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Surgical Consultations in Pediatric Gastroenterology

Paisarn Vejchapipat, MD PhD FACS

Department of Surgery,

Faculty of Medicine, Chulalongkorn University

Introduction

Disclosure: NONE

Examples of cases

www.pedsurgery.md.chula.ac.th

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Case 1

Newborn with bilious vomiting (mostly)

No abdominal distension

Hx of polyhydraminos

Down’s syndrome

Duodenal Atresia

Failure of recanalization

Polyhydramnios

Bilious vomiting (mostly)

No abdominal distension

Down’s syndrome (30%)

‘DOUBLE BUBBLE SIGN’

Rx: Duodenoduodenostomy

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Types of Duodenal Atresia

Duodenoduodenostomy for Duodenal Atresia

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Duodenal Stenosis

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Giant duodenum in duodenal stenosis

Case 2

Newborn with bilious vomiting with mild abdominal distension

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Jejuno-ileal Atresia

Intrauterine vascular accident

Bilious vomiting (always)

Abdominal distension depends on the site of atresia

No associated anomalies

Multiple atresia (10%)

Jejunal Atresia & Ileal Atresia

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Types of Jejuno-Ileal atresia

Type I Jejuno-Ileal Atresia

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Case 3

A 2-week-old neonate with bilious vomiting

Malrotation

Entire duodenum is on the right side of SMA with caecum is at RUQ

Obstruction from Ladd’s band or midgut volvulus

Bird beak apperance or cork-screw sign of duodenum on UGI film

Rx: Ladd’s operation + appendectomy

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Malrotation: D-J junction Classification of malrotation based on the location of the

D-J junction in comparison with the midline of the vertebral body and the level of gastric outlet

Malrotation and Midgut Volvulus

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Malrotation with midgut volvulus

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Malrotation with midgut volvulus

Midgut Volvulus

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Ladd

’s op

erat

ion

Malrotation with midgut volvulus

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Case 4

A 4-week-old infant with projectile non-bilious vomiting

Infantile Hypertrophic Pyloric Stenosis

Projectile non-bilious vomiting Male: Female = 4:1 Abdominal mass RUQ Dx: ultrasound, UGI study ‘Hypokalemic hypochloremic

metabolic alkalosis’ Rx: Ramstedt’s operation

(pyloromyotomy)

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IHPS

Ramstedt’s Operation or Pyloromyotomy

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Ramstedt’s Operation or Pyloromyotomy

Minimally Invasive Surgery

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Case 5

A 5-month-old, previously healthy, infant with suddenly red-coloured stools and vomiting

Intussusception

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Intussusception

1 mo. – 2 yrs (idiopathic)

Bilious vomiting, currant jelly stool

Abdominal mass, PR blood

Dx: ultrasound, barium enema (crescent and coil-spring signs)

Rx: pneumatic or hydrostatic reduction, manual reduction

Pneumatic reduction

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Intussusception

Case 6

A 2-month-old neonate with constipation and abdominal distension

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Hirschsprung’s disease

Congenital colonic aganglionosis Constipation, abdominal

distension PR: burst of feces (low lesion) Dx: barium enema, manometry,

rectal suction biopsy Rx: Staged pull-through or

primary pullthrough

Transition zone in Hirschsprung’s disease

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Hirschsprung’s disease andRectal Suction Biopsy

Primary Transanal Endorectal Pullthrough for Hirschsprung’s disease

Transanal submucosal dissection

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Abdominal pain in children

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D/Dx abdominal pain

Acute abdomen in a 4-year old boy

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Gut obstruction from Meckel’s diverticulum

Bleeding Meckel’s diverticulum

Age 1-5 yrs

Significant painless rectal bleeding

Anemia, hypotension

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Appendicitis

Diagnosis sometimes can be difficult

Never say “never”

Ultrasound is helpful in selected cases

Roles of CT-scan is increasing

Plain film in acute appendicitis

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Possible differential diagnoses of acute appendicitis

Diagnosis of Appendicitis

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Unusual cases

High fever precedes abdominal pain Left lower quadrant pain Colicky pain Diarrhea Wbc 3,000 Platelet 80,000 UA: wbc numerous Etc.

Appendectomy

Open appendectomy

Lap. assisted appendectomy

Laparoscopic appendectomy

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Management of perforated appendicitis

Pelvic absesses in perforated appendicitis

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Using weight for height (>140% of ideal body weight) 268 children (222 non-obese vs. 46 obese) Ultrasound or CT was used in 6.3% No difference between non-obese & obese groups regarding

Operative time negative appendectomy rate (6.7% vs. 8.7%) perforation rate (18% vs. 9%) hospital stay wound infection (4.9% vs.4.3%)

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Clinical Presentation

Jaundice, acholic stools, dark urine and hepatomegaly

If left untreated, the patients will die within two years of complications of portal hypertension

The diagnosis of BA

Babies (0-4 months old) with cholestatic jaundice and persistent acholic stools

Ultrasound

Triangular cord sign +ve IOC

Triangular cord sign –ve

IOC (age> 60days)

DISIDA (age <60days)

Choledochalcyst Surgery

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Type

s of

Bilia

ry A

tresia

Intra-operative Cholangiography

BA Non-BA

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Kasai operation

Kasai operation

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Chulalongkorn’s Experience 1986-1995:

115 cases Chula Med J 1996

1996-2001: 92 cases Asian J Surg 2005

2002-2005: 53 cases J Pediatr Surg 2007

2006-2011: 60 cases RCST meeting 2012 Chulalongkorn University

Clearance of jaundice within 6 months after Kasai Operation

38%

50.7%

56.6%

58.3%

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Native liver survival after Kasai op.

Chusilp et al. Pediatr Surg Int 2016

(n=68)

(n=58)

P<0.001

Overall survival after Liver Tx

Failed Kasai -> Tx (n=36)Primary liver Tx (n=26)

Chuongboonsri et al. ISPSR, Fukuoka, Japan 2019

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Prognostic factors The age at the time of operation Syndromic form The status of the liver The size of bile canaliculi at porta hepatis CMV infection Serum TB at 7th day post-Kasai Various serum growth factors & cytokines Surgeons’ experience Patient load per year at that centre

The fate of biliary atresia

Biliary atresia

Kasai operation

Transplantation

Poor outcome Good outcome

Short-term~40% ~60%

Deterioration Normal life

Long-term50% 50%

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Summary

Intestinal atresia

Malrotation with midgut volvulus

Hirschsprung’s disease

Intussusception

Meckel’s diverticulum

Appendicitis

Biliary atresia

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Any questions?