Transcript OVERVIEW OF NEONATAL SURGERY

OVERVIEW OF NEONATAL
SURGERY
ANNE ASPIN
2010
Gastroschisis
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Defect lies to right of umbilicus
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Central abdominal wall defect
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No sac
Embryology
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6TH Week intestine grows rapidly
Rotates and inverts by 10th week
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Liver, bladder, stomach
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Can be caused by vascular accident.
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Incidence
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Omphalocele 1 :4000
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Gastroschisis 1:6000 – 10,000
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Increasing over last 30 years
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Common in young mums, <20yrs.
Associated anomalies
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Gastro-intestinal tract, atresia,stenosis
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Duplication cysts.
Feeding problems
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Gastro-oesophageal reflux
Vomiting
Poor weight gain
Colic
Fractious, fussy, crying
Irregular bowel actions
NEC What is it?
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Infection of the mucosal lining of the
bowel
Lactobacilli
Clostridium
Unknown
Who does it effect?
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Maternal factors
prematurity
Hypoxic episodes
Cardiac anomaly
Exchange transfusion
Umbilical line near mesenteric artery
High osmolarity feeding
Increasing feeds quickly
Signs and symptoms
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Change in behaviour
Subtle signs
Lethargy
Increasing naso-gastric aspirates
Labile temperature, labile blood sugars
Vomiting, bile later
Blood in stools
Abdominal distension
Later
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Mottled, grey, capillary refill <4 secs
Apnoeic
Bradycardia
Oxygen requirement
Abdominal tenderness
Oedema
Dilated abdominal veins, dilated loops of
bowel
Flare around umbilicus
Even later
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Thrombocytopenia
Raised CRP
Pneumoperitoneum
Collapse, ventilation
Abdominal drain
Surgery, stoma’s
Short bowel
What to do
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Large ng tube, aspirate and free
drainage
Nil by mouth
IVI, Antibiotics
Blood sugar monitoring
Sepsis screen. Blood gas, FBC, U/E’s,
Blood cultures
Urine MC/S, CXR, AXR
Types of oesophageal atresia
and fistula
86%
7%
4%
Types continued
1%
<
<
1
1
History
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First case recorded Durston (1670)
Gibson (1697) first recorded with fistula
Ladd (1939) first staged repair
Height (1941) first successful primary
repair.
Survival
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Survival rate of around 90%
Incidence 1: 4500
Antenatal diagnosis – polyhydramnios
and absent stomach 56% predictive of
OA.
After birth
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Large NG tube
CXR, AXR
Replogle tube, 10 min suction to
pharynx
Associated anomalies
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50% associated anomalies
Cardiac 29%
Vertebral, Anorectal, Cardiac, Tracheo,
Oesophageal, Renal, Limb
Table 1
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Cardiovascular 29%
Gastro intestinal (anorectal 14%) 27%
Genito urinary 13%
Vertebral and skeletal 10%
Respiratory 6%
Genetic 4%
Primary repair
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Paralyse and ventilate 5 days post op
Long gap – gastrostomy and
assessment of gap, may leave 6 – 12
weeks before primary closure.
Gap of more than 6-8 vertebrae,
oesophageal replacement
Post operation- early
complications
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Anastomotic leak , 27%, 24 – 72hrs
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Anastomotic stricture
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Recurrent tracheo oesophageal fistula
Late complications
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Tracheomalacia
Gastro oesophageal reflux
Respiratory problems
Motility disorders
Growth
Short Bowel Syndrome
Definition
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Rickham (1967) – an extensive resection to
maximum of 75cm
Kuffer (1972) – 15cm with ileocaecal valve
- 38cm without ileocaecal valve
Dorney (1985) – 11cm with I/C valve or 25cm
without I/C valve
Introduction
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Most common cause of intestinal
failure.
NEC, Congenital atresia, Gastroschisis
and volvulus.
Promote adaptive response through
enteral feeding and careful
management of TPN.
What is SBS
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Reduced bowel surface area for
absorption of nutrients together with
rapid transit of intestinal contents.
TPN reduced as enteral feeds are
introduced.
Need to promote intestinal adaptation.
Motility
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The IC valve and colon is important to
slow intestinal transit.
Proteins, Fats and Carbohydrates are
absorbed almost completely within first
150cm of small bowel.
After resection.
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Increase gastric emptying.
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Ileal resection, increased transit time
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An intact IC valve prolongs gut transit, loss of
this causes an increase.
If colon resected transit increases.
How does the bowel adapt?
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Cellular hyperplasia
Villous hypertrophy
Intestinal
lengthening
Altered motility
Hormonal changes
Takes approx 2
years to reach max
effect.
Central line complications
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Infection
Thrombosis
Break in catheter
Air embolus
Tissue necrosis
Malposition
Cardiac tamponade
It takes approximately two years
to achieve some normal diet
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Gastroschisis
NEC
Bowel atresia, stenosis, web,
duplication cyst
Meconium ileus
Jejunostomy, ileostomy, colostomy.
Bowel atresia, stenosis, web,
duplication cyst
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Interruption in the bowel
Effects motility
Adhesive bowel obstruction
Nil by mouth again
Meconium ileus
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Thick, sticky meconium, secretions
Perforation or not (Ileum)
Stoma
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Absorption, enzymes, EBM
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Jejunostomy
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High stoma
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Trophic feeding, EBM, Donor EBM
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Electrolytes
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Six weeks reversal
Ileostomy
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High or low
Milk
Stomal diarrhoea
Electrolytes
Prolapse, inversion, sore, thrush
Failure to thrive
Colostomy
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Milk
Prolapse, inversion, soreness,
Diarrhoea
Constipation
Electrolytes
Important issues
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Temperature
Fluid and electrolytes
Glucose
Management of reflux
Speech and language therapy
family
Management of gastrooesophageal reflux
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Thick n easy, Thix od
Gaviscon
Erythromycin
Domperidone
Ranitidine
Omeprazole