SURGICAL PROBLEMS IN THE concentration ability (limited urea in

NEWBORN medullary interstitium) which makes

Dr. Noel Binayas them less tolerant to dehydration.
June 26, 2013 The neonate is metabolically active and
Group 9 v2.0 production of solute to excrete in the
urine is high. The kidney in the newborn
SURGICAL NEONATE can only concentrate to about 400
A. Neonatal Physiologic Characteristics mOsm/L initially (500-600 mOsm/L the
1. Water metabolism full term compared to 1200 mOsm/L for
2. Fluid and electrolytes concepts an adult), and therefore requires 2-
B. Variations in Individual Newborns 4cc/kg/hr urine production to clear the
1. Types of Newborn Infants renal solute load.
2. Metabolic and Host Defense
3. Surgical Response of Newborn Fluid and Electrolyte Concepts
Electrolyte requirements of the full-
VARIATIONS IN INDIVIDUAL NEWBORNS term neonates are:
1. Types of newborn Infants  Sodium 2-3 meq/kg/day
a. The full term, full-size infant with a gestational  Potassium 1-2 meq/kg/day
age of 38 weeks and a body weight greater than  Chloride 3-5 meq/kg/day
2500 grams (TAGA) - they received adequate At a fluid rate of 100cc/kg/24 hrs for
intrauterine nutrition, passed all fetal tasks and the first 10 kg of weight
their physiologic functions are predictable.
As a rule of thumb, the daily fluid
b. The preterm infant with a gestational age below
requirement can be approximated too:
38 weeks and a birth weight appropriate for that
age ( PreTAGA)  Prematures
120-150cc /kg/24 hrs
c. The small-for-gestational-age infant (SGA) with a
gestational age over 38 weeks and a body  Neonates (term)
weight below 2500 grams-has suffered growth 100cc/kg/24 hrs
retardation in utero.  Infants >10kg
d. A combination of (b) and (c), i.e., the preterm 1000cc +50 cc/kg/24hrs
infant who is also small for gestational age. Impaired ability to excrete a sodium
load can be amplified with surgical
NEONATAL PHYSIOLOGIC CHARACTERISTICS stress (progressive renal retention of
Water Metabolism sodium). Estimations of daily fluid
Water represents 70-80% of the body requirements should take into
weight of the normal neonate and consideration:
premature baby respectively. 1. Urinary water losses
There is a gradual decrease in body 2. Gastrointestinal losses
water and the extracellular fluid 3. Insensible water losses and
compartment with a concomitant 4. Surgical losses (drains)
increase in the intracellular fluid
compartment. This shift is interrupted NEWBORN FLUID VOLUME REQUIREMENTS (ML/KG/24HRS)
FOR VARIOUS SURGICAL CONDITIONS
with a premature birth.
The newborns body surface area is
Group Day 1 Day 2 Day 3
relatively much greater than the adult Mod. surgical conditions 80+25 80+30 80+30
and heat loss is a major factor. (e.g. colostomies, laparo-
Insensible water loss are from the lung tomies for intestinal
(1/3) and skin (2/3) atresia, Hirschsprung's
Neonatal renal function is generally disease
adequate to meet the needs of the Severe surgical condition 140+45 90+20 80+15
normal full-term infant but may be (gastrochisis, mid gut
limited during periods of stress. Renal volvulus, meconium peritonitis)
characteristics of newborns are low Necrotizing enterocolitis 145+70 135+50 130+40
with perforation
glomerular filtration rate and
The degree of dehydration can be measured by clinical Hypocalcemia
parameters such as:  The preterm and surgical neonate is more
Body weight prone to hypocalcemia due to reduced stores,
Tissue turgor renal immaturity, and relative
State of peripheral circulation hypoparathyroidism (high fetal calcium levels).
Depression of fontanelle  Symptoms are jitteriness and seizures with
Dryness of the mouth and increased muscle tone.
Urine output  Calcium maintenance is 50mg/kg/day

MINIMUM NEWBORN IDEAL URINE OUTPUT Hypothermia

(ML/KG/HR) FOR VARIOUS SURGICAL CONDITIONS  There is an association between the
hypothermia and mortality in the NICU's
Group Day 1 Day 2 Day 3  The surgical neonate is prone to hypothermia
Mod. surgical 2+0.96 2.63+1.71 2.38+0.92  Infants produce heat by increasing metabolic
conditions activity and using brown fat. Below 35oC the
(e.g. colostomies, newborn experiences lassitude, depressed
laparotomies respiration, bradycardia, metabolic acidosis,
for intestinal hypoglycemia, hyperkalemia, elevated BUN and
atresia, Hirschsprung's oliguria (neonatal cold injury syndrome)
disease)  Factors that further precipitate these problems
Severe surgical condi- 2.67+0.92 2.96+0.54 2.96+1.0 are: prematurity, prolonged surgery, and
tion (gastrochisis, mid gut eviscerated bowel (gastroschisis)
volvulus, meconium
peritonitis) SURGICAL RESPONSE OF NEWBORN
Necrotizing 2.58+1.04 3.17+1.67 3.46+1.46  The endocrine and metabolic response to
enterocolitis with perforation surgical stress in newborns (NB) is characterized
by catabolic metabolism. An initial elevation in
 The newborn infants require 100-200 cathecolamines, cortisol and endorphins upon
calories/kg/day for normal growth. This is increased
stimulation by noxious stimuli occurs; a defense
during stress, cold, infection, surgery and trauma.
mechanism of the organism to mobilize stored
 Minimum daily requirements are 2-3 gm/kg of energy reserves, form new ones and start
protein, 10-15 gm/kg of carbohydrate and small cellular catabolism
amount of essential fatty acids.  Cortisol is responsible for protein breakdown,
release of gluconeogenic aminoacids from
METABOLIC AND HOST DEFENSES ‘ADAPTATIONS' muscle, and fat lipolysis with release of fatty
Jaundice acids.
 "physiological Jaundice"  Glucagon secretion is increased. Plasma insulin
 ability of the immature liver to conjugate increase is a reflex to the hypoglycemic effect,
bilirubin is reduced, the life span of the red although a resistance to its anabolic function is
blood cell is short, and the bilirubin load present.
presented to the circulation via the  During surgical stress NB release glucose, fatty
enterohepatic route is increased. acids, ketone bodies, and amino acids;
*other problems affecting the baby include the rapid necessary to meet body energy needs in time of
development of "HYPOGLYCEMIA' (35mg%) increase metabolic demands.
* Newborns have a poorly developed gluconeogenesis
system, and depends on glycolysis from liver glycogen Factors correlating with a prolonged catabolic response
stores (depleted 2-3 hrs after birth) and central during surgery are:
nutrition.  The degree of neuroendocrinological
maturation
 Duration of operation
 Amount of blood loss
 Type of surgical procedure, extent of surgical
trauma
  Associated conditions (hypothermia, 9. Esophageal atresia with or without TE fistula
prematurity, etc.) (TEF)
 They could be detrimental due to the NB's 10. Gastroesophageal reflux and hiatal hernia
limited reserves of nutrients, the high metabolic 11. Hirschsprung's disease (megacolon)
demands impose by growth, organ maturation 12. Hydrometrocolpos and imperforate hymen
and adaptation after birth. Anesthetics such as 13. Imperforate anus including persistent cloaca
halothane and fentanyl can suppress such 14. Inguinal hernias
response in NB. 15. Intestinal obstruction including duodenal
atresia, annular pancreas, malrotation,midgut
ESTIMATION OF BLOOD VOLUME volvulus, intestinal atresia, meconium ileus and
meconium peritonitis
Group Blood volume (ml/kg) 16. Necrotizing enterocolitis
Premature infants 85-100 17. Ovarian cysts
Term newborns 85 18. Pyloric stenosis
1mo 75 19. Rib cage and sternal deformities
3 mos -adult 70 20. Teratoma (sacrococcygeal) and other tumors of
the newborn
 Obstructive and GI problems 21. Umbilical anomalies including hernia, patent
Obstructions urachus, patent omphalo-mesenteric duct
Bleeding (NEC) 22. Undescended testes
 Thoracic (respiratory distress) problems
Hernias, diaphragmatic, etc.  Many of these neonatal surgical problems are very
Lung bud anomalies rare, occurring in 1 in 5,000 to 1 in 25,000 live
 Abdominal wall defects births. Pediatric surgeons have specialized training
Umbilical hernias and granulomas in treating these conditions.
Omphalocele and gastroschisis
Cloacal extrophy "The Neonate has innate disadvantages in the
Epigastric hernias immediate period of extra-uterine existence."
Recurrent inguinal hernias " The Child is not a small adult neither is the neonate
Acute scrotum & epididymis just a small child! "
 Pancreatic, biliary, splenic, hepatic conditions
(biliary atresia, choledochal cyst) "the neonate is not just a small child"
 Tumors (wilms tumor, neuroblastomas, germ
cell tumors)
 Gynecological intersex conditions SURGICAL PECULIARITIES
 Twinning and deformities (mostrosity)
 Miscellaneous (trauma, etc) Anatomic Disadvantages (Peculiarities)
-Small Size (parts, orifices, vessels)
-Small weight to BSA ratio
INTESTINAL OBSTRUCTION IN THE NEONATE -Pliable and Delicate tissues, vessels
-Head and Neck peculiar
Neonatal surgical conditions which are best managed by -Thoracic wall/Lungs peculiar
pediatric surgeons include -CVS peculiar
1. Abdominal wall defects including gastroschisis, -Abdomen peculiar…
omphalocele, and Pentalogy of Cantrell
2. Biliary atresia and choledochal cyst Functional Disadvantages (Peculiarities)
3. Cloacal exstrophy -Poor thermo-regulation
4. Conjoined twins -Glucose source is limited
5. Cystic adenomatoid malformation of the lung -Obligate nose-breather
and other types of bronchogenic cysts -Diaphragmatic breather
6. Cystic hygroma and other neck masses -Easily fatigued
7. Diaphragmatic hernia -Respiratory failure
8. Duplication cysts and mesenteric cysts -Poor renal handling of fluid volume
- Small blood volume; inadequate sympathetic response * manifestations : whole midgut rotaton OR ischemic
* "These peculiarities must be considered in any midgut
surgical neonate… in addition to the specific effects and *amount of distention is determined by the distance of
consequence of any persistent congenital anomaly… obstruction. The farther, the better.
and dealt with appropriately!" - Anal Fissures
6. Masses or tumors;
- Wilm's Tumor
- Neuroblastoma
7. Jaundice
- Biliary Atresia
- Choledochal Cyst

**BROWN FAT is located in the interscapular areas

and around the big vessels of the neck, chest and
abdomen.

NEONATAL SURGICAL EMERGENCIES

LOGICAL APPROACH TO NEONATAL INTESTINAL
Manifested AFTER Birth! OBSTRUCTION

1. Breathing problems: Signs and Symptoms:

-apnea, respiratory distress, dyspnea, cyanosis, 1. Bilious vomiting is always abnormal.
- Congenital Diaphragmatic Hernia; 2. Abdominal distention
- Esophageal Atresia (scaphoid abdomen possible).
2. Feeding Problems: 3. Delayed, scanty or no passage of meconium.
-vomiting (bilious), regurgitation 4. Polyhydramnios in mother
- Malrotation 5. Down's syndrome
- Intestinal Atresias 6. Family history
-Hypertrophic Pyloric Stenosis a. Hirschsprung's disease
3. Delay, Failure in passage of meconium; b. Diabetic mother
- Hirschsprung Disease c. Jejunal atresia
- Anorectal Malformation
4. Abdominal Defects * "The surgeon must have a high index of suspicion"
- Omphalocele
- Gastroschisis
5. GI Bleeding
- Volvulus Neonatorum
Dr. C.E. Coop's "2-minute test"
1. High Index of suspicion in the delivery room.
2. Within two minutes of birth,
1. Inspection
2. Palpation
3. Rectal probing / digital examination
4. OGT-NGT insertion / gastric aspiration

*While in the Delivery Room: you should be able to

rule-out or consider the following (as yet) unapparent
anomalies:
1. Choanal atresia
2. Esophageal Atresia
3. Gastric Outlet/ Duodenal Obstruction
-congenital pyloric obstruction
-duodenal or jejunal atresia/stenosis
-congenital bands/malrotation
4. Anorectal Anomalies/ Imperforate Anus
5. Anal stenosis

WORK-UP (LOGICAL APPROACH)

"double bubble" - pathognomonic of duodenal atresia
1. While the infant is being studied, it must be kept in
mind that the problem may be "non-surgical".
a. Sepsis of the newborn with associated ileus is the
most important cause of non-surgical bilious vomiting and
abdominal distention.
b. Intracranial lesions
2. Plain roentgenograms of the abdomen.
a. Diagnostic in complete high intestinal obstruction- no
gas in distal small bowel.
b. Many gas filled loops (requires 24 hours) indicates some
form of low intestinal obstruction.
c. May be nonspecific in instances of malrotation of the
intestines. This diagnosis must always be considered in
neonates with unexplained bilious vomiting.
d. Calcifications - at some time during fetal life meconium is
present in the abdomen.
3. Contrast enema will differentiate the various types
Roentgenogram (X-Ray) of person with duodenal of low intestinal obstruction.
atresia a. Microcolon - complete obstruction of the small
bowel.
b. Meconium plug syndrome - colon dilated proximal
to an intraluminal mass.
c. Hirschsprung's disease - although it may appear to
be diagnostic, not reliable in the newborn.
d. Small left colon syndrome - colon dilated to the splenic
flexure, then becomes narrow.

4. Upper G.I. series - the procedure of choice in

diagnosing malrotation of the intestines.
*In the past a contrast enema was thought to be the
diagnostic test of choice in instances of malrotation but the
cecum and ascending colon can be in normal position in an
infant or child with malrotation of the intestines.
5. Rectal biopsy- a pathologist competent in reading the
slides is essential and should not be taken for granted
a. Suction biopsy of the rectal mucosa and
submucosa
b. Full thickness biopsy of the rectal wall may be
necessary if the suction biopsy is non-diagnostic or
if the pathologist is unwilling or unable to make the
diagnosis of aganglionosis on a suction biopsy
specimen.
c. All newborns who have delayed passage of
meconium associated with a suspicious contrast
enema should have a suction biopsy of the rectal
mucosa and submucosa.
d. Suction biopsy of the rectum is probably
indicated in all cases of so called meconium plug
syndrome or small left colon syndrome.
MALROTATION
-refers to a group of congenital anomalies resulting
from aberrant intestinal rotation and fixation during the
first 3 months of gestation.
"Bilious emesis in the newborn is a surgical emergency
until proven otherwise."
• Due to the risk of significant adverse outcome,
malrotation should be the first consideration.
• The anomalies of intestinal rotation and fixation
consist of a spectrum of anatomic defects and a
wide range of clinical findings.
 Acute mid-gut Volvulus - Duodenal
Obstruction
• Asymptomatic or present during infancy and
early childhood
• Nonrotation - Incomplete rotation (70%)
• Mixed rotational and fixation anomalies
• Mesocolic hernias
Keys to Diagnosis
• High Index of Suspicion
• Radiographic Studies :
- Plain x-ray (Obstructive series)
- Upper GI series
1. Incomplete duodenal obstruction, usually in the third
portion.
2. The ligament of Treitz not to the left of midline or at the
level of the gastric antrum.
3. Abnormal position of the proximal jejunal loops to the right
of the midline.
4. Deformity of the duodenum, "bird's beak", "corkscrew" or
"coiled" configuration.
5. Delayed films show intestine-cecum junction not in the
RLQ.
* Barium enema has known limitations in
diagnosis of malrotation.
*In cecum malrotation- bilious emesis is a
surgical emergency until proven otherwise
*If the history and physical findings are highly
suspicious for acute mid-gut volvulus in the newborn,
urgent operative intervention is indicated without
confirmatory radiographic studies.
This is justified due to the disastrous
consequences related to delayed treatment of this
potentially correctable process. " - paul stockmann
NEONATAL HIRSCHPRUNG DISEASE
Signs and Symptoms
• Delayed passage of meconium
• Sudden/acute abdominal distention frank
obstruction
• Progressive abdominal Distension acute
obstruction
• Intermittent Abdominal Distension relieved by
passage of stool and gas
• Constipation from newborn and early infancy
• Large abdomen, meconium with rectal
stimulation, whitish OGT drainage
• Visible bowel loops
• Gush of stool and gas (diarrhea) with rectal
stimulation/examination
* most common distal obstruction which involves:
- post prandial vomiting
-non bilious
- hypertrophic Pyloric Stenosis
Surgical procedure: cut the muscle in pylorus but
do not include the mucosa
In summary
* Malrotation of the intestines and Hirschsprung's
disease must be ruled out before a newborn with
unexplained bilious vomiting and/or abdominal
distention is sent home. It can be unsafe to rely on
parents to observe their infant for problems
resulting from the above conditions.
* If diagnosed late, malrotation of the intestines or
Hirschsprung's disease can become life threatening
or result in life long problems.