Pediatric Surgery

Annular Pancreas

• embryonic ring of pancreas around duodenum
• Sx: GOO, vomiting, bloating, PO intolerance, upper abdominal pain; biliopancreatic problems
• Dx: CT, MRCP, ERCP
• Tx:
  • duodenoduodenostomy in neonates
  • duodenojejunostomy or gastrojejunostomy in adults
    • may need choledochoenterostomy or biliary stent for biliary obstruction
    • pancreaticoduodenectomy for pancreatic lesions or obstructive pancreatic duct stones

Pyloric Stenosis

• presents 2-12 weeks of age
• Sx: progressive non bilious emesis; hypokalemic hypochloremic metabolic alkalosis
• Dx: palpable Olive
• Tx: pyloromyotomy

Duodenal Web

• persistent gestational membrane in the duodenum
• Sx: abdominal distention, emesis
• Dx: UGI; Windsock appearance
• Tx: duodenotomy with excision of web

Duodenal Atresia

• persistent complete membranous obstruction of duodenum
• Sx: bilious emesis, gastric distention, poor PO intake
• Dx: double bubble on XR; no contrast study due to risk of aspiration
• Tx: NG decompression, duodenoduodenostomy or duodenojejunostomy

Biliary Atresia

• Dx: Suspected with jaundice > 2wk old. Differential includes inborn error of metabolism, CF, alpha-1-antitripsin.
  • US
  • HIDA
  • Biopsy
  • Surgery with cholangiogram
• Tx: Kasaii

Choledochal Cyst

• Dx: Type is determined by CT.
  • Type I= fusiform
  • Type II= diverticulum
  • Type III= choledochalcele
  • Type IV= intra/extra hepatic
  • Type V= intrahepatic
• Tx: Management is based on type.
  • Type I - resection of biliary tree and hepaticojejunostomy
  • Type II - resect diverticulum and close
  • Type III - resect and reanastamose with duodenum or sphincterotomy with ERCP
  • Type IV - resect
  • Type V - lobectomy if unilateral

Hydrocele

• Dx: Patients have fluid in scrotum, it transiluminates.
• Tx: Repair If:
  • not resolved by 2 yrs old.
  • unsightly or painful.
  • infected.
  • enlarging.

Cryptorchidism

• Dx: The testicle is not descended in the scrotum, but must differentiate from retractile testes (hold in place for 1 min, retractile testes will remain in place because cremasterics are fatigued).
  • karyotype for bilateral cryptorchidism.
• Tx: Main reason for treatment is to allow for continued screeing for testicular cancer which has an increased incidence.
  • Repair before 1yr old. After 2yr, there is no fertility.

Pediatric DVT prophylaxis

• In children hospitalized after trauma who are at low risk of bleeding, we conditionally recommend pharmacologic prophylaxis be considered for children older than 15 years old and in younger postpubertal children with Injury Severity Score (ISS) greater than 25.
• No chemoprophylaxis in prepubertal children, even with ISS greater than 25.
• Second, in children hospitalized after trauma, we conditionally recommend mechanical prophylaxis be considered for children older than 15 years and in younger postpubertal children with ISS greater than 25 versus no prophylaxis or in addition to pharmacologic prophylaxis.

Pediatric CT Scan Practice Guideline