Year : 2018 | Volume
: 23 | Issue : 4 | Page : 180--181
Pediatric surgical diseases and legacy of pediatric surgery in adults - Responsibility of pediatric surgeons
Department of Paediatric Surgery, Park Medical Research and Welfare Society, Kolkata, West Bengal, India
Prof. Sachchidananda Das
35 C, Radha Madhav Dutta Garden Lane, Kolkata - 700 010, West Bengal
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Das S. Pediatric surgical diseases and legacy of pediatric surgery in adults - Responsibility of pediatric surgeons.J Indian Assoc Pediatr Surg 2018;23:180-181
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Das S. Pediatric surgical diseases and legacy of pediatric surgery in adults - Responsibility of pediatric surgeons. J Indian Assoc Pediatr Surg [serial online] 2018 [cited 2019 Feb 15 ];23:180-181
Available from: http://www.jiaps.com/text.asp?2018/23/4/180/242705
The necessity of pediatric surgery as a subspecialty came up when it was realized that it was not a mere miniature adult surgery, rather it was something more. The neonates and children have different physiological responses and fluid requirement. Moreover, a majority of surgical problems are presented with congenital anomalies. Their pathophysiological changes and structural changes are very important while venturing their surgical treatment.
Age of the patient is still the only landmark to get passport to be admitted in a pediatric ward, though pediatric surgery now involves fetal surgery, neonatal surgery, and the surgery of the children, adolescents, and young adults. In our country, age limit varies between 8 and 12. This age bar creates two problems. In our country, and perhaps in all the developing and underdeveloped countries, patients with some nonlethal congenital defects may present even in adult life. Rectovestibular fistula is a well-known example. Another issue is the late complication of neonatal surgery, particularly intestinal surgeries. A second abdominal surgical condition amidst intense intestinal adhesions following neonatal surgery is not an easy task for a general surgeon without having any clue of the past surgery.
Presentation of rectovestibular fistula in adolescents and adults is not very infrequent. I had even the opportunity of operating on a girl of 23 years who had rectovaginal fistula. The girl was passing stool regularly. No one of her close relatives noticed that she had no anus. When she became adolescent, she could understand her problem. She started menstruating from the same bowel opening but could not tell anybody out of shame. After her brother's marriage, she divulged her plight to her sister-in-law who brought her for treatment. They attended the general surgery outpatient department and the concerned surgeon asked me to see the patient. She was admitted in general surgery ward under the care of the referral surgeon who operated on her in three stages. In general surgery ward, pediatric surgeons cannot admit these special cases, and it is too much to expect from general surgeon to reconstruct bowel vagina and urethra in anorectal malformations.
In another occasion, I had to operate on a lady of 34 years who had a choledochal cyst. She presented with the symptoms of cholecystitis with mild jaundice. Ultrasonography picked up the cyst. She was admitted in a private setup and choledocho-Roux-n-y jejunostomy was performed. I believe this problem is better tackled by a pediatric surgeon who regularly does this operation than a general surgeon who is an occasional surgeon for such anomalies.
Complications of pediatric surgical procedures may present late in adult life. One of my own follow-up case of choledochal cyst, operated at the age of 3, presented with abdominal pain and jaundice at age 17. She had developed anastomotic stricture near porta hepatis. It is a very difficult surgical problem, may be more difficult task for a general surgeon. Another patient who was operated by me at the age of 2 days had jejunal atresia with meconium peritonitis. She came to me after a long gap of 22 years in a very pathetic condition. She had developed cholelithiasis when she was 10, operated by a general surgeon in a very good setup. Surgical note mentioned there was intense intestinal adhesion. Five days following cholecystectomy abdomen had to be reexplored. An intestinal injury was detected and repaired. After 10 days, a fecal fistula developed. Subsequently, three attempts were made to repair the fistula without success and the patient was left with the fistula. When I saw the patient, she had been living with the fecal fistula for 10 years. She had visible peristalsis, X-ray showed features of subacute intestinal obstruction. I advised for laparotomy, adhesiolysis, and fistula repair. The scared patient and her parents took 1 year to consent for surgery which was successfully done.
The idea of presenting these cases is to promote my opinion that pediatric surgeons are in a better position to tackle congenital anomalies that may present in adult life. The services of pediatric surgeons are also preferred when follow-up neonatal and pediatric surgical patients present late with complications in adolescents and adults.
To promote my views, further I take the help of a great pediatric surgeon, Dr. Judson Randolph. In the presidential address of APSA 1985, he said: “Pediatric surgeons are general surgeons and something more and something more.”
|1||Randolph J. The first of the best. J Pediatr Surg 1985;20:580-91.|