World J Surg (2007) 31:24052409

DOI 10.1007/s00268-007-9206-0

RURAL AND INTERNATIONAL SURGERY

Trends in Neonatal Intestinal Obstruction in a Developing

Country, 19962005
S. O. Ekenze S. N. Ibeziako U. O. Ezomike

Published online: 1 September 2007

Societe Internationale de Chirurgie 2007

Abstract
Background Despite the advances in neonatal surgery,
the outcome of neonatal intestinal obstruction (NIO) in
many developing countries has been reported to be poor.
This study describes the trends in NIO, including the
contributory factors in southeast Nigeria.
Methods We performed a comparative analysis of 128
consecutive NIO managed from January 1996 to December
2005 at the University of Nigeria Teaching Hospital,
Enugu, in southeast Nigeria.
Results Fifty-five (43.0%) neonates were managed in the
first 5 years (group A) and 73 (57.0%) in the last 5 years
(group B). Etiology of obstruction did not vary significantly in the two groups. Average duration of symptoms
before presentation fell from 5.9 days (group A) to 4.7 days
(group B). With exception of Hirschsprungs disease (HD),
all other cases required operative treatment. In HD,
colostomy rate declined from 44.4% (group A) to 26.7%
(group B). More neonates in group B were managed with
general anesthesia and perioperative third-generation
cephalosporin antibiotics (p \ 0.01). While complication
rate did not vary significantly in the two groups (group A,
42%; group B, 40.3%), survival improved (group A,
61.8%; group B, 72.6%). Earlier presentation, improved
S. O. Ekenze
U. O. Ezomike
Subdepartment of Paediatric Surgery, University of Nigeria
Teaching Hospital, Enugu, Nigeria
S. N. Ibeziako
Newborn Special Care Unit, Department of Paediatrics,
University of Nigeria Teaching Hospital, Enugu, Nigeria
S. O. Ekenze (&)
Department of Surgery, University of Nigeria Teaching Hospital,
Enugu, Nigeria
e-mail: soekenze@yahoo.com

manpower, and use of potent antibiotics may have contributed to the improved outcome. Challenges in the form
of lack of neonatal intensive care facilities and dearth of
qualified personnel persist.
Conclusion There is a trend toward earlier presentation
and increased survival of babies with NIO in our setting.
Improving the existing facilities and trained manpower,
and establishing collaboration with centers that have
excellent results may further encourage the trend.

Intestinal obstruction in the neonatal period may be caused

by a variety of mostly congenital abnormalities. Over the
past decades, the outcome in neonatal intestinal obstruction
(NIO) in many developed countries has improved dramatically, largely due to advances in the understanding of
neonatal physiology, improvements in diagnostic facilities
and neonatal intensive care, and surgical advances [13]. In
many developing countries, however, the management of
neonates with this condition remains problematic, with
resultant high morbidity and mortality [47]. Factors
identified as contributing to the poor outcome include late
presentation, resource deficiency, shortage of personnel,
and inadequate facilities.
Most of the earlier reports from developing countries
[59] have concentrated on the outcome of treatment of
NIO and paid scant attention to possible trends in pattern,
management, and outcome. This study aims to look at the
trends in neonatal intestinal obstruction at the University of
Nigeria teaching hospital (UNTH), Enugu, southeast
Nigeria. It is hoped that the information from this study
will highlight areas of need and provide an avenue for
possible collaboration with centers in more developed
countries that have better outcome.

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Age distribution of the 128 neonates at presentation
45

Group A

Etiology of NIO

Group A Group B Total (%) p value

Anorectal malformation

22

33

55 (43.0) 0.555

Hirschsprungs disease

15

24 (18.7) 0.548

30

Jejunoileal atresia

11

20 (15.6) 0.841

25

Malrotation with obstruction

11 (8.6) 0.129

Duodenal atresia

10 (7.8) 0.558

Obstructed hernia

8 (6.3) 0.475

Group B

40
35
Number of neonates

Table 1 Etiology of intestinal obstruction among the two groups of

neonates

20
15
10
5
0
0 - 7 days

8 - 15 days

16- 22 days

23 - 30 days

Age

Fig. 1 Age distribution of the 128 neonates with intestinal obstruction at presentation

Materials and methods

The University of Nigeria teaching hospital (UNTH) is the
main referral center for neonatal surgery in southeast
Nigeria. The Paediatric Surgery subdepartment of the
hospital is responsible for their definitive management.
Referrals come from both the Newborn Special Care Unit
(NSCU) of the hospital and the peripheral hospitals in the
region. For this study a neonate was defined as a child
presenting within the first 30 days of life. Diagnosis of
intestinal obstruction involved clinical and radiologic
evaluation. The etiology of obstruction is confirmed at
operation.
Over a 10-year period (January 1996 to December
2005), a total of 128 neonates were managed for intestinal
obstruction. These cases were analyzed. Data on age at
presentation, duration of symptoms before presentation,
gender, clinical features, investigation, anesthetic technique employed, findings at operation, and the operative
procedure were obtained from the case notes and theatre
records. Also assessed were the complications of treatment
and outcome, and the number of qualified specialists in the
departments involved in the management of NIO.
From 2001, UNTH Enugu employed more qualified
specialists in anesthesiology, neonataology, and pediatric
surgery. To determine trends in NIO, the data were divided
into two groups based on the time the patients were managed with respect to these developments. The first group
consisted of neonates managed from January 1996 to
December 2000 (group A, n = 55). The second group of
neonates were managed from January 2001 to December
2005 (group B, n = 73). The data from these two groups
were compared with respect to duration of symptoms

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before presentation, etiology of obstruction, management,

postoperative complications, and outcome. The data were
analyzed using EPI Info version 6.04. Proportions were
compared with v2 and mean value with an independent t
test.

Results
The age of the neonates ranged from 2 to 27 days (overall
mean age = 9.8 days; group A = 10.3 days, group B = 9.4
days). Twenty-seven (21.1%, 10 in group A, 17 in group B)
were referred from the NSCU and 101 (78.9%, 45 in group
A, 56 in group B) from the peripheral hospitals. Figure 1
show the age distribution of the neonates at presentation.

Etiology of intestinal obstruction

Table 1 summarizes the etiology of intestinal obstruction
in the two groups of neonates.
Anorectal malformation There were 55 cases (22 in
group A, 33 in group B). Associated Tetralogy of Fallot
occurred in three (2 in group A, 1 in group B), ventricular
septal defect in two (all in group A), and esophageal atresia
in two (1 in each group). The average duration of symptoms before presentation which corresponds with the age at
presentation was 5 days (range = 29 days) in group A and
3.9 days (range = 27 days) in group B. In group A, 16
(72.7%) had high anorectal malformation and required a
defunctioning colostomy, while 6 (27.3%) had low malformation and were managed by perineal anoplasty. The
figures for group B were 25 (75.8%) for high malformation/colostomy and 8 (24.2%) for low malformation/
perineal anoplasty.
Hirschsprungs disease (HD) There were 24 neonates
with HD (9 in group A, 15 in group B) who presented after
a mean duration of 15.4 days in group A and 12 days in
group B. In group A, four (44.4%) required emergency
colostomy while five (55.6%) had their obstruction temporarily decompressed by suppository insertions and rectal
washouts. The HD in group B required colostomy and

World J Surg (2007) 31:24052409

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Table 2 Trend in management among the two groups of neonates

Overall (n = 128)

Group A (n = 55)

Group B (n = 73)

p value

Average duration of symptoms before presentation

5.2 days

5.9 days

4.7 days

0.092

Operation anesthesia

112 (87.5%)

50 (90.9%)

62 (84.9%)

0.311

General

106 (94.6%)

44 (88.0%)

62 (100%)

0.006*

Local

6 (5.4%)

6 (12.0%)

0 (0%)

0.006*

Antibiotics used perioperatively

Ampicillin/cloxacillin and metronidazole

48 (42.9%)

39 (78.0%)

9 (14.5%)

0.000*

Cephalosporin and metronidazole

64 (57.1%)

11 (22.0%)

53 (85.5%)

0.000*

Significant value

nonoperative temporary bowel decompression in 4 (26.7%)

and 11 (73.3%), respectively. After the emergency bowel
decompression in the neonatal period, elective definitive
surgical treatment requiring resection of aganglionic bowel
was performed in late infancy.
Jejunoileal atresia Twenty neonates (9 in group A, 11 in
group B) had type I jejunoileal atresia confirmed at laparotomy. The average age at presentation was 4.1 days in
group A (range = 27 days) and 2.9 days for group B
(range = 25 days). Of these neonates, six (66.7%) in
group A and five (45.5%) in group B had received oral
feeds before presentation. Six (66.7%) neonates in group A
and four (36.4%) in group B had temporary ostomy and
delayed anastomosis. The rest of the neonates (3 in group
A, 7 in group B) had primary anastomosis. Total parenteral
nutrition was not administered to any of the neonates.
Malrotation with volvulus This was the finding at
operation in seven neonates in group A and four neonates
in group B. Two in group B had associated omphalocele.
The average duration of obstructive symptoms before
presentation was 2.0 days in each group. Three (1 in group
A, 2 in group B) neonates had bowel gangrene necessitating resection. The rest of the children had Ladds
procedure.
Duodenal atresia There were four neonates with this
diagnosis in group A and six in group B. Associated cardiac anomaly occurred in four neonates (2 in each group)
and Downs syndrome in one of the neonates in group B.
The average age at presentation was 5.8 days in group A
and 4.7 days in group B. All the neonates had
gastrojejunostomy.
Obstructed inguinal hernia There were four neonates
with obstructed hernia in each of the groups. The average
duration of obstructive symptoms before presentation was
2.0 days in group A and 1.5 days in group B. Taxis
reduction was attempted in two neonates from each group
and was successful in three (1 in group A, 2 in group B).
Two (50.0%) patients in group A and 1 (25.0%) in group B
had gangrenous bowel requiring resection. The rest of the
neonates had inguinal exploration and herniotomy.

Management trends
The average duration of symptoms before presentation was
5.9 days (range = 1-21 days) in group A and 4.7 days
(range 1 17 days) in group B. Overall, 112 (87.5%) of the
neonates (50 in group A, 62 in group B) had operative
treatment. The remaining 16 (12.5%) were cases of HD (5
in group A, 11 in group B) whose obstructions responded
to nonoperative treatment.
In terms of anesthesia, 100% of the operations in group
B were done with general anesthesia as opposed to 88% in
group A. The rest (12.0%) of the neonates in group A were
operated on with local anesthesia. The number of qualified
anesthesiologists increased from one in the first 5 years to
three in the last 5 years. Also increased was the number of
residents in anesthesia, from 4 in the first 5 years to 13 in
the last 5 years. From 2001, pulse oximetry was routinely
used in the management of NIO, unlike the period prior to
2001 during which it was used in only 40% of the cases.
The number of qualified pediatric surgeons and neonatologists also increased from two and three, respectively,
before 2001 to three and four, respectively, from 2001.
There are emerging trend toward the use of perioperative third-generation cephalosporins in group B compared
to group A [used in 53 (85.5%) neonates in group B
compared to 11 (22.0%) in group A]. The rest of the
neonates [9 (14.5%) in group B and 39 (78.0%) in group A]
were managed with an ampicillin-cloxacillin combination
and metronidazole. In the last two years of the study period, only third-generation cephalosporin was used. Table 2
shows the trend in management between the groups of
neonates.
Postoperative complications
There were 46 complications (21 in group A, 25 in group
B). The complication rate in group A was 42.0%, while the
rate in group B was 40.3%. Table 3 summarizes the
complications in the 112 neonates operated for intestinal
obstruction.

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Table 3 Complications in the

112 neonates operated for
intestinal obstruction

Complications

Overall (n = 112)

Surgical site infection

Colostomy prolapse

12 (24.0%)

14 (22.6%)

0.859

4/20 (20.0%)

7/29 (24.1%)

0.507

5 (4.5%)

0.398

2/20 (10.0%)

0.608

46 (41.1%)

21 (42.0%)

25 (40.3%)

0.857

p value

5/22 (22.7%)

6/33 (18.2%)

0.467

Hirschsprungs disease

2/9 (22.2%)

3/15 (20.0%)

0.640

Jejunoileal atresia

7/9 (77.8%)

6/11 (54.5%)

0.272

Malrotation with
obstruction

3/7 (42.9%)

2/4 (50.0%)

0.651

Duodenal atresia

2/4 (50.0%)

2/6 (33.3%)

0.547

Obstructed hernia

2/4 (50.0%)

(25.0%)

0.500

21/55 (38.2%)

20/73 (27.4%)

0.195

Outcome
Overall, 87 (70.0%) neonates survived: 34 (61.8%) in
group A and 53 (72.6%) in group B. The causes of death
(n = 41) were infection (n = 25; 14 in group A, 11 in group
B), multiple congenital anomalies (n = 8; 4 in group A, 4
in group B), respiratory insufficiency (n = 7; 2 in group A,
5 in group B), anesthetic accident (n = 1 in group A).
Table 4 summarizes the causes and rates of mortality for
the two groups. For those that survived, the average
duration of hospital stay for the initial management was
23.7 days (range = 1036 days).

Discussion
This study suggests that there is an increase in the incidence of neonatal intestinal obstruction in our hospital.
This increase may indicate that more of these neonates are
presenting to tertiary centers for appropriate treatment.
This is a deviation from previous reports [4, 10] where
resource deficiency and ignorance compelled parents to
seek treatment for their children in an inappropriate place
like herbal homes. Improvements in socioeconomic status
and educational campaigns may have contributed to this
trend. Conversely, the change in incidence may represent a
true increase.
One of the factors responsible for poor outcome of NIO
in the previous reports from developing countries is late
presentation [4, 5]. Unarguably, in the present report late
presentation for treatment occurred in the two groups of
neonates, but it was more prominent in those managed in

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2 (3.2%)

2/16 (12.5%)

Anorectal malformation

Total

3 (6.0%)

4/36 (11.1%)

Table 4 Mortality among the two groups of neonates

Group B

p value

26 (23.2%)

Total

Group A

Group B (n = 62)

11/49 (22.4%)

Wound dehiscence
Anastomotic leak

Group A (n = 50)

earlier years. It may be that NIO is currently recognized

and referred earlier than previously reported. The high
proportion of cases referred by the NBSCU and the
improved manpower in that unit from 2001 may be contributory. Nonetheless, efforts are still needed to ensure
early presentation. As routine well-baby examinations are
no longer the norm in most hospitals in Nigeria, early
presentation of NIO needs to be reemphasized and equally
the healthcare workers need to be educated on early recognition of NIO. Close liaison between the primary,
secondary, and tertiary healthcare facilities as well as
provision of readily available patient transfer facilities are
equally indispensable. A recent report from the United
Kingdom [3] indicated that these measures, among other
factors, will provide good outcome.
Interestingly, this study has also demonstrated a significant trend toward exclusive use of general anesthesia and
perioperative third-generation cephalosporins in the management of NIO. Previous reports from developing
countries [4, 9] have emphasized that the moribund state of
some of the neonates at presentation and lack of monitoring
facilities and trained personnel led to the use of local
anesthesia for operative treatment. This trend may have
resulted from improvements in trained manpower and
facilities and earlier presentation.
Operative techniques employed in the treatment of the
neonates were similar in the two groups of neonates except
in those with jejunoileal atresia (JIA) where there was a
trend toward primary anastomosis. Among other factors,
primary end-to-end anastomosis in JIA is reported to
contribute to early recovery of bowel function and
improved outcome [1, 11]. The poor outcome in JIA in our
setting could be improved upon if this approach is more
universally adopted.
The postoperative complications observed in the present
report did not differ appreciably from 1996 to 2005. Similar complications have been reported in some studies from
other developing [4, 6, 7] and developed countries [3, 12,
13] and may indicate that improved facilities could only
minimize but not completely obviate these complications.
Some other factors like operative technique and tissue
handling may be contributory [1, 3].
The overall mortality of 32% in this study implies that
the outcome of NIO in our setting is still poor. The modest

World J Surg (2007) 31:24052409

improvement observed in the later years may be related to

earlier presentation, improved manpower, and use of more
potent antibiotics. Nonetheless, this is still a far cry from
the survival rates of 84%-92% reported from some developed countries [1, 11, 12, 14, 15]. yThis discrepancy may
reflect persistence of fundamental problems such as lack of
facilities, resource deficiency, lack of neonatal intensive
care units, ignorance, and a dearth of sufficient specialized
manpower. Collaboration between the developed countries
and the less developed parts of the world may be necessary
to significantly improve outcome. This collaboration could
be in the form of provision of facilities, research, and
training of specialized personnel.
Limitations of the study
Our study findings were limited by incomplete data on
gestational age at delivery and birth weight of most of the
neonates. Absence of these important data precluded a
more detailed analysis.
Conclusion
Overall, the hospital-based incidence of NIO appears to be
on the rise in our setting. Earlier presentation, improved
manpower, and use of more potent antibiotics may have
contributed to the modestly improved outcome. Nonetheless, a more significant improvement in outcome may be
obtained with earlier detection and referral, provision of a
neonatal intensive care unit, training of specialized personnel, and collaboration with centers in developed
countries with proven excellent results.

2409

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