late onset pyloric stenosis

7/30/2019 late onset pyloric stenosis

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INTRODUCTION


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The presence of unilateral cleftlip is one of the most common

congenital deformities.

A broad spectrum of variations in clinicalpractice exists.

Unilateral cleft lip involves :deformity of the lip in addition to the alveolusand nose.

Patients with deformity require :short-term care and long-term care and followup from practitioners in multiple specialties.


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Cleft lip surgeryhas evolved from asimple adhesion of paired margins of

the cleft to an understanding of thevarious malpositioned elements of the lip toa more complicated reconstruction usingtransposition, rotation and advancement

flaps


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It is still somewhat controversial.

Some centers have advocated surgery in theearly neonatal period,with an approved benefit inthe scar appearance and nasal cartilage adaptability,thus minimizing nasal deformity.

In general however most centers prefer toperform the unilateral cleft lip repair when the

infant aged 2-4 months,AS: anasaethesia risks are lower, the child is better ableto withstand the stress of surgery, and lip elements arelarger and allow for meticulous reconstruction.


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Mesenchymal migration and fusion of theprimitive somite-derived facial elements(central frontonasal, 2 lateral maxillary,

mandibular processes), at 4-7 weeksgestation, is necessary for the normal

development of embryonic facialstructures.

When migration and fusion areinterrupted for any reason, a facial cleftdevelops along embryonic fusion lines.


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Normal lip and nasal anatomy is essential for anunderstanding of the distortion caused by a facialcleft.

The elements of the normal lip are composed

of: the central philtrum,demarcated laterally by: the philtral columns andinferiorly by: the Cupid's bow and tubercle.

Just above the junction of the

vermilion-cutaneous border:

is a mucocutaneous ridge

frequently referred to as the white roll.


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The orbicularis oris muscle in the lateral lip

element ends upward at the margin of the cleft to insertinto the alar wing.

In cases of incomplete clefting:the muscle does not, as a rule, cross the cleft unless the

bridge is at least one-third the height of the lip.

The philtrum :is short.

Two-thirds of the Cupids bow, one philtral column,and a dimple holloware preserved.

The musculature betweenthe filtral midline and the cleft is hypoplastic.


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The overall occurrence of cleft lip with orwithout cleft palate:

is approximately 1 in 750-1000 live births. Racialdifferences exist,

with the incidence in Asians : (1:500)greater than in Caucasians (1:750)

greater than in African Americans (1:2000).

The incidence of cleft lip is more in males.


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The most common presentation: is cleft lipand palate (approximately 45%),

Followed by: cleft palate alone (35%) and cleftlip alone (approximately 20%).

Unilateral cleft lips are more common thanbilateral cleft lips and occur more commonlyon the left side (left cleft lip: right cleft lip:

bilateral cleft lip = 6:3:1).


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Surgical Therapy

The objectives of surgical repair : eliminate any notch of the vermilion.

correct the drooping or flattened ala.

restore muscle continuity with a minimal amount

of scarring of the lip.

h dd l f d i h i


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Parents who suddenly are faced with caringfor a child with a facial cleft are overwhelmed.

The importance of : spending sufficient time with them to allay their fears.

discuss staging and timing of reconstruction.

stress the need for involvement of other specialists.

instruct them on the importance of long-term andconsistent follow-up care from birth throughadolescence cannot be overemphasized.


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Results in: symmetrically shaped nostrils, nasal sill, and alar

bases.

a well-defined philtral dimple and columns. a natural appearing Cupid's bow with a pout to the

vermilion tubercle.

In addition, it results in a functional muscle repair

that with animation mimics a normal lip. While ideally the lip scars approximate natural

landmarks, ultimately the eye first focuses onsymmetry and then normal contours of the lip at

rest and in animation.


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LeMesurier quadrilateral flap repair.

Randall-Tennison triangular flap

repair. Millard rotation-advancement repair.


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While none of the repairs is ideal, each hasadvantages and disadvantages, and each result in

an excellent repair in experienced hands,underscoring the fact that more than a singleacceptable technique, rather than a single idealrepair, is available.

However, because of the limitations of this article,the authors choose to focus on the repair

Millard

first described in 1955, as today it isperhaps the most commonly adapted

repair of cleft lip.


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It advances a mucocutaneous flap from the laterallip element into the gap of the upper portion of thelip resulting from the inferior downward rotationof the medial lip element.

The repair attempts to:

place the lip scars along anatomic lines of the

philtral column and nasal sill.


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Conceptually, Millard's approach is elegant but it isnot always technically easy to accomplish without

some modifications to deal with the wide variation inclefts.

As with any other repair, consistency in achieving a good resultis operator-dependent.


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The aim of this work is to:

evaluate the clinical course and operativeoutcome of primary cleft lip repair in

neonates.

Aiming at:

proper and early oral feeding well as thepotential psychosocial benas efits to the

family of bringing home a child of normalappearance.


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The present study will be carried out on 20neonates patients admitted to PediatricSurgery Department at Chatby UniversityHospital ,

in the period from September 2009 to

October 2010.


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Patients photographic images in staticand dynamic positions in frontal andsubmental views were analyzed, afterone year follow up:

The ala developed with position maintenance withoutnasal stenosis in all cases.

All the patients had good lip function (100%),

There were no growth facial disturbances.

Minimal scar (10 cases with good scar) and (10 caseswith excellent scar) as reported by parents.

No wound infection has been reported.


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The height of the repaired side as comparedto the non cleft side was equal in:

18 cases (90% of cases).

The lip was found to be shorter in:

2 cases by 0.3 mm, the 2 cases was of the completetype.


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The average width of our 20cases :

showed an average of 23.1mm forwidth of the repaired side compared to23.2 mm of the non cleft side, thus a

narrower lip by average of 1 mm.


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Flattening of ala nasii leading to a height of thenostril on the repaired side less than the noncleft side was in 3 cases (15% of cases) withaverage nasal height on the repaired side

being less than the non cleft side by 1.4mm in all20 cases.

A wider nostrilwas seen in 4 cases (20% ofcases) on the cleft side, with an average of 1.7mm.


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We conclude that the neonatal cleft liprepair can safely be done in a highlyequipped and specialized center inneonatal surgery

with all available facilities as regardsincubators, specialized nurses, monitors,

neonatal anesthesia, warm blankets , highlyequipped operating theaters and availableblood bank for safe surgery.


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We recommend a long term follow up of thecases

(one year follow up is not enough).

We recommend increasing the practice ofneonatal cleft lip repair in Egypt togetherwith multi specialties team

including anesthetist, surgeon, specialized nurseand neonatologist.


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cleft surgeons must be perfectionistsFree to aspire

Willing to work in millimeters

For the best possible resultsD. Ralph Millard M.D


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late onset pyloric stenosis