title: Gastrointestinal complications after stage I Norwood versus hybrid procedures.
abstract: BACKGROUND
  Patients undergoing palliation for hypoplastic left heart syndrome are at risk for gastrointestinal complications including necrotizing enterocolitis, gastroesophageal reflux, and intolerance to oral feeding. Few data exist comparing these outcomes between patients undergoing the Norwood and hybrid procedures.
  
  
  METHODS
  Forty-three patients with hypoplastic left heart syndrome or variants underwent 50 Norwood (n = 34) or hybrid (n = 16) procedures (2004 to 2011). Routine preoperative assessments included flexible fiberoptic laryngoscopy and oral feeding evaluations. Examinations were repeated postoperatively with modified barium swallows. A retrospective review was conducted to examine the incidence, causes, and consequences of gastrointestinal complications.
  
  
  RESULTS
  In 18 of 50 cases (38%), patients were tolerating full oral feeding at discharge; abnormal preoperative feeding evaluation predicted the inability to feed orally (p < 0.002, positive predictive value 100%). Hybrid and Norwood patients had a similar incidence of vocal fold palsy (20.0% versus 34.5%, p = 0.3), and inability to feed orally at discharge (67.5% versus 56.3%, p = not significant). Both groups had a high incidence. Postoperative abnormalities were common, namely, abnormal oral feeding evaluations (70.7%) or modified barium swallows (81.8%). Predictors of abnormal postoperative examinations included noncardiac congenital anomalies (p = 0.08), preoperative mechanical ventilation (p = 0.01), and younger age (p = 0.01). Grade IIA/IIB necrotizing enterocolitis was more common among patients having hybrid procedures (26.7%, versus 2.9%, p = 0.01).
  
  
  CONCLUSIONS
  Gastrointestinal complications are common after initial palliation of patients with hypoplastic left heart syndrome. Preoperative and perioperative factors play a significant role. Despite a more "limited" intervention, patients undergoing hybrid procedures remain at high risk for feeding issues, commonly leading to a prolonged hospital course. Close attention and proactive management are essential to optimize the nutritional status in these patients.
authors.affiliation: Nemours Cardiac Center, Nemours/A.I. duPont Hospital for Children, Wilmington, Delaware 19806, USA. rdavies@nemours.org
authors.forename: Ryan R
authors.initials: RR
authors.lastname: Davies
authors.forename: Stephanie W
authors.initials: SW
authors.lastname: Carver
authors.forename: Richard
authors.initials: R
authors.lastname: Schmidt
authors.forename: Heather
authors.initials: H
authors.lastname: Keskeny
authors.forename: Jeannine
authors.initials: J
authors.lastname: Hoch
authors.forename: Christian
authors.initials: C
authors.lastname: Pizarro
mesh_terms: D006348:Cardiac Surgical Procedures / Q000009:adverse effects*; D003691:Delaware / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D005767:Gastrointestinal Diseases / Q000453:epidemiology / Q000209:etiology*; D006801:Humans; D018636:Hypoplastic Left Heart Syndrome / Q000601:surgery*; D015994:Incidence; D007231:Infant, Newborn; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors