Pediatric General Surgery

James Wall MD, MSE¹

Craig Albanese MD, MBA¹

Rebecca E. Claure MD²

Brenda Golianu MD²

Gregory B. Hammer MD²

¹SURGEONS

²ANESTHESIOLOGISTS

RESECTION OF CYSTIC HYGROMA, BRANCHIAL CLEFT CYST, THYROGLOSSAL DUCT CYST, OR OTHER CERVICAL MASS

SURGICAL CONSIDERATIONS

Description: Common lesions requiring dissection in the neck and floor of the mouth include branchial cleft remnants; thyroglossal duct remnants; vascular malformations (hemangiomas); lymphatic malformations (cystic hygromas); and infected or enlarged lymph nodes refractory to antibiotic therapy.

Surgical approach: Ideally, an acutely inflamed node (typically Staphylococcus aureus) usually is incised and drained; a chronically infected node (e.g., cat-scratch disease, atypical TB) or an enlarged node (lymphoma) is excised. Remnants of the first and second (rarely third) branchial clefts are lateral masses found and excised from (respectively), the parotid region anterior to the ear, sometimes extending to the external auditory canal, or the anterior border of the sternocleidomastoid muscle, sometimes extending through the carotid bifurcation to the tonsillar fossa. Thyroglossal duct remnants are midline lesions that involve the central portion of the hyoid bone and may extend up to the base of the tongue. When acutely infected and resistant to a course of antibiotics, they can be drained; when quiescent, thyroglossal duct remnants are excised. Occasionally, it is advantageous for the anesthesiologist to digitally depress the tongue near the foramen cecum to help the surgeon know when the dissection approaches this structure. Vascular and lymphatic malformations may overlap; they tend to be lateral and are sometimes extensive. Significant blood loss may result, and resection may involve tedious dissection of neurovascular structures, including the carotid sheath, brachial plexus, sympathetic chain, phrenic nerve, and cranial nerves V, VII, X, XI, and XII.

Transaxillary subcutaneous endoscopic surgery allows an alternate approach to resecting selected lesions. This approach involves using tiny incisions placed in the ipsilateral axilla through which endoscopic ports are placed and tunneling under the skin to the neck, aided by carbon dioxide insufflation, to resect benign lesions using laparoscopic tools. This approach is not widely practiced; however, it appears to be safe and effective for a wide variety of lesions, including thyroid and parathyroid lesions. It completely avoids a neck incision, which can be cosmetically unappealing.

Usual preop diagnosis: Cystic hygroma; branchial cleft cyst/fistula; thyroglossal duct cyst; atypical mycobacterial adenitis

▪ SUMMARY OF PROCEDURES

	Lateral Lesions (Branchial Cleft Remnant Lymph Node, Vascular + Lymphatic Malformations)	Midline Lesions (Thyroglossal Duct Remnants)
Position	Neck extended, turned to contralateral side	Neck extended
Incision	Oblique	Transverse
Special instrumentation	Facial nerve monitor; nerve stimulator	None
Unique considerations	Nerve testing	None
Antibiotics	Cefazolin 25 mg/kg iv	⇚
Surgical time	1-6 h	1 h
EBL	5-20 mL/kg	< 5 mL/kg
Postop care	PICU; airway monitoring	None
Mortality	< 2%	< 1%
Morbidity	Airway compromise Fluid accumulation Infection	⇚ ⇚ ⇚
Pain score	3-4	3-4

ANESTHETIC CONSIDERATIONS

PREOPERATIVE

These patients generally are otherwise healthy children. Cervical masses, including cystic hygroma (cystic lymphangioma), may cause airway obstruction and difficult intubation (also see Exit Procedures, p. 1346).

Respiratory	The size and extent of the cervical mass should be defined carefully in an effort to detect the potential for airway compromise. Inspiratory stridor suggests supraglottic obstruction, whereas expiratory stridor is associated with subglottic/intrathoracic obstruction. If these patients have had prior CT/MRI imaging, these records, including prior anesthesia records, should be reviewed. Tests: CXR ± CT/MRI scans
Cardiovascular	Cervical masses may be adherent to and/or cause compression of the great vessels. Tests: CT/MRI scans
Hematologic	Tests: For cystic hygroma, or if a cervical mass involves great vessels or extends into the mediastinum, T&C and HcT.
Laboratory	Other tests as indicated from H&P
Premedication	If patient > 7-9 mo and asymptomatic, consider midazolam (0.5 mg/kg po) 30 min. prior to arrival in OR. Use premedication cautiously in patients with potential airway compromise.

INTRAOPERATIVE

Anesthetic technique: GETA with pediatric circuit; OR temperature 75-80°; forced-air warmer on OR table; maintain SpO₂ between 92-94% to minimize retinopathy in premature infants at risk.

Induction	Standard pediatric induction (see p. D-1) in patients without airway compromise. IV access should be secured before induction when airway compromise is present or suspected. Mask induction with sevoflurane in 100% O₂. As plane of anesthesia deepens, gently assist ventilation. (Keep PIP < 20 cmH₂O). Prior to laryngoscopy, consider atropine (0.02 mg/kg, minimum dose 0.1 mg), if < 1 month, to prevent vagal response. If difficult airway is anticipated, proceed with difficult airway algorithm. If partial airway obstruction exists, maintain spontaneous ventilation and perform laryngoscopy under deep anesthesia (e.g., ˜2 MAC of volatile agent). FOB should be available. Have full range of ETT sizes available because airway narrowing may be present. Once airway is secured, proceed with NMB (e.g., rocuronium 0.6 mg/kg iv, or vecuronium 0.1 mg/kg iv), unless monitoring facial nerve function.
Maintenance	Standard pediatric maintenance (see p. D-3). Surgeon may infiltrate incision with local anesthetic. Limit bupivacaine to 2.5 mg/kg (maximum: 10 mL of 0.25 % bupivacaine).
Emergence	Reverse neuromuscular blockade with neostigmine (0.07 mg/kg) and glycopyrrolate (0.01 mg/kg). Confirm air leak around ETT and extubate when fully awake.
Blood and fluid requirements	Minimal blood loss usually IV: 20-22 ga × 1; 2nd iv if great vessel involvement NS/LR @ maintenance (see D-3).	Minimal 3rd-space losses. Each mL blood loss can be replaced with 3 mL NS/LR, or 1 mL albumin 5%. If great vessels are involved, place at least one iv in lower extremity. Blood loss can be quite sudden; have blood available in OR.
Monitoring	Standard monitors (see p. D-1) ± Arterial line, 22 ga	An arterial line is used when there is risk of large blood loss or to assist management of ventilation
Positioning	[check mark] and pad pressure points [check mark] eyes
Complications	ETT dislodged/loss of airway Laryngospasm Bronchospasm Hemorrhage	ETT must be carefully secured. Liberal use of benzoin. Avoid tension on ETT by circuit hoses. Hold ETT during surgeon’s intraoral examination.

POSTOPERATIVE

Complications

Subglottic edema

Upper-airway obstruction from edema related to tumor resection

Recurrent laryngeal nerve injury

Dexamethasone (0.5-1 mg/kg) and nebulized racemic epinephrine (2.25%) with mist O₂.

Pain management

Morphine (0.05-0.1 mg/kg q 1-2 h)

Hydromorphone (0.005-0.01 mg/kg q 1-2°)

Acetaminophen (10 mg/kg iv q6°; 20 mg/kg PR q6°, one-time dose 30-40 mg/kg PR)

Tests

As indicated.

Suggested Readings

1. Esmaeli MR, Razavi SS, Havofteh MR, et al: Cystic hygroma: anesthetic considerations and review. J Res Med Sci 2009; 14(3):191-5.

2. Foley DS, Fallat ME: Thyroglossal duct and other congenital midline cervical anomalies. Semin Pediatr Surg 2006; 15(2):70-5.

3. Gross, E, Sichel JY: Congenital neck lesions. Surg Clin North Am 2006; 86(2):383-92.

ESOPHAGUS-FOREIGN BODY REMOVAL AND DILATION

SURGICAL CONSIDERATIONS

Description: Flexible, diagnostic esophagogastroduodenoscopy—a common procedure in pediatrics—usually is performed under GA or heavy sedation in an endoscopy suite or special procedure area. Rigid esophagoscopy usually is performed for therapeutic indications such as removal of a foreign body (FB), dilation of an esophageal stricture, or injection of varices. The procedure is similar for each diagnosis and generally is performed with ET intubation. FB removal is normally a very short procedure, whereas dilation and variceal injection can be prolonged and may require multiple insertions/removals of the endoscope. Compression of the trachea distal to the ETT by the rigid esophagoscope may occur. Radial balloon dilation, which involves less shear stress than repeatedly passing a bougie catheter, is becoming a popular method of dilation. This is done under endoscopic and fluoroscopic guidance and is accompanied by a very low rate of complications.

Usual preop diagnosis: Esophageal FB; stricture; esophageal varices

ANESTHETIC CONSIDERATIONS

PREOPERATIVE

Esophagoscopy for FB removal is usually performed in healthy infants and toddlers, although it can occur in any age group. All of these patients should be treated with full-stomach precautions (see p. B-5). Esophageal dilation is usually performed in three distinct patient populations: (a) those with prior tracheoesophageal fistula (TEF) repair;
(b) those with prior ingestion of a caustic substance; and (c) those with skin and connective tissue diseases (e.g., epidermolysis bullosa [EB]).

Respiratory	Patients with TEF may have residual BPD, chronic lung disease, or subglottic stenosis. Check anesthesia records for ETT size used. Those with prior caustic ingestion and pulmonary aspiration may have resultant chemical pneumonitis and/or fibrosis. Patients with EB may have limited mouth opening and may have a difficult airway or require special care regarding placing and securing of ETT. Tests: CXR, if clinically indicated
Cardiovascular	There may be persistent congenital cardiac anomalies in the TEF patient. Tests: EKG, ECHO as indicated. Cardiology consultation, as needed.
Laboratory	No routine lab analyses are required.
Premedication	For esophageal dilation, patient preference is extremely important because some patients have undergone this procedure several times. For FB removal, iv access is usually recommended before induction, though a mask induction may be selected by the anesthesiologist as well.

INTRAOPERATIVE

Anesthetic technique: GETA, using a pediatric circuit. Room temperature should be maintained at 75-80°F. Forced-air warmer may be used.

Induction	If the patient is presenting for dilation alone and has no evidence to suggest reflux or retained food in the esophagus, a standard inhalation or iv induction may be performed. Rapid-sequence induction is usually appropriate for FB removal. Atropine (0.02 mg/kg if < 1 mo, minimum 0.1 mg) may be administered to attenuate bradycardia from intubation. Preoxygenate for 2-3 min. Apply cricoid pressure. Propofol (2-3 mg/kg) followed by succinylcholine (1-2 mg/kg). Rocuronium (1 mg/kg) may be used if longer procedure anticipated. Intubate trachea with age-appropriate ETT. If succinylcholine was used, consider additional neuromuscular blockade.
Maintenance	Maintain anesthesia with volatile agent/N₂O/O₂ or propofol (100-250 mcg/kg/min) + remifentanil (0.05-0.2 mcg/kg/min). Supplement inhalation anesthetic with small doses of fentanyl (e.g., 1-2 mcg/kg), hydromorphone (0.005-0.01 mg/kg), or morphine (0.05-0.1 mcg/kg). Maintain neuromuscular blockade or deep plane of anesthesia. Movement must be avoided with rigid esophagoscopy.
Emergence	Extubate when fully awake. Neostigmine (0.07 mg/kg) and glycopyrrolate (0.01 mg/kg) to reverse neuromuscular blockade. Do not attempt reversal of neuromuscular blockade until first twitch of train-of-four has returned.
Blood and fluid requirements	IV: 20-22 ga × 1 NS/LR @ maintenance (See p. D-3)
Monitoring	Standard monitors (see p. D-1) Peripheral nerve stimulator
Positioning	[check mark] and pad pressure points [check mark] eyes
Complications	Esophageal perforation Aspiration Accidental extubation Stridor 2° subglottic edema	Esophageal perforation, more common with rigid esophagoscopy, may lead to pneumothorax (R > L).

POSTOPERATIVE

Complications

Residual neuromuscular blockade

Pneumothorax, esophageal perforation

Pain management

Minimal postop pain

If patient reports marked substernal discomfort, suspect esophageal perforation.

Tests

None

Suggested Readings

1. Gercek A, Ay B, Dogan V, et al: Esophageal balloon dilation in children: prospective analysis of hemodynamic changes and complications during general anesthesia. J Clin Anesth 2007; 19:286-89.

2. Lan LC, Wong KK, Lin SC, et al: Endoscopic balloon dilatation of esophageal strictures in infants and children: 17 years’ experience and a literature review. J Pediatr Surg 2003; 38(12):1712-5.

3. Landsmen IS, Werkhaven JA, Motoyama EK: Anesthesia for pediatric otorhinolaryngologic surgery. In: Davis PT, Cladis FP, Motoyama EK, eds. Smith’s Anesthesia for Infants and Children, 8th edition. Elsevier Publishing, Philadelphia: 2011, 819-20.

4. Li ZS, Sun ZX, Zou DW, et al: Endoscopic management of foreign bodies in the upper-GI tract: experience with 1088 cases in China. Gastrointest Endosc 2006; 64(4):485-92.

5. Parray T, Siddiqui SM, Hughes M, et al: Tension pneumothorax and subcutaneous emphysema during retrieval of an ingested lithium button battery. J Anesth 2010; 24:469-71.

REPAIR OF TRACHEOESOPHAGEAL FISTULA AND ESOPHAGEAL ATRESIA

SURGICAL CONSIDERATIONS

Description: The majority of infants with tracheoesophageal fistulae (TEF) have an associated esophageal atresia (EA), as shown in Fig. 12.5-1 (Type C). The Dx is made presumptively when an NG tube cannot be advanced past 8-13 cm and gas is present in the stomach. The complications of aspiration (gastric contents come up the fistula into the trachea) and GI distention compromising respiration (from passage of air down the fistula into the intestines) are diminished by repair within a few days of birth. Primary repair without gastrostomy is routine. The absence of stomach and bowel gas suggests a pure EA without fistula (Type A). A staged procedure—initial gastrostomy with deferred EA repair—may be used in babies < 1 kg, those with pure EA, or with more critical associated anomalies.

Surgical approach: All cases with TEF should begin with rigid bronchoscopy while the patient is spontaneously breathing. Bronchoscopy allows identification of the level of the TEF, detection of a second fistula, and rules out a tracheosophageal cleft that would be managed differently. The operation is performed in left-lateral decubitus position through a 4th interspace right thoracotomy. Preop ECHO is advised to look for cardiac anomalies and confirm a normal left-sided aortic arch. In the case of a right-sided arch (10%), most surgeons approach the fistula through a left thoracotomy. Debate continues on whether the best approach is retropleural or transpleural. The former is slower, but it may diminish the chances of empyema if the esophageal anastomosis leaks.

Another approach is thoracoscopy. There is now extensive experience with this approach, and it is proven to be a safe and effective method of repair in children, even those with complex congenital heart disease. It is performed using three or four trocars in the modified (prone) left-lateral decubitus position, causing the lung to drop forward as 5 mm Hg capnothorax is achieved. Dividing the azygous vein is necessary to find the subjacent fistula, branching off the posterior aspect of the trachea (Type C). The right bronchus, aorta, and (rarely) left bronchus may be mistaken for this structure. Division of the fistula may dramatically improve ventilation; until this moment, it is sometimes necessary to operate in short 3- to 5-min bursts, relaxing lung and mediastinal retraction for 1-2 min when saturations descend to critical levels. Afterward, the proximal fistula is located (when the anesthesiologist pushes downward on the indwelling [Replogle] tube), and then is dissected upward into the root of the neck to achieve sufficient length for anastomosis. After the posterior wall of the anastomosis is complete, some surgeons will ask for the NG tube to be
replaced by a small (5 or 6 Fr) feeding tube, which is advanced into the stomach, separating the anterior from posterior esophageal wall during closure and permitting enteric feeds during the customary 1 wk before an esophagram is performed. This tube must be fixed in place because it has a tendency to become dislodged. Because neck hyperextension, as would occur during direct laryngoscopy, places significant tension on the anastomosis, postoperative reintubation is to be avoided. When the length of native esophagus is too short, even after lengthening maneuvers, both ends can be tied to the prevertebral fascia or attached to monofilament sutures and brought tangentially out of the back skin (Foker). In the former case, one reoperates months later, after differential growth of the esophagus elongates it relative to the vertebral bodies—or if not, to replace it with stomach or bowel. In the latter case, stretching daily over 1-2 wk may provide sufficient length for secondary anastomosis. A chest tube usually is left in place.

Figure 12.5-1. Types of esophageal atresia: A: pure esophageal atresia; B: proximal fistula; C: esophageal atresia, distal fistula; D: proximal and distal fistula; E: pure tracheoesophageal fistula. (Redrawn from Ravitch MM, et al, eds: Pediatric Surgery, Vol 1, 3rd edition. Year Book Medical Publishers, Chicago: 1979.)

Variant procedures or approaches: Pure EA without fistula (Type A) indicates a long gap—the initial operation is a feeding G-tube along the lesser gastric curve, followed by definitive operation months later or the Foker procedure. A pure fistula without EA (Type E) is usually diagnosed later in life and occurs in the neck; it is repaired through a cervical incision.

Usual preop diagnosis: EA; TEF

▪ SUMMARY OF PROCEDURES

	Primary Repair	Gastrostomy
Position	Lateral	Supine
Incision	Posterolateral thoracotomy (side opposite aortic arch)	LUQ
Special instrumentation	NG tube in upper pouch	G-tube
Unique considerations	Loss of ventilation via fistula; lung compression	May be done under local anesthesia
Antibiotics	Preop: ampicillin 25 mg/kg iv + gentamicin 2.5 mg/kg iv	⇚
Surgical time	2-4 h	1 h
Closing considerations	Extubation favored	Local anesthetic; wound infiltration
EBL	10 mL/kg	5 mL/kg
Postop care	NICU; humidified mist; avoid CPAP and neck hyperextension	⇚
Mortality	1-20%, depending on associated anomalies	5%
Morbidity	Stricture: 20-40% Leak: 10-20% Aspiration Atelectasis Stridor	– – ⇚ – –
Pain score	7-8	3-4

ANESTHETIC CONSIDERATIONS

PREOPERATIVE

EA and TEF usually are detected in the first day of life, although TEF without atresia may be difficult to diagnose until the patient experiences recurrent pneumonia, cyanosis associated with feeding, or abdominal distention. The fistula is usually at the distal trachea near the carina. Because of the risk of pulmonary aspiration, initial gastrostomy may be performed in babies < 1 kg. Associated conditions frequently associated with TEF include prematurity (30-40%) and congenital anomalies such as cardiac (20-35%), VATER, and VACTERL associations (see above).

Respiratory	The upper esophageal pouch should be suctioned to minimize aspiration. These patients frequently have respiratory insufficiency 2° prematurity (RDS), or aspiration pneumonitis, and may be intubated and on mechanical ventilation. Single-lung ventilation is typically not tolerated in small babies, and unnecessary surgical working space is created by regulated pneumothorax for thoracoscopy or retraction for open surgery. Tests: CXR, ABG
Cardiovascular	Associated cardiac abnormalities include VSD, PDA, tetralogy of Fallot, ASD, and coarctation of the aorta. At risk for pulmonary HTN with R → L shunt. In ductal-dependent patients, maintain prostaglandin infusion (PGE₁). Tests: ECHO
Gastrointestinal	Associated GI anomalies may occur (e.g., imperforate anus, midgut malrotation, duodenal atresia, pyloric stenosis).
Musculoskeletal	Musculoskeletal anomalies are usually of little anesthetic significance, except for possible C-spine involvement.
Hematologic	For the first 2-3 mo of life, the O2-carrying capacity of blood is increased because of the presence of fetal Hb with its ↓ sensitivity to 2,3-DPG. A shift to the right of the O₂ sat curve results in ↑ O₂-Hb affinity. As a result, tissue oxygenation may be reduced, especially with anemia (Hb < 12 g/dL @ < 2-3 mo). Although TEF repair is not usually associated with significant blood loss, a T&C is indicated. Patients should be well hydrated and should have adequate urine output. Tests: Hct; T&C; others as indicated from H&P.
Laboratory	Serum electrolytes, ABG, blood glucose, to determine metabolic state.
Premedication	Usually none

INTRAOPERATIVE

Anesthetic technique: GETA for thoracoscopy, using a pediatric circuit. Warm room to 75-80°F and use forced-air warmer. If thoracotomy, the child is otherwise healthy and extubation is planned within 48 h, consider placing a caudal or lumbar epidural catheter (see p. D-4) after airway is secured and the child is anesthetized. Patients with large fistulas may need awake gastrostomy or a Fogarty catheter placed via the gastrostomy, using FOB, to occlude the distal end of the fistula. Alternatively, the Fogarty catheter can be used to occlude the proximal end of the fistula via the trachea.

Induction	Atropine (0.02 mg/kg iv in children < 1 mo, minimum 0.1 mg) is given before induction to ablate vagal response to laryngoscopy. Traditionally, spontaneous ventilation is advocated to minimize gastric distention; however, most cases will do well with iv induction. IV induction may be performed with care during ventilation to minimize PIP and potential inflation of stomach. Advance ETT to right mainstem and withdraw until bilateral breath sounds are present. Rotate ETT so the bevel faces posteriorly (to prevent intubation of the fistula). If rigid bronchoscopy is performed after induction, place ETT 1 cm above where fistula was visualized. Otherwise, have flexible pediatric bronchoscope available to verify placement of ETT and site of TEF. Keep air leak around ETT to a minimum (leak at 18-35 cmH₂O) to minimize alterations in ventilation 2° changes in chest and pulmonary compliance. The depth of the TEF should be noted on the initial rigid bronchoscopy. This depth guides ETT placement intraop and any postop attempts at reintubation that can be catastrophic if the ETT is advanced through the fistula repair.
Maintenance	Standard maintenance with inhalational anesthetic, TIVA, or combination. Avoid high FiO₂ if possible in premature neonates at risk for retinopathy. Use air/O₂ mixture for ventilation to maintain O₂ sat between 95% and 100%. Use low PIPs to avoid gastric distention by gases passing through fistula. Careful adjustment of ventilation will be necessary during surgical retraction of lung or during insufflation if procedure is done thoracoscopically. Manual ventilation may be helpful in assessing pulmonary compliance. If the patient is not tolerating manipulation by the surgeon, brief breaks may be necessary to restore ventilation and oxygenation. Muscle relaxation (rocuronium 0.6 mg/kg iv, vecuronium 0.1 mg/kg iv) is usually necessary. If epidural is used, GA drug requirements will be reduced. Frequent tracheal suctioning may be needed.
Emergence	Patients usually remain intubated. Opioid-sparing techniques and either thoracoscopic surgery or the use of regional anesthesia may facilitate earlier extubation. Reintubation may compromise the new anastomosis.
Blood and fluid requirements	Blood loss usually minimal IV: 22-24 ga × 2 NS/LR (maintenance) (see p. D-3). 5% albumin	Continue dextrose-containing solution from NICU. Replace 3rd-space losses (6-8 mL/kg/h) with NS/LR. Replace blood loss with 5% albumin mL for mL; maintain Hct > 35%.
Monitoring	Standard monitors (see p. D-1). Arterial line (24 ga)	ABG, Hct, and glucose q 60 min. Consider preductal, postductal SaO₂ in premature neonates or those with cardiac lesions.
Positioning	[check mark] and pad pressure points [check mark] eyes Axillary roll	The patient is turned to the left-lateral decubitus position for a right thoracotomy. Monitor breath sounds in dependent lung. Consider using FOB to recheck tube position.
Complications	Hypothermia Metabolic acidosis Hypoxemia Aspiration/gastric insufflation Pneumothorax Mucus plug	Migration of ETT above fistula may lead to gastric insufflation and difficult ventilation. Typically in ETT or large bronchi

POSTOPERATIVE

Complications

Apnea/hypoventilation

Pneumothorax

Tracheal leak

Recurrent laryngeal nerve injury

Pneumonia

Maintenance of normothermia lessens incidence of apnea, hypoventilation, and metabolic acidosis.

Spontaneous hip flexion is the most reliable indication of adequate neuromuscular function.

Pain management

Morphine (0.05-0.1 mg/kg q 1-2 h)

Hydromorphone (0.005-0.01 mg/kg q 1-2 h)

Acetaminophen (10 mg/kg iv/po q 6; 20 mg/kg PR q 6; one-time dose perioperatively 30-40 mg/kg pr)

Tests

ABG; Hct

Suggested Readings

1. Brett C, Davis PJ: Anesthesia for general surgery in the neonate. In: Davis PT, Cladis FP, Motoyama EK, eds. Smith’s Anesthesia for Infants and Children, 8th edition. Elsevier Publishing, Philadelphia: 2011, 574-78.

2. Broemling N, Campbell F: Anesthetic management of congenital tracheoesophageal fistula. Pediatric Anesthesia 2011; 21:1092-99.

3. Diaz LK, Akpek EA, Dinavahi R, et al: Tracheoesophageal fistula and associated congenital heart disease: implications for anesthetic management and survival. Pediatr Anesth 2005; 15:862-69.

4. Holcomb GW III, Rothenberg SS, Bax KM, et al: Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula: a multi-institutional analysis. Ann Surg 2005; 242(3):422-8.

5. Knotten G, Costi D, Stephens P: An audit of anesthetic management and complications of trachea-esophageal fistula and esophageal atresia repair. Pediatr Anesth 2012; 22:268-74.

6. Krosnar S, Baxter A: Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula: anesthetic and intensive care management of a series of eight neonates. Pediatric Anesthesia 2005; 15:541-6.

7. Liu LM, Pang LM: Neonatal surgical emergencies in anesthesiology. Clin North Am 2001; 19(2):272-6.

8. Morton NS, Fairgrieve R, Moores A, et al: Anesthesia for the full-term and ex-premature infant. In: Gregory GA, Andropoulos DB, eds. Gregory’s Pediatric Anesthsia 5th edition. Wiley-Blackwell Pub, West Sussex, UK: 2012, 506-10.

9. Motoyama EK, Davis PJ, eds: Smith’s Anesthesia for Infants and Children, 7th edition. Mosby-Elsevier, Philadelphia: 2006, 550-2.

10. Rice-Townsend S, Ramamoorthy C, Dutta S: Thoracoscopic repair of a type D esophageal atresia in a newborn with complex congenital heart disease. J Pediatr Surg 2007; 42(9):1616-9.

MEDIASTINAL MASS—BIOPSY OR RESECTION

SURGICAL CONSIDERATIONS

Description: Mass lesions in the mediastinum are classified as anterior, middle, and posterior, based on their relationship to the heart, which occupies the middle mediastinum. Anterior tumors include lymphomas, thyroid tumors, teratomas, and thymomas. Large lymphomas and, less commonly, teratomas or metastatic germ cell tumors may cause anterior mediastinal mass syndrome and/or SVC compression. Preop preparation includes a rigid bronchoscope, plans to advance the ETT into a mainstem bronchus, and consideration of the need to rapidly roll the patient prone. These masses often are approached through a 3rd-rib anterior mediastinotomy (Chamberlain procedure) or thoracoscopically. For patients with compromised airway, light sedation and core-needle biopsy after appropriate imaging (e.g., MRI or CT scan) are preferable. Middle mediastinal tumors include esophageal duplications, bronchogenic cysts, lymphangiomas and variants, pericardial cysts, and lymph nodes. They are typically approached through a 5th intercostal space posterolateral thoracotomy or thoracoscopically. Posterior mediastinal lesions are usually neurogenic tumors; less commonly, neuroenteric cysts. The former may communicate with the spinal cord through the intervertebral foramina, giving them the appearance of central narrowing (“dumbbell tumor”). They usually arise from the sympathetic ganglia, and when high in the chest, excision may cause Horner’s syndrome. They are approached thoracoscopically or via posterolateral thoracotomy.

Figure 12.5-2. Distribution of mediastinal cysts and tumor. (Reprinted with permission from Ravitch MM, et al: Pediatric Surgery. Year Book Medical Publishers, Chicago: 1986.)

Surgical approach: The potential for blood loss and airway compromise must always be anticipated when operating on chest lesions adjacent to the great vessels and tracheobronchial tree. When SVC or anterior mediastinal mass syndromes are suspected, they may be confirmed clinically and should be discussed among surgeon, anesthesiologist, and oncologist. Thoracoscopy is the gold standard for biopsy. In the absence of an adequate workspace, a mini-thoracotomy may be necessary, but adequate biopsy for diagnostic purposes can typically be achieved with core needle biopsy. For resection, thoracotomy or median sternotomy is performed based on location of the tumor. A chest tube is typically left in place after resection or biopsy to drain the pleural space and ensure lung expansion postop.

Variant Procedure: In the past, it was a dictum that at least 1 cm2 of tumor was needed for architecture to diagnose and classify lymphomas. In the age of histochemistry and chromosomal studies, this is less true. Sometimes the Dx can be made on bone marrow aspirate, pleural effusion aspirate, or a Tru-Cut needle biopsy. These alternatives should be considered when large anterior mediastinal masses are encountered. Endoscopic ultrasound-guided needle biopsy is an accepted technique for lesions near the esophagus. A new technique of transesophageal endoscopic surgery has been used for excision of mediastinal lymph nodes and masses.

Usual preop diagnosis: Neuroblastoma; teratoma; duplication cyst of foregut; mediastinal mass (lymphoma)

▪ SUMMARY OF PROCEDURES

	Lateral Thoracotomy	Median Sternotomy
Position	Lateral	Supine or semirecumbent
Incision	Posterolateral	Median, parasternal
Special instrumentation	None	Bronchoscope; ± CPB
Unique considerations	Airway or cardiovascular collapse after induction in anterior mediastinal masses	⇚
Antibiotics	Preop: ampicillin 25 mg/kg iv + gentamicin 2.5 mg/kg iv; intraop: cephalosporin irrigation (1 g/500 mL NS)	⇚
Surgical time	2-4 h	1-4 h
Closing considerations	Lung inflation; intercostal block; epidural catheter	⇚
EBL	10-30 mL/kg	10-50 mL/kg
Postop care	Aggressive respiratory therapy; analgesia	⇚
Mortality	< 5%, except symptomatic anterior masses	⇚
Morbidity	Atelectasis/respiratory Cardiovascular collapse with anterior masses	⇚ ⇚
Pain score	7-8	6-7

ANESTHETIC CONSIDERATIONS

PREOPERATIVE

The clinical presentation of a mediastinal mass is often nonspecific in an otherwise healthy child. Often, a routine CXR (for some incidental Sx) will show the presence of an anterior mediastinal mass. These patients may suffer acute cardiorespiratory compromise on induction of anesthesia. A careful preop workup is essential. The presence of orthopnea, dyspnea, use of accessory muscles of ventilation, or upper body edema may indicate compression of trachea and/ or great vessels and increase risk of anesthesia-related complications. Radiological evaluation, including CXR, CT or MRI, and ECHO will be essential in guiding treatment plan.

For large masses, consider rigid bronchoscopy and/or CPB standby. If severity of symptoms and size of tumor preclude anesthesia, possible options include preop radiation therapy or steroids. Both of these therapies will decrease tumor mass and relieve airway obstruction, but will interfere with accurate histologic diagnosis.

Current practice is to obtain a diagnostic biopsy under light sedation, due to concern for airway compromise. Treatment is then initiated to decrease tumor burden. Patients may return after treatment for resection of residual tumor.

Respiratory	Respiratory Sx (e.g., dyspnea, cough, stridor, wheezing) are extremely important. Note that, when mild airway compromise is present in the awake patient, this can indicate that total obstruction may occur when the patient is anesthetized or after muscle relaxation. The ability to lie supine without respiratory compromise should be determined, but does not guarantee adequate air exchange after receiving sedation or anesthesia. Tracheal and bronchial compression from the tumor may be positional. Tests: CXR; chest CT/MRI; echocardiogram; supine-sitting flow/volume loops can be useful for evaluating location and extent of airway obstruction in patients who are cooperative > 5 yr; oxygen saturation or ABG is indicated if symptomatic.
Cardiovascular	May include SVC syndrome (e.g., venous engorgement of head and neck, edema of upper body). Other Sx and signs may include syncope and headaches (↑ ICP) made worse in the supine position, JVD, papilledema. Cardiac insufficiency may occur due to tumor compression. NB: In severely symptomatic patients or large mediastinal masses, consider necessity for cardiopulmonary fem-fem bypass standby. Tests: ECHO
Laboratory	Electrolytes; CBC; If resection, T&C for 2-4 U, depending on body weight and tumor size; other tests as indicated from H&P.
Premedication	IV premedication with midazolam (0.02-0.05 mg/kg). Use premedication cautiously especially in patients with large masses, or those that are symptomatic.

INTRAOPERATIVE

Anesthetic technique: GETA using pediatric circle. OR temperature 75-80°; forced-air warmer.

Induction	For diagnostic biopsy, the usual practice is light sedation with ketamine/midazolam and/ or dexmedetomidine/midazolam, with generous infiltration of local anesthetic by the surgeons. If patient has undergone treatment, tumor has decreased in size, and there is no risk for airway compromise, a standard iv induction is appropriate. An iv is mandatory. If SVC syndrome is present, it is important to have iv access in the lower extremity. An awake FOB and intubation in the sitting position may be necessary. A mask induction with sevoflurane/O₂ in the semi-Fowler’s (reclining) position may also be performed. Intubation should be performed with preservation of spontaneous ventilation. Have small styletted ETTs available, in the event of tracheal compression. Use muscle relaxants with caution because the change from spontaneous to positive pressure ventilation may not be tolerated and may lead to obstruction. Be prepared for obstruction distal to ETT. If obstruction occurs, gently pushing a smaller ETT into the R mainstream bronchus may alleviate obstruction. Rigid bronchoscopy/one lung ventilation may be needed. NB: Surgeon must be present (with rigid bronchoscope immediately available) in the event of acute airway obstruction on induction. If obstruction is unabated, options include median sternotomy and femoral access for CPB. NB: A simple positional change (e.g., supine to lateral, prone or sitting) may relieve cardiorespiratory collapse.
Maintenance	Spontaneous ventilation/assisted ventilation with volatile agent and 100% O₂ may be appropriate. Supplemental epidural analgesia may be administered if a major resection is planned as opposed to a small incision for biopsy (see p. D-2). Have surgeon infiltrate wound with local anesthetic to reduce volatile anesthetic and opiate requirements.
Emergence	Confirm air leak around ETT (with cuff deflated). Have all emergency airway equipment available and surgeon present. Patient should be fully awake before extubation.
Blood and fluid requirements	Usually minimal blood loss IV: 18-24 ga × 2, depending on age NS/LR @ maintenance (see p. D-1) T&C for major resections	If mediastinoscopy is performed, sudden blood loss from torn great vessel may occur.
Monitoring	Standard monitors (see p. D-1) ± Arterial line	Esophageal or precordial stethoscope is earliest monitor of airway obstruction. Preop a-line may be indicated in patients with large masses or in symptomatic patients.
Positioning	[check mark] and pad pressure points [check mark] eyes
Complications	Cardio/respiratory failure Loss of airway Hypotension	If obstruction worsens acutely, be prepared to change to lateral-decubitus or prone position, which may help alleviate tracheal, bronchial compression and cardiovascular collapse. These cases require great attention to detail. All efforts must be made to maintain spontaneous ventilation. Preparations must be made for resuscitation.

POSTOPERATIVE

Complications

Respiratory failure

Pneumothorax

Anesthesiologist must be readily available in the PACU to manage acute airway problems.

Pain management

Ketorolac 0.5 mg/kg (up to 30 mg)

iv q 6 h × 24 h

Epidural analgesia

PCA (see pp. E-3-E-4)

Cervical biopsy/mediastinoscopy have minimal postop pain and can be effectively treated with NSAID and local anesthetic infiltration.

Use opiates cautiously.

Tests

Hct, ABG, CXR, as clinically indicated.

Suggested Readings

1. Anghelescu DL, Burgoyne LL, Liu T, et al: Clinical and diagnostic imaging findings predict anesthetic complications in children presenting with malignant mediastinal masses. Pediatr Anesth 2007; 17(11):1090-8.

2. Golianu B, Hammer GB: Pediatric thoracic anesthesia. Curr Opin Anaesth 2005; 18(1):5-11.

3. Hack HA, Wright NB, Wynn RF: The anesthetic management of children with anterior mediastinal masses. Anesthesia 2008; 63:837-46.

4. Hammer G, Hall S, Davis PJ: Anesthesia for general abdominal, thoracic, urologic, and bariatric surgery. In: Davis PT, Cladis FP, Motoyama EK, eds. Smith’s Anesthesia for Infants and Children, 8th edition. Elsevier Pub, Philadelphia: 2011, 772-78.

5. Hammer GB: Anesthetic management for the child with a mediastinal mass. Pediatric Anaesth 2004; 14:95-7.

6. McJadyen G, Budac S, Richards M, et al: Anesthesia for thoracic surgery. In: Gregory GA, Andropoulos DB, eds. Gregory’s Pediatric Anesthesia, 5th edition. Wiley-Blackwell Pub, West Sussex, UK: 2012, 580-3.

7. Narang S, Harte BH, Body SC: Anesthesia for patients with a mediastinal mass. Anesth Clin North Am 2001; 19(3):559-79.

8. Tsao K, St Peter SD, Sharp SW, et al: Current application of thoracoscopy in children. J Laparoendosc Adv Surg Tech A 2008; 18(1):131-5.

NEONATAL LUNG RESECTION

SURGICAL CONSIDERATIONS

Description: Neonatal lung resection is performed for a few disorders relatively unique to children, including congenital pulmonary airway malformations (CPAM); sequestrations (intralobar 75%, extralobar 25%); congenital lobar overdistention (CLO, formerly called “emphysema”); and congenital pulmonary cysts (Fig. 12.5-3). Many lesions are
asymptomatic; they are diagnosed by antenatal ultrasound or later when a CXR is performed for other reasons. CPAMs may compromise respiration, develop infections, and have a small but real risk of malignant degeneration. Sequestrations have little long-term risk, but they are frequently fed by a large systemic artery of near-aortic caliber (often from below the diaphragm) with independent venous drainage back into the vena cava, causing significant L → R shunting. CLO resection is performed when the volume of ineffective, dilated lung compresses adjacent functioning lobes, compromising their function. (This condition is worsened by positive pressure ventilation.) The key therapy is surgical— opening the hemithorax enables an oversized lobe to herniate through the incision, decompressing the healthy lung beneath. Most resections are performed on a ventilated lung because it is difficult to selectively intubate small airways.

Figure 12.5-3. Classic developmental abnormalities of the tracheobronchial tree. (Reproduced with permission from Oldham KT, Colombani PM, Foglia RP: Surgery of Infants and Children. Lippincott-Raven, 1997. After Haller JA Jr, Golladay ES, Pickard LR, et al: Surgical management of lung bud anomalies: lobar emphysema, bronchogenic cyst, cystic adenomatoid malformation, and intralobar pulmonary sequestration. Ann Thorac Surg 1979; 28:34.)

Surgical approach: Patients undergoing lateral thoracotomy through the 4th, 5th, or 6th intercostal space benefit from preop placement of an epidural catheter. In some institutions, thoracoscopic resection may be performed. Significant blood loss is possible (infrequent). Often ventilation improves when the aberrant lung segment is removed. A large CPAM, intralobar sequestration, or CLO usually requires formal lobectomy. Smaller CPAMs, pulmonary cysts, and extralobar sequestrations are treated with lesser resections. A chest tube usually is left in place at the end of the case to drain the pleural cavity and promote lung expansion.

Variant procedures or approaches: Thoracoscopic lobectomy is increasingly the technique of choice for lung resections. It can be performed safely and effectively and avoids the morbidity and poor cosmesis of a thoracotomy. Upper-lobe resections can be technically more challenging, but are still possible with thoracoscopy. Insufflation of the hemithorax with 7 mm Hg carbon dioxide can aid in lung collapse. Some argue for observation of asymptomatic low-risk cystic lung lesions, but the criteria for observation are yet to be rigorously studied.

Usual preop diagnosis: CPAM; sequestration; CLO; pulmonary cysts; congenital diaphragmatic hernia; pneumothorax

▪ SUMMARY OF PROCEDURES

	Thoracotomy	Thoracoscopy
Position	Lateral decubitus	⇚
Incision	Lateral thoracotomy	⇚
Special instrumentation	Pediatric rib retractor	4 mm 30° scope
Unique considerations	Rapid thoracotomy improves ventilation in CLO. Aggressive high-pressure ventilation should be avoided.	Controlled pneumothorax creates working space but can increase CO₂ through absorption.
Antibiotics	Cefazolin 25 mg/kg	⇚
Surgical time	2 h	2-3 h
Closing considerations	Extubation preferable and aided by epidural catheter.	Extubation preferable, intercostal block, epidural unnecessary
EBL	10 mL/kg	5 mL
Postop care	NICU	NICU/PICU
Mortality	< 5%	< 2%
Morbidity	Bleeding Air leak Atelectasis pneumothorax	⇚
Pain score	7-8	4-5

ANESTHETIC CONSIDERATIONS

PREOPERATIVE

In general, children have significantly decreased respiratory reserve compared with adults because:

FRC is closer to RV in children, thereby making airway closure more likely.
O₂ consumption is higher (6-8 mL/kg/min vs. 3 mL/kg/min).
In adults, the decubitus position increases blood flow to the ventilated, dependent lung, while decreasing perfusion to the operated nondependent lung. In children, the nondependent lung may actually receive greater perfusion than the dependent lung, which may be due to a more compliant chest wall in infants and young children.

Premedication

None usually needed. In older infants > 7-9 mo, consider midazolam 0.5 mg/kg or 1-2 mg iv. If airway obstruction or severe pulmonary disease is present, use premedication judiciously.

INTRAOPERATIVE

Anesthetic technique: GETA, forced-air warmer; OR warmed to 75-80°F; use warming pad on OR table, and warm iv fluids. Consider epidural if thoracotomy.

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