PEDIATRIC SURGERY 2
Category: Pediatric Surgery
Abstract : Congenital diaphragmatic hernia (CDH) CDH can be diagnosed by the fourth month of pregnancy via ultrasound studies. Of the infants with congenital diaphragmatic hernia (CDH), 44–66% have other congenital abnormalities as a result of developmental malformations. Anatomically, patients with CDH have a defect in development that allows a communication between the chest and abdomen. Through
Congenital diaphragmatic hernia (CDH)
CDH can be diagnosed by the fourth month of pregnancy via ultrasound studies. Of the infants with congenital diaphragmatic hernia (CDH), 44–66% have other congenital abnormalities as a result of developmental malformations. Anatomically, patients with CDH have a defect in development that allows a communication between the chest and abdomen.
Through this defect, the abdominal contents enter the lung cavity and interfere with normal lung development. The incidence is approximately one per 2,200 live births, and males are more commonly affected than females. Usually the infants are full-term, and the defect occurs on the left side in the majority—88%—of patients.
Treatment is extensive, and usually requires three major areas:
• stabilization of patient and preoperative preparation
• operative treatment
• postoperative respiratory, metabolic, circulatory, and nutritional supportive measures
Postoperatively, the infant is monitored in the neonatal intensive care setting. The postoperative period is more critical if a lung is severely underdeveloped.
Pyloric stenosis (PS)
Pyloric stenosis is an obstruction in the intestine due to a larger-than-normal size of the muscle fibers of the pylorus (lower stomach opening). Pyloric stenosis is a common hereditary condition that affects males more than females, and occurs in one per 750 births. The typical symptoms include a progressive, often projectile, vomiting after attempted feedings. The gastric vomitus (bloody in 80% of patients) usually begins during the second and third week of life, and increases in force and frequency. Typically, the infant fails to gain weight, and the number of bowel movements and rate of urination decreases.
Physical examination is usually helpful in establishing a diagnosis. Palpation of the enlarged muscle fibers can be felt as an olive-shaped mass located in the midline approximately one-third to one-half of the distance from the umbilicus to the xiphoid (end of the breast bone), when the stomach is empty. Careful abdominal examination and palpation can usually identify the pyloric mass in 85% of cases.
Gastroesophageal reflux
Gastroesophageal reflux (GER) is a common disorder in infancy, and usually disappears by the baby’s first birthday. The largest group of patients with clinically significant GER are those who have neurologic impairment. Symptoms often include vomiting, repeated lung infections (from aspirating gastric contents during regurgitation of foodstuffs), and delayed gastric emptying. The success rate with infants who have procedures necessary to correct GER is over 90%.
Meckel’s diverticulum
Meckel’s diverticulum occurs in approximately 2% of the U.S. population. The diverticulum is an outgrowth of intestine is located in a portion of the intestines called the ileum. Symptoms of obstruction are more often observed in infants, and bleeding is more common in patients after age four.
Intestinal polyps
Juvenile polyps are usually present between the ages of four and 14 years, and tend to be inflammatory. The most common symptom of intestinal polyps is rectal bleeding, which is commonly due to a solitary polyp (80% of cases). Diagnosis can be done by proctosigmoidoscopy, which allows visualization of 85% of polyps.
Acute appendicitis
Acute appendicitis is a relatively common surgical emergency that is misdiagnosed in 28% of patients due to a broad spectrum of symptoms that can confuse the clinician. The classic clinical symptom of acute appendicitis is the onset of pain in the middle region of the abdomen that is followed by anorexia, nausea, and vomiting. The pain is persistent and radiates to the right lower abdomen, becoming more intense and localized. The physical and abdominal examinations must be carefully and accurately performed. Patients with acute appendicitis usually have an increased white blood cell (cells that fight infection) count.
Once the diagnosis is established, the child is prepared for surgery. Preoperative antibiotics are started at least one-half hour before the operation. If the appendix is perforated (ruptured), complications can occur as a result of kidney (renal) failure, seizures due to fever, and gram-negative sepsis (an infection that enters the bloodstream and interferes with life-saving chemical reactions). Patients who are very young, or those who were misdiagnosed and incurred long delays in treatment, are susceptible to death.
Inflammatory bowel diseases
Some cases (approximately 25%) of inflammatory bowel disease are found in persons younger than 20 years of age. Two types can occur, Crohn’s disease and ulcerative colitis.
The diagnosis of inflammatory bowel disease is usually based on presenting clinical symptoms, laboratory analysis results, endoscopic appearance, and radiologic findings. Approximately 50–60% of patients have bloody diarrhea, severe cramping, abdominal pain, and urgency.
CROHN’S DISEASE
The symptoms of Crohn’s disease includes cramping abdominal pain, diarrhea, and strictures (constriction) resulting from bowel obstruction. Removal of diseased portions in children with Crohn’s disease may be temporarily beneficial, but recurrence after surgical removal occurs in about 50% of cases within four years. Chronic symptoms may remain into adult life, making long-term follow-up essential.
ULCERATIVE COLITIS
Ulcerative colitis is limited to the colon. A surgical procedure known as colectomy is curative, and indicated for intractable disease (64% of patients). Colectomy is the removal of the entire colon, or the inflamed part of it.
Biliary tract disorders
A variety of biliary tract conditions may be present at birth, some requiring surgical correction.
NEONATAL JAUNDICE
Neonatal jaundice is common, and results from an immature system not capable of some basic biochemical reactions. Food intake can help speed these reactions, which usually resolves the condition within seven to 10 days. Jaundice that persists for over two weeks is abnormal, and could be caused by over 30 possible disorders.
BILIARY ATRESIA
Biliary atresia is a disease that causes inflammation of the ducts within the biliary system, resulting in fibrosis of these ducts. The incidence of biliary atresia is one per 15,000 live births, and is more common in females. Time is critical, and most patients must have surgery by two months of life. Approximately 25–30% of patients who receive early operative intervention have long-term successful outcomes. Some patients may require liver transplantation, and 85–90% of these patients survive.
CHOLELITHIASIS. Gallbladder obstruction in infants and young children is usually caused by pigmented (colored) stones resulting from blood disorders. Removal of the gallbladder (laparoscopic cholecystectomy) is the treatment of choice.
Trauma
Accidents are the leading cause of death in children between the ages of one and 15 years, and accounts for 50% of all deaths in the pediatric age group. More than half of these deaths are due to motor vehicle accidents, followed by falls, bicycle injuries, drowning, burns, child abuse, and birth trauma. Head trauma is the single most common organ associated with traumatic death. Within recent years, the number of fatalities related to the use of firearms and violence has increased.
More than 20 million children each year sustain injuries requiring treatment. These injuries account for 100,000 cases of permanent pediatric disability. Response to trauma in pediatric patients is significantly different from older patients. Pediatric patients require special attention concerning temperature regulation, blood volume, metabolic rate and requirements, and airway maintenance. Other special pediatric considerations include response to stress, communication difficulties, psychological trauma, a different pediatric trauma score system, smaller airway diameter, and increased risk of aspirating gastric contents (which could cause pneumonia). Pediatric trauma patients should have access to appropriate pre-hospital transportation, and must receive medical attention in a pediatric trauma center capable of providing the complex level of care necessary for serious pediatric trauma situations.
Neck masses
Neck masses during infancy and childhood may be caused by tumors or infections, or they may be congenital. Lymphadenitis is an infection of a lymph node that becomes enlarged and tender. Most cases are resolved by treating the primary source of infection (i.e., middle ear infection and tonsillitis). Some inflamed nodes may require an incision and drainage of infection.
Hernias
INGUINAL HERNIA AND HYDROCELE.
Inguinal (groin) hernia is the most frequent disorder requiring surgery in the pediatric age group. Clinically, a rightsided inguinal hernia is more common in males (60% of cases), and there is a familial tendency. The incidence is higher in full-term infants (3.5–5%). Full-term infants and older children (without underlying diseases) can receive surgical repair in an outpatient setting. An inguinal hernia may result in herniation of the scrotum, and a communicating hydrocele (hernia with a small connection to the peritoneal cavity).
UMBILICAL HERNIA. Umbilical hernia is a defect of the umbilical ring, and is more common in females and African American children. Spontaneous involution occurs in 80% of cases. Larger defects may be observed for several years without complications, and their spontaneous resolution is possible. If the umbilical hernia persists, patients may develop feeding intolerance, pain, and local skin breakdown.
Undescended testes
Undescended testes are observed in 1–2% of fullterm males. Approximately 30% of preterm males may have an undescended testis. Undescended testis in premature infants may descend by the first year of life, and observation is often the treatment during that time.
Tumors Wilm’s tumor (nephroblastoma) is a tumor in the kidneys that forms during embryonic development. The tumor is due to a genetic abnormality; and approximately 80% of children are diagnosed between one and five years of age. In about 75–95% of cases, the patient has an abdominal mass that is detected by a parent during bathing. Blood in the urine (hematuria) occurs in 10–15% of cases, and high blood pressure (hypertension) is present in 20–25% of cases. Hypertension is the result of the tumor compressing the kidney in a specific area, causing it to release a chemical called renin, which elevates blood pressure. During physical examination, the Wilm’s tumor is a smooth, round, hard, nontender flank mass. The treatment of Wilm’s tumor depends on its stage, and may include surgery, chemotherapy, or radiotherapy.
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