2Department of Pediatric Surgery, Katip Çelebi University, Tepecik Training Hospital, Izmir, Turkey
Volkan Sarper Erikci, Attending Pediatric Surgeon, Associate Professor of Pediatric Surgery, Sağlık Bilimleri University, Turkey, GSM: +90 542 4372747, Business phone: +90 232 4696969, Fax: +90 232 4330756; E-mail:
Pneumoperitoneum is usually an indication of perforated intestine and requires prompt surgical intervention [17,18]. In addition to bluish discoloration of the abdominal wall, a gasless abdomen and absence of pneumatosis intestinalis have also been reported as further significant markers in infants with SIP . All these finfings were observed in our patient. Other radiological findings of intestinal perforation other than pneumoperitoneum include clear visualisation of the outer and the inner wall of bowel loops (Rigler’s sign), triangular gas collections between the intestinal loops (sign of triangle) and gasless abdomen [2,16,19]. Only gasless abdomen on x-ray was observed in our patient preceeding pneumoperitoneum.
Although spontaneous healing of gut perforations in neonates have been documented and an initial conservative management for intestinal perforation have been suggested by some authors, early surgical intervention remains to be cornerstone in the treatment of SIP. Primary peritoneal drainage (PD) have been suggested as a primary or definitive procedure [20-25]. It allows acute improvement, systemic recovery but most of these infants require a subsequent laparotomy. Initially PD was performed in our patient because general anesthesia and laparotomy were regarded as risky and it provided time for stabilization of the baby. Definitive surgical treatment in SIP include primary closure if possible, resection and re-anastomosis and ileostomy formation [16,26]. Due to abdominal contamination with bile and intestinal material, primary closure or resection and re-anastomosis were found to be hazardous and a loop ileostomy at the ileal perforation site was performed.
Although there is no general concensus concerning timing of stoma closure in neonates and prematures, early ileostomy closure can be safely done and should not be delayed [27-29]. Ileostomy complications occur as the time passes by and include stomal prolapse, skin excoriation, stricture etc. It has been reported that patients with ileostomy face with more stomal complications if ostomy closure was performed 2 months or later after ileostomy procedure . Although stoma closure was performed on the 5th postoperative week in our patient, stomal prolapse was observed during her stay in NICU. Nevertheless, as sson as the patient gains weight and after performing a distal ileostography confirming the patency and integrity of the bowel distal to ostomy, there should not be a delay for stomal closure in these patients.
SIP is a distinct clinical entity in neonates and prematures. Apart from PD, ileostomy formation especially critically ill prematures may be life saving procedure. SIP seems to have a good prognosis even in VLBW infants if diagnosed and treated promptly.
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