Gastric Outlet Obstruction in an infant - Department of Surgery at ...
Gastric Outlet Obstruction in an infant - Department of Surgery at ...
Gastric Outlet Obstruction in an infant - Department of Surgery at ...
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downst<strong>at</strong>esurgery.org<strong>Gastric</strong> <strong>Outlet</strong> <strong>Obstruction</strong><strong>in</strong> <strong>an</strong> <strong>in</strong>f<strong>an</strong>tSophia L Fu, MDRichmond University Medical CenterSt<strong>at</strong>en Isl<strong>an</strong>d, NYSUNY Downst<strong>at</strong>e Medical Center,Brooklyn, NYJ<strong>an</strong>uary 20, 2010
<strong>Gastric</strong> <strong>Outlet</strong> <strong>Obstruction</strong>downst<strong>at</strong>esurgery.orgHistory‣ 14 mo male with <strong>in</strong>termittent nonbilious, nonprojectile,nonbloody vomit<strong>in</strong>g, ~30m<strong>in</strong>-2hrs s/p feed<strong>in</strong>g, 3 lb wt loss<strong>in</strong> 2 mo, no ↓ appetite, ↓ stool & wet diapers‣ PMH: BW 6lbs 7oz, NICU stay x2mo 2º withdrawal Sx;4day stay for RSV @6mo‣ FHx: m<strong>at</strong>ernal drug addiction‣ SocHx: FT, NSVD, older sister, immuniz<strong>at</strong>ions
<strong>Gastric</strong> <strong>Outlet</strong> <strong>Obstruction</strong>downst<strong>at</strong>esurgery.orgPhysical Exam<strong>in</strong><strong>at</strong>ion‣ VS 98º 125/83 149 24‣ Wt 20.2lbs (3-10%) Ht 27.5<strong>in</strong> (
<strong>Gastric</strong> <strong>Outlet</strong> <strong>Obstruction</strong>downst<strong>at</strong>esurgery.orgLabor<strong>at</strong>ory work-up20.714.340.75831342.180.338.9130.213010.77.35.149192131.1UA – neg
Pyloro-<strong>an</strong>tral Webdownst<strong>at</strong>esurgery.orgAbdom<strong>in</strong>al X-ray
<strong>Gastric</strong> <strong>Outlet</strong> <strong>Obstruction</strong>downst<strong>at</strong>esurgery.orgInitial M<strong>an</strong>agement & Endoscopy‣ Resuscit<strong>at</strong>ion‣ D5 ¼ NS +20mEq KCl @80‣ NGT placement‣ GI Consult‣ Peds <strong>Surgery</strong> Consult
<strong>Gastric</strong> <strong>Outlet</strong> <strong>Obstruction</strong>downst<strong>at</strong>esurgery.orgUpper GI Series
<strong>Gastric</strong> <strong>Outlet</strong> <strong>Obstruction</strong>downst<strong>at</strong>esurgery.orgSurgical Explor<strong>at</strong>ion
<strong>Gastric</strong> <strong>Outlet</strong> <strong>Obstruction</strong>downst<strong>at</strong>esurgery.orgP<strong>at</strong>hologyAntral Web
Par<strong>at</strong>hyroid Adenomadownst<strong>at</strong>esurgery.orgOper<strong>at</strong>ive M<strong>an</strong>agement/ Recovery‣ Tr<strong>an</strong>sverse upper abdom<strong>in</strong>al <strong>in</strong>cision‣ Gastrotomy – web resection‣ 14Fr Bougie fit‣ Total OR time: 2:10‣ EBL m<strong>in</strong>imal‣ D5 1/3NS180mL‣ POST-OP recovery‣ Await BM‣ Adv<strong>an</strong>ce diet‣ D/C Home POD#4
downst<strong>at</strong>esurgery.orgPyloro-<strong>an</strong>tral Web
Pyloro-<strong>an</strong>tral Webdownst<strong>at</strong>esurgery.orgEtiology‣ M<strong>at</strong>ernal <strong>in</strong>trauter<strong>in</strong>e vascularaccidents‣ Ischemic necrosis‣ Subsequent bowel <strong>at</strong>resia‣ Failure <strong>of</strong> rec<strong>an</strong>aliz<strong>at</strong>ion‣ Redund<strong>an</strong>cy <strong>an</strong>d slipp<strong>in</strong>g <strong>of</strong>epithelial l<strong>in</strong><strong>in</strong>g‣ Genetics‣ Pyloroduodenal obstruction
Pyloro-<strong>an</strong>tral Webdownst<strong>at</strong>esurgery.orgCl<strong>in</strong>ical Present<strong>at</strong>ion‣ M<strong>at</strong>ernal Hx <strong>of</strong> polyhydramnios‣ Nonbilious vomit<strong>in</strong>g‣ <strong>Gastric</strong> outlet obstruction‣ Respir<strong>at</strong>ory Sx‣ Dyspnea‣ Tachypnea‣ Cy<strong>an</strong>osis‣ Excessive saliv<strong>at</strong>ion‣ Epigastric fullness‣ Perfor<strong>at</strong>ion
Pyloro-<strong>an</strong>tral Webdownst<strong>at</strong>esurgery.orgAbdom<strong>in</strong>al Radiography
Pyloro-<strong>an</strong>tral Webdownst<strong>at</strong>esurgery.orgUpper GI Series
Pyloro-<strong>an</strong>tral Webdownst<strong>at</strong>esurgery.orgP<strong>at</strong>hology
downst<strong>at</strong>esurgery.org<strong>Surgery</strong>
Pyloro-<strong>an</strong>tral WebTre<strong>at</strong>ment <strong>of</strong> Pyloric Atresia‣ Gastrotomy‣ Distal passage <strong>of</strong> a c<strong>at</strong>heterdownst<strong>at</strong>esurgery.org‣ Detect membr<strong>an</strong>ous obstructions‣ Excision <strong>of</strong> complete or partial diaphragm‣ He<strong>in</strong>eke-Mikulicz or F<strong>in</strong>ney Pyloroplasty‣ Gastroduodenostomy‣ Altern<strong>at</strong>ive procedures us<strong>in</strong>g endoscopy‣ Balloon dil<strong>at</strong><strong>at</strong>ion‣ Laser web excision‣ Laser radial <strong>in</strong>cisions <strong>of</strong> membr<strong>an</strong>e
Zenker’s Diverticulumdownst<strong>at</strong>esurgery.orgReferences• Balaji NS, Peters JH: M<strong>in</strong>imally <strong>in</strong>vasive surgery for esophageal motility disorders. Surg Cl<strong>in</strong> North Am 82:763–82, 2002.• Brace M, Taylor SM, Trites JR, Bethune D, Attia E, Hart RD. Endoscopic stapl<strong>in</strong>g versus externaltr<strong>an</strong>scervical approach for the tre<strong>at</strong>ment <strong>of</strong> Zenker diverticulum. J Otolaryngol Head Neck Surg. 2010 Feb1;39(1):102-6.• Bremner CG, DeMeester TR: Endoscopic tre<strong>at</strong>ment <strong>of</strong> Zenker's diverticulum. Gastro<strong>in</strong>test Endosc49:126–8, 1999.• Sen P, Bh<strong>at</strong>tacharyya AK: Endoscopic stapl<strong>in</strong>g <strong>of</strong> pharyngeal pouch. J Laryngol Otol 118:601–6, 2004.• Sohn H. J, DeMeester S. R, "Chapter 25. Resection <strong>of</strong> Esophageal Diverticula" (Chapter). Sugarbaker DJ, BuenoR, Krasna MJ, Mentzer SJ, Zellos L: Adult Chest <strong>Surgery</strong>:http://www.accesssurgery.com/content.aspx?aID=5287346.• Souba W, F<strong>in</strong>k M( \Jurkovich G, \Kaiser L, Pearce W, Pemberton J, Soper N. ACS <strong>Surgery</strong>: Pr<strong>in</strong>ciples<strong>an</strong>d Practice 2010.• Zoll<strong>in</strong>ger RM Jr, Zoll<strong>in</strong>ger RM Sr, "Zenker's Diverticulectomy" (Chapter). Zoll<strong>in</strong>ger RM Jr, Zoll<strong>in</strong>ger RM Sr:Zoll<strong>in</strong>ger's Atlas <strong>of</strong> Surgical Oper<strong>at</strong>ions, 8th Edition: http://www.accesssurgery.com/content.aspx?aID=61515.
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