OVERVIEW OF NEONATAL

SURGERY

ANNE ASPIN2010

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 gastro- oesophageal reflux

Thick n easy, Thix od Gaviscon Erythromycin Domperidone Ranitidine Omeprazole