eMedicine Specialties > Pediatrics: Surgery > General Surgery
Atresia, Stenosis, and Other Obstruction of the Colon: Treatment
Updated: Apr 28, 2008
Treatment
Medical Therapy
Initial treatment of newborns with colonic atresia is directed toward resuscitation. The child is often distended and dehydrated. Usual treatments prior to operative intervention include the following:
- Nasogastric decompression
- Intravenous fluid resuscitation
- Intravenous antibiotics
Surgical Therapy
The management of colonic atresia is directed at eliminating the bowel obstruction and establishing intestinal continuity. In selected cases (with limited comorbidities and limited associated malformations), this may be performed in one operation by resecting the atretic ends and anastomosing the colon. If the child has significant comorbidities, a diverting enterostomy may be brought out just proximal to the atresia, and intestinal continuity may be restored during a second operation.
Many authors advocate resection with primary anastomosis for right colon lesions and colostomy diversion with subsequent reconstruction for left-sided atresia and stenosis. Theoretically, the liquid feces in the right colon pose less risk to a fresh anastomosis than formed stool. However, in practice, Davenport et al noted that the type of procedure had no effect on survival rates, and outcomes were excellent using either technique.5
Colonic atresia associated with Hirschsprung disease is often, but not exclusively, associated with abnormal distal colonic fixation.43,29 The association of nonfixation with aganglionosis seems significant enough to warrant obtaining biopsy results prior to establishing intestinal continuity in those selected cases. Diverting enterostomy alone is always a safe option if the suspicion of aganglionosis is significant and experienced pediatric pathology services are unavailable.
In congenital colonic stenosis, one usually finds less difference in the sizes of the proximal and distal limbs, making resection with primary anastomosis the preferred treatment.
In acquired colonic stenosis following necrotizing enterocolitis, primary excision and anastomosis is the treatment of choice for stable patients without life-threatening comorbidities.
Preoperative Details
Basic preoperative laboratory measurements for all neonates should include a CBC count, electrolyte assessment, and a crossmatch. If time permits, a contrast enema can be quite useful in assessing the colon and excluding any other narrowings in that area, which can sometimes be difficult intraoperatively.
A rectal biopsy should be performed if possible to eliminate the slight chance of Hirschsprung disease, but all care should be taken to ensure that it does not delay prompt operative intervention.
Intraoperative Details
Primary repair in one stage
- Laparotomy: A transverse supraumbilical laparotomy is usually performed. The abdomen is eviscerated, and the bowel is inspected. The atresia should be readily visible by the dilated bulbous proximal portion and a microcolon on the other side. A large mesenteric or intestinal gap may be observed between the proximal and distal ends, reflective of the region that would have been supplied by the vessel that had the prenatal vascular accident, which hypothetically caused the atresia.
- Full exploration: The abdomen must now be fully explored. The full intestinal length must be examined for the presence of other atresias. This may require passing a catheter distally into the open end of the distal segment and distending the bowel with saline to ensure the lumen is patent. The presence of multiple atresias may require multiple resections and should be assessed together to minimize intestinal loss and the number of anastomoses.
- Proximal segment: In preparing to put the two ends of the colon together, the dilated proximal portion must be resected. The dilated proximal bowel functions poorly due to dysmotility. Resecting the proximal intestine back to an area of normal caliber is essential for postoperative function and lessens the size discrepancy when performing the anastomosis.
- Distal segment: Minimal distal bowel is removed, although the atretic end is thickened and should not be used in closure. That end is resected, and the distal colon is usually divided on a bias, removing more bowel on the antimesenteric side than the mesenteric side (to promote better blood supply at the anastomosis). The antimesenteric side is usually opened further to counter the size discrepancy with the proximal end.
- Mesenteric gap: If present, the mesenteric gap is usually closed primarily, if possible.
Diversion with primary repair at a second stage
The operation is much the same as for primary repair above.
- Proximal segment: The proximal end of the atresia is again resected back to a normal-caliber bowel. This end is then brought out onto the anterior abdominal wall and matured as an ostomy.
- Distal segment: If the patient is critically ill, the distal segment may be left completely undisturbed until the patient's status changes in the future. For stable patients, the distal end of the atresia should have its end removed, and the fresh end should be brought up to the abdominal wall skin as a mucous fistula.
- Ostomy location and maturation: Both ostomies can be brought out at the same location, which may be at the corner of the laparotomy incision or may be through a separate incision. They may also be separated by a skin bridge; however, that is nonessential. What is most important is that the colostomy be matured and positioned on the abdominal wall in such a way that an appliance can be securely placed around it.
- Mucous fistula: The mucous fistula should not be matured like a mushroom but should be flush with the skin and should only be large enough to be able to admit a catheter for irrigations or contrast radiography. If it is placed immediately next to the colostomy with no skin bridge, it should be small enough to allow appliance placement over both. If the surgeon prefers a skin bridge between the ostomy and mucous fistula, it should be either small enough to be directly covered by the ostomy appliance wafer or should be far enough away as to not interfere with ostomy appliance placement.
Postoperative Details
The neonate who has undergone surgical correction of atresia or stenosis requires neonatal critical care in conjunction with the pediatric surgical care.
In the early postoperative period, the intestine and soft tissues absorb fluid, which surgeons refer to as third-space losses. This requires significant hydration to ensure the maintenance of intravascular volume and adequate tissue perfusion. Inadequate hydration can lead to pressor administration, which can impair intestinal perfusion. Third-space losses usually persist for 24-48 hours if no source of sepsis is present.
All children who undergo laparotomy need adequate analgesia. Narcotics should only be administered to babies in a monitored setting (ie, a neonatal intensive care unit with apnea, pulse-oximetry, and cardiac monitors). No baby should be prevented from getting adequate analgesia simply because they cannot articulate the need for it.
Antibiotics are usually administered to all patients, although the indications are not clearly evidence based. Within the first 3 days of life, the intestinal flora is not yet colonized with anaerobes, so gram-positive and gram-negative coverage is sufficient at that time.
Early parenteral nutrition should be started in all patients. Patients with atresia, despite having their bulbous dysmotile proximal portions resected, can have prolonged postoperative ileus and usually benefit from early parenteral nutrition.
If a nasogastric tube was placed during the operation, it usually remains in place at the discretion of the surgeon. The most traditional approach is to keep a nasogastric tube to suction (taking care to replace its output with intravenous fluids) until the child is passing flatus or stool. When that occurs, the tube may be placed to bedside gravity drainage; if that is well tolerated, the tube may be removed. Some surgeons clamp the tube prior to removal as a final test to see if the child can truly tolerate their own intestinal gases and secretions.
When the tube is removed, the diet may be started. Most surgeons start with clear liquids, such as sugar water or a balanced electrolyte solution. When that is well tolerated, the diet is advanced to either breast milk or formula.
Patients who have undergone a colostomy require specific care for the stoma and its output. Return of bowel function in these patients is usually faster after colostomy than in those who undergo resection and anastomosis. Colostomy closure is performed electively at a future date. Most surgeons prefer to wait a minimum of 6-8 weeks to allow intraperitoneal inflammation to subside.
Follow-up
Follow-up imaging studies are not performed unless indicated by clinical issues. Children who have had a stoma created usually undergo contrast enema prior to stomal closure to evaluate the distal limb for stricture or obstruction.
Follow-up in the office is essential. Many of these babies have residual intestinal motility problems that may manifest in either the proximal or distal segments. Close follow-up is essential to ensure that they are appropriately managed.
Complications
Complications of surgery for colonic atresia and stenosis are those of any bowel resection with stoma creation or anastomosis. Wound infection or incisional hernia can occur after any surgery.
The complication surgeons are most concerned about is anastomotic leak. Leaks may manifest at any time but usually become noticeable several days to a week after surgery. Signs may be as subtle as mild tachycardia and fever, or the patient may rapidly progress from mild illness into full-blown septic shock. Radiography may reveal intra-abdominal free air. CT scanning could reveal abscesses. Anastomotic leak requires exploration and diverting enterostomy.
Intra-abdominal abscesses may occur without leak but are rare. Intraoperative bleeding that leads to postoperative clot can be a setup for abscess, which may be amenable to drainage by interventional radiology.
Anastomotic narrowing may occur and may be related to technical error, ischemia, or leakage.
Patients who undergo colostomy may have stoma narrowing, prolapse, or parastomal herniation.
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References
Oldham KT. Atresia, stenosis and other obstructions of the colon. In: O' Neill JA, Jr, Rowe MI, Grosfeld JL, Fonkalsrud EW, Coran AG, eds. Pediatric Surgery. St. Louis, Mo: Mosby; 1998:1361-68.
Gaub OC. Congenital stenosis and atresia of the intestinal tract above the rectum; with a report of an operated case of atresia of the sigmoid in an infant. Tr Am S A. 1922;40:582.
Potts WJ. Congenital atresia of the intestine and colon. Surg Gynecol Obstet. 1947;85:14.
Evans CH. Collective review: atresias of the gastrointestinal tract. Surg Gynecol Obstet. 1955;92:1-8.
Davenport M, Bianchi A, Doig CM, Gough DC. Colonic atresia: current results of treatment. J R Coll Surg Edinb. Feb 1990;35(1):25-8. [Medline].
Webb CH, Wangensteen OH. Am J Dis Child. 1931;4:232.
Benson CD, Lotfi MW, Brogh AJ. Congenital atresia and stenosis of the colon. J Pediatr Surg. Apr 1968;3(2):253-7. [Medline].
Powell RW, Raffensperger JG. Congenital colonic atresia. J Pediatr Surg. Apr 1982;17(2):166-70. [Medline].
Freeman NV. Congenital atresia and stenosis of the colon. Br J Surg. 1966;53:595-7.
Gross RE. The surgery of infancy and childhood. Philadelphia, Pa: WB Saunders & Co; 1953:150-74.
Dalla Vecchia LK, Grosfeld JL, West KW, et al. Intestinal atresia and stenosis: a 25-year experience with 277 cases. Arch Surg. May 1998;133(5):490-6; discussion 496-7. [Medline].
Kim S, Yedlin S, Idowu O. Colonic atresia in monozygotic twins. Am J Med Genet. Mar 20 2000;91(3):204-6. [Medline].
Janik JS, Ein SH, Mancer K. Intestinal stricture after necrotizing enterocolitis. J Pediatr Surg. Aug 1981;16(4):438-43. [Medline].
Kosloske AM, Burstein J, Bartow SA. Intestinal obstruction due to colonic stricture following neonatal necrotizing enterocolitis. Ann Surg. Aug 1980;192(2):202-7. [Medline].
Virjee JP, Gill GJ, Desa D, et al. Strictures and other late complications of neonatal necrotising enterocolitis. Clin Radiol. Jan 1979;30(1):25-31. [Medline].
Millar AJW, Rode H, Cywes S. Intestinal atresia and stenosis: colonic atresia. In: Ashcraft KW, ed. Pediatric Surgery. 3rd ed. Philadelphia, Pa: WB Saunders Company; 2000.
Landes A, Shuckett B, Skarsgard E. Non-fixation of the colon in colonic atresia: a new finding. Pediatr Radiol. 1994;24(3):167-9. [Medline].
Nitta K, Iwafuchi M, Ohsawa Y, et al. A case of congenital colonic atresia associated with atresia ani. J Pediatr Surg. Nov 1987;22(11):1025-6. [Medline].
Asabe K, Nagasaki A. Double atresia of hindgut with ileal stenosis: a case report. Asian J Surg. Jan 2004;27(1):49-51. [Medline].
Digray NC, Mengi Y, Goswamy HL, Thappa DR. Colorectal perforations in neonates with anorectal malformations. Pediatr Surg Int. 2001;17(1):42-4. [Medline].
Pohlson EC, Hatch EI Jr, Glick PL, Tapper D. Individualized management of colonic atresia. Am J Surg. May 1988;155(5):690-2. [Medline].
Akgur FM, Tanyel FC, Buyukpamukcu N, Hicsonmez A. Colonic atresia and Hirschsprung's disease association shows further evidence for migration of enteric neurons. J Pediatr Surg. Apr 1993;28(4):635-6. [Medline].
Kim PC, Superina RA, Ein S. Colonic atresia combined with Hirschsprung's disease: a diagnostic and therapeutic challenge. J Pediatr Surg. Aug 1995;30(8):1216-7. [Medline].
Siu KL, Kwok WK, Lee WY, Lee WH. A male newborn with colonic atresia and total colonic aganglionosis. Pediatr Surg Int. 1999;15(2):141-2. [Medline].
Williams MD, Burrington JD. Hirschsprung's disease complicating colon atresia. J Pediatr Surg. Apr 1993;28(4):637-9. [Medline].
Wang KS, Cahill JL, Skarsgard ED. Omphalocele, colonic atresia, and Hirschsprung's disease: an unusual cluster of malformations in a single patient. Pediatr Surg Int. Mar 2001;17(2-3):218-20. [Medline].
Croaker GD, Harvey JG, Cass DT. Hirschsprung's disease, colonic atresia, and absent hand: a new triad. J Pediatr Surg. Sep 1997;32(9):1368-70. [Medline].
Akgur FM, Olguner M, Hakguder G, Ozer E, Aktug T. Colonic atresia associated with Hirschsprung's disease: it is not a diagnostic challenge. Eur J Pediatr Surg. Dec 1998;8(6):378-9. [Medline].
Draus JM Jr, Maxfield CM, Bond SJ. Hirschsprung's disease in an infant with colonic atresia and normal fixation of the distal colon. J Pediatr Surg. Feb 2007;42(2):e5-8. [Medline].
Applegate KE, Sargent SK. Spontaneous colonic ischemia in a patient with Riley-Day syndrome. Pediatr Radiol. 1995;25(4):312-3. [Medline].
Patten BM. Human Embryology. New York, NY: McGraw-Hill; 1953.
Louw JH, Barnard CN. Congenital intestinal atresia. Lancet. 1955;ii:1065-7.
Fairbanks TJ, Kanard RC, Del Moral PM, et al. Colonic atresia without mesenteric vascular occlusion. The role of the fibroblast growth factor 10 signaling pathway. J Pediatr Surg. Feb 2005;40(2):390-6. [Medline].
Hollinshead WH. Anatomy for Surgeons. Vol 2. New York, NY: Hoeber-Harper; 1956.
Gornall P. Management of intestinal atresia complicating gastroschisis. J Pediatr Surg. Jun 1989;24(6):522-4. [Medline].
Wang NL, Yeh ML, Chang PY, et al. Prenatal and neonatal intussusception. Pediatr Surg Int. Apr 1998;13(4):232-6. [Medline].
Al-Wafi A, Morris-Stiff G, Lari A. Colonic atresia secondary to a choledochal cyst. Pediatr Surg Int. Jul 1998;13(5-6):422-3. [Medline].
Louw JH. Investigations into the etiology of congenital atresia of the colon. Dis Colon Rectum. 1964;7:471-478.
Werler MM, Sheehan JE, Mitchell AA. Association of vasoconstrictive exposures with risks of gastroschisis and small intestinal atresia. Epidemiology. May 2003;14(3):349-54. [Medline].
de Jesus LE, Marques AM, Rocha MS, et al. Left colon stenosis caused by tuberculosis. J Pediatr Surg. Oct 2004;39(10):e5-7. [Medline].
Bland-Sutton JD. Imperforate ileum. Am J Med Sci. 1889;98:457-62.
Cox SG, Numanoglu A, Millar AJ, Rode H. Colonic atresia: spectrum of presentation and pitfalls in management. A review of 14 cases. Pediatr Surg Int. Oct 2005;21(10):813-8. [Medline].
Fishman SJ, Islam S, Buonomo C, Nurko S. Nonfixation of an atretic colon predicts Hirschsprung's disease. J Pediatr Surg. Jan 2001;36(1):202-4. [Medline].
Ameh EA, Nmadu PT. Intestinal atresia and stenosis: a retrospective analysis of presentation, morbidity and mortality in Zaria, Nigeria. West Afr J Med. 2000;19:39-42. [Medline].
Abu-Judeh HH, Methratta S, Ybasco A, et al. Congenital colonic stenosis. South Med J. Mar 2001;94(3):344-6. [Medline].
Sturim HS, Ternberg JL. Congenital atresia of the colon. Surgery. Mar 1966;59(3):458-64. [Medline].
Coran AG, Eraklis AJ. Atresia of the colon. Surgery. May 1969;65(5):828-31. [Medline].
Smith GH, Glasson M. Intestinal atresia: factors affecting survival. Aust N Z J Surg. Feb 1989;59(2):151-6. [Medline].
Barrack SM, Kyambi JM, Ndungu J, et al. Intestinal atresia and stenosis as seen and treated at Kenyatta National Hospital, Nairobi. East Afr Med J. Sep 1993;70(9):558-64. [Medline].
Further Reading
Keywords
colonic atresia, colonic stenosis, colonic stricture, colonic obstruction, congenital colon obstruction, colonic narrowing, abdominal distention, failure to pass meconium, narrowed colon, Hirschsprung disease, small left colon syndrome, obturation obstruction, meconium ileus, meconium plug, abdominal distention, failure to pass meconium, congenital stenosis, acquired stenosis, stricture, necrotizing enterocolitis, intestinal blockage, bowel obstruction, feeding intolerance
failure to thrive, colon atresia, small intestinal atresia, dilated bowel loops, polyhydramnios, abdominal wall defects, genitourinary tract abnormalities, anal atresia, imperforate anus, colonic perforation, omphalocele, aganglionosis, mesenteric vascular incident, cryptophthalmia syndrome, cleft lip and palate, dysplastic kidneys, proximal jejunal atresia, arthrogryposis, proximal intestinal atresia, neoplasm, malrotation, Riley-Day syndrome, spontaneous colon ischemia, coloboma, cataracts, facial hemihypertrophy
facial asymmetry, exophthalmia, bilateral optic nerve hypoplasia, vascular interruption, thrombosis, volvulus, herniation, bowel necrosis, duodenal atresia, bowel ischemic injury, internal hernia, choledochal cyst, volvulus, bowel infarction, Crohn disease, tuberculosis
