Topics for discussion. Pediatric General Surgery. Physiology. Surgical Newborns. Neonatal Intestinal Obstruction

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1 Topics for discussion Pediatric General Surgery Professor General & Thoracic Surgery What makes Pediatric Surgery unique? Neonatal intestinal obstruction Abdominal wall defects Inguinal hernias Appendicitis Malignancies Why is it different from adult surgery? Different diseases Responses to surgery and trauma Physiology Cure vs. Palliation Family dynamics Ability to take a history True general surgery Physiology Children are not little adults Problems and physiologic maturity vary at different ages Surgical Newborns Common Symptoms Vomiting Abdominal distension Bloody stool Respiratory distress Neonatal Intestinal Obstruction

2 Esophagus Esophagus Stomach Duodenum Colon Stomach Duodenum Colon Small intestine Small intestine Tracheoesophageal Fistula (TEF) and Esophageal Atresia (EA) Esophageal Atresia VACTERL Anomalies Coiled tube in the proximal pouch Air distally in the stomach and GI tract Outcome: 85-90% survival 100% without associated anomalies Associated Defects VACTERL Repair of TEF and EA

3 Repair of TEF and EA Repair of TEF and EA Pyloric stenosis Esophagus Duodenum Stomach Colon Small intestine Metabolic abnormality: Hypokalemic Hypochloremic Metabolic alkalosis Paradoxic aciduria Fredet Ramstad Pyloromyotomy

4 Beware the child that vomits green Esophagus Stomach Duodenum Colon Small intestine Duodenal atresia Double Bubble Annular pancreas

5 Malrotation Better term is absence of normal rotation Normal anchor points are absent Normal Rotation Effect of no anchor point Volvulus Ladd s Procedure Small bowel on Right Large bowel on Left L - aparotomy A - ppendectomy D - ivide bands D - eliver bowel to sides Appendectomy End of Ladd s Procedure

6 Intestinal Atresia Esophagus Stomach Duodenum Colon Presumed to be vascular accident in utero leading to infarction of portion(s) of bowel Small intestine Ileocolic Intussusception Small bowel telescopes through the ileocecal valve leading to obstruction Mesentery is caught in the process leading to ischemia Contrast Enema Reduction Air or liquid is used to push the bowel back thereby reducing the intussusception Red currant jelly stools

7 Esophagus Stomach Duodenum Colon Small intestine Hirschsprung s Disease Etiology: arrest in migration of ganglion cells from the neural crest -> absence of ganglion cells in Auerbach s and Meissner s plexus Pathology: spastic contraction, no relaxation, functional obstruction Imperforate Anus Associated Anomalies Spinal / Sacral (most common) Urogenital VACTERL association Imperforate anus

8 Perineal/Vestibular Fistula Imperforate anus Posterior Sagittal Anorectoplasty Abdominal Wall Defects Gastroschisis Associated anomalies much less common Malrotation (all) Short bowel Intestinal atresia Hypothermia and hypovolemia are of greatest concern In utero

9 Omphalocele Anomalies in 50% Trisomy 13, 18, 21 BeckwithWiedemann Syndrome Cardiac, Skeletal, GU, Neurologic Intestinal tract Cloacal extrophy, Pentalogy of Cantrell Silicone Ventral Wall Defect Silo Bag Staged closure of gastroschisis Place infant in warm saline bag Peel on bowel Omphalocele

10 Omphalocele Omphalocele Inguinal Hernias Omphalocele Inguinal Hernia 5% incidence in full term infants M:F 10:1 Risks: Incarceration (30% in first 6 months for term; 60% in first 6 months for premie) Infarcation (Low incidence (1%) Fix when found

11 Appendicitis Appendicitis Appendix is a vestigial organ in RLQ

12 Appendicitis Appendix is a vestigial organ in RLQ Obstruction of the lumen may lead to swelling Appendicitis Appendix is a vestigial organ in RLQ Obstruction of the lumen may lead to swelling Pressure in the lumen builds leading to ischemia Appendicitis Appendicitis Appendix is a vestigial organ in RLQ Obstruction of the lumen may lead to swelling Pressure in the lumen builds leading to ischemia Ultimately, necrosis of the wall will lead to perforation and leakage of infected contents Typical history in only ~50% Pain poorly localized Children < 4 years Retrocecal location Perforation hours, younger children 24 hours, 25% 36 hours, 50% 48 hours, 80% Appendicitis ~1% Mortality 5% incidence pelvic abscess <1% incidence postoperative bowel obstruction Pediatric Malignancies

13 10 Most Common Cancers Adult Cancers 1. Melanoma 2. Colorectal adenocarcinoma 3. Breast adenocarcinoma 4. Prostate adenocarcinoma 5. Lung adenocarcinoma 6. Pancreatic adenocarcinoma 7. Thyroid carcinoma 8. Leukemia 9. Endometrial carcinoma 10. Renal cell carcinoma Childhood Cancers 1. Leukemia 2. CNS tumors 3. Neuroblastoma 4. Nephroblastoma 5. Lymphoma 6. Retinoblastoma 7. Sarcomas 8. Bone Tumors 9. Hepatoblastoma 10. Germ Cell Tumors Neuroblastoma Most common abdominal malignancy of childhood Often will surround major vessels thereby making surgery challenging Nephroblastoma (Wilms Tumor) Most common malignant renal tumor of childhood Combination of surgery, chemotherapy, and radiotherapy Hepatoblastoma Most common malignant lesion of the liver in childhood Complete resection is the most important aspect of therapy Pediatric Surgery Our scope is the skin and its contents The last true general surgeon Children are not little adults

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