Beruflich Dokumente
Kultur Dokumente
SURGERY
Neonate
-
Air
distends
GIT,
splinting
diaphragm
-
Gastric
fluid
refluxes
into
lungs
-
Saliva
pools
in
pouch
&
aspirated
Recognition
Prenatal
-
Ultrasound
Polyhydraminos
No gastric bubble
Neonate
-
Clinical
Excessive drooling
Intraembryonic pressure
Epithelial closure
Vascular accident
Radiologic
Also
confirms:
Distal
TEF
Duodenal
atresia
Incidence:
Types:
80-90%
5-8%
2-4%
1%
1%
Isolated EA
Limit stress
Keep warm
Hydration
EA
with
distal
TEF
Isolated
EA
Isolated
TEF
EA
with
proximal
TEF
EA
with
proximal
&
distal
TEF
Survival
97
59
22
Associated
Anomalies:
1. Cardiovascular
anomalies
11-49%
2. GUT
24%
3. GIT
24%
4. Skeletal
13%
5. Neural
tube
defects
23%
6. Hydrocephalus
5.2%
Pathophysiology:
In
utero
-
Upper
pouch
distends,
compressing
trachea
&
causing
tracheomalacia
-
Amniotic
fluid
in
airways
drain
to
GIT
(through
fistula),
with
decreased
stenting
of
alveoli
Surgical
Options:
Staged
Procedure
-
Several
successive
surgeries
as
the
patients
condition
permits
-
Supportive
care
not
too
demanding
Surgical Procedures:
Staging
Procedures
-
Gastrostomy
-
Medium-
to
long-term
vascular
access
-
Cervical
esophagostomy
-
TEF
occlusion
or
ligation
(w/o
esophageal
anastomosis)
-
Esophageal
lengthening
-
Esophageal
replacement
Primary
Correction
-
Trans0thoracic
ligation
of
TEF
with
esophageal
anastomosis
-
Throacoscopic
approach
recent
development
Complications:
Anastomotic leak
Stricture
Recurrent TEF
Gastroesophageal reflux
Tracheomalacia
Diagnosis:
Amniocentesis
Chromosomal analysis
Chest
X-ray
air
and
fluid
loops
within
the
left
hemithorax
-
Mediastinal
shift
-
Minimal
gas
within
abdomen
Management:
1. Prenatal
Care
-
Support
the
fetus
and
bring
to
term
-
Refer
to
the
appropriate
tertiary
perinatal
center
2.
Preoperative
care
-
Conventional
mechanical
ventilation
Avoid
mask
-
Endotracheal
intubation
-
Control
pul,onary
HPN
-
Neuromuscular
blockade
-
NGT
-
Echocardiography
-
Surfactant
replacement
therapy
-
Nitric
oxide
-
Extracorporeal
membrane
oxygenation
(ECMO)
3.
Surgical
Management
-
Timing
delayed
until
there
is
evidence
that
the
pulmonary
hypertension
has
been
resolved
-
Technique
repair
of
defect
primarily
or
with
prosthesis
Types:
Bochdalek
85-90%
-
Posterolateral
-
Left-sided
80-90%
Morgagni
2.6%
-
Retrosternal
Pentalogy
of
Cantrell
1. Omphalocoel
2. Inferior
sternal
cleft
3. Severe
cardiac
defect
ectopia
cordis
4. Pericardial
defects
5. Hiatal
hernia
Defects:
Pulmonary
hypoplasia
-
Decreased
pulmonary
mass
and
weight
-
Decreased
branchial
divisions
-
Reduction
in
the
number
of
alveoli
and
bronchioles
Surfactant deficiency
Associated
anomalies
Clinical
Presentation:
Respiratory
distress
-
Tachypnea,
grunting
respiration,
chest
retraction,
pallor
cyanosis
-
Hypoxia,
hypercarbia,
acidosis
Scaphoid
abdomen
Increased
chest
diameter
Mediastinal
shift
Bowel
sounds
in
the
chest
Decreased
breath
sounds
Clinical Manifestations:
Respiratory distress
Tachypnea
Pallor
Mediastinal shift
Chest Radiology:
Elevated
hemidiaphragm
Fluoroscopy
or
Ultrasound:
Mediastinal
shift
Treatment:
Plication
of
the
diaphragm
Page
2
of
6
Vomiting
Normal vomiting
Abnormal
vomiting
-
Medical
vs.
Surgical
-
Color
(bilious
=
surgical)
-
Timing
-
Manner
of
vomiting
Diagnostics:
Ultrasound
-
Doughnut
sign
-
Target
bulls
eye
sign
-
3-4
mm
muscle
thickness
(normal
1-2
mm)
UGIS
-
String
sign
-
Shoulder
sign
Electrolyte disturbance
Management
Ramstedts
pyloromyotomy
Classification
Bilious
vomiting
w/
minimal
abdominal
distention
(a) Proximal
obstruction
Paucity
of
gas
No
distal
air
(b) Distal
Bilious
emesis
and
abdominal
obstruction
distention
DUODENAL
OBSTRUCTION
Duodenal
atresia
Duodenal
web
Duodenal
stenosis
Annular
pancreas
Duodenal
duplication
Malrotation
w/
midgut
volvulus
Duodenal Atresia
Type
I
II
III
Management:
-
Fluid
and
electrolyte
correction
-
OGT
-
Duodenoduodenostomy
Associated
Anomalies:
-
Annular
pancreas
-
Malrotation
-
Anterior
portal
vein
-
Downs
syndrome
Incidence:
M-F
=
4:1
Associated Anomalies:
Intestinal malrotation
Obstructive uropathy
Esophageal atresia
Etiology:
Clinical Presentation:
Differential Diagnosis:
Overfeeding
GER
Elevated ICP
Antral web
Gastric neoplasm
Gastric duplication
JEJUNOILEAL
ATRESIA
Etiology:
Vascular occlusion
Incidence:
Type
I
II
IIIa
Diagnosis:
Bilious vomiting
Abdominal distention
Management:
NGT
Antibiotics
Surgical
Management
-
Upper
abdominal
distention
-
Reestablish
intestinal
continuity
-
Preserve
bowel
length
and
normal
anatomy
-
End-to-oblique
anastomosis
Nutritional
support
Morbidity:
Pneumonia
Peritonitis
Sepsis
MALROTATION
AND
VOLVULUS
Congenital
abnormal
positioning
of
midgut
Elongation
Rotation
Fixation
Clinical
Presentation:
st
Abdominal distention
Intestinal
Development
6
weeks
rapid
growth
of
intestines
10-12
weeks
midgut
returns
to
abdominal
cavity
o
270
counter-clockwise
rotation
around
the
superior
mesentery
C-loop
duodenum
fixed
retroperitoneally
at
the
right
upper
quadrant
Cecum
fixed
to
the
lateral
abdominal
wall
at
the
right
lower
quadrant
Radiologic Diagnosis:
Incomplete Rotation:
UGIS
-
Preferred
diagnostic
study
-
Corkscrew-like
deformity
of
the
duodenum
-
Duodenum
and
jejunum
is
in
the
right
upper
(normally
wala
sa
right)
-
Dilated
stomach
and
airless
abdomen
Barium
enema
is
only
suggestive
of
Management:
OGT
IVF resuscitation
Antibiotics
Clinical Presentation:
Pathology:
Idiopathic
intussusception
-
Less
than
1-year-old
-
During
attacks
of
upper
respiratory
tract
infections
and
diarrhea
-
Adenovirus,
rotavirus,
rheovirus,
echovirus
-
Hypertrophy
of
Peyers
patches
Diagnostic Studies:
Abdominal
ultrasound
-
Target
lesion
-
Pseudokidney
sign
-
-
-
-
Antibiotics
BT
Hydrostatic
barium
enema
or
saline
reduction
Pneumatic
reduction
Surgical
-
When
non-operative
management
fails
-
Manual
reduction
anastomosis
if
gangrenous
-
Appendectomy
HIRSCHPRUNGS
DISEASE
Congenital
absence
of
parasympathetic
ganglia
cells
in
the
wall
of
the
GT
tract
Bowel
unable
to
relax
and
without
peristalsis
Involves
rectum
extending
proximally
75%
rectosigmoid
Incidence:
Clinical Presentation:
Newborn
-
Non-passage
or
delayed
passage
of
meconium
-
Abdominal
distention
-
Bilious
vomiting
-
Visible
bowel
loops
-
Rectal
exam
Diagnosis:
Barium
enema
-
Spasm
and
a
narrowed
lumen
-
Transition
zone
Management:
Page
5
of
6
Malrotation:
Ladds
Procedure
-
Straightening
of
Duodenbum
-
Widening
of
Mesentery
-
Small
bowel
at
the
right
hemiabdomen;
large
bowel
at
the
left
-
Appendectomy
(optional)
INTUSSUSCEPTION
Invagination
of
a
portion
of
the
intestine
into
itself,
producing
vascular
compromise
Differential Diagnosis:
Premature infant
Sepsis
NEC
Functional
constipation
Preoperative Management
Gastric decompression
Treat enterocolitis
Nutrition
Operative Management:
Goal:
-
Resection
of
the
involved
segment
-
Re-establishment
of
functional
and
continent
anus
Definitive
procedures:
-
Swenson
procedure
-
Duhamel
procedure
-
Scott
Boleys
endorectal
pullthrough
Pull-Through Procedures:
Soave-Boley technique
Swensons
technique