Neonatal Intestinal Obstruction (NNO) is an occlusive syndrome marked either by a delay or by the absence of intestinal transit, most often due to an obstacle downstream of the pylorus [1]. It is the consequence of a functional and/or mechanical anomaly. It is a frequent medico-surgical emergency in neonatology [2]. It ranks second among surgical pathologies after wall pathologies [2].Its frequency is different depending on the country. In Niger, Ali and coll [3] reported a frequency of 31.9%, in Nigeria Ademuyiwa and coll [4] found 23.5%. In Morocco Imane O and coll found a frequency of 25.5% in 2017 [5].The diagnosis of NNO is based on clinical and paraclinical examinations. It can be evoked in the antenatal period during the ultrasound of the 2nd and 3rd trimester in front of a polyhydramnios, a dilation of the digestive loops and the hyperchogenicity of the hail [1].Whatever the etiology, mortality in developing countries varies from 20 to 70%; this high mortality is linked to the diagnostic and therapeutic delay which varies from one series to another. In Mali a mortality of 32% in 2008 was found by Aliou T and coll [1] and in Morocco, it was 39% according to Imane and coll in 2017 [5].Mortality is low in developed countries where the diagnosis is most often antenatal, allowing early medical and surgical treatment [6,7].In sub-Saharan Africa, particularly in GABON, the diagnostic and therapeutic problems of these conditions remain. The lack of data on the issue led us to carry out this study, the main purpose of which is to contribute to improve the care of newborns with ONN.

Type and Duration of the StudyThis is a descriptive and retrospective study which took place over a period from January 1, 2019 to December 31, 2021, i.e. over a period of 3 years.Study FrameworkThis study took place in the neonatal medicine and pediatric surgery departments of the Jeanne Ebori Foundation mother-child university hospital center (CHUME-FJE).

Study PopulationInclusion Criteria: We included in our study all newborns (0 to 28 days), admitted to the services for confirmed occlusive syndrome or having presented an occlusive syndrome during hospitalization during the study period.

Criteria for Non-InclusionEsophageal atresia and incomplete records were not included.Data CollectionThe data collection was made from the medical records of hospitalization of the neonatal medicine department of pediatric surgery and the registers of the operating room of the CHUMEFJE. These data were then collected on a standardized form.Statistical AnalysisStatistical analysis was performed with SPSS software version 24. Categorical variables were expressed as a percentage and quantitative variables as mean and standard deviation. The association between qualitative variables was assessed by the Chi2 test (or Fisher test for small numbers) and the comparison of means by the Mann Whitney/Wilcoxon test. The significance threshold was set at 5%.

FrequencyDuring the study period, 1140 patients were hospitalized in the pediatric surgery department of CHUME-FJE. Among which 661 operated. The patients operated for a surgical emergency numbered 274. Those who presented NNO were 74. Sixty-nine patients met the inclusion criteria.Thus the ONN represented a frequency of 6.05% of operated patients, 10% of hospitalized patients and 25.2% of operated emergencies.Sociodemographic DataSex: Forty-four patients were male (63.7%). The sex ratio was 1.9.

AgeThe average age was 5.4±6.3 days with extremes of 0 to 25 days. Fifty-five patients (79.7%) were less than 7 days old.

OriginFifty patients resided in urban areas (72.4%) and 27.5% in rural areas. In 87.0% of cases, patients came from a health facility, including 63.7% from university hospitals.

Clinical DataBackground: Forty-one patients (59.4%) had practiced at least 4 (prenatal consultation) CPN and twenty-eight (40.5%) more than 4 CPN.Fourteen patients had not performed an ultrasound in the 1st trimester of pregnancy and 11 in the 3rd trimester.Prenatal diagnosis was not made in any patient.In our series, 27 newborns were born prematurely (39%). Among them, 22 presented an average prematurity (81.5%), 5 severe premature newborn (18.5%).

Reason for AdmissionFigure I provides information on the distribution of newborns according to the reasons for admission.Bloating was the reason for admission in 52.1% of cases, followed by meconium emission anomaly (46.3%) and vomiting in 40.5%.

Figure 1: Distribution of Newborns According to Reasons for Admission

Admission DeadlineThe average admission time was 2.2±1.7 days. It was ≤ 2 days in 62%.

Anthropometric ParametersIn our series, 27 newborns were born prematurely, a proportion of 39.0%. Among them, 22 presented an average prematurity and 5 a great prematurity.On admission, 48 newborns weighed between (2500-4000 g), 15 weighed between (1500-2500 g), 5 weighed less than 1500 g and 1 weighed more than 4000 g (Table 1).

Table 1: Anthropometric Data

Clinical SignsFunctional Signs: The delay or absence of meconium emission was observed in 32 patients or 46.3% (Table 2).

Table 2: Distribution of Patients According to Functional Signs

The physical examination found abdominal distension in 36 patients, i.e. 52% (Figure 2).

Figure 2: Distribution of Patients According to Physical Signs

Paraclinical DataBiological Data: Natremia was lowered in 31.0% of patients with an average of 131.55±10.76 mmol/L.CRP was high in 50.7% of patients with an average of 60.85±83.47 mg/L >15 mg/L and extremes of 1 to 390 mg/L.NFS was performed in all patients. The average hemoglobin level was 13.6 g/dl with extremes of 6.7 and 20.8 g/dl, 53.7% newborns had anemia. The average leukocyte rate was 10664 elements/ml with extremes of 1050 and 37770 elements/m, 24.6% presented with leukopenia and 26% with hyperleukocytosis. The mean platelet count was 333,458 elements/ml with extremes of 36,000 and 644,000 elements/ml, 37.6% had thrombocytopenia and 10 thrombocytosis.

Morphological DataAbdomen Without Preparation (AWP): Figure 3 shows the distribution of patients according to the results of the (AWP).

Figure 3: Distribution of Patients According to AWP Results

WAGENSTEEN and RICE IncidenceIt was performed in 16 newborns (23%) and found 10 cases of high anorectal malformation (ARM, 63%), 1 case of intermediate ARM (6%) and 5 cases of low ARM (31%).

UltrasoundAbdominal ultrasound was performed in 18 patients. The results have been shown in the table. Digestive aerocoly was the most observed ultrasound sign in 27.7% of cases.

Other ExamsTwo newborns had performed a esogastroduodenal transit in favor of duodeno-jejunal dilation, 2 water-soluble enemas in favor of a microcolon appearance and a CT scan in favor of pneumoperitoneum with peritoneal effusion were performed.

Time To DiagnosisThe average diagnostic delay was 3.12±2.36 days with extremes of 1 and 13 days.

Etiological DataIn our study ARM represented 30% of etiologies among them, high forms in 15 cases (71.4%), intermediate in 1 case (4.7%) and low forms in 5 cases (23.8). Associated malformations were found in 7 cases (33.3%) including 3 cases of urogenital malformations, 2 esophageal atresia, 1 case of dextrocardia, 1 case of trisomy 21 (Figure 4).

Figure 4: Distribution of Patients According to Etiology

Therapeutic DataMedical Treatment: Pre, per and post operative resuscitation was performed in all patients and included:

• A correction of hydro-electrolyte disorders

• The placement of a nasogastric tube,

• Administration of a broad-spectrum antibiotic therapy (Betalactamine+Aminoside+Imidazole, Betalactam+Aminoside+Imidazole)

• Parenteral nutrition made of infusion solution

   

Surgical TreatmentIn our series, 44 patients underwent surgery. The three main surgical procedures performed were colostomy in 34.1% of cases, end-to-end resection anastomosis in 31.8% of cases and duodeno-duodenostomy in 13.6% of cases.

Surgical Intervention TimeThe average time elapsed between the date of admission and the date of surgery was 3.38±1.14 days for all operated with extremes of 1 and 21.The mean time between symptoms and intervention was 4.25±2.20 days with extremes ranging from 1 to 25 days (Table 3).

Table 3: Distribution of Patients According to the Surgical Procedure Performed

EvolutionComplications were noted in 9% (n = 6) patients and then resolved. These were: jaundice (in 2 cases), severe anemia (2 cases), malnutrition (in 1 case) and dehydration (in 1 case) (Figure 5).

Figure 5: Distribution of Patients According to the Evolution

Mortality RateIn our series, 22 (31.8%) patients had died (9 non-operated patients and 13 operated patients).

Operative MortalityOf the 44 patients operated on, 13 patients died, 2 intraoperatively and 11 postoperatively. The circumstances of death were 10 cases of septic shock, 3 cases of severe malnutrition.

Characteristics of Deceased PatientsPatient Mortality by Etiology: In our study, 7 deceased patients had ECUN, i.e. 31.8%.5 ARM (22.7%), 4 (18%) duodenal atresia, 3 (13.6%) small bowel atresia, 2 volvulus on common mesentery, 1 Hirschsprung disease.Among the 22 patients who died, 16 were male, 9 were premature 16 were less than 7 days old (Table 4).

Table 4: Provides Information on the Characteristics of Deceased Patients

The general objective of this work was to study the therapeutic methods and the evolution of neonatal occlusions at the CHUME FJE. Our study has a limitation due to its retrospective nature.

Frequency

NNO represented a frequency of 6.05% of operated patients, 10% of patients hospitalized in surgery, 1.7% of neonatal medicine hospitalizations and 25.2% of operated emergencies. In Bamako Kone [4] found that NNO represented 0.7% of hospital frequency, 3.92% of all operated cases and 8% of surgical emergencies. It must be said that the population studied was much larger than ours (1301/13122 cases). There are factors predisposing to the occurrence of congenital malformations, in particular cultural practices such as consanguineous marriages [8-10].

Sociodemographic DataHistory and Comorbidities: 

In our series. Three quarters of the patients had performed a maximum of 4 CPNs, according to the WHO [11], it is recommended to perform 8 CPNs. This therefore amounts to saying that more than three quarters of women had poorly followed pregnancies. not allowing early detection of anomalies. In our countries, it is very often during an occlusive episode that the diagnosis is made. [12,13], rather than following an antenatal ultrasound.In our series, 27 newborns were born prematurely (39%). According to Moukiti and coll [14] prematurity is the most important predictor of (necrotisis ulcerative enterocolitis ) ECUN.

Age

The average age of our series was 5.4±6.3 days with extremes of 0 to 25 days. They are comparable to those found in Mbonicura JC and coll [15] with an average age of 6.8 ±5.1 days with extremes of 1 and 24 days. Indeed these similarities could be explained by the delimitation of the age group which was between 0-25 days. These results are lower than those found by Hounnou GM and coll [16] where the average age at admission was 14 days±5 with extremes at 1 and 55 days. Our average age which is low compared to that found by Hounnou GM and coll [16] could find its explanation in the definition of the limits of the neonatal period in our respective studies. Indeed, the neonatal period in our study was defined as that ranging from 0 to 28 days unlike the other author who considered it as a period ranging from 0 to 55 days. According to the WHO, this period is from birth to 28 days of age.

Sex

The predominance was male with a sex ratio of 1.9. This predominance was found by Saleem and coll [17]. Gender is not a factor in the occurrence of neonatal intestinal obstruction [18]. The male predominance observed in our study is consistent with data from the literature.

Weight

The average weight at admission was 2695±80 g with extremes of 600-5000. These results are similar to those found by Hounnou and coll [16] who found an average weight of 2648±152 g with extremes of 1430 g and 3530 g, Mbonicura and coll [15] who found 2844±152 g with extremes 2000-4000g. weight is not incriminated as a risk factor for occurrence but can influence prognosis [16]. Nagpure and coll [19] demonstrated in their study that newborns weighing less than 2000 g had a high mortality rate of 81.6% against 1.3% mortality in newborns weighing more than 2000g. Prematurity and hypotrophy have been described by some authors as being risk factors for ECUN [20,21].

Clinical Data

Etiological diagnosis, treatment and evolution.

Admission Deadline

Mbonicura and coll [15] who found an average delay of 3.51±2.88 days. This delay is lower than those found by Ali and coll [3] who found an average delay of 4.7 days and Hounnou and coll [16] with an average delay of 11±4 days. Our delay remains quite long for a pathology with rapid evolution potential.In our developing countries, it is in front of the occlusive picture in a newborn that the diagnosis is made. Unlike in developed countries where the diagnosis is most often antenatal, allowing early medical and surgical management [15,16]. In most developed countries, early diagnosis, including prenatal diagnosis and planned delivery in a fully equipped pediatric surgical center, has significantly improved newborn survival [22].In addition, the lack of knowledge of these conditions by certain medical or paramedical practitioners who refer newborns late, sometimes consulted quite early [ 23].

Reason for Hospitalization

The 3 main reasons for hospitalization observed in our study were abdominal distension (52.1%), abnormal emission of meconium (46.3%) and vomiting (40.5%). These results are similar to different proportions to those of Ali et al. [3] and Imane et al. [5].

Etiologies and Their Treatment

The most common etiologies were: ARM (30%), enterocolitis (27%) and small bowel atresia (16%).This agrees with data from the teams of Rehman [24], Ada [25] Inyang [26 ], Talari [27]. There were 17 newborn males and 4 females, their age varied between 1 and 15 days. Mean time to admission was 3.35±2.52 days. The clinical examination in our series found: 23 cases of abdominal bloating (33.3%), 23 cases of abnormal emission of meconium (33.3%). Kassanga and coll [28] had mainly found the occlusive syndrome in 50% followed by meconiuria and anal imperforation.The management consisted in: fourteen colostomies (13 high ARM and 1 intermediate ARM), 05 (low ARM) benefited from anorectoplasty. Kasanga [28] and Habou [29] recommend colostomy in high and intermediate forms and anorectoplasty in low forms. The death rate of MAR was 22.7% (n = 3/19). These were three patients who could not be operated on because they died before surgery. Kasanga and coll [28] found 25% and Habou and coll [29] 17%.

Ulcerative Necrotizing Enterocolitis (ECUN)

Nineteen cases of ulcerative-necrotizing enterocolitis were collected in our study, i.e. 27.5% of cases Uchenna E and coll [30] in Nigeria found 48.8% and Nandi B and coll [31] in Canada found found 72%. The results vary from country to country. Prematurity and low weight have been recognized as the 2 most consistent risk factors for ECUN [20,21].Indeed, abdominal distension, infectious syndrome and vomiting on the ground of prematurity were revealing signs of ECUN in newborns, especially before confirmation using radiology. The thoraco-abdominal X-ray was performed in all newborns, it was found mainly intestinal pneumatosis (pathognomonic sign of ECUN) in 89% of cases. This predominance was found in Moukity and coll [14] who found pneumatosis intestinalis in 71.4% of cases.Urgent medical treatment was based on rehydration, fasting, placement of a nasogastric tube, correction of electrolyte disorders and antibiotic therapy, the most used combination of which was 3rd generation cephalosporin + imidazole + Aminoside. Of the 19 patients, seven died, five of whom had received strictly medical treatment and two surgical treatment. Moukity and coll only medical treatment had been undertaken. In the Phani [32] and Cassir ​​[33] teams, surgery was necessary in 50% of cases. The ECUN mortality rate was 36%. Moukity and coll found a mortality of 49%. The death rate from enterocolitis is still high in our country.

Small Bowel Atresia

We identified 11 cases (16%) of small bowel atresia, 1%. It is lower than that found in Hounnou [16].Their age varied between 2 and 25 days. All parturients had performed a 2nd-3rd trimester ultrasound and no abnormality had been detected. Unlike Awana et al. [35], Kasanga [34] Calisti et al. [28] in whom ultrasound revealed polyhydramnios suggesting a digestive anomaly. All patients underwent end-to-end resection anastomosis. According to the literature, it is the most commonly used surgical treatment [23,36]. The postoperative course was favorable in 9 patients, 3 patients had died, i.e. a mortality of 4.3%. (2 septic shocks, severe malnutrition), Maonea and coll had found a mortality of 100% the circumstance of death was severe dehydration.

Hirschsprung Disease

It represented 8.6% of etiologies in our study. This result is similar to that of Talari et al. [37] who found 9.3%. It concerned 5 newborns males and 1 female. The average age of admission was 2.66±6.38 days. For Sekou and coll [38] the average age was 42 months. This age difference could be explained by the fact that in our sample the age ranges were 0-28 days while Sekou had a sample with age ranges of 0-16 years.The clinical examination mainly found: meconium emission abnormality, abdominal bloating, positive probe test, enterocolitis and vomiting and a similarity had been found by some authors [38].In our series, all the patients had benefited from nursing and 1 patient was complicated by enterocolitis and had benefited from a colostomy. Sékou and coll [38], performed nursing in 66 (73%) of cases and a colostomy in 25 (27%). Bandre and coll [39], had practiced nursing in 67.3% and a colostomy in 75%. Our results agree with data from the literature [38,40]. The mortality was 1.4%. This result is comparable to other authors [38,40].

At the end of our study on the management of neonatal occlusions in the surgery department of the mother-child university hospital of Libreville from 2019 to 2021, we can say that neonatal occlusions are frequent conditions, burdened with high mortality. They represent 10% of the department's surgical activity and a quarter of the emergencies operated on. The most frequently encountered etiologies are anorectal malformations (30.4%), ulcerative necrotizing enterocolitis (27.5%) and small bowel atresia (16%). Their management was mainly surgical (63.7%) but also medical (36.2%). Unfortunately 31.9% of them died.The improvement of diagnostic and therapeutic delays, the optimization of antenatal diagnosis and the awareness of midwives, gynecologists and pediatricians on these different conditions would improve their prognosis. Finally, collaboration between neonatologists, gynecologists, resuscitators and pediatric surgeons would be a major asset in reducing the lethality of these pathologies.

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