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11/59. Graft failure secondary to necrotizing enterocolitis in multi-visceral transplantation recipients: two case reports.

    We report on two recipients of multi-visceral grafts who exhibited sudden onset of acute abdomen discomfort 2 weeks post-transplantation after a fairly uneventful immediate post-operative course. Both patients were shown to have pneumatosis intestinalis and one had air in the portal vein. Both patients underwent exploration, which showed non-viable intestine (terminal ileum and colon in the first patient and the entire small intestine distal to the ligament of Treitz in the second patient). There was no vascular thrombosis. The necrotic intestine was resected in both cases. The first patient developed sepsis and died 15 days later despite the rescue efforts. The second patient was re-transplanted twice and is doing well. The histopathology of the segments involved revealed cryptitis, vasculitis, and features of transmural necrosis. Accordingly, both clinical and pathologic features are diagnostic of necrotizing enterocolitis. To our knowledge this is the first report of this complication following intestinal or multi-visceral transplantation.
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12/59. Inflammatory polyps after necrotizing enterocolitis.

    Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in the neonatal period. NEC causes ulceration of the intestinal mucosa and may lead to perforation or a stricture. To the best of the authors' knowledge intestinal inflammatory polyps after NEC have not been described previously. The authors report on a 17-week-old boy with pseudopolyps at the site of a colonic stricture after NEC.
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13/59. Successful use of the "patch, drain, and wait" laparotomy approach to perforated necrotizing enterocolitis: is hypoxia-triggered "good angiogenesis" involved?

    The traditional and most frequently employed surgical approach to perforated necrotizing enterocolitis (NEC), laparotomy and bowel resection with enterostomy creation, has been associated with an unacceptably high mortality and major morbidity (sepsis, short-gut syndrome, strictures, long-term total parenteral nutrition (TPN), prolonged and costly hospitalizations with multiple operations, the inevitable open-and-close procedure for "hopeless" extensive gut ischemia in approximately 10% of laparotomy cases, etc.). The use of the laparotomy "patch, drain, and wait" (PD&W) approach to this serious of NEC complication has provided a simple, direct, and effective means of dealing with this problem. The basic principle is to resect no gut and do no enterostomies. The details are presented here as well as the multiple types of "patching" and the importance of use of extensive direct-vision draining with bilateral small Penrose drains from the undersurfaces of both diaphragms into the pelvis with exit sites in both lower quadrants. Proper and effective patching and draining cannot be done blindly,but requires direct vision (laparotomy or laparoscopy). The critical components and timing of the "waiting" are emphasized, including the vital importance of strict avoidance of early post-drainage laparotomy in the 7- to 14-day post-drainage period (whether the drainage is percutaneous, laparotomy PD&W, or laparoscopy PD&W) due to the early, life-threatening-ending hypervascularity that occurs at this time and if left unmolested will function beneficially as life- and gut-saving "good angiogenesis". The bilateral Penrose drains capture fecal fistulas and function quite well as de-facto enterostomies as the peritoneal cavity is rapidly obliterated by adhesions and massive, florid hypervascularity/gut hypoxia triggered "good angiogenesis" (no peritoneal cavity, no peritonitis). Broad-spectrum triple antibiotics and the routine use of TPN contribute to favorable results. The lessons/experiments of nature encountered in newborns with midgut atresia(s) and remarkable levels of gut survival, in the occasional case with only meconium peritonitis and no obstruction ("auto-anastomosis") are pertinent here as the TPN of PD&W is provided in atresia(s) by the maternal-placental circulation and the sterile peritoneal cavity of atresia(s) is simulated by the combination of antibiotics and peritoneal-cavity obliteration. life- and gut-saving "good angiogenesis" is common to both situations. A 15-year personal experience with the PD&W laparotomy approach to perforated NEC in 23 cases is reported here with no mortality in the initial 60 postoperative days, no major morbidity, and no second operation required in 70% (spontaneous "auto-anastomosis") of cases. All infants with extensive gut ischemia/necrosis (NEC totalis) who would otherwise be classified as "hopeless" and managed by open-and-close only were managed in this experience successfully by PD&W with preservation of both life and an adequate amount of gut, although a second operation was required in these cases to re-establish intestinal continuity. A particularly striking observation was the rapid transition of these infants from profound illness to near-normalcy in a matter of hours after the initiation of PD&W--much like the rapid clinical changes accompanying the lancing of a boil or an abscess. An involvement of hypoxia-induced "good angiogenesis" with marked hypervascularity and involving molecules, genes, and receptors of the vascular endothelial growth factor family of hypoxia-induced angiogenesis molecules is speculated upon, and clinical studies to document these speculations are suggested as well as studies evaluating the potential of laparoscopic PD&W. The usefulness of Argyle chest-tube "venting" and "stenting" by trans-anal passage above colonic "patched" areas as seen in 2 cases is worthy of further study and use.
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14/59. Neonatal wound dehiscence and the subsequent healing process: a case study.

    Many neonates require abdominal surgery for a variety of reasons, including necrotizing enterocolitis (NEC). Secondary complications of abdominal surgery include alterations in skin integrity and potential wound dehiscence. These alterations may actually worsen when treated with products "traditionally" used postoperatively. The author simultaneously utilized basic wound care products with currently recognized therapies in managing a 29-week premature infant who experienced dehiscence secondary to bowel repair. By utilizing the correct products and incorporating the principles of moist wound healing and occlusion, this Stage III/IV wound, measuring 12 cm x 3 cm, closed within 35 days of dehiscence. A team-oriented and coordinated approach proved that wounds can, and will, improve, even in this fragile population.
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15/59. Pneumatosis of the bladder wall associated with necrotizing enterocolitis.

    Increasing use of sonography for imaging the abdomen of neonates has brought greater recognition of its value in diagnosing and monitoring complications of necrotizing enterocolitis. We describe a case in which pneumatosis of the bladder wall was visualized by sonography in a neonate with down syndrome and necrotizing enterocolitis.
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16/59. Echovirus 7 infection and necrotizing enterocolitis-like symptoms in a premature infant.

    Echovirus type 7 has been previously recognized as a virulent serotype in the premature neonate. However, reports of fatal disseminated infections have often been perinatally acquired from symptomatic mothers at the time of delivery. Nosocomial outbreaks in full-term and premature infants have been reported from newborn intensive care units; however, deaths attributed to Echovirus 7 in convalescing prematures are rare in the literature. We report the case of a growing premature neonate presenting with an overwhelming sepsis-like syndrome, including symptoms consistent with necrotizing enterocolitis. Despite intensive supportive care including ventilatory support, cardiovascular pharmacotherapy, and blood product administration, the infant succumbed to overwhelming Echovirus 7 infection.
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17/59. Hirschsprung's disease presenting with diffuse intestinal pneumatosis in a neonate.

    In the neonate, pneumatosis intestinalis is almost always associated with necrotizing enterocolitis. The manifestation of diffuse intestinal pneumatosis in Hirschsprung's disease has been reported rarely. It may occur as a result of Hirschsprung's disease complicated with enterocolitis. We report a two-day-old female baby born at term with the problems of failure to pass meconium, progressive abdominal distension and bile stained vomiting. There was an early roentgenographic presentation of pneumatosis intestinalis which might have led to a diagnosis of necrotizing enterocolitis. However, the intestinal pneumatosis resolved within 48 hours. After anorectal manometry and contrast enema examination, an ileostomy was performed at the age of 23 days, and multiple biopsies of intestine showed aganglionosis up to the ileum at the level of 85 cm above the ileocecal valve. Unfortunately, the patient developed short bowel syndrome after operation and died suddenly after an accidental choking at the age of three months. This case suggests that Hirschsprung's disease may have an unusual early roentgenographic presentation with diffuse intestinal pneumatosis in the first few days of life. Anorectal manometries and suction biopsies are crucial for further diagnosis.
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18/59. pneumoperitoneum: an absolute indication for surgery in infants with necrotizing enterocolitis?: Report of a case.

    It is generally agreed that neonates with necrotizing enterocolitis (NEC) and pneumoperitoneum should be treated surgically. We report herein the case of a 3-day-old male newborn with NEC in whom a pneumoperitoneum subsequently developed without any cause found at laparotomy. This case is presented to discuss the nonsurgical management of pneumoperitoneum in selected patients.
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19/59. Necrotizing enterocolitis in a married couple due to a staphylococcal toxin.

    A married couple affected by necrotizing enterocolitis is described. Both had the same toxin-producing staphylococcus aureus which was considered to be responsible for the necrotizing enterocolitis.
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keywords = necrotizing
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20/59. Postoperative necrotizing enterocolitis following incarcerated inguinal hernia repair: report of a case.

    The postoperative development of necrotizing enterocolitis (NEC) following major surgery in neonates has often been described. We report herein the case of an older infant in whom postoperative NEC developed following emergency repair of an incarcerated inguinal hernia.
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