| Gastrojejunostomy
tube (GJT) insertion is a common procedure performed to provide
postpyloric enteral nutrition in children and adults. GJT is an
alternative to gastrostomy tubes when the stomach cannot be fed
directly due to history of gastroparesis, gastroesophageal reflux,
failed fundoplication, aspiration pneumonia or small capacity stomach
(microgastria). GJT are placed via open laparotomy, endoscopic-assisted
laparoscopy or fluoroscopic technique after a previous gastrostoma.
Open, endoscopic and laparoscopic technique includes the used if
intraoperative fluoroscopy. GJT tip placement should be placed distal
to the third portion of the duodenum. All cases should have
fluoroscopic contrast studies during insertion to demonstrate that no
bowel perforation has occurred. Complications associated with the use
of GJT include the need for tube replacement, peristomal granulation or
leakage, recurrent symptoms of gastroesophageal reflux, intussusception
and intestinal perforation. The most frequent reported complications
are the need for tube replacement due to mechanical failure from tube
fracture or balloon rupture, tube obstruction from clogging or tube
displacement from complete removal or distal migration. Almost 75% of
children require a return to the operating room for GJT replacement
with a mean of two replacements per year. Children weighting less than
6 kilograms or younger than six months of age are at a higher risk of
suffering an intestinal perforation with the use of GJT. The
complication with the greatest potential morbidity is that related to
intestinal perforation which can lead to death. The perforation occurs
nears the ligament of Treitz and usually occurs within the first 30
days after insertion. This occurs due to the relative rigidity of the
jejunal extension of the GJT which exerts radial pressure on the
duodenojejunal junction in the area of the ligament of Treitz where the
bowel makes a sharp turn. The smaller the child the smaller the bowel
diameter and size. The tip causes pressure necrosis leading to
perforation. References: 1- Jaskolka D, Brown N, Cohen E, Mounstephen W, Connolly B: Evaluating the implementation of a quality improvement initiative: weekend gastrojejunostomy tube maintenance service in a tertiary pediatric center. Can Assoc Radiol J. 64(3):229-35, 2013 2- Crowley JJ, Hogan MJ, Towbin RB: Quality improvement guidelines for pediatric gastrostomy and gastrojejunostomy tube placement. J Vasc Interv Radiol. 25(12):1983-91, 2014 3- Richards MK, Li CI, Foti JL, Leu MG, Wahbeh GT, Shaw D, Libby AK, Melzer L, Goldin AB: Resource utilization after implementing a hospital-wide standardized feeding tube placement pathway. J Pediatr Surg. 51(10):1674-9, 2016 4- Demehri FR, Simha S, Herrman E, Jarboe MD, Geiger JD, Teitelbaum DH, Gadepalli SK: Analysis of risk factors contributing to morbidity from gastrojejunostomy feeding tubes in children. J Pediatr Surg. 51(6):1005-9, 2016 5- Morse J, Baird R, Muchantef K, Levesque D, Morinville V, Puligandla PS: Gastrojejunostomy tube complications - A single center experience and systematic review. J Pediatr Surg. 52(5):726-733, 2017 6- Onwubiko C, Weil BR, Bairdain S, Hall AM, Perkins JM, Thangarajah H, McSweeney ME, Smithers CJ: Primary laparoscopic gastrojejunostomy tubes as a feeding modality in the pediatric population. J Pediatr Surg. pii: S0022-3468(17)30333-0. doi: 10.1016/j.jpedsurg.2017.05.015, 2017 |
| Gastroschisis
is a congenital abdominal wall defect to the right of the umbilical
cord resulting in uncovered bowel protruding. The exposed viscera
bathing in the amniotic fluid create a serositis with a foreshortened
edematous bowel. Gastroschisis is a newborn emergency that should be
managed by reducing progressively the exposed abdominal content and
closing the abdominal wall defect surgically. Closure depends on the
degree of viscero-abdominal disproportion found upon birth, the
condition of the bowel and the presence of an associated intestinal
atresia. Management can consist of closure using a silo-spring loaded
silo where the bowel is housed and progressively reduced over the next
few days then followed by fascial closure or primary closure if the
defect can be closed initially. The advent of staged closure allowed
for a reduction of pulmonary, renal and ischemic complications related
to increased intra-abdominal pressure caused by aggressive primary
reduction. Sutureless umbilical technique closure refers to the use of
remnant umbilical cord as a biological dressing reinforce with a
non-adherent synthetic material such as Tegaderm dressing on top. The
procedure may be performed bedside in the NICU with minimal sedation.
Adhesive dressing are changed over the umbilical cord closure every
other day for two weeks and the wound quickly epithelizes during this
time. The proposed advantages of this technique include lower total
cost, better cosmetic outcome and transfer of the procedure from the
operating room to bedside. Sutureless closure of gastroschisis reduces
the time to extubation independently of all variables due to the impact
of this approach on intraabdominal pressure, the secondary improvement
of ventilation mechanics and reduced need for narcotics and sedation.
Time to feeding is not altered by either sutureless or surgical closure
techniques. Almost all cases of sutureless technique closures develop
an umbilical hernia. Most resolve spontaneously and do not require
formal repair. Sutureless closure of uncomplicated gastroschisis is a
safe technique that reduces need of intubation and provides excellent
cosmetic results. References: 1- Sandler A, Lawrence J, Meehan J, Phearman L, Soper R: A "plastic" sutureless abdominal wall closure in gastroschisis. J Pediatr Surg. 39(5):738-41, 2004 2- Weinsheimer RL, Yanchar NL, Bouchard SB, Kim PK, Laberge JM, Skarsgard ED, Lee SK, McMillan D, von Dadelszen P; Canadian Pediatric Surgery Network: Gastroschisis closure--does method really matter? J Pediatr Surg. 43(5):874-8, 2008 3- Riboh J, Abrajano CT, Garber K, Hartman G, Butler MA, Albanese CT, Sylvester KG, Dutta S: Outcomes of sutureless gastroschisis closure. J Pediatr Surg. ;44(10):1947-51, 2009 4- Choi WW, McBride CA, Bourke C, Borzi P, Choo K, Walker R, Nguyen T, Davies M, Donovan T, Cartwright D, Kimble RM: Long-term review of sutureless ward reduction in neonates with gastroschisis in the neonatal unit. J Pediatr Surg. 47(8):1516-20, 2012 5- Chesley PM, Ledbetter DJ, Meehan JJ, Oron AP, Javid PJ: Contemporary trends in the use of primary repair for gastroschisis in surgical infants. Am J Surg. 209(5):901-5, 2015 6- Zajac A, Bogusz B, Soltysiak P, Tomasik P, Wolnicki M, Wedrychowicz A, Wojciechowski P, Gorecki W: Cosmetic Outcomes of Sutureless Closure in Gastroschisis. Eur J Pediatr Surg. 26(6):537-541, 2016 |
| Fetal
ovarian cysts are the most common abdominal masses detected with an
increased incidence since the advent of prenatal ultrasonography. Fetal
ovarian cysts are usually seen toward the end of the second trimester
of pregnancy. Stimulation of the fetal ovary by placental and maternal
chorionic gonadotropin hormones leads to development of ovarian cysts.
Once diagnosed prenatally, ovarian cysts should be monitored carefully
since hemorrhage, torsion and rupture with loss of ovarian tissue can
ensue. Postnatally the baby should have an US to determine of the cyst
is simple or complex. Simple cysts also referred as follicular cysts
are usually unilocular and completely anechoic on US. Most simple
cysts below the average size of 4 cm can be observed for spontaneous
resolution. Those beyond 4 cm are at risk to developed torsion and
should be aspirated either open, percutaneously or laparoscopically.
Complex cysts which are more concerning can have echogenic wall,
internal septa, fluid-debris level or a blood clot. Most (86%)
postnatal hemorrhagic ovarian cysts have sustained torsion. Ovarian
torsion occurs from either partial or complete twist of the ovary and
fallopian tube. Conservative surgery is recommended in the first days
of life if there are US signs of hemorrhage within the cyst during
birth or immediately after birth. When torsion of a cyst occurs its
size increases rapidly and US features change to complex. Complex cysts
will have debris, internal septa or hemorrhage. Color spectral Doppler
US can be used to evaluate ovarian vascularity. Unilaterally enlarged
ovary with peripheral cysts containing fluid-debris level are highly
suspicious for ovarian torsion and hemorrhagic infarction. Absence of
blood flow is indicative of torsion. If the US findings are
equivocal, an MRI can be performed for further characterization. Most
torsion of fetal ovarian cysts occurs prenatally. A calcified abdominal
mass, with or without wandering, can be an autoamputated ovary. References: 1- Galinier P, Carfagna L, Jurisic M, et al: Fetal ovarian cysts management and ovarian prognosis: a report of 82 cases. J Pediatr Surg 43: 2004-2009, 2008 2- Koike Y, Inoue M, Uchida K, Kawamoto A, Yasuda H, Okugawa Y, Otake K, Kusunoki M: Ovarian autoamputation in a neonate: a case report with literature review. Pediatr Surg Int. 25(7):655-8, 2009 3- Sheth R, Hoelzer D, Scattergood E, Germaine P: In utero fetal ovarian torsion with imaging findings on ultrasound and MRI. Case Rep Radiol. 2012;2012:151020 4- Levit A, Voci SL: In utero fetal ovarian torsion. Ultrasound Q. 30(3):249-50, 2014 5- Ozcan HN, Balci S, Ekinci S, Gunes A, Oguz B, Ciftci AO, Haliloglu M: Imaging Findings of Fetal-Neonatal Ovarian Cysts Complicated With Ovarian Torsion and Autoamputation. AJR Am J Roentgenol. 205(1):185-9, 2015 6-Kim HS, Yoo SY, Cha MJ, Kim JH, Jeon TY, Kim WK: Diagnosis of neonatal ovarian torsion: Emphasis on prenatal and postnatal sonographic findings. J Clin Ultrasound. 44(5):290-7, 2016 |
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