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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?