The patient was a male newborn aged 6 days, born at 38 weeks + 2 days of gestation from a well-monitored pregnancy. The birth weight was 4900 g. The Apgar score was not documented; however, there was an absence of an immediate cry at birth, followed by the return of crying after stimulation, suggesting initial neonatal adaptation difficulty. The neonatal context was marked by amniotic fluid aspiration at birth, complicated by respiratory distress requiring oxygen therapy.

On the second day of life, progressive abdominal distension appeared, initially associated with the absence of meconium passage, suggesting neonatal intestinal obstruction. However, perineal examination revealed a normally patent anus, excluding anorectal malformation. Due to worsening abdominal distension and respiratory distress, an abdominal X-ray without preparation (ASP) in the referring center revealed massive pneumoperitoneum, prompting referral to the Yaoundé Central Hospital for specialized management.

On admission, the newborn presented an altered general condition with respiratory distress. Vital parameters were as follows: heart rate 163 beats/min, respiratory rate 60 cycles/min, temperature 37.8˚C, and oxygen saturation 78% - 79% on room air. The abdomen was markedly distended, hypermeteoric and tympanic, with an abdominal circumference of 69 cm, associated with collateral venous circulation (Figure 1). A disappearance of prehepatic dullness was noted, suggesting perforation of a hollow organ.

A repeat abdominal X-ray without preparation confirmed the presence of massive pneumoperitoneum (Figure 2), indicating digestive perforation.

The surgical indication was therefore established. Preoperative management consisted of strict digestive rest with placement of a nasogastric tube for free drainage, urinary catheterization, broad-spectrum probabilistic antibiotic therapy

Figure 1. Abdominal distension in newborns (photo library YCH).

Figure 2. ASP showing massive pneumoperitoneum (photo library YCH).

(ceftazidime, amikacin and metronidazole), oxygen therapy, hydro-electrolytic correction, and monitoring of vital signs. Due to the compressive pneumoperitoneum responsible for respiratory distress, emergency abdominal decompression was performed before surgery in order to stabilize the newborn prior to laparotomy (Figure 3). Because of the urgent context, only routine preoperative tests were carried out.

Under general anesthesia with orotracheal intubation, the newborn was warmed using soft bands and hot water bottles. A right supra-umbilical transverse incision was performed. Exploration revealed purulent peritoneal fluid with numerous false membranes (Figure 4), indicating a long-standing peritonitis. A large gastric perforation located on the superior surface of the stomach near the cardia, measuring approximately 3 - 4 cm in diameter, was identified (Figure 5). The nasogastric tube was seen communicating directly with the peritoneal cavity through the perforation.

The surgical procedure consisted of excision of the perforation edges followed by a two-layer gastric suture reinforced with an omental patch, associated with abundant peritoneal lavage and placement of abdominal drainage (Figure 6). Peritoneal samples were sent for bacteriological and histopathological analysis.

Figure 3. Appearance after exsufflation; (A) newborn; (B) ASP (photo library YCH).

Figure 4. False membranes (photo library YCH).

Figure 5. Gastric perforation (photo library YCH).

Figure 6. Gastric suture with omental patch (photo library YCH).

Postoperative management included continuation of antibiotic therapy, analgesia, hydro-electrolytic rehydration, and strict fasting with nasogastric aspiration. In the absence of parenteral nutrition, amino acid supplementation (Astymin®) was administered.

The postoperative course was marked by transient respiratory distress and inflammatory syndrome, which were controlled after adjustment of antibiotic therapy. Feeding was progressively resumed on postoperative day 6. The bacteriological and histopathological results were not available at the time of manuscript preparation. The newborn was discharged on the tenth day of hospitalization with a favorable outcome.