The abdomen was explored thoroughly. Kocherization of the duodenum was done, and the dilated proximal duodenum was identified. When there was a significant gap between the proximal and distal ends, the distal duodenum was mobilized.
A duodenoduodenostomy was the procedure of choice using a diamond-shaped technique. A transverse incision was made in the proximal duodenum and a longitudinal incision of the same length in the distal segment.
The site of the ampulla of Vater was detected through gentle pressure on the gall bladder, and then saline was injected through a small catheter passing through the distal duodenotomy to exclude other distal atresia. Thereafter, a single layer anastomosis with 6-0 vicryl interrupted sutures was done.
In cases of duodenal web, the ampulla was identified and the web was excised from the lateral duodenal wall, leaving the medial alone to avoid damaging the sphincter of Oddi or ampulla. The resection line was oversewn with 6-0 vicryl interrupted sutures, and the duodenotomy was closed transversely in one layer as described before.
We started oral feeding when bowel sounds were heard, the stool was passed, and the gastric aspirate was limited (<1 ml/kg/h of clear or pale-green fluid). Oral feeding was gradually introduced, starting with clear fluids and aspirating the stomach before each feed.
A total of 20 patients admitted to Cairo University Specialized Pediatric Hospital during the period from January 2017 to January 2018 were studied. There were 11 (55%) males and nine (45%) females. The study included 12 (60%) cases of duodenal atresia in neonates (three cases of web in the first part of the duodenum, four cases of web in the second part, two cases of annular pancreas, two cases type II, and one case type III), and eight (40%) of cases duodenal obstruction in infants ranging from 5 months to 2 years of age (two cases of web in the first part of the duodenum and six cases of web in the second part).
We did duodenoduodenostomy in 15 cases (cases of web in the second part of the duodenum, types II and III), and excision of the web in the first part of the duodenum was done in five cases. Laparoscopic repair was done in 11 (55%) cases (diamond duodenoduodenostomy in nine cases and web excision in two cases) whereas open technique was performed in nine (45%) cases (diamond duodenoduodenostomy in six cases and excision of the web in three cases). The average operative time in cases of laparoscopic duodenoduodenostomy was 120 min whereas in the cases of open technique was 90 min. The average time needed until full feeding to be achieved was 6–7 days in cases done laparoscopically, whereas in the other group was 10–20 days. In this cohort, no stricture, leakage, or wound dehiscence was found in both groups. Laparoscopic group afforded a better cosmesis and more parent satisfaction (Table 1).
Of 12 cases of neonatal duodenal atresia, nine cases presented with bilious vomiting and three cases presented with nonbilious vomiting, whereas in children with duodenal atresia, the presenting symptom was bilious vomiting in six cases and nonbilious vomiting in two cases.
Minimal invasive surgery is a safe procedure in cases of duodenal atresia/partial duodenal obstruction/duodenal stenosis.
In this study, we had 12 cases of duodenal atresia in neonates (three cases of web in the first part of the duodenum and four cases of web in the second part, two cases of annular pancreas, two cases of type II, and one case type of III) and eight cases of duodenal atresia in children (two cases of web in the first part of the duodenum and six cases of web in the second part), whereas Mustafawi and Hassan 9 reported 21 (52.5%) of 40 cases of duodenal atresia had a type I atresia, 5% had a type II atresia, and one (2.5%) case had a type III atresia.
The incidence of associated congenital anomalies in this study was 35%, including congenital heart disease (n=2, 10%), trisomy 21 (n=4, 20%), and tracheoesophageal fistula (n=1, 5%), whereas Choudhry et al. 10 reported that 71% of all cases in their series had associated anomalies, including congenital heart disease (24%), trisomy 21 (19%), malrotation (12%), gastroschisis (9%), esophageal atresia (8%), anal atresia (6%), volvulus (5%), colon atresia (3%), mucoviscidosis (3%), and finally Meckel diverticulum (2%).
The average operative time in web excision in open repair was 60 min and in laparoscopic repair was 90 min, whereas in duodenoduodenostomy, it 90 min in open and 120 min in laparoscopic, whereas Parmentier reported that average operative time in cases of laparoscopic duodenoduodenostomy was 90 min 11.
In this study, in the five cases of web excision, feeding was started on the third day regardless of the type of technique, whereas in the 15 cases of duodenoduodenostomy, total parentral nutrition was started on the second day, and then oral feeding after 4–5 days, whether open or laparoscopic.
The time to achieve full feeding was 7 days in cases of laparoscopic duodenoduodenostomy and 12 days for those performed by open technique. This means cases done laparoscopically require less time to achieve full feeding if compared with those done by open repair. Spilde et al.12 compared laparoscopic and open procedures and demonstrated that time to initiation of feeding was shorter in cases completed laparoscopically (5–8 days for laparoscopic vs. 8–11 days for open groups), as was the time to discharge (12–21 days for laparoscopic vs. 20–24 days for open groups).
In five cases of web excision only, cases were discharged in 1–2 weeks, whereas in the 15 cases of duodenoduodenostomy, cases done laparoscopically were discharged earlier than those done by open technique (9 vs.14 days).
In our series, no anastomotic leakage, stenosis or wound dehiscence was encountered in both techniques (open or laparoscopic); however, laparoscopic repair provided a better cosmetic result and more parent satisfaction than open repair. Our results are comparable to Kay et al.13 who reported a series of 17 laparoscopic duodenoduodenostomy procedures with no short-term complications and excellent results, apart from the excellent cosmetic benefit of laparoscopy.
Use of the laparoscope in duodenal obstruction in either neonates or children is a safe and easy technique, and despite being a lengthier operation, feeding could be established earlier, taking less time in hospital until full feeding orally, and overcoming difficulty in obtaining and maintaining parenteral nutrition for long time.
Conflicts of interest
There are no conflicts of interest.
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