Journal of Neonatology

Vol. 25, No. 2, AprilJune 2011

ORIGINAL PAPER

Neonatal gastrointestinal perforation: our experience over 10 years

K.N. Rattan, S. Agarwal*, Y.S. Kadian
Department of Pediatric Surgery and Radiology* Pt. BD Sharma PGIMS Rohtak, Haryana- 124001 agar_shalini@yahoo.com; yogarin@gmail.com

Abstract
Sixty six neonates who were diagnosed and managed as gastrointestinal perforation during the period 01 Jan 1997 to 31 Dec 2007 were retrospectively analyzed for age, sex, clinical features, management, per-operative findings and mortality. All neonates with associated congenital anomalies and gastrointestinal perforation caused by iatrogenic causes were excluded from the study. There were 43 boys and 23 girls. The mean gestational age was 35 weeks and mean birth weight was 2.10 Kg. Out of 66 neonates, 4 had stomach, 2 duodenal, 45 small intestinal, 14 colonic and 1 rectal perforation. Eighteen neonates underwent an initial peritoneal drainage under local anaesthesia because of poor general condition. 8 out of 18 died in this group. 8 neonates required further laparotomy. 56 patients underwent surgical intervention, 27 were finally diagnosed as NEC and 29 as Spontaneous Intestinal Perforation (SIP) based on peroperative findings. Multiple perforations were seen in 22 neonates,. Resection and anastomosis was performed in 14 of these, entrostomy in 7, whereas, 1 expired during surgery. Primary closure of site was performed in 31 out of 34 patients of single perforation and entrostomy in three. Post-operative stay ranged between 10-30 days. Mortality was 59.3% in NEC patients and 41.4% in SIP patients. Mortality in neonates with gastric, duodenal, small bowel and isolated colonic perforation was 25.00, 50.00, 35.55 and 42.85% respectively. Four patients developed stricture during follow-up. Key words: Gastro-intestinal Perforation; Spontaneous intestinal perforation, Nectrotizing Enterocolitis; Neonates

have resulted in growing number of infants susceptible to aquired illnesses of the gastrointestinal tract.1 Abdominal complaints in these infants do not represent a homogenous group of illnesses. Apart from congenital malformations and functional disorders viz., intestinal obstruction, volvulus, intrauterine intussusception, gastrointestinal immaturity and "meconium disease". Necrotizing Enterocolitis (NEC) is considered to be the most frequent and hazardous acquired cause of gastrointestinal disease with subsequent intestinal perforation in preterms. Localized spontaneous intestinal perforations (SIP), without clinical and histological evidence of NEC has been established as a distinct clinical entity in VLBW infants.2-5 The management of neonates with generalized peritonitis secondary to gastro-intestinal perforations remains a major challenge to the pediatric neonatal surgeons. Outcome remains poor in developing countries due to lack of neonatal intensive care services. In the developed countries the outcome has improved largely due to advances in parenteral nutrition and neonatal intensive care.6-12

Material and Methods

All neonates who were diagnosed and treated for gastrointestinal perforation during the period 01 Jan 1997 to 31 dec 2007 were included in the study. These were analysed for age, sex, clinical features, site of perforation, per-operative findings and mortality rates. All neonates with associated congenital anomalies like Hirschsprung's disease, Ano-rectal malformation and atresias as well as gastrointestinal perforation caused by iatrogenic causes were excluded from the study.

Introduction Results
Ongoing advances in the management of very-lowbirth-weight (VLBW) infant in level II to IV Neonatal Intensive Care Units, particularly during initial 1 hour,
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Out of 66 neonates with gastro intestinal perforation, 43 were boys and 23 girls. The mean gestational age

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Vol. 25, No. 2, AprilJune 2011

was 35 weeks (range 32-39 wks) and mean birth weight was 2.10 Kg (range 1.67-2.9Kg). There were 4 neonates with stomach perforation, 2 with duodenal perforation, 45 with small intestinal perforation, 14 with isolated colonic perforation and 1 with rectal perforation. 18 neonates were treated with primary peritoneal drainage under local anaesthesia (LA) because of the poor general condition. The clinical signs and symptoms in these patients were abdominal distension and increased bilious gastric aspirate in all cases, bloody stools in 12, bluish discolouration in 5, episodic apnea in 10, bradycardia in 9 patients. All neonates were born preterm. Mean age at presentation was 8 days. Antenatal history was not very reliable. Laboratory investigations revealed leucocytosis in 8 and thrombocytopenia in 5 patients. Skiagram abdomen revealed free air in 16, pneumatosis intestinalis in 12 and portal venous gas in 2, thickened bowel loops in 12, permanently distended bowel loops in 8 and gaseless abdomen in 1 neonate. Fifty six neonates underwent surgical intervention. The diagnosis of cause of intestinal perforation was based on per-operative observations made by the surgeon. Of these 27 were finally diagnosed as NEC and 29 diagnosed as cases of SIP. Four patients with gastric perforation, 2 patients with duodenal perforation and 1 patient with rectal perforation were included in SIP and the remaining had small bowel perforation. Clinical presentation of these cases at presentation has been shown in Table 1. Fifteen diagnosed patients of NEC were preterm, while 21 diagnosed patients of SIP were preterm 36 of 56 neonates were delivered at home, 22 neonates had multiple perforations and rest had isolated localized perforations. Six patients Table 1. Intraoperative Findings in NEC Versus SIP cases Characteristics Pneumatosis Pneumoperitoneum Gaseless abdomen Portal vein air "Blue" abdomen NEC n=27 12 24 01 01 02 SIP n=29 03 17 --05

had both ileal and colonic perforation. The distribution of perforations according to the site, their age at presentation and mortality are shown in Table 2. Surgical Intervention Resection and anastomosis was done in 14/22 patients of multiple perforations, enterostomy was performed in 7 patients while 1 expired during surgery. Primary closure of site was performed in 31 out of 34 of neonates with single perforation while entrostomy had been performed in the rest. In case of the two patients with duodenal perforation primary closure of the site was performed using omental patch. Post-operative period Post- operative hospital stay ranged from 10-30 days. Eleven neonates of NEC (40.74%) survived the initial episode with the mortality being 59.25%, while 17 patients of SIP (58.62%) survived with the mortality being 41.37%. Follow-up was poor with the period ranging from 1 to 6 months. During this period 4 neonates presented with stricture.

Discussion
Localized perforation was first described as spontaneous gastrointestinal perforation (SIP) by Seibold in 1825, also is referred to as idiopathic or focal, and is now considered as a separate clinical entity from NEC.13-17 The absence of typical clinical and histological signs of classic NEC characterize SIP as a distinct entity in preterm infants.18-19 and SIP is considered to be more benign condition compared to NEC. SIP will generally respond well to treatment and therefore has a good prognosis.20 The isolated nature of the perforation in SIP distinguishes it from the more widespread involvement of NEC, however, the pathogenesis, pathology, clinical presentation, morbidity and mortality, are less obviously different. This realization has led to the theory that NEC and SIP, contrary to the popular belief, may be a spectrum of the same pathology.20-21 Blakely et al22 found that NEC and SIP could be

Table 2. Relationship between site of perforation age at presentation & mortality (n=56) Stomach No. of patients (n=56) Mean age at presentation (days) Mortality 4 7.0 1 Duodenum 2 12.0 1 Small Bowel 37 6.7 16 Colon 18 7.2 6/12* Rectum 1 14.5 Nil

*12 neonates had only colonic perforation, while 6 had an ileal perforation in addition
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distinguished preoperatively. The most important criteria found by them have been used in our study. To distinguish these two conditions preoperatively, based on perinatal characteristics, physical examination, abdominal skiagram / imaging is difficult. If these two entities can be distinguished preoperatively, the impact on prognosis maybe different.22 Stress, hypoxia or shock predispose the individual to regional hypoperfusion and transient intestinal ischemia, which is liable to initiate defense mechanisms with local hyperactivity, resulting in perforation.15,16, 23,24 The terminal ileum receives its blood supply in a watershed fashion and is more likely to be susceptible to local ischemia, but isolated perforations were also observed in the transverse and descending colon-areas that should ordinarily have sufficient blood supply.1 Extremely low birth-weight (ELBW) premature infants who develop NEC or SIP represent a group of patients with extremely high morbidity and mortality.8 Most studies report the mortality in ELBW infants who undergo operation for NEC upto 50%.22,25,26 Many surgeons initially treat intestinal perforation in premature neonates with peritoneal drainage, especially if the diagnosis is thought to be SIP. However, drainage alone may be definitive treatment for SIP but not for NEC.11, 23-29 Moss et al30 found that the type of operation performed for perforated NEC does not influence survival or other clinically important early outcomes in preterm infants. At 90 days postoperatively, death rate of infants assigned to primary peritoneal drainage was 34.5% while in case of infants assigned to laparotomy was 35.5%. The number of infants in the former group who depended on total parenteral nutrition was 47.2%, while it was 40.0% in the later group. The mean length of hospitalization in the two groups was also similar. In present study the mortality in the neonates who underwent primary peritoneal drainage was 44.44%. Ehrlich et al31 hypothesized that survival of very low-birth weight neonates with perforated NEC may be more dependent on clinical status than on treatment modality. Similar observations were reported by Upadhyay et al11. Mortality for neonatal GI perforation remains unacceptably high. Hospital statistics are just the tip of the iceberg as most of the deliveries in the third world are still conducted at home and a number of these neonates don't receive proper treatment in time.

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