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112

~o}!ij3l}: :111 7 i! fil1 2 ~ 2001';1 Vol. 7, No, 2, December 2001

Intestinal Perforations in Very Low Birth Weight Infants

Dae Yeon Kim, M.D., Seong Chul Kim, M.D., Ai-Rhan Kim*, M.D., Ki Soo Kim*, M.D., Soo Young Pi*, M.D., In Koo Kim, M.D.

Department of Surgery and Pediatrics*, Asan Medical Center, University of Ulsan College of Medicine Seoul, Korea

With the advances in neonatal intensive care, pediatric surgeons experience very low birth weight infants, weighing (1,500 g, more frequently. We report our 14 cases of very low birth weight infants with intestinal perforations without congenital causes, at the Asan Medical Center during the ll-year period from 1989 to 2000. The average birth weight was 919 g(563-1,490), and average gestational age was 206 days061-286)' There were nine males and five females , Operation was performed at an average age of 14.0 days(3-38). Ten neonates with symptomatic PDA were given indomethacin in an attempt to close the ductus. Bowel perforation involved the jejunum in two and ileum in twelve. At laparotomy, there were seven focal intestinal perforations, five typical NEC, one intussusception, and an unknown cause, Four neonates underwent resection and anastomosis of the bowel, and nine underwent exteriorization. One underwent resection and anastomosis after peritoneal drainage. Four patients had postoperative complications; two leakage of anastomosis, one stoma necrosis , and one internal herniation. Seven of fourteen patients survived(50.0 %). Seven patients died of septic complication. There was a significant difference in the birth weight and gestational age in survivors compared with those who died(p(0.05). There was an increased risk of bowel perforation in indomethacin treatment for PDA. Careful clinical observation and keen judgment are essential for this particular group of infants.

(J

Kor

Assoc

Pediatr

Surg 7(2):112-117), 2001.

Index Words: Very low birth weif!ht infants, Intestinal perforation

(very low birth weight infant),

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Table 1. Summary of Cases

Case GA(wk) BW(kg) Age at Op (ds) . PDAllndo Lesion Cause Operation Outcome/Complication

Extremely Vel}' Low Birth Weight Infant «7S0g)

23 563 26 +/+ Ileum NEC, standard Ileostomy Died at POD#3

2 25 645 20 +/+ Ileum Focal perforation Ileostomy Survive/Stoma necrosis

3 24 684 3 +/+ Ileum Focal perforation Ileostomy Died at POD#2

4 24 730 7 +/+ Ileum Focal perforation Ileostomy Died at POD#1

Extremely Vel}' Low Birth Weight Infant (7S0-1000g)

rr

0

5 24 783 16/25 +/+ Jejunum Unknown PO/ R & A Died at POD#30 ~

¥

6 25 798 10 +/+ Ileum Focal perforation Ileostomy Survive 11!.

-..J

ri!.

7 29 831 7 +/+ Ileum Focal perforation Ileostomy Died at POD#7

11!.

~

8 25 841 9 +/+ Ileum NEC, standard Ileostomy Died at POD#2 foi'

~ 0

9 28 967 6 +/+ Jejunum Focal perforation R&A Died at POD#65/Leakage 0

~

10 28 992 3 +/+ Ileum Focal perforation R&A Survivellnternal herniation

Vel}' Low Birth Weight Infant(1000-1,SOOg)

11 29 1150 12 +/+ Ileum NEC, standard Ileostomy Survive

12 27 1185 25 -/- Ileum Intussusception R&A Survive/Leakage

13 32 1212 38 -/- Ileum NEC, standard Ileostomy Survive

14 30 1490 11 +/- Ileum NEC, standard R&A Survive

Abbrevation: GA; gestational age, BW; birth weight, PDA; patent ductus arteriosus, Indo; indomethacin, PO; peritoneal drainage, R & A; resection and anastomosis

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1. %~J-91: ~Agof ~f1: ~o}J!}~(

6Jt!), All 12:AJ-.

t11~lli J!}.Al ('?), 1997, Pp244-245

2. Hack M, Friedman H, Fanaroff AA: Outcomes of extremely low birth weight irifants. Pediatrics 98(5):931-937, 1996 3. Lemons JA, Bauer CR, Oh W, Korones SB, Papile LA,

Stoll BJ, Verter J, Temprosa M, Wright LL, Ehrenkranz RA, Fanaroff AA, Stark A, Carlo W, Tyson JE, Do- novan EF, Shankaran S, Stevenson DK: Very low birth weight outcomes of the National Institute of Child health and human development neonatal research network, January 1995 through December 1996. NICHD Neonatal Research Network. Pediatrics \o7(l):El, 2001 4. Reller MD, Lorenz JM, Kotagal UR, Meyer RA, Kaplan

S: Hemodynamically significant PDA: an echocardiographic and clinical assessment of incidence, natural history, and outcome in very low birth weight infants maintained in negative fluid balance. Pediatr Cardiol 6(1):17-23, 1985 5. Rajadurai VS, Yu VY: Intravenous indomethacin th-

erapy in preterm neonates with patent ductus arteriosus.

J Paediatr Child Health 27(6):370-375, 1991

6. Trus T, Winthrop AL, Pipe S, Shah J, Langer JC, Lau GY: Optimal management of patent ductus arteriosus in the neonate weighing less than 800 g. J Pediatr Surg 28(9):1137-1139, 1993

7. Grosfeld JL, Chaet M, Molinari F, Engle W, Engum SA, West KW, Rescorla Fl, Scherer LR 3rd: Increased risk of necrotizing enterocolitis in premature infants

with patent ductus arteriosus treated with indomethacin.

Ann Surg 224(3):350-355; discussion 355-357, 1996 8. Buchheit JQ Ste'Mllt DL: Clinical comparison of localized

inLestinal peiforation and necrotizing en1erocolitis in neonates.

Pediatrics 93(1 ):32-36, 1994

9. Shotter NA, Liu JY, Mooney DP, Harmon BJ:

Indomethacin-associated bowel peiforations: a study of possible risk factors. J Pediatr Surg 34(3):442-444, 1999 10. Mavroudis C, Cook LN, Fleischaker JW, Nagaraj HS, Shott RJ, Howe WR, Gray LA Jr: Management of patent ductus arteriosus in the premature infant: indomethacin versus ligation. Ann Thorac Surg 36(5):561-566, 1983 II. Robie DK, Waltrip T, Garcia-Prats JA, Pokorny WJ, Jaksic

T: Is surgical ligation of a patent ductus arteriosus the priferred initial approach for the neonate with extremely low birth weight? J Pediatr Surg 31(8):1134-1137,1996 12. Halac E, Halac J, Begue EF, Casanas JM, lndiveri DR,

Petit JF, Figueroa MJ, Olmas JM, Rodriguez LA, Obregon RJ: Prenatal and postnatal corticosteroid the- rapy to prevent neonatal necrotizing enterocolitis: a controlled trial. J Pediatr 117: 132-138, 1990

13. Gennari R, Alexander JW, Gianotti L, Eaves-Pyles T, Hartmann S: Granulocyte macrophage colony-stimulating factor improves survival in two models of gut-derived sepsis by improving gut barrier function and modulating bacterial clearance. Ann Surg 220(1):68-76, 1994 14. Maxson RT, Jackson RJ, Smith SD: The protective role

of enteral IgA supplementation in neonatal gut origin sepsis. J Pediatr Surg 30(2):231-233; discussion 233-234, 1995

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16. Azarow KS, Ein SH, Shandling B, Wesson D, Superina R, Filler RM: Laparotomy or drain for peiforated necrotizing enterocolitis: who gets what and why? Pediatr Surg Int 21;12(2/3):137-139, 1997

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recommendations from recent experience. J Pediatr Surg 33(10):1468-1470, 1998

19. Harberg FJ, McGill CW, Saleem MM, Halbert R, Anastassiou P: Resection with primary anastomosis for necrotizing enterocolitis. J Pediatr Surg 18(6):743-746, 1983

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20. Frawley G, Bayley G, Chondros P: Laparotomy for necrotizing enterocolitis: intensive care nursery com- pared with operating theatre. J Paediatr Child Health 35(3):291-295, 1999

21. Kosloske AM, Musemeche CA: Necrotizing enterocolitis

of the neonate. Clin Perinatol 16(1):97-111, 1989 22. Mintz AC, Applebaum H: Focal gastrointestinal per-

forations not associated with necrotizing enterocolitis in velY low birth weight neonates. J Pediatr Surg 28(6 :857-860, 1993

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Table  1.  Summary  of  Cases

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