Original articles 151

Ileus in the Newborn: A Study of Decreasing Mortality* Waldemar eh. Hecker, Stephanie Naegele

w. eh. Hecker) im Dr. von Haunerschen Kinderspital der Universität München

Summary The authors' experience with operative therapy for ileus - duodenal, small intestinal, colon, and rectal in newborns is presented with an analysis of the improvements in prognosis over the last 30 years. For the time period 1980-1989, the following survival rates were achieved: duodenum: 100 %; small bowel: overall 96.8 %, for uncomplicated cases 100 %; congenital megacolon: overall 89 %, for uncomplicated cases 100 %; ileus of all intestinal portions together: 97.5 0/0, for uncomplicated cases 100 %.

Keywords Ileus in newborns - Obstruction of duodenum, small and large intestine, and rectum

Resume Les auteurs rapportent leur experience dans le traitement des occlusions neo-natales duodenales, ileales ou jejunales, coliques et rectales. L'amelioration du pronostic au cours des trente dernieres annees est tres importante. De 1980 a 1989, le taux de survie fut de 100 % pour les occlusions duodenales, des 87,8 % dans les occlusions du grele (100 % dans les cas non compliques), et de 89 % en ce qui concerne le megacolon cöngenital (100 % dans les formes

hIt would be advantageous if every surgeon from time to time would give an account of whether he has been successful in improving his operative results, based not on superficial estimates but on precise, straightforward statistics." These - modified - words of Rudolf Stich, the surgeon from Göttingen whose school produced the first author via K. H. Bauer and Fritz Linder, are still valid today. The following treatise presents the experience of the first author during 32 years' practice in treating ileus in newborns in Berlin, Heidelberg, and Munich. Only mechanical

non compliquees). Sur l'ensemble de la serie, le taux de survie est de 87,5 % (100 % dans les formes non compliquees).

Mols-eIes Ileus du nouveau ne - Obstruction du duodenum, de l'intestin grele, du gros intestin et du rectum

Zusammenfassung Es wird die eigene operative Therapie des Neugeborenen-Ileus - Duodenum, Dünndarm, Kolon und Rektum dargelegt und die Verbesserung der Prognose innerhalb der letzten 30 Jahre analysiert. Im Zeitabschnitt 1980/ 89 wurde folgende Überlebensquote erreicht: Duodenum: 100%ige Überlebenschance. Dünndarm gesamt: 96,8 % Heilung, bei unkomplizierten Fällen 100 %. Megacolon-congenitum-Gesamtüberlebensquote 89 %, bei unkomplizierten Fällen 100 %. Ileus aller Darmabschnitte zusammengefaßt: Überlebenschance 97,5 0/0, bei unkomplizierten Fällen 100%.

Schlüsselwörter Neugeborenenileus - Obstruktion des Duodenums, Dünn- und Dickdarms und Rektums

ileus will be discussed, in the absence of inflammatory processes and, in particular, of necrotizing enterocolitis. The patients are divided into three groups: mechanical ileus of the duodenum (atresia, stenosis, malrotation, annular pancreas, volvulus), the small intestine (atresia, stenosis, volvulus, meconium ileus), and congenital megacolon. The newborn period was considered to comprise the period from birth up to and including the 28 th day of life. We examined the mortality of our patients during this period and subdivided the patients into complicated (prematurity and concomitant severe malformations) and uncomplicated cases.

Received February 12, 1991 Eur J Pediatr Surg 1 (1991) 151-153 C Hippokrates Verlag Stuttgart . Masson Paris

* For the occasion of Prof. Dr. Fritz Rehbein's 80th birthday.

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Kinderchirurgische Klinik (ehern. Direktor Prof. Dr.

EurJ Pediatr Surg 1 (1991)

W. eh. Hecker, Stephanie Naegele

96

1957-1969 1970-1989

32 9.5 21.7

Total

o

1980-1989

Table 2

lost (Table 1). These figures reflect the experience repIted in literature (Table 2): the survival rate during the initial decades after World War 11 was very low, but improved 10 100 % in the 1980s (4, 9).

Treatment results of duodenal ileus in newborn.

Authors

Glover 1949 Rehbein 1976 uncompi icated cases Lister 1978 Harburg 1979 total uncompiicated complicated

Table 1 Lethality of duodenal ileus in newborn. Own patient material 1957-1989 (Berlin, Heidelberg, Munieh).

ISurvival % 11 58.6 91.7 69 92 100 85

Bachmann 1980 (Collective statistics, uncomplicated cases complicated cases associated with mongoi ism volvulus cardiac defect esophageal atresia Daum 1982 total Daumseries

1962-1971

870 cases) 92

Small intestine We followed these principles in the operative therapy of small-bowel obstruction: For atresia and stenosis re· section and end-to-back anastomosis, sometimes with tunnelshaped reduction of the afferent loop using Rehbein's technique; for volvulus, reverse torsion and occasionally resection with end-to-end anastomosis; for meconium ileus, if the radiologist was unable 10 flush the meconium out of the distal bowel in several sittings resection and Koop anas1omosis was carried out. A gastrostomy was also performed in all cases.

72 76 68 30 86 75

Daumseries

1972-1980 Schnaufer 1988 Heckerand Naegele 1990

1980-1989

The mortality among the complicated cases was, as would be expected, substantially higher than that of the uncomplicated cases (Table 3). The 25 % mortality in the overall patient population did not improve during the study periods 1957-1969 and 1970-1980, but during the most recent 10

100 91 100

96

1957-1969

25

Table 3 Lethality of the mechanical ileus of the intestine in newborn. Own patient material 1957-1989 (Berlin, Heidelberg, Munieh).

25 1970-1989 Total

1980-1989

21 51

24

8

1

11

52 57 12.5

58 88 23

8 10

o

19 19 38

13 10

Duodenum Our therapy was aimed at establishing a free passageway through the duodenum as directly as possible. If a membrane was present this involved a longitudinal incision over the membrane, excision, and then transverse suturing of the bowel. For atresias we performed an end-to-end anastomosis, for stenosis Heinicke-von M ickulicz dilatation plasty, for annular pancreas side-to-side anastomosis around the ring of pancreas. For malrotation, after division of adhesions the malrotation was converted 10 a nonrotation and appendectomy was carried out; a gastrostomy was performed in all cases. The mortality from duodenal ileus for the complicated cases in the first time period, from 195710 1969 (Berlin and Heidelberg), was 41 %; in the second, from 1970 10 1989 (Munieh), it had declined 10 20 %. For the uncomplicated cases the mortality improved from 19 % to 6 %, respectively. Ouring the last 10 years no patient, complicated or uncomplicated, was

o

1

25 24 24.5

3.2

years none of the uncomplicated patients died, so that the over· all mortality for these 10 years decreased 10 3.2 %. A similar tendency is observed in literature (Table 4): The survival of newborns with small·bowel obstruction was minimal in the 1920s (5),80% in the 1950s and 1960s (2,3,12,18), and is presently over 90 % (7, 13, 15). We can therefore state that a term newborn with no further malformations now has excellent chances of surviving a mechanical ileus of the small intestine. Tab.4

Results of treatment of ileus of the small intestine in newborn.

Authors

Davis and Pointner 1922 Petterson 1951 Benson 1961 Rehbein 1963 Joppich 1967

Is~rvival in % IAuthors 10 80 80 80

I Survival in % 81 32 75 91 96.8

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152

Eur J Pediatr Surg 1 (1991)

Ileus in the Newborn: A Study ofDecreasing Mortality

%

1957-1969 1970-1989

10

Total

11 14

14

1980-1989

Treatment results in newborn ileus caused by megacolon conge-

ISurvival in %

Author

Ehrenpreis 1955 Pellerin 1966 Hofmann and Rehbein 1966 Lister and Rickham 1978 Hecker and Naegele 1990

92 57 73 94.4

89

Congenital megacolon At our institution, in a newborn with ileus due to megacolon a colostomy is performed oral to the narrowed aganglionic segment. At this time biopsies are taken from the rectum, the colostomy area, and segments of rectum and small bowel in order to identify the not unusual combination with neuronal intestinal dysplasia. The definitive correction is carried out when the child has reached a weight of about 5,000 g and has developed satisfactorily. We then resect the colostomy together with the narrow aganglionic segment and perform, as advised by Rehbein, a low anterior end-to-end anastomosis. We

have had no fatality among the 152 patients operated upon since 1972 (Schmidt, Hecker). The mortality associated with colostomy creation for ileus due to congenital megacolon in newborns has remained fairly constant over 32 years among our patient population at 11 % (Table 5). A review ofthe literature (Ehrenpreis [6], Pellerin [16], Hofmann and Rehbein [11], Lister and Rickham [13]) shows that the survival rate in the 1960 s lay between 60 0/0 and 70 % and is now around 90 % (Table 6). If the three groups discussed above are again lumped together as mechanical ileus in newborns, the following conclusions can be drawn from our population of 275 patients (Table 7): The mortality decreased from 25 % in the period 1957-1969 to 18.5 % in the period 1970-1980. In the last 10 years, none of the 40 uncomplicated patients and 2 of the 19 complicated patients died, giving an overall mortality of 3.3 % for the 59 children. It can therefore be stated that a term newborn with a mechanical ileus has a 100 % chance of survival and that the overall survival of newborns with ileus is over 95 %. We found no comparable figures on mechanical ileus in newborns according to our definition in literature.

%

1957-1969 1970-1989

25

Total

21.8 3.3

References Bachmann KD: Die angeborene Duodenalstenose. Dtsch Med Wschr 105 (1980) 1428-1430

Benson CD, Lojti M L, Brough AJ: Congenital atresia and stenosis of the colon. J Pediatr Surg 3 (1968) 253 3 Benson CD, Lloyd JR, Smith D}: Resection and primary anastomosis in the management of stenosis and atresia of the jejunum and ileum. Pediatrics 26 (1960) 265 and Amer J Surg 101 (1961) 610 4 Daum R, Roth H, Schüler B, Bolkenius M: Zur Problematik des kongenitalen Duodenalverschlusses. Bericht über 123 Fälle. Z Kinderchir 2

35 (1982) 125-129

Davis DC, Pointner CWM: Congenital occlusion of the intestine. Surg Gynec 34 (1922) 35 6 Ehrenpreis T: Hirschsprung's disease in the neonatal periode Arch Dis Childh 30 (1955) 8 7 Grosftld JL, Clatworth HW jr: Intrauterine midgut strangulation in a gastroschisis defecL Surgery 67 (1970) 519 8 Glover DM, Barry F: Intestinal obstruction in the newborn. Am Surg 130 (1949) 480 9 Harburg FJ, Ponkorny WJ, Hahn H: Congenital duodenal obstruction. Amer J Surg 138 (1979) 825-828 10 Hecker WCh, Dennhardt D: Fehlbildungen des Darmkanals, operative Ergebnisse und Aufgaben der Nachsorge. Dtsch Med J 21 (1970) 5-11 5

Table 7 Lethality of mechanical ileus in newborn. Own patient material 1957-1989 (Berlin, Heidelberg, Munieh).

18.5

1980-1989

1

Table 5 Lethality of ileus in newborn caused by megacolon congenitum. Own patient material 1957-1989 (Berlin, Heidelberg, Munieh).

Hofmann S, Rehbein F: Die Hirschsprungsehe Erkrankung im Neugeborenenalter. Z Kinderchir 3 (1966) 182 12 }oppich I, Hecker WCh: Behandlungsergebnisse des Dünndarmileus im Neugeborenen- und Kindesalter. Chirurg 38 (1967) 293-295 13 Lister J: Intestinal Obstruction. In: Neonatal Surgery, Herausgeber Rickham PP, ListerJ, London, Boston: Butterworth 1978 14 Mengel W, Hecker WCh: Die besondere Problematik des Ileus im Kindesalter. In: Ileussymptomatik Marburg, Herausgeber: Richter H, Eckert P: Stuttgart, Thieme 1978 15 Nixon HH, Tawes R: Etiology and treatment of small intestinal atresia. Surgery 69 (1971) 41 16 Pellerin D: La maladie de Hirschsprung chez l'enfant de moins de 2 mois. Am Chir Infant 7 (1966) 329 17 PettersonJ: Ileus. Acta Chir Scand 130 (1952) 331 18 Rehbein F: Kinderchirurgische Operationen: Hippokrates, Stuttgart 11

1976

Prof Dr. W. Ch. Hecker, Dr. Stephanie Naegele Kinderchirurgische Klinik im Dr. von Haunerschen Kinderspital der Universität München Lindwurmstraße 4 0-8000 München 2

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Table 6 nitum.

153