Surgical Emergencies In Neonatal Dr.Mohammad Saquib Mallick,FRCS Associate Professor and Consultant , Division of Pediatric Surgery, Department of Surgery, College of Medicine and King Khalid University Hospital, Riyadh

Principles of Neonatal Surgery Types of Newborns: Full-term: >38 weeks and weight > 2.5 kg preterm infant: <38 weeks with appropriate weight SGA: >38 weeks and weight< 2.5 kg VLBW: <32 weeks and <1.5 kg There are physiologic differences between all these infants

Principles of Neonatal Surgery Metabolic considerations 1: Thermoregulation 2: Glucose homeostasis 3: Calcium and Magnesium homeostasis 4: Blood volume 5: Jaundice 6: Energy requirement Fluid & Electrolytes Concepts 1: water metabolism

Principles of Neonatal Surgery 2: Maintenance needs 3: Monitoring fluid & electrolytes 4: perioperative management General considerations 1: GIT decompression 2: Antibiotic therapy 3: Vitamin K 1 mg I/M or I/V 4: Diagnostic study 5: Transport of neonates

High intestinal obstruction in neonate Oesophageal atresia with/without Tracheo-esophageal Fistula (TOF) Infantile hypertrophy pyloric stenosis Duodenal obstruction: Duodenal atresia or web or stenosis Annular pancrease Ladd band (malrotation) Proximal jejunal obstruction: Atresia, web, stenosis.

Oesophageal atresia & TOF High intestinal obstruction in neonate Oesophageal atresia & TOF Incidence: 1: 5000 live births, 50% associated with anomalies Types: Symptoms and Signs: Excessive salivation Respiratory Distress Inability to pass NG tube Choking and coughing on feeding VACTERL Syndrome

Oesophageal atresia & TOF High intestinal obstruction in neonate Oesophageal atresia & TOF Diagnosis – Clinical & CXR Management: Resuscitation Common type Right thoracotomy Division and repair of TOF Primary anastomosis Pure TOF Division and repair Isolated atresia >3 vertebra Staged surgery (gastrostomy and followed in 3-6 months by delayed repair. If fails then need esophageal replacement (stomach or colon)

Duodenal obstruction Divided into: Antenatal diagnosis: High intestinal obstruction in neonate Duodenal obstruction Divided into: Complete (atresia) Partial (web, stenosis, ladd band, annular pancreas)) Antenatal diagnosis: Polyhydramnios Dilated stomach and 1st part Duodenum Down syndrome 30% Symptoms and Signs: vomiting, bilious 80% High gastric aspiration: >30ml

Duodenal obstruction X-rays: Management: Double bobble shadow High intestinal obstruction in neonate Duodenal obstruction X-rays: Double bobble shadow Management: Exclude the Volvulus and resuscitation NGT, Vitamin K, stabilized before surgery Duodeno-duodenostomy

Proximal jejunal obstruction Atresia Web Stenosis Treatment: End to end anastomosis

Case study A 3-day old baby boy who presented with H/O of vomiting which was formula milk and then green for last 12 hrs. He passed meconium last night. His mother told that his abdomen is full and feel firm. No perinatal problem O/E He is active and mildly dehydrated. Abdomen is distended and non tender with no mass. PR examination showed normal anus Plain X-rays was a lot of dilated loops with multiple fluid levels

Clinical presentation Low intestinal obstruction in neonate Clinical presentation

Low intestinal obstruction in neonate- Differential Diagnosis Ileal/Colon atresia Meconium ileus Hirschsprung's Disease, Meconium plug syndrome, Left micro-colon syndrome, Malrotation with volvulus ((Anorectal malformation)) Medical causes- sepsis, ileus, electrolytes imbalance

Common presentations Bilious vomiting Low intestinal obstruction in neonate Common presentations Bilious vomiting Failure or delayed to pass meconium Abdominal distension Multiple fluid levels in plain AXR

Ileal /Colon atresia

Meconium ileus

Hirschsprung's Disease Pathology cont.. Due to congenital absence of ganglion cells in the distal bowel. Incidence: 1/4500-5000 live births Sex: 4:1 male predominance, Age: 96% Full term & 4% premature Site: Commonly: rectum/rectosigmoid Less commonly: total colonic with or without small intestine

Hirschsprung's Disease Diagnosis Neonatal: Delayed or failure to pass meconium with low intestinal obstruction. late presentation: *Failure to thrive, *Poor feeding *Diarrhea with abdominal distension and occasionally with enterocolitis. Examination: Abdominal Distension PR: tight sphincter with gush of loose stool Malnutrited child, Enterocolitis

Hirschsprung's Disease Management At birth Pull through operation At 6-9 months of age *Primary pull-through procedure without colostomy*

Anorectal Malformation (imperforate anus) Incidence 1:5000 live births Common in boys than girls(55%-65%) Low - below levator sling High - above levator sling Intermedate - not fit above Rectovestibular fistula - commonest in girls Rectourtheral fistula - commonest in boys

No anal opening

ARM

Management at birth

Posterior sagittal anorectoplasty (PSARP)

Principles of Neonatal Surgery The newborn suspected of having intestinal obstruction should be studied in a logical step by step manner. It is important that it be definitely established that the infant has a surgical problem before surgery is performed. Resuscitation must be done before operation Every condition will be dealt according

Respiratory Distress Causes Surgical Upper airway obstruction Congenital diaphragmatic hernia Eventration of Diaphragm Esophageal atresia with TOF Congenital lobar emphysema Congenital cystic adenomatoid malformation Pulmonary Sequestration

Respiratory Distress Congenital Diaphragmatic Hernia Incidence: 1:2000 to 5000, female more affected, prematurity and low BW, Left side

Diaphragmatic Hernia Symptoms None to severe Polyhydramnios Presents birth to after many days Signs Scaphoid abdomen Audible bowel sound in the chest

Diaphragmatic Hernia Diagnosis: Prenatal <25wks, prognosis bad Clinical CXR 10% >after neonatal period

Diaphragmatic Hernia

Diaphragmatic Hernia Management Reussciataion and stabilization Laparotomy Primary Patch by silo or muscle Laparoscopic repair

Eventration of Diaphragm Def: Abnormal elevation of diaphragm that results in paradoxical motion of affected hemidiaphragm during inspiration and expiration Cause: Congenital Acquired Symptoms: None Resp. distress Wheezing, repeated URI, exercise intolerance

Eventration of Diaphragm Diagnosis: CXR Fluoroscopy or Real time US

Eventration of Diaphragm Management: Conservative plication

Respiratory Distress The newborn suspected of having respiratory distress should be studied in a logical step by step manner. It is important to establish that the infant has a surgical problem before surgery is performed. Resuscitation must be done before operation Every condition will be dealt accordingly

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