This document discusses pediatric surgery and focuses on congenital hypertrophic pyloric stenosis (CHPS). It describes CHPS as a condition that affects babies between birth and 6 months, causing forceful vomiting. The pathology involves hypertrophy of the pylorus muscle layer. Clinical features include projectile vomiting. Investigation may include ultrasound and barium meal. Treatment is resuscitation followed by Ramestedt pyloromyotomy surgery to cut the thickened pylorus muscle layer. Complications can include perforation or wound infection but recurrence is rare.

1. Pediatric Surgery
MAGDI AHMED LOULAH
PROFESSOR OF PEDIATRIC SURGERY

2. Introduction
 Neonates, Infants, and children are not a young adults
 They have their own physiology& anatomy
 CVS, Respiratory system, Renal Function, Thermoregulation, and fluids
percentages.
 They have their own pathology
 Genetic origin, multifactorial causes, congenital aberrations.
 They have their own diseases and different differential diagnosis.
 Fluids and drug doses depend on body weight.

3. Fetal Circulation
The oxygenated blood flow through the
Umbilical cord Umbilical vein
Ductus venosus Right side o
heart it pases to the left side of
the heart through foramen ovale and
dutus arteriosus & then distributed to
the whole fetus
and then returnes back to the
mother through the umbilical arteries
• After labour the umbilical vein & the
ductus venosus thrombose.
• The foramen ovale & the ductus
arteriosus close.

4. Lung Development
 The size of the lung & the number of alveoli increase
gradually with age.
 𝟏𝟎 × 𝟏𝟎 𝟔Alveoli at birth
 𝟑𝟎𝟎 × 𝟏𝟎 𝟔
Alveoli (age 8 years)
 Principal breathing pattern is diaphragmatic, they
prone to breathing difficulties with abdominal
distention

5. Thermoregulation
 Thermoregulation is the ability to balance
heat production and heat loss in order to
maintain body temperature within a certain
normal range.
 Impaired thermoregulation (immature sweating, high
surface area to body weight)
 Maintaining a neutral thermal environment is
one of the key physiologic challenges that a
newborn must face after delivery. Thermal
care is central to reducing morbidity and
mortality in newborns.

6. Pathology
 Neonates and children have different differential diagnosis than
adults
 The basic principal of the pathology of neonatal diseases:
1. Genetic
2. Abnormal embryogenesis (Malrotation of intestine, maldescended testicle)
3. Failure of disintegration of some fetal parts (PDA, VSD, ASD & Presistent
processus vaginalis)
4. Vascular incidence (Intestinal atresia, haemangioma & lymphangioma)
5. Metabolic problem

7. Congenital Hypertrophic Pyloric Stenosis
(CHPS)
 Pyloric stenosis is a problem that affects babies between birth and 6 months of
age and causes forceful vomiting that can lead to dehydration. It is the second
most common problem requiring surgery in newborns.

8. Incidence & Etiology
 CHPS affects 1-3 /1000
 Boys are 4 times affected than females (4-1)
 Etiology is unknown
 Some probable theories include
 Increased acidity leading to pylorospasm
 Gastrin production due to alkaline milk and stasis leads to acid production
 Excess substance p
 Genetic causes

9. Pathology
• Hypertrophy of the circular
muscle layer of the pylorus
• Increased thickness of the
pylorus more than 3mm, and
elongated pyloric canal 14
mm or more.
• Dilated stomach.
• Multiple superficial gastric
ulcers.

10. Clinical features
Classic clinical pictures
Non bilious projectile
vomiting in a full term
baby, typically between
3 and 6 weeks of age.
Forceful, coffee ground
vomiting later due to
gastritis.
Loss of weight
Failure to thrive
Constipation
Dehydration
Jaundice (rare).

11. Examination
 Dehydration
 Loss of subcutaneous fat
 Sunken fontanell
 Visible gastric peristalsis.
 Olive like mass.

12.  Hyponatremia
 Hypochloremia
 Hypokalemia
 Alkalosis
 Paradoxical aciduria

13. investigations
 Biochemical
 US.
 Barium meal.

15. Management
 Resusscitation
 IV fluids using normal saline 10-20 ml/kg as a bolus to correct hyponatremia
 IV maintenance fluids using Dextrose 5% with ½ strength normal saline (Pediament)
 Nasogastric tube and repeated gastric lavage.
 Antibiotics
 Insure normal biochemical values and adequate urine output.

16. Surgery
 Ramestedt pyloromyotomy (1911)
 Laparoscopic pyloromyotomy.

19. Complication
 Recurrence (rare)
 Perforation
 Wound infection