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Morning Meeting Pediatric surgery case presentation

Morning Meeting Pediatric surgery case presentation. Presenter: R1 張凱惟 Supervisor: Chief 陳肇真 Date: 2010/01/12 Place: 501 教室. Case identification. Name: 劉 X 嬅 Gender: female Chart No.: 13526468 Born in NCKUH: 2009/11/18 Age: 3 days old

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Morning Meeting Pediatric surgery case presentation

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  1. Morning MeetingPediatric surgery case presentation Presenter: R1 張凱惟 Supervisor: Chief 陳肇真 Date: 2010/01/12 Place: 501 教室

  2. Case identification • Name: 劉X嬅 • Gender: female • Chart No.: 13526468 • Born in NCKUH: 2009/11/18 • Age: 3 days old • Chief complaint: abdominal distension on 11/21

  3. Brief history Prenatal exam in 周宗盛婦產科 -Pregnancy induced hypertension (-) -Gestational diabetes mellitus (-) 2009/11/18 BW: 1205gm G2P2A0, C/S (pre-C/S) GA 28 weeks, BBW: 1205gm (VLBW) Apgar score: 79 (s/p ambu-bagging) -acrocyanosis, bradycardia, weak / irregular breathing CXR → Respiratory distress syndrome, grade II -on bubble-CPAP -Aminophylline

  4. Images 2009/11/19 00:30 • OG tube inserted • Coarsening of bronchovascular bundle • Fine granulation of lung parenchyma • (ground glass appearance)

  5. Images 2009/11/19 00:30 2009/11/19 12:18

  6. Brief history Prenatal exam in 周宗盛婦產科 -Pregnancy induced hypertension (-) -Gestational diabetes mellitus (-) 2009/11/18 BW: 1205gm G2P2A0, C/S (pre-C/S) GA 28 weeks, BBW: 1205gm (VLBW) Apgar score: 79 (s/p ambu-bagging) -acrocyanosis, bradycardia, weak / irregular breathing CXR → Respiratory distress syndrome, grade II -on bubble-CPAP -Aminophylline 2009/11/21 BW: 1100gm Abdominal distension

  7. Image 2009/11/21 12:38

  8. Lab Data (11/21) <緊急血液檢驗報告> 醫師: 林毓志 採檢:98/11/21 全血 8262N73722 -------- ------------- ------------- -------- ------------- --------- Hb 10.1 g/dl | Pl 246 K/cmm WBC 12.5 K/cmm | Myelo 1 % Meta 4 % | Band 13 % Seg 59 % | Mono 10 % Lymph 13 % | CRP <7 mg/L <緊急尿液，糞便檢驗報> 醫師: 林毓志 採檢:98/11/21 糞便 8263L64220 -------- ------------- ------------- -------- ------------- ---- O.B. + | RBC 0-1 /HPF PUS 0-2 /HPF |

  9. micro-Gas (11/21)

  10. Physical Examination • Vital Sign: • BT: 37.6℃, P: 154/min, R: 52/min • BP: 78/42mmHg • Activity: good • OG: no coffee ground or bile content • Abdomen: extremely distended • L/S: impalpable / impalpable • Skin: no erythematous skin change • Bowel sound: hypo-active

  11. Impression Focal intestinal perforation Necrotizing enterocolitis

  12. OP finding

  13. Image 2009/11/21 15:52

  14. micro-Gas (11/21)

  15. Blood culture (11/21) <細菌檢查報告> 醫師: 林毓志 檢查:98/11/21 全血 8240M69393 ------- ------------- ------------- -------- ------------- ---- BLOOD CULTURE REPORT No aerobic and no anaerobic pathogens were isolated after 5 days of incubation.

  16. Post OP course 2009/11/21 Focal intestinal perforation s/p beside peritoneal drainage NPO, on TPN Antibiotics: Unasyn+ Amikacin + Metronidazole 2009/11/23 RHB, grade II systolic murmur over LUSB Cardiac echo → PDA(0.25cm, LA/AO: 1.79) 2009/11/30 PDAs/pbedside PDA ligation

  17. Serial images 2009/11/23 18:08 2009/11/30 14:15

  18. Post OP course 2009/11/21 Focal intestinal perforation s/p beside peritoneal drainage NPO, on TPN Antibiotics: Unasyn+ Amikacin + Metronidazole 2009/11/23 RHB, grade II systolic murmur over LUSB Cardiac echo → PDA (0.25cm, LA/AO: 1.79) 2009/11/30 PDA s/p bedside PDA ligation 2009/12/01 Hypoactive bowel sound and dilated gastric bubble

  19. Serial images 2009/12/01 12:24 2009/12/01 15:49 2009/12/01 16:29

  20. Serial images 2009/12/07 13:48 2009/12/23 21:32

  21. Post OP course 2009/12/10 Try feeding Remove penrose 2009/12/11 2009/12/24 Remove PICC and DC TPN 2009/12/28 Transferred to level II ward 2010/01/04 DC IVF (Milk: 50~55 ml Q4H) 2010/01/08 BW 2096gm GA 35+2 wk Discharge

  22. DiscussionFocal intestinal perforation (FIP)Necrotizing enterocolitis (NEC)

  23. Focal intestinal perforation (FIP) S/S: abdominal distension Time: around the first week of life Etiologic factors: Neonatal ventilation The use of umbilical catheters Receive Indomethacin or post-natal steroid Congenital deficiency of enteric smooth muscle Small bowel perforation in the premature neonate: congenital or acquired? Pediatr Surg Int 2003; 19:489-494 New insights into spontaneous intestinal perforation using a national data set: antenatal steroids have no adverse association with spontaneous intestinal perforation. J Perinatol. 2006 Nov;26(11):667-70. Epub 2006 Oct 5.

  24. Necrotizing Enterocolitis (NEC) The most frequent cause of gastrointestinal perforation in premature neonates S/S: feeding intolerance and bloody stools Time: in the second or third week of life Three key contributing factors: Prematurity (90% of NEC cases) Early enteral feeding Bacterial colonization

  25. Necrotizing Enterocolitis (NEC) • Pathophysiology:Ischemia • Initial ischemic mucosal damage  loss of mucosal integrity  enteral feeding  bacterial proliferation  intramural bowel gas  transmural necrosis, gangrene  perforation, peritonitis

  26. Image • Focal intestinal perforation (FIP) • Gasless abdomen • Pneumoperitoneum • Necrotizing Enterocolitis (NEC) • Pneumatosisintestinalis • Portal venous gas

  27. Focal intestinal perforation (FIP) • Isolated mucosal ulceration with normal surrounding tissue • Submucosaledema and serosalinflammation

  28. Necrotizing enterocolitis(NEC) • Necrotic mucosa • Numerous small gas-filled cysts in the wall (Pneumatosisintestinalis) Rosai: Surgical Pathology 9th edition

  29. Necrotizing enterocolitis(NEC) • Extensive ulceration, necrosis, and hemorrhage Rosai: Surgical Pathology 9th edition

  30. Distribution of pathogens FIP ( ■; n = 36) NEC ( ■; n = 80) 75% 50% 44% * : P < .0001 +: P = .001 Distinctive Distribution of Pathogens Associated With Peritonitis in Neonates With Focal Intestinal Perforation Compared With Necrotizing Enterocolitis PEDIATRICS Vol. 116 No. 2 August 2005, pp. e241-e246

  31. Surgical Management • 1970s: • Laparotomy in ELBW with NEC → very poor outcome • 1977: • Peritoneal drainage under local anesthesia → could recover fully Chardot et al, Journal of Pediatric Surgery, Vol38, No2, 2003: pp167-172

  32. NCKUH experiences • Extremely-low-birth-weight (ELBW) neonates • 47 cases of FIP or NEC • Group 1 (1989-1993) FIP: 3 NEC: 2 • Group 2 (1994-1998) FIP: 4 NEC: 6 • Group 3 (1999-2006) FIP: 13 NEC: 9 • Group 4 (2007-2009) FIP: 7 NEC: 3 • Operative methods • LAP: laparotomy • PD: peritoneal drainage

  33. Group 1 (1989-1993)

  34. Mortality rate

  35. Complications

  36. Conclusions • PD is proved to be successful and definite treatment for neonates with FIP. • PD can improve clinical condition of patients with severe NEC to buy time, but the definite treatment of NEC need LAP after poor response to PD. • LAP is the better procedure for patients with good operative risk but irreversible bowel injury.

  37. FIP - x • Unstable V/S? • Irreversible • bowel injury? PD x o LAP Susp. FIP or NEC V/S stable? NEC PD x FIP o Irreversible bowel injury? NEC o LAP

  38. FIP or NEC? • Poor feeding, bloody stool, lethargy • Temperature instability, bradycardia, apnea, BP↓ • Abdominal wall erythema, persistent local mass • Metabolic acidosis, thrombocytopenia, shock • KUB: • Ground glass appearance • Pneumatosisintestinalis • Portal venous gas • Pneumoperitoneum • Definite ascites

  39. Thanks for your attention

  40. Reference • Principles and Practice of Pediatric Surgery 6th edition • Rosai: Surgical Pathology 9th edition • Distinctive Distribution of Pathogens Associated With Peritonitis in Neonates With Focal Intestinal Perforation Compared With Necrotizing Enterocolitis, PEDIATRICS Vol. 116 No. 2 August 2005, pp. e241-e246 • Small bowel perforation in the premature neonate: congenital or acquired? Pediatr Surg Int 2003; 19:489-494 • New insights into spontaneous intestinal perforation using a national data set: antenatal steroids have no adverse association with spontaneous intestinal perforation. J Perinatol. 2006 Nov;26(11):667-70. Epub 2006 Oct 5. • Prophylactic indomethacin for preterm infants: a systematic review and meta-analysis, Arch Dis Child Fetal Neonatal Ed. 2003 November; 88(6): F464–F466. • Prevention and treatment of necrotisingenterocolitis in preterm neonates, Early Human Development (2007) 83, 635–642 • Treatment and prevention of necrotizingenterocolitis, Seminars in Neonatology (2003) 8, 449–459 • Mortality of necrotizing enterocolitis expressed by birth weight categories, Journal of Pediatric Surgery (2009) 44, 1072–1076 • Prolonged Duration of Initial Empirical Antibiotic Treatment Is Associated With Increased Rates of Necrotizing Enterocolitis and Death for Extremely Low Birth Weight Infants, Pediatrics 2009;123:58–66

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