Surgical emergencies in newborn
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Surgical disorders in Newborn
Dr. Abhijeet Deshmukh
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• Fetal surgical disorders:Polyhydramnios:
- 1:1000 birthsCauses:1. GI obstruction2. Abdominal wall defects Omphalocele, gastroschisis, diaphragmatic hernia, tight nuchal cord
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• Oligohydramnios:Renal dysgenesis/ agenesis
• Meconium peritonitis:Antenatal perforation of GITIntestinal obstruction
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• Fetal ascites:
Urinary tract anomalies – Posterior urethral valve, thoracic duct obstruction, hepatic/portal vein obstruction
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• Postnatal surgical disorders:A. Respiratory distress:- Diaphragmatic hernia- Coanal atresia- Laryngeal clefts- Tracheal agenesis- Oesophageal atresia- Congenital lobar emphysema- Cystic adenomatoid malformation of lung
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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
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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
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- Annular pancreas- Hirschprung disease- Preduodenal portal veins- Peritoneal bands- Persistent omphalomesenteric duct- Duodenal duplication- Decreased motility of intestine
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2. Nonbilious emesis:- Excessive feeding- Milk intolerance- Sepsis- Lesions above ampulla of Veter
> Pyloric stenosis> Upper duodenal stenosis> Annular pancreas
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F. Failure to develop transient stools:- volvulus- MalrotationG. Hematemesis/ Hematochezia:- Nonsurgical conditions :
> Milk intolerance> Instrumentation> Swallowed maternal blood
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- 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
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> Meckel diverticulum> Duplication of small intestine
H. Abdominal mass :- GU abnormalities - Hepatosplenomegaly- TumorsI . Birth trauma:- Fractured clavicle- IC haemorrhages- Spinal cord transection
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Lesions causing Respiratory distress
A. EA and TEF:- 85% association- Absence of stomach bubble
• Postnatal presentation- Excessive salivation & vomiting soon after birth- Scaphoid abdomen
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• 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
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• Management:- Oro-nasal suction- Head end elevation -45 degree- Immediate gastrostomy tube placement.
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Tracheo Esophageal Fistula (TEF)
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• 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
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• Clinical Presentation
choking on 1st feed
coughing
cyanosis
excessive salivation
aspiration pneumonia
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• Diagnosis
• Inability to pass a suction catheter into the
stomach
• CXR: Coiled orogastric tube in the cervical
pouch, air in the stomach and intestine
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Esophageal Atresia Tracheoesophageal Fistula
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• 5 Types (Gross and Vogt)
7.7% 4.2% 0.8% 86% 0.7%0.7%
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• 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
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Laboratory studies
CBC
Electrolytes
Glucose
Calcium
ABGs
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- 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
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• Surgical repair
• Ligation of fistula
• Esophageal repair
– Chest tube placement and closure of
thoracic cavity
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Diaphragmatic Hernia
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- 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.
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Classification• Absent diaphragm : rare• Diaphragmatic hernia
80% posterolateral L >R
(Bochdalek)
2% anterior (Morgagni)
15 - 20% paraesophageal• Eventration (15 - 20%)
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• Symptoms :- Cyanosis at birth- Respiratory distress- Scaphoid abdomen- Decreased / absent breath sounds on hernial side- Shift of cardiac sounds opposite to the
hernia
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• 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
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2. Postnatal diagnosis:
X ray : cardiothymic shift
- loops of bowel in the chest
- mediastinal shift
- absent lung markings
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• 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.
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Extracorporeal Membrane Oxygenation (ECMO)
• Use: controversial• Allows the lungs to develop & restructure• Expensive
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Criteria for ECMO• Gestational age ≥ 34 wks• Weight ≥ 2000 grams
Predicted mortality ≥ 80%
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• Associated anomalies (20-50%) :
cardiovascular 13 - 23%
CNS 28%
gastrointestinal 20%
genitourinary 15%
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Anorectal malformations
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Frequency
• 1 : 5000 live births
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TYPES
• HIGH TYPE• LOW TYPE
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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).
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INVERTOGRAM16-24 hours
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A flat perineum
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A flat perineum-GIRL
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Perineal fistula
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bucket-handle malformation
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Associated malformations
Genitourinary :- Absent, dysplastic, or horseshoe
kidneys- Vesicoureteral reflux- Hydronephrosis- Hypospadias- Bifid scrotum
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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
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Spinal anomalies :• Tethered cord• Dural sac stenosis• Narrow spinal canal• Myelomeningocele, meningocele• Intraspinal teratoma• Neurogenic bladder
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Gastrointestinal and Cardiovascular Systems
• VATER and VACTERL associations:– Esophageal atresia– Duodenal atresia– Ventricular or atrioseptal defects– Tetrology of Fallot– Hirschsprung's disease
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Surgical therapy
• Colostomy• Definitive repair
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Colostomy Newborn boys
• Rectobulbar urethral fistula• Rectoprostatic urethral fistula• Rectovesical fistula• Imperforate anus without fistula• Rectal atresia
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Newborn girls Colostomy -
• Rectovestibular fistula• Imperforate anus without fistula• Persistent cloaca• Rectal atresia• Rectovaginal fistula
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COLOSTOMY
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Definitive repair
• Anoplasty : Indications– Rectoperineal fistula - girls & boys– Covered anus– Bucket-handle malformation
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• posterior sagittal ARP• Laprotomy
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PSARP
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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.
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Necrotizing Enterocolitis
(NEC)
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• 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%
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• Single most important factor
PREMATURITY
• Can occur in:
LBW infants
Full term infants
Fed and unfed infants
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• Other factors
- ischemia
- bacterial infection
- GI endotoxemia
- enteral feeding
- use of hyperosmolar formula
- congenital heart disease
- umbilical arterial catheterization
- exchange transfusion
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Early signs
- ↑ gastric residuals with feedings
- temperature instability
- poor feeding
- bilious vomiting
- lethargy
- mucoid or bloody stool
- apnea and bradycardia
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• Late Signs
• Hemodynamic instability
• Anemia
• Thrombocytopenia
• Coagulopathy, DIC
• Prerenal azotemia
• Metabolic acidosis
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Physical Examdistended and tender abdomen
Labs: CBCelectrolytes and glucoseplatelets and coagulation profile DIC profileABG
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Abdominal X-ray• signs of bowel obstruction• Ileus with edematous bowel• Pneumatosis intestinalis or
intramural air (arrow)• Air in portal vein• pneumoperitoneum
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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
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• Surgical Indications
Absolute Indications
1) bowel perforation
2) intestinal gangrene
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• Relative Indications– metabolic acidosis– respiratory failure– oliguria, hypovolemia– thrombocytopenia– leucopenia, leukocytosis – air in the portal vein– bowel wall edema– persistent dilated bowel loops
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• Non-Surgical Indications
severe GI hemorrhage
abdominal tenderness
intestinal obstruction
gasless abdomen with ascites
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Thank You!