General Surgery

ALERT BAR

Pediatric Surgical Services

UTMB is committed to providing the highest quality of care for infants and children with surgical conditions. We offer a full range of services to our pediatric patients, working closely with our experienced pediatric anesthesiologists, neonatologists, and perioperative staff. In addition to surgical support, we provide extracorporeal life support (ECMO) for critically ill infants and children. We are available for prenatal consultations to prepare parents for the birth and care of neonates with complex congenital anomalies. Listed below is a partial outline of common procedures we perform in the areas of oncology, minimally invasive surgery, abdomen, chest, and head and neck.

Neuroblastoma

Neuroblastoma is a tumor that may arise at any site in the sympathetic nervous system, including the brain, neck (3%), chest next to the spine (20%), abdomen on either side of the aorta (24%), pelvis (3%), and adrenal gland (50%) (Figure 1). It is the second most common solid tumor of infancy and childhood, being exceeded only by brain tumors. More than 25% of cases are diagnosed before 1 year of age; 50% of cases by age 2 years, and 90% by age 8 years. [more...]

Pancreas Tumors

Malignant tumors of the pancreas are rare in infants and children. In most patients, by the time the diagnosis is made, a mass can be felt, and yellowing of the skin and eyes is often present. Patients with malignant pancreatic tumors range in age from 3 months to 16 years with most patients younger than 10 years old. [more...]

Solid Chest (Medistinal) Tumors

Mediastinal tumors are fairly common in children and can be either benign (noncancerous) or cancerous (malignant). Approximately 60% are malignant. These tumors include Hodgkin’s disease, non-Hodgkin’s lymphoma, neurogenic tumors, thymomas, teratomas, lipomas, lipoblastoma, germ cell tumors, and other rare lesions. [more...]

Wilms' Tumor

Wilms’ tumor is a cancer of childhood that arises in the kidney. It is made up of cells that originate from immature tissue. Approximately 500 new cases are seen in the United States each year, representing slightly more than 10% of all cases of childhood cancer. [more...]

What is ECMO?

ECMO stands for Extra Corporeal Membrane Oxygenation. ECMO is a procedure during which blood oxygenation and cardiac function are performed by a mechanical pump outside the body. This can be used if the child is critically ill and awaiting surgery or if the heart and lungs need to rest. ECMO works by removing blood from the patient’s body and pumping it through an artificial lung called a membrane oxygenator. This artificial lung takes over some of the work of patient’s lungs by exchanging both oxygen and carbon dioxide. The pump also takes over some of the work of the heart. The blood is then pumped through a heat exchanger where is it warmed before being returned to the patient. Two types of ECMO can be used. It can either be V-V or V-A ECMO and this depends on your child’s condition and the reason for placing your child on ECMO.

Meet the ECMO team

The team is comprised of a pediatric surgeon, ICU physicians, respiratory therapists, nurse practitioners and registered nurses. All members of the ECMO team are employees of UTMB and are available in-house 24/7. We do not contract out our ECMO program. The team meets regularly to ensure that protocols are up to date and all safety measures are met.

When is it used?

Patients are placed on ECMO when they have a serious but reversible medical condition that impairs the function of the heart and/or lungs. Although ECMO is not a cure, the treatment allows the heart and lungs time to rest and recover function. ECMO maintains the blood circulation of the body so that the other body organs are preserved and maintained.

How is my child placed on ECMO?

The pediatric surgeon places the cannula for ECMO. There can either be one or two cannula placed depending on what type of ECMO your child will be on. Depending on the size and age of your child the cannula can either be placed in the neck or the groin. In some instances the cannula can be placed directly into the chest cavity. The cannulas are then connected to the ECMO machine that has been prepared for your child. Your child will have to be sedated and in some cases be medically paralyzed throughout the ECMO process. This is because there are many wires and tubes connected to your child and we do not want your child moving, which can cause some of the tubes to become disconnected.

How long will my child be on ECMO?

This depends on your child’s condition and how they are improving while on ECMO. Every child is different and there is no real way to determine how long is long enough. Generally speaking, children do not stay on ECMO longer than three weeks.

What are the complications of ECMO?

One of the most common complications seen on patients who are on ECMO is bleeding. This is because that while your child is on ECMO they will be receiving heparin which is a blood thinner. The heparin is used to prevent blood clots from forming which can affect the blood flow through the ECMO circuit. You may or may not see bleeding in your child. Sometimes the bleeding can occur inside the body and we are not able to see it. Your child’s heparin will be adjusted frequently to try and prevent bleeding. The ability of your child’s blood to clot will be monitored using tests for anticoagulation.

Minimally invasive surgery offers many advantages, including faster healing, shorter hospital stays, less pain, and reduced trauma to normal tissues.

Minimally invasive procedures

Technological advancements have now allowed surgeons to do many surgical procedures in a minimally invasive manner. Instead of traditional incisions, which may require weeks for complete healing, minimally invasive procedures use instruments that allow physicians to see inside the body and perform the needed procedures with only small incisions for more rapid healing.

Thoracoscopic procedures involve the chest, while laparoscopic procedures involve the abdomen. Scopes used in either area are useful for diagnostic testing as well as in therapeutic intervention.

Many procedures can be performed using minimally invasive techniques, from common procedures such as:

  • Appendectomy (removal of appendix)
  • Cholecystectomy (removal of the gall bladder)
  • Pyloromyotomy (cutting pylorus for pyloric stenosis)
  • Fundoplication (for the treatment of gastro-esophageal reflux disease or GERD)

to the correction of more complex congenital anomalies such as:

  • Tracheo-esophageal fistula repair
  • Duodenal atresia repair
  • Congenital diaphragmatic hernia repair
  • Chest wall reconstruction (Pectus Excavatum)

The technology for minimally invasive procedures is changing rapidly, allowing for more complex conditions to be treated minimally invasively. Families interested in minimally invasive techniques can meet with the pediatric surgery team at UTMB to discuss the options available and see if minimally invasive surgery is appropriate for their child.

Single incision laparoscopic surgery (SILS)

In addition to standard laparoscopy, single incision laparoscopic surgery (SILS) is being performed at UTMB for a number of different pediatric procedures including, but not limited to appendectomies, cholecystectomies, and reduction of intussusceptions.

SILS is a technique by which all the laparoscopic instruments are placed through the same incision at the umbilicus. The incision, which is buried within the folds of the belly button or umbilicus, is essentially lost deep down in the umbilicus and leaves no obvious scarring. While SILS requires advanced laparoscopic skills, many common operations can now be successfully and safely completed using a single incision laparoscopic techniqu

Annular Pancreas

The most frequent abnormality of the pancreas is annular pancreas in which a thin flat band of pancreatic tissue surrounds the first part of the small intestine (duodenum) and continues on either side into the head of the pancreas. [more...]

Appendicitis

Acute appendicitis is one of the most common causes of abdominal pain in childhood. This diagnosis must be considered in all age groups but is more common between the ages of 4 and 15 years. The function of the appendix is unknown. However, in rabbits and other animals the cecum is similar in shape to the appendix and plays a role in digestion of food. The middle, inside portion of the appendix may be irregular and somewhat narrow because of the presence of lymph nodes in the wall of the appendix. [more...]

Biliary Atresia

In normal infants bile drains from the liver to the duodenum (the first portion of the small intestine) through a series of ducts. Ducts are like pieces of hollow tubing. Thousands of very small ducts in the liver become two large ducts that join to form a single hepatic duct that drains into the intestine. The gallbladder is a reservoir for bile that empties into the hepatic duct halfway between the liver and the duodenum. After the gallbladder joins the main duct draining the liver, the duct is called the common bile duct. Biliary atresia is a disorder occurring in infants in which the bile ducts disappear or scar closed, preventing the passage of bile out of the liver. [more...]

Biliary Dyskinesia

A problem that occurs mostly in older children and adults is biliary dyskinesia. This happens when the gallbladder does not squeeze properly and the bile does not drain out of the gallbladder properly. [more...]

Cholecystitis Acalculous - (Gallbladder inflammation without gallstones)

Acalculous cholecystitis may occur as a complication during treatment of various diseases. This condition may occur in newborns but is more common in older children. Boys and girls are affected equally. Patients are often severely ill as a result of prior surgery; a severe burn; extensive trauma; massive blood transfusion; and various infections, including pneumonia, a generalized infection (sepsis), typhoid, salmonella, otitis media with meningitis, giardiasis, and Kawasaki disease. The cause is unknown, but may be in part due to dehydration, ileus (a condition where the bowel does not squeeze properly), gallbladder stasis (bile not being squeezed out of the gallbladder), treatment with total parenteral nutrition (TPN), and breakdown of blood from multiple transfusions. [more...]

Choledochal Cyst

When bile is made in the liver it is first stored in the gall bladder, which connects to the common bile duct, and the gallbladder empties when fat enters the intestine. Bile contains digestive enzymes as well as the breakdown products of old red blood cells, which can no longer fulfill their function. When there is any disturbance in bile flow, liver damage may result. If there is a blockage, bile builds up in the blood and the patient becomes jaundiced with a yellow color to the eyes and skin.[more...]

Cholelithiasis (Gallstones)

Gallstones are relatively uncommon in blacks (except in sickle cell disease), exceptionally common in groups of Native Americans and Hispanics, and a frequent occurrence in whites. Gallstones currently are being recognized in children with increased frequency. Whether this increase in diagnosis is related to an increase in frequency of the disease or an increase in recognition because of the widespread use of ultrasound for abdominal complaints is unclear. The incidence currently is reported to be 0.15% to 0.22% in children. In comparison, gallstones are found in approximately 10% of adults. [more...] 

Crohn's Disease

Crohn's disease (CD), also known as regional enteritis, is a type of inflammatory bowel disease (IBD) described by Crohn in 1932. The most common affected site of bowel inflammation is the distal part of the small intestine known as the ileum, although the colon and other segments of the intestinal tract can be involved as well. The other common type of IBD is termed ulcerative colitis, although this disease is limited to the colon (large intestine). [more...]

Gastroesophageal Reflux and Other Disorders of Esophageal Function

Fundoplication is currently either the first or the second most commonly performed intra-abdominal procedure in infants and children in most pediatric surgical centers. Since the 1970s, surgical correction for gastroesophageal reflux (GER) has been performed by wrapping the upper stomach around the esophagus either a partial (Thal, Boix-Ochoa, Dor, Toupet) or complete (Nissen) fundoplication. In general,   it seems that the Nissen fundoplication is more effective in preventing GER, but it may lead to difficulty swallowing and troublesome bloating in some patients compared with a partial fundoplication, which seems not as effective in preventing reflux. These symptoms after the Nissen procedure seem to be minimized with use of an appropriate-sized esophageal tube used as a “sizer” and division of the blood vessels that attach the stomach to the spleen for sufficient mobilization of the stomach. [more...]

Gastroschisis

Prior to the 1960s, the outcome of infants born with holes in their abdominal wall (abdominal wall defects) was poor. The development of modern breathing machines for infants, nutrition that could be delivered directly into the blood, and man made synthetics that could act as a covering for the abdomen greatly improved the survival of these patients. Recently, the ability to diagnose these defects during pregnancy, further advances in the neonatal intensive care unit (NICU) management of infants, and the development of the modern operating room techniques and technology have led to most patients surviving. [more...]

Hirschsprung's Disease

Descriptions of children with Hirschsprung's Disease date back to the 17th century, when Ruysch (1691), a Dutch anatomist, described a 5-year-old girl who died of intestinal obstruction. The first clinical description of Hirschsprung's Disease was presented at the Berlin Society of Pediatrics in 1886 by Hirschsprung. He thought that the disease was caused by distention of the colon, as evidenced by the title of his presentation: "Constipation in Newborns Due to Dilation and Hypertrophy of the Colon." As a result of Hirschsprung's presentation, however, attention was focused on the consequences of the abnormality rather than the actual cause of the disease.  Hirschsprung’s disease often presents in newborns as intestinal blockage or obstruction occurring most commonly in the colon or rectum. The child may or may not have an infection called enterocolitis, resulting from the obstruction. This is caused by to many bacteria (overgrowth) in the affected segment of intestine. Although the incidence of enterocolitis is variable, this complication makes the diagnosis and early treatment of Hirschsprung’s disease urgent. In the mildest case, delayed passage of meconium (the stool first passed by a baby) may be the only abnormality. [more 123...]

Hydrops (Swelling) of the Gallbladder

Acute swelling of the gallbladder in the absence of gallstones is a well-recognized problem. Hydrops may occur as a newborn and in older children. This condition is characterized by the development of a fluid collection around the gallbladder and main bile duct that drains the liver. [more...]

Hyperinsulinism

Congenital hyperinsulinism, also called nesidioblastosis, is a problem in babies in which insulin control is abnormal, causing low blood sugar. Patients with this syndrome may have signs of low blood sugar without actually having a high insulin level, showing that they have a problem with insulin control. [more...]

Imperforate Anus

A series of developmental steps are involved in the formation of the normal anatomy of the lower end of the anus, rectum, and genitourinary (GU) tract. By the fourth week of development, the cloaca and a structure called the cloacal membrane are present. The cloaca is a normal structure in birds and is present for a short period of time during the development of the human before birth. A cloaca is a structure into which the colon, urinary tract and genitalia all drain and exit the body with a single opening. A human goes thorough a stage of development where a cloaca normally exists and then goes on to develop separate openings for the rectum, urinary tract and in girls, the vagina. This normal development is in much part due to the development of a structure called the cloacal membrane. If the membrane does not develop normally the cloaca may persist at birth in girls or boys will develop some variant of imperforate anus. [more...]

Intussusception

There are many forms and causes of intussusception, but the most common in children is where the last portion of the intestine (the ileum) goes into the first portion of the colon (cecum). This intussusception is an important cause of belly pain and intestinal blockage in infants and requires immediate medical attention. Intussusception occurs in the United States in 2 to 4 per 1000 live births and more commonly (60%) in boys. Intussusception of infancy is seen most commonly between 6 and 10 months of age, with 65% of the children being less than 1 year of age. There seems to be a seasonal incidence, with two peaks occurring (1) in spring and summer and (2) in the middle of winter, corresponding to times of the year with an increased incidence of viral gastroenteritis (GI virus), colds, and flu. While there is no obvious cause, it generally is believed that GI virus leads to swelling of lymph glands in the intestine which leads to one piece of intestine "telescoping" into another. [more...]

Laparoscopic Cholecystectomy

The need to have one’s gallbladder removed is generally due to the formation of gallstones. Gallstones form when there is an imbalance in the components in the bile that is normally stored in the gallbladder. For most people, there is no known reason why gallstones develop. Nevertheless, there are diseases that can predispose your child to form gallstones. Children who have problems with blood cells being broken down easily such as can happen in spherocytosis and sickle cell anemia have increased incidence of gallstone formation. [more...]

Malrotation

Malrotation is an abnormal arrangement or twisting of the intestine inside the abdomen, which is also known as volvulus, that may result in loss of blood flow to the intestine. This abnormal arrangement or twisting of the intestine can also cause blockages of the intestines by causing a kinking of the intestine without loss of blood flow. A delay in recognizing these conditions can result in damage to the intestine as well as danger to the life of the child. [more...]

Meckel's Diverticulum

Meckel's diverticulum is an out pouching from the intestine caused by an abnormality during the development of the fetus and it occurs between 5 and 7 weeks after conception. [more...]

Meconium Ileus

Meconium ileus is the intestinal blockage which is due to cystic fibrosis. Approximately 15% to 20% of infants with CF present with intestinal obstruction related to meconium ileus. Although it originally was thought that CF primarily affected the pancreas, it now is known that it also affects the secretions from the intestine. [more...]

Meconium Plug/Small Left Colon Syndrome

Meconium plug and neonatal small left colon syndromes share sufficient similarities to be discussed together. Patients have transient colonic obstruction most likely due to poor function. The principles of diagnosis and management are similar. [more...]

Necrotizing Enterocolitis (NEC)

Necrotizing enterocolitis (NEC) is the most serious and frequent stomach and intestinal (gastrointestinal, GI) problem of low-birth-weight infants. The result of dramatic improvements in the management of the lung and nutritional needs of premature infants has improved the immediate survival of the infants so now they are living longer and, thus, have a greater chance of developing NEC. [more...]

Omphalocele

An omphalocele is a covered defect of the umbilicus (belly button) with a “sac” which contains abdominal contents. The skin and the muscle of the abdomen are missing. This problem is thought to start in the third week of development when the intestines elongate and normally reside in the yolk sac outside of the abdomen. Omphaloceles are covered by a sac composed of an outer layer and an inner layer. The umbilical cord s right into the sac. A separate compartment containing a jelly-like material also may be observed. If the omphalocele is above the umbilicus there may be other defects involving the diaphragm, sternum, and heart. If the omphalocele is below the umbilicus there may be other defects affecting the bladder, rectum, and lower spinal cord. [more...]

Pancreas Divisum

Pancreas divisum results when the back of the pancreas drained by one pancreatic tube and the front of the pancreas drained by another tube fail to join before joining with the main bile tube. The chances of someone having pancreas divisum are believed to be 5% to 10%, but drainage is normal in most of these people without any site of blockage. [more...]

Pancreatic Cysts

Papillary neoplastic cysts, which are rare in childhood, should be assumed to cause cancer. Only by looking at the cyst under the microscope after surgery can doctors tell if the cyst is cancerous. They are easily ruptured, and the fluid inside the cyst is extremely irritating to the inside of the belly.  [more...]

Pancreatitis

The pancreas is very important to a child’s normal growth and development. It sits in the back of the abdomen, behind the stomach and does two things: 1) It produces enzymes, which help with digesting food and 2) it produces hormones such as insulin and glucagon, which help control blood sugar. In the fetus and newborn baby, the pancreas produces almost no pancreatic enzymes (amylase and lipase); then, the child’s pancreas starts making these enzymes, which help in the digestion of food. Production of these enzymes is at full adult levels by age 2 years. [more...]

Perianal and Perirectal Abscess

Perianal abscesses (pus collection) and fistulas (tunnels that connect the inside of the anus to the skin outside) are seen commonly in male infants younger than 1 year of age with a peak incidence at 4 months of age. [more...]

Pyloric Stenosis

Pyloric stenosis is the most common disorder causing vomiting in infancy which requires surgery. [more...]

Short-Bowel Syndrome

There are numerous definitions for short-bowel syndrome (SBS). The simplest definition is that there is inadequate intestine to maintain normal nutrition by eating. Because infants and children require increased calories to grow and develop, SBS can have a more devastating effect in these patients. [more...]

Spleen Problems

The spleen was long believed to be an unnecessary organ that could be removed without causing any problems. Important functions of the spleen have now been discovered, however, including the removal of bacteria and waste from the blood, the making of antibodies, and the making of red blood cells. [more...]

Ulcerative Colitis

Ulcerative colitis (UC) was described almost 150 years ago. Despite significant advancements in the knowledge of inflammatory bowel disease (IBD), this disorder’s cause and treatment remain unresolved. Although classically thought of as a disorder of adults, many children are affected. The pediatric surgeon is often instrumental in caring for patients with this disabling disease. [more...]

Umbilical (belly button) Hernia

After birth, when the end of the umbilical cord, along with the umbilical vein, umbilical arteries, and urachal remnant, dry up, a small opening is left in the abdominal wall. Failure of the muscles to close around this opening causes an umbilical hernia. [more...]

Umbilical Granuloma/Polyp

After normal separation of the umbilical cord; pink, healing tissue called granulation tissue may persist in the belly button and enlarge into a mass called an umbilical granuloma . This is often associated with umbilical drainage and swelling with redness of the surrounding skin. [more...]

Umbilical Infection (omphalitis)

Umbilical infections in older children are usually due to bacterial growth in a cavity from a left over fetal structure, most commonly a structure that was once attached to the bladder called the urachus. [more...]

Umbilical Problems

Beginning in the fourth week of fetal life the front of the abdomen develops by tissue folding in from the sides, top and bottom. Between 6 and 10 weeks’ gestation, some of the fetus’ intestine is located outside of the main body cavity but it returns to the developing abdomen by the 10th week. By 12 weeks’ gestation, the large abdominal wall muscles in the front, called the rectus muscles, join each other in the midline except at the site of the umbilical ring (belly button), where the muscles are separated by tissue. [more...]

Branchial Cysts, Sinuses and Remnants

Branchial arches are structures that appear in the fourth week of development on either side of the head and neck. Paired outpouchings from the inner lining of the early part of the mouth and throat along with clefts (inward indentations) appear along with muscular, nervous structures, and connective tissue in the neck area. Continued development in this area, from the outpouchings and from the clefts results in the ear canal, tonsil, throat structures, parathyroid glands and thymus. There are four distinct clefts, each giving rise to abnormalities if incomplete development occurs or there is a failure of these primitive structures to go away. [more...]

Cervical Cysts, Sinuses, and other Neck Lesions

Cysts (fluid filled lumps), solid lumps, and sinuses (small openings) found about the head and neck are frequently residual structures from embryologic development that have failed to resorb completely or mature. Some lumps may be caused by inflammation, infection or even tumors affecting lymph nodes in the neck area. [more...]

Cystic Hygroma

Cystic hygromas are varying sized cystic abnormalities of the lymphatic system occurring in perhaps 1 in 10,000 births. The word is derived from the Greek meaning moist or watery tumor and can occur equally in boys and girls. Approximately 50 or 60 percent are present at birth and about 80-90 percent appear or are detected before the end of the second year of life. [more...]

Hyperthyroidism

Grave’s disease (hyperthyroidism) is generally diagnosed in adults, but can be seen in children. This can cause enlargement of the thyroid gland (goiter). Although this usually occurs in older children, it can be seen in infants of mother’s with Grave’s disease. Infants generally respond to medicines (iodine and propylthiouracil) and do not require surgery. [more...]

Neck Abnormalities

Cysts (fluid filled lumps), solid lumps, and sinuses (small openings) found about the head and neck are frequently residual structures from embryologic development that have failed to resorb completely or mature. Some lumps may be caused by inflammation, infection or even tumors affecting lymph nodes in the neck area. [more...]

Parathyroid

There are four parathyroid glands along the behind the thyroid glands and near the edges of the gland. They are pea-sized and control calcium levels in the body. The most common disease of the parathyroid glands in children is hyperpararthyroidism. [more...]

Thyroglossal Duct Cysts and Sinuses

Embryology: The thyroid gland, although situated in the lower portion of the neck around the trachea, originates in the mouth at the back of the tongue and then moves down the neck during development. As the thyroid gland moves down to its normal position, there is a connection to the base of the tongue that should disappear by the time the thyroid reaches its final position. If it does not, there may be a persistent hollow tube that may allow accumulation of mucoid material and the formation of a cyst at the end. [more...]

Thyroid Cancer

The frequency of thyroid cancer has increased since the 1960’s, and is one of the most common pediatric cancers. [more...]

Thyroid Nodules

A thyroid nodule is a lump found in the gland. They can be malignant (cancer) or benign (not cancer). Although thyroid nodules are more common in adults than children, they are more likely (20-30%) to be malignant in children. [more...]

Thyroid Tissue at the Wrong Site (Ectopic)

Ectopic tissue is normal tissue that is found in a part of the body where it is not usually meant to be. During normal development, the thyroid forms at the base of the tongue, and later drops down into the neck. A remnant is left behind which usually involutes (goes away). If the thyroid does not descend normally, it may remain at the base of the tongue (called a lingual thyroid) or within the muscles of the neck. [more...]

Thyroiditis

Thyroiditis is enlargement of the thyroid gland from an autoimmune (antibodies to one’s own body) reaction. In this disease, the thyroid cells are damaged by antibodies. This is most commonly called Hashimoto’s thyroiditis, or autoimmune chronic lymphocytic thyroiditis. It is a common cause of enlargement of the thyroid in children, although it is more common in adults. Hashimoto’s thyroid is 10 times more common in females. [more...]

Torticollis

Torticollis, or wry neck, results from scarring and a mass in the middle portion of the large muscle in the neck known as the sternocleidomastoid muscle. [more...]

Achalasia

Achalasia is a motor disorder usually affecting the entire length of the esophagus. Although the cause of achalasia is unclear, approximately 10% of cases occur in children. Even though this disease is relatively uncommon in children, it seems to be increasing in frequency. [more...]

Breast Problems

Pediatric breast problems can be categorized to those that arise in infancy and those later in childhood. They may manifest as nipple discharge, masses or lumps, with redness or swelling of the breast area. It is not uncommon for some children to have extra breast tissue or extra nipple tissue. This extra tissue rarely causes any physical symptoms but can be removed if it leads to emotional or psychological problems. [more...]

Chest (Mediastinal) Cysts

Mediastinal cysts and tumors are relatively common in infants and children. Although cysts of the mediastinum are often asymptomatic, they usually require removal. If cysts are symptomatic, they may present with chest pain, cough, breathing problems, bloody cough or bloody vomiting, and difficulty swallowing. The various cysts encountered include bronchogenic cysts, thymic cysts, enterogenous cysts, neurenteric cysts, dermoid cysts, cystic hygroma, and pericardial cysts. [more...]

Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernia (CDH) is a condition where there is a hole in the diaphragm and organs from the abdomen go up into the chest cavity. CDH was described in 1848 and the first repair in a baby was by Robert Gross in 1946. [more...]

Empyema

Empyema is a chest infection. Unlike pneumonia, which is an infection in the lung, empyema occurs in the space between the lung and the chest wall known as the pleural space (or pleural cavity). In children, empyema is usually a complication of pneumonia. Inflammatory reaction to the pneumonia produces fluid in the pleural space (“effusion”). If the infection from the pneumonia spreads to this fluid, pus may accumulate, resulting in empyema. [more...]

Pectus Carinatum

Protrusion deformities of the anterior chest wall are 10 times less frequent than depression deformities. Associated disorders, including congenital heart disease, Marfan’s syndrome, spine abnormalities, and musculoskeletal defects are as frequent as in patients with pectus excavatum. The deformity typically is mild or absent in early childhood and becomes increasingly prominent during the rapid growth in early adolescence. [more...]

Pectus Excavatum

Pectus excavatum, or funnel chest, is a congenital malformation of the anterior chest characterized by a prominent depression of the body of the sternum, usually involving its lower half to two-thirds. The lower rib cartilages bend posteriorly to form a depression. The first and second ribs, and the upper sternum are essentially normal. Asymmetric deformities are common, with the depression being deeper on the right with the sternum being rotated posteriorly to that side. In most instances however, the depression is involves the lower half of the sternum and is symmetrical with a decrease in the depth of the chest cavity. [more...]

Ambiguous Genitalia

Ambiguous genitalia refers to a condition of the genitals in which there is a question about whether the sex of the child is male or female. Proper male or female assignment to a newborn with ambiguous genitalia should be expeditious and timely, but it is crucial that it be proper and accurate. Proper gender assignment should entail an approach that includes, but is not limited to, input from pediatric endocrinology, surgery, urology, psychiatry, and radiology consultants and the parents. When an appropriate sex assignment has been made, it is possible to proceed with an operation procedure in a timely fashion, if one is required. [more...]

Epididymitis and Orchitis

Epididymitis is a collection of tissue just behind the testicle. Epididymitis may have an infectious or inflammation. Most commonly, epididymitis occurs from the reflux of infected urine or from sexually acquired disease caused by gonococci and Chlamydia . This distinction is important because different antibiotics are needed for the different causes. Occasionally, epididymitis develops after excessive straining or lifting and the reflux of urine into the vas deferens, which causes a chemical epididymitis; this usually resolves promptly. Any non–sexually active child, especially a pre-pubertal child who develops epididymitis, should be evaluated for a urinary tract abnormality. [more...]

Testicular Torsion

Torsion of Testicular Appendix Torsion of an appendix testis and appendix epididymis are common causes of torsion. Both of these are small tags of normal tissue attached to the testicle. [more...]

Torsion of Testicular Appendix

Torsion of an appendix testis and appendix epididymis are common causes of torsion. Both of these are small tags of normal tissue attached to the testicle. [more...]

Undescended Testis

An empty scrotum is found in 20% to 30% of premature infants and 1.2% to 4% of mature newborns. This means that there is no testicular tissue that can be found in the scrotum. The diagnosis of true undescended testis may be difficult to determine before age 6 months, particularly in premature infants. [more...]

Urachal Abnormalities

The urachus is a fetal structure that extends up from the top of the bladder to the lower part of the umbilicus (belly button). While it may remain open throughout life, the urachus usually collapses and becomes occluded after birth. The urachus may produce symptoms if some or all of it remains open after birth. [more...]

Conjoined Twins

Conjoined twinning is a rare and challenging congenital malformation, which has stimulated human interest from early times. For example, conjoined twins have been depicted in sculpture and art dating back from before the time of Christ. Early, though unsuccessful efforts were undertaken to separate the conjoined twins, but occasional successful separation was not reported until the 1960s. More routine success with separation has only occurred over the last 15 to 20 years. [more...]

Foreign Bodies and Bezoars

Ingestion of foreign bodies is a problem because of the tendency for small children to put everything into their mouths. There may or may not be history of ingestion of a foreign body. If a foreign body does not become stuck in the duodenum or at the first part of the small intestine (ligament of Treitz), it ordinarily passes through the intestinal tract. A foreign body that perforates the intestine may produce obstruction. [more...]

Inguinal Hernia and Hydrocele

Inguinal hernia is a common condition of infancy and childhood, and repair is the most frequently performed general surgical operation in childhood. [more...]

If your child has been diagnosed with portal hypertension, you may be wondering what this is and where it can be treated. This information is intended to provide an introduction into pediatric portal hypertension and the various surgical treatment options available.

Dr. Ravi S. Radhakrishnan, MD, at the Children’s Hospital of the University of Texas Medical Branch, has received specialized training to help manage and treat pediatric portal hypertension from the nation’s leading expert in the surgical treatment of pediatric portal hypertension, Dr. Riccardo Superina at Children’s Memorial Hospital in Chicago.

The following sections will provide a brief overview of pediatric portal hypertension and some of the options that are available at our center. Each child’s anatomy and disease process is unique and, after a thorough evaluation by our team, we hope to provide a treatment plan tailored to your child’s specific needs.

What is portal hypertension?

Portal hypertension means that there is high blood pressure in the portal vein. The portal vein drains the blood from the intestines and supplies vital nutrients from the intestine to the liver. Portal hypertension can happen because the liver is damaged and is slowly being replaced with scar tissue, called cirrhosis. Portal hypertension can also happen after a blood clot forms in the portal vein, called portal vein thrombosis or extra-hepatic portal vein thrombosis (EHPVT). This prevents normal blood flow through the portal vein to the liver leading to an increase in portal venous pressure. When portal venous flow is obstructed, it must flow through other vessels, or varices, to return to the heart. As the pressure in the portal vein increases, more varices are formed to try to return all the blood to the heart. These varices are not designed to handle the large volume of blood or the high pressure from the portal vein. As a result, varices can burst, leading to significant bleeding, typically from the esophagus or the stomach, leading to vomiting of blood or bloody bowel movements.

What causes pediatric portal hypertension?

Portal hypertension in children can develop from scar formation in the liver (cirrhosis) or from portal vein blockage (thrombosis). Cirrhosis can be due to a number of conditions, including metabolic abnormalities, genetic diseases, infectious diseases, or congenital abnormalities. While children with cirrhosis have underlying liver disease, the majority of children with portal vein thrombosis have an otherwise normal liver. The risk of EHPVT may be increased in children with hypercoagulable conditions or intravenous catheters placed in the umbilical vein at birth. However, in the majority of children, the cause is unknown.

What symptoms will my child have?

Children with portal vein thrombosis may have a variety of different symptoms but typically have an enlarged spleen, distended abdomen, vomit blood or pass blood in bowel movements, low platelet counts or low white blood cell counts. While this can be diagnosed in infants or adults, the most common age at diagnosis is 2-4 years old.

How is the diagnosis made?

EHPVT may be suspected by symptoms and confirmed by a variety of tests, including ultrasound, CT scan, MRI, or angiography.

Treatment options
Medical options

The initial treatment of EHPVT often involves blood transfusions, medications to decrease the blood flow through the varices, or endoscopic procedures such as banding or sclerosis. These treatments are designed to control bleeding from the varices. However, they do not correct the underlying problem. If your child’s symptoms do not improve after these initial therapies, surgical evaluation may be appropriate.

Surgical options

Your child may be referred for surgery after the initial diagnosis of portal hypertension or later after his symptoms are controlled. Many different surgical options are available and a specific treatment plan will be created for each patient, addressing their particular needs and anatomy. The following paragraphs will briefly discuss a few of these options and is not intended to be a complete list. Portal hypertension surgery falls into two categories: palliative and restorative. Palliative shunts are effective in decompressing varices and reducing the symptoms of portal hypertension. These include the mesocaval and distal splenorenal shunts that have been performed for many years with high success rates. However, these shunts do not restore the nutrient blood flow to the liver.

What is the Rex shunt?

The restorative shunt, the meso-Rex bypass — or “Rex shunt” for short — has been successfully performed in the US for the last 14 years, with success in over 90% of patients. In addition to relieving the symptoms of portal hypertension (bleeding and dilated varices), it restores blood flow to an otherwise normal liver and results in reduction in spleen size. Because the rex shunt restores normal blood flow to an otherwise normal liver, we believe that this is the treatment of choice for children with extra-hepatic portal vein thrombosis (EHPVT).

The shunt bypasses the blocked portal vein and restores venous blood flow to the liver. A vein (usually the jugular vein in the neck) is used to build a bridge around the blockage. Blood flows from the large intestinal veins, across the bridge, around the blockage and back into the liver. Blood can then flow from the intestines into the liver in the “normal” way. If for some reason your child cannot have this procedure, other procedures may be considered. Your surgeon will review the different options with you to determine the best procedure for your child.

Following the surgery, the symptoms of portal hypertension usually resolve very quickly. In addition, restoring normal portal blood flow to the liver allows the liver to recover some of its functions that may have been impaired, allowing the child to grow and develop to their full potential.

How long will my child stay in the hospital?

Children typically spend seven days in hospital after the surgery. Your child will spend 1 to 2 days in the pediatric intensive care unit (PICU) and then the remainder of the stay will be spent on the general inpatient unit. All children receive blood thinners for the first few days after the operation to ensure that the new venous bridge does not clot off. In some cases, oral blood thinning medications are continued after discharge from the hospital. After the children are eating, medicines are given by mouth to slow down clot formation. Prior to discharge, imaging studies (Ultrasound or CT scan) are ordered to confirm that the shunt is working. Children are usually sent home 1 week after surgery.

What follow-up care will my child need?

Routine blood tests and ultrasounds are repeated every three months and possibly a CT scan one year after the surgery. Most children can be monitored at their home centers and return to Galveston for their one-year follow-up. Some families prefer to come to the Children’s Hospital at UTMB for their check-ups, and we will do everything possible to make their stay as brief and pleasant as possible.

Pediatric Surgery Locations


Prenatal Consults

The pediatric surgery team at UTMB is available for prenatal consults.  During your prenatal care you may have an ultrasound that shows an abnormality that may need surgical correction after delivery.  You and your family can first discuss these results with your obstetrician and you may be referred to the maternal fetal medicine group, which manages high risk pregnancies.  During your discussion with your obstetrician and the maternal fetal medicine group, the topic of surgery for your child may arise.

If surgery needs to be performed after delivery, you can request a consultation with the pediatric surgery team. This consultation time can be used to discuss any surgical needs your child may need after delivery.  We can use this time both to answer any questions you have after your initial discussion with your obstetrician as well as discuss any surgery that needs to be performed.  The consultation can be done in the presence of not only yourself but your family as well if you wish them to be present.  Facing these types of discussions on your own can be difficult and it will be necessary to have a strong support system available to you throughout this time.

There are some cases in which surgery or surgical interventions need to be implemented shortly after delivery due to your child’s condition.  By having this prenatal consultation our team will be able to discuss these interventions with you and your family before there is an immediate need for them.  By discussing these surgical procedures prior to delivery, you and your family will have a better understanding of the surgery needed and can have your questions answered extensively.  After your initial consultation, the pediatric surgery team will always be available for any further questions or concerns you may have.  If you would like to meet again to discuss things further, we are able to coordinate this as well.

Some of the more common reasons for a prenatal consultation with our team are for congenital diaphragmatic hernias, abdominal wall defects, and abdominal/chest masses.  Although this does not encompass everything we treat, these are some of the more common prenatal findings that require prenatal planning.  We will work closely with your obstetrician and the maternal fetal medicine team to coordinate the best care for both you and your child.

Many times when your child requires surgery shortly after birth they may be transferred to our Infant Special Care Unit or ISCU.  This unit is specifically designed to provide the intensive care your child may require.  This unit is staffed with neonatal nurses, respiratory therapists, occupational therapists as well as neonatal nurse practitioners and neonatologists that specifically care for small or sick infants after delivery.  If you would like to also meet with the neonatal team to discuss care options for your child this can easily be done.  Tour times can be made available so you may tour the ISCU as well as the Labor and Delivery area to make your time at UTMB more comfortable.