524 Section III / Subspecialty Surgery

CYSTIC HYGROMA

What is it?	Congenital abnormality of lymph sac
	resulting in lymphangioma
What is the anatomic	Occurs in sites of primitive lymphatic
location?	lakes and can occur virtually anywhere in
	the body, most commonly in the floor 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	Enlargement in critical regions, such as
complications?	the floor of the mouth or paratracheal
	region, may cause airway obstruction;
	also, they tend to insinuate onto major
	structures (although not malignant),
	making excision difficult and hazardous

ASPIRATED FOREIGN BODY (FB)

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

What is the most commonly aspirated object?

What is the associated risk with peanut aspiration?

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

How can you tell on

A-P CXR if a coin is in the esophagus or the trachea?

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)

Peanut

Lipoid pneumonia

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

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

Chapter 67 / Pediatric Surgery 525

What is the treatment of tracheal or esophageal FB?

Remove FB with rigid bronchoscope or rigid esophagoscope

CHEST

What is the differential	Bronchial adenoma (carcinoid is most
diagnosis of a lung mass?	common), pulmonary sequestration,
	pulmonary blastoma, rhabdomyosarcoma,
	chondroma, hamartoma, leiomyoma,
	mucus gland adenoma, metastasis
What is the differential	1. Neurogenic tumor (ganglioneuromas,
diagnosis of mediastinal	neurofibromas)
tumor/mass?	2. Teratoma
	3. Lymphoma
	4. Thymoma
	(Classic “four T’s”: Teratoma, Terrible
	lymphoma, Thymoma, Thyroid tumor)
	Rare: pheochromocytoma, hemangioma,
	rhabdomyosarcoma, osteochondroma
PECTUS DEFORMITY
What heart abnormality	Mitral valve prolapse (many patients
is associated with pectus	receive preoperative echocardiogram)
abnormality?
PECTUS EXCAVATUM
What is it?	Chest wall deformity with sternum caving
	inward (Think: exCAVatum CAVE)

Pectus

excavatum

526 Section III / Subspecialty Surgery
What is the cause?	Abnormal, unequal overgrowth of rib
	cartilage
What are the signs/	Often asymptomatic; mental distress,
symptoms?	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	Placement of metal strut to elevate
procedure?	sternum without removing cartilage
PECTUS CARINATUM
What is it?	Chest wall deformity with sternum outward
	(pectus chest, carinatum pigeon);
	much less common than pectus excavatum

Pectus

carinatum

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

Chapter 67 / Pediatric Surgery 527

ESOPHAGEAL ATRESIA WITHOUT TRACHEOESOPHAGEAL (TE) FISTULA

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	Suction blind pouch, IVFs, (gastrostomy to
treatment?	drain stomach if prolonged preoperative
	esophageal stretching is planned)
What is the definitive	Surgical with 1 anastomosis, often
treatment?	with preoperative stretching of blind
	pouch (other options include colonic or
	jejunal interposition graft or gastric tube
	formation if esophageal gap is long)
ESOPHAGEAL ATRESIA WITH TRACHEOESOPHAGEAL (TE) FISTULA
What is it?	Esophageal atresia occurring with a
	fistula to the trachea; occurs in 90% of
	cases of esophageal atresia
What is the incidence?	One in 1500 to 3000 births
Define the following types
of fistulas/atresias:
Type A	Esophageal atresia without TE fistula (8%)

528 Section III / Subspecialty Surgery
Type B	Proximal esophageal atresia with proximal
	TE fistula (1%)

Type C	Proximal esophageal atresia with distal
	TE fistula (85%); most common type

Type D	Proximal esophageal atresia with both
	proximal and distal TE fistulas (2%)
	(Think: D Double connection to
	trachea)

	Chapter 67 / Pediatric Surgery 529
Type E	“H-type” TE fistula without esophageal
	atresia (4%)

How do you remember	Simple: Most Common type is type C
which type is most common?
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 film
	demonstrates tube coiled in the upper
	esophagus; “pouchogram” (contrast in
	esophageal pouch); gas on AXR
	(tracheoesophageal fistula)
What is the initial	Directed toward minimizing
treatment?	complications from aspiration:
	1. Suction blind pouch (NPO/TPN)
	2. Upright position of child
	3. Prophylactic antibiotics (Amp/gent)
What is the definitive	Surgical correction via a thoracotomy,
treatment?	usually through the right chest with
	division of fistula and end-to-end
	esophageal anastomosis, if possible

530 Section III / Subspecialty Surgery

What can be done to lengthen the proximal esophageal pouch?

Which type should be fixed via a right neck incision?

What is the workup of a patient with a TE fistula?

Delayed repair: with or without G-tube and daily stretching of proximal pouch

“H-Type” (type E) is high in the thorax and can most often be approached via a right neck incision

To evaluate the TE fistula and associated anomalies: CXR, AXR, U/S of kidneys, cardiac echo (rest of workup directed by physical exam)

What are the associated	VACTERL cluster (present in about 10%
anomalies?	of cases):
	Vertebral or vascular, Anorectal, Cardiac,
	TE fistula, Esophageal atresia
	Radial limb and renal abnormalities,
	Lumbar and limb
	Previously known as VATER:
	Vertebral, Anus, TE fistula, Radial

What is the significance of a “gasless” abdomen on AXR?

No air to the stomach and, thus, no tracheoesophageal fistula

CONGENITAL DIAPHRAGMATIC HERNIA

What is it?	Failure of complete formation of the
	diaphragm, leading to a defect through
	which abdominal organs are herniated

What is the incidence?

What are the types of hernias?

What are the associated positions?

One in 2100 live births; males are more commonly affected

Bochdalek and Morgagni

Bochdalek—posterolateral with L R Morgagni—anterior parasternal hernia,

relatively uncommon