PERINATOLOGY • Vol 24 • No. 1 • May–Aug 2023 • 71 are intestinal obstruction, persistent peritonitis, large abdominal mass, abdominal wall with signs of cellulitis, and sepsis.13 Initial imaging studies such as ultrasound and abdominal radiography help decide on the initial management. Findings such as signs of intestinal obstruction, ascites, pneumoperitoneum, and volvulus predict the need for surgical management.14 Postnatal clinical manifestations include respiratory distress and abdominal distension, among others, as in our case.15 In the surgical management of meconium peritonitis, enterotomy and intraluminal lavage are performed with water-soluble hyperosmolar solutions to unblock the intestine. The Bishop-Koop procedure described a surgical technique in which the objective was to perform a “chimney” anastomosis by resection with endto-end Roux-en-Y anastomosis with distal enterostomy. Likewise, the Santulli procedure described a technique of performing a proximal “chimney” anastomosis but with a Roux-en-Y lateral terminal anastomosis and proximal enterostomy.16 Although multiple surgical techniques have been described, none of them are completely successful. It is important to mention that the surgical technique used for the neonate in this case was different from that reported in the literature, as complete correction was not performed in any surgeries or “chimney” anastomosis. The first-stage procedure was performed as a damage control surgery, leaving the ostomies and abdomen open, with intraluminal hyperosmolar solution irrigation during surgery to facilitate the evacuation of thick meconium in loops proximal to the resection. In the early second-stage procedure, the intestinal lavage with diatrizoic acid and end-toend anastomosis were completed. Although the surgical procedures done in our case study are different from that referred to in the literature for cases of complicated meconium peritonitis, the neonate in our case study recovered well. The advantages of the techniques used in our case study are decreased bleeding, avoiding long-term ostomies, faster mixed refeeding with its subsequent hepatic protective effect, reducing the risk of infection, and finally, avoiding more intra-abdominal surgical procedures with potential complications that could generate a greater loss of the intestine.3,16 Finally, in our case, the histopathologic study confirmed the diagnosis with findings such as rough peritoneal surface and numerous greenish yellow and reddish plaques and calcifications.17 The anatomopathological study reports 3 variants of meconium peritonitis: (1) a fibro-adhesive, the most common form, generating the seal perforation; (2) cystic form, with the inability to seal the defect, generating increased meconium outflow into the peritoneal cavity; and (3) a generalized, more severe, and less frequent form, where meconium is distributed throughout the peritoneal cavity.18 The neonate in this case study had the second variant. Patients with simple meconium ileus or uncomplicated meconium peritonitis will require watchful waiting (as not all such patients need surgical treatment) or conservative medical management. The conservative medical management is based on the use of hyperosmolar solutions that help correct intestinal obstruction, which include 4% N-acetylcysteine, sodium diatrizoate (Hypaque), meglumine amidotrizoate, and sodium amidotrizoate (Gastrografin) among others.19 These contrast media are used in adjunctive management in patients with complicated meconium peritonitis during surgery, as in this case. Medical management of such patients is also reported to be successful. Neonates with meconium ileus were managed with acetylcysteine enemas at a rate of 5 mL/kg, twice a day, which resulted in evacuations and regulation of intestinal transit. Some patients may have intestinal motility alterations, secondary to chronic inflammation, resulting in slowing down of peristalsis. Such patients may require management with prokinetic or evacuating enemas.20,21 In our case study, we used enemas for approximately 3 weeks because of the presence of postoperative ileus. Conclusion We studied a full-term neonate with a secondary acute abdomen due to meconium peritonitis without a prenatal diagnosis. Meconium peritonitis is a rare pathology, with highly variable clinical presentation. We emphasize that prenatal diagnosis is a tool to improve the postnatal interventions, although some studies do Alvarez Saenz MP, et al. Meconium Peritonitis Case Report
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