Clinical and Experimental Pediatrics

The Korean Pediatric Society (대한소아청소년과학회)
권호 표지
DOI QR코드

DOI QR Code

Clinical experience of therapeutic effect of peritoneal drainage on intestinal perforation in preterm infants

미숙아의 장천공에서 복막 배액술의 치료효과에 관한 임상적 경험

  • Lee, Jun Seok (Departments of Pediatrics, Yonsei University College of Medicine) ;
  • Koo, Kyo Yeon (Departments of Pediatrics, Yonsei University College of Medicine) ;
  • Lee, Soon Min (Departments of Pediatrics, Yonsei University College of Medicine) ;
  • Park, Min Soo (Departments of Pediatrics, Yonsei University College of Medicine) ;
  • Park, Kook In (Departments of Pediatrics, Yonsei University College of Medicine) ;
  • Namgung, Ran (Departments of Pediatrics, Yonsei University College of Medicine) ;
  • Lee, Chul (Departments of Pediatrics, Yonsei University College of Medicine) ;
  • Choi, Seung Hoon (Departments of Surgery, Yonsei University College of Medicine)
  • 이준석 (연세대학교 의과대학 소아과학교실) ;
  • 구교연 (연세대학교 의과대학 소아과학교실) ;
  • 이순민 (연세대학교 의과대학 소아과학교실) ;
  • 박민수 (연세대학교 의과대학 소아과학교실) ;
  • 박국인 (연세대학교 의과대학 소아과학교실) ;
  • 남궁란 (연세대학교 의과대학 소아과학교실) ;
  • 이철 (연세대학교 의과대학 소아과학교실) ;
  • 최승훈 (연세대학교 의과대학 외과학교실)
  • Received : 2009.06.08
  • Accepted : 2009.09.11
  • Published : 2009.11.15
Download PDF
⟨ Previous Next ⟩

Abstract

Purpose:To analyze and compare various cases in which peritoneal drainage was used as the primary treatment method in preterm infants with intestinal perforation. Methods:Among the preterm infants of less than 28 weeks of gestation who were admitted to the neonatal intensive care unit (NICU) at the Gangnam Severance Hospital from April 2006 to April 2009, 7 who had developed intestinal perforation were studied retrospectively. We investigated the clinical characteristics, secondary operation performances, morbidities, complications, and mortalities. Results:Among the 7 infants, 5 survived. Of the 5 cases, 3 received laparotomy, of which 2 were confirmed as having necrotizing enterocolitis. Of the 2 infants who died, 1 had received laparotomy before 48 h of peritoneal drainage, while the other had not received any subsequent treatment. Of the 7 children, 4 had patent ductus arteriosus (PDA), of which 3 had received indomethacin injection. Five infants had begun enteral feeding before they developed intestinal perforation. Of the 5 infants who survived, 4 were diagnosed with cholestasis. Of the 7 infants, 4 developed periventricular leukomalacia (PVL) and 3 developed rickets. Conclusion:Although the use of peritoneal drainage as the primary management of intestinal perforation in preterm infants is controversial, we suggest that it can be used for treating extreme premature neonates. Further randomized controlled study will be required to determine the feasibility of using this method.

목 적:미숙아의 장천공의 치료법으로 고전적으로 개복술이 추천되지만 활력징후가 불안정한 초극소 미숙아에서 복막배액술이 새로운 치료법으로 제안되고 있다. 본 연구에서는 미숙아에서 발생한 장천공에서 일차적 치료로 복막배액술을 시행한 증례들을 비교 분석하였다. 방 법: 2006년 4월부터 2009년 4월까지 최근 3년동안 연세대학교 강남세브란스 병원 신생아 중환자실에서 집중치료를 받던 28주 이하의 미숙아들 중에서 장천공이 발생한 7명을 대상으로 후향적으로 연구하였다. 천공된 미숙아들의 임상적 특성과 이차적 수술의 시행 여부, 질병 이환, 합병증과 사망률을 조사하였다. 결 과:대상 환아 7명의 제태 연령 중앙값은 26주 2일(24주 2일-28주 2일)이며 출생체중 중앙값은 921 g(640g-1,210g)이었다. 장천공은 평균 생후 15일(6일-33일)에 발생하였으며, 5명(71%)이 생존하였고, 3명(43%)이 이차적 개복술을 시행하였으며 개복술을 시행한 3명 중 2명이 조직 검사상 괴사성 장염이 확진되었다. 사망한 2명 중 1명은 2차 개복술을 복막배액술 시행 48시간 이내에 시행 받았으며, 다른 1명은 2차 수술적 처치를 시행받지 않고 사망하였다. 동반 질환으로 동맥관 개존증이 4명(57%)에서 발생하였고, 이중 indomethacin을 3명(43%)에서 투여하였으며, 6명(86%)에서 범발성 혈관내응고증 소견을 보였으며, 5명(71%)의 환아에서 장천공이 발생하기 전에 장관영양을 시행하였다. 생존한 환아 중 4명(80%)에서 담즙정체가 발생하였으며, 4명(40%)에서 뇌실주위 백질연화증, 3명(60%)에서 구루병이 발생하였다. 결 론:복막배액술은 미숙아의 장천공에 대한 초기치료법으로써 논란의 여지가 있지만, 생체징후가 불안정한 초극소 미숙아에서 일차적 치료로 고려해 볼 수 있으리라 생각된다. 향후 대규모 무작위 대조법에 의한 임상 연구가 필요할 것으로 생각된다.

Keywords

References

  1. Thompson AM, Bizzarro MJ. Necrotizing enterocolitis in newborns:pathogenesis, prevention and management. Drugs 2008;68:1227-38 https://doi.org/10.2165/00003495-200868090-00004
  2. Rees CM, Pierro A, Eaton S. Neurodevelopmental outcomes of neonates with medically and surgically treated necrotizing enterocolitis. Arch Dis Child Fetal Neonatal Ed 2007;92: 193-8 https://doi.org/10.1136/adc.2006.099929
  3. de Souza JC, da Motta UI, Ketzer CR. Prognostic factors of mortality in newborns with necrotizing enterocolitis submitted to exploratory laparotomy. J Pediatr Surg 2001;36:482-6 https://doi.org/10.1053/jpsu.2001.21603
  4. Ricketts RR, Jerles ML. Neonatal NEC: Experience with 100 consecutive surgical patients. World J Surg 1990;14:600-5 https://doi.org/10.1007/BF01658800
  5. Chwals WJ, Blakely ML, Cheng A, Neville HL, Jaksic T, Cox CS Jr, et al. Surgery-associated complications in necrotizing enterocolitis: a multi-institutional study. J Pediatr Surg 2001;36:1722-4 https://doi.org/10.1053/jpsu.2001.27975
  6. Hintz SR, Kendrick DE, Stoll BJ, Vohr BR, Fanaroff AA, Donovan EF, et al. NICHD Neonatal Research Network: Neurodevelopmental and growth outcomes of extremely low birth weight infants after necrotizing enterocolitis. Pediatrics 2005;115:696-703 https://doi.org/10.1542/peds.2004-0569
  7. Ein SH, Marshall DG, Girvan D. Peritoneal drainage under local anesthesia for perforations from necrotizing enterocolitis. J Pediatr Surg 1977;12:963-7 https://doi.org/10.1016/0022-3468(77)90607-8
  8. Morgan LJ, Shochat SJ, Hartman GE. Peritoneal drainage as primary management of perforated NEC in the very low birth weight infant. J Pediatr Surg 1994;29:310-5 https://doi.org/10.1016/0022-3468(94)90338-7
  9. Meyer CL, Payne NR, Roback SA. Spontaneous, isolated intestinal perforations in neonates with birth weight less than 1,000 g not associated with necrotizing enterocolitis. J Pediatr Surg 1991;26:714-7 https://doi.org/10.1016/0022-3468(91)90017-N
  10. Uceda JE, Laos CA, Kolni HW, Klein AM. Intestinal perforations in infants with a very low birth weight: a disease of increasing survival? J Pediatr Surg 1995;30:1314-6 https://doi.org/10.1016/0022-3468(95)90493-X
  11. Cheu HW, Sukarochana K, Lloyd DA. Peritoneal drainage for necrotizing enterocolitis. J Pediatr Surg 1988;23:557-61 https://doi.org/10.1016/S0022-3468(88)80368-3
  12. Ahmed T, Ein S, Moore A. The role of peritoneal drains in treatment of perforated necrotizing enterocolitis: Recommendations from recent experience. J Pediatr Surg 1998;33: 1468-70 https://doi.org/10.1016/S0022-3468(98)90476-6
  13. Dimmitt RA, Meier AH, Skarsgard ED, Halamek LP, Smith BM, Moss RL. Salvage laparotomy for failure of peritoneal drainage in necrotizing enterocolitis in infants with extremely low birth weight. J Pediatr Surg 2000;35:856-9 https://doi.org/10.1053/jpsu.2000.6865
  14. Azarow KS, Ein SH, Shandling B, Wesson D, Superina R, Filler RM. Laparotomy or drain for perforated necrotizing enterocolitis: who gets what and why? Pediatr Surg Int 1997;12:137-9 https://doi.org/10.1007/BF01349981
  15. Cass DL, Brandt ML, Patel DL, Nuchtern JG, Minifee PK, Wesson DE. Peritoneal drainage as definitive treatment for neonates with isolated intestinal perforation. J Pediatr Surg 2000;35:1531-6 https://doi.org/10.1053/jpsu.2000.18299
  16. Rovin JD, Rodgers BM, Burns RC, McGahren ED. The role of peritoneal drainage for intestinal perforation in infants with and without necrotizing enterocolitis. J Pediatr Surg 1999;34:143-7 https://doi.org/10.1016/S0022-3468(99)90245-2
  17. Camberos A, Patel K, Applebaum H. Laparotomy in very small premature infants with necrotizing enterocolitis or focal intestinal perforation: postperative outcome. J Pediatr Surg 2002;37:1692-5 https://doi.org/10.1053/jpsu.2002.36697
  18. Ein SH, Shandling B, Wesson D, Filler RM. A 13-year experience with peritoneal drainage under local anesthesia for necrotizing enterocolitis perforation. J Pediatr Surg 1990; 25:1034-7 https://doi.org/10.1016/0022-3468(90)90213-S
  19. Gerald G, Aaron A, Joanne EB. Peritoneal Drainage as definitive management of intestinal perforation in extremely low birth weight infants. J Pediatr Surg 2003;38:1814-7 https://doi.org/10.1016/j.jpedsurg.2003.08.029
  20. Pumberger W, Mayr M, Kohlhauser C, Weninger M. Spontaneous localized intestinal perforation in very-low- birth-weight infants: a distinct clinical entity different from necrotizing enterocolitis. J Am Coll Surg 2002;195:796-803 https://doi.org/10.1016/S1072-7515(02)01344-3
  21. Nagaraj HS, Sandhu AS, Cook LN, Nuchino JJ, Groff DB. Gastrointestinal perforation following indomethacin therapy in very low birth weight infants. J Pediatr Surg 1981;16: 1003-7 https://doi.org/10.1016/S0022-3468(81)80865-2
  22. Buchheit JQ, Stewart DL. Clinical comparison of localized intestinal perforation and necrotizing enterocolitis in neonates. Pediatrics 1994;93:32-6
  23. Adderson EE, Pappin A, Pavia AT. Spontaneous intestinal perforation in premature infants: a distinct clinical entity associated with systemic candidiasis. J Pediatr Surg 1998;33: 1463-7 https://doi.org/10.1016/S0022-3468(98)90475-4
  24. Aschner JL, Deluga KS, Metlay LA, Emmens RW, Hendricks- Munoz KD. Spontaneous focal gastrointestinal perforation in very low birth weight infants. J Pediatr 1988;113:364-7 https://doi.org/10.1016/S0022-3476(88)80285-3
  25. Mintz AC, Applebaum H. Focal gastrointestinal perforations not associated with necrotizing enterocolitis in very low birth weight neonates. J Pediatr Surg 1993;28:857-60 https://doi.org/10.1016/0022-3468(93)90345-L
  26. Nam SH, Kim DY, Kim SC, Kim AR, Kim KS, Pi SY, et al. Experience with Peditoneal Drainage in Extremely Low- birth-weight infants. J Korean Assoc Pediatr Surg 2008;14: 37-47