Neonatal Gastric Necrosis: Pediatric Surgery Difficult Cases-Innovative...

Patient was a twin girl born at 27 weeks weighing just over 1 kg with prenatal diagnosis of twin-to-twin transfusion syndrome as the recipient twin

Laser ablation for TTTS was performed at 22 weeks gestation

Stat C-section performed due to maternal septic shock from E. coli sepsis (initially thought to be amniotic fluid embolus) with premature rupture of membranes, vertically transmitted to both neonates

Apgar scores were 3 at 1 minute and 1 at 5 minutes, patient intubated at birth

On day 3 of life, iatrogenic manipulation of umbilical venous line caused atrial flutter and significant tachycardia with hemodynamic instability requiring cardioversion

At presentation for cardioversion, patient had significant abdominal distention with imaging showing very large amount of free air and unusual shadow in left upper quadrant appearing like loculated free air

For subtotal gastric necrosis in unstable neonate, damage control approach should remove frankly necrotic tissue, control upper leakage with tie/vessel loop or drain, and create distal feeding access

Operative findings showed longitudinal perforation along greater curvature with entire corpus extending into fundus and cardia necrotic and not holding stitches, with only margin at cardia and couple centimeters of antrum appearing healthy

Drain placement for gastric necrosis with unidentifiable proximal extent should be positioned under the liver near the GE junction to drain whatever comes out

First operation performed damage control: removed necrotic stomach, placed Foley catheter (0.5cc balloon) in distal esophagus, left Penrose drain under left lobe of liver, created ostomy from 2.5cm gastric remnant

Small bowel was like wet toilet paper and multiple hematomas developed in bowel wall from handling, several of which perforated requiring multiple enterorrhaphies

Patient was quite coagulopathic by end of first operation but became hemodynamically stable within 12 hours without pressors and with good urine output

On postoperative day 3, bilious drainage appeared from Penrose drain; on day 4 patient re-distended with difficulty ventilating and imaging showed significant free air again

Second laparotomy revealed no problem with distal esophagus or gastric remnant, but new intestinal perforations: 3cm proximal jejunal necrosis 5cm from ligament of Treitz and spontaneous distal ileal perforation, not at sites of previous repairs

Jejunal necrosis treated with resection and primary anastomosis; ileal perforation debrided and repaired; gastrostomy and esophagostomy tubes left intact

Patient required only CPAP after 7 days of mechanical ventilation despite extreme prematurity

Contrast studies at 2 weeks post-op showed esophagus became like atresic esophagus with segment below diaphragm, no leak around Foley balloon, and esophagus had fibrosed around the catheter

Distal contrast study showed gastric remnant emptied well with healed resections and no stenosis

Initial gastric feeding was limited by gastric capacity at approximately 34cc, with leak around G-tube when larger volumes attempted

Gastroduodenal feeding tube advanced through gastrostomy successfully weaned patient off TPN with all feeds through small intestine plus small amounts of sham feeds suctioned through esophageal tube

For reconstruction with remaining proximal and distal stomach segments, attempting to connect the two stomach ends is reasonable but if unsuccessful a jejunal conduit should be used

Salvaging a 4 cubic centimeter stomach would create microgastria with attendant problems of reflux and other issues

Two patients with Hunt-Lawrence pouch (not performed by speaker) had persistent trouble emptying with significant stasis and poor progression

Pre-reconstruction contrast study showed small gastric segment remaining with esophagus distending nicely without strictures

Reconstruction performed at 5 months of age, 55 weeks post-conception age, weight 5kg, using Roux-en-Y fundojejunostomy with segment 15cm distal to ligament of Treitz and 25cm limb

Post-reconstruction contrast study on postoperative day 6 showed good emptying, allowing start of combination oral and gastrostomy feeds

Patient discharged 52 days after reconstruction with total hospital stay of 207 days

At 2.5 years old, patient takes normal diet for age on full oral feeds with only nighttime gastrostomy supplementation anticipated to be discontinued early in new year, and is larger than unaffected twin