Cronicon OPEN ACCESS EC PAEDIATRICS Research Article Citation: Tembely Samba., et al. “Meconium Peritonitis: Management in a Developing Country in Sub-Sahara Africa”. EC Paediatrics 8.9 (2019): 941-947. Meconium Peritonitis: Management in a Developing Country in Sub-Sahara Africa Tembely Samba*, Kouamé Yapo Guy Serge, Yaokreh Jean Baptiste, Odéhouri-Koudou Thierry Hervé, Thomas H A, Kouamé DB and Ouattara O Pediatric Surgery Department, CHU de Yopougon, Côte d’Ivoire *Corresponding Author: Tembely Samba, Pediatric Surgery Department, CHU de Yopougon, Côte d’Ivoire. Received: December 26, 2018; Published: August 30, 2019 Abstract Keywords: Intestinal Perforation; Meconium Peritonitis; Newborn Introduction Meconium peritonitis is defined as a localized or generalized peritonitis; sterile, chemical or foreign body, due to leakage of meconium into the peritoneal cavity correlated with antenatal perforation of the digestive tract. Meconium, in the peritoneal cavity, may or may not be calcified. This pathology was first described by Morgagni in 1761, and the first surgical treatment. The incidence of meconium perito- nitis is about 1:30,000 [1]. Due to area sealing of intestinal perforation and spontaneous regression of the inflammatory process without neonatal clinical manifestations, the incidence is probably underestimated. Continued progress in prenatal diagnosis procedures and providing neonatal intensive care have resulted in a decrease of 10% of the mortality rate in developed countries [2]. Perinatal morbidity and mortality reached 80% in underdeveloped countries. Early recognition of the etiology, pathophysiology, and a specific perinatal management represent the requirements necessary for optimizing the postnatal results. The aim of this study is to report our single-center experience of meconium peritonitis with a focus on the clinical outcome. This is a retrospective study including all neonates with meconium peritonitis treated in the pediatric surgery unit at Yopougon teach- ing Hospital from January 2012 to December 2017. Patients and Method Introduction: Meconium peritonitis is defined as a localized or generalized peritonitis. The incidence of meconium peritonitis is about 1:30,000. With the development of neonatal care, the prognosis of meconium peritonitis improved much. The aim of this study is to report our single-center experience with a focus on the clinical and outcome Patients and Methods: A retrospective study of 19 patients with meconium peritonitis treated in the pediatric surgery unit at Yo- pougon teaching Hospital from January 2012 to December 2017. The following parameters were recorded: epidemiology, therapeutic and outcome, morbidity and mortality. Results: The 19 patients consisted of 13 males and 6 female newborn. In 4 (21%) patients, prenatal diagnosis using ultrasonography (US) was made from 26 to 35 weeks of pregnancy. All patients were referred to our institute for abdominal distension, bilious vomit- ing. Age at admission was 6,31 ± 5,54 (ranging from 1 to 18 days). After birth, abdominal X-ray shown pneumoperitoneum (n = 4) or calcifications (n = 2). Surgery was performed at a mean age of 7.1 ± 5.95 days (ranging from 1 to 20 days). All patients underwent exploratory laparotomies. The most common cause of meconium peritonitis was intestinal atresia (n = 9). The global mortality rate was 47.37%. Conclusion: Our results suggest that resection primary and end to end anastomosis should be used with caution, it seems to be the safer procedure.mies. The most common cause of meconium peritonitis was intestinal atresia (n = 9). The global mortality rate was 47.37%.
Transcript
CroniconO P E N A C C E S S EC PAEDIATRICS
Research Article
Citation: Tembely Samba., et al. “Meconium Peritonitis: Management in a Developing Country in Sub-Sahara Africa”. EC Paediatrics 8.9 (2019): 941-947.
Meconium Peritonitis: Management in a Developing Country in Sub-Sahara Africa
Tembely Samba*, Kouamé Yapo Guy Serge, Yaokreh Jean Baptiste, Odéhouri-Koudou Thierry Hervé, Thomas H A, Kouamé DB and Ouattara OPediatric Surgery Department, CHU de Yopougon, Côte d’Ivoire
*Corresponding Author: Tembely Samba, Pediatric Surgery Department, CHU de Yopougon, Côte d’Ivoire.
Received: December 26, 2018; Published: August 30, 2019
Meconium peritonitis is defined as a localized or generalized peritonitis; sterile, chemical or foreign body, due to leakage of meconium into the peritoneal cavity correlated with antenatal perforation of the digestive tract. Meconium, in the peritoneal cavity, may or may not be calcified. This pathology was first described by Morgagni in 1761, and the first surgical treatment. The incidence of meconium perito-nitis is about 1:30,000 [1]. Due to area sealing of intestinal perforation and spontaneous regression of the inflammatory process without neonatal clinical manifestations, the incidence is probably underestimated.
Continued progress in prenatal diagnosis procedures and providing neonatal intensive care have resulted in a decrease of 10% of the mortality rate in developed countries [2]. Perinatal morbidity and mortality reached 80% in underdeveloped countries. Early recognition of the etiology, pathophysiology, and a specific perinatal management represent the requirements necessary for optimizing the postnatal results. The aim of this study is to report our single-center experience of meconium peritonitis with a focus on the clinical outcome.
This is a retrospective study including all neonates with meconium peritonitis treated in the pediatric surgery unit at Yopougon teach-ing Hospital from January 2012 to December 2017.
Patients and Method
Introduction: Meconium peritonitis is defined as a localized or generalized peritonitis. The incidence of meconium peritonitis is about 1:30,000. With the development of neonatal care, the prognosis of meconium peritonitis improved much. The aim of this study is to report our single-center experience with a focus on the clinical and outcomePatients and Methods: A retrospective study of 19 patients with meconium peritonitis treated in the pediatric surgery unit at Yo-pougon teaching Hospital from January 2012 to December 2017.The following parameters were recorded: epidemiology, therapeutic and outcome, morbidity and mortality.Results: The 19 patients consisted of 13 males and 6 female newborn. In 4 (21%) patients, prenatal diagnosis using ultrasonography (US) was made from 26 to 35 weeks of pregnancy. All patients were referred to our institute for abdominal distension, bilious vomit-ing. Age at admission was 6,31 ± 5,54 (ranging from 1 to 18 days). After birth, abdominal X-ray shown pneumoperitoneum (n = 4) or calcifications (n = 2). Surgery was performed at a mean age of 7.1 ± 5.95 days (ranging from 1 to 20 days). All patients underwent exploratory laparotomies. The most common cause of meconium peritonitis was intestinal atresia (n = 9). The global mortality rate was 47.37%.Conclusion: Our results suggest that resection primary and end to end anastomosis should be used with caution, it seems to be the safer procedure.mies. The most common cause of meconium peritonitis was intestinal atresia (n = 9). The global mortality rate was 47.37%.
Citation: Tembely Samba., et al. “Meconium Peritonitis: Management in a Developing Country in Sub-Sahara Africa”. EC Paediatrics 8.9 (2019): 941-947.
Meconium Peritonitis: Management in a Developing Country in Sub-Sahara Africa
The following parameters were recorded: gender, maternal age, number of prenatal consultation (PNC), prenatal diagnosis, gestation-al age, delivery type, weight at birth, age at admission, time for surgery, the intraoperative findings, operative techniques performed, mor-bidity and mortality. We reviewed clinical course of our patients with MP, and analyzed predictors of outcome. Typical findings such as dilated bowel, fetal ascites, pseudocyst and polyhydramnios just before delivery were evaluated in this study. Polyhydramnios is defined as an amniotic fluid index > 24 cm. After birth, patients were transferred to pediatric surgery unit and evaluated by pediatric surgeons. All patients received pre, per and post-operative care. Our surgical strategy for MP after laparotomy is to perform resection primary and end to end anastomosis (RPA), abdominal drainage, temporary enterostomy and elective reconstruction of intestinal continuity (stoma closure) according to the cases.
Results
In order to clarify prognostic factors, we examined the relationship between prognosis and several factors. We divided 19 patients into 2 groups according to the occurrence of morbi-mortality after the surgery; Group A with morbi-mortality and Group B without morbi-mortality (Table 2). All patients were investigated after obtaining the parent's or guardian's informed consent to participate in this study.
All statistical analyses were performed using excel logiciel. The results were expressed as means ± standard deviation (S.D.). The Chi-square test was used for comparisons among unpaired groups. P values of less than 0.05 were considered to be statistically significant.
The patient’s characteristics summarized in table 1. The 19 patients consisted of 13 males and 6 female newborn. In 4 (21%) of 19 patients, prenatal diagnosis using ultrasonography (US) was made from 26 to 35 weeks of pregnancy. Polyhydramnios was detected in 4 patients: bowel dilatation (n = 2), ascites in (n = 2). All patients were referred to our institute for abdominal distension, bilious vomiting. After birth, abdominal X-ray was performed to all patients. It’s shown pneumoperitoneum (n = 4) and calcifications (n = 2) (Figure 1). Surgery was performed at a mean age of 7.1 ± 5.95 days (ranging from 1 to 20 days). All patients underwent exploratory laparotomies. Generalized-type meconium peritonitis was seen in all patients The most common cause of meconium peritonitis was intestinal atresia (n = 9). Other causes of meconium peritonitis included small bowel volvulus (n = 3). The causes were uncertain in the others: ileum perfora-tion (n = 2) (Figure 2), meconium-containing ascites without bowel perforation (n = 3), and caecum perforation (n = 2). No associated abnormality was found in our series. The most commonly performed procedure was resection and end to end anastomosis (n = 9). In 3 patients, only drainage procedures were performed. Seven patients underwent enterostomy (Figure 3).
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Citation: Tembely Samba., et al. “Meconium Peritonitis: Management in a Developing Country in Sub-Sahara Africa”. EC Paediatrics 8.9 (2019): 941-947.
After surgery, 3 morbidities occurred including wound infection in 2 patients, intestinal fistula in 1 patient. We divided 19 patients into 2 groups according to the occurrence of morbi-mortality after the surgery; Group A with morbi-mortality and Group B without morbi-mortality (Table 2).
Number of prenatal consultation (mean ± SD) 3,78 ± 2,35 (0 - 7)Gestational age (weeks) mean ± SD 37,64 ± 2,75 (32 - 42)
Weight at birth (g) (mean ± SD) 2764,22 ± 597,64 (1520 - 3500)Age at admission (mean ± SD) 6,31 ± 5,54 (1 - 18)Time for surgery (mean ± SD) 7,15 ± 5,95 (1 - 20)
Follow up period (months) 14,3 (6 - 36)
Table 1: Patient’s characteristics.
Figure 2: Ileum perforation.
Figure 3: Enterostomy after laparotomy.
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Citation: Tembely Samba., et al. “Meconium Peritonitis: Management in a Developing Country in Sub-Sahara Africa”. EC Paediatrics 8.9 (2019): 941-947.
Nine patients died due to multiple organ failure (MOF) and malnutrition. The global mortality rate was 47.37%. The mean follows up period was 14.3 months (ranging, from 6 to 36 months). Table 3 summarize patients characteristic and outcome.
Item Groupe A (n = 12) Groupe B (n = 7) P valuePrenatal diagnosis (yes/no) 0/12 4/7 0,00
Gestational age (week) 38,42 ± 2,35 36,28 ± 3,04 0,12Delivery type (NVD/CS) 8/4 6/1 0,73
Weight at birth (g) 2868,33 ± 547,92 2585,71 ± 679,90 0,36Admission day (day) 5 ± 5,75 8,57 ± 4,72 0,15
Time for surgery 6,5 ± 6,92 10,71 ± 5,25 0,15
Table 2: Patient’s characteristic with and without morbi-mortality.
The Chi-square test were used for analysis. NVD: Normal Vaginal Delivery; CS: Caesarean Section.
N° Age (day) Gender Delivery type GA (wee) Prenatal
diagnosisBirth
weight (g) Cause of MP Treatment Evolution
1 1 F NVD 37 No 1650 Intestinal atresia Enterostomy Died2 1 M NVD 34 No 1520 Intestinal atresia Enterostomy Died3 4 F NVD 32 Yes 1750 Ascite Drainage Alive4 7 M CS 40 No 3500 Ascite Drainage Alive5 17 M NVD 37 Yes 2700 Caecum perforation Enterostomy Alive6 1 M CS 39 no 2600 Small bowel volvulus RPA Died7 11 M NVD 33 No 3000 Intestinal atresia RPA Alive8 3 M NVD 37 No 3050 Intestinal atresia RPA Died9 1 M NVD 36 No 2350 Caecum perforation Enterostomy Died
10 1 F NVD 41 No 3500 Ileum perforation Enterostomy Died11 11 M NVD 39 Yes 3000 Ascite Drainage Alive12 3 M CS 37 No 2600 Ileum perforation RPA Died
13 12 F CS 42 No 3500 Atresia intestinal RPA Died14 4 F NVD 35 Yes 2500 Caecum perforation Enterostomy Alive15 7 M CS 38 No 3000 Intestinal atresia Enterostomy Alive16 1 M NVD 40 No 3100 Intestinal atresia RPA Died17 11 M NVD 37 No 2950 Small bowel volvulus RPA Alive18 18 M NVD 39 No 3250 Intestinal atresia RPA Alive19 6 F NVD 38 No 3000 Intestinal atresia RPA Alive
Table 3: Distribution of patients characteristics and outcome
NVD: Normal Vaginal Delivery; RPA: Resection Primary and End to End Anastomosis ; GA: Gestational Age.
Our experience show that MP has low rate, we noticed 19 cases in 5 years. This relatively low frequency is due to the fact that this study was monocentric. Also, meconium peritonitis is rare [1]. Many investigators have studied the pathogenesis of meconium peritonitis; it is not yet well understood [3,4]. A decrease in blood flow to the mesentery may lead to mucosal necrosis and subsequent bowel obstruction, and any further decrease in mesenteric blood flow may cause necrosis and perforation of the intestinal wall [5]. Ischemia, however, is not the sole cause of meconium peritonitis. Intraluminal problems such as meconium plugs and extramural conditions such as volvulus, band or hernia, can also cause obstruction and perforation of the intestinal wall [5]. The underlying causes of meconium peritonitis thus include meconium ileus, intestinal atresia, stenosis, internal hernia, neonatal Hirschsprung's disease, volvulus, intussusception, extrinsic
Discussion
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band, duplication and Bowel Perforation in a Neonatal Anorectal Malformation [6-10]. Colonic atresia [11], torsion of a fallopian tube cyst [12], fetal appendiceal perforation [13], perforated duplications [14] and fetus-in-fetu [15] have been reported as rare causes of meco-nium peritonitis. In our study, intestinal atresia was the most common cause of meconium peritonitis. We demonstrated in the preopera-tive condition, there were no differences between the groups for gestational age, delivery type, body weight at birth, age at admission and time for surgery.
Uchida., et al. [16] reported respectively 92,7% and 73,3% (11/15) of prenatal diagnosis in their studies. besides polyhydramnios, bowel dilatation, ascites such as our study, they suspected calcification, pseudocyst and echogenic bowel. Several studies have assessed the accuracy of prenatal US examination for diagnosing MP and IMR and predicting patients' outcomes [2,16-21]. In our study, prenatal diagnosis was made in 21% of patients. There is a significant difference between two groups for prenatal diagnosis (p = 0,00). Low rate of prenatal diagnosis is explained by the fact that the pregnant do not follow the prenatal consultation (PNC) correctly. Sometimes Some do not do any prenatal consultation until birth. The ultrasound realized during the PNC, shown bowel dilatation (n = 2), ascites in (n = 2). The early detection of fetal ascites, before the 24th week of GA, is associated with a significant risk of perinatal death; otherwise, a late diagnosis of fetal ascites is associated with an increased risk of gastrointestinal diseases, especially with meconium peritonitis [22]. Fetal ascites and abdominal calcifications are the most common ultrasound findings, while pseudocyst formation predicts an uncertain prena-tal outcome. The resolution of dilated bowel loops and polyhydramnios are related to low rates of postnatal surgery. Early detection of MP is not indicative of poor neonatal outcomes [23]. However, we found that our patients diagnosed prenatally had no favorable resolution at birth. They evolved towards the MP. They were operated on.
MP diagnosis relies on imaging that can reveal the presence of intraperitoneal calcifications in the newborn [24,25]. The extruded meconium can be or not calcified and when there was no calcification, X-rays suggest the presence of fluid in the abdomen. When calcifica-tions are seen, meconium peritonitis diagnosis is established [26,27].
Prognosis and natural evolution of meconium peritonitis, when it is diagnosed in the fetal period, are different from that diagnosed postnatally. If at the intraperitoneal fetal ultrasound are present only calcifications without bowel dilatation, polyhydramnios, ascites or pseudocyst, the prognosis is favorable. These features constitute simple meconium peritonitis. If all the features listed above are associ-ated, the prognosis is bad and need for surgical intervention increase [26].
Any operative strategy is dependent on clinical manifestations and patient's general condition. The 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 [28]. Recent studies do not provide clear guidelines concerning surgical strategies for MP [29-32]. Enterostomy; T-tube ileostomy [33]; primary anastomosis [34]; Bishop-Koop procedure; Santulli procedure and Mikulicz procedure are common procedures for MP. Although every author seems to have a preferred technique, few comparative studies have been performed. Miyake., et al. [9] consider primary anastomosis as a safe option for almost all patients with MP, except for those with extremely low birth weight and in an unstable condition. The advantages of primary anastomosis are reduced hospital stay, avoidance of stoma-related morbidity and second laparotomy for stoma closure. For all these reasons we performed 9 RPA in newborns weighing between 2500 and 3000g. Nam., et al. [29] reported a preference for primary resection and anastomosis of the intestinal segment involved. However, severe complications related to the surgical procedure itself, such as peritonitis from anastomotic leakage and perforation cause by frequent manipulation, are more often seen in primary anastomosis. It is difficult to assess objectively the viability and condition of the intestine; therefore, Karimi., et al. [32] considered primary anastomosis for complex MP as hazardous, which was in line with Nagar's experience [31]. They recommended resection with temporary double-barreled enterostomy as the safest treatment. In our center, we also performed 7 enterostomy face to patients in an unstable condition, with sepsis important of abdominal cavity. Three patients had reconstruction of intestinal continuity(stoma closure) 3 weeks later. we performed drainage procedures in 3 cases. Any of them didn’t need second operation. A drainage pro-cedure was always accompanied by supportive treatment of broad-spectrum antibiotics. In our opinion, operative strategy depends onclinical manifestations, patient's general condition and cause of MP.
Our mortality rate was 47,37% (9/19). Nam., et al. [29] reported 2.4% of mortality rate.
Citation: Tembely Samba., et al. “Meconium Peritonitis: Management in a Developing Country in Sub-Sahara Africa”. EC Paediatrics 8.9 (2019): 941-947.
Meconium Peritonitis: Management in a Developing Country in Sub-Sahara Africa
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Citation: Tembely Samba., et al. “Meconium Peritonitis: Management in a Developing Country in Sub-Sahara Africa”. EC Paediatrics 8.9 (2019): 941-947.
As this is a retrospective study with a limited number of patients, collected a period of 5 years, the results should be interpreted with care. Yet, our results suggest that RPA should be used with caution, it seems to be the safer procedure, but the difficulty of this procedure is to appreciate the intestinal viability during surgery. Enterostomy prevents peritonitis due to anastomotic leakage, the necessity of a second operation for the restoration of intestinal continuity being a relative disadvantage.
Conclusion
Four patients who underwent to enterostomy died in denutrition and MOF. three morbidities occurred including wound infection in 2 patients, intestinal fistula in 1 patient after RPA. five patients who had RPA are died in sepsis and denutrition. In general, mortality-related factors were preterm labor, persistent ascites, and persistent pulmonary hypertension owing to lung hypoplasia secondary to abdominal distension [16]. Nevertheless, beside these mortality-related factors this high mortality in our study is not surprising considering the myriad problems faced by our patients including low rate of prenatal diagnosis, late presentation, financial constraints, significant infra-structure gaps, lack of a neonatal intensive care and total parenteral nutrition.
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