Pediatric Surgical Conditions, Diagnostics & Treatments

The surgical procedure used to treat gastroesophageal reflux disease is called fundoplication. In this procedure, the upper part of the stomach (the fundus) is wrapped behind the esophagus and attached to the esophagus in back and the stomach in front. This keeps the esophagus in place in the abdomen. This procedure is effective and relatively free of complications.

At Cedars-Sinai fundoplication is done using minimally invasive techniques. Five small incision are made. These incisions allow the surgeon to insert instruments and use a tiny camera to watch the surgery. The abdomen is pumped up with gas to make it easier for the surgeon to see what he or she is doing.

In rare cases, it is not possible to fundoplication using minimally invasive techniques. In that case, open traditional surgery can be used.

Minimally invasive techniques allow for faster healing with less scarring and less risk of complications.

Following the surgery, the patient may need to eat a special diet for five to 10 days until the swelling from the surgery done on the stomach and esophagus go down.

Because the surgery tightens the opening between the stomach and the esophagus, a child who has had fundoplication will not burp or be able to vomit normally. (If a child does have to vomit, he or she will have dry heaves. As the swelling from the surgery goes away and normal eating stretches the wrap, a child will again be able to burp and vomit normally.

If a baby or child swallows a lot of air when he or she eats, the doctor can give medicines that can break up the gas and ease any pain.

In most cases, babies or children who have had fundoplication recover well without any complications or lasting problems.

Hirschsprung's disease is a condition that causes a baby to be born with nerve cells in his or her intestines missing. Sometimes the missing nerve cells affect only a small part of the bowel. In other cases, large sections of the nerve cells are missing. Hirschsprung's disease causes 15 to 20 percent of intestinal obstructions that occur in newborns.

Most babies with Hirschsprung's are diagnosed within the first six weeks after birth. If the disease affects only a small portion of the bowel, it may take long to discover the problem.

Specific treatment for Hirschsprung's disease will be determined by your child's doctor based on:

Once the condition has been diagnosed, treatment focuses on removing or bypassing the section of the intestine that lacks nerves and replacing it with normal bowel tissue.

Both minimally invasive and open, traditional approaches are used to surgically treat Hirschsprung's disease. Infants that are stable may be candidates for minimally invasive surgery. When the baby is very ill or when the surgery is likely to be unusually complicated, a more traditional approach may be used. Sometimes both approaches are used at different stages of treatment to do different things.

This approach uses only four to five small incisions. The procedure is done with an endoscope. An endoscope is a tube with a camera on it that allows the surgeon to see what he is doing inside the body. The surgeon to view the procedure on a television monitor.

Sometimes this approach is used only to remove the blockage and tissue that is missing nerves. The healthy sections of bowel are then reconnected. This is called a pull-through procedure.

In other cases, the surgeon will connect the open end of the bowel to the surface of the skin. This is called a colostomy. It makes it possible for wastes to be eliminated through the hole to the outside of the body. This protects the area where the bowel was removed until it has healed. The colostomy may be closed in four to six weeks.

This is done when minimally invasive surgery isn't possible. This procedure uses a large incision to bring a piece of the bowel to the surface of the skin to remove the block. When the baby has recovered, the minimally invasive approach can be used to eliminate the piece of bowel without nerves.

Most people who undergo surgery for Hirschsprung's disease recover without problems. Any time a person has a general anesthesia and surgery, however, there is a possibility of complications. These include bleeding, infection or a blockage of the bowel after surgery due to scarring or other factors.

With minimally invasive surgery, there are generally fewer complications. Sometimes the blood supply to the intestines can be disturbed in a pull through operation. If this happens, more surgery may be needed.

It's very important for a person who has had the pull-through surgery to avoid constipation. Constipation can lead to enterocolitis or infections of the intestine that can be life threatening. Whenever a young child who has been treated for Hirschsprung's disease changes his or her diet (such as going to vacation or starting school), it is important to be alert to constipation issues.

A baby or child who becomes constipated, has small watery stools, a swollen belly, lacks energy or runs a fever should be taken to a doctor right away.

A small number of people (about 5 percent) may have severe constipation or incontinence. These may be treated by medical means such as stool softeners, laxatives, enemas or procedures to stretch the muscles of the anus or rectum.

Patients with Down Syndrome and neurologic impairment will have a higher incidence of constipation and incontinence. They can only be treated with medical management and a great deal of patience.

The long range outlook for a child who has been treated for Hirschsprung's disease will vary depending on the amount of intestine that lacked nerve cells and how much of the intestine was removed.

Children who are able to have their colostomy closed may have problems that come and go such as:

If a large section of intestine had to be removed, a child may have longer term problems. Shortening the intestine may make it harder for the child's body to absorb enough nutrition and fluids. This in turn may cause poor digestion or slow growth.

It's best to discuss these issues with your doctor as every child is different.

Two types of surgery can be used to treat pectus excavatum. Both types require a child to have a general anesthesia before the operation. The child then must stay in the hospital for four to six days after surgery.

The traditional approach to repairing pectus excavatum requires that an incision be made across the child's chest below the level of the nipples. The chest muscles must be raised from the breastbone and ribs. Part of the cartilage where the ribs join the breastbone is removed. A wedge of the breastbone is also removed. The breastbone is lift upward and a strut is inserted behind it to hold it forward during the healing process. When the cartilage and bone grow back, they grow in a more normal position.

Nuss repair is a minimally invasive approach to repairing pectus excavatum. In this type of surgery, two incisions are made on either side of the depressed area of the chest. A C-shaped metal strut is inserted behind the breastbone and in front of the heart. It is then rotated halfway around. This lifts the breastbone and bends the cartilage of the ribs to a more natural position. This approach may not be suitable for older adolescents or children with a lopsided sunken area.

Regardless of which approach is used, the child's vital signs are monitored throughout the surgery. Before the surgery, a breathing tube will be inserted after the child is asleep. Lines going into the veins may be inserted (IV lines). A catheter to drain the bladder may also be inserted.

After the surgery, the child goes to the recovery room. After an hour or two, he or she will be moved to the surgical floor. The child may have a small rubber tube under the incision to drain fluids that may collect. This will be removed in one to two days. The day after the surgery, the child will be helped to walk and encouraged to eat or drink, if he or she feels well enough to.

If there is pain, a variety of approaches can be used to manage it. The pain specialists at the Cedars-Sinai Pain Center are available 24 hours a day to help.

The child will need to come back to see the surgeon for a follow up visit two weeks after surgery. This is to make sure that the area is healing and that there are no problems. Until this visit, the child shouldn't go to gym class, do strenuous activities or play contact sports.

After surgery, the child should be monitored. If any of the following appear, the doctor should be called:

These could be signs of infection or a complication.