Pediatric Surgery - Surgery - Lecture Slides, Slides of General Surgery

Download Pediatric Surgery - Surgery - Lecture Slides and more Slides General Surgery in PDF only on Docsity! Pediatric Surgery Docsity.com 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. Docsity.com 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. Docsity.com 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. Docsity.com 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. Docsity.com 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. Docsity.com 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. Docsity.com 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. Docsity.com 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). Docsity.com 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 Docsity.com 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. Docsity.com 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. Docsity.com 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. Docsity.com 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. Docsity.com 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. Docsity.com 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. Docsity.com 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 Docsity.com 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 Docsity.com 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. Docsity.com NEC • A 7 day old premature infant has emesis, abdominal distension, and bloody stools. • Differential includes: • NEC • Malrotation Docsity.com 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! Docsity.com 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% Docsity.com 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). Docsity.com Intussusception • Indications for surgery: • Enema not success • Third episode • Peritonitis Docsity.com 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! Docsity.com 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: Docsity.com Biliary Atresia • Hallmarks: • Bile duct proliferation • Cholestasis with plugging • Inflammatory cell infiltrate • Progression to cirrhosis Docsity.com Biliary Atresia • Must rule out hepatocellular dysfunction due to infectious, metabolic, hematologic, or genetic disoders. • Elevated conjugated bilirubin? • Elevated unconjugated bilirubin? Docsity.com 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! Docsity.com 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. Docsity.com 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) Docsity.com 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. Docsity.com Omphalocele • Associated anomalies • Cardiac most common • Pericardial, sternal, diaphragmatic • Musculoskeletal • GI,GU • Beckwith-Weidmann syndrome (omphalocele, hyperinsulinema, macroglossia) Docsity.com 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. Docsity.com 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. Docsity.com 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. Docsity.com Neuroblastoma • Age at presentation is major prognostic factor. • Less than 1 year >70% survival • Older than 1 year <35% survival • Good prognostic features: • Tumors with <10 copies of N-myc gene • Aneuploid tumors • Low mitosis index • Normal LDH and catecholamine levels. Docsity.com Neuroblastoma • Rarely mets • If able, surgical excision is treatment of choice, chemo may be beneficial. • The N-myc gene is associated with neuroblastoma! Docsity.com 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. Docsity.com 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). Docsity.com Most Common Malignancy in Children? • Leukemia Docsity.com