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Staged Surgery for Meconium Peritonites– A Case Report

M. Abbas, S. Al-Hindi, A. Hasan

 

Correspondence:

Mahmood Abbas

Department of Surgery, Unit of Pediatric Surgery

Salmania Medical Complex

PO Box, Manama, Kingdom of Bahrain

Tel: 0097339652551, E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

We present a newborn with meconium peritonitis secondary to ileal atresia with perforation which was diagnosed in utero. Open drainage of the free meconium was initially performed, followed by elective definitive surgery at the age of 10 days.

 

 

Introduction

Meconium peritonitis is an aseptic chemical peritonitis resulting from in utero perforation of the obstructed gastrointestinal tract and is most commonly secondary to intestinal atresia. Most of these cases can be diagnosed by fetal ultrasound. Management of such cases is controversial and varies between definitive surgery in the early neonatal period and staged surgery consisting of initial drainage followed by elective definitive surgery [1, 2]. We report a newborn with generalized meconium peritonitis who was initially treated with open drainage of meconium followed by conservative therapy and elective surgery.

The case

A 3.5 kg female baby born at 35 weeks of gestation by caesarean section because of premature labor and fetal distress. The antenatal ultrasound at 30 weeks of gestation showed polyhydramnios and fetal bowel dilatation suggestive of meconium peritonitis (fig. 1). Immediately after birth, the baby was in severe respiratory distress and was intubated and ventilated. The abdomen was severely distended, tense, silent and dull on percussion and the abdominal wall was edematous and erythematous. The baby did not pass meconium and the nasogastric tube drained minimal greenish fluid. The plain abdominal x-ray was suggestive of ascites and the abdominal ultrasound showed multiple distended bowel loops and a large collection with debris in the upper abdomen (fig. 2). Seven hours postnatally, the baby underwent emergency mini-laparotomy in the neoatal ICU. The peritoneal cavity was filled with large amount of free meconium and the bowel loops were meconium-stained and densely adherent. The meconium was evacuated and two penrose drains were placed in the abdomen. Postoperatively, the neonate was put on mechanical ventilation, parenteral nutrition, intravenous antibiotics and decompression of the gastrointestinal tract. Abdominal distention significantly reduced and her general condition improved. Gastrograffin study of the bowel showed a perforation in the terminal ileum. At age of 10 days, the baby underwent re-look laparotomy and a large terminal ileal perforation was identified 10 cm proximal to the ileocecal junction with a large mesenteric defect. Resection of the perforated ileal atretic segment and primary anastomosis was performed. Patient received 30 ml of packed red blood cells intraoperatively. The postoperative course was unremarkable. Cystic fibrosis was ruled out.

Discussion

Meconium peritonitis is very rare and the actual incidence is not known but it is estimated to be 1 case in 30000 births. The most common causes are small bowel atresia, volvulus and meconium ileus [1, 3]. The clinical manifestations of meconium peritonitis depend on the time of perforation and whether the perforations were closed [2]. The free meconium acts as an irritant and an inflammatory serosal reaction develops leading to the formation of adhesions, pseudocyst and calcification [1]. Lorimer and Ellis classified meconium peritonitis into generalized, fibroadhesive, cystic, and healed type. In the generalized type, thick meconium spreads over the whole abdominal cavity. In the fibroadhesive type, inflammatory responses lead to intensive fibroblastic reactions and severe chemical peritonitis by fluids containing digestive enzymes. In the cystic type, the perforation site does not heal effectively, and a thick-walled cyst forms by fixation of bowel loops. The clinical presentation in the neonatal period includes abdominal distention with erythematous and edematous abdominal wall, a palpable abdominal mass and occasional respiratory compromise [4].

The diagnosis of meconium peritonitis is possible by prenatal ultrasound examination. Common findings include: intraabdominal calcifications, ascites, intraabdominal masses, bowel dilatation and polyhydramnios [3]. The prognostic value of these findings is a subject of controversy. Dirkes et al found that the presence of bowel abnormalities carries 50% risk of postnatal intestinal complications, whereas Moslinger et al found that the postnatal outcome cannot be predicted from the prenatal sonographic findings [4, 5 and 6].

The prenatally diagnosed meconium peritonitis carries overall morbidity rate of 22% and mortality rate of 11% and it has better prognosis than postnatally diagnosed meconium peritonitis [4].

In many cases, immediate surgery is necessary to release the intestinal obstruction and to avoid bacterial infection. The operative strategy is dependent on clinical manifestations and patient’s general condition. Tanaka et al [1] noted that operation of meconium peritonitis was difficult because the patient’s general condition was poor, and dissection of the adhesion was difficult owing to severe inflammation and bleeding. An ultrasound guided drainage of the cystic meconium peritonitis was performed at first followed by a delayed definitive operation [1]. While Nam SH et al prefer resection and anastomosis of the involved intestinal segment in the majority of cases [2]. In some cases, however, enterostomy or drainage only was inevitable when there was severe distension, adhesion, or uncertainty of the viability of bowel[2].

In our case, the postnatal ultrasound showed meconium with large amount of debris and decision for open drainage instead of percutaneous drainage was made to ensure better evacuation of the free meconium. Initial drainage was chosen because of the poor general condition, extensive adhesions, difficulty in identifying the meconium-stained bowel loops and the significant risk of intraoperative bleeding from the edematous and inflamed peritoneal surfaces. During the second operation, the general condition was stable, the adhesions were less, the identification of the bowel loops was easier and the bleeding was minimal.

Conclusion

Meconium peritonitis is a rare disorder of intestinal perforation in utero. Management is difficult and controversial. Initial drainage of meconium and later definitive surgery in critically ill patients, is safe and effective.

 

 

REFERENCES

  1. K Tanaka, K Hashizume, H Kawarasaki, et al. Elective surgery for cystic meconium peritonitis: Report of two cases. J Pediatr Surg 1993 Jul; 28(7): 960-1.
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