Surgical Emergencies in the Newborn

Surgical Emergencies in the Newborn
University of North Carolina at Chapel Hill
Pediatric Surgery Division
Patty Lange

Emergencies
* Types
o Airway/Respiratory
o Intestinal Obstruction
o Intestinal Perforation
* Signs
o Respiratory distress
o Abdominal distension
o Peritonitis
o Pneumoperitoneum

Airway/Respiratory
* Neck Masses
* Thoracic masses/pulmonary lesions

Cystic Hygroma
* Multiloculated cystic spaces lined by endothelial cells
* Incidence about 1 in 12,000 births
* Complications
* Treatment
* Postnatal overdistension of one or more lobes of histologically normal lung
* Location

Congenital Lobar Emphysema
* Diagnosis
* Treatment

Congenital Cystic Adenomatous Malformation (CCAM)
* Mass of cysts lined by ciliated cuboidal or columnar pseudostratified epithelium
* Three types
* More common on the left side, 2% bilateral

CCAM
* Diagnosis
* Treatment
Congenital Diaphragmatic Hernia
* Intro
* DX
* Treatment
Tracheoesophageal Fistula and Esophageal Atresia
Intestinal Obstruction
Anatomic Differentiation
* Upper GI
* Lower GI
Anatomic Differentiation
Urgency to Treat
* Emergencies
* Further workup
Common Disorders
* NEC
* Duodenal Atresia
* Small Bowel Atresia
* Malrotation/Volvulus
* Hirschsprung’s
* Presentation

NEC Treatment
* Medical
* Surgical indications
NEC Outcomes
* Overall survival ~ 80%, improving in LBW
* In pts w/perforation, 65% perioperative mortality, no perf--30% mortality
* 25% of Survivors develop stricture
* 6% pts have recurrent NEC
* Postop NEC--Myelomeningocele, Gastroschisis--45-65% mortality

Pneumatosis
Pneumoperitoneum
NEC--Abd Distension/Erythema
Necrotic Segment Ileum
Resection
Specimen--Ileocecectomy
Ileostomy
Common Disorders
* NEC
* Duodenal Atresia
* Small Bowel Atresia
* Malrotation
* Hirschsprung’s

Duodenal Atresia
* Incidence--1 in 5,000 to 10,000 live births
* 75% of stenoses and 40% of atresias are found in Duodenum
* Multiple atresias in 15% of cases
* 50% pts are LBW and premature
* Polyhydramnios in 75%
* Bilious emesis usually present
* Associated Anomalies

Duodenal Atresia Diagnosis
* Radiographs
* Workup of potential associated anomalies
“Double Bubble”
Duodenal Atresia Treatment
* Nasogastric decompression, hydration
* Surgery
Common Disorders
* NEC
* Duodenal Atresia
* Small Bowel Atresia
* Malrotation
* Hirschsprung’s

Small Bowel Atresia
* Jejunal is most common, about 1 per 2,000 live births
* Atresia due to in-utero occlusion of all or part of the blood supply to the bowel
* Classification--Types I-IV
* Presents w/bilious emesis, abd distension, failure to pass meconium (70%)

Intestinal Atresia Classification
* Associated Anomalies
o other atresias
o Hirschsprung’s
o Biliary atresia
o polysplenia syndrome (situs inversus, cardiac anomalies, atresias)
o CF (10%)

Atresia--Diagnosis and Treatment
* Plain films show dilated loops small bowel
* Contrast enema shows small unused colon
* UGI/SBFT shows failure of contrast to pass beyond atretic point
* Treatment is surgical

Common Disorders
* NEC
* Duodenal Atresia
* Small Bowel Atresia
* Malrotation/Volvulus
* Hirschsprung’s

Malrotation
* 1 per 6,000 live births
* can be asymptomatic throughout life
* Usually presents in first 6 months of life
* 18% children w/short gut had malrotation with volvulus
* Etiology
o physiologic umbilical hernia--4th wk gestation
o Reduction of hernia 10th - 12th wks of gestation

Normal Embryology
Malrotation Classification
* Nonrotation
* Abn Rotation of Duodenojejunal limb
* Abn rotation of Cecocolic limb

Abnormal Rotation/Fixation
Malrotation Diagnosis
* Varying symptoms from very mild to catastrophic
* **Bilious emesis is Volvulus until proven otherwise**
* Bilious emesis, bloody diarrhea, abd distension, lethargy, shock
* UGI shows abnormal position of Duodenum
o if Volvulus, see “bird’s beak” in duodenum

Malrotation UGI
Intraop Volvulus
Bowel Necrosis--Volvulus
Malrotation--Treatment
* Surgical--Ladd’s Procedure
Common Disorders
Hirschsprung’s Disease
* Migratory failure of neural crest cells
* Incidence 1 in 5,000 live births, males affected 4:1 over females
* 90% of pts w/H’sprung’s fail to pass meconium in first 24-48 hrs
* Abd distension, bilious emesis, obstructive enterocolitis
Hirschsprung’s Diagnosis
* Barium Enema
* Anorectal Manometry
* Rectal Biopsy

Transition Zone on BE
Hirschsprung’s Treatment
Pull-Through Procedure
Summary
* BILIOUS EMESIS IS VOLVULUS UNTIL PROVEN OTHERWISE
* Signs of surgical emergency
o free air, abd wall cellulitis, fixed loop on xray, rapid distension, peritonitis, clinical deterioration
* History and plain films will guide sequence of additional studies
* Remember associated anomalies

Surgical Emergencies in the Newborn.ppt