Mangament, Surgical and non Surgical management of meconium ileus

1. Review of Surgical
options in Simple
Meconium Ileus
Dr. Almumtin, Ahmed

2. Introduction
• Isolated versus part of an entity.
• Simple and Complicated types.

3. Incidence and pathogenesis
• 9-33% of all intestinal obstruction.
• 1:25000 newborns.
• 3rd case of neonatal small bowel obstruction.
• prenatal detection.
• association with congenital anomalies

4. Genuine associations
• Cystic fibrosis and meconium ileus.
• Meconium ileus and the premature infants.
• Meconium with lower carbs, high proteins, and
albumin.
• CFTR gene, approx 1000 mutations.

5. Clinically and Gross
description
• Presentation:
• Abd. distension 96%
• bilious vomiting 50%
• delayed passage of
meconium.

6. Differential Diagnosis

7. Radiographically
• Plain X-rays:
• Unevenly dilated loops of bowel
• Variable presence of air-fluid levels
• Bubbles of gas.
• Contrast enema:
• Microcolon.

8. Treatment
• Non-Operative.
• Operative.

9. Non-Operative treatment
• Volume resuscitation.
• Gastric decompression
• Respiratory support if needed.
• empirical antibiotics.
• Hyperosmolar enema washout

10. Hyperosmolar Enema
• Aims for hydration and softening of meconium mass.
• Careful resuscitation, hydration, appropriate electrolytes
repletion and maintenance of normothermia.
• Must be performed under fluoroscopic control.
• slow infusion to the rectum. Meconium pellets usually will
pass in the next 24-48 hours.
• Warm saline enemas with 1% N-acetylcysteine is of help

11. Hyperosmolar Enema
• after successful evacuation, 5 ml of 10% N-
acetylcysteine is given through NGT Q6 hours.
• Consider pancreatic enzymes if suspecting CF.
• Success rate range 63-83%

12. Operative Management
• Indications:
• Inadequate meconium evacuation or
complications of contrast enema.
• failure of hyperosmolar enema to promote
passage of meconium in 24-48 hours.
• if associated with intestinal atresia

13. Principles
• Manual evacuation.
• Entrotomy, intraoperative
saline irrigation,
mechanical separation of
pellets from bowel wall.
• 2% or 4% N-
acetylcysteine or 50%
hyperosmolar solution
instillation can be helpful.

14. Principles
• Resection of the extremely dilated proximal
segment (in order to avoid size discrepancy)
anastomosis.
• Complication is leak.
• The other option; resection, with creation of
stoma.

15. Techniques
• Mikulicz Double barrel enterostomy.
• Advantages:
• Less operative time.
• Risk of leak is avoided.
• Solubilizing agents can then be administered
in distal and proximal loops.
• Disadvantages:
• Potential high stoma output and fluid
losses.
• long resections can result in short bowel
• the need for another surgery to restore
continuity in later time.

16. Techniques
• Distal chimney enterostomy (Bishop-
Koop procedure )
• resection with anastomosis between the
end of the proximal segment and the side
of the distal segment of bowel
approximately 4 cm from the opening of
the distal segment
• The distal end is brought out as the
ileostomy
• This technique allows for normal
gastrointestinal transit while providing a
means for management of the distal
obstruction through the ileostomy should it
occur

18. Techniques
• Proximal chimney enterostomy
(Santulli)
• Distal limb end is anastomosed to
the side of proximal limb
• enhanced proximal irrigation and
decompression.
• no need for evacuation at the time of
surgery
• risk of high output stoma, and
consequent electrolyte disturbance
and dehydration.

19. Techniques
• Primary resection and anastomosis
• resection of the obstructed segment.
• irrigation of remaining pellets in the
distal bowel.
• ileocolic anastomosis.
• disadvantages:
• Anastomosis complications.
• resection of additional bowel
(terminal ilium containing pellets with
the dilated segment of ileum)

20. Post-operative management
• Resuscitation, maintenance fluids.
• Replacement of fluid losses ( through NGT or
ileostomy)
• 2 or 4% N-acetylcystein via NGT or ileostomy.
• Workup of Cystic fibrosis.
• Keeping the placed stoma in mind for future
closure.

21. Nutrition Support
• As bowel function resumes, oral feeding can start with
breast milk or infant formula.
• Supplemental pancreatic enzymes and vitamin.
• those with long post-surgical course might require
enteral feeds or TPN.
• watch for TPN associated cholestasis.
• Glutamine-enriched formulas to the distal bowel maybe
tried to enhance bowel growth

22. References
• Pediatric Surgery Diagnosis and Management,
Prem Puri, Michael Holwarth
• Ashcraft’s pediatric surgery, 5th edition.
• Pediatric Surgery (Springer Surgery Atlas Series).
• Operative pediatric suregry, Lewis Spitz, Arnold
G Coran. 7th edition

23. Thank You