11/2/2013

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Pediatric SurgeryNICU Cases

Pediatric Surgery

• Goals and Objectives:

– Introduction to pediatric surgical cases seen

in the NICU

• Scope of Practice

• Common Cases & Congenital Anomalies

• Discuss Pre-op and Post-op considerations

This Lecture

• Case Based

• Informal

• Interactive

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Case #1

• Former 30 week EGA

• Now DOL 14

• Just achieved full feeds

• Develops feeding

intolerance, abdominal

distention, and bloody

stools.

Case #1

Reference Film Case Film

Necrotizing Enterocolitis

• Most common GI emergency in neonates

• Clinical findings:– Abdominal distention,

gastrointestinal bleeding, and pneumatosis intestinalis

• Risk factors include:– prematurity

– congenital heart disease

– neonatal distress

– enteral feeding

• Mortality 20-40%, higher for pan-intestinal necrosis

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Indications for Operative Intervention

in Necrotizing Enterocolitis

• Absolute

• Pneumoperitoneum

• Peritonitis

• Clinical deterioration

• Sepsis refractory to

medical therapy

• Intestinal obstruction

or stricture

• Relative

• Abdominal wall

erythema

• Fixed loop of intestine

• Portal venous gas

• Positive paracentesis

• Thrombocytopenia

Nursing Considerations

• GI decompression

• IV access

– Initiation of abx

– Transfusion of blood products

– Serial labs

• Bedside laparotomy

Case #2

• A 2 day old girl

develops bilious

emesis.

– Tolerated initial feeds

• What is the

diagnosis?

• Do you need another

study?

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Case #2

• Limited upper GI

series

Malrotation w/ Volvulus

• Bilious emesis in a child < 1 year is malrotation with midgut volvulus until proven otherwise

• Upper gastrointestinal contrast series and urgent operation are indicated

Normal Rotational Anatomy

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360º Counterclockwise Detorsion

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Second 360º Counterclockwise Detorsion

Nursing Considerations

• GI Decompression

• Prepare the child for transport

– Radiology

– OR

• Post-op

– Resumption of bowel activity may take up to a

week

Case #3

• A newborn girl develops

vomiting of bile stained fluid in

the first few hours of life.

• Prenatal ultrasonography

demonstrated polyhydramnios.

Her abdominal radiograph is

shown.

• What is the diagnosis? What

other anomalies are

associated with this problem?

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Duodenal Atresia

• Duodenal obstruction results from webs or atresias, thought to be caused by failure of recannalization in weeks 8-10 of development

• 50% have cardiac, genitourinary, anorectal, or esophageal abnormalities

• Up to 40% have trisomy 21 and 30% have malrotation

• Most atresias are post-ampullary

• Operate early if malrotation suspected

• Surgical treatment is web excision or duodenoduodenostomy with or without tapering

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Duodenal Web

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Duodenal Web

Case #4

• Newborn infant

• Polyhydramnios

• Bilious Emesis

Jejunal and Ileal Atresias

• Jejunal and ileal

atresias are caused by

intra-uterine vascular

evens

• 10% are multiple

• Surgical treatment

involves resection of

stenotic or dilated bowel

and anastomosis with or

without tapering

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Type I

Type II

Type III

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Case #5

• Term 3kg female with

antenatal dx of cystic

fibrosis

– Prenatal US revealed

distended echogenic

bowel

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Meconium Ileus

• Distal intestinal obstruction due to abnormally

thick meconium

– Most commonly occurs in infants with cystic fibrosis

• 20% infants with CF will have meconium ileus

• Most infants with MI will have CF

• Cystic Fibrosis

– Autosomal recessive

– Defect in the gene for CFTR

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Meconium Ileus

• Treatment

– Contrast enema

– Operative Decompression

• Nursing Considerations

– Pre-op: GI Decompression

– Post-Op: intestinal

irrigation, enzyme

replacement

Case #6

• A newborn develops progressive abdominal distention

• Does not pass meconium at 36 hours of life.

• Perineal exam reveals a patent anus

• Catheter introduction produces an explosive discharge of gas and meconium.

• Contrast enema is show at left.

• What is the diagnosis?

Hirschsprung’s Disease

• Failure of migration of ganglion cells to the hindgut– Continuous segment of intestine, beginning at anorectal junction

• Submucosal (Meissner’s) plexus and intermuscular (Auerbach’s) plexus involved

• Transition most commonly in recto-sigmoid area

• RET mutations in 50% of familial and 15-20% of sporadic cases

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Hirschsprung’s Disease• 1 in 5000 newborns affected (70-80% male)

– 3 – 16% have trisomy 21

– 11 – 30 % have associated anomalies (urogenital, cardiac, and gastrointestinal most common)

• Failure to pass meconium, abdominal distention, and vomiting in newborns

• Chronic constipation in older children

• Diagnosis via contrast enema and rectal biopsy– Hypertrophied nerves and increased acetylcholinesterase staining

– Negative Calretinin staining

• Treatment with endorectal pull-through with or without colostomy

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Nursing Considerations

• Pre-op

– GI decompression

– Avoid rectal stimulation immediately prior

contrast enema

– Serial colonic irrigations pre-op

• Post-op

– Sign over bed “Nothing per rectum”

Case #7

• A newborn is noted to have excessive oral secretions

• Feeding produces respiratory distress.

• A nasogastric tube is passed, and resistance is met.

• The radiograph at left is obtained.

• What is the diagnosis?

Esophageal Atresia and

Tracheoesophageal Fistula

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VACTERL Syndrome• Vertebral abnormalities: (70%) hypoplastic or

hemivertebrae, risk for scoliosis

• Anal abnormalities: (55%) anal atresia, imperforate anus

• Cardiac anomalies: (66%) ASD, VSD, tetralogy of Fallot

• Tracheoesophageal fistula / esophageal atresia: (70%)

• Renal anomalies: (50%) renal agenesis, horseshoe kidney, vesicoureteral reflux, hypoplastic or dysplasic kidneys

• Limb anomalies: (70%) missing or displaced digits, polydactyly, syndactyly, forearm defects

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Two Cases of Esophageal Atresia

– What’s the difference?

Part 3

• Newborn with feeding

difficulties

– Apnea and

bradycardia with feeds

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H-Type Fistula

Cephalad

Posterior

Nursing Considerations

• Pre-op

– Decompression of the upper pouch

• Post-op

– Chest tube

– OGT in place across the esophageal

anastomosis

– Position of ETT is critical

• May be above or below the tracheal repair

• Avoid emergent re-intubation

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Abdominal Wall Defects

Abdominal Wall Defects

Abdominal Wall Defects

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Abdominal Wall Defects

• Gastroschisis

– “Bad bowel, good baby”

– Defect to right of

umbilicus

– No sac, bowel

edematous with variable

peel

– 15% have intestinal

atresia

– Slow return of bowel

function

• Omphalocele

– “Good bowel, bad baby”

– Midline defect

– Sac contains abdominal

contents

– 66% associated

anomalies, 50% cardiac

and 40% chromosomal

– Prognosis depends on

associated anomalies

Questions?