Surgical disorders in Newborn

Dr. Abhijeet Deshmukh

• Fetal surgical disorders:Polyhydramnios:

- 1:1000 birthsCauses:1. GI obstruction2. Abdominal wall defects Omphalocele, gastroschisis, diaphragmatic hernia, tight nuchal cord

• Oligohydramnios:Renal dysgenesis/ agenesis

• Meconium peritonitis:Antenatal perforation of GITIntestinal obstruction

• Fetal ascites:

Urinary tract anomalies – Posterior urethral valve, thoracic duct obstruction, hepatic/portal vein obstruction

• Postnatal surgical disorders:A. Respiratory distress:- Diaphragmatic hernia- Coanal atresia- Laryngeal clefts- Tracheal agenesis- Oesophageal atresia- Congenital lobar emphysema- Cystic adenomatoid malformation of lung

B. Scaphoid abdomen- Diaphragmatic hernia- EA without TEFC. Excessive mucus & salivation- EA with/ without TEFD. Abdominal distention- Pneumoperitonium

Causes are : NEC, bowel wall ischemia, instrumentation, TEF

E. Vomiting:1. Bilious emesis : Can be a life threatening emergency

20% require immediate surgical interventionCauses:- Malrotation with/ without volvulus- Duodenal/jejunal/ileal/colonic atresias

- Annular pancreas- Hirschprung disease- Preduodenal portal veins- Peritoneal bands- Persistent omphalomesenteric duct- Duodenal duplication- Decreased motility of intestine

2. Nonbilious emesis:- Excessive feeding- Milk intolerance- Sepsis- Lesions above ampulla of Veter

> Pyloric stenosis> Upper duodenal stenosis> Annular pancreas

F. Failure to develop transient stools:- volvulus- MalrotationG. Hematemesis/ Hematochezia:- Nonsurgical conditions :

> Milk intolerance> Instrumentation> Swallowed maternal blood

- Surgical conditions:> NEC (most frequent in premature infants)> Gastric/duodenal ulcers (stress/steroids)> Coagulation disorders (DIC/ Vit K def.)> Volvulus> GI obstructions> Intussuception> Polyps/ hemangiomas

> Meckel diverticulum> Duplication of small intestine

H. Abdominal mass :- GU abnormalities - Hepatosplenomegaly- TumorsI . Birth trauma:- Fractured clavicle- IC haemorrhages- Spinal cord transection

Lesions causing Respiratory distress

A. EA and TEF:- 85% association- Absence of stomach bubble

• Postnatal presentation- Excessive salivation & vomiting soon after birth- Scaphoid abdomen

• Diagnosis:- Inability to pass NG tube- Confirmed by X ray : coiled catheter ,

distended upper oesophagus after pushing air.

• Other associated anomalies:- Vertebral defects- Imperforate anus- Cardiac defects- Renal dysplasia- Limb anomalies

• Management:- Oro-nasal suction- Head end elevation -45 degree- Immediate gastrostomy tube placement.

Tracheo Esophageal Fistula (TEF)

• Incidence: 1:4000 live births

• M > F (25:3)

• 10-40% are preterm

• Antenatal history: polyhydramnios (60%)

• Etiology: failure in mesenchymal separation of upper foregut

• Clinical Presentation

choking on 1st feed

coughing

cyanosis

excessive salivation

aspiration pneumonia

• Diagnosis

• Inability to pass a suction catheter into the

stomach

• CXR: Coiled orogastric tube in the cervical

pouch, air in the stomach and intestine

Esophageal Atresia Tracheoesophageal Fistula

• 5 Types (Gross and Vogt)

7.7% 4.2% 0.8% 86% 0.7%0.7%

• 35-65% have associated anomalies

V Vertebral anomalies or VSD

A Anorectal malformation

C Cardiac anomalies (common)

T TEF

E Esophageal atresia

R Renal abnormalities

L Limb/radial malformation

Laboratory studies

CBC

Electrolytes

Glucose

Calcium

ABGs

- NPO

- IVF & Antibiotics

- Ensure availability of blood in the OT

- Optimize volume status and metabolic state

- Intubation preferably in the operating room under

controlled situation

- Echo

• Surgical repair

• Ligation of fistula

• Esophageal repair

– Chest tube placement and closure of

thoracic cavity

Diaphragmatic Hernia

- Most difficult of all neonatal emergencies- Most common site is left hemithorax.- Incidence 1 : 4000 live births- Associated with trisomies 13 & 18, 45 XO

Goldenhar syndrome,Backwith- Wiedmann synd.Pierre robin synd.Goltz-Gorlin synd.Rubella synd.

Classification• Absent diaphragm : rare• Diaphragmatic hernia

80% posterolateral L >R

(Bochdalek)

2% anterior (Morgagni)

15 - 20% paraesophageal• Eventration (15 - 20%)

• Symptoms :- Cyanosis at birth- Respiratory distress- Scaphoid abdomen- Decreased / absent breath sounds on hernial side- Shift of cardiac sounds opposite to the

hernia

• Diagnosis:1. Antenatal diagnosis –- Often undetected as it occurs mostly after 16 wks.- Presence of liver in the thorax asso with

increased severity & poor prognosis

2. Postnatal diagnosis:

X ray : cardiothymic shift

- loops of bowel in the chest

- mediastinal shift

- absent lung markings

• Treatment:- Immediate intubation- Bag & mask is contraindicated- immediate NG tube insertion & continuous suction.- Low pressure ventilation - to avoid damage to contra lateral lung.- Surgical repair with reduction of intestine into abdominal cavity.

Extracorporeal Membrane Oxygenation (ECMO)

• Use: controversial• Allows the lungs to develop & restructure• Expensive

Criteria for ECMO• Gestational age ≥ 34 wks• Weight ≥ 2000 grams

Predicted mortality ≥ 80%

• Associated anomalies (20-50%) :

cardiovascular 13 - 23%

CNS 28%

gastrointestinal 20%

genitourinary 15%

Anorectal malformations

Frequency

• 1 : 5000 live births

TYPES

• HIGH TYPE• LOW TYPE

Clinical Findings

• High type :– A flat perineum & lack of a midline gluteal fold – Absence of an anal dimple

• Low type :– the presence of meconium at the perineum, – A bucket-handle malformation – Anal membrane (through which meconium is visible).

INVERTOGRAM16-24 hours

A flat perineum

A flat perineum-GIRL

Perineal fistula

bucket-handle malformation

Associated malformations

Genitourinary :- Absent, dysplastic, or horseshoe

kidneys- Vesicoureteral reflux- Hydronephrosis- Hypospadias- Bifid scrotum

Skeletal System :• Partial or complete lumbosacral agenesis• Hemivertebrae• Agenesis of thoracic vertebrae• Scoliosis• Hemisacrum or scimitar sacrum• Asymmetric sacrum• Posterior protruding sacrum• Agenesis of the coccyx

Spinal anomalies :• Tethered cord• Dural sac stenosis• Narrow spinal canal• Myelomeningocele, meningocele• Intraspinal teratoma• Neurogenic bladder

Gastrointestinal and Cardiovascular Systems

• VATER and VACTERL associations:– Esophageal atresia– Duodenal atresia– Ventricular or atrioseptal defects– Tetrology of Fallot– Hirschsprung's disease

Surgical therapy

• Colostomy• Definitive repair

Colostomy Newborn boys

• Rectobulbar urethral fistula• Rectoprostatic urethral fistula• Rectovesical fistula• Imperforate anus without fistula• Rectal atresia

Newborn girls Colostomy -

• Rectovestibular fistula• Imperforate anus without fistula• Persistent cloaca• Rectal atresia• Rectovaginal fistula

COLOSTOMY

Definitive repair

• Anoplasty : Indications– Rectoperineal fistula - girls & boys– Covered anus– Bucket-handle malformation

• posterior sagittal ARP• Laprotomy

PSARP

Outcome after surgery

• Altered bowel habits in most of the cases• 50% - few episodes of accidental soilage • Few of them require major adjustments in lifestyle

secondary to fecal incontinence, chronic constipation, and odor.

Necrotizing Enterocolitis

(NEC)

• Life-threatening intestinal inflammation or injury

• Caused by bacterial invasion of previously injured

or ischemic bowel wall

• Incidence: 5 -10% in infants <1500g birth weight

• Mortality rate: 10 - 30%

• Single most important factor

PREMATURITY

• Can occur in:

LBW infants

Full term infants

Fed and unfed infants

• Other factors

- ischemia

- bacterial infection

- GI endotoxemia

- enteral feeding

- use of hyperosmolar formula

- congenital heart disease

- umbilical arterial catheterization

- exchange transfusion

Early signs

- ↑ gastric residuals with feedings

- temperature instability

- poor feeding

- bilious vomiting

- lethargy

- mucoid or bloody stool

- apnea and bradycardia

• Late Signs

• Hemodynamic instability

• Anemia

• Thrombocytopenia

• Coagulopathy, DIC

• Prerenal azotemia

• Metabolic acidosis

Physical Examdistended and tender abdomen

Labs: CBCelectrolytes and glucoseplatelets and coagulation profile DIC profileABG

Abdominal X-ray• signs of bowel obstruction• Ileus with edematous bowel• Pneumatosis intestinalis or

intramural air (arrow)• Air in portal vein• pneumoperitoneum

Medical Management

• No enteral feedings for 10-14 days

• NGT on intermittent suction

• Hydration and correction of electrolytes

• Ventilatory support

• Antibiotics

• Blood and platelet transfusion if needed

• Surgical Indications

Absolute Indications

1) bowel perforation

2) intestinal gangrene

• Relative Indications– metabolic acidosis– respiratory failure– oliguria, hypovolemia– thrombocytopenia– leucopenia, leukocytosis – air in the portal vein– bowel wall edema– persistent dilated bowel loops

• Non-Surgical Indications

severe GI hemorrhage

abdominal tenderness

intestinal obstruction

gasless abdomen with ascites

Thank You!