Home / Archives / Vol 46 No 1 (2020) / Research Articles

A study of Neonatal Surgical patients and their characteristics in a tertiary care hospital

Abdul Hanif
Department of Neonatal Surgery, Dhaka Medical College and Hospital, Dhaka, Bangladesh.

Kaniz Hasina
Department of Paediatric Surgical Oncology, Dhaka Medical College and Hospital, Dhaka, Bangladesh.

Muhammad Abdur Rouf
Department of Surgery, North Bengal Medical College and Hospital, Sirajganj, Bangladesh.

K.M. Shaiful Islam
Department of Paediatrics, Bangabandhu Sheikh Mujib Medical University, Bangladesh.

Nazmus Sakib Ferdous
Department of Paediatric Surgery, Dhaka Medical College and Hospital, Dhaka, Bangladesh.

Jaglul Gaffer Khan
Department of Neonatal Surgery, Dhaka Medical College and Hospital, Dhaka, Bangladesh

Md. Ashraful Huq Kazal
Department of Paediatric Surgery, Dhaka Medical College and Hospital, Dhaka, Bangladesh.

Keywords: Neonatal surgery, neonatal intestinal obstruction (NIO), anorectal malformation (ARM).

DOI: 10.3329/bmrcb.v46i1.47462

Abstract

Introduction

The neonatal period is the most vulnerable time for a child. Over one third of the global 10.8 million deaths of children under age 5 in the year 2000 occurred in the neonatal period (Black et al 2003). Globally, 2.5 million children died in the first month of life in 2017 alone – approximately 7,000 neonatal deaths every day – most of which occurred in the first week, with about 1 million dying on the first day and close to 1 million dying within the next six days (Alkema et al 2016). Declines in neonatal mortality over the last three decades have been slower than declines in post neonatal or early child (1 to 5 years) mortality. In order to achieve the Sustainable Development Goal (SDG) 3 target of reduction in under-five mortality below 25 per thousand live births by the year of 2030, major reductions are going to be required in neonatal mortality (UN 56^th assembly 2001).

Congenital anomalies have become the 4th cause of neonatal death and most of these are curable (Lawn et al 2005). Among maternal and fetal risk factors; parental consanguinity, maternal under nutrition and obesity, positive history of an anomaly in family, low birth weight and prematurity were significantly associated with higher frequency of congenital anomalies. Birth defects are a diverse group of disorders of prenatal origin that can be caused by single gene defect, chromosomal disorders, multifactorial inheritance, environmental teratogens and micronutrients deficiencies (WHO 126^th session 2009, Tanteles & Suri 2007).

Population of Bangladesh is approximately 163.05 million (World Population Review 2019) and about 20.628 million people live in Dhaka. The largest public hospital of Bangladesh is serving these poor and lower middle class people where surgery and medical facilities are mostly free of cost. The congenital anomalies treated in this hospital are Anorectal malformation (ARM), Hirschsprung’s disease, Gastroschisis, Omphalocele, Intestinal atresia, Meconium ileus, Volvulous neonatoram, Septicemia, Posterior Urethral Valve, Abscess, Infantile pyloric stenosis, Prune belly syndrome, Neonatal injury, Congenital Diaphragmatic Hernia, Ectopia Vesicae, Oesophageal atresia, Tracheo-Oesophageal fistula, Conjoint twin,etc. NIO is the most common form of neonatal emergencies in neonatal surgical patients. It is caused by a group of congenital anomalies and some other acquired conditions (Mortality Country Fact Sheet 2006). Neonatal surgeries require surgical management by pediatric surgeons in medical centers with facilities for pediatric anesthesia, radiology and the specialized nursing care for successful survival (Ravitch et al 1998). Maternal polyhydramnios, dilated fluid filled loops of gut at maternal ultrasonography and family history of cystic fibrosis or Hirschsprung disease are the antenatal diagnostic tool for NIO. It is an urgent condition that requires immediate involvement of a team of pediatric surgeon and neonatologist for peri-operative management. Fluid loss, electrolyte imbalance, metabolic acidosis, hypoglycemia, hypothermia, respiratory distress and sepsis lead to high morbidity and mortality due to intestinal obstruction (Murphree & Dunkley 1992). Among urological cases, hydronephrosis may result from obstruction or reflux of urine which needs careful evaluation. The most common cause of fetal hydronephrosis is ureteropelvic junction (UPJ) obstruction (Hanif et al 2009).

In the developed countries, intrauterine diagnosis, fetal intervention, planned delivery, better pediatric anesthetic support, improved neonatal intensive care, ventilator support and prompt surgical management of relatively clinically stable neonates are possible (Gattett et al 2002; Rowe 1998 and Blyth et al 1993). These were not so in our country where a majority of surgical neonates present very late (Seth et al 2015). Late presentation is another major challenge facing the delivery of neonatal surgical services to children in Bangladesh. Many of these neonates are brought to hospital several days or sometimes weeks after the onset of illness with severe fluid and electrolyte deficits, anemia, sepsis, and malnourishment. Frequently, even the neonates who are delivered in the hospitals are referred late to specialist centers, often not well resuscitated and transported in suboptimal conditions from far locations. These babies are usually hypothermic, septic, and hemo-dynamically unstable and frail on arrival at the referral centers, further compounding the problems. Coupled with inadequate manpower and poor facilities with often lack of neonatal intensive care even at the major tertiary health institutions, the majority of these babies eventually die. Besides, surgical intervention in such babies often leads to high postoperative morbidity and mortality (Chirdan et al 2012).

By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortalities to at least as low as 25 per 1,000 live births (UN 56^th assembly 2001). Bangladesh has a stable, growing economy, but living standards have yet to improve for the poor and vulnerable segments of the population (WHO 126^th session 2009). This study is done to see the types of neonatal surgical patients admitted in this hospital and their management, outcome with limited facilities and find out the ways to improve the scenario to contribute in achieving SDG 3.

Materials and Methods

This was a descriptive study with retrospective record review of all admitted neonates done over a period of 17 years from July 2001 to June 2018 and carried out in the Department of Pediatric Surgery of Dhaka Medical College Hospital. A total of 2492 neonates were admitted during this period and it was the 16.16% of total number of 15414 pediatric surgical admission upto12 years of age. Parameters of clinical presentations at the time of admission, measures of resuscitation and peri-operative measures were taken and recorded. Diagnoses of the patients were based on detailed history, complete physical examination and laboratory and radiological findings. A pre-designed, semi-structured questionnaire was used to collect information. Detail history of each patient was collected and recorded from previous record. Age, sex, date of delivery, mode of delivery, weight during admission, detail history of presenting complaints, history of consanguinity and family history of birth defects were taken. Thorough examination history of baby including abdomen, perineum, head neck region and limbs were recorded. History of resuscitation, types of antibiotics, surgical interventions, morbidity and mortality were also recorded. Statistical assessments were done by SPSS version 22. An Ethical clearance had been sought.

Results

Total number of neonates admitted during the study period was 2492 having surgical problems. The age of the neonates ranged from birth to 28 days with the mean age of 7.9 ± 4 days, weight ranged from 1.0 to 3.9 kg. Majority of the patients came from poor and lower middle class socioeconomic condition. Male: female ratio was 3:2.

The major clinical presentations of the patients included abdominal distension (29.17%), bilious vomiting (22.51% and failure to pass meconium (28.0%) (Table I). Some patients exhibited dehydration (8.71%) and fever (7.78%), abdominal wall defects (4.29%), dribbling of urine (2.97%) and respiratory distress (0.88%).

The most common variety of neonatal surgical patients was ARM (806). Among these 516 (64.02%) patients had high variety and 290 (35.98%) patients had low variety ARM. This was followed next by Hirschsprung disease, 487 (19.54%) of the total cases. Intestinal atresia 246 (09.87%), omphalocele 163 (06.54%), meconium ileus 154 (06.18%), volvulous neonatoram 125 (05.02%), septicemia 114 (04.57%), posterior urethral valve 78 (03.13%), gastroschisis 75 (03.01%), abscess 57 (02.29%), congenital diaphragmatic hernia 54 (02.17%), ectopia vesicae 50 (02.01%), infantile pyloric stenosis 42 (01.68%), tracheo-oesophageal fistula 24 (0.96%), prune belly syndrome 8 (0.32%), neonatal injury 5 (0.20%), conjoint twin 4 (0.16%) were the patients (Table II).

One thousand seven hundred and ninety-one patients (71.86%) were managed surgically (Table III).

Out of 2492 patients, wound infection developed in 160 (6.42%) patients and total 351 died, 127 (5.10%) before surgery and 224 (8.99 %) after surgery (Table IV). The mortality rate was 14.09%.

Discussion

The first 28 days of life – the neonatal period – is the most vulnerable time for a child’s survival. Children face the highest risk of dying in their first month of life at an average global rate of 18 deaths per 1,000 live births in 2017. Comparatively, the probability of dying after the first month but before reaching age 1 was 12 and after age 1 but before age 5 was 10. Globally, 2.5 million children died in the first month of life in 2017 alone – approximately 7,000 neonatal deaths every day – most of which occurred in the first week, with about 1 million dying on the first day and close to 1 million dying within the next six days (Alkema et al 2016). A child born in a least developed country is almost 14 times more likely to die during the first 28 days of life than a child born in an industrialized country. And these burdens of death are heavy for Africa and Asia, accounts for 95 per cent maternal and 90 per cent newborn deaths (Ameh and Nmadu 2000).

Congenital abnormalities accounted for over 82% of all neonatal surgical conditions. This finding was similar to other studies (Seth et al 2015; Nwomeh and Mshelbwala 2004). The most common surgical conditions in the newborn involve the gastrointestinal tract. This finding was similar to other studies (Osifo and Ovueni 2009; White 2000). Boys were predominant group in this study, similar finding was noted in other studies (Wella and Farahat 2015; Sharif et al 2014 and Ilori et al 2013).

In this study, early presentation was observed among ARM, gastroschisis, omphalocele major and meconium ileus. Early onset of symptom and rapid deterioration of patients’ condition in intestinal obstruction and easy approach to diagnosis in ARM was probably the cause of early presentation. On the other hand, presentation was later in Hirschsprung disease, sepsis and malrotation because of variability in onset of symptom and lack of specificity.

In the present study, the commonest congenital abnormalities requiring surgical intervention were anorectal malformations, Hirschsprung disease, small intestinal obstruction, omphalocele and gastroschisis. Similar finding was noted by other studies (Seth et al 2015; Osifo and Ovueni 2009). Neonatal intestinal obstruction (NIO) was the most common form of neonatal emergencies 1932 (77.53%), similar finding to other studies (Sowande et al 2007 and Adejuyigbe et al 1992).

Neonatal intestinal obstruction (NIO) was the most common form of neonatal emergencies. It was caused by a group of congenital anomalies and some other acquired conditions. NIO presented with a triad of bile stained vomiting, abdominal distension and failure to pass meconium. The disease process of neonates with surgical problems varies day to day, even start in intrauterine life. In present study, anorectal malformation was the most common presentation among surgical neonates (32.34 % of all neonates) and the disease process start just after birth. It was to be showed that late presentation of neonates was a risk factor for surgical outcome. Babies delivered outside the hospital need to travel several hours to get to a specialist hospital that offers neonatal surgical services during which time the baby’s condition may detoriate, leading to increased operative risk and mortality (Seth et al 2015).

In this study, various modalities of management were used. Sigmoid colostomy was done for 541 ARM patients. Transverse colostomy and multiple biopsies were done for 376 Hirschsprung disease and rest cases improved by per rectal normal saline irrigation, laxatives. Primary repair was done for gastroschisis, esophageal atresia and bladder exstrophy. Definitive surgery was done in remaining cases as resection and anastomosis was done for intestinal atresia and midgut volvulus cases.

In case of neonate diaphragm is the only respiratory muscle for respiration, which is abdomino-thoracic. After laparotomy wound closure abdominal movement becomes restricted during reversal and postoperative period due to pain in incision line. In this study, all cases were given pre-emptive analgesia with 0.5-1 ml/kg local anesthetic (both lignocaine and bupivacaine) in incision line before the incision was made. So for this simple but good pain management technique recovery from anesthesia was good as well as postoperative period was uneventful without any ventilatory support - which this hospital could not provide due to absence of NICU. Thus this technique helps in reducing mortality. Similar finding was found in Landsman et al 2006.

Total 163 patients with omphalocele were admitted during the study period. 42 patients were treated surgically. Out of them 12 patients were died preoperatively and 16 patients were died postoperatively due to infection, membrane rupture & other congenital anomalies. 109 patients were managed conservatively with 0.5% mercurochrome, alcohol, povidone iodine.

Number of patients withPosterior Urethral Valvewere 78. Cutaneous vesicostomy was done on 29 patients and catheterizations were done on 16 patients for temporary relief of symptoms. Fulgaration was done on 33 cases.

Total 54 patients with Congenital Diaphragmatic Hernia were admitted. Out of them 10 patients were died preoperatively during resuscitation. Forty-four neonates were treated surgically and 6 patients were died postoperatively due to unsuccessful recovery from anesthesia & lack of NICU support. Outcome of other patients were good. Survival rate was 70.37%. The largest multicenter report on CDH mortality to date is that of the CDH Study Group, which has reported an overall survival of 68% (Rahman et al 2004, Bagolan et al 2004) which is similar to current study.

Seventy-five patients with Gastroschisis were visited as emergency basis & referred from other centres. Out of them18 were died preoperatively during resuscitation & 20 patients were died postoperatively due to inadequate reversal from anesthesia & lack of NICU support. Total 50 Ectopia Vesicae patients were treated during study period. All of them were treated surgically by primary closure of anterior urinary bladder wall & anterior abdominal wall. 12 patients were developed postoperative wound dehiscence. Outcome of other neonates were uneventful.

In case of Conjoint Twin & Esophageal Atresia, total 24 patients were treated during study period for esophageal atresia with distal tracheo-oesophageal fistula. All cases were treated surgically and reversal were good but unfortunately babies were died on postoperative period due to lack of NICU support and septicaemia. One pygopagus twin was successfully separated by multidisciplinary team approach. Department’s surgical team on emergency basis also separated 2 conjoint twin from its dead sibling but the baby died two hours after operation in the way for NICU support.

Out of 2492 patients, wound infection developed in 160 (6.42%) patients and total 351 died, 127 (5.10%) before surgery and 224 (8.99 %) after surgery. The mortality rate was 14.09%. In India it was 20% and other authors noted higher mortalities ranging from 30% to more than 42% (Seth et al 2015 and Cantre et al 2013).

Significantly, more deaths occurred in preterm babies and low birth weight babies. Mortality was higher in preterm babies because of the immaturity of all physiologic functions. Higher mortality was observed in laparotomy for intestinal resection and anastomosis (either for small intestinal obstruction or ruptured NEC), closure of ruptured omphalocele, colostomy, thoracostomy with esophageal anastomosis, and associated with multiple congenital abnormalities, this finding was similar to another study (Sowande et al 2007).

Mortality was high among children aged less than a week due to more serious conditions being in this group. Higher mortality was observed in early presenters in this survey probably because most of them were under weight, preterm with multiple associated anomalies and also had high risk types of conditions like gastroschisis, esophageal atresia and intestinal atresia, this was similar to other study (Wella and Farahat 2015). Presence of associated anomalies was associated with high mortality as reported by other studies (Cantre et al 2013 and Manchanda et al 2012).

Presentation, diagnosis and treatment modalities of this study are more or less consistent with the other studies (Welch et al 1983, Nixon 1977, Robertson et al 1987). Fluid loss and electrolyte imbalance, metabolic acidosis, hypoglycemia, hypothermia results from inadequate warming during examination and/or negligence, respiratory distress and septicemia are the leading factors for high morbidity and mortality of intestinal obstruction (Landsman et al 2006).

Many of these neonates are brought to hospital several days or sometimes weeks after the onset of illness with severe fluid and electrolyte deficits, anemia, sepsis, and malnourishment. Frequently, even the neonates who are delivered in the hospitals are referred late to specialist centers, often not well resuscitated and transported in suboptimal conditions from far locations on bad roads. These babies are usually hypothermic, septic, and hemodynamically unstable and frail on arrival at the referral centers, further compounding the problems Previously mortality was decreased but in the recent year it was increasing, mostly due to more admission occurs in neonatal emergencies.

Conclusion

In developing countries, the role of pediatric surgeons is multidimensional due to socio-political and economic reasons. Pediatric surgeons by their skill and teamwork greatly improved the neonatal surgical services and contributing significantly in reducing infant as well as neonatal mortality rate and thus help in achieving SDG3. But to improve further NICU and other support systems are very essential. It is advisable that UNICEF and WHO should include pediatric surgery in their activities including training and infrastructure development especially in developing countries to design the future for the children.

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Correspondence: Abdul Hanif
Department of Neonatal Surgery, Dhaka Medical College and Hospital, Dhaka, Bangladesh.
ahaniftablu@hotmail.com
0000-0002-0466-9858