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Pediatric Surgery (Pg 68-81) - page 4 / 33

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Pediatric Surgery       p. 81-91

I. Anorectal Malformations

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aka imperforate anus; rectum does not reach its normal perineal termination

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high malformation – rectum ends above levator muscles

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rectum may end blindly, but usually terminates in anterior fistulous tract

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Boys – fistula to urethra or bladder

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Girls – fistula to vagina

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low malformation – rectum passes through levator muscles but does not terminate at external sphincter

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fistula drains externally, but anterior to normal anal site

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boys – small opening in ant. Perineum or forward to scrotal raphe

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girls – small opening in ant. Perineum or posterior vulva behind hymen

cloaca – rare, occurs in girls; single opening for rectum, vagina, and urethra

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diagnosis

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if low lesion, can usu. see external fistula

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if no external fistula, assume high lesion; may see stool from vagina or urethra in high lesion

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if high or low is unclear, may do “invertogram” by holding baby upside down and performing lateral x-ray.  If air is seen within 1 cm of perineal skin, probably low lesion.

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treatment

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continence depends on:  external sphincter, internal sphincter, and levator muscles (most important)

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low lesion – if fisula is only slightly anterior, may not need modification

if too anterior to function, surgery – perineal anoplasty

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intermediate or high lesion – needs initial colostomy.  Then, pull-through procedure in next few months where rectum is pulled through levator swing and anastamosed to perineum.  Most common operation:  Pena operation.

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prognosis

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low – excellent prognosis

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high – difficult to toilet train, may have occasional soiling, may need daily enemas

II. Neonatal Jaundice:  Biliary Atresia and Choledochal Cyst

normal neonatal jaundice is usu. self-limited; indirect hyperbilirubinemia

beware of direct bilirubin >2mg/dL for 2 weeks

neonatal cholestatic jaundice:  biliary atresia, choledochal cysts, screen for TORCH infections, antitrypsin def., galactosemia, and TPN or hypoxic injury to liver

Biliary atresia, neonatal hepatitis, and infantile choledochal cysts may be manifestations of the same disease, but the etiology is unknown

percutaneous liver biopsy may also be helpful in dx

biliary atresia – progressive inflammatory obliteration of the bile ducts, beginning around the time of birth

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