catheter sepsis, respiratory insufficiency, and problems related to securing central venous access. Long-term problems include cholestasis, nutritional deficiencies, and development of oral aversion.

As with any laparotomy, postoperative adhesions may develop. Operative technique that avoids unnecessary manipulation of the bowel and spillage of enteric contents is perhaps the best prevention against the development of intraperitoneal scar tissue.

Poor motility is often observed following bowel resection for obstruction. Chronic dilation of the intestinal segment proximal to the obstruction may alter normal peristalsis across that segment of bowel. For example, persistent constipation and delayed intestinal transit may not resolve after relief of chronic partial volvulus via Ladd procedure. Interruption of vagal neuroenteric pathways by an atresia or surgical anastomosis may also contribute to abnormal intestinal motility.

Short bowel syndrome deserves special mention. Short bowel syndrome results when the remaining length of intestine cannot sustain normal absorptive functions. Normal length of the small bowel in a term infant is approximately 250 cm and in an adult is 600-800 cm. The estimated minimum jejunoileal length for sufficient bowel function in a term infant is 75 cm. Resection of more than 60% of the small bowel predisposes the child to malabsorption, resulting in failure to grow and develop normally.

Every effort is made intraoperatively to preserve bowel length. Some children with short bowel syndrome manage to survive with the aid of parenteral nutrition. Bowel lengthening procedures, creation of intraluminal valves, and manipulation of bowel recovery with nutritional and hormonal treatments can help wean the patient with short gut syndrome from dependence on parenteral nutrition. In patients with severe volvulus with infarction of the entire midgut or multiple intestinal atresias, the child may clearly not have enough bowel length to survive. A difficult ethical decision must be made at the time of operation whether to proceed with resection.