OVERVIEW OF NEONATAL SURGERY
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Transcript OVERVIEW OF NEONATAL SURGERY
OVERVIEW OF NEONATAL
SURGERY
ANNE ASPIN
2010
Gastroschisis
Defect lies to right of umbilicus
Central abdominal wall defect
No sac
Embryology
6TH Week intestine grows rapidly
Rotates and inverts by 10th week
Liver, bladder, stomach
Can be caused by vascular accident.
Incidence
Omphalocele 1 :4000
Gastroschisis 1:6000 – 10,000
Increasing over last 30 years
Common in young mums, <20yrs.
Associated anomalies
Gastro-intestinal tract, atresia,stenosis
Duplication cysts.
Feeding problems
Gastro-oesophageal reflux
Vomiting
Poor weight gain
Colic
Fractious, fussy, crying
Irregular bowel actions
NEC What is it?
Infection of the mucosal lining of the
bowel
Lactobacilli
Clostridium
Unknown
Who does it effect?
Maternal factors
prematurity
Hypoxic episodes
Cardiac anomaly
Exchange transfusion
Umbilical line near mesenteric artery
High osmolarity feeding
Increasing feeds quickly
Signs and symptoms
Change in behaviour
Subtle signs
Lethargy
Increasing naso-gastric aspirates
Labile temperature, labile blood sugars
Vomiting, bile later
Blood in stools
Abdominal distension
Later
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
Thrombocytopenia
Raised CRP
Pneumoperitoneum
Collapse, ventilation
Abdominal drain
Surgery, stoma’s
Short bowel
What to do
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
First case recorded Durston (1670)
Gibson (1697) first recorded with fistula
Ladd (1939) first staged repair
Height (1941) first successful primary
repair.
Survival
Survival rate of around 90%
Incidence 1: 4500
Antenatal diagnosis – polyhydramnios
and absent stomach 56% predictive of
OA.
After birth
Large NG tube
CXR, AXR
Replogle tube, 10 min suction to
pharynx
Associated anomalies
50% associated anomalies
Cardiac 29%
Vertebral, Anorectal, Cardiac, Tracheo,
Oesophageal, Renal, Limb
Table 1
Cardiovascular 29%
Gastro intestinal (anorectal 14%) 27%
Genito urinary 13%
Vertebral and skeletal 10%
Respiratory 6%
Genetic 4%
Primary repair
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
Anastomotic leak , 27%, 24 – 72hrs
Anastomotic stricture
Recurrent tracheo oesophageal fistula
Late complications
Tracheomalacia
Gastro oesophageal reflux
Respiratory problems
Motility disorders
Growth
Short Bowel Syndrome
Definition
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
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
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
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.
Increase gastric emptying.
Ileal resection, increased transit time
An intact IC valve prolongs gut transit, loss of
this causes an increase.
If colon resected transit increases.
How does the bowel adapt?
Cellular hyperplasia
Villous hypertrophy
Intestinal
lengthening
Altered motility
Hormonal changes
Takes approx 2
years to reach max
effect.
Central line complications
Infection
Thrombosis
Break in catheter
Air embolus
Tissue necrosis
Malposition
Cardiac tamponade
It takes approximately two years
to achieve some normal diet
Gastroschisis
NEC
Bowel atresia, stenosis, web,
duplication cyst
Meconium ileus
Jejunostomy, ileostomy, colostomy.
Bowel atresia, stenosis, web,
duplication cyst
Interruption in the bowel
Effects motility
Adhesive bowel obstruction
Nil by mouth again
Meconium ileus
Thick, sticky meconium, secretions
Perforation or not (Ileum)
Stoma
Absorption, enzymes, EBM
Jejunostomy
High stoma
Trophic feeding, EBM, Donor EBM
Electrolytes
Six weeks reversal
Ileostomy
High or low
Milk
Stomal diarrhoea
Electrolytes
Prolapse, inversion, sore, thrush
Failure to thrive
Colostomy
Milk
Prolapse, inversion, soreness,
Diarrhoea
Constipation
Electrolytes
Important issues
Temperature
Fluid and electrolytes
Glucose
Management of reflux
Speech and language therapy
family
Management of gastrooesophageal reflux
Thick n easy, Thix od
Gaviscon
Erythromycin
Domperidone
Ranitidine
Omeprazole