Quiz peritoneal drainage in pneumoperitoneum

[Admin]

A ten-day old 1100-g ex 28-week gestational age infant girl previously advancing well on enteral feeds becomes acutely distended. Abdominal radiographs reveal moderate pneumatosis intestinalis. Two hours later, a radiograph reveals pneumoperitoneum. In deciding which intervention would be most appropriate, which of the following can be expected from peritoneal drainage?

A ten percent likelihood of avoiding laparotomy

B less effective physiologic stabilization than laparotomy

C greater risk of intestinal stricture than laparotomy

D faster return to enteral feeding than laparotomy

E equivalent survival compared to laparotomy

 

[Sharon]

E

 

[Admin]

E

correct

Peritoneal drainage (PD) for the treatment of intestinal perforation in premature babies was developed in response to the concern for performing a laparotomy (LAP) requiring general anesthesia in very small fragile infants. Some early successes with survival and the avoidance of subsequent laparotomy allowed this practice to generate favor as an alternative to laparotomy. Perforation may be due to either necrotizing enterocolitis (NEC) or spontaneous isolated intestinal perforation (SIP). Due to the presence of pneumatosis the patient in this scenario appears to have perforation due to necrotizing enterocolitis.

A multicenter retrospective study and two multicenter prospective randomized studies revealed no difference between PD or LAP with respect to mortality within ninety days or six months from the procedure, need for parenteral nutrition for more than three months, recurrent NEC, abdominal abscess, intestinal fistula, intestinal stricture, urinary fistula, time to full enteral feeds or length of stay. A subsequent report showed no difference in physiologic status response as manifested by measurements of heart rate, blood pressure, inotrope requirement or arterial partial pressure of oxygen/fraction of inspired oxygen ratio. These studies did not differentiate between perforation due to SIP or NEC. Multiple series indicate that the need for subsequent LAP after PD ranges from 30 to 80% with a LAP more likely needed and overall outcomes worse if the diagnosis is NEC rather than SIP.