The surgery of neonatal jaundice

Most neonatal jaundice is ''medical', and only occasionally is it ''surgical'. Surgically, a child's biliary tract can be blocked by epithelial debris or biliary sand (less common), in which case it may be temporary and clear spontaneously, or by atresia of his biliary tree (more common), for which his only hope is surgery. If much of his bile-duct is not canalized (25%), nothing can be done. If however his bile duct is sufficiently canalized for his gall-bladder to be distended, and in connection with his proximal duct system (75%), it can be anastomosed to his proximal jejunum. If he has an extra-hepatic stump, this too can be anastomosed. Without surgery, he will die. Even in experienced hands his outlook is only fair. If a neonate passes clay-coloured stools, try to refer him before 8 weeks.

NEONATAL JAUNDICE The time of onset is of great diagnostic value.

If a child starts to become jaundiced in the first 6 to 24 hours, his jaundice is likely to be haemolytic as the result of: (1) Septicaemia from an umbilical infection. Look for signs of infection of his cord and the surrounding tissues (septicaemia from cord infection can also occur later). (2) Haemolytic disease of the newborn (uncommon in Africa). Usually, he is D[+]ve, his mother is D[-]ve and has anti-D antibodies as the result of having had a previous D[+]ve child or abortion, or of having been given D[+]ve blood. Other blood group incompatibilities may have the same effect (for example ABO). (3) Congenital syphilis (severe infection).

If he starts to become mildly jaundiced at 24[nd]72 hours, he is likely to have ''physiological jaundice' due to a deficiency of glycuronidase (common, especially in ''small for dates' babies). This usually clears spontaneously, but can be helped by sunlight and phenobarbitone 1[nd]2 mg/kg 12-hourly.

If he starts to become jaundiced at 24[nd]72 hours, and is severely jaundiced by the 3rd to the 5th day, he may have G6PD (glucose-6-phosphate dehydrogenase) deficiency. This is common, especially in SE Asia and the Mediterranean littoral; a less severe form occurs in parts of sub-Saharan Africa.

If he has little or no jaundice for 3 to 6 weeks, by which time his liver is enlarged, and his stools are clay- coloured, he probably has some ''surgical' reason for his jaundice. Sometimes he is slightly jaundiced at birth, or becomes so a few days later; his urine is dark brown early.

CHOLECYSTOJEJUNOSTOMY Surgery and anaesthesia are difficult, so refer him if you can; he is very small, and tends to bleed. If you cannot refer him and decide to operate, give him vitamin K[,1] (water-soluble) 2 mg intramuscularly, and operate next day.

ANAESTHESIA. (1) General anaesthesia. (2) Intramuscular ketamine, followed by small intravenous doses.

INCISION. Make a subcostal, transverse or right upper paramedian incision. If he has a distended gall-bladder, proceed. If he has some inoperable anomaly, close his abdomen.

Anastomose the fundus of his gall-bladder to his jejunum using interrupted sutures of 3/0 catgut or 4/0 multifilament (e.g. silk). See Fig. 13-5.

Postoperatively, manage him as in Section 28.3.