**3. Conclusion**

*Pediatric Surgery, Flowcharts and Clinical Algorithms*

ing distinct advantages:

**2.6 Postoperative care**

of anastomotic leakage.

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 follow-

• The procedures reduce operating and anesthetic times because complete

• The procedures avoid intra-abdominal anastomosis, which eliminates the risk

• The bowel can be opened after complete closure of the abdominal wound; this

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,

Immediately postoperatively, management involves ongoing resuscitation with special attention given to replacement of the fluid losses caused by surgery and preoperative hyperosmolar enemas (if attempted), as well as correction of ongoing losses (i.e., losses from nasogastric suction and ileostomy) [31]. Also, the infant is initially on bowel rest with general supportive care provided after any major laparotomy. The oral gastric tube is maintained until bowel function returns, and further acetylcysteine irrigations can be done via the tube as described for nonoperative management. Combining this with rectal irrigations may further aid passage of retained meconium in the distal loop as well. Most infants will need central venous access for parenteral nutrition during this period. If cystic fibrosis has not been confirmed preoperatively, the sweat chloride test should be done to confirm or rule it out. Close attention has to be given to pulmonary care in infants with cystic fibrosis. Multiple pediatric subspecialists including gastroenterologists, geneticists, pulmonologists, and pediatric surgeons are required for a good outcome of management in infants with meconium ileus, more so when they have cystic fibrosis. Once they have established a normal stooling pattern (usually within 1–2 weeks postoperative), they are commenced on graded oral feedings with pancreatic enzyme supplementation. Infants with uncomplicated meconium ileus and cystic fibrosis may receive breast milk or routine infant formula, enzymes, and vitamins, while complicated cases would benefit from predigested infant formulas (e.g., Alimentum and Pregestimil), for enteral feeding [31]. For those with stomas, administering of ostomy-drip feeds of glutamine-enriched formula at low volumes enhances bowel growth and helps prevent bacterial translocation [31]. After 4–6 weeks, when symptoms would have resolved and the infant attained an adequate weight gain, the stomas can be taken down. It is advisable to perform a distal contrast study to rule out obstruction before embarking on this procedure of

Short-term complications are uncommon in infants with simple meconium ileus.

evacuation of inspissated meconium is unnecessary.

reduces the risk of intraperitoneal contamination.

and preserving an adequate blood supply to the anastomosis [34, 35].

**80**

reanastomosis.

**2.7 Postoperative complications**

Meconium ileus is a cause of neonatal small intestinal obstruction which mainly affects the ileum and common in infants with cystic fibrosis. Contrast (gastrografin) enema is usually diagnostic and may sometimes be therapeutic. Infants who have unsuccessful management with enemas and those with complications related to the obstruction, including volvulus, perforation, or atresia, require operative intervention.

At laparotomy, a small enterotomy is done for those with simple meconium ileus to irrigate the bowel lumen with acetylcysteine solution and thus promote effective evacuation of the highly viscous meconium. Patients with complicated meconium ileus may require bowel resection with anastomosis or tube enterostomy or creation of a stoma. Various types of stomas have been described over the years for management of the disease, but the Bishop-Koop enterostomy seems to be widespread.

Most patients respond well to therapy in the short-term but need to be followed closely for long-term complications like bowel obstruction, which has many potential causes in these patients. Advances in perinatal diagnosis and management of meconium ileus and cystic fibrosis have vastly improved the outlook for affected infants.
