Surgical Emergencies in the Newborn

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Surgical Emergencies in the Newborn

• Michael H. Ratner MD
• Chief, Pediatric Surgery
• SUNY Upstate Medical U.
• Syracuse, NY

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I have no relevant financial relationships with
any commercial interest

• Michael H. Ratner MD

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They are out of the Barn Door

• These are all non-NICU Cases

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Mild Respiratory Distress in a Three Month Old

• A three month old male, born at term and
  discharged at 36 hours was well until two days
  prior to an ER visit. Since then mom has noticed
  increasing respiratory effort and this morning,
  some difficulty feeding.
• Other than a respiratory rate of 60-80 the babys
  VS are normal. Chest exam reveals mildly
  decreased breath sounds on the left.

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A two month old female with Vomiting

• A two month old previously well full-term infant
  has had two days of increasing vomiting which has
  become green in the last twelve hours. The baby
  is breast fed and has not fed well for the last 2
  days.
• The baby was seen by the primary care physician
  who noted a distended abdomen and sent the baby
  to the ER.

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Common Scenarios

• The patient has had previous abdominal surgery
• The patient has an incarcerated inguinal hernia-
  we always examine with the diaper off, dont we.

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Post-op adhesions
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Common Scenarios

• Well just skip over those

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A two month old female with Vomiting

• A two month old previously well full-term infant
  has had two days of increasing vomiting which has
  become green in the last twelve hours. The baby
  is breast fed and has not fed well for the last 2
  days.
• The baby was seen by the primary care physician
  who noted a distended abdomen and sent the baby
  to the ER.

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How about some plain films?
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Now what?

• For this scenario
• This patient has a normal stooling history

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Contrast enema

• You are going to the OR for this patient, unless
  one of two circumstances occur
• A. Ileo-colonic Intussusception which is
  hydrostatically reducible If this patient was 6
  months old we would have done an U/S first
• B. Hirschsprungs disease the baby is breast
  fed and has short segment disease so a problem
  was undetected

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Differential Diagnosis

• Big list eg Meckels with band or
  intussusception, Internal hernia, duplication
  cyst
• All Rare
• The key is to know
  that early
• resuscitation and
  surgery
• is the answer

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Lets change the stooling history

• Breast fed
• Stooled QOD until mom weaned to formula. Now
  stools every 4-5 days with difficulty.

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Hirschsprungs Disease
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Hirschsprungs Disease
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Lets change the plain films
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Now what

• What are we thinking about?

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Upper GI Series
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Three answers for this picture

• Duodenal stenosis Is this a Downs baby?
• Malrotation with Ladds bands and duodenal
  obstruction
• Annular pancreas

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Remember

• If the patient looks ill with these films think
  of Malrotation with mid-gut volvulus

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MALROTATION

• Acute Duodenal Obstruction

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NORMAL ROTATION
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ROTATIONAL ABNORMALITIES

• Omphalocele, the ultimate failure
• No rotation and no return to the abdomen

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ROTATIONAL ANOMALIES

• Mixed Rotation
• 180 degrees instead of 270
• Ileum enters abd. First
• Cecum sub-pyloric
• Ladds bands- Cecum fixed to abd. wall

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ACUTE DUODENAL OBSTRUCTION

• Almost uniformly due to incomplete rotation
• 75 occur by 1 week of age
• 90 occur by 1 month of age
• Essentially all occur by 1 year

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ACUTE DUODENAL OBSTRUCTION
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ACUTE DUODENAL OBSTRUCTION

• Presentation
• Bilious Vomiting
• Dehydration
• Upper Abdominal Distention

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ACUTE DUODENAL OBSTRUCTION
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Malrotation with Ladds Bands
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Is there a place for advanced Imaging?

• Not needed
• But if the patient comes with U/S or CT the
  diagnosis can be made

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ACUTE DUODENAL OBSTRUCTION

• Surgery
• Lysis Ladds bands
• Appendectomy
• Widen mesentery-SMA
• Place colon on left, jejunum on right
• Remember congenital intrinsic obstruction

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CHRONIC DUODENAL OBSTRUCTION

• Due to incomplete rotation
• Symptoms occur early but can continue for years
  intermittently
• Patients occasionally make it to adulthood before
  diagnosis

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CHRONIC VOLVULUS WITH PARTIAL DUODENAL OBSTRUCTION

• Usually occurs in children lt 10years
• Delays in diagnosis are common
• Same partial or mixed rotation group

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CHRONIC VOLVULUS WITH PARTIAL DUODENAL OBSTRUCTION

• Several different presenting syndromes
• Chronic abdominal pain/ intermittent vomiting
• Poor eater/ malabsorption

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CHRONIC VOLVULUS WITH PARTIAL DUODENAL OBSTRUCTION

• Diagnosis
• Same-UGI
• Treatment
• Same- Ladds Procedure

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THE PEDIATRIC NUMBERS Chronic

• 90 present by age 1 year
• At gt 30 days of age about 10 of patients will
  present with peritonitis and shock
• Numbers fairly consistent over many large series

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MALROTATION-CNY-2007

• 10 patients
• 50 lt 1 year
• Of patients gt 1 year, ages ranged from 4 12
  years, mean age was 7.7 years
• 3 patients with volvulus
• 1 patient in shock
• 1 bowel resection performed

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The End