Anemia of Prematurity - Portal Neonatal

POSTOPERATIVE CARE FOLLOWING SURGERY FOR BOWEL
OBSTRUCTION
Section 7 of
11
Although laparotomy in the newborn period poses a significant stress to the patient, most infants
recover well following successful surgical correction of the cause of the bowel obstruction.
In the initial postoperative period, derangements in fluid balance, glucose metabolism, and respiratory
status are common. Most infants have some third-space fluid sequestration following laparotomy and
may require additional fluids in the postoperative period. Maintenance IV fluid requirements are initially
at least 1.5 times normal. Nasogastric decompression until normal bowel function is established aids
in the decompression of proximal bowel and facilitates healing of a bowel anastomosis. Following
surgery for bowel obstruction, a transient ileus is invariably present. If postoperative bowel function is
not expected to rapidly return, parenteral nutrition support is indicated. Patience before feeding a child
may avoid anastomotic breakdown or postoperative obstruction.
Once bowel motility is reestablished, an infant frequently demonstrates intolerance to lactose and
other complex carbohydrates. A predigested or lactose-free formula may initially aid in absorption. If
the terminal ileum is resected, derangements in folate metabolism and the enterohepatic circulation
may be observed. Wound care is usually straightforward, and empiric antibiotics are not generally
recommended after the perioperative period.
LONG-TERM OUTCOMES Section 8 of 11
In general, most infants with bowel obstruction who are expeditiously identified and treated have an
excellent outcome. Survival usually depends on comorbidities, such as degree of prematurity,
associated cardiac anomalies, and the presence of peritonitis or bowel compromise at the time of
surgery. The survival rate for duodenal atresia is greater than 90%. Long-term survival in patients with
volvulus and jejunoileal atresia depends upon the amount of bowel remaining after resection, but an
80-90% survival rate is expected. The rate of leaking anastomoses following repair of newborns with
jejunoileal atresia is approximately 15%.
Total parenteral nutrition and better methods for central IV access have greatly improved outcomes for
neonates who undergo surgery for bowel obstruction. Often, bowel function is not established for a
prolonged interval postoperatively. While total parenteral nutrition can support an infant through this
period, both long- and short-term complications are observed. Short-term complications from
parenteral nutrition include catheter sepsis, respiratory insufficiency, and problems related to securing
central venous access. Long-term problems include cholestasis, nutritional deficiencies, and
development of oral aversion.
As with any laparotomy, postoperative adhesions may develop. Operative technique that avoids
unnecessary manipulation of the bowel and spillage of enteric contents is perhaps the best prevention
against the development of intraperitoneal scar tissue.
Poor motility is often observed following bowel resection for obstruction. Chronic dilation of the
intestinal segment proximal to the obstruction may alter normal peristalsis across that segment of
bowel. For example, persistent constipation and delayed intestinal transit may not resolve after relief of
chronic partial volvulus via Ladd procedure. Interruption of vagal neuroenteric pathways by an atresia
or surgical anastomosis may also contribute to abnormal intestinal motility.
Short bowel syndrome deserves special mention. Short bowel syndrome results when the remaining
length of intestine cannot sustain normal absorptive functions. Normal length of the small bowel in a
term infant is approximately 250 cm and in an adult is 600-800 cm. The estimated minimum jejunoileal
length for sufficient bowel function in a term infant is 75 cm. Resection of more than 60% of the small
bowel predisposes the child to malabsorption, resulting in failure to grow and develop normally.