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BOWEL OBSTRUCTION LONG TERM OUTCOMES
Category: Child Health
Abstract : 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
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.
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