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Pediatric Surgery

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Contrast enema demonstrates a micro colon and no reflux into dilated intestines. ... A contrast enema reveals a narrow rectum, compared to the sigmoid. ... – PowerPoint PPT presentation

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Title: Pediatric Surgery


1
Pediatric Surgery
  • Vic V. Vernenkar, D.O.
  • St. Barnabas Hospital
  • Dept. of Surgery

2
Epiglottitis
  • H. Influenza is most common organism
  • A lateral xray may show edema of the epiglottis
    (birds beak)
  • Orotracheal intubation should be performed in the
    OR so that an open tracheostomy can be done if
    needed.
  • Never nasotracheally intubate a child because the
    angle between the superior and inferior glottis
    is too large.

3
Tracheoesophageal Fistula
  • A newborn infant has excessive salivation,
    choking, and regurgitation with feeding.
  • Results from abnormal ingrowth of ectodermal
    ridges during the 4th week of gestation.
  • 25-40 of neonates are premature, low bith
    weight.
  • A maternal history of polyhydramnios is common
  • 50 of neonates with TEF have an associated
    anomaly (cardiovascular most common)
  • GI malformation
  • GU anomalies
  • Skeletal
  • CNS
  • Associated with VACTERL (vertebral, anorectal,
    cardiac, TE, renal, Limb)
  • 5 types of TEF
  • Proximal esophageal atresia with distal TEF (85)
  • Isolated esophageal atresia
  • H-type TEF without atresia
  • Proximal TEF with distal atresia

4
Tracheoesophageal Fistula
  • Proximal and distal TEF
  • Diagnosis
  • Inability to pass nasogastric tube
  • CXR to deternime length of esophageal gap
  • Abdominal Xray with air in the stomach excludes
    esophageal atresia
  • Treatment
  • Right thoracotomy thru 4th intercostal space
  • Proximal esophagus blood supply is from
    thyrocervical trunk

5
Tracheoesophageal Fistula
  • Distally supplied by more tenuous intercostals
  • Operation includes TEF ligation, transection, and
    restoration with end-to-end anastamosis.
  • POD 5-7 esophagram, if no leak, feed, remove
    drain.

6
Tracheoesophageal Fistula
  • Early complications include
  • Anastamotic leak, recurrent TEF, tracheomalacia.
  • Late Complications include
  • Anastamotic stricture (25), reflux (50),
    dysmotility (100).
  • Proximal atresia with distal TEF most common.

7
Immunoglobulins
  • Which immunoglobulin is secreted in breast milk?
  • Which immunoglobulin does not cross blood brain
    barrier?
  • IGA is most common antibody in breast milk, the
    gut, saliva, bodily secretions.
  • IGM is large and does not cross the placenta.

8
Resuscitation
  • An 8 year old boy presents following a bicycle
    crash with a ruptured spleen.What is the best
    indicator of early shock?
  • Tachycardia in childhood is defined as a heart
    rate 150 for a neonate, 120 in the first year,
    100 after one year. It is the best indicator of
    shock.
  • Fluid resuscitation in children

9
Resuscitation
  • 20cc/kg crystalloid bolus for trauma
  • If shock persists after a second bolus, give
    blood at 10cc/kg
  • Children have a lower GFR in comparison to
    adults.

10
Malrotation
  • A healthy infant presents with bilious vomiting,
    abdominal distension, and shock.
  • A surgical emergency, bilious vomiting in a
    newborn is malrotation until proven otherwise.

11
Malrotation
  • During 6-12 week of gestation, the intestine
    undergoes evisceration, elongation, and eventual
    return to the abdominal cavity in a 270 degree
    counterclockwise rotation with fixation.
  • Malrotation is associated with abnormal rotation
    and fixation.

12
Malrotation
  • Ladds bands extend from the colon to the
    duodenum, causing duodenal obstruction and
    biliary emesis.
  • Midgut volvulus refers to the narrow based
    mesentery twisting around the SMA (usually
    clockwise).
  • This results in obstruction and vascular
    compromise.

13
Malrotation
  • Most develop symptoms in first month of life.
  • If patient stable do UGI series (gold standard).
  • See birds beak in third part of duodenum
  • Ligament of Treitz is right of midline.

14
Malrotation
  • Midgut volvulus is a surgical emergency.
  • Volume resuscitation is essential.
  • If patient in shock, no studies are warranted.

15
Malrotation
  • Immediate exploration to avoid loss of small
    bowel and resultant SBS, death.
  • Surgical treatment is the Ladds procedure.
  • This consists of division of bands, correction of
    malrotation, restoration of broad based
    mesentery, appendectomy (because it is in the
    wrong place in LUQ).

16
Duodenal Atresia
  • A newborn full term neonate with Downs syndrome
    had bilious vomiting during the first day of
    life. The abdominal exam is normal.
  • Duodenal atresia. Malrotation can present
    similarly but less common.
  • Failure of recanalization during 8-10th week of
    gestation.
  • Presents in first 24hrs of life.
  • Trisomy 21 is present in about 25
  • Characterized by bilious emesis
  • Abdominal distension is absent
  • 85 distal to ampulla of vater

17
Duodenal Atresia
  • Check for patent anus
  • Rule out anorectal anomalies
  • Abdominal x-ray reveals double bubble sign
  • Air in the stomach, and 1st and 2nd portions of
    duodenum.
  • If there is no distal air, the diagnosis is
    secure.
  • If there is distal air, and urgent UGI needed to
    rule out midgut volvulus.
  • Surgical treatment is a duodenoduodenostomy.

18
Jejunoileal Atresia
  • A 3 day old infant has bilious vomiting,
    abdominal distension.
  • Differential includes
  • Duodenal atresia
  • Malrotation
  • Meconium ileus
  • Imperforate anus
  • Hirchsprungs

19
Jejunoileal Atresia
  • Jejunoileal atresia is caused by an in utero
    vascular accident.
  • Presents within first 2-3 days
  • Associated with Cystic Fibrosis in 10

20
Jejunoileal Atresia
  • Abdominal distension is usually present with
    distal atresia.
  • Abd. X-ray demonstrates multiple distended loops
    of bowel with A-F levels
  • Contrast enema demonstrates a micro colon and no
    reflux into dilated intestines.
  • Multiple areas of involvement in 10.
  • Surgical correction involves end-to end
    anastamosis. Preserve length to prevent SBS.

21
Colonic Atresia
  • Caused by in utero mesenteric vascular accident.
  • Similar to above in presentation
  • Abdominal distention present
  • X-rays show obstructive picture
  • Contrast enema shows microcolon with a cut off in
    proximal colon.
  • Surgical correction involves end-to-end
    anastamosis.
  • Intestinal atresia can be associated with
    gastrochisis.

22
Meconium Ileus
  • A newborn with cystic fibrosis presents with mild
    abdominal distension. An X-ray demonstrates a
    ground glass appearing mass on the right side of
    the abdomen.
  • A gastrograffin enema may be all that is needed
    to treat meconium ileus, complicated cases may
    need surgery.
  • Caused by obstruction of terminal ileum with
    meconium.

23
Meconium Ileus
  • 15 have CF
  • Simple MI can be treated with enemas.
  • Complex MI requires enterotomy, resection,
    evacuation.
  • Mucomyst enemas can be used for this.
    (N-acetylcysteine)

24
Hirchsprungs Disease
  • A full-term neonate has bilious emesis during
    first and second days of life. The abdomen is
    distended. X-rays show dilated loops of small
    bowel. A contrast enema reveals a narrow rectum,
    compared to the sigmoid. The baby failed to
    evacuate the contrast the following day.
  • A bedside suction rectal biopsy at least 2cm
    above dentate line is the gold standard test.

25
Hirchsprungs Disease
  • Failure of the normal migration of neural crest
    cells.
  • Absent ganglia in the myenteric and submucosal
    plexus.
  • The absence always occurs in the distal rectum
    and extends proximally.
  • 80-85 localized to rectosigmoid.

26
Hirchsprungs Disease
  • Diagnostic work-up includes
  • Contrast enema showing a contracted rectum with
    dilated bowel above.
  • Failure to evacuate contrast 24h later can be
    diagnostic.

27
Hirchsprungs Disease
  • Rectal biopsy is required to confirm absence of
    ganglion cells and nerve hypertrophy.
  • Surgical treatment
  • Soave endo-rectal pull through with removal of
    the diseased distal bowel with coloanal
    anastamosis

28
Hirchsprungs Disease
  • Children who present acutely ill may need staged
    procedure with colostomy.
  • Need to do intraoperative frozen section to help
    determine the anatomic location of transition
    zone.

29
Imperforate Anus
  • Anus absent or misplaced
  • Usually form anterior fistulous tract
  • Associated with coloanal deformity

30
Imperforate Anus
  • Divided into high and low malformations with
    respect to the levators.
  • High fistula to bladder, vagina, or urethra, are
    treated with colostomy and posterior sagital
    anorectoplasty (PSARP), and genitourinary
    reconstruction if necessary.
  • Low PSARP

31
Imperforate Anus
  • Preop anal dilatation may be needed to prevent
    stricture.
  • A colostomy is generally not needed to treat a
    low (below levator) imperforate anus.

32
NEC
  • A 7 day old premature infant has emesis,
    abdominal distension, and bloody stools.
  • Differential includes
  • NEC
  • Malrotation

33
NEC
  • More common in premature infants after initiation
    of feeding.
  • Abdominal x-ray often reveals pneumotosis
    intestinalis or portal vein air.
  • Treatment is conservative NPO, NGT, antibiotics,
    serial x-rays.
  • Medical management is successful in 50 of cases.

34
NEC
  • Surgical treatment for
  • Free air
  • Abdominal wall erythema, cellulitis
  • Worsening acidosis
  • Hyperkalemia
  • Palpable mass
  • Worsening distension
  • Overall deterioration

35
NEC
  • Surgery often involves resection of affected
    intestine and creation of and end ileostomy and
    mucous fistula.
  • If the neonate survives, reverse around 4-6 weeks
    later after a contrast study rules out
    strictures.
  • NEC is the most common cause of SBS in childhood
  • Abdominal erythema is an indication for surgery!

36
Hypertrophic Pyloric Stenosis
  • A 4 week old infant presents with non-bilious
    vomiting and hypochloremic, hypokalemic,
    metabolic alkalosis.
  • Idiopathic thickening and elongation of the
    pylorus causing GOO.
  • Age is 3-6 weeks (1 month of age)
  • Initially fed normally then projectile vomiting.
  • An olive is palpated in 50

37
Hypertrophic Pyloric Stenosis
  • Mild jaundice in 5 due to reduced glucoronyl
    transferase activity
  • Dx is confirmed by US
  • Pyloric diameter 1.4 cm
  • Pyloric wall 0.4cm
  • Pyloric channel 1.6cm
  • Ramstedt pyloromyotomy is treatment of choice
    (open or laparoscopic).
  • Surgery is not an emergency (resuscitate).

38
Intussusception
  • A healthy 11 month boy presents with sudden
    emesis, crampy abdominal pain, bloody stools.
  • Intussusception is most common cause of
    intestinal obstruction in early childhood and
    classically present between ages 3 months and 3
    years.
  • Air contrast enema is diagnostic and therapeutic.

39
Intussusception
  • Most occur before age of two.
  • Etiology is thought to be lymphoid hyperplasia in
    terminal ileum after a viral illness.
  • Proximal bowel (intussusceptum) invaginates into
    the distal bowel (intussuscipien) causing
    swelling, obstruction, and possible vascular
    compromise.
  • Controlled air contrast enema is successful in 90

40
Intussusception
  • Indications for surgery
  • Enema not success
  • Third episode
  • Peritonitis

41
Intussusception
  • Surgery involves reduction, appendectomy, and
    bowel resection for pathology.
  • Recurrence after radiographic or surgical
    treatment is 5.
  • Lead point present in 10 of cases (increases
    with age)
  • Meckels diverticulum is most common lead point
  • In adults it is malignancy!
  • Currant jelly stool!

42
Meckels Diverticulum
  • A healthy 2 year old presents with painless
    bloody stools.
  • Patent vitelline duct
  • True diverticulum
  • Located on anti-mesenteric border
  • A technetium-99 scan can assist with diagnosis
    and localization.
  • Segmental resection is indicated for symptoms.
  • Rule of twos

43
Meckels Diverticulum
  • 2 of population
  • 2 symptomatic
  • 2 times more in males
  • 2 feet from valve
  • 2 years of age or less
  • 2 presentations (bleeding or obstruction)
  • 2 tissue types (pancreatic, gastric)
  • Most common cause of bleeding in children.

44
Biliary Atresia
  • A 1 month old infant has acholic stools and
    persistent jaundice.
  • Jaundice in the newborn that persists 2 weeks is
    no longer considered physiologic.
  • Early diagnosis is critical (before 2 months) to
    prevent progressive liver damage.

45
Biliary Atresia
  • Hallmarks
  • Bile duct proliferation
  • Cholestasis with plugging
  • Inflammatory cell infiltrate
  • Progression to cirrhosis

46
Biliary Atresia
  • Must rule out hepatocellular dysfunction due to
    infectious, metabolic, hematologic, or genetic
    disoders.
  • Elevated conjugated bilirubin?
  • Elevated unconjugated bilirubin?

47
Biliary Atresia
  • Ultrasound helps to determine bile duct size and
    if a gallbladder is present.
  • Bile ducts are not enlarged in atresia
  • If atresia is suspected do mini RUQ incision for
    local exploration and biopsy.
  • Initial goal is to establish diagnosis!

48
Biliary Atresia
  • If gallbladder is present do cholangiogram.
  • If cholangiogram demonstrates a patent but
    hypoplastic biliary system, the incision is
    closed.

49
Biliary Atresia
  • If a patent GB or biliary tract cannot be
    identified, the incision is elongated and a Kasai
    procedure is performed portoenterostomy.
  • The fibrotic GB and extrahepatic biliary tree is
    dissected to the porta hepatis and resected.

50
Biliary Atresia
  • A Roux-en-Y is created and the roux jejunal limb
    is sutured to the porta hepatis to help
    reestablish bile flow from the minute bile ducts.
  • Liver transplant is reserved for progression to
    liver disease, failed Kasai, cases where delayed
    diagnosis.

51
Gastrochisis
  • A neonate is born with an abdominal waal defect
    to the right of the umbilicus. The eviscerated
    intestines appear thickened and do not have a
    peritoneal covering.
  • Caused by intrauterine rupture of umbilical vein.
    (1 vein 2 arteries)

52
Gastrochisis
  • Eviscerated intestines have no covering
  • 2-5 cm defect to right of umbilicus
  • Intestines are thickened, edematous and
    foreshortened.
  • Associated anomalies are uncommon (except
    intestinal atresia in 10-15)
  • Perioperative management includes volume, NGT,
    confirmation of bowel viability and protective
    dressings.

53
Gastrochisis
  • Treatment
  • Attempt primary reduction, if unsuccessful, use a
    silo.
  • A silo allows for a bedside staged closure to be
    followed by primary closure.
  • During exploration confirm presence or absence of
    atresia.
  • Post-op ileus common, TPN life saving.

54
Omphalocele
  • A baby is born with an abdominal wall defect. The
    exposed intestines have an intact peritoneal
    covering and appear normal.
  • Omphalocele is associated with 40-80 incidence
    of another congenital anomaly!
  • Defect thru umbilicus, 4-10cm defect.
  • Covered, normal appearing.

55
Omphalocele
  • Associated anomalies
  • Cardiac most common
  • Pericardial, sternal, diaphragmatic
  • Musculoskeletal
  • GI,GU
  • Beckwith-Weidmann syndrome (omphalocele,
    hyperinsulinema, macroglossia)

56
Omphalocele
  • Perioperative management includes volume, NGT, ID
    other anomalies.
  • Primary reduction is optimal, but if defect too
    large, then staged closure.
  • Outcomes related more to associated anomalies
    than to the omphalocele itself.

57
Congenital Diaphragmatic Hernia
  • A few hours after birth, a newborn develops
    dyspnea, cyanosis, retractions.
  • Two types
  • Bochdalek (posterolateral) most common, 80 on
    left
  • Morgnani (anteromedial)
  • CXR shows loops of intestine or gastric bubble in
    chest. NGT helps in diagnosis.

58
Congenital Diaphragmatic Hernia
  • Resuscitate, stabilize first!
  • May require ECMO
  • Beware of contralateral PTX due to aggressive
    ventilation.
  • Surgical repair is done through subcostal
    incision, with reduction of organs, closure of
    defect.
  • Primary repair is optimal but may need patch to
    avoid tension.

59
Neuroblastoma
  • A 2 year old boy complains of belly pain and lack
    of appetite. Physical reveals a large abdominal
    mass.
  • Most common malignant solid tumor in children.
  • Derived from neural crest tissue
  • May arise anywhere along sympathetic ganglia.
  • Most common in adrenal medulla (50)

60
Neuroblastoma
  • Age 1-2 years
  • Extends across midline
  • Ocular involvement may present as raccoon eyes.
  • Calcifications on x-ray
  • Elevated catecholamines, VMA, metanephrines.
  • Due to production of hormones, children may
    present with flushing, HTN, watery diarrhea,
    periorbital ecchymosis.

61
Neuroblastoma
  • Age at presentation is major prognostic factor.
  • Less than 1 year 70 survival
  • Older than 1 year
  • Good prognostic features
  • Tumors with
  • Aneuploid tumors
  • Low mitosis index
  • Normal LDH and catecholamine levels.

62
Neuroblastoma
  • Rarely mets
  • If able, surgical excision is treatment of
    choice, chemo may be beneficial.
  • The N-myc gene is associated with neuroblastoma!

63
Wilms Tumor (Nephroblastoma)
  • Second most common solid tumor in children.
  • Mass palpable and HTN, hematuria
  • Derived from kidney
  • 3-4 years of age
  • Rare to extend across midline

64
Wilms Tumor (Nephroblastoma)
  • No x-ray calcifications
  • Prognosis based on tumor grade
  • Mets to bone and lung
  • Primary surgical excision very important
  • Neoadjuvant chemo for large tumors
  • Overall survival is good (85)
  • Wilms tumors replace renal parenchyma on CT
    scans whereas Neuroblastoma displaces it.

65
Hepatoblastoma
  • A 7 year old boy presents with precocious puberty
    and elevated Alfa fetal protein.
  • Most common liver tumor in children.
  • Liver cancer variant (better prognosis than
    hepatocellular ca in adults)
  • Beta HCG release results in puberty
  • AFP elevated
  • Surgical resection is treatment of choice.

66
Mediastinal Masses in Children
  • A 7 year old girl presents with dysphagia. A CT
    scan reveals a mediastinal mass.
  • Most common is T-Cell lymphoma
  • Teratoma
  • Tumor (neuroblastoma, neurofibroma,
    neuroganglionoma, germ-cell tumors).

67
Most Common Malignancy in Children?
  • Leukemia

68
Hernia
  • A 14 month old presents with incarcerated right
    inguinal hernia. What do you do?
  • Reduce, admit, do semielective repair in future.
  • High ligation and division of sac.
  • Elective repair to avoid reincarceration (16)

69
Hernia
  • 10-30 incidence of contralateral inguinal
    hernia.
  • Watch out for a normal ovary in an inguinal
    hernia in females.
  • Umbilical hernias occur in 10-30 of live births
  • Incarceration very rare
  • If less than 2cm, frequently close spontaneously,
    closure and repair should be delayed until age of
    4.
  • If larger than 2cm, repair at time of diagnosis.
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