Peritoneal drainage versus laparotomy as an initial treatment in complicated necrotizing enterocolitis: a single institution experience

Objective To determine whether initial peritoneal drainage (PD) or primary laparotomy is the most effective intervention in very-low-birth-weight and extremely lowbirth- weight infants who are diagnosed with necrotizing enterocolitis (NEC, Bell’s stage II and stage III).Patients and methods It is a retrospective chart review study. Demographic data, clinical characteristics, and outcome were reviewed from records of neonates with severe NEC requiring surgical intervention (Bell’s stage II and stage III) at our institution from 2003 to 2009.Results Thirty-two patients were included in our study. Seventeen patients (53.1%) underwent PD and 15 patients (46.8%) underwent laparotomy. Out of 17 patients in the drainage group, 11 patients (64.7%) underwent laparotomy and six patients (35.2%) did not undergo laparotomy because they were sick and died within few days. Difference in gestational age, sex, and birth weights between two groups was not statistically significant. Similarly, difference in variables as mode of delivery and days of enteral feeding was not statistically significant. Mean age at diagnosis was 31.5 days for the laparotomy group and 18.4 days for the drainage group. P value was 0.026 in the univariate analysis, but P value in the final model of analysis was found to be statistically not significant. It was found from our study that patients with many associated diseases were more in the PD group (P value was 0.008). Almost all patients were mechanically ventilated. Mean pH was 7.29 in the laparotomy group and 7.25 in the drainage group, which was statistically not significant. In the PD group, 13 patients required vasopressors; however, only four patients in the laparotomy group were on vasopressors (P value was 0.017). Difference in variables such as indomethacin, white blood cell count, and platelet count was found to be statistically not significant between the two groups. Six patients were on steroids in the PD group and only one patient was on steroid in the laparotomy group (P value is 0.007). In addition, outcome at 90 days was analyzed; nine patients died in the PD group, whereas four patients died in the laparotomy group (P value is 0.081). Data were also analyzed for complications such as stricture, short bowel syndrome, and cholestasis and the difference was not significant. Finally, total parenteral nutrition dependency difference was found to be statistically not significant between two groups.Conclusion Patients were very sick in the PD group and they were on vasopressors and steroids. Moreover, it was found that diagnosis of NEC early in life signifies a higher mortality. Insertion of a PD is still useful in resuscitating small critically ill infants with NEC; however, the majority of these infants will require subsequent laparotomy. Early diagnosis and early intervention are necessary to decrease the inflammatory insults to the body systems and this reflects on survival.Keywords: drainage versus laparotomy, less than 1500 g, necrotizing enterocoliti

Infantile hypertrophic pyloric stenosis: a single institution’s experience

Background/purpose Infantile hypertrophic pyloric stenosis (IHPS) is said to be relatively common in the western world, but its incidence in the Kingdom of Saudi Arabia is unknown. We set out to study the incidence of IHPS in children presenting at our hospital and review the clinical presentation and treatment outcomes of such patients.Patients and methods A retrospective chart review of all cases with IHPS admitted to a tertiary hospital, Riyadh Military Hospital, over 18 years (1990–2008) was conducted. Diagnosis was confirmed by ultrasonography according to the length of the pyloric channel and thickness of the pyloric muscles. An analysis of demographic data, clinical presentation, diagnostic modality, and associated congenital anomalies was carried out. Operative technique, postoperative course, and complication rates were identified.Results The review of the medical records showed 22 patients with a diagnosis of IHPS. The incidence rate of IHPS was 1.4/10 000 live births. Demographically, most cases presented in the first month of life. It is more common in boys. In all, 55% of infants were first borns. Clinically, nonbilious projectile vomiting was the main symptom. Mild dehydration was found in half of the cases with alkalotic changes. Ultrasonography was the main diagnostic modality in 82% of cases. Others were diagnosed by contrast study. Open Ramstedt pyloromyotomy was the surgical approach in 20 (91%) cases and the laparoscopic approach in 2 cases (9%). Fourteen (14%) patients had an associated congenital inguinal hernia. The mean length of hospital stay was 5.5 days. The most common postoperative complication was wound infection in 4.5% of patients. Incidence of IHPS had obvious seasonal association.Conclusion Incidence of IHPS at our hospital (the biggest hospital in the Kingdom of Saudi Arabia with an annual birth record of 14 000) is far less common than international incidences reported in North America and Europe. More reports from Saudi Arabia, the Middle East, and Asia are recommended to support the rarity of IHPS in this region of the world. Seasonal variation suggests a possible etiological role for environmental factors. It is of practical use for both epidemiologists and clinicians for future comparability.Keywords: incidence, infantile pyloric stenosis, risk factor