*Divisions of Pediatric Gastroenterology, USA
†Pediatric Surgery, USA
‡Pediatric Radiology, University of Mississippi Medical Center, Jackson, USA
Received 5 October, 2007
Accepted 21 December, 2007
Address correspondence and reprint requests to Michael Nowicki, MD, Division of Pediatric Gastroenterology, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216 (e-mail: firstname.lastname@example.org).
The authors report no conflicts of interest.
Duodenal webs are rare, with a reported incidence ranging from 1 in 10,000 to 1 in 40,000 (1,2). By virtue of being a congenital disorder, duodenal webs are more commonly seen in infants and children. The mainstay of therapy has been surgical intervention, although the advent of therapeutic endoscopy has provided new options. To date, the majority of endoscopic treatment of duodenal webs has been reported in adults, using techniques seldom practiced by pediatric gastroenterologists. We present a young child with a duodenal web that was repaired endoscopically using a combination of partial membrane excision by hot biopsy forceps and balloon dilation. These techniques are commonly practiced by pediatric gastroenterologists, allowing endoscopic-directed correction of a historically surgical problem.
A 15-month-old boy was referred for evaluation of persistent vomiting. He had a lifelong history of intermittent vomiting that was increasing in frequency and severity. The vomiting occurred without pattern, occurring both during the day and at night, and there was no history of bile, gross blood, or coffee-ground material in the vomit. Prenatal history was negative for polyhydramnios. His medical history was significant for situs inversus of the thoracic contents. Examination was remarkable for a weight of 11.5 kg (50th percentile). His abdominal examination was benign. Laboratory evaluation revealed normal electrolytes, except for mild acidosis (CO2 = 18 mmol/L). A contrast upper gastrointestinal study demonstrated a curvilinear lucency at the junction of the second and third portions of the duodenum consistent with a duodenal web (Fig. 1A). Therapeutic endoscopy was performed in an attempt to avoid surgery. A pediatric surgeon was in attendance in case the endoscopic procedure failed or complications occurred. Because of the child's age—and concerns about pain, prolonged procedure time, and patient cooperation—the endoscopy was performed under general anesthesia. At endoscopy, a duodenal web was confirmed, with an opening on the medial aspect approximately 2 mm in diameter (Fig. 2). The ampulla of Vater was not identified, and was thought to be posterior to the web adjacent to the opening. Under direct visualization, a catheter was placed across the web and water-soluble contrast injected under fluoroscopy to confirm connection with the distal duodenum. To avoid potential ampullary trauma, a second opening was made in the middle of the web using hot biopsy forceps. Briefly, the central portion of the web was grasped with hot biopsy forceps (EndoJaw, Olympus, San Jose, CA), cauterized, and then cut using a setting of 25 W for both (Sabre 180 electrosurgical unit, Conmed/Aspen Labs, Utica, NY). This opening was dilated using balloon dilators (Controlled Radial Expansion Dilatation catheter, Boston Scientific/Microvasive, Boston, MA), with outside diameters ranging from 18 to 20 mm. The balloons were expanded with normal saline under direct visualization and held for 1 minute at each diameter. Next, an ultraslim endoscope (5.9-mm OD, GIF XP160, Olympus) was introduced across the web in an effort to visualize the ampulla; however, it was not seen. With the thought that the ampulla could be within the medial aspect of the web, excision of portions of the web was done piecemeal using hot biopsy forceps along the lateral and superior aspects. Cautery and cutting were performed simultaneously using the blend setting at 25 W for both. Membranectomy was discontinued before reaching the junction of the web and duodenal wall. Following the membranectomy, a standard endoscope (8.6-mm OD, GIF 160, Olympus) could easily be passed across the opening. The child was observed overnight in the hospital and was discharged the following day after tolerating a full diet. Ten days later, the patient returned to the emergency department with complaints of vomiting, diarrhea, fever, and decreased oral intake. An abdominal radiograph showed an unremarkable bowel gas pattern. It was felt that the infant had an acute gastroenteritis, but because of his recent procedure a repeat contrast upper gastrointestinal study was done to rule out partial obstruction due to a residual duodenal web. The study was interpreted as having no evidence of duodenal obstruction (Fig. 1B). The child has remained asymptomatic with good growth for 20 months of follow-up.
Duodenal web is a rare cause of duodenal obstruction found across all age groups, but most commonly seen in infants. These webs are thin, consisting of mucosa and submucosa, usually lacking a muscular layer (3,4). Peristalsis causes the diaphragm to balloon distally, resulting in the classic appearance of a wind sock. Duodenal webs are thought to arise from incomplete recanalization of the duodenal lumen during the fourth and fifth weeks of gestation. Presentation is typically early in life with evidence of proximal bowel obstruction; however, presentation late in adulthood has been reported (5,6).
Before the mid-1980s, surgical repair was the only treatment available for duodenal webs, with endoscopy being relegated to a diagnostic role. Advancement of therapeutic endoscopic techniques has revolutionized the approach to duodenal webs in adults. Excellent results have been accomplished with a combination of dilation and laser, papillotome, or sphincterotome, with follow-up extending to 18 months (5,6). It has been suggested that therapeutic endoscopy may be the preferred method of treatment for duodenal webs in adults because of its efficacy, relative simplicity, safety, and lack of invasiveness (6). To this can be added the cost savings offered by endoscopy including sedation in lieu of anesthesia, avoidance of surgery, and decreased recovery time.
The reported experience of endoscopic treatment of duodenal webs in children is limited (7,8), possibly related to the inexperience most pediatric gastroenterologists have with the needed therapeutic techniques. The armamentarium of the pediatric gastroenterologist typically includes dilation; however, the needs for laser therapy and cutting with a papillotome or sphincterotome are uncommon in children. To date, the endoscopic therapy of duodenal webs in children has included laser therapy performed by pediatric surgeons (8) and sphincterotome performed by pediatric gastroenterologists who received training from surgical colleagues (7). Outcomes were good with no complications reported, such as stricture formation and need for redilation. We were able to obtain excellent results using hot biopsy forceps and dilation, techniques common to pediatric gastroenterology. Although more tedious than cutting with a sphincterotome, piecemeal excision with hot biopsy forceps worked well in our patient and was without complications. A similar technique has been described, albeit piecemeal membrane excision was accomplished using “cold” biopsy forceps through an enterotomy (9). The benefits of endoscopic membrane excision in children are similar to those in adults. In our experience it is easier and safer to use general anesthesia when performing long and/or complicated endoscopic procedures in infants and children, negating the cost savings obtained with sedated procedures. Other benefits of an endoscopic approach are absence of an abdominal scar and minimal risk for intraabdominal adhesions.
To date, reports of endoscopic treatment for duodenal webs have been free of significant complications. In particular, the development of posttreatment strictures has not been reported (2,4–6,9). It has been proposed that the use of radial incisions for endoscopic treatment of duodenal web is less apt to lead to stricture formation than circumferential excision (4). Another potential serious complication is injury to the ampulla of Vater. It may be difficult to ascertain the exact position of the ampulla in the presence of a duodenal web. We chose not to dilate the small natural opening in the web because it was along the medial wall of the duodenum, where the ampulla naturally arises. Rather, we created a second opening in the center of the web followed by direct visualization distant to the web for the ampulla. Because the ampulla could not be identified, we partially excised the membrane in lateral and superior directions, being sure to stop before reaching the junction of the web and duodenal wall. This ensured that regardless of position the ampulla would not be injured.
In summary, we report the successful treatment of a duodenal web with a combination of hot biopsy partial membrane excision and balloon dilation. Although the patient described had an excellent outcome, care must be taken when considering therapies based on case reports and small series. Insufficient numbers have been reported to adequately determine the true prevalence of serious complications associated with endoscopic membranectomy, including perforation, bleeding, injury to the ampulla, and stricture formation. Ultimately, the decision to approach a duodenal web endoscopically will depend on a number of factors, including the technical abilities of the endoscopist and the ready availability of a pediatric surgeon.
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