neonatal stomas why, how and where...•management depends on level of arm •broad spectrum...
TRANSCRIPT
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Neonatal StomasWhy, How and Where
Jonathan Wells
Locum Paediatric Surgeon
Christchurch Hospital
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•Conditions requiring stomas
•Duration of need for stoma
•Specific concerns of stoma
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Why
•Gastrointestinal (GI)
•Genitourinary
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Congenital and Neonatal GI Indications
• Anorectal malformation
• Necrotising enterocolitis
• Hirschsprung disease
• Malrotation with volvulus
• Meconium ileus
• Intestinal atresia
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Anorectal malformation
• 1 in 4000 births
• Management depends on level of ARM• Broad spectrum
• Primary anoplasty for low
• Stoma and delayed reconstruction for high• Recto-urethral fistula most common in boys
• Recto-vestibular fistula most common in girls
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Anorectal malformation - Male
From: Carachi et al, 2013, Basic Techniques in Paediatric Surgery
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Recto vestibular fistula – Female
From: Carachi et al, 2013, Basic Techniques in Paediatric Surgery
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Surgical Management
• Alberto Pena
• 3 stage procedure• Split sigmoid colostomy – at birth
• Posterior sagittal anorectoplasty – PSARP• Approx 3-6 months post birth
• Stoma closure – 3 months post PSARP
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Split proximal sigmoid colostomy
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Loop sigmoid colostomy
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Prolapsed loop ileostomy
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Complex ARM with neurogenic bladder
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Distal loopogram
From: Carachi et al, 2013, Basic Techniques in Paediatric Surgery
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Posterior sagittal anorectoplasty - female
From: Carachi et al, 2013, Basic Techniques in Paediatric Surgery
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Posterior sagittal anorectoplasty - female
From: Carachi et al, 2013, Basic Techniques in Paediatric Surgery
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Stoma closure
• Dilatation of neoanus 2 weeks after repair
• Dilatation 1-2 day, increasing size till achieve adequate calibre
• Stoma closed approx. 3 months later
• Total duration of stoma 6 months – 1 year
• Generally uncomplicated post closure
• Perianal Skin excoriation – barrier cream
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Necrotising Enterocolitis – NEC
• 90% in preterm 10% in term babies
• 2-14% of all babies admitted to Neonatal Unit
• Multifactorial pathogenesis• Inflammation and coagulative necrosis
• 20-40% require surgery• Up to 50% mortality reported in those requiring surgery
• Worst outcome extremely low weight preterm babies
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Clinical Signs – NEC
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Radiological signs
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Necrotising Enterocolitis
• Surgery indicated for:• Worsening clinical condition despite maximal supportive therapy
• Perforation
• Laparotomy• Assess extent of disease – may be total gut necrosis
• Resection anastomosis – if appropriate
• Resection and stomas
• ‘Clip and drop’
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Malrotation of midgut
• 1 in 6000 babies present as an emergency• 0.5% of autopsies show degree of malrotation
• SURGICAL EMERGENCY
• Bilious vomiting in neonate
• Upper GI contrast to diagnose – only if stable
• Emergency laparotomy to devolve bowel
• Total gut necrosis – life threatening
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Malrotation of midgut
• 1 in 6000 babies present as an emergency• 0.5% of autopsies show degree of malrotation
• SURGICAL EMERGENCY
• Bilious vomiting in neonate
• Upper GI contrast to diagnose – only if stable
• Emergency laparotomy to devolve bowel
• Total gut necrosis – life threatening
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Normal Rotation Malrotation
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Contrast study
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Malrotation + volvulus – Total Gut Necrosis
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Where is the stoma?
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Vital to know anatomy
• If proximal stoma – jejunostomy• LESS absorptive capacity
• LESS ability to tolerate feeds
• Damaged but recovering bowel
• Risk of high stoma output
• DO NOT tolerate high stoma output• 20-30mL/Kg/day
• Monitor effluent for fats and reducing substances
• Monitor growth – weight gain
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Stoma in the wound?
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Small bowel atresia
• 1 in 5000 births
• Aetiology – antenatal vascular compromise
• May be in jejunum or ileum
• May have short bowel
• Resection and anastomosis• May be multiple
• May require tapering
• May be end to end or end to side depending on discrepancy
• May require stoma
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Abdominal X-ray – intestinal atresia
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Types of small bowel atresia
• Stenosis – 11%
• Type 1 – 23%
• Type 2 – 10%
• Type 3 – 35%
• Type 4 – 21%
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Type 3A Type 3B
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Hirschsprung Disease
• 1 in 5000 births
• M:F 4:1
• Associated with Trisomy 21
• Delayed passage of meconium >48hours
• Abdominal distension
• Vomiting – may be bilious
• Diagnosis – rectal biopsy• Aganglionosis, thickened nerve trunks, increased acetylcholinesterase
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Hirschsprung Disease
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Hirschsprung Disease
• Variable failure of neural crest cell migration• Rectosigmoid – 75%
• Long (colonic) segment – 15%
• Total colonic – 5-7%
• Total interstinal – <5%
• Spastic bowel – failure to relax
• Requires decompression – rectal washouts
• Definitive surgery – pullthrough of ganglionic bowel
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Need for stoma in Hirschsprung disease
• Failure to decompress with rectal washouts
• Associated comorbidities
• ‘long segment’ – ‘levelling stoma’• Colostomy
• Ileostomy
• Jejunostomy
• Generally not needed
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Meconium Ileus
• CF – 1 in 2500 births
• ~16% of babies with CF
• Inspissated sticky meconium• Distal small bowel obstruction
• May be complicated
• Microcolon on contrast enema• may be therapeutic
• Contrast enema
• Laparotomy and washout of bowel +/- stoma
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Microcolon in Meconium ileus
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Need for ileostomy
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Congenital Genitourinary Causes
• Posterior urethral valves
• ‘Prune Belly’ or Eagle-Barrett syndrome
• Cloacal Exstrophy
• Neuropathic bladder• Spina bifida
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Posterior urethral valves
• Congenital obstruction of posterior urethra by ‘valve’
• Generally picked up antenatally• Dilated kidneys, ureters and bladder
• Neonatal cystoscopy to divide valves
• Associated with chronic renal failure
• May rarely need vesicostomy:• Low birthweight baby – unable to cystocope
• Thick walled bladder which does not empty
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Normal PUV
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Prune Belly / Eagle-Barrett syndrome
• 1 in 40,000 births, majority boys
• Absent or weak abdominal wall muscles
• Dilated and obstructed renal tract• Kidneys• Ureters• Urethra
• If urethral obstruction• Dilate urethra• Vesicostomy
• Associated renal impairment
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Prune belly - vesicostomy
Vesicostomy drains into nappy
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Cloacal Exstrophy
• Very rare – 1 in 300000 births
• Male and female
• Require:• Closure of abdomen
• Closure of bladder
• Closure of pelvis
• Reconstruction of genitalia
• Ileostomy
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Stoma complications
• Similar to adults
• Mechanical• Prolapse
• Retraction
• Stenosis (narrowing)
• Effluent• Skin excoriation
• Skin breakdown
• Appliance issues
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Summary
• Wide and complex neonatal reasons for stomas
• Vital to understand anatomy
• Vital to understand effluent
• Complications similar to adults
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Questions?