Tricks - Neonatal Gastric Necrosis - Sherif Emil

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

Twin-to-twin transfusion ablation 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), vertically transmitted to both neonates

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

On day 3, 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 large amount of free air on imaging, including unusual shadow in left upper quadrant appearing like loculated free air

Intraoperative findings: longitudinal perforation along greater curvature with entire corpus and fundus/cardia necrotic, not holding stitches, with only couple centimeters of good antrum remaining

For subtotal gastric necrosis in unstable 1-kg neonate, damage control approach includes removing necrotic tissue, controlling proximal extent with tie or vessel loop, stapling or sewing distal end, placing feeding jejunostomy, and leaving drain near GE junction

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

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

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

On post-op day 3, bilious drainage appeared from Penrose drain; on day 4, patient distended and became difficult to ventilate with large amount of free air on imaging

Second laparotomy findings: no problem with distal esophagus or gastric remnant, but new intestinal perforations at different sites than previous repairs

Second operation addressed 3cm proximal jejunal necrosis 5cm from ligament of Treitz (resection and primary anastomosis) and spontaneous distal ileal perforation (debridement and repair)

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

At 2 weeks post-op, contrast studies showed esophagus became like atresic esophagus with segment below diaphragm; no leak around Foley balloon as esophagus had fibrosed around catheter

Distal contrast study through gastric remnant showed all resections healed without stenosis, with contrast traversing bowel in short period

Initial gastric remnant feeding limited by capacity (maximum 34cc); leak around G-tube occurred with larger volumes and poor pyloric emptying

Gastroduodenal feeding tube advanced through gastrostomy under fluoroscopy successfully weaned patient off TPN; small amounts of sham feeds given orally and suctioned through esophageal tube

Salvaging remaining 1cm of cardia to create 4 cubic centimeter stomach would result in microgastria with attendant reflux and other problems

Hunt-Lawrence pouch has been described for microgastria but in speaker's experience with two patients, they had trouble emptying with significant stasis and poor progression

Michigan group published case report of microgastria treated with Roux-en-Y esophago-fundojejunostomy (approach used for adult gastric cancer)

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, 5kg weight) using Roux-en-Y fundojejunostomy with segment 15cm distal to ligament of Treitz and 25cm limb

Post-op day 6 contrast study through esophagus showed good emptying; combination oral and gastrostomy feeds started

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 nighttime gastrostomy supplementation (anticipated to discontinue early in new year), and is bigger than unaffected twin