Guidelines for Pediatric Surgery

Intussusception
Definition: a telescoping of one portion of intestine into in another, which results in decreased blood supply of involved segment. Incidence: 1.9~4 /1000 , male preponderance with a 3:2 ratio, intussusception most common in babies between 5 months and 12 months. Symptoms and signs: Intermittent colic abdominal pain Vomiting Currant jelly stool or bloody stool Shock Fever

Physical examination: abdominal mass and distension Dehydration

Examination: CBC D/C , electrolyte and renal function,

Image studies: If intussusception is strongly suspected, perform a contrast enema without delay. This is contraindicated in patients with an obvious surgical abdomen (eg, signs of peritonitis or perforation) and in unstable patients.

Plain abdominal x-ray findings may be normal early in the disease or may show perforation, typical obstructive pattern, or soft tissue mass of the intussusception on the right side. A paucity of gas in the right upper quadrant may be present. Ultrasound has been used to diagnose intussusception

Predisposing factors: Recent upper respiratory illness Recent diarrheal illness Henoch-Schonlein purpura Cystic fibrosis Treatment: IV hydration Non-operative reduction ( air or barium enema)---No peritoneal sign , no bowel perforation. Contrast enema can reduce the intussusception in approximately 75% of cases. SurgeryReduction failure or suspected bowel gangrene

Surgery: Milking reduction and appendectomy Bowel resection or enterostomy Bowel gangrene Looking for lead point Lead point: most cases are idiopathic, however, in neonates and children older than 3 years , a mechanical lead point usually can be found: Meckels diverticulum Intestinal polyp (Peutz-Jeghlers syndrome , Familial polyposis coli, juvenile polyposis , intestinal lymphoma) Hemangioma Henoch-Schonlein purpura

 Other problems to be considered: Adhesive bands Meckels diverticulum Mesenteric adenitis Any process causing abdominal pain or GI bleeding Postoperative care: IV hydration Intake and output monitor Adequate decompression Antibiotics treatment and fever control Complication: Bowel perforation and necrosis Shock and sepsis Intestinal hemorrhage Wound infection

Prognosis Well in early treatment, in old children, intussusception may develop because presence of polyp or tumor Patient and family education Recurrence rate: about 5%

Fig 1:Intussusceptionileocecal type

Fig 2:Intussusceptionileo-ileal type

Fig 3:Intussusception with gangreneMeckels diverticulum as lead point

Fig 4:Late stage of intussusception presence of bloody stool and shock

Guidelines for Pediatric Surgery

Infantile hypertrophic pyloric stenosis:

Definition: A narrowing of the outlet from the stomach to the small intestine (called the pylorus) that occurs in infants. Pathophysiology: Full-thickness biopsies demonstrate both hypertrophy and hyperplasia of the circular muscle layer of the pylorus. No clear pathophysiologic sequence or etiology has been described. Proposed theories include, among others, abnormal circular muscle innervation, immature ganglion cells, decreased nitric-oxide stimulation of muscle fibers, immature ganglion cells, and abnormal levels of gastrin.

Incidences: 2~3 /1000 Sex: male to female: 4~6:1 , most common in first born male Strong genetic factor Risk to son if affected mother = 20% o Risk to daughter if affected mother = 7% o Risk to son if affected father = 5% o Risk to daughter if affected father = 2% Age: HPS most commonly is seen in infants aged 3-6 weeks
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Symptoms: Vomitingnon bilious projectile vomiting Infant appears constantly hungery Loose greenish stool passage Belching Dehydration Failure to thrive

 Physical examination: Upper abdominal mass like olive shape palpable Dehydration signs

Examination: CBC, electrolyte and blood gashypochloremic metabolic alkalosis

Image study: Abdominal radiographs may show a fluid-filled or airdistended stomach, suggesting gastric outlet obstruction. A markedly dilated stomach with exaggerated incisura (caterpillar sign) may be seen, which represents increased gastric peristalsis in these patients. Abdominal echo: MT (serosa to mucosa) greater than 3 mm, Pyloric channel length greater than 17 mm, Pyloric thickness (serosa to serosa) of 15 mm or greater, Target sign on transverse images of the pylorus. UGI: Delayed gastric emptying ,Cephalic orientation of the pylorus, Shoulder sign , String sign, Umbrella sign

Other problems to be considered: GER Malrotation Prepyloric web Gastric duplication

Treatments: IV hydration, urine output > 1~2 cc/kg/hour Corrected electrolyte unbalance OG decompression

SurgeryRamstedts pyloromyotomy Transverse right upper quadrant or circumumbilical incision Longitudinal incision in pylorus down to mucosa Incision extend from duodenum onto the gastric antrum Need to try and avoid mucosal perforation Postoperative management: No OG decompression Early feeding: 8~12 hrs after postoperatively with glucose water and advance to milk wound care

Complication: Postoperative vomiting (This is very common and generally improves with time.) Failure to gain weight in the newborn period Risks associated with any surgery Prognosis: well

Fig 1: Anatomy of infantile hypertrophy pyloric stenosis

Fig 2:UGI study : string sign

Fig 3:Infantile hypertrophy pyloric stenosis as an olive mass

Fig 4:Post operation: mucosa bulging