*2.5.7 Resection with enterostomy or anastomosis*

Bowel resection is indicated when meconium ileus is associated with a nonviable bowel, bowel perforation, atresia, volvulus, and the like. Resection is usually combined with enterostomy procedure, but primary anastomosis may be done if the intraoperative findings and the patient's general condition are favorable. The disadvantages of the procedures involving resection and stoma(s) or anastomosis are potential postoperative fluid losses through high-volume stomas, bowel shortening by resection, and the need for a second procedure to reestablish intestinal continuity [25, 31]. Hence, they are rarely used today.

Various stoma operations have been described with the most widespread being the Bishop-Koop-type anastomosis. This is a Roux-en-Y construct in which the distal limb is brought out as an end stoma and the proximal bowel is anastomosed end-toside approximately 4 cm from the opening of the distal segment (**Figure 2**). Normal gastrointestinal transit is permitted by this technique, and should distal obstruction occur, it provides a means for management through the ileostomy [25, 31].

The reverse of the Bishop-Koop enterostomy is the proximal enterostomy, described by Santulli and Blanc in 1961 [25, 31]. In this technique, the end of the distal limb is anastomosed to the side of the proximal limb after resection, while the end of the proximal limb is brought out as the enterostomy (**Figure 2**). This arrangement enhances proximal irrigation and decompression, thus making intraoperative evacuation of the dilated proximal bowel loop unnecessary. A catheter can be inserted into the distal limb through the stoma for irrigation of the distal bowel. The proximal stoma created in this technique predisposes to high-output losses with inherent risk of dehydration.

The Mikulicz enterostomy, first reported by Gross in 1953, consists of a doublebarrel stoma in which the two ends are sutured together side to side for some length

**Figure 2.** *Schematic description of some enterostomies as copied from Ref. [36].*

proximal to the end of the stoma (**Figure 2**) [25, 31]. It was designed for bedside stoma closure in which the common wall was crushed and obliterated with a specially designed clamp and the bowel ends were closed over the top. It has the following distinct advantages:


Swenson was the first to suggest resection with primary anastomosis in 1962 [25, 31]. Anastomotic leakage was initially a major issue with such operation; however some authors have reported improved results with adequate resection of the compromised bowel, complete evacuation of proximal and distal meconium, and preserving an adequate blood supply to the anastomosis [34, 35].
