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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 127-129

Jejunostomy for enteral trophic feeding in the management of apple-peel intestinal atresia


1 Department of Pediatrics, Pediatric Surgery Section, Castellon General University Hospital, Castellón, Spain
2 Department of Pediatrics, Castellon General University Hospital, Castellón de la Plana, Castellón, Spain

Date of Submission14-Sep-2020
Date of Decision14-Jan-2021
Date of Acceptance28-Jan-2021
Date of Web Publication15-May-2021

Correspondence Address:
Natalie Isabel Garcia Smith
Department of Pediatrics, Pediatric Surgery Section, Castellon General University Hospital, Avenida de Benicassim s/n, 12004 Castellon de la Plana, Castellon
Spain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.jcn_147_20

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  Abstract 


Apple-peel (or Type IIIb) is an unusual and severe type of intestinal atresia that has generally been treated with anastomosis, entailing considerable morbidity. The aim of this case report is to present an alternative management option that allows intestinal adaptation before performing the anastomosis. We present a case of apple-peel atresia, born at 27 weeks, which during surgery presented a large discordance between the duodenum and the atretic segment. A jejunostomy of the distal atretic bowel was performed to initiate enteral trophic feeding and stimulate its growth. At 2 months of life, both anastomotic ends were similar in caliber and a side-to-side anastomosis was performed. Jejunostomy is an alternative management option that allows to perform a deferred anastomosis in better conditions.

Keywords: Enteral nutrition, intestinal atresia, jejunostomy, therapeutics


How to cite this article:
Garcia Smith NI, Casano CJ, Comella BP, Muñoz MO. Jejunostomy for enteral trophic feeding in the management of apple-peel intestinal atresia. J Clin Neonatol 2021;10:127-9

How to cite this URL:
Garcia Smith NI, Casano CJ, Comella BP, Muñoz MO. Jejunostomy for enteral trophic feeding in the management of apple-peel intestinal atresia. J Clin Neonatol [serial online] 2021 [cited 2022 Dec 2];10:127-9. Available from: https://www.jcnonweb.com/text.asp?2021/10/2/127/316174




  Background Top


Apple-peel (or type IIIb) intestinal atresia (APIA) is unusual (10%–15% of small bowel atresias).[1] Its appearance, at Treitz angle, is of an atretic segment that spirals like an apple peel following an aberrant artery, in the absence of superior mesenteric artery.[2]

APIA has two issues: intestinal ends have different calibers, and intestinal length is shortened.[2],[3] Traditionally, anastomosis and duodenal reduction/tapering are performed at 24–48 h.[2] Moreover, intestinal-lengthening procedures (enteroplasty, STEP, etc.) are often needed.

We describe an alternative management: jejunostomy and enteral trophic feeding (ETF), allowing a deferred anastomosis to be performed in better conditions.[4]


  Case Report Top


A 1105 g female was born at 27 weeks of gestation with prenatal diagnosis of duodenal atresia. An orogastric tube was placed, and antibiotic prophylaxis initiated. An X-ray confirmed the diagnosis [Figure 1]. At 48 h, a laparotomy disclosed a typical APIA distribution [Figure 2]. The proximal end was considerably dilated (2 cm diameter).[2] The distal bowel had a small caliber (0.4 cm diameter) and length (80 cm). Prematurity, low weight and discordance between intestinal ends made it difficult to perform an anastomosis in optimal conditions, reason why a jejunostomy was preferred. The proximal duodenum was left closed.
Figure 1: “Double bubble” image suggesting duodenal atresia

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Figure 2: Typical apple-peel (or type IIIb) intestinal atresia distribution following an aberrant vessel (A). Jejunostomy (J). Dilated duodenum (D)

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Parenteral nutrition was initiated, and a transpiloric tube was placed for suction (initially continuous but, due to technical problems, soon changed to manual suction every 8 h). We did not use any medication (such as somatostatin) to decrease duodenal drainage. Ten days after, ETF through jejunostomy was initiated with physiologic serum and 7 days after, elemental formula at 20 ml/kg/day, increasing progressively until 50 ml/kg/day. A rectal bleeding forced us to stop enteral nutrition, which was slowly reinitiated until 155 ml/kg/day (at 2 months of life). Parenteral nutrition was then removed, and a contrast radiography through the jejunostomy showed an adequate intestinal caliber.

A primary side-to-side anastomosis was then performed, at 2 months of life, with anastomotic ends of similar caliber. One month later (43 weeks of gestational age; 7th weight-for-age percentile; 3rd length-for-age percentile), the patient was discharged with exclusive breastfeeding.

The patient is now 3 years old (20th weight-for-age percentile; 3rd length-for-age percentile) and has a well-formed bowel movement a day. No other surgical procedures have been required, and there have been no bowel obstruction episodes.


  Discussion Top


Optimal surgery for APIA remains unclear.[2] There are few publications about surgical techniques for APIA, mostly case reports recommending initial anastomosis.

Initial anastomosis needs of a duodenal resection/tapering (decreasing nutrient absorbance) and entails severe morbidity immediately after surgery:

  • Functional bowel obstruction: despite a wide anastomosis, the dilated duodenum favors blockage of intestinal content.[1],[2],[4] Reason why it is important to adjust the caliber of intestinal ends in atresias
  • Anastomotic leak: intestinal content can leak through the anastomosis, leading to neonatal sepsis. A dilated duodenum or duodenal tapering increases this risk
  • Transanastomotic tube displacement: due to difficulty for tube fixation. If this happens early, feeding cannot be initiated and risk for anastomotic leak increases.


Initial anastomosis also entails long-term complications:

  • Short bowel syndrome: duodenal reduction/tapering decreases mucosal surface and nutrient absorbance.[2] These patients often need further bowel lengthening surgeries and depend on parenteral nutrition
  • Recurrent bowel obstructions: usually at the anastomotic site and within the 1st year of life.


We performed a jejunostomy to avoid the morbidity of anastomosis, especially because the duodenum was very dilated, and the patient had a very low weight. This technique has been used in the past, but it was replaced by anastomosis to avoid a second surgery for duodenojejunostomy.[4] It is technically simpler and preserves absorbent intestinal surface. It enabled us to feed the patient directly to jejunum, avoiding complications derived from the anastomosis. ETF, defined as administration of insignificant volumes to increase bowel diameter and nutrient absorbance, stimulated intestinal development, avoiding further intestinal lengthening techniques.[5] Performing the anastomosis in a second surgery allowed us to do it in safer conditions (technically easier and in better health conditions).

The main inconvenience of jejunostomy is that it requires a second surgery. Nevertheless, if we think of complications that initial anastomosis entails and surgical treatments required to resolve them; global number of surgeries may probably be higher.

Looking for faults in this case, we concluded that a contrast enema before surgery would have probably revealed the APIA distribution.[1],[4] This would not have changed the treatment, but it is always advisable to have a precise diagnosis before surgery.

Jejunostomy is an alternative technique if primary anastomosis is not viable, especially in low-weight prematurity or if other comorbidities are associated. It promotes stimulation for nutrient absorbance and intestinal caliber growth, guaranteeing a functional deferred anastomosis.

Acknowledgments

We would like to express our gratitude to the Pediatric Intensive Care Unit in Hospital General Universitario de Castellón, who have made substantial contributions to the clinical assistance of the patient reported in the manuscript.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Herman TE, Siegel MJ. Apple peel small bowel. J Perinatol 2008;28:380-2.  Back to cited text no. 1
    
2.
Onofre LS, Maranhão RF, Martins EC, Fachin CG, Martins JL. Apple-peel intestinal atresia: Enteroplasty for intestinal lengthening and primary anastomosis. J Pediatr Surg 2013;48:E5-7.  Back to cited text no. 2
    
3.
Balanescu R, Topor L, Stoica I, Moga A. Associated type IIIB and type IV multiple intestinal atresia in a pediatric patient. Chirurgia (Bucur) 2013;108:407-10.  Back to cited text no. 3
    
4.
Federici S, Domenichelli V, Antonellini C, Dòmini R. Multiple intestinal atresia with apple peel syndrome: Successful treatment by five end-to-end anastomoses, jejunostomy, and transanastomotic silicone stent. J Pediatr Surg 2003;38:1250-2.  Back to cited text no. 4
    
5.
Ben XM. Nutritional management of newborn infants: Practical guidelines. World J Gastroenterol 2008;14:6133-9.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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