OVERVIEW OF NEONATAL SURGERY

1
OVERVIEW OF NEONATAL SURGERY

• ANNE ASPIN
• 2005

2
Gastroschisis

• Defect lies to right of umbilicus
• Central abdominal wall defect
• No sac

3
Embryology

• 6TH Week intestine grows rapidly
• Rotates and inverts by 10th week
• Liver, bladder, stomach
• Can be caused by vascular accident.

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Incidence

• Omphalocele 1 4000
• Gastroschisis 16000 10,000
• Increasing over last 30 years
• Common in young mums, lt20yrs.

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Associated anomalies

• Gastro-intestinal tract, atresia,stenosis
• Duplication cysts.

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Feeding problems

• Gastro-oesophageal reflux
• Vomiting
• Poor weight gain
• Colic
• Fractious, fussy, crying
• Irregular bowel actions

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NEC What is it?

• Infection of the mucosal lining of the bowel
• Lactobacilli
• Clostridium
• Unknown

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Who does it effect?

• Maternal factors
• prematurity
• Hypoxic episodes
• Cardiac anomaly
• Exchange transfusion
• Umbilical line near mesenteric artery
• High osmolarity feeding
• Increasing feeds quickly

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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

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Later

• Mottled, grey, capillary refill lt4 secs
• Apnoeic
• Bradycardia
• Oxygen requirement
• Abdominal tenderness
• Oedema
• Dilated abdominal veins, dilated loops of bowel
• Flare around umbilicus

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Even later

• Thrombocytopenia
• Raised CRP
• Pneumoperitoneum
• Collapse, ventilation
• Abdominal drain
• Surgery, stomas
• Short bowel

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What to do

• Large ng tube, aspirate and free drainage
• Nil by mouth
• IVI, Antibiotics
• Blood sugar monitoring
• Sepsis screen. Blood gas, FBC, U/Es, Blood
  cultures
• Urine MC/S, CXR, AXR

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Types of oesophageal atresia and fistula
86
7
4
14
Types continued
1
lt1
lt1
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History

• First case recorded Durston (1670)
• Gibson (1697) first recorded with fistula
• Ladd (1939) first staged repair
• Height (1941) first successful primary repair.

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Survival

• Survival rate of around 90
• Incidence 1 4500
• Antenatal diagnosis polyhydramnios and absent
  stomach 56 predictive of OA.

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After birth

• Large NG tube
• CXR, AXR
• Replogle tube, 10 min suction to pharynx

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Associated anomalies

• 50 associated anomalies
• Cardiac 29
• Vertebral, Anorectal, Cardiac, Tracheo,
  Oesophageal, Renal, Limb

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Table 1

• Cardiovascular 29
• Gastro intestinal (anorectal 14) 27
• Genito urinary 13
• Vertebral and skeletal 10
• Respiratory 6
• Genetic 4

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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

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Post operation- early complications

• Anastomotic leak , 27, 24 72hrs
• Anastomotic stricture
• Recurrent tracheo oesophageal fistula

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Late complications

• Tracheomalacia
• Gastro oesophageal reflux
• Respiratory problems
• Motility disorders
• Growth

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Short Bowel Syndrome
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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

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Introduction

• Most common cause of intestinal failure.
• NEC, Congenital atresia, Gastroschisis and
  volvulus.
• Promote adaptive response through enteral feeding
  and careful management of TPN.

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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.

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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.

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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.

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How does the bowel adapt?

• Cellular hyperplasia
• Villous hypertrophy
• Intestinal lengthening
• Altered motility
• Hormonal changes
• Takes approx 2 years to reach max effect.

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Central line complications

• Infection
• Thrombosis
• Break in catheter
• Air embolus
• Tissue necrosis
• Malposition
• Cardiac tamponade

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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.

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Bowel atresia, stenosis, web, duplication cyst

• Interruption in the bowel
• Effects motility
• Adhesive bowel obstruction
• Nil by mouth again

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Meconium ileus

• Thick, sticky meconium, secretions
• Perforation or not (Ileum)
• Stoma
• Absorption, enzymes, EBM

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Jejunostomy

• High stoma
• Trophic feeding, EBM, Donor EBM
• Electrolytes
• Six weeks reversal

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Ileostomy

• High or low
• Milk
• Stomal diarrhoea
• Electrolytes
• Prolapse, inversion, sore, thrush
• Failure to thrive

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Colostomy

• Milk
• Prolapse, inversion, soreness,
• Diarrhoea
• Constipation
• Electrolytes

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Important issues

• Temperature
• Fluid and electrolytes
• Glucose
• Management of reflux
• Speech and language therapy
• family

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Management of reflux

• Thick n easy, Thix od
• Gaviscon
• Erythromycin
• Domperidone
• Ranitidine
• Omeprazole