Pediatric Surgery

1. Pediatric Surgery

2. Epiglottitis • H. Influenza is most common organism • A lateral xray may show edema of the epiglottis (bird’s 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 distalTEF 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 bird’s 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 Ladd’s 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 Down’s 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. Hirchsprung’s 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. Hirchsprung’s 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. Hirchsprung’s 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. Hirchsprung’s 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. Hirchsprung’s 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) • Meckel’s diverticulum is most common lead point • In adults it is malignancy! • Currant jelly stool!

42. Meckel’s 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. Meckel’s 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 inchildren.

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.