The Telegraph
Since 1st March, 1999
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Double-barrel surgery to bridge gap in intestine

This year’s Durga puja came with doleful tidings for the Bera family of Midnapore. Their first child was diagnosed with a congenital malformation of the gut called ‘jejunal atresia’ with perforation in-utero and meconium peritonitis, a dreaded complication.

It was apparent that something was very wrong with the baby when he did not pass stool even two days after birth. “Normally babies pass tarry, sticky stool within the first 24-48 hours after birth. Known as ‘meconium’, this is present in the intestine from before the baby is born,” said Amitava Pahari, consultant paediatrician, Apollo Gleneagles Hospitals, where the baby was referred.

“When the baby came to us on July 23, two days old, he had a very distended abdomen with episodes of yellow vomiting, which suggested intestinal obstruction,” said Shampa Mitra Pahari, consultant neonatologist at the same hospital.

Since the baby’s life was in danger, an emergency surgery was performed on the two-day-old the same day. But “unpleasant surprises” awaited paediatric surgeon Debasish Mitra, who performed the operation. Because of a probable vascular accident while in the womb, a portion of the baby’s jejunum, or the upper part of the small intestine, was absent, leading to jejunal atresia or a gap in the mesenteries.

The proximal region was largely dilated and blood supply to the gut was affected. Meconium that had leaked from the gut, transformed into a calcified mass, producing a dense adhesion. This is the worst complication of jejunal atresia and is responsible for a high rate of infant mortality, the doctors maintained.

Compounding the problem further, the milk, fed after birth, could not make its way beyond the atresia and dilated the proximal part of the jejunum even more, resulting in visible distention of the baby's little tummy. Although the rest of his small intestine beyond the atresia and the large intestine was narrower than normal (microcolon), it was open throughout.

To save the infant’s life, the doctors performed a ‘double-barrel enterostomy’, an emergency surgery where the two ends of the jejunum are brought to the exterior through an opening created in the abdomen. “With compromised blood supply to the dilated intestine, this was the only surgical option at that time. Direct anastomosis could have led to complications like peritonitis, leakage from anastomosis, sepsis, pneumonia, etc,” explained Mitra.

After the surgery, the baby was maintained on total parenteral nutrition (TPN) for three weeks, following which, oral feed with an imported special pre-digested formula, was commenced. The doctors were happy to find the baby passing a “very watery stool” through the jejunal opening, as it meant the gut was gradually recovering and there was normal peristaltic movement.

“The main challenge in this surgery is to compensate the jejunal loss and maintain body weight, and we had to calculate the daily fluid loss and decide on the amount to be administered,” said Mitra Pahari.

After monitoring the baby very closely in the neonatal intensive care unit, doctors decided to take him to the OT for definitive surgery when he was 35 days old. In a delicate procedure known as ‘enterostomy closure’, the surgeons cut off the atretic or narrowed part of the small intestine and stitched the two ends.

As anticipated, the surgical team found that one end of the small intestine was still larger than the other. “We had to anastomose the two ends very securely to prevent any leakage of contents in future,” explained Mitra. A gain in weight and well-formed stool passed from the anal opening was clear indication of the baby’s recovery.

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