1. Bespghan – Belaps congress
Feeding difficulties in neurologically impaired children : Case presentation
Bespghan – Belaps congress
22 Oct 2016
Ann-Sophie D’hont, Paediatric Gastro-enterology, UZ Leuven
Pierre Lingier, Abdominal Surgery, ULB Hôpital Erasme

2. CHARLOTTE, 14 years Spastic quadriplegia Myoclonic epilepsy
Central blindness
Psychomotor development delay
Medical history
Ex-premature, preterm birth at PMA 27 weeks, birth weight 1040g
Second member of twins, other member † due to TTS
Neonatal convulsions, MRI: A. cerebri media infarct
Bilateral ROP stage 3
bilateral retinal detachment, surgically treated
Familial history
Oldest brother † age 6 months, cardiac problems

3. CHARLOTTE, 14 years
Dec 2015: Failure to thrive → referral to paediatric gastro-enterology with request for gastrostomy placement
Feeding status:
Variable oral intake, mainly bread and mixed solid foods
No gastric tube feeding
Occasionally choking with liquids, no choking with solid foods
Current medication:
Domperidone, omeprazole
Valproate
Baclofen
Clobazam, melatonine
Upper GI series:
Normal anatomy. Good passage of (limited) contrast.

4. TO NISSEN OR NOT TO NISSEN?
No Nissen
Previous symptoms of GERD / No more at time of surgery
Parents reluctant to any invasive surgery / only one narcosis
Literature
Improvement of symptoms only with gastrostomy placement
This does not prevent the subsequent realization of a Nissen
More morbidity and mortality after Nissen procedure in NIC

5. CHARLOTTE, 14 years March 2016: Laparoscopic gastrostomy placement
Conversion to laparotomy because of technical difficulties
Uncomplicated early post-operative course
April 2016:
Abdominal pain syndrome, feeding intolerance, fever
Increased inflammatory parameters
RX: subobstruction
CT: collection right fossa ilaca – due to leakage of gastrostomy?
→ IV piperacillin-tazobactam, stop enteral feeding, gastric drainage
Dienst kinderradiologie, UZ Leuven

6. HIGH INTESTINAL (SUB)OBSTRUCTION
CHARLOTTE, 14 years
April 2016: further course
Disappearance of fever
Decrease of inflammatory parameters
Improving general condition
BUT…
Persistent drainage of bile fluid through the gastrostomy
Recurrent nausea and vomiting when restarting enteral feeds
Weight loss
HIGH INTESTINAL (SUB)OBSTRUCTION
Intestinal adhesion?
Inflammatory/
Infectious?
Dismotility?

7. Dienst kinderradiologie, UZ Leuven

8. SUPERIOR MESENTERIC ARTERY SYNDROME
VASCULAR COMPRESSION ON D3
Risk factors:
Loss of mesenteric/retroperitoneal fat
Anatomical variants
Surgery
Acute or chronic presentation:
Postprandial epigastric pain
Nausea and vomiting (bile)
Early satiety
Anorexia and weight loss

9. SUPERIOR MESENTERIC ARTERY SYNDROME
Diagnosis:
Imaging: contrast studies, CT (angio), ultrasound, MRI
Endoscopy
Treatment:
Conservative treatment:
ACUTE Correction of electrolytes, maintenance of fluid balance
Nasogastric decompression
Postprandial positioning
LONG-TERM → weight gain
Frequent oral feeds
Nasojejunal feeding
Parenteral nutrition (TPN)
Surgical treatment

10. SUPERIOR MESENTERIC ARTERY SYNDROME
Rokitansky Anatomy Text
Wilkie Largest study on 75 cases
Diagnosis is made by a process of exclusion
October 22 , 2016

11. SUPERIOR MESENTERIC ARTERY SYNDROME -Surgical Techniques
Strong Procedure Lysis of Treitz Ligament
75 % success rate
Gastro Jejunostomy Failure to relieve duodenal obstruction
Blind Loop / Peptic ulceration
Duodeno Jejunostomy Higher success rate
Open Stavely
Laparoscopic Gersin –Henniford
Blind loop Roux-en-Y loop duodeno jejunal bypass

12. SUPERIOR MESENTERIC ARTERY SYNDROME
Zhuo Sun et all / Surg Endosc :

13. SMAS in neurologically impaired children
Precipitating factors:
Lumbar lordosis, scoliosis
Prolonged supine position
Loss of abdominal muscle tone
Poor communication of symptoms

14. SMAS in neurologically impaired children
Precipitating factors:
Lumbar lordosis, scoliosis
Prolonged supine position
Loss of abdominal muscle tone
Poor communication of symptoms
Pediatric Emergency Care, 2012 : Case series
January 1999 – July 2010
16 patients with SMAS
11/16 intellectually disabled

15. SMAS in neurologically impaired children
ID vs non-ID
Similar presenting symptoms
82% of ID: gastrostomy feeding, 78% feeding difficulties
ID significantly lower weight-for-age percentiles
No significant difference in the degree of weight loss
No significant difference in time or number of health care visits before diagnosis was made
→ difficult diagnosis in both ID and non-ID

16. SMAS in neurologically impaired children
ID vs non-ID
Similar presenting symptoms
No significant difference in time or number of health care visits before diagnosis was made
No significant difference in median number of comorbidities (4)
→ SMAS occurs predominantly in children with complex medical histories
No significant difference in outcome of treatment
75% response to conservative treatment

17. CHARLOTTE, 14 years TPN via PICC
Intermittent suction via nasogastric tube
Gastrostomy passive drainage
After 1 week: transfer regional hospital
Stop suction after 2 weeks
After 3 weeks: stop passive drainage, restart enteral nutrition
Stop TPN after 1 month

18. TAKE HOME MESSAGES - HIGHLIGHTS
SMAS is a rare cause of small intestinal obstruction in paediatric patients
Neurologically impaired children are at specific risk
Need to consider SMAS in neurologically impaired children presenting with feeding intolerance, especially when weight for age percentiles <5%
Surgery only when conservative treatment fails