1. OVERVIEW OF NEONATAL SURGERY
ANNE ASPIN
2010

2. Gastroschisis Defect lies to right of umbilicus
Central abdominal wall defect
No sac

3. Embryology 6TH Week intestine grows rapidly
Rotates and inverts by 10th week
Liver, bladder, stomach
Can be caused by vascular accident.

4. Incidence Omphalocele 1 :4000 Gastroschisis 1:6000 – 10,000
Increasing over last 30 years
Common in young mums, <20yrs.

5. Associated anomalies Gastro-intestinal tract, atresia,stenosis
Duplication cysts.

6. Feeding problems Gastro-oesophageal reflux Vomiting Poor weight gain
Colic
Fractious, fussy, crying
Irregular bowel actions

7. NEC What is it? Infection of the mucosal lining of the bowel
Lactobacilli
Clostridium
Unknown

8. Who does it effect? Maternal factors prematurity Hypoxic episodes
Cardiac anomaly
Exchange transfusion
Umbilical line near mesenteric artery
High osmolarity feeding
Increasing feeds quickly

9. 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

10. Later Mottled, grey, capillary refill <4 secs Apnoeic Bradycardia
Oxygen requirement
Abdominal tenderness
Oedema
Dilated abdominal veins, dilated loops of bowel
Flare around umbilicus

11. Even later Thrombocytopenia Raised CRP Pneumoperitoneum
Collapse, ventilation
Abdominal drain
Surgery, stoma’s
Short bowel

12. 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

13. Types of oesophageal atresia and fistula
86% 7% 4%

14. Types continued 1%
<1
<1

15. History First case recorded Durston (1670)
Gibson (1697) first recorded with fistula
Ladd (1939) first staged repair
Height (1941) first successful primary repair.

16. Survival Survival rate of around 90% Incidence 1: 4500
Antenatal diagnosis – polyhydramnios and absent stomach 56% predictive of OA.

17. After birth Large NG tube CXR, AXR
Replogle tube, 10 min suction to pharynx

18. Associated anomalies 50% associated anomalies Cardiac 29%
Vertebral, Anorectal, Cardiac, Tracheo, Oesophageal, Renal, Limb

19. Table 1 Cardiovascular 29% Gastro intestinal (anorectal 14%) 27%
Genito urinary 13%
Vertebral and skeletal 10%
Respiratory 6%
Genetic 4%

20. 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

21. Post operation- early complications
Anastomotic leak , 27%, 24 – 72hrs
Anastomotic stricture
Recurrent tracheo oesophageal fistula

22. Late complications Tracheomalacia Gastro oesophageal reflux
Respiratory problems
Motility disorders
Growth

23. Short Bowel Syndrome

24. 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

25. Introduction Most common cause of intestinal failure.
NEC, Congenital atresia, Gastroschisis and volvulus.
Promote adaptive response through enteral feeding and careful management of TPN.

26. 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.

27. 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.

28. 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.

29. How does the bowel adapt?
Cellular hyperplasia
Villous hypertrophy
Intestinal lengthening
Altered motility
Hormonal changes
Takes approx 2 years to reach max effect.

30. Central line complications
Infection
Thrombosis
Break in catheter
Air embolus
Tissue necrosis
Malposition
Cardiac tamponade

31. It takes approximately two years to achieve some normal diet

32. Gastroschisis
NEC
Bowel atresia, stenosis, web, duplication cyst
Meconium ileus
Jejunostomy, ileostomy, colostomy.

33. Bowel atresia, stenosis, web, duplication cyst
Interruption in the bowel
Effects motility
Adhesive bowel obstruction
Nil by mouth again

34. Meconium ileus Thick, sticky meconium, secretions
Perforation or not (Ileum)
Stoma
Absorption, enzymes, EBM

35. Jejunostomy High stoma Trophic feeding, EBM, Donor EBM Electrolytes
Six weeks reversal

36. Ileostomy High or low Milk Stomal diarrhoea Electrolytes
Prolapse, inversion, sore, thrush
Failure to thrive

37. Colostomy Milk Prolapse, inversion, soreness, Diarrhoea Constipation
Electrolytes

38. Important issues Temperature Fluid and electrolytes Glucose
Management of reflux
Speech and language therapy
family

39. Management of gastro- oesophageal reflux
Thick n easy, Thix od
Gaviscon
Erythromycin
Domperidone
Ranitidine
Omeprazole