Ebook Surgical recall (7th edition): Part 2

Chapter 66 / Vascular Surgery 515

Axillofemoral bypass gra —gra not
in a normal vascular path; usually,
the gra goes from the axillary artery
to the femoral artery and then from one
femoral artery to the other (fem-fem
bypass)

What is an endovascular
repair?

Placement of a stent proximal and distal
to an AAA through a distant percutaneous
access (usually through the groin); less
invasive; long-term results as good as open

2

0'

fr

h

What is an extra-anatomic
bypass gra ?

CLASSIC INTRAOP QUESTIONS DURING AAA REPAIR
Which vein crosses the neck of
the AAA proximally?

Renal vein (le )

What part of the small bowel
crosses in front of the AAA?

Duodenum

Which large vein runs to the
le of the AAA?

IMV

Which artery comes o the
middle of the AAA and runs
to the le ?

IMA

Which vein runs behind the
RIGHT common iliac artery?

LEFT common iliac vein

Which renal vein is longer?

Le

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516 Section II / General Surgery

MESENTERIC ISCHEMIA
Chronic Mesenteric Ischemia
What is it?

Chronic intestinal ischemia from
long-term occlusion of the intestinal
arteries; most commonly results from
atherosclerosis; usually in two or
more arteries because of the extensive
collaterals

What are the symptoms?

Weight loss, postprandial abdominal
pain, anxiety/fear of food because of
postprandial pain, heme occult,
diarrhea/vomiting

What is “intestinal angina”?

Postprandial pain from gut ischemia

What are the signs?

Abdominal bruit is commonly heard

How is the diagnosis made?

A-gram, duplex, MRA

What supplies blood to the gut?

1. Celiac axis vessels
2. SMA
3. IMA

What is the classic nding on
A-gram?

wo of the three mesenteric arteries are
occluded, and there is atherosclerotic
narrowing of the third patent artery

What are the treatment
options?

Bypass, endarterectomy, angioplasty,
stenting

Acute Mesenteric Ischemia
What is it?

Acute onset of intestinal ischemia

What are the causes?

1. Emboli to a mesenteric vessel from

the heart
2. Acute thrombosis of long-standing
atherosclerosis of mesenteric artery

What are the causes of emboli
from the heart?

AFib, MI, cardiomyopathy, valve
disease/endocarditis, mechanical
heart valve

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Chapter 66 / Vascular Surgery 517

What drug has been associated
with acute intestinal ischemia?

Digitalis

To which intestinal artery do
emboli preferentially go?

Superior Mesenteric Artery (SMA)

What are the signs/symptoms
of acute mesenteric ischemia?

Severe pain—classically “pain out of

proportion to physical exam,” no
peritoneal signs until necrosis, vomiting/
diarrhea/hyperdefecation, heme stools

What is the classic triad of
acute mesenteric ischemia?

1. Acute onset of pain
2. Vomiting, diarrhea, or both
3. History of AFib or heart disease

What is the gold standard
diagnostic test?

Mesenteric A-gram

What is the treatment of a
mesenteric embolus?

Perform Fogarty catheter embolectomy,
resect obviously necrotic intestine, and
leave marginal looking bowel until a
“second look” laparotomy is performed
24 to 72 hours postoperatively

What is the treatment of acute
thrombosis?

Papaverine vasodilator via A-gram
catheter until patient is in the OR;

then, most surgeons would perform a
supraceliac aorta gra to the involved
intestinal artery or endarterectomy;
intestinal resection/second look as needed

MEDIAN ARCUATE LIGAMENT SYNDROME
What is it?

Mesenteric ischemia resulting from
narrowing of the celiac axis vessels by
extrinsic compression by the median
arcuate ligament

What is the median arcuate
ligament comprised of?

Diaphragm hiatus bers

What are the symptoms?

Postprandial pain, weight loss

What are the signs?

Abdominal bruit in almost all patients

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518 Section II / General Surgery

How is the diagnosis made?

A-gram

What is the treatment?

Release arcuate ligament surgically

CAROTID VASCULAR DISEASE
Anatomy
Identify the following structures:

1. Internal carotid artery
2. External carotid artery
3. Carotid “bulb”
4. Superior thyroid artery
5. Common carotid artery
(Shaded area: common site of plaque
formation)

What are the signs/symptoms?

Amaurosis fugax, IA, RIND, CVA

De ne the following terms:
Amaurosis fugax

emporary monocular blindness (“curtain
coming down”): seen with microemboli to

retina; example of IA

TIA

Transient Ischemic Attack: focal
neurologic de cit with resolution of all
symptoms within 24 hours

RIND

Reversible Ischemic Neurologic De cit:
transient neurologic impairment (without
any lasting sequelae) lasting 24 to 72 hours

CVA

CerebroVascular Accident (stroke):
neurologic de cit with permanent brain
damage

What is the risk of a CVA in
patients with TIA?

10% a year

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Chapter 66 / Vascular Surgery 519

What is the noninvasive method
of evaluating carotid disease?

Carotid ultrasound/Doppler: gives
general location and degree of stenosis

What is the gold standard
invasive method of evaluating
carotid disease?

A-gram

What is the surgical treatment
of carotid stenosis?

Carotid EndArterectomy (CEA): the
removal of the diseased intima and media
of the carotid artery, o en performed with
a shunt in place

What are the indications for
CEA in the ASYMPTOMATIC
patient?

Carotid artery stenosis 60% (greatest
bene t is probably in patients with 80%
stenosis)

What are the indications for
CEA in the SYMPTOMATIC

(CVA, TIA, RIND) patient?

Carotid stenosis

Before performing a CEA in
the symptomatic patient, what
study other than the A-gram
should be performed?

Head C

In bilateral high-grade carotid
stenosis, on which side should
the CEA be performed in the
asymptomatic, right-handed
patient?

Le CEA rst, to protect the dominant
hemisphere and speech center

What is the dreaded
complication a er a CEA?

Stroke (CVA)

What are the possible
postoperative complications
a er a CEA?

CVA, MI, hematoma, wound infection,

hemorrhage, hypotension/hypertension,
thrombosis, vagus nerve injury (change
in voice), hypoglossal nerve injury
(tongue deviation toward side of injury—
“wheelbarrow” e ect), intracranial
hemorrhage

What is the mortality rate a er
CEA?

1%

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520 Section II / General Surgery

What is the perioperative
stroke rate a er CEA?

Between 1% (asymptomatic patient) and
5% (symptomatic patient)

What is the postoperative
medication?

Aspirin (inhibits platelets by inhibiting
cyclo-oxygenase)

What is the most common
cause of death during the early
postoperative period a er a CEA?

MI

De ne “Hollenhorst plaque”?

Microemboli to retinal arterioles seen as
bright defects

CLASSIC CEA INTRAOP QUESTIONS
What thin muscle is cut right
under the skin in the neck?

Platysma muscle

What are the extracranial
branches of the internal carotid
artery?

None

Which vein crosses the carotid
bifurcation?

Facial vein

What is the rst branch of the

external carotid?

Superior thyroidal artery

Which muscle crosses the
common carotid proximally?

Omohyoid muscle

Which muscle crosses the
carotid artery distally?

Digastric muscle (T ink: Digastric
Distal)

Which nerve crosses
approximately 1 cm distal to
the carotid bifurcation?

Hypoglossal nerve; cut it and the tongue
will deviate toward the side of the injury
(the “wheelbarrow e ect”)
Inte rnal
c aro tid arte ry
Hypo g lo s s al
ne rve

Exte rnal
c aro tid
arte ry

Co mmo n
c aro tid
arte ry

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Chapter 66 / Vascular Surgery 521

Which nerve crosses the internal
carotid near the ear?

Facial nerve (marginal branch)

What is in the carotid sheath?

1. Carotid artery
2. Internal jugular vein
3. Vagus nerve (lies posteriorly in 98% of
patients and anteriorly in 2%)
4. Deep cervical lymph nodes

SUBCLAVIAN STEAL SYNDROME
What is it?

Arm fatigue and vertebrobasilar
insu ciency from obstruction of the le
subclavian artery or innominate proximal to
the vertebral artery branch point; ipsilateral

arm movement causes increased blood ow
demand, which is met by retrograde ow
from the vertebral artery, thereby “stealing”
from the vertebrobasilar arteries

Which artery is most
commonly occluded?

Le subclavian

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522 Section II / General Surgery

What are the symptoms?

Upper extremity claudication, syncopal
attacks, vertigo, confusion, dysarthria,
blindness, ataxia

What are the signs?

Upper extremity blood pressure
discrepancy, bruit (above the clavicle),
vertebrobasilar insu ciency

What is the treatment?

Surgical bypass or endovascular stent

RENAL ARTERY STENOSIS
What is it?

Stenosis of renal artery, resulting in
decreased perfusion of the juxtaglomerular
apparatus and subsequent activation of the
renin-angiotensin-aldosterone system (i.e.,
hypertension from renal artery stenosis)

S te no s is

What is the incidence?

10% to 15% of the U.S. population have
H N; of these, 4% have potentially
correctable renovascular H N
Also note that 30% of malignant H N
have a renovascular etiology

What is the etiology of the
stenosis?

66% result from atherosclerosis
(men women), 33% result from
bromuscular dysplasia (women
men, average age 40 years, and 50%
with bilateral disease)
Note: Another rare cause is hypoplasia of
the renal artery

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Chapter 66 / Vascular Surgery 523

What is the classic pro le of
a patient with renal artery
stenosis from bromuscular
dysplasia?

Young woman with hypertension

What are the associated risks/
clues?

Family history, early onset of H N, H N
refractory to medical treatment

What are the signs/symptoms?

Most patients are asymptomatic but may
have headache, diastolic H N, ank bruits
(present in 50%), and decreased renal
function

What are the diagnostic tests?
A-gram

Maps artery and extent of stenosis (gold

standard)

IVP

80% of patients have delayed nephrogram
phase (i.e., delayed lling of contrast)

Renal vein renin ratio
(RVRR)

If sampling of renal vein renin levels shows
ratio between the two kidneys 1.5, then
diagnostic for a unilateral stenosis

Captopril provocation test

Will show a drop in BP

Are renin levels in serum
ALWAYS elevated?

No: Systemic renin levels may also
be measured but are only increased
in malignant H N, as the increased
intravascular volume dilutes the elevated
renin level in most patients

What is the invasive
nonsurgical treatment?

Percutaneous Renal Transluminal
Angioplasty (PRTA)/stenting:
With FM dysplasia: use PR A
With atherosclerosis: use PR A/stent

What is the surgical treatment?

Resection, bypass, vein/gra interposition,
or endarterectomy

What antihypertensive
medication is
CONTRAINDICATED in
patients with hypertension
from renovascular stenosis?

ACE inhibitors (result in renal
insu ciency)

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524 Section II / General Surgery

SPLENIC ARTERY ANEURYSM
What are the causes?

Women—medial dysplasia
Men—atherosclerosis

How is the diagnosis made?

Usually by abdominal pain S U/S or
C scan, in the O.R. a er rupture, or
incidentally by eggshell calci cations
seen on AXR

What is the risk factor for
rupture?

Pregnancy

What are the indications
for splenic artery aneurysm
removal?

Pregnancy, 2 cm in diameter, symptoms,
and in women of childbearing age

What is the treatment for
splenic aneurysm?

Resection or percutaneous catheter
embolization in high-risk (e.g., portal
hypertension) patients

POPLITEAL ARTERY ANEURYSM
What is it?

Aneurysm of the popliteal artery caused

by atherosclerosis and, rarely, bacterial
infection

Po plite al
arte ry

Kne e

How is the diagnosis made?

Ane urys m

Usually by physical exam S A-gram, U/S

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Chapter 66 / Vascular Surgery 525

Why examine the contralateral
popliteal artery?

50% of all patients with a popliteal artery
aneurysm have a popliteal artery aneurysm
in the contralateral popliteal artery

What are the indications for
elective surgical repair of a
popliteal aneurysm?

1. 2 cm in diameter
2. Intraluminal thrombus
3. Artery deformation

Why examine the rest of the
arterial tree (especially the
abdominal aorta)?

75%of all patients with popliteal
aneurysms have additional aneurysms
elsewhere; 50% of these are located in
the abdominal aorta/iliacs

What size of the following
aneurysms are usually
considered indications for
surgical repair:
oracic aorta?

6.5 cm

Abdominal aorta?

5.5 cm

Iliac artery?

4 cm

Femoral artery?

2.5 cm

Popliteal artery?

2 cm

MISCELLANEOUS
De ne the following terms:
“Milk leg”

A.k.a. phlegmasia alba dolens
(alba white): o en seen in pregnant
women with occlusion of iliac vein
resulting from extrinsic compression by
the uterus (thus, the leg is “white” because
of subcutaneous edema)

Phlegmasia cerulea dolens

In comparison, phlegmasia cerulea dolens
is secondary to severe venous out ow
obstruction and results in a cyanotic leg;
the extensive venous thrombosis results in
arterial in ow impairment

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526 Section II / General Surgery

Raynaud’s phenomenon

Vasospasm of digital arteries with color
changes of the digits; usually initiated
by cold/emotion
White (spasm), then blue (cyanosis), then
red (hyperemia)

Takayasu’s arteritis

Arteritis of the aorta and aortic branches,
resulting in stenosis/occlusion/
aneurysms
Seen mostly in women

Buerger’s disease

A.k.a. thromboangiitis obliterans:
occlusion of the small vessels of the hands
and feet; seen in young men
who smoke; o en results in digital
gangrene S amputations

What is the treatment for
Buerger’s disease?

Smoking cessation,

What is blue toe syndrome?

Microembolization from proximal
atherosclerotic disease of the aorta
resulting in blue, painful, ischemic toes

What is a “paradoxical
embolus”?

Venous embolus gains access to the le
heart a er going through an intracardiac
defect, most commonly a patent foramen
ovale, and then lodges in a peripheral
artery

What size iliac aneurysm
should be repaired?
What is Behçet’s disease?

sympathectomy

4 cm diameter

Genetic disease with aneurysms from loss
of vaso vasorum; seen with oral, ocular, and
genital ulcers/in ammation (c incidence in
Japan, Mediterranean)

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SubspecialtySurgery

Chapter 67 PediatricSurgery
What is the motto o pediatric
surgery?

“Children are NOT little adults!”

What is a simple way to
distract a pediatric patient
when examining the abdomen
or tenderness?

Listen to the abdomen with the
stethoscope and then push down on the
abdomen with the stethoscope to check for
tenderness

PeDiA Ri iV FLUiDS A D U Ri i
What is the maintenance IV
f uid or children?

D5 1/4 NS

Why 1/4 NS?

Children (especially those younger than
4 years of age) cannot concentrate their
urine and cannot clear excess sodium

How are maintenance f uid
rates calculated in children?

4, 2, 1 per hour:
4 cc/ kg or the rst 10 kg o body weight
2 cc/kg or the second 10 kg o body
weight
1 cc/ kg or every kilogram over the
rst 20 (e.g., the rate for a child
weighing 25 kg is 4 10 40 plus
2 10 20 plus 1 5 5, for an
IVF rate of 65 cc/hr)

What is the minimal urine
output or children?

From 1 to 2 mL/kg/hr

What is the best way to present
urine output measurements on
rounds?

Urine output total per shi , THEN cc/kg/hr

What is the major di erence
between adult and pediatric
nutritional needs?

Premature infants/infants/children need
more calories and protein/kg/day

WhiteKnightLove

20 mEq KCl

527


528 Section III / Subspecialty Surgery

What are the caloric
requirements by age or the
ollowing patients:
Premature in ants?

80 Kcal/kg/day and then go up

Children younger than
1 year?

100 Kcal/kg/day (90–120)

Children ages 1 to 7?

85 Kcal/kg/day (75–90)

Children ages 7 to 12?

70 Kcal/kg/day (60–75)

Youths ages 12 to 18

40 Kcal/kg/day (30–60)

What are the protein
requirements by age or the
ollowing patients:
Children younger than
1 year?

3 g/kg/day (2–3.5)

Children ages 1 to 7?

2 g/kg/day (2–2.5)

Children ages 7 to 12?

2 g/kg/day

Youths ages 12 to 18?

1.5 grams/kg/day

How many calories are in
breast milk?

PeDiA Ri BL

20 Kcal/30 cc (same as most formulas)

D V LUMeS

Give blood volume per
kilogram:
Newborn in ant?

85 cc

In ant 1–3 months o age?

75 cc

Child?

70 cc

Fe AL iR ULA i
What is the number o
umbilical veins?

1 (usually)

What is the number o

umbilical arteries?

2

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Chapter 67 / Pediatric Surgery 529

Which umbilical vessel
carries oxygenated blood?

Umbilical vein

T e oxygenated blood travels
through the liver to the IVC
through which structure?

Ductus venosus

Oxygenated blood passes
rom the right atrium to the
le atrium through which
structure?

Foramen ovale

Unsaturated blood goes rom
the right ventricle to the
descending aorta through

which structure?

Ductus arteriosum

De ne the overall etal
circulation
Caro tid arte rie s
To arm

To arm
Duc tus arte rio s is

Lung

Lung
Fo rame n
ovale

Live r

Kidney
Plac e nta

Gut

Fe mo ral arte ry
Fe mo ral arte ry

What are the ADUL
structures o the ollowing

etal structures:
Ductus venosus?

Ligamentum venosum

Umbilical vein?

Ligamentum teres

Umbilical artery?

Medial umbilical ligament

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530 Section III / Subspecialty Surgery

Ductus arteriosus?

Ligamentum arteriosum

Urachus?

Median umbilical ligament

ongue remnant o thyroid’s
descent?

Foramen cecum

Persistent remnant o
vitelline duct?

Meckel’s diverticulum

S to mac h
Duo de num
S upe rio r
me s e nte ric
arte ry
Vite lline duc t
Umbilic us

e M
What is ECMO?

ExtraCorporeal Membrane Oxygenation:
chronic cardiopulmonary bypass—for
complete respiratory support

What are the types o ECMO?

Venovenous: Blood from vein S
oxygenated S back to vein
Venoarterial: Blood from vein (IJ) S
oxygenated S back to artery (carotid)

What are the indications?

Severe hypoxia, usually from congenital
diaphragmatic hernia, meconium
aspiration, persistent pulmonary
hypertension, sepsis

What are the
contraindications?

Weight 2 kg, IVH (IntraVentricular
Hemorrhage in brain contraindicated
because of heparin in line)

WhiteKnightLove


Chapter 67 / Pediatric Surgery 531

e k
What is the major di erential
diagnosis o a pediatric neck
mass?

yroglossal duct cyst (midline), branchial
cle cyst (lateral), lymphadenopathy,
abscess, cystic hygroma, hemangioma,
teratoma/dermoid cyst, thyroid nodule,
lymphoma/leukemia (also parathyroid
tumors, neuroblastoma, histiocytosis
X, rhabdomyosarcoma, salivary gland
tumors, neuro broma)

hyroglossal Duct yst
What is it?

Remnant of the diverticulum formed
by migration of thyroid tissue; normal
development involves migration of thyroid
tissue from the foramen cecum at the base
of the tongue through the hyoid bone to its
nal position around the tracheal cartilage

What is the average age at
diagnosis?

Usually presents around 5 years of age

How is the diagnosis made?

Ultrasound

What are the complications?

Enlargement, infection, and stula
formation between oropharynx or salivary
gland; aberrant thyroid tissue may
masquerade as thyroglossal duct cyst, and
if it is not cystic, deserves a thyroid scan,
MALignancy

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532 Section III / Subspecialty Surgery

What is the anatomic location?

Almost always in the midline

How can one remember the
position o the thyroglossal
duct cyst?

ink: thyroGLOSSAL
midline sticking out

What is the treatment?

Antibiotics if infection is present,
then excision, which must include
the midportion of the hyoid bone and
entire tract to foramen cecum (Sistrunk
procedure)

ONGUE

Branch al l ft Anomal s
What is it?

Remnant of the primitive branchial cle s
in which epithelium forms a sinus tract

between the pharynx (second cle ), or the
external auditory canal ( rst cle ), and the
skin of the anterior neck; if the sinus ends
blindly, a cyst may form

What is the common
presentation?

Infection because of communication
between pharynx and external ear canal

What is the anatomic position?

Second cle anomaly—lateral to the
midline along anterior border of the
sternocleidomastoid, anywhere from
angle of jaw to clavicle
First cle anomaly—less common than
second cle anomalies; tend to be
located higher under the mandible

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Chapter 67 / Pediatric Surgery 533

What is the most common cle
remnant?

Second; thus, these are found most o en

laterally versus thyroglossal cysts, which are
found centrally ( ink: Second Superior)

What is the treatment?

Antibiotics if infection is present, then
surgical excision of cyst and tract once
in ammation is resolved

What is the major anatomic
di erence between thyroglossal
cyst and branchial cle cyst?

yroglossal cyst midline
Branchial cle cyst lateral
( ink: brAnchial lAteral)

Str dor
What is stridor?

Harsh, high-pitched sound heard on
breathing caused by obstruction of the
trachea or larynx

What are the signs/
symptoms?

Dyspnea, cyanosis, di culty with feedings

What is the di erential

diagnosis?

Laryngomalacia—leading cause of stridor
in infants; results from inadequate
development of supporting laryngeal
structures; usually self-limited and
treatment is expectant unless
respiratory compromise is present
Tracheobronchomalacia—similar to
laryngomalacia, but involves the entire
trachea
Vascular rings and slings—abnormal
development or placement of thoracic
large vessels resulting in obstruction of
trachea/bronchus
Acute Allergic Reaction

What are the symptoms o
vascular rings?

Stridor, dyspnea on exertion, or dysphagia

How is the diagnosis o
vascular rings made?

Barium swallow revealing typical
con guration of esophageal compression
Echo/arteriogram

What is the treatment o

vascular rings?

Surgical division of the ring, if the patient
is symptomatic

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534 Section III / Subspecialty Surgery

yst c Hygroma
What is it?

Congenital abnormality of lymph sac
resulting in lymphangioma

What is the anatomic location?

Occurs in sites of primitive lymphatic
lakes and can occur virtually anywhere
in the body, most commonly in the oor
of mouth, under the jaw, or in the neck,
axilla, or thorax

What is the treatment?

Early total surgical removal because they
tend to enlarge; sclerosis may be needed if
the lesion is unresectable

What are the possible
complications?

Enlargement in critical regions, such as the
oor of the mouth or paratracheal region,
may cause airway obstruction; also, they
tend to insinuate onto major structures
(although not malignant), making excision
di cult and hazardous

ASPiRA eD F Rei

B D (FB)

Which bronchus do FBs go into
more commonly (le or right)?

Younger than age 4—50/50
Age 4 and older—most go into right
bronchus because it develops into a
straight shot (less of an angle)

What is the most commonly
aspirated object?

Peanut

What is the associated risk with
peanut aspiration?

Lipoid pneumonia

How can an FB result in “air
trapping and hyperinf ation”?

By forming a “ball valve” (i.e., air in, no
air out) as seen on CXR as a hyperin ated
lung on expiratory lm

How can you tell on
A-P CXR i a coin is in the
esophagus or the trachea?

Coin in esophagus results in the coin lying
“en face” with face of the coin viewed as a
round object because of compression by
anterior and posterior structures
If coin is in the trachea, it is viewed as a
side projection due to the U-shaped
cartilage with membrane posteriorly

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Chapter 67 / Pediatric Surgery 535

What is the treatment o
tracheal or esophageal FB?

Remove FB with bronchoscope or

esophagoscope

HeS
What is the di erential
diagnosis o a lung mass?

Bronchial adenoma (carcinoid is most
common), pulmonary sequestration,
pulmonary blastoma, rhabdomyosarcoma,
chondroma, hamartoma, leiomyoma,
mucus gland adenoma, metastasis

What is the di erential
diagnosis o mediastinal
tumor/mass?

1. Neurogenic tumor (ganglioneuromas,
neuro bromas)
2. Teratoma
3. Lymphoma
4. ymoma
(Classic “ our ’s”: eratoma, errible
lymphoma, hymoma, hyroid tumor)
Rare: pheochromocytoma, hemangioma,
rhabdomyosarcoma, osteochondroma

P ctus D form ty
What heart abnormality
is associated with pectus
abnormality?

Mitral valve prolapse (many patients
receive preoperative echocardiogram)

P ctus excavatum
What is it?

Chest wall deformity with sternum caving
inward ( ink: exCAVatum CAVE)

Pe c tus
e xc avatu m

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536 Section III / Subspecialty Surgery

What is the cause?

Abnormal, unequal overgrowth of rib
cartilage

What are the signs/symptoms?

O en asymptomatic; mental distress,
dyspnea on exertion, chest pain

What is the treatment?

Open perichondrium, remove abnormal
cartilage, place substernal strut; new
cartilage grows back in the perichondrium
in normal position; remove strut 6 months
later

What is the NUSS procedure?

Placement of metal strut to elevate
sternum without removing cartilage

P ctus ar natum
What is it?

Chest wall deformity with sternum outward
(pectus chest, carinatum pigeon); much
less common than pectus excavatum

Pe c tus
c arinatum

What is the cause?

Abnormal, unequal overgrowth of rib
cartilage

What is the treatment?

Open perichondrium and remove
abnormal cartilage

Place substernal strut
New cartilage grows into normal position
Remove strut 6 months later

WhiteKnightLove


Chapter 67 / Pediatric Surgery 537

esophag al Atr s a w thout rach o sophag al ( e) F stula
What is it?

Blind-ending esophagus from atresia

What are the signs?

Excessive oral secretions and inability to
keep food down

How is the diagnosis made?

Inability to pass NG tube; plain x-ray
shows tube coiled in upper esophagus and
no gas in abdomen

What is the primary treatment?

Suction blind pouch, IVFs, (gastrostomy
to drain stomach if prolonged preoperative
esophageal stretching is planned)

What is the de nitive
treatment?

Surgical with 1 anastomosis, o en
with preoperative stretching of blind
pouch (other options include colonic or
jejunal interposition gra or gastric tube
formation if esophageal gap is long)

esophag al Atr s a W th rach o sophag al ( e) F stula
What is it?

Esophageal atresia occurring with a stula
to the trachea; occurs in 90% of cases of
esophageal atresia

What is the incidence?

One in 1500 to 3000 births

De ne the ollowing types
o stulas/atresias:
ype A

Esophageal atresia without TE
stula (8%)

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538 Section III / Subspecialty Surgery

ype B

Proximal esophageal atresia with proximal
TE stula (1%)

ype C

Proximal esophageal atresia with distal TE
stula (85%); most common type

ype D

Proximal esophageal atresia with both
proximal and distal TE stulas (2%)
( ink: D Double connection to
trachea)

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Chapter 67 / Pediatric Surgery 539

ype E

“H-type” TE stula without esophageal
atresia (4%)

How do you remember which
type is most common?

Simple: Most Common type is type C

What are the symptoms?

Excessive secretions caused by an
accumulation of saliva (may not occur
with type E)

What are the signs?

Obvious respiratory compromise,
aspiration pneumonia, postprandial
regurgitation, gastric distention as air
enters the stomach directly from the
trachea

How is the diagnosis made?

Failure to pass an NG tube (although this
will not be seen with type E); plain lm
demonstrates tube coiled in the upper
esophagus; “pouchogram” (contrast
in esophageal pouch); gas on AXR
(tracheoesophageal stula)

What is the initial treatment?

Directed toward minimizing complications
from aspiration:
1. Suction blind pouch (NPO/TPN)
2. Upright position of child
3. Prophylactic antibiotics (Amp/gent)

What is the de nitive
treatment?

Surgical correction via a thoracotomy,
usually through the right chest with
division of stula and end-to-end
esophageal anastomosis, if possible

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