Pediatric

Question 1

Operative steps in pyloromyotomy

Answer 1

1. Begin incision 2mm proximal to pyloric vein 2. incise to see bulging of mucosa 3. Muscle on either side should move independently. 4. If perforation of duodenal mucosa, close in layers, including serosa, flip pylorus over and do myotomy on other side. 5. Insufflate the NG at end of case to check for leak.

Question 2

Feeding after pyloromyotomy

Answer 2

1. STart 4-6 hours post op with Pedialyte 2. If tolerates, advance 10-15 cc per feed until at 90cc 3. Transition to breast milk or forumla. 4. If emesis, hold for 3 hours and try again.

Question 3

Differential diatnosis of bilious emesis

Answer 3

1. malrotation
2. duodenal stenosis/web/atresia
3. jejunal atresia
4. NEC
5. GERD
6. Meconium ileus
7. annular pancreas

Question 4

Timing of diagnosis of malrotation (% diagnosed at 3 days, 1 week, 1st month)

Answer 4

30%, 50%, 80%

Question 5

Studies available to help diagnose malrotation if UGI negative

Answer 5

CT abdomen and pelvis

U/S looking for SMV to the left or anterior to SMA

Question 6

Ladd’s procedure in newborn or infant

Answer 6

1. Horizontal supraumbilical incision
2. Counterclockwise rotation of bowel between 1 and 3 full roations.
3. Take down Ladd’s bands - right colon to right abdominal wall
4. Appendectomy
5. May incise peritoneum over mesentery to move colon further left.
6. Place duo and small bowel on right and colon on left.

Question 7

Neuroblastoma stats

Answer 7

most common cancer of infants

Most common solid tumor of children (10% of childhood malignancies)

50% diagnosed by 2 years old

50% in adrenal gland

Question 8

Imaging work up for neuroblastoma, biopsy?

Answer 8

1. U/S
2. CT scan
3. MIBG scan
4. Biopsy needed of mass and bone marrow for staging.

Question 9

Treatment for neuroblastoma

Answer 9

Complex decision making - surgery for early or low stage disease, induction chemo (Carboplatin/etopiside) + / - surgery for mid stage disease.

Question 10

Imaging work up for abdominal mass in children

Answer 10

1. U/S
2. CT with IV/PO contrast
3. May need doppler U/S to analyze IVC involvement (Wilms)

Question 11

Principles of surgical management of Wilms’ tumor

Answer 11

1. Diagnosis
2. Resection without tumor spillage
3. Avoid resection of adjacent organs

If can’t obtain all these initially (or if have IVC tumor thrombi) need pre-operative Chemotherapy (Vincristin, dactinomycin)

If abdomina spillage, patient will also need abdominal radiation.

of note, chemotherapy is started in hospital before discharge.

Question 12

In addiiton to U/S and CT, what imaing and labs necessary if concern for hepatoblastoma

Answer 12

1. MRI
2. CBC, lytes, liver profile, AFP, B HCG, urinalysis

Question 13

If hepatoblastoma is metastatic or unresectalbe?

Answer 13

need biopsy, then neoadjuvant therapy

Question 14

Diagnostic work up for RLQ pain in child (intussuception)

Answer 14

Ultrasound, target sign

Treatment: air contrast enema

Question 15

Instructions for air contrast enema

Answer 15

1. Rectal tube
2. Insufflation up to 120 mm Hg under fluoroscopy.
3. Air in small bowel is diagnostic of success.
4. Need to keep for observation for several hours prior to discharge

Question 16

Answer 16

NEC with portal venous gas

Question 17

Minimum length of viable and functioning bowel

Answer 17

40 cm

Question 18

Length of bowel to have nutritional autonomy

Answer 18

Historically 100 cm of small bowel without IC valve and 70 with IC valve and some colon

Question 19

Differential for lower GI bleed in child

Answer 19

1. Meckel’s
2. Anal fissures
3. IBD
4. Intestinal polyps or duplications

Question 20

Work up for Lower GI bleed and concern for Meckel’s

Answer 20

Meckel’s scan (Technetium 99 pertechnetate) (gastric mucosa)

Question 21

Rule of 2s for Meckel’s

Answer 21

1. 2% of population
2. 2 feet of IC valve
3. 2 in in length
4. symptomatic by 2
5. 2 times more common in boys
6. 2 types of mucosa (gastric, pancreatic)
7. 2 presentations (obstruction - more common, bleeding)

Question 22

If Meckel’s scan is negative, further work up?

Answer 22

Diagnostic laparoscopy looking for Meckel’s with false negative

Question 23

How to resect Meckel’s

Answer 23

If not bleeding, with narry neck - may staple diverticulum off

If bleeding - wedge resection to inspect mucosa of ileum and then Transverse closure

If wide neck or complicaitons - segmental bowel resection.

Question 24

Omphalocele classificaiton

Answer 24

small - < 5 cm - only bowel

Giant > 5 cm - liver, bowel, spleen

IN midline covered by peritoneum

Question 25

Gastroschisis

Answer 25

Defect to right of umbilicus, with protruding bowel, not covered by peritoneum

Question 26

Basic work up with omphalocele

Answer 26

Chromosomal analysis Cardiac work up Temperature management Frequent glucoses IV, gastric, bladder access Antibiotics and vitamin K

Question 27

Treatment for giant (\> 5 cm) omphalocele that can't be primarily closed

Answer 27

Paint and wait

Question 28

Most common types of TEF

Answer 28

A. esophageal atresia and distal TEF (~80%) B. Esophageal atresia alone E. H type with no atresia, but fistula to trachea

Question 29

VACTERL

Answer 29

1. vertebral 2. Anorectal 3. cardiac 4. TEF 5. renal 6. LImb all diagnosed with physical exam and X ray for Vertebral and ECHO