Most pediatric surgeons who operate on neonates have seen an expansion over the last few decades from being a subspecialty of pediatric surgery to a superspecialty in its own right. Modern technological advances have contributed to the better care and survival of this group of patients. The evidence for this is based on the experience of most large centers. I have included here our data on neonatal surgical activity over the last three and a half decades.
Our total neonatal surgical activity over the last 35 years (10,465 patients) is illustrated in Figure 1. The number of admissions has consistently increased by an average of at least 100% during the study period (range 139 in 1973 to 433 in 1988). At the same time, mortality has been decreasing significantly, from a mean of >10% in the first half of the study (max 17.5%) to well below 2.5% for each year in the last 10 years (P < 0.01), and even this was, to a large extent, because of either the presence of multiple congenital anomalies or extreme prematurity. Figure 2 demonstrates the admissions of neonates with esophageal atresia (OA), neural tube defects (NTD), and congenital diaphragmatic hernia (CDH). Admissions with OA remained relatively constant (median 11, range 5-16). Only three patients with OA died in the last 10 years, one due to extreme prematurity and the others due to coexistence of major congenital anomalies. The number of admissions with NTD decreased markedly during the study period (median 15, range 64-1) but have shown a moderate increase recently. The study period spans the pre- and post-VP shunt era for hydrocephalus in Scotland. Mortality during the first quarter of the study ranged between 20% and 40%, but remained 0% for each year during the last 10 years. The admissions for CDH varied considerably during the last 35 years both in numbers (median 9, range 1-17) and in type of patient; over the last 15 years, sicker neonates who would otherwise have died without referral were able to be transported long distances by the neonatal transfer team by plane and helicopter services for the whole of Scotland, parts of England, Ireland, and mainland Europe to the Regional Unit at Yorkhill Hospital. Despite this new population of sicker patients, mortality decreased from an average of approximately 40% in the first half of the study period to 9% in the last quarter.
In this Seminars issue on neonatal surgery, we have approached world experts to write on the following topics: abdominal wall defects, esophageal atresia, congenital diaphragmatic hernia, necrotizing enterocolitis, and Hirschsprung disease.
Congenital abdominal wall defects: contemporary management and outcomes
Early definitive closure of abdominal wall defects is possible in most cases, and staged reduction does offer distinct advantages. Risk stratification may be used to better tailor the management of difficult cases in the form of a clinical pathway. Stem cell technology in the future could offer the ideal allogenic prosthesis in complex cases.
Esophageal atresia (OA): the total care in a high-risk population
The outcome of cases of OA depends on many factors that affect the prognosis. These factors have been identified since Waterston aimed to classify the anomaly according to the risk factors. There are other factors that affect the outcome, and these differ in various parts of the world. This comprehensive review from the All India Institute of Medical Sciences in New Delhi attempts to incorporate all the factors (preoperative, operative, and postoperative) that can pose risks to the ultimate survival of the baby. Early detection for proper management of these cases is essential. Feasibility to perform early esophageal replacement is to be considered in these high-risk cases in the Indian subcontinent. Total care in a high-risk population of OA depends on the investigative modalities adopted, available neonatal ICU care, and the surgeon's experience.
Congenital diaphragmatic hernia (CDH): a modern day approach
This is a review from Mannheim, a large regional center that carries out trials for CDH in Germany. Their large experience in managing diaphragmatic hernia has produced a comprehensive up-to-date review. Persistent pulmonary hypertension plays an important factor in the management of CDH and is responsible for the morbidity and mortality of this condition. Antenatal diagnosis and the introduction of fetal surgery in some selected centers have helped in the early management of severe cases. Lung volume measurements by MRI may predict risk stratification in those who need high-risk therapy using extracorporeal membrane oxygenation. Fetal surgery and the introduction of liquid ventilation with perflurocarbon are discussed.
Necrotizing enterocolitis (NEC): bench to bedside: novel and emerging strategies
NEC is a devastating illness that predominantly affects premature neonates. Depressingly, the mortality associated with this disease has changed very little during the last two decades. Neonates with NEC fall into two categories: those who respond to medical management alone and those who require surgical treatment. The disease distribution may be focal, multifocal, or panintestinal. Surgical treatment should therefore be based on disease presentation. Recent studies have added significant insight into our understanding of the pathogenesis of NEC. Several groups have shown that upregulation of nitric oxide (NO) plays an integral role in the development of epithelial injury in NEC. As a result, some treatment strategies have been aimed at abrogating the toxic effects of NO. In addition, several investigators have reported the cytoprotective effect of epidermal growth factor, which is found in high levels in breast milk, on the intestinal epithelium. Thus, fortification of infant formula with specific growth factors could soon become a preferred strategy to accelerate intestinal maturation in the premature neonate to prevent the development of NEC. One of the most devastating complications of NEC is the development of short bowel syndrome (SBS). The current treatment of SBS involves intestinal lengthening procedures or bowel transplantation. An emerging method for treating SBS involves the use of tissue-engineered intestine. In laboratory animals, tissue-engineered small intestine has been successful in treating intestinal failure. This article examines recent data regarding surgical treatment options for NEC as well as emerging treatment modalities.
Hirschsprung disease
Hirschsprung disease is a relatively common condition managed by most pediatric surgeons. Significant advances have been made in understanding its etiologies in the last decade, especially with the explosion of molecular genetic techniques and early diagnosis. The surgical management has progressed from a two- or three-stage procedure to a primary operation in the neonate. More recently, definitive surgery for Hirschsprung disease through minimally invasive techniques has gained popularity. In neonates, the advancement of treatment strategies for Hirschsprung disease continues with reduced patient morbidity and improved outcomes.
The last three articles illustrate the improved care of the surgical neonate with better understanding of the physiology of metabolism and nutrition, pain relief and the understanding of stress in the neonate, and finally, the importance of specialist nursing care in the management of surgical neonates.
Metabolism and nutrition in the surgical neonate
Considerable improvements have been achieved in pediatric surgery during the last two decades: the mortality rate of neonates undergoing major operations has declined to <10%, and the morbidity of major operations has become negligible. This considerable improvement can be partly ascribed to a better understanding of the physiological changes that occur after an operation and to more appropriate management and nutrition of the critically ill and “stressed” neonates and children. The metabolic response to an operation is different in neonates than adults: there is a small increase in oxygen consumption and resting energy expenditure immediately after surgery with return to normal by 12 to 24 hours. The increase in resting energy expenditure is significantly greater in infants having a major operation than in those having a minor procedure. The limited increase in energy expenditure may be due to diversion of energy from growth to tissue repair. During parenteral nutrition, it is not advisable to administer more than 18 g/kg/day of carbohydrate, because this intake will be associated with lipogenesis, increased CO2 production, and increased free radical-mediated lipid peroxide formation. Glutamine intake is potentially beneficial during total parenteral nutrition, although a large randomized controlled trial in surgical neonates requiring parenteral nutrition is needed to provide evidence demonstrating its benefit.
Stress and pain relief in the care of the surgical neonate
Over recent years, there has been a major change in our thinking about the way neonates experience stress. This understanding has led to advances in anesthetic technique and the pre- and postoperative care of the surgical neonate. Stress can develop before birth due to placental insufficiency. This can lead to preterm delivery, and the preterm infant is much more vulnerable to stressful stimulus. Stress is detrimental to the neonate in the short term and can also have adverse effects on the future wellbeing of the child. Limiting stress is not just about good pain control. The nursing environment is vitally important. Much can be achieved with good attention to detail in this respect. The effects of stress and the ways they can be minimized are discussed.
Nursing care of the surgical neonate
Nursing the surgical neonate requires skill and expertise. Team care and input from the neurodevelopment team improve the long-term outcome of premature infants. Positioning and handling guidelines to promote midline development, hand-to-mouth consideration, and visual tracking are all of importance in the long-term outcome. Some specialist nurses are important in the care of surgical neonates. These include: tissue viability nurse specialists, stoma nurse specialist (gastrostomy, tracheostomy), nutrition nurse specialist (eg, in short gut syndrome), advanced neonatal nurse practitioners, clinical nurse educators for evidence-based care, and extracorporeal life support specialist nurse. In this article, the authors outline the immediate preoperative management, stabilization, and subsequent postoperative nursing care of the surgical neonate.
FULL TEXT00050-4/journalimage?img=PIIS1055858608000504.gr1.lrg.gif&fig=fig1&kwhquery=&issn=1055-8586&ishighres=false&allhighres=false&free=yes','journalimage');)
00050-4/journalimage?img=PIIS1055858608000504.gr2.lrg.gif&fig=fig2&kwhquery=&issn=1055-8586&ishighres=false&allhighres=false&free=yes','journalimage');)
