Small Bowel Atresia: Recommended Treatment
Definitive Treatment Recommendation
Surgical resection with primary anastomosis is the only definitive treatment for small bowel atresia in newborns and should be performed urgently after diagnosis and stabilization. 1, 2
Immediate Management Protocol
Initial Stabilization
- Make the newborn NPO immediately and place a nasogastric tube for gastric decompression to prevent aspiration and reduce proximal bowel distension 1
- Establish intravenous access and initiate fluid resuscitation if signs of shock or dehydration are present, with strict monitoring of fluid balance 1
- Obtain immediate pediatric surgical consultation as this represents a surgical emergency requiring urgent evaluation 1
- Administer broad-spectrum antibiotics empirically if sepsis or bowel compromise is suspected 1
Diagnostic Workup
- Plain abdominal radiographs are mandatory as the first imaging study and will demonstrate dilated bowel loops with air-fluid levels 1
- The "triple bubble" sign suggests jejunal atresia specifically 1
- Contrast enema is the diagnostic procedure of choice for suspected distal obstruction and can demonstrate microcolon in cases of distal atresia 1
- Never delay surgical consultation for imaging studies if peritoneal signs are present, as this leads to significant morbidity and mortality 1
Surgical Approach
Standard Surgical Technique
The definitive surgical treatment consists of resection of the atretic segment with primary end-to-end or end-to-back anastomosis, with or without tapering of the dilated proximal bowel 2, 3, 4
Minimally Invasive Options
Modern surgical approaches offer excellent outcomes with superior cosmesis:
- Laparoscopic-assisted repair is safe and feasible for most cases of small bowel atresia, combining diagnostic laparoscopy with exteriorization through a circumumbilical incision for the anastomosis 2, 5
- Supra-transumbilical laparotomy (STL) provides adequate exposure for jejunal and ileal atresia repair when malrotation and multiple atresias are ruled out preoperatively 4
- The circumumbilical approach permits adequate correction with minimal complications and superior cosmesis compared to classical transverse laparotomy 3, 4
Surgical Considerations by Location
- Jejunal atresia (most common presentation): Standard resection with end-to-end or end-to-back anastomosis through minimal access approach 3, 5, 4
- Ileal atresia: Similar approach with attention to preserving bowel length 5, 4
- Multiple atresias: May require conversion to larger transverse incision for adequate exposure 4
Critical Pitfalls to Avoid
- Do not delay surgery for extensive imaging workup when clinical presentation clearly indicates obstruction 1
- Rule out malrotation preoperatively with contrast studies, as associated malrotation requires Ladd's procedure in addition to atresia repair 4
- Be prepared to convert to larger incision if multiple atresias, colonic involvement, or malrotation is encountered intraoperatively 4
- Preserve maximal bowel length in all cases to prevent short bowel syndrome, which occurs in less than 5% of patients but carries significant morbidity 2, 6
Postoperative Management
Expected Outcomes
- Mortality rate is less than 5% and primarily related to associated comorbidities rather than the surgical repair itself 2
- Complications occur in less than 5% of patients and include anastomotic leak, stricture, adhesions, and small bowel obstruction 2
- Laparoscopic-assisted repair has lower re-operation rates compared to traditional laparotomy 2
Nutritional Support
- Initiate parenteral nutrition postoperatively until full enteral feeding is established 6
- Advance enteral feeds gradually as bowel function returns, typically within 7-10 days 6
- Monitor for delayed gastric emptying and bacterial overgrowth 2
Special Circumstances
In cases of severe ischemic bowel segments that are potentially salvageable, consider isolation with proximal stoma and staged anastomosis 2-3 months later to restore continuity and maximize functional bowel length 6