Pediatric Surgery

Trauma

• #1 cause of death in children
• What is the best indicator of shock in pediatric patients?
• Tachycardia
• Children look well until they decompensate quickly Tachycardia by age group (general rule of thumb): Neonate = > 150 beats per minute Age 1 - 6 = > 120 bpm Age 6 - 12 = > 110 bpm Age 13+ = same as adult
• What are the targets for fluid resuscitation?
• Crystalloid = 20 mL/kg
• Blood = 10 mL/kg (give after 2 fluid boluses in hypotensive)
• UOP = 2-3 mL/kg/hr in neonate/infant, 1 mL/kg/hr in toddlers and older
• MIVF = 4 mL/kg/hr for 1st 10 kg → 2 for 2nd 10 → 1 for the rest
• How do you choose ETT in children < 10 years old?
• Uncuffed tube for neonates only
• Size = , size of pinkie, or Breslow tape Emesis Important to know age group for most common presentations and bilious vs non-bilious
• What is the differential by age?
• Neonates
• Nonsurgical: infectious, allergy, metabolic disorder

• Surgical: GERD, pyloric stenosis, intestinal obstruction, atresia

• Infants/toddlers
• Nonsurgical: infectious, neurologic/psychologic, gastroparesis
• Surgical: intussusception
• Adolescents
• Nonsurgical: functional disorder, IBD, psychologic
• Surgical: appendicitis
• What is the differential for non-bilious emesis?
• Pyloric stenosis
• Buzz words: projectile vomiting, olive mass
• Metabolic disturbance: HYPOchloremic, HYPOkalemic, metabolic alkalosis + paradoxic aciduria
• Diagnosis = ultrasound → pylorus > 4 mm thick and > 14 mm long PIloric stenosis (pi = 3.14): > 3mm thick and > 14 mm long
• Treatment = RESUSCITATE first with normal saline → dextrose containing MIVF → OR for pyloromyotomy Do not resuscitate with lactated Ringer’s, which contains potassium, until metabolic disturbance is resolved.
• What are the features of tracheoesophageal fistula?
• Five types
• Type C most common with blind ending esophageal atresia and distal TE fistula
• Type A is the next most common and is the only one without a TE fistula, just esophageal atresia
• Diagnosis = AXR (Type C will have gas + distended stomach vs Type A will be gasless)
• Important in diagnostic workup- check for VACTERL

• What are the VACTERL syndrome components?

• Vertebral anomalies → sacral US
• Anorectal- imperforate anus → rectal exam
• Presentation: meconium in urine or vagina from fistula if high or to perineal skin if low
• Treatment = above levators need colostomy first, below levators straight to posterior sagittal anoplasty + postop anal dilation
• Cardiac → echocardiogram
• TE fistula
• Renal → US
• Limb anomalies
• Treatment = resuscitate with Replogle tube (double-lumen tube to suction saliva and keep esophagus patent) → G-tube + primary repair (right extrapleural thoracotomy)
• Common complications: similar to esophagectomy → GERD, leak, stricture, fistula

Figure 1 - Types of trachea-esophageal fistulae

• Intussusception (will be bilious if obstructed)
• Buzz words: currant jelly stools, target sign on imaging

• Underlying etiology: #1 inflamed Peyer’s patches after viral illness, #2 lymphoma, #3 Meckel’s diverticulum Intussusception in adults are commonly caused by a malignant lead point → OR, no air contrast enema

• Diagnosis = US
• Treatment = air-contrast enema
• What if it recurs?
• 15% recur, repeat air-contrast enema
• When do you operate?
• If unable to reduce with enema, peritonitis, obstruction After successful reduction with enema → observe for 4 hours, PO challenge, discharge
• What is the differential for bilious emesis?
• Malrotation with midgut volvulus (malrotation on its own is asymptomatic)
• Malrotation etiology = failure of normal 270-degree rotation during intestinal development
• Volvulus caused by Ladd’s bands (adhesions from right retroperitoneum)
• If child with malrotation is going to develop volvulus, majority present by 1 year old
• Diagnosis = always #1 on differential in pediatric bilious emesis → emergent upper GI to rule it out (duodenum doesn’t cross midline)
• Associations: CDH in 20%, omphalocele
• Treatment = resect Ladd’s bands and counterclockwise detorsion to place small intestine on right and large intestine on left + appendectomy (to avoid future diagnostic uncertainty) Turn back time: counterclockwise detorsion
• Duodenal atresia

• Buzz words: double-bubble sign on X-ray (image search this)

• #1 cause of duodenal obstruction in neonates
• What are some associations?
• Polyhydramnios (not swallowing the amniotic fluid)
• Cardiac, renal, GI anomalies
• Down’s syndrome in 20%
• Diagnosis = AXR + UGI
• Treatment = resuscitate → reconnect to duodenum or jejunum
• Other intestinal atresias are due to intrauterine vascular accidents - most commonly in jejunum and can be multiple Duodenal atresia is caused by failure of recanalization
• Meconium ileus
• Presentation: no meconium passed in first 24 hours
• Diagnosis = AXR shows dilated small bowel without air- fluid level + sweat chloride test
• Association: 10% of cystic fibrosis patients
• Treatment = Gastrogafin enema or N-acetylcysteine (NAC) enema
• When should you operate?
• Perforation, ostomy creation for antegrade NAC enemas
• What’s another disease that doesn’t pass meconium in first 24 hours?
• Hirschsprung’s disease
• #1 cause of colonic obstruction in infants, 2-3 years old will have chronic constipation
• Presentation: distention +/- colitis

• Diagnosis = suction rectal biopsy → absent ganglion cells in myenteric plexus (due to failure to progress caudad)

• Treatment = resect rectum and colon until ganglion cells present → can reconnect colon to anus later
• If colitis (foul smelling diarrhea, sepsis) → rectal irrigation +/- emergency colectomy Bloody stools
• Intussusception - remember currant jelly stools
• How does necrotizing enterocolitis present?
• Bloody stools after 1st feeding, premature baby, abdominal distension, septic
• Diagnosis = AXR → pneumatosis (not an indication for surgery alone), free air, portal venous gas (portends poor prognosis) + serial lateral decubitus films to monitor for perforation
• Treatment = resuscitate, NPO, Abx, TPN, orogastric tube
• When to operate?
• Pneumoperitoneum, peritonitis, clinical deterioration, abdominal wall erythema
• Barium enema prior to taking down ostomies down the road to rule out stenotic distal obstruction
• What is a Meckel’s diverticulum?
• Due to persistent vitelline (omphalomesenteric) duct
• Presentation: painless lower GI bleed most commonly
• What is the rule of 2s?
• 2 inches long
• 2 cm diameter
• < 2 years old
• 2:1 male to female predominance
• 2 feet from ileocecal valve
• 2% of the population
• 2% symptomatic

• 2 types of tissue- pancreatic and gastric

• Gastric most likely to be symptomatic
• 2 presentations - diverticulitis and bleeding
• Diagnosis = Meckel’s scan for operative preparation (will only pick up gastric mucosa)
• Treatment = resection of diverticulum + segmental resection if involving base or >1/3 size of bowel or diverticulitis Abdominal Wall Defects Table 1 - Features of gastroschisis versus omphalocele
• in omphalocele: looks like a complete sac (covered by peritoneum), looks like a belly button (midline)
• When do you repair a pediatric umbilical hernia?
• If it hasn’t closed by 5 years of age
• What is the etiology of inguinal hernias?
• Due to persistent processus vaginalis
• Treatment = elective high ligation of sac, OR within 72 hours of reduction if incarcerated

• Explore contralateral side if left-sided, female, or < 1 year old In adults, hernias are typically repaired with resection of the hernia sac.

• Hydrocele similar but no sac extending into internal ring
• Communicating vs noncommunicating
• Noncommunicating usually resolve by 1 year
• Communicating wax and wane
• Treatment = surgery at 1 year old if not resolved or communicating → resect hydrocele and ligate processus vaginalis
• What are the features of undescended testicles?
• Associations: risk of testicular CA even after orchiopexy, seminoma, chromosomal disorder if undescended bilaterally
• Treatment = orchiopexy (can divide spermatic vessels because of vas deferens collateral) Abdominal Masses
• How do neuroblastomas present?
• Usually asymptomatic, can have HTN, diarrhea, raccoon eyes from orbital metastases, or unsteady gait
• Most commonly adrenal, but can be anywhere along sympathetic chain
• Most commonly < 2 years old with best prognosis if < 1 year old
• Rarely metastasizes
• Diagnosis = catecholamines, metanephrines VMA, HVA, AXR showing stippled calcifications, CT showing renal displacement (vs Wilms replaces parenchyma)
• High risk/worse prognosis: neuron-specific enolase, LDH, HVA, diploid tumor, N-myc amplification Similar to pheochromocytoma

• Treatment = resection, can try neoadjuvant doxorubicin if unresectable

• What is a nephroblastoma (Wilms tumor)?
• Presentation: asymptomatic, hematuria, HTN, 10% are bilateral, average age 3 years old
• Metastasizes to bone and lung (requires radiation)
• Diagnosis = abdominal CT with replacement of renal parenchyma
• WAGR = Wilms + aniridia + GU malformation + mental retardation
• Treatment = nephrectomy without rupturing (will upstage) + actinomycin and vincristine chemo
• What are the features of a hepatoblastoma?
• Elevated AFP
• Treatment = resection, chemotherapy if unresectable Hepatobiliary
• Choledochal cyst [See Hepatobiliary chapter]
• Thought to be caused by reflux of pancreatic enzymes in utero
• 5 types- most common is Type I fusiform dilation of CBD
• Treatment = resection, some require hepaticojejunostomy or liver TXP

Figure 2 - Types of choledochal cysts

• What is biliary atresia?
• Most common indication for pediatric liver transplant
• Presentation: persistent neonatal jaundice
• Diagnosis = liver biopsy → periportal fibrosis, bile plug; US, cholangiography
• Treatment = Kasai (hepaticoportojejunostomy) is first step

if < 3 months of age → transplant

• 1/3 improve, 1/3 progress to transplant, 1/3 die Thoracic
• What are the types of congenital lung disease?
• Pulmonary sequestration
• Lung tissue that doesn’t communicate with tracheobronchial tree with independent blood supply from aorta
• Venous drainage can be systemic (extra-lobar) or pulmonary (intra-lobar)
• Presentation: infection, abnormal CXR
• Treatment = ligate arterial supply → lobectomy
• Congenital cystic adenoid malformation
• Communicates with tracheobronchial tree (vs pulmonary sequestration)
• Treatment = lobectomy
• Congenital lobar emphysema
• Failure of cartilage development
• Presentation: similar to tension PTX

• Treatment = lobectomy Do not place a chest tube in congenital lobar emphysema.

• Bronchogenic cyst
• Extrapulmonary cysts of bronchial tissue and cartilage
• Presentation: mediastinal cystic mass
• Treatment = resect
• What are the features of congenital diaphragmatic hernia?
• Two types:
• Bochdalek = most common, posterior
• Morgagni = rare, anterior

Bochdalek is back and to the left

• Most commonly left sided because the liver protects the right; usually both lungs are dysfunctional
• Associations: severe pulmonary HTN, cardiac and neural tube defects, malrotation
• Diagnosis = prenatal US, CXR will show bowel in chest
• Treatment = ventilation, inhaled nitric oxide, ECMO; stabilize → OR to run the bowel and repair defect Neck
• Where do branchial cleft cysts present?
• Most commonly 2nd branchial cleft cysts which are on the middle of the anterior SCM
• Treatment for all 3 branchial cleft cysts = resection
• How do thyroglossal duct cysts present?
• Midline (vs branchial cleft), goes through hyoid bone
• Formed from abnormal descent of thyroid gland and may be patient’s only thyroid tissue
• Treatment = Sistrunk procedure → excision of cyst, tract, and hyoid bone to base of tongue
• What is a cystic hygroma?
• Lymphangioma, lymphatic malformation connecting to IJ
• Presentation: Lateral neck in posterior triangle, soft, cystic, multi-loculated; gets infected
• Treatment = resection

Figure 3 - Common cystic lesions of the neck Quick Hits

• Which immunoglobulin crosses the placenta?
• IgG
• Which immunoglobulin is transferred through breast milk?
• IgA
• 1 month old with elevated AFP and beta-HCG . Diagnosis?
• Sacrococcygeal teratoma - usually malignant after 2 months old
• Most common anterior mediastinal mass = teratoma
• Most common overall mediastinal mass = neurogenic tumor (posterior mediastinum)
• 6-month-old with red lesions growing on face and scalp . Diagnosis and treatment?

• Hemangioma will resolve by 8 years old, otherwise steroids or laser

• 13-year-old boy with large sunken area of chest?
• Pectus excavatum → treat with strut if symptomatic
• Pectus carinatum = pigeon chest, doesn’t need correction (chest brace) unless emotional distress

Figures