Early Human Development 90 (2014) 933
Contents lists available at ScienceDirect
Early Human Development journal homepage: www.elsevier.com/locate/earlhumdev
Introduction
Neonatal surgical conditions Over the years, best practice guidelines for neonatal surgical conditions have improved due to technological advancement. Incidence of premature babies has increased and survival has improved with better supportive care. All conditions now require a multidisciplinary management approach for the best outcomes from the combined feto-neonatalsurgical approach. Incidence of oesophageal atresia and trachea-oesophageal fistula (OA + TOF) has remained unchanged and so has the postnatal diagnostics. The accuracy in foetal detection for this condition remains about 50%. The survival of extremely premature babies has increased the surgical challenge in the repair of oesophageal atresia. For this vulnerable group the selection for primary or delayed repair has a great impact on survival and morbidity. Outcomes for primary repair, delayed repair or replacement of oesophagus are all dependent on co-morbidities and require long term follow-up to manage the difficult oesophagus. Repair of OA + TOF using the thoracoscopic approached has been the new innovation and technically feasible, however advantages of this technique over the traditional open approach await further investigation. As outlined by Smith et al. long-term management for this condition still remains a challenge. Congenital cystic lung lesions (CCLL) comprise a spectrum of anomalies and are most commonly detected antenatally. The incidence has recently shown to increase due to improvement in antenatal diagnosis and postnatal CT scan is the best investigative modality in confirming an antenatal lesion. About 10% will require antenatal intervention but most are managed postnatally. CCLL may present with symptoms ranging from foetal demise to chronic cough/infections to incidental detection in the asymptomatic child. Symptomatic lesions are managed acutely with surgical intervention however there remains controversy over the pathophysiology of CCLL and the management of asymptomatic lesions. Co-morbidities in congenital diaphragmatic hernia (CDH) highly influence the prognosis in this condition. Antenatal ultrasound can be used to help prognosticate postoperative outcome if uniformity in measuring and reporting is used. The use of observed to expected antenatal measurements is preferred as they give more specific and accurate information. Antenatal surgery has not been influential in improving outcomes however antenatal intervention in the group of patients with worst outcome is part of an on-going clinical trial awaiting reporting of outcome as mentioned by Mc Honey et al. Thoracoscopic approach to CDH remains controversial as early outcomes are less promising and long-term. There is no clear evidence with regard to the best results in those requiring a patch however the design of a more recent biodegradable patch shows promising outcomes. Routine fundoplication at the time of CDH repair is not supported by the evidence of 1 randomised controlled study. Outcomes may be measured more objectively by means of a multi-disciplinary clinic.
http://dx.doi.org/10.1016/j.earlhumdev.2014.09.015 0378-3782/© 2014 Elsevier Ireland Ltd. All rights reserved.
Increase in the incidence of gastroschisis is well publicised with the aetiology still debated. The knowledge from prenatal diagnosis has highlighted the 80% hidden mortality for exomphalos. Simple gastroschisis may be managed with primary repair or preformed silo application with no variation in the overall outcome from both techniques. Thankfully the incidence of complex gastroschisis is low as the outcome for this group is less satisfactory. Exomphalos without associated anomalies have reasonable outcome however the challenge lies in large and giant exomphalos in obtaining closure with patches that bring their own morbidity and difficulties. Ideal patches are yet to be made available however biodegradable patches are more promising. For malrotation highlighting the urgency for action with bile stained vomiting cannot be further emphasised. Delay in outcome can be catastrophic as outlined by Stanton et al. Need for education and protocols at all levels of newborn care can provide for best practice guidelines. Incidence and management for bowel atresia have not changed in recent years but awareness of associated anomalies such as Down's Syndrome and duodenal atresia are important for foetal counselling. Outcomes have remained good. Hirschprung disease (HD) and anorectal malformation (ARM) are both congenital anomalies presenting as neonatal lower bowel obstruction with difficulty in antenatal detection. Both conditions are frequently associated with congenital abnormalities with a higher genetic association with HD. HD is a functional bowel obstruction resulting from the abnormal development of the enteric nervous system causing aganglionosis of the distal gut whereas ARM comprises a spectrum of anatomical anomalies causing a mechanical bowel obstruction. Surgical intervention is usually required for both conditions either as primary procedure or staged with a stoma. Long term follow up allows early identification and treatment of potentially debilitating symptoms, which include faecal incontinence. Specialist nurse practitioner is a key to the long-term management of both conditions as emphasised by Sudcliffe et al. Thanking all authors for their contribution to the best practice guidelines for neonatal surgical conditions and hope the readership will find this useful for their practice. Conflict of interest There is no conflict of interest. Kokila Lakhoo PhD, FRCS (Eng + Edin), FCS (SA), MRCPCH, MBCHB Oxford Children's Hospital, University of Oxford, Oxford OX3 9DU, United Kingdom Tel.: +44 1865 234197; fax: +44 1865 234211. E-mail address: [email protected].
Contents lists available at ScienceDirect
Early Human Development journal homepage: www.elsevier.com/locate/earlhumdev
Introduction
Neonatal surgical conditions Over the years, best practice guidelines for neonatal surgical conditions have improved due to technological advancement. Incidence of premature babies has increased and survival has improved with better supportive care. All conditions now require a multidisciplinary management approach for the best outcomes from the combined feto-neonatalsurgical approach. Incidence of oesophageal atresia and trachea-oesophageal fistula (OA + TOF) has remained unchanged and so has the postnatal diagnostics. The accuracy in foetal detection for this condition remains about 50%. The survival of extremely premature babies has increased the surgical challenge in the repair of oesophageal atresia. For this vulnerable group the selection for primary or delayed repair has a great impact on survival and morbidity. Outcomes for primary repair, delayed repair or replacement of oesophagus are all dependent on co-morbidities and require long term follow-up to manage the difficult oesophagus. Repair of OA + TOF using the thoracoscopic approached has been the new innovation and technically feasible, however advantages of this technique over the traditional open approach await further investigation. As outlined by Smith et al. long-term management for this condition still remains a challenge. Congenital cystic lung lesions (CCLL) comprise a spectrum of anomalies and are most commonly detected antenatally. The incidence has recently shown to increase due to improvement in antenatal diagnosis and postnatal CT scan is the best investigative modality in confirming an antenatal lesion. About 10% will require antenatal intervention but most are managed postnatally. CCLL may present with symptoms ranging from foetal demise to chronic cough/infections to incidental detection in the asymptomatic child. Symptomatic lesions are managed acutely with surgical intervention however there remains controversy over the pathophysiology of CCLL and the management of asymptomatic lesions. Co-morbidities in congenital diaphragmatic hernia (CDH) highly influence the prognosis in this condition. Antenatal ultrasound can be used to help prognosticate postoperative outcome if uniformity in measuring and reporting is used. The use of observed to expected antenatal measurements is preferred as they give more specific and accurate information. Antenatal surgery has not been influential in improving outcomes however antenatal intervention in the group of patients with worst outcome is part of an on-going clinical trial awaiting reporting of outcome as mentioned by Mc Honey et al. Thoracoscopic approach to CDH remains controversial as early outcomes are less promising and long-term. There is no clear evidence with regard to the best results in those requiring a patch however the design of a more recent biodegradable patch shows promising outcomes. Routine fundoplication at the time of CDH repair is not supported by the evidence of 1 randomised controlled study. Outcomes may be measured more objectively by means of a multi-disciplinary clinic.
http://dx.doi.org/10.1016/j.earlhumdev.2014.09.015 0378-3782/© 2014 Elsevier Ireland Ltd. All rights reserved.
Increase in the incidence of gastroschisis is well publicised with the aetiology still debated. The knowledge from prenatal diagnosis has highlighted the 80% hidden mortality for exomphalos. Simple gastroschisis may be managed with primary repair or preformed silo application with no variation in the overall outcome from both techniques. Thankfully the incidence of complex gastroschisis is low as the outcome for this group is less satisfactory. Exomphalos without associated anomalies have reasonable outcome however the challenge lies in large and giant exomphalos in obtaining closure with patches that bring their own morbidity and difficulties. Ideal patches are yet to be made available however biodegradable patches are more promising. For malrotation highlighting the urgency for action with bile stained vomiting cannot be further emphasised. Delay in outcome can be catastrophic as outlined by Stanton et al. Need for education and protocols at all levels of newborn care can provide for best practice guidelines. Incidence and management for bowel atresia have not changed in recent years but awareness of associated anomalies such as Down's Syndrome and duodenal atresia are important for foetal counselling. Outcomes have remained good. Hirschprung disease (HD) and anorectal malformation (ARM) are both congenital anomalies presenting as neonatal lower bowel obstruction with difficulty in antenatal detection. Both conditions are frequently associated with congenital abnormalities with a higher genetic association with HD. HD is a functional bowel obstruction resulting from the abnormal development of the enteric nervous system causing aganglionosis of the distal gut whereas ARM comprises a spectrum of anatomical anomalies causing a mechanical bowel obstruction. Surgical intervention is usually required for both conditions either as primary procedure or staged with a stoma. Long term follow up allows early identification and treatment of potentially debilitating symptoms, which include faecal incontinence. Specialist nurse practitioner is a key to the long-term management of both conditions as emphasised by Sudcliffe et al. Thanking all authors for their contribution to the best practice guidelines for neonatal surgical conditions and hope the readership will find this useful for their practice. Conflict of interest There is no conflict of interest. Kokila Lakhoo PhD, FRCS (Eng + Edin), FCS (SA), MRCPCH, MBCHB Oxford Children's Hospital, University of Oxford, Oxford OX3 9DU, United Kingdom Tel.: +44 1865 234197; fax: +44 1865 234211. E-mail address: [email protected].
