Congenital atresia of the small intestine - treatment - acute processes in the abdominal cavity in children. Treatment of intestinal atresia. Diagnosis and treatment

The invention relates to medicine and will find application in surgery for the treatment of atresia small intestine in newborns. The method is carried out as follows. A laparotomy is performed. The blind end of the efferent part of the small intestine is resected and a microcatheter is placed in its lumen to the ileocecal angle. After resection of the enlarged part, the afferent section of the small intestine is anastomosed into the side of the afferent small intestine, 6–8 cm from its end, which is brought out to the anterior visceral wall through a separate incision in the form of an intestinal stoma. IN postoperative period, starting from 2 - 3 days, a glucose-polyglucin mixture consisting of equal volumes 40% glucose and 33% polyglucin. The amount of the administered mixture corresponds to the volume of the lumen of the outlet section of the small intestine. The mixture is administered for 5 to 10 days until independent stool appears. The introduction of a glucose-polyglucin mixture into the lumen of the functionally defective efferent section of the small intestine promotes a more rapid restoration of its motor-evacuatory function and thereby prevents significant losses intestinal contents through a T-shaped stoma. 4 ill.

The invention relates to medicine and will find application in surgery in the treatment of small intestinal atresia in newborns. Among the causes of congenital intestinal obstruction requiring surgical treatment in the first days of life, small intestinal atresia is observed in 42% of cases. Postoperative mortality for this malformation, according to both domestic and foreign authors, exceeds 50%. Research conducted in scientific, medical and patent literature has identified a number of methods for treating this pathology. In the monograph "Surgical gastroenterology" childhood"(A.G. Pugachev. M. Medicine, 1982, p. 288) on pp. 121 and 122 a method of treating small intestinal atresia is described, which is carried out as follows. After laparotomy, the loops of the small intestine are removed into the wound. Dilated adductor section of the small intestine (Fig. 1, position 1) is resected over a length of 10–15 cm. The efferent colon (Fig. 1, position 2) after cutting off the blind end is washed with warm isotonic solution. Then, a direct end-to-end anastomosis is performed between the afferent and efferent parts of the small intestine. This method has the following disadvantages. Firstly, despite the resection of the distal end of the afferent colon, there remains a significant discrepancy between its diameter and the diameter of the afferent colon, which significantly complicates the application of an end-to-end anastomosis. Secondly, this method does not take into account the violation of the motor-evacuation function of the abducens intestine, which did not function during the period intrauterine development from the moment of atresia formation. Overlay direct anastomosis with a functionally inferior, and in some cases hypoplastic, outlet colon can lead to failure of this anastomosis and the development of peritonitis. There is a known method of treating intestinal atresia, which consists in bringing it to the anterior abdominal wall in the form of a double-barreled stoma of the adducting (Fig. 2, position 1) and efferent (Fig. 2, position 2) parts of the small intestine after preliminary resection of their blind ends (“ Operative surgery", edited by Prof. Littmann, Hungarian Academy of Sciences, Budapest: pp. 477 and 478). This method is a selection operation when in serious condition child when performing radical surgical intervention contraindicated. The disadvantage of this method is that, while eliminating intestinal obstruction, it does not restore gastrointestinal continuity. -intestinal tract. In the immediate postoperative period, these children require additional intervention aimed at connecting the adductor and efferent parts of the small intestine. The prototype of the invention is a method for treating small intestinal atresia. This method consists of resection of the expanded part of the adductor section of the small intestine and the imposition of a T-shaped anastomosis from the end of the adductor section (Fig. 3, position 1) to the side of the abductor section (Fig. 3, position 2), 10 cm away from its blind end. Then the blind end of the efferent colon is resected and brought to the anterior abdominal wall in the form of an enterostomy. In foreign literature, this method is known as the Bishop-Coop operation. Enterostomy with this method of treatment performs a decompressive function, reducing intraluminal pressure in the anastomosis area, and thereby preventing its failure. The disadvantage of this method is that restoration of the motor-evacuation function of the efferent part of the small intestine occurs over a long period of time and can lead to significant loss of intestinal contents through the T-shaped stoma, maceration of the skin around the stoma and exhaustion of the child. The purpose of the invention is to prevent postoperative complications at surgical treatment small intestinal atresia caused by prolonged loss of intestinal contents through a stoma. This goal is achieved by introducing a glucose-polyglucin mixture, which has high osmotic and hydrophilic activity, into the lumen of the outlet portion of the small intestine through a microcatheter in the postoperative period. The implementation of the method is illustrated in Fig. 4. The method is carried out as follows. A laparotomy is performed. The blind end of the outlet section of the small intestine is resected for 2-3 cm. A microcatheter (Fig. 4, position 1) with a diameter of 2 mm with side holes located at a distance of 10 cm from each other is placed into the lumen of the outlet section along its entire length to the ileocecal angle. Then the expanded part of the afferent section of the small intestine is resected over a length of 10-15 cm. After this, the afferent section (Fig. 4, position 2) is anastomosed to the side of the abductor section (Fig. 4, position 3), 6-8 cm from its end. The end of the outlet section of the small intestine is brought out to the anterior abdominal wall through a separate incision and an intestinal stoma is formed (Fig. 4, position 4). The laparotomy wound is sutured in layers. The catheter is fixed to the skin of the anterior abdominal wall. In the postoperative period, starting from 2-3 days. daily, a glucose-polyglucin mixture consisting of equal volumes of 40% glucose and 33% polyglucin is injected into the lumen of the efferent intestine. Both drugs are approved for use in clinical practice. The amount of the injected mixture corresponds to the volume of the lumen of the outlet section of the small intestine, which is determined by the formula V PR 2 x L, where P is constant 3.14; R radius of the lumen of the efferent colon; L length of the efferent part of the small intestine. A 40% glucose solution has high osmotic activity (1000 mOsmol/L). As a result, the liquid part of the plasma from the bloodstream (plasma osmotic activity is 310 mOsmol/l) enters the lumen of the efferent intestine and the diameter of the latter increases by 1.5-2 times. Polyglucin, having a high hydrophilicity, prevents the reabsorption of water and retains the liquid released into the intestinal lumen for a long time. Daily “training” of the efferent colon contributes to a more rapid restoration of its motor-evacuation function. The inventive method was tested in the pediatric surgery clinic of the Russian State Medical University in patients with small intestinal atresia. As an example, we give the following observation. Patient B. case history N 5958/432, boy, was admitted to the pediatric surgery clinic on the 2nd day. after birth with a diagnosis of: Congenital complete intestinal obstruction. After preoperative preparation, a right transrectal laparotomy was performed under endotracheal anesthesia. During examination of the abdominal organs, atresia of the small intestine was discovered at a distance of 40 cm from the ligament of Treitz. The blind end of the adductor section of the small intestine is expanded to 3.5 cm in diameter. The distal section is collapsed with a diameter of up to 6 mm and a length of about 35 cm. The blind end of the efferent colon is resected and a microcatheter is inserted into its lumen to the ileocecal angle. Then the adductor colon, after resection of its expanded part, is anastomosed to the side of the efferent colon, 7 cm from its end. The end of the efferent intestine is brought to the anterior abdominal wall in the right iliac region in the form of an intestinal stoma. On the 2nd day. After the operation, the administration of a glucose-polyglucin mixture in an amount of 10 ml was started through a catheter into the outlet section of the small intestine, which corresponded to the volume of the intestinal lumen (V 3.14 x 0.3 2 x 35 10 cm 3). On the 8th day. After the operation, the amount of discharge from the stoma decreased significantly, independent stool appeared, and the catheter was removed from the lumen of the outlet intestine. On the 14th day of the postoperative period, the stoma stopped functioning, stool was independent 3-4 times a day. IN satisfactory condition the child was discharged home. Thus, the glucose-polyglucin mixture was introduced into the lumen of the efferent colon for 7 days. after the operation until the restoration of her motor-evacuation function, as evidenced by the appearance of independent stool in the child. Compared with the prototype, the proposed method has the following advantages: the introduction of a glucose-polyglucin mixture into the lumen of the functionally defective outflow section of the small intestine in the postoperative period contributes to a more rapid restoration of its motor-evacuation function and thereby prevents significant losses of intestinal contents through a T-shaped stoma, leading to to the development of postoperative complications: maceration of the skin around the stoma and exhaustion of the child.

Claim

A method for the treatment of small intestinal atresia in newborns, including resection of sections of the small intestine and the imposition of a T-shaped anastomosis of the end of the afferent section of the small intestine to the side of the efferent section with removal of the free end of the latter in the form of a stoma, characterized in that through the stoma into the abductor section of the small intestine along its entire A microcatheter is placed throughout the postoperative period, through which a glucose-polyglucin mixture is administered daily in the postoperative period, consisting of equal volumes of a 40% glucose solution and a 33% polyglucin solution, in an amount equal to the volume of the diverting colon, for 5-10 days until the appearance of independent chair.

Congenital intestinal obstruction still remains main reason requiring emergency surgical intervention in the neonatal period. The clinical picture of intestinal obstruction in a newborn develops in the next few hours and days after birth, and in the absence timely diagnosis and subsequent surgical intervention leads to the death of the child due to dehydration, intoxication, lack of nutrition and aspiration of gastric contents.

Epidemiology
On average, intestinal obstruction occurs in 1 in 1500-2000 live births.

Etiology
The causes of congenital intestinal obstruction may be the following:
- malformations of the intestinal tube (atresia, stenosis);
- developmental defects that cause compression of the intestinal lumen (ring-shaped pancreas, aberrant vessel, tumor);
- anomalies of intestinal rotation and fixation (midgut volvulus, Ladd syndrome);
- obstruction of the intestinal lumen with viscous meconium in cystic fibrosis (meconium ileus);
- disturbance of intestinal innervation (Hirschsprung's disease, neuronal dysplasia).

Based on the level of location of the obstacle, high and low intestinal obstruction are distinguished; each of them has a characteristic clinical picture.

High obstruction is caused by obstruction at the level of the duodenum and initial sections jejunum, low - at the level of the distal parts of the jejunum, as well as the ileum and colon.

Duodenal obstruction
Epidemiology
The detection rate averages 1 case per 5,000–10,000 live births. In 30% of cases it is combined with Down syndrome.

Etiology
Considering the anatomical features of the duodenum, obstruction of this section can be caused for the following reasons: stenosis, atresia, compression of the lumen by abnormally located vessels (preduodenal portal vein, superior mesenteric artery), embryonic cords of peritoneum (Ledd syndrome) and annular pancreas.

Prenatal diagnosis
Fetal ultrasound visualizes an expanded and fluid-filled stomach and duodenum in the upper abdominal cavity - a symptom of a double bladder, which, in combination with polyhydramnios, makes it possible to establish a diagnosis as early as 20 weeks of pregnancy.

If parents decide in favor of prolonging pregnancy, then in case of severe polyhydramnios it is advisable to carry out therapeutic amniocentesis in order to prevent premature birth. Early diagnosis is extremely important: genetic counseling and fetal karyotype testing are required, since in 30% of cases this diagnosis is combined with Down syndrome.

Syndromology
When establishing a prenatal diagnosis of duodenal atresia, it is indicated comprehensive examination fetus, since in 40-62% of cases combined anomalies are possible. Among them, the most common birth defects hearts and genitourinary system, defects of the gastrointestinal tract and hepatobiliary system. In addition, duodenal atresia may be part of a number of hereditary syndromes, among which should be highlighted Fanconi pancytopenia, hydantoin syndrome, Fryns syndrome, Opitz G, ODED (oculo-digito-esophageal-duodenal syndrome - syndrome of the eyes, limbs, esophagus, duodenum), Townes-Brocks and TAR (thrombocytopenia with absence radius).

In addition, heterotaxy and the above-mentioned VACTER association have been described in duodenal atresia. Special attention in case of duodenal atresia, prenatal karyotyping should be considered, since chromosomal abnormalities have a probability of 30-67%. Most often - Down syndrome. Familial cases with presumed autosomal recessive inheritance have been described.

Intrauterine diagnosis of duodenal atresia informs doctors of the neonatal team in advance about the birth of such a child and makes it possible to organize emergency assistance sick newborn. If congenital intestinal obstruction is suspected, immediately after birth, a tube is inserted into the child’s stomach to decompress the gastrointestinal tract and prevent aspiration syndrome, enteral load is excluded, and the newborn is transferred under the supervision of a pediatric surgeon.

Clinical picture
Symptoms of high intestinal obstruction are detected already in the first hours after birth. The earliest and constant signs are repeated regurgitation and vomiting, while the gastric contents may contain a small admixture of bile. By installing a nasogastric tube immediately after birth, the stomach is evacuated a large number of contents (more than 40.0-50.0 ml), in further liquid continues to flow passively through the probe. An intermittent but characteristic symptom is bloating in the abdomen. epigastric region, in other parts the stomach is sunken. Immediately after vomiting, bloating decreases. Palpation of the abdomen is painless. Obtaining meconium during a cleansing enema indicates partial intestinal obstruction or obstruction above the papilla of Vater, judging by the unimpeded flow of bile into the distal parts of the intestine. Together with gastric contents, the child loses a large amount of potassium and chlorides. Without treatment, dehydration quickly occurs. The child becomes lethargic, adynamic, physiological reflexes are reduced, the skin becomes pale and marbling, and microcirculation deteriorates.

Diagnostics
To confirm the diagnosis, use radiographic examination. For diagnostic purposes, direct radiography of the abdominal cavity is performed vertical position, at which two gas bubbles and two liquid levels corresponding to distended stomach and duodenum. For most patients, this test is sufficient to make a diagnosis. IN in doubtful cases the stomach is additionally filled with air or a water-soluble contrast agent, and the contrast accumulates above the obstruction zone.

Treatment
In case of high intestinal obstruction, the operation is performed on the 1st-4th day of the child’s life, depending on the severity of the condition at birth and concomitant diseases.

Forecast
Mortality is determined by the severity of combined malformations. In the long-term period, complications such as megaduodenum, duodeno-gastric and gastroesophageal reflux, peptic ulcers and cholelithiasis are noted in 12-15% of observations. Overall, the prognosis is favorable, with survival rates exceeding 90%.

Small bowel atresia
Congenital anomalies of the small intestine in most cases are represented by atresia.

Epidemiology
Occurs with a frequency of 1 in 1000-5000 live births. Distal section ileum more often affected - 40%, and the proximal and distal parts of the jejunum - in 30 and 20% of cases, respectively, obstruction occurs less often proximal part ileum - 10%.

Prenatal diagnosis
Small intestinal obstruction in the fetus is visualized as multiple dilated intestinal loops, with the number of loops reflecting the level of obstruction. Increased amount of water and multiple dilated loops of the small intestine, especially with enhanced peristalsis and floating particles of meconium in the intestinal lumen, allow one to suspect atresia small intestine.

Syndromology
There are combined malformations, mainly of the gastrointestinal tract (Hirschsprung's disease, additional areas of intestinal atresia, anomalies of the anorectal region) and urinary tract.Most cases of small bowel atresia are sporadic. Unlike duodenal atresia, chromosomal aberrations are rare in small atresia. Prenatal karyotyping can be avoided because the frequency of chromosomal abnormalities in this defect is low. When pregnancy is prolonged and severe polyhydramnios is present, therapeutic amniocentesis is indicated to prevent premature birth.

Helping a newborn in the delivery room
Intrauterine signs congenital obstruction small intestine in the fetus require organized action by the maternity hospital staff. Low level obstruction causes a significant increase in the abdomen in volume, which draws the doctor’s attention already at the initial examination. When inserting a gastric tube, a large amount of content is obtained, often stagnant in nature with an admixture of dark bile and small intestinal contents. The absence of meconium during a cleansing enema confirms the suspicion; an emergency transfer of the child to a pediatric surgical hospital is required.

Clinical picture
The child’s behavior in the first hours after birth does not differ from healthy behavior. The main sign of low intestinal obstruction is the absence of meconium. When performing a cleansing enema, only impressions of uncolored mucus are obtained. By the end of the first day of life, the child’s condition gradually worsens, anxiety and painful cry appear. Intoxication phenomena quickly increase - lethargy, adynamia, gray-earthy coloration of the skin, impaired microcirculation. Uniform bloating of the abdomen progresses, with intestinal loops contouring through the anterior abdominal wall. There is vomiting of stagnant intestinal contents. Upon examination, the abdomen is soft, accessible to palpation, painful due to overstretching of the intestinal loops. The course of the disease can be complicated by perforation of an intestinal loop and fecal peritonitis, in which case the child’s condition sharply worsens and signs of shock appear.

Diagnostics
Straight plain radiography abdominal cavity in an upright position demonstrates a significant expansion of intestinal loops, increased uneven gas filling and fluid levels in them. There is no gas filling of the underlying parts of the abdominal cavity. The more loops are visualized, the more distal the obstacle is located.

Treatment
A newborn with signs of low intestinal obstruction requires emergency surgical treatment. Preoperative preparation can take place within 6-24 hours, which allows for additional examination of the child and elimination of water and electrolyte disturbances. Extend preoperative preparation should not be used due to the high risk of complications (intestinal perforation and peritonitis). The goal of surgery is to restore the integrity of the intestine while possibly maintaining its maximum length.

Forecast
The survival rate of patients with uncomplicated small bowel atresia is close to 100%. Mortality is caused by complications and unfavorable background such as prematurity, intrauterine growth retardation, intestinal perforation or volvulus, and cystic fibrosis of the pancreas.

Atresia and stenosis of the colon
Epidemiology
This is the most rare view intestinal atresia: occurs in no more than 1 in 20,000 live births. Lesions of the transverse colon and sigmoid colon. Colon atresia occurs in less than 5% of all intestinal atresia cases.

Prenatal diagnosis
Obstruction of the colon in the fetus can be suspected if dilated loops of the colon filled with hypoechoic contents with inclusions are detected. However, in most cases, this pathology is not diagnosed prenatally due to the resorption of fluid from the intestine and uniform expansion of the intestine throughout - without areas of significant increase in diameter. When dilated loops of the colon are detected, the differential diagnosis should be made with Hirschsprung's disease, anorectal pathology, megacystis-microcolon-intestinal hypoperistaltic syndrome and meconium peritonitis.

Localized mainly in the lower part of the ileum, near the cecum and less often in upper sections small intestine. Atresias can be single or multiple. On average, for every 15,000-20,000 newborns, one child falls from congenital atresias small intestine. According to our observations, they are more common.

With atresia, an entire section of the intestine may be missing, and the upper and lower ends are connected to each other by a thin fibrous cord. Sometimes obstruction is caused by a membranous septum located transversely in the intestinal lumen itself. Proximal to the atresia, the intestine is greatly dilated, swollen, and its wall is thickened. In the area of ​​blind protrusion, the intestinal wall is often paper-thin, with impaired viability, and is easily subject to necrosis, so there is a risk of perforation.

Symptoms the same as with duodenal atresia, with the difference that soon after vomiting bile and blood, an admixture of feces appears in the vomit. As a rule, there is no passage of meconium through the anus, which is important for diagnosis. After each feeding, increased peristalsis is visible through the abdominal wall, which is also felt with careful palpation. The abdomen quickly swells, urine output decreases sometimes to complete anuria. Constant vomiting lead to exicosis and toxicosis. The baby's weight drops quickly despite the fact that he sucks greedily. Sudden retraction of the abdominal wall indicates perforation. In these cases, the child’s general condition deteriorates sharply, he takes on the appearance of being intoxicated with gray-green color faces. Absence of tension or distended abdominal wall in a newborn does not exclude peritonitis.

For diagnosis X-ray examination with the child in an upright position is important. If, in addition to the gas bubble, 1-3 more bubbles with a level are visible in the stomach area, it should be assumed that atresia is localized in the upper parts of the small intestine. The presence of multiple air bubbles with levels throughout the entire abdominal cavity indicates the presence of atresia primarily in the lower ileum or the beginning of the large intestine. Under no circumstances should X-ray examinations be carried out using barium porridge administered orally. Barium porridge causes severe distension of the intestine and, thus, can contribute to perforation, increases vomiting, and this is dangerous aspiration pneumonia. Only if you suspect the presence of atresia of the large intestine, you can administer a reactantly rare solution of barium porridge or, even better, a solution soluble in water contrast agent(ioduron, etc.), which makes it possible to better delineate the large intestine. It is also important to know that with atresia of the small intestine, meconium does not contain keratinized skin epithelium and lanugo. This is proven by the Fairber breakdown. To do this, take a piece from the central part of meconium onto a glass slide and wash it with ether for one minute to dissolve the fats. Then the preparation is stained with henician violet for 1 minute, washed with running water and decolorized with alcohol - hydrochloric acid. Only keratinized epithelial cells retain staining. With atresia of the small intestine they are absent.

Forecast very bad. With early surgical intervention and with a limited number of atresias and stenoses, full-term infants have a better prognosis. The operation should be performed within the first 24 hours. The bacterial flora during this period is poorly developed, and the likelihood of infection from the intestines is much less. It should not be forgotten that newborns often suffer heavy operations. Preoperative preparation is the same.

Meconium ileus. It's about about blockage of the small intestine, mainly in its lower sections, with very thick, sticky, tar-like meconium. According to Grab, 40% of small intestinal obstruction in newborns is due to meconium ileus. Meconium in this part of the intestine has a stringy consistency and a yellowish or whitish-greenish color. Thick meconium sometimes reaches the cecum.

Meconium ileus is the most important and most severe manifestation of cystic fibrosis of the pancreas and is observed in 5-1.5% of cases of cystic fibrosis of the pancreas. Condensed meconium has previously been associated with pancreatic achylia, the absence or insufficient levels of pancreatic enzymes. It is currently believed that cystic fibrosis of the pancreas is one of the manifestations of dysfunction of the mucus-secreting glands, a condition of cystic fibrosis in which the secretory glands secrete secretions from increased viscosity. Insufficiency or absence of pancreatic enzymes favors thickening, but this is not the primary cause and is not of decisive importance. Cystic fibrosis is an autosomal recessive disease.

Clinical picture the same as for any intestinal obstruction. Its signs appear in the first 24 hours of life and rarely later. It should be noted that the child does not pass meconium, despite the good patency of the rectum and anus. The abdomen quickly swells, the veins on it expand. Uncontrollable vomiting with an admixture of bile appears. Through the abdominal wall, swollen loops of the small intestine with increased peristalsis are visible. Not very much bloated belly Dense masses of meconium may also be palpable. Sometimes stringy, grayish-white meconium passes spontaneously or after an enema in the form of plugs or a thick, hard lump. The child's general condition quickly deteriorates, and dehydration develops. The complexion becomes grayish-yellow. Children most often die from peritonitis. X-ray reveals a picture of intestinal obstruction, but there are no typical levels of it, since stringy meconium adheres tightly to the intestinal wall and prevents the formation of fluid levels. Research using barium porridge is also useless and dangerous in relation to perforation.

When making a differential diagnosis, all causes of intestinal obstruction (atresia, volvulus, etc.) should be taken into account. Similar clinical picture It is also observed with the so-called meconium blockade, in which the abdomen is also swollen, vomiting and meconium retention are observed. It comes off spontaneously 2-3 days or after an enema and in these cases has a normal consistency.

Diagnosis found out during laparotomy. In cases where there is a history of meconium ileus or bronchiectasis in the same family as other children, the likelihood of having this condition increases. Irrigoscopy allows you to immediately exclude the existence of colonic atresia or megacolon. The BM test is the most commonly used method for determining albumin in meconium. Concentrations above 20 mg per 1 g of dry meconium have a value. The method is simple, quick to implement and, despite some disadvantages, convenient for mass screening.

Treatment- surgical. After the operation it is prescribed long-term treatment pancreatic drugs (pancreatin, pancrest) 0.3-0.5 g three times a day. For milder cases, you can try tall, warm enemas. Children who have had meconium ileus may later experience various complications associated with the presence of cystic fibrosis. Sooner or later there will be a change of scenes followed by a new act of tragedy, which after weeks or months leads to death.

Here is the following observation:

Diana Ts.M., two days old, and. b. 7315 from 22.IX., ISUV, Children's Clinic.

Normal birth during a normal pregnancy. From the moment of birth until admission to the clinic, the child did not have stool. My stomach started to swell. When probing through the anus, the probe enters approximately 8 cm and has no traces of meconium. Roentgenoscopically, there is severe distention of the intestine with gases without the presence of levels. The child's general condition is good - he is calm and does not cry. During the operation, a double inversion of the radix mesenterii was found. The loop of the ileum under the valvule Bauchni for about 30 cm is strongly swollen, cyanotic, with thickened walls, filled with meconium. Meconium was removed through an incision in the intestinal wall. After the operation, the child's condition worsened somewhat, vomiting appeared, and meconium appeared in the vomit. After gastric lavage and a salt enema, the vomiting stopped, the child’s condition improved and spontaneous bowel movements appeared with greenish-black, liquid-mushy, non-viscous feces. On the second day after the operation, the child began to be fed breast milk.
Women's magazine www.

Intestinal atresia is the most common reason congenital intestinal obstruction - accounts for one third of all intestinal defects in newborns. Average frequency births of children with intestinal atresia are approximately 1:2710 newborns, and this defect is observed 2 times more often than esophageal atresia and diaphragmatic hernia and 3 times more often.

Unlike atresia, which causes complete obstruction of the intestinal lumen, congenital stenosis causes partial obstruction, often with much later clinical manifestations.

Classification of intestinal atresia

Duodenal atresia and stenosis can be either proximal or distal to the ampulla of Vater, which is clinically reflected in the nature of the gastric contents, with or without an admixture of bile. Preampullary obstruction is much less common and, according to summary statistics from the Surgical Section of the American Academy of Pediatrics, was detected in only 99 of 503 patients with congenital duodenal obstruction. A membrane with lumen was found in 206 patients. Rare reasons obstructions were intestinal atresia with a cord between the atretic areas and complete absence duodenum. Infrequently, a sagging membrane is also of great clinical significance, since it can be mistaken for a more distal duodenal obstruction, and also in connection with the possible entry of an anomalous bile duct along its medial edge.

An annular pancreas occurred in 21% of patients. This pathology is an embryologically complex defect, which is usually combined with internal duodenal obstruction, without being, however, its root cause. Now that the site of obstruction is being examined more carefully before surgical correction is performed, it is becoming clear that the true incidence of annular pancreas and biliary tract anomalies is significantly higher than previously thought.

Intestinal atresia and stenosis of the small intestine are equally common along its entire length from the ligament of Treitz to the ileocecal angle.

Meet 4 various types intestinal atresia.

Type 1 - a membrane with a single continuous muscle layer of the proximal and distal segments, occurs in approximately 20% of all cases.

Type 2 - intestinal atresia with a cord between the blind ends of the intestine, about 35%.

Type 3 - intestinal atresia with complete separation of the blind ends and a Y-shaped defect of the mesentery, about 35%.

Type 3b - intestinal atresia with a large mesenteric defect, when the entire distal ileum receives its blood supply only from the ileocolic artery and is “twisted” around the vessel in the form of “ apple peel" This anomaly has special meaning, since it is accompanied by deep prematurity, an unusually small distal part of the intestine, and a significant shortening of the length of the entire intestine. There are also reports of hereditary predisposition with this form of intestinal atresia.

Type 4 - multiple small bowel atresia, occurs in approximately 6% of all cases.

With atresia of the proximal jejunum, radiographs show a small number of fluid levels with gas bubbles and lack of gas in the lower abdomen. The lower the intestinal atresia, the higher the fluid levels on radiographs. Sometimes the most dilated segment of the intestine is not visible on plain radiograph, because it is filled with liquid contents. In such cases, an error may be made in determining the level and nature of obstruction. Atresia of the ileum or colon can be imitated by meconium plug syndrome and meconium ileus. In most cases, differential diagnosis with the listed types of pathology can be made using barium irrigography. The diameter of the colon allows us to clarify the level of atresia. With duodenal localization of the defect, the large intestine has a normal diameter; with atresia of the distal ileum, the microcolon is narrowed. Especially sharp narrowing colon is observed in children with meconium obstruction.

Treatment of intestinal atresia

Treatment is only surgical. Endotracheal anesthesia using fluorothane and muscle relaxants. Function vital important organs monitored using Doppler blood pressure and ECG monitoring, as well as a precordial or esophageal stethoscope. Hypothermia can be avoided by using heat lamps, a heated mattress, and special surgical gowns. Even if all these measures are applied, it is necessary to measure body temperature using a rectal probe and telethermometer.

The right superior transverse incision provides excellent access to the entire gastrointestinal tract. The diagnosis of duodenal atresia is confirmed after dividing the greater omentum, “entering” the cavity of the lesser omentum and revision of the duodenum to the site of obstruction. In most cases, to facilitate anastomosis ascending department The colon should be retracted medially, and the proximal and distal portions of the duodenum should be well mobilized. A single-row side-to-side duodenoduodenoanastomosis is preferred, however, with large diastasis between atretic segments, duodenojejunostomy is indicated.

After opening the proximal segment, careful inspection, both visual and with a probe, is necessary in order to exclude a sagging membrane. Unfortunately, there are cases of anastomosis distal to such a septum, which requires repeated surgery. An alternative to the traditional side-to-side duodenoduodenoanastomosis is the diamond-shaped type of this anastomosis, which allows early start of enteral nutrition and reduces the length of the patient's stay in the hospital. Passing a feeding tube beyond the anastomosis should be avoided, preferring short-term parenteral nutrition through a peripheral vein until the anastomosis begins to function, which usually occurs approximately 4-7 days after surgery.

In case of small intestinal atresia, it is necessary to inspect the distal parts of the intestine to exclude multiple defects. This is best done by injecting into the intestinal lumen just below the atresia. saline or Vaseline oil and carefully “milking” the contents in the distal direction. It is important to make sure that the large intestine is not changed, because atresia can be multiple and occur throughout both the small and large intestine.

Regarding modern ideas about the choice of species intestinal anastomoses, then over the last 20 years, undoubted preference for intestinal atresia has been given to primary end-to-end anastomosis, which will give better results compared to the previously widely used side-to-side anastomosis.

The sometimes long-term functional obstruction of the anastomotic zone can be prevented by resection (before anastomosis) of a sharply expanded section of the intestine (usually 15-20 cm) and creation of an anastomosis end to end with an oblique cut (distal) or other types of anastomosis that involve reducing the size of the proximal segment. The “oblique” end-to-end anastomosis eliminates the development of blind loop syndrome, which often occurs with side-to-side anastomosis. The extended part of the proximal atretic segment must always be resected, while the distal segment should be preserved as much as possible, because it is the terminal ileum that plays the most important role in the absorption of fat-soluble vitamins and in the enterohepatic circulation of bile acids. To ensure that the walls of the anastomosed segments are well compared, an oblique cut should be made at an angle of 45° relative to the antimesenteric edge of the intestine, followed by extending the cut to the required length. The anastomosis is performed with one row of inverted (screwing in) separate sutures through all layers of the proximal and distal segments using 5-0 cardiovascular silk. The use of such inverted sutures allows the serous surfaces to be compared without the risk of narrowing the lumen of the anastomosis.

With atresia of the distal part of the duodenum or proximal jejunum, anastomosis is difficult due to significant hypertrophy and dilatation of the intestine, which, however, cannot be resected. Artificial narrowing of the afferent segment of the jejunum or duodenum using special devices or by intestinoplication (creating folds of the intestine) makes it possible to reduce the diameter of the lumen of the atretic section and contributes to a more rapid restoration of peristalsis and patency of the anastomosis. Of these methods of narrowing the proximal part, we prefer intestinoplication, the advantage of which is to preserve the absorbent surface of the mucosa, which is extremely important in cases of the development of short bowel syndrome after surgery.

Atresia with apple peel syndrome will create special problems during reconstructive operations due to the presence in this variant of pathology of not only a sharply dilated jejunum, but also a completely unrelated, very narrowed distal section. In such cases, it is imperative to narrow the proximal segment and attempt an end-to-end anastomosis. An alternative intervention for this form of intestinal atresia is the creation of a side-to-end (crater-shaped) jejunojejunostomy with the adductor section brought out in the form of a stoma. This approach allows for complete decompression of the proximal jejunum with nutrition beyond the anastomotic area through a catheter. The enterostomy is subsequently closed.

In cases of intestinal atresia when primary anastomosis is not indicated or it is impossible to impose it, double enterostomy according to Mikulicz is sometimes quite effective. Similar situation may occur in newborns with severe malnutrition, in premature infants, or in atresia combined with volvulus and meconium peritonitis. The advantage of double enterostomy is that it allows you to relieve the intestine and reduce its size to normal by the time the stoma is closed. When performing this operation, the proximal and distal sections are stitched with thin silk along the antimesenteric edge over a sufficiently large area so that deeper than the aponeurosis their walls are compared with each other for at least 1 cm. The connected sections are then brought out through a separate incision. The formation of a stoma can be completed by “turning out” the edges of the mucosa. In most cases, there is no need to suture the intestine to the skin.

In case of colonic atresia, the most extended portion of the proximal segment should be resected and a temporary end colostomy should be created. Anastomosis of the colon is usually performed at the age of one year or even earlier if the diameter of the proximal colon quickly returns to normal. A significant difference in the size of the adducting and efferent (“non-functioning”) sections of the colon is quite typical for this type of defect, but this usually does not affect the restoration (after surgery) of intestinal function.

Treatment of intestinal artesia after surgery

Basic principles postoperative treatment intestinal atresia - adequate intestinal decompression using a nasogastric tube (of appropriate size) in all patients and total parenteral nutrition in children with prematurity, malabsorption (due to a decrease in the absorptive surface of the intestine), or when obstruction of the anastomotic zone forces enteral nutrition to be delayed for more than 5 days. Parenteral nutrition through peripheral vessels is usually performed in all these children, starting on the 1st day after surgery.

One of the forms of colonic atresia is atresia anus and rectum - is one of the most common forms obstruction digestive tract in newborns who require emergency surgical intervention. Atresia of the ascending, transverse and descending colon observed extremely rarely. Rectal atresia is often combined with the presence of various fistulas in the (uterus, vagina, vestibule of the vagina), urinary system (bladder, urethra) and perineum. The presence of such fistulas, especially in the urinary system, significantly aggravates the child’s condition, as it can be a source of infection of the urinary tract with the development of an ascending infection, which leads to pyelonephritis. Considering the possibility of fistulas in the urinary system, if you suspect atresia of the anus and rectum, it is necessary to be especially attentive to the nature of the urine: the appearance of cloudy urine or urine mixed with meconium is the basis for diagnosing communication between the rectum, bladder or urethra.

Clinic and diagnosis The main symptom of colonic atresia is the absence of meconium passage during childbirth or in the next hour after it. Vomiting occurs much later compared to other forms of obstruction of the digestive tract. The stomach is always completely swollen. Sometimes peristalsis of intestinal loops is visible to the eye.

If there is anal atresia, the diagnosis is not difficult. However, sometimes with a normally formed anus there is rectal atresia. In this case, it can be difficult to make an early diagnosis, especially if there are no clear instructions regarding the passage of meconium.

To diagnose rectal atresia, a cleansing enema with a 3% pancreatin solution is given to eliminate thick meconium or meconium plug. If meconium is not obtained, a digital examination of the rectum is performed. Sometimes it is also unconvincing. Then irrigography is used.

The choice of tactics depends on the level of rectal atresia. Indicators of high atresia are the absence of a bulge at the site of the supposed anus during the child's crying and breathing, the distance between the ischial tuberosities is less than 1 - 1.5 cm and x-ray data.

X-ray examination when diagnosing rectal atresia has its own characteristics. When X-rayed, the newborn is upside down. A small metal object is placed at the site of the intended anus and secured with a strip of adhesive tape. X-rays are taken in frontal and lateral projections. Before radiography, the child should lie for at least 30 minutes with the head end of the bed lowered so that the meconium in the rectum moves upward and the air moves closer to the atretic part of the intestine (Fig. 13). On the radiograph, the distance between the mark and the upper edge of the air bubble is measured. If this distance is more than 3.5-4 cm, then it is extremely difficult to bring the rectum into the perineum, then either a colostomy is performed, or combined operation- laparotomy with reduction of the atretic intestine and proctoplasty (abdominoperineal proctoplasty). When the intestine is close to skin fold limited to one proctoplasty. The rule is to disconnect the message between urinary system, if there is one, in order to prevent infection.

13. X-ray of a newborn with anal atresia. The child is turned upside down (description in the text)

14. Shede position

After surgery it is necessary careful care behind the perineal area, since usually, to eliminate possible scarring of the anal area in the future, the surgeon mobilizes and lowers the rectum beyond the anus by 1 - 1.5 cm. It is convenient to care for the child if he is in the Shede position with his legs apart ( Fig. 14).