The initial clinical findings were sudden-onset hemorrage and âcoffee-groundâ vomiting in 5 of the 9 full-term neonates, and abdominal disten- sion and vomiting ...
Surg Today (2004) 34:243–245 DOI 10.1007/s00595-003-2675-3
Neonatal Gastric Perforation: Review of 23 Years’ Experience . . Cem Sultan Kara, Zekeriya Ilçe, Sinan Celayır, Nüvit Sarimurat, Ergun Erdogan, and Daver Yeker Department of Pediatric Surgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
Abstract Purpose. To review our experience of treating 13 neonates with gastric perforation (GP) over the past 23 years. Methods. The records of all 13 patients were reviewed, noting gender, weight, gestational age, age at admission, associated anomalies, site of perforation, type of operation, and clinical outcome. Results. There were 11 boys and 2 girls, with a mean body weight of 2 375 g, including 4 (45%) preterm infants. The mean age at admission was 3.2 days. Three (23%) infants had associated anomalies. Perforation occurred in the lesser curvature and anterior wall in 3 (23%) infants, at the greater curvature and anterior wall in 2 (15.4%), in necrosis of anterior wall in 1 (7.7%), at the esophageal junction and posterior wall in 2 (15.4%), at the lesser curvature and posterior wall in 1 (7.7%), at the lesser curvature and esophageal junction in 1 (7.7%), and the site was not specified in 3 (23%). Twelve patients were treated with gastrorrhaphy and drainage, and 1 was treated with gastrorrhaphy alone. Three patients required additional gastrostomy. Mortality was 53.8% (n ⫽ 7). Early diagnosis and management before clinical deterioration of the metabolic status improved the prognosis. Conclusion. The pattern of presentation and surgical findings should be investigated comparatively in premature and full-term neonates, as the etiology of this condition is likely to differ in these two gestational groups. Key words Gastric perforation · Neonate
. Reprint requests to: S. Celayır, Sakacı Sokak, Mehmet Sayman Apt. No: 77, Daire: 8, 34736 Kazasker, Kadiköy, Istanbul, Turkey Received: November 25, 2002 / Accepted: May 27, 2003
Introduction Neonatal gastric perforation (GP) is a very rare event associated with a poor prognosis. There is still much debate about its etiology,1–3 but recent findings suggest that lack of the interstitial cells of Cajal (ICC) may be implicated in the etiology of idiopathic GP in neonates.4 Most historical reports describe GP in the neonatal population as “spontaneous”;5–10 however, several variables, including prematurity and nasal ventilation, have recently been implicated as contributing factors.6,8,10 The purpose of this study was to review our experince of treating newborns with GP and discuss the underlying etiology of this life-threatening condition.
Patients and Methods We reviewed the records of all newborns admitted to our hospital between 1978 and 2001 with regard to gender, age at admission, site of perforation, type of operation, associated anomalies, contributing factors, and outcome.
Results Gastric perforation was diagnosed in 13 neonates: 11 (85%) boys and 2 (15%) girls. The mean body weight was 2 375 g (range 990–3 100 g). There were 4 (30.7%) preterm infants and gestational age ranged from 29 to 35 weeks. The mean age at admission was 3.2 days (range 1–7 days). The initial clinical findings were sudden-onset hemorrage and “coffee-ground” vomiting in 5 of the 9 full-term neonates, and abdominal distension and vomiting in the other four. The initial finding in the 4 preterm neonates was abdominal distension. Radiographic evidence of gastric distension was typical and preceded the clinical signs of hematemesis and
C.S. Kara et al.: Neonatal Gastric Perforation
Died Alive Died Died Alive Died Died Died Alive Died Alive Alive Alive Ant., anterior; Post., posterior, Cur. Min., curvatura minor; Cur. Maj., curvatura major; EG, esophagogastric; Gast., gastrostomy
⫹ Gast. ⫹ drainage ⫹ drainage
Hydrocephaly — — Hydrocephaly — — — — Intestinal volvulus — — — — ⫹ drainage ⫹ Gast. ⫹ drainage ⫹ drainage ⫹ Gast. ⫹ drainage ⫹ drainage ⫹ drainage ⫹ drainage ⫹ drainage ⫹ drainage ⫹ drainage
Gastrorrhaphy Gastrorrhaphy Gastrorrhaphy Gastrorrhaphy Gastrorrhaphy Gastrorrhaphy Gastrorrhaphy Gastrorrhaphy Gastrorrhaphy Gastrorrhaphy Gastrorrhaphy Gastrorrhaphy Gastrorrhaphy Cur. Min. — Ant. Cur. Min. — Ant. Cur. Min. — Ant. wall necrosis Cur. Min. — Ant. EG junction — Post. Cur. Maj. — Ant. Cur. Maj. — Ant. Unknown Unknown Unknown EG junction — Post. Cur. Min. — EG junction Cur. Min. — Post. M M M M F M F M M M M M M 1 2 3 4 5 6 7 8 9 10 11 12 13
1/365 1/365 1/365 2/365 2/365 7/365 6/365 5/365 3/365 3/365 3/365 4/365 4/365
Site of perforation Time of admission Sex Patient no.
Table 1. Demographics of the 13 infants with gastric perforation
Surgery
Associated anomaly
Outcome
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GP. Three (23%) infants had associated anomalies, namely, intestinal volvulus in 1 and hydrocephaly in 2. Abdominal plain X-ray films always showed pneumoperitoneum. The most common site of perforation was the curvatura minor of the stomach, seen in 5 infants (38.5%). The exact site of perforation was the curvatura minor and anterior wall in 3 infants (23%), the curvatura major and anterior wall in 2 (15.4%), necrosis of the anterior wall in 1 (7.7%), the esophageal junction and posterior wall in 2 (15.4%), the curvatura minor and posterior wall in 1 (7.7%), the curvatura minor and esophageal junction in 1 (7.7%), and the exact perforation site was not documented in 3 (23%). Twelve infants were treated by gastrorrhaphy and drainage, and 1 was treated by gastrorrhaphy alone. Three patients required additional gastrostomy. The demographics are summarized in Table 1. There were no predisposing factors such as mechanical ventilation or nasal O2 therapy. Seven (53.8%) infants died, 6 from septicemia and 1, with hydrocephaly, from respiratory failure. The remaining 6 (46.2%) recovered and were discharged from hospital.
Discussion In the field of pediatric surgery, GP is a well-recognized complication of esophageal atresia with distal tracheoesophageal fistula, and is usually associated with extreme prematurity, hyaline membrane disease, and mechanical ventilation.6 On the other hand, spontaneous neonatal GP is a rare neonatal event, occurring in 1 : 2 900 live births, and its etiology is controversial. Rosser et al.1 and Leone and Krasna2 reported a congenital muscular defect in the muscularis as a causative factor in neonatal spontaneous gastric perforation, while Touloukian found ischemic changes in their series and postulated a vascular etiology.11 Although the stomach is well vascularized, spontaneous perforations and necrosis do occur in neonates. The majority of defects are proximal linear tears along the greater curvature that occur as a seromuscular laceration, resulting in mucosal ballooning with a pinhole perforation in the top. These findings have led some authors to think that the perforation is caused by a mechanical rupture of the stomach wall, as a result of increased intragastric pressure, in both full-term and premature infants.12 Prematurity has recently been shown to be a common feature in spontaneous gastric perforation.2–4,6,7 Corresponding to this finding, apart from prematurity, there was no other predisposing factor in our patients. The most common clinical findings are tachypnea, respiratory distress, abdominal distension, and pneumoperitoneum, which also correspond to our findings. Gastric perforation is one of the most common causes of pneu-
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moperitoneum during the first week of life. The third day has the highest incidence but it an occur at any time in early infancy.9,10,13,14 The differential diagnoses of neonatal spontaneous GP include acute necrotizing enterocolitis, septicemia, intestinal obstruction, and pneumoperitoneum without GP.1 In our series, GP most commonly occurred in the anterior surface of the lesser curvature (55.5%) and the preferred surgical treatment was gastrorrhaphy with drainage, similar to other reports. We performed additional gastrostomy in three infants, but the need for this is still controversial. Although GPs occur in healthy full-term infants, despite the advances in surgical and perioperative management, it is still associated with very high mortality rates of up to 70%.9 In our series, all of the premature infants died. Moreover, delayed admission increased the risk of mortality and septicemia was the main cause of death. As gastrointestinal perforation is a lifethreatening condition in neonates, cooperation among neonatologists, pediatric surgeons, and nursing staff is essential for improving the survival of these high-risk babies. According to past records most cases of GP were considered spontaneous. Our review of these 13 cases over a 23-year period also supports the term “spontaneous,” because apart from prematurity and concomitant associated anomalies, no cause was found in any of our patients. However, when GP occurs in a neonate, a contributing cause must still be investigated. This study was retrospective and observational. The most notable difference from past reports was the distribution of perforation sites. Gastric perforation usually occurs in the gastric fundus or greater curvature area, but in our series the most common site of perforation was the lesser curvature. The distribution of gestational age was also unusual, with only four premature infants, considering that most of infants described in other re-
ports were very premature or of very low birth weight. We think that the etiology of this condition is likely to differ between the two gestational groups, and that the pattern of presentation and surgical findings should be investigated in premature and full-term infants. The results of such a study could provide clues about the etiology of neonatal GP.
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