Surgical Consultations in Pediatric Gastroenterology- review/Surgical...¢  Jejuno-ileal Atresia Intrauterine

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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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    La dd

    ’s op

    er at

    io n

    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 and Rectal 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

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    Ty pe

    s of

    B ilia

    ry A

    tre sia

    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 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-term 50% 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?