OVERVIEW OF NEONATAL SURGERY ANNE ASPIN 2010. Gastroschisis Defect lies to right of umbilicus...
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Transcript of OVERVIEW OF NEONATAL SURGERY ANNE ASPIN 2010. Gastroschisis Defect lies to right of umbilicus...
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OVERVIEW OF NEONATAL
SURGERY
ANNE ASPIN2010
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Gastroschisis
Defect lies to right of umbilicus
Central abdominal wall defect
No sac
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Embryology
6TH Week intestine grows rapidly Rotates and inverts by 10th week
Liver, bladder, stomach
Can be caused by vascular accident.
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Incidence
Omphalocele 1 :4000
Gastroschisis 1:6000 – 10,000
Increasing over last 30 years
Common in young mums, <20yrs.
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Associated anomalies
Gastro-intestinal tract, atresia,stenosis
Duplication cysts.
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Feeding problems
Gastro-oesophageal reflux Vomiting Poor weight gain Colic Fractious, fussy, crying Irregular bowel actions
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NEC What is it?
Infection of the mucosal lining of the bowel
Lactobacilli Clostridium Unknown
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Who does it effect? Maternal factors prematurity Hypoxic episodes Cardiac anomaly Exchange transfusion Umbilical line near mesenteric artery High osmolarity feeding Increasing feeds quickly
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Signs and symptoms Change in behaviour Subtle signs Lethargy Increasing naso-gastric aspirates Labile temperature, labile blood sugars Vomiting, bile later Blood in stools Abdominal distension
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Later Mottled, grey, capillary refill <4 secs Apnoeic Bradycardia Oxygen requirement Abdominal tenderness Oedema Dilated abdominal veins, dilated loops of
bowel Flare around umbilicus
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Even later
Thrombocytopenia Raised CRP Pneumoperitoneum Collapse, ventilation Abdominal drain Surgery, stoma’s Short bowel
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What to do
Large ng tube, aspirate and free drainage
Nil by mouth IVI, Antibiotics Blood sugar monitoring Sepsis screen. Blood gas, FBC, U/E’s,
Blood cultures Urine MC/S, CXR, AXR
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Types of oesophageal atresia and fistula
86% 7%4%
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Types continued
1%<1
<1
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History
First case recorded Durston (1670) Gibson (1697) first recorded with
fistula Ladd (1939) first staged repair Height (1941) first successful
primary repair.
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Survival
Survival rate of around 90% Incidence 1: 4500 Antenatal diagnosis –
polyhydramnios and absent stomach 56% predictive of OA.
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After birth
Large NG tube CXR, AXR Replogle tube, 10 min suction to
pharynx
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Associated anomalies
50% associated anomalies Cardiac 29%
Vertebral, Anorectal, Cardiac, Tracheo, Oesophageal, Renal, Limb
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Table 1 Cardiovascular 29% Gastro intestinal (anorectal 14%)
27% Genito urinary 13% Vertebral and skeletal 10% Respiratory 6% Genetic 4%
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Primary repair Paralyse and ventilate 5 days post
op Long gap – gastrostomy and
assessment of gap, may leave 6 – 12 weeks before primary closure.
Gap of more than 6-8 vertebrae, oesophageal replacement
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Post operation- early complications
Anastomotic leak , 27%, 24 – 72hrs
Anastomotic stricture
Recurrent tracheo oesophageal fistula
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Late complications
Tracheomalacia Gastro oesophageal reflux Respiratory problems Motility disorders Growth
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Short Bowel Syndrome
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Definition Rickham (1967) – an extensive resection to
maximum of 75cm
Kuffer (1972) – 15cm with ileocaecal valve - 38cm without ileocaecal valve
Dorney (1985) – 11cm with I/C valve or 25cm without I/C valve
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Introduction Most common cause of intestinal
failure.
NEC, Congenital atresia, Gastroschisis and volvulus.
Promote adaptive response through enteral feeding and careful management of TPN.
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What is SBS
Reduced bowel surface area for absorption of nutrients together with rapid transit of intestinal contents.
TPN reduced as enteral feeds are introduced.
Need to promote intestinal adaptation.
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Motility
The IC valve and colon is important to slow intestinal transit.
Proteins, Fats and Carbohydrates are absorbed almost completely within first 150cm of small bowel.
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After resection. Increase gastric emptying.
Ileal resection, increased transit time
An intact IC valve prolongs gut transit, loss of this causes an increase.
If colon resected transit increases.
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How does the bowel adapt? Cellular hyperplasia Villous hypertrophy Intestinal
lengthening Altered motility Hormonal changes
Takes approx 2 years to reach max effect.
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Central line complications
Infection Thrombosis Break in catheter Air embolus Tissue necrosis Malposition Cardiac tamponade
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It takes approximately two years to achieve some normal diet
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Gastroschisis NEC Bowel atresia, stenosis, web,
duplication cyst Meconium ileus Jejunostomy, ileostomy, colostomy.
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Bowel atresia, stenosis, web, duplication cyst
Interruption in the bowel Effects motility Adhesive bowel obstruction Nil by mouth again
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Meconium ileus
Thick, sticky meconium, secretions
Perforation or not (Ileum) Stoma
Absorption, enzymes, EBM
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Jejunostomy
High stoma
Trophic feeding, EBM, Donor EBM
Electrolytes
Six weeks reversal
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Ileostomy
High or low Milk Stomal diarrhoea Electrolytes Prolapse, inversion, sore, thrush Failure to thrive
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Colostomy
Milk Prolapse, inversion, soreness, Diarrhoea Constipation Electrolytes
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Important issues
Temperature Fluid and electrolytes Glucose Management of reflux Speech and language therapy family
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Management of gastro- oesophageal reflux
Thick n easy, Thix od Gaviscon Erythromycin Domperidone Ranitidine Omeprazole