Open vs laparoscopic repair of congenital duodenal obstructions: a concurrent series

Laparoscopic repair of duodenal atresia: systematic review and meta-analysis after consistent implementation of the technique in the past decade

BACKGROUND

Laparoscopic repair of duodenal atresia (LRDA) remains a technically challenging procedure and its benefits ambiguous. To assess the safety and efficacy of LRDA, we performed a systematic review of techniques and material for LRDA and a meta-analysis comparing outcomes with open repair (OR).

METHODS

Comprehensive search of EMBASSE, PubMed and Cochrane was performed from 2000 to 2023. Studies comparing LRDA with OR were identified and outcomes extracted included operative time, time to enteral feeds, length of hospitalisation, anastomotic leaks and stricture and total complications. χ2 was used to assess associations between complications and conversions rates of different LRDA approaches (laparoscopic technique, suturing technique). Comprehensive meta-analysis was used for Meta-analysis.

RESULTS

Twelve studies were identified and 1731 patients were enrolled in the study (398 [LRDA] and 1325 [OR]). Total rate of complications and conversion for LRDA was 15.58% and 18.84%, respectively. Complication rates were not significantly affected by operative technique and suturing technique. Conversion rates were not significantly affected operative technique; using a combination of interrupted and running suturing was significantly higher than using running or interrupted (χ2 = 7.45, p < 0.05). Anastomotic leaks, strictures and total complications were equivocal between LRDA and OR (OR 1.672, 95% CI 0.796-3.514; OR 2.010, 95% CI 0.758-5.333; OR 1.172, 95% CI 0.195-7.03). Operative time was significantly greater for LRDA (SDM 1.035, 95% CI 0.574-1.495, p < 0.001). Time to initial and full enteral feeds and length of hospitalisation were shorter in the LRDA group (SDM - 0.493, 95% CI - 2.166 to 1.752, p = 0.466; SDM - 0.207, 95% CI - 1.807 to 0.822, p = 0.019; SDM - 0.111, 95% CI - 1.101 to 0.880, p = 0.466, respectively).

CONCLUSIONS

LRDA showed equivalent complication rates compared to OR with an additional benefit of quicker establishment of feeds. There was no significant difference in complication and conversion rates between laparoscopic techniques. Despite a longer operative time, LRDA provides a safe minimal access approach for neonates after this consistent implementation of the technique in the past decade.

Duodenal Atresia Repair: A Single-Center Comparative Study

BACKGROUND

The use of laparoscopy in the repair of duodenal atresia has been increasing. However, there is no consensus regarding which surgical approach has better outcomes. We aimed to compare the different surgical approaches and types of anastomoses for duodenal atresia repair.

METHODS

Patients who underwent duodenal atresia repair at a single pediatric center were identified between January 2006 and June 2022. Those with concomitant gastrointestinal anomalies or who required other simultaneous operations were excluded. The primary outcome was rate of complications, defined as rate of leak, stricture, and re-operation by surgical approach and technique of anastomosis.

RESULTS

A total of 78 patients were included. The majority were female (51.3%, n = 40), with a median age of 4 days (IQR 3.0,8.0) and a median weight of 2.7 kg (IQR 2.2,3.3) at repair. The re-operation rate was 7.7% (n = 6), of which two were anastomotic leaks, and four were anastomotic strictures. The leak rate was 5.6% (n = 1/18) for the open handsewn and 4.8% (n = 1/21) for the laparoscopic handsewn technique. The stricture rate was 12.5% (n = 1/8) for the laparoscopic-assisted handsewn, 9.1% (n = 2/22) for the laparoscopic U-clip, 4.8% (n = 1/21) for the laparoscopic handsewn, and none with laparoscopic stapled and laparoscopic converted to open handsewn techniques. No differences were found in complication rate when controlling for surgical approach.

CONCLUSION

The method of surgical approach did not affect the outcomes or complications in the repair of duodenal atresia.

Post-discharge follow-up of congenital duodenal obstruction patients: a systematic review

PURPOSE

Long-term follow-up of congenital duodenal obstruction patients often falls on care providers with little experience of this condition. We performed a systematic review of the long-term outcomes of duodenal obstruction and provide a summary of sequelae care providers should anticipate.

METHODS

In 2022, after registering with PROSPERA, Medline (Ovid), EMBASE, PSYCHINFO, CNAHL and SCOPUS databases were searched using the title keyword 'intestinal atresia'. Abstracts were filtered for inclusion if they included the duodenum. Papers of filtered abstracts were included if they reported post-discharge outcomes. Methodological Index for Non-Randomized Studies was used to grade the papers.

RESULTS

Of the 1068 abstracts were screened, 32 papers were reviewed. Eleven studies were included. Thirty additional papers were included after reviewing references, for a total of 41 papers. The average MINORS was 7/16.

CONCLUSION

There is good evidence that children with congenital duodenal obstruction do well in terms of survival, growth and general well-being. Associated cardiac, musculoskeletal and renal anomalies should be ruled-out. Care providers should be aware of anastomotic dysfunction, blind loop syndrome, bowel obstruction and reflux. Reflux may be asymptomatic. Laparoscopic repair does not change long-term outcomes, and associated Trisomy 21 worsens neurodevelopmental outcomes.

Cardiac anomalies in children with congenital duodenal obstruction: a systematic review with meta-analysis

BACKGROUND

Cardiac anomalies occur frequently in patients with congenital duodenal obstruction (DO). However, the exact occurrence and the type of associated anomalies remain unknown. Therefore, the aim of this systematic review is to aggregate the available literatures on cardiac anomalies in patients with DO.

METHODS

In July 2022, a search was performed in PubMed and Embase.com. Studies describing cardiac anomalies in patients with congenital DO were considered eligible. Primary outcome was the pooled percentage of cardiac anomalies in patients with DO. Secondary outcomes were the pooled percentages of the types of cardiac anomalies, type of DO, and trisomy 21. A meta-analysis was performed to pool the reported data.

RESULTS

In total, 99 publications met our eligibility data, representing 6725 patients. The pooled percentage of cardiac anomalies was 29% (95% CI 0.26-0.32). The most common cardiac anomalies were persistent foramen ovale 35% (95% CI 0.20-0.54), ventricular septal defect 33% (95% CI 0.24-0.43), and atrial septal defect 33% (95% CI 0.26-0.41). The most prevalent type of obstruction was type 3 (complete atresias), with a pooled percentage of 54% (95% CI 0.48-0.60). The pooled percentage of Trisomy 21 in patients with DO was 28% (95% CI 0.26-0.31).

CONCLUSION

This review shows cardiac anomalies are found in one-third of the patients with DO regardless of the presence of trisomy 21. Therefore, we recommend that patients with DO should receive preoperative cardiac screening.

LEVEL OF EVIDENCE

II.

Laparoscopic versus open repair of congenital duodenal obstruction: a systematic review and meta-analysis

PURPOSE

To assess the safety and efficacy of laparoscopic versus open repair of congenital duodenal obstruction (CDO), we conducted a systematic review and meta-analysis (CDO).

METHODS

A literature search was conducted to identify studies that compared laparoscopic surgery (LS) and open surgery (OS) for neonates with CDO. Meta-analysis was used to pool and compare variables such as operative time, time to feeding, length of hospital stay, anastomotic leak or stricture, postoperative ileus, wound infection, and overall postoperative complications.

RESULTS

Among the 1348 neonatal participants with CDO in the ten studies, 304 received LS and 1044 received OS. When compared to the OS approach, the LS approach resulted in shorter hospital stays, faster time to initial and full feeding, longer operative time, and less wound infection. However, no significant difference in secondary outcomes such as anastomotic leak or stricture, postoperative ileus, and overall postoperative complications was found between LS and OS.

CONCLUSIONS

LS is a safe, feasible and effective surgical procedure for neonatal CDO when compared to OS. Compared with OS, LS has a faster time to feeding, a shorter hospital stay, and less wound infection. Furthermore, in terms of anastomotic leak or stricture, postoperative ileus, and overall postoperative complications, LS is equivalent to OS. We conclude that LS should be considered an acceptable option for CDO.

Postoperative feeding in neonatal duodenal obstruction

Background

Findings from manometry studies and contrast imaging reveal functioning gastric physiology in newborns with duodenal atresia and stenosis. Stomach reservoir function should therefore be valuable in aiding the postoperative phase of gastric feeding. The aim of this study was therefore to compare the feasibility of initiating oral or large volume(s) gavage feeds vs small volume bolus feeds following operation for congenital duodenal anomalies.

Methods

Single-center electronic medical records of all babies with duodenal atresia and stenosis admitted to a university surgical center during January 1997–September 2021 were analyzed. A fast-fed group (FF) included newborns fed with oral or gavage feeds advanced at a rate of at least 2.5 ml/kg and then progressed more than once a day vs slow-fed group (SF) fed with gavage feeds at incremental rate less than 2.5 ml/kg/day for each time period of oral tolerance or by drip feeds. Total feed volume was limited to 120–150 ml/kg/day in the respective study cohort populations.

Results

Fifty-one eligible patients were recruited in the study - twenty-six in FF group and twenty-five in SF group. Statistically significant differences were observed in the (i) date of first oral feeds (POD 7.7 ± 3.2 vs 16.1 ± 7.7: p < 0.001), and (ii) first full feeds (POD 12.5 ± 5.3 vs 18.8 ± 9.7: p < 0.01) in FF vs SF study groups.

Conclusion

Initial feeding schedules with oral or incremental gavage-fed rates of at least 2.5 ml/kg in stepwise increments and multi-steps per day is wholly feasible in the postoperative feeding regimens of neonates with congenital duodenal disorders. Significant health benefits are thus achievable in these infants allowing an earlier time to acquiring full enteral feeding and their hospital discharge.

Laparoscopic Versus Open Surgical Repair of Duodenal Atresia: An NSQIP-Pediatric Analysis

INTRODUCTION

Laparoscopic repair of duodenal atresia in neonates has gained popularity among some pediatric surgeons. Single-center studies suggest comparable short-term outcomes to open surgery. The purpose of this study was to utilize a large, multi-institutional pediatric dataset to examine 30-day post-operative outcomes by operative approach for newborns who underwent duodenal atresia repairs.

METHODS

We identified neonates aged ≤1 wk in the 2016-2018 National Surgical Quality Improvement Program-Pediatric -database that underwent a laparoscopic or open repair for duodenal atresia. Preoperative characteristics were compared between operative approaches. Postoperative complications, operative time, postoperative length of stay (LOS), and supplemental nutrition at discharge were assessed using multivariate regressions.

RESULTS

There were 267 neonates who met inclusion criteria. There were 233 (87%) infants who underwent open repairs and 34 (13%) who underwent laparoscopic repairs. Ten (29%) children who had laparoscopy were converted to open. After adjusting for confounding, laparoscopy was associated with an increase in operative time by 65 min (95% confidence interval 45-87 min, P < 0.001) but a five-day shorter LOS (95% confidence interval -9 to -2, P = 0.006) when compared to laparotomy. There were no significant differences in postoperative complications or supplemental nutrition at discharge.

CONCLUSIONS

Our findings suggest that laparoscopic repairs of duodenal atresia are associated with shorter postoperative LOS but longer operative times when compared to open repairs. Although the conversion rate to laparotomy remained relatively high, the laparoscopic approach was associated with comparable 30-day postoperative outcomes.

Congenital duodenal obstruction - Advances in diagnosis, surgical management, and associated controversies

Congenital duodenal obstruction (CDO) occurs due to intrinsic and extrinsic mechanisms but is most often caused by intrinsic duodenal atresia and stenosis. This review will summarize the history, epidemiology, and etiologies associated with the most common causes of CDO. The clinical presentation, complex diagnostic considerations, and current surgical repair options for duodenal atresia and stenosis will also be discussed. Finally, both historical and recent controversies which continue to affect the surgical decision-making in the management of these patients will be highlighted.

Laparoscopic versus Open Pediatric Surgery: Three Decades of Comparative Studies

INTRODUCTION

 Despite its wide acceptance, the superiority of laparoscopic versus open pediatric surgery has remained controversial. There is still a call for well-founded evidence. We reviewed the literature on studies published in the last three decades and dealing with advantages and disadvantages of laparoscopy compared to open surgery.

MATERIALS AND METHODS

 Studies comparing laparoscopic versus open abdominal procedures in children were searched in PubMed/MEDLINE. Reports on upper and lower gastrointestinal as hepatobiliary surgery and on surgery of pancreas and spleen were included. Advantages and disadvantages of laparoscopic surgery were analyzed for different types of procedures. Complications were categorized using the Clavien-Dindo classification.

RESULTS

 A total of 239 studies dealing with 19 types of procedures and outcomes in 929,157 patients were analyzed. We identified 26 randomized controlled trials (10.8%) and 213 comparative studies (89.2%). The most frequently reported advantage of laparoscopy was shorter hospital stay in 60.4% of studies. Longer operative time was the most frequently reported disadvantage of laparoscopy in 52.7% of studies. Clavien-Dindo grade I to III complications (mild-moderate) were less frequently identified in laparoscopic compared to open procedures (80.3% of studies). Grade-IV complications (severe) were less frequently reported after laparoscopic versus open appendectomy for perforated appendicitis and more frequently after laparoscopic Kasai's portoenterostomy. We identified a decreased frequency of reporting on advantages after laparoscopy and increased reporting on disadvantages for all surgery types over the decades.

CONCLUSION

 Laparoscopic compared with open pediatric surgery seems to be beneficial in most types of procedures. The number of randomized controlled trials (RCTs) remains limited. However, the number of reports on disadvantages increased during the past decades.

The incidence of different forms of ileus following surgery for abdominal birth defects in infants: a systematic review with a meta-analysis method

Objectives

Ileus following surgery can arise in different forms namely as paralytic ileus, adhesive small bowel obstruction or as anastomotic stenosis. The incidences of these different forms of ileus are not well known after abdominal birth defect surgery in infants. Therefore, this review aims to estimate the incidence in general between abdominal birth defects.

Content

Studies reporting on paralytic ileus, adhesive small bowel obstruction or anastomotic stenosis were considered eligible. PubMed and Embase were searched and risk of bias was assessed. Primary outcome was the incidence of complications. A meta-analysis was performed to pool the reported incidences in total and per birth defect separately.

Summary

This study represents a total of 11,617 patients described in 152 studies of which 86 (56%) had a follow-up of at least half a year. Pooled proportions were calculated as follows; paralytic ileus: 0.07 (95%-CI, 0.05-0.11; I 2=71%, p≤0.01) ranging from 0.14 (95% CI: 0.08-0.23) in gastroschisis to 0.05 (95%-CI: 0.02-0.13) in omphalocele. Adhesive small bowel obstruction: 0.06 (95%-CI: 0.05-0.07; I 2=74%, p≤0.01) ranging from 0.11 (95% CI: 0.06-0.19) in malrotation to 0.03 (95% CI: 0.02-0.06) in anorectal malformations. Anastomotic stenosis after a month 0.04 (95%-CI: 0.03-0.06; I 2=59%, p=0.30) ranging from 0.08 (95% CI: 0.04-0.14) in gastroschisis to 0.02 (95% CI: 0.01-0.04) in duodenal obstruction. Anastomotic stenosis within a month 0.03 (95%-CI 0.01-0.10; I 2=81%, p=0.02) was reviewed without separate analysis per birth defect.

Outlook

This review is the first to aggregate the known literature in order approximate the incidence of different forms of ileus for different abdominal birth defects. We showed these complications are common and the distribution varies between birth defects. Knowing which birth defects are most at risk can aid clinicians in taking prompt action, such as nasogastric tube placement, when an ileus is suspected. Future research should focus on the identification of risk factors and preventative measures. The incidences provided by this review can be used in those studies as a starting point for sample size calculations.

Multicenter Comparison of Laparoscopic Versus Open Repair of Duodenal Atresia in Neonates

Introduction: Traditional duodenal atresia (DA) repair involves a laparotomy. There have been reports of laparoscopic repair (LAP), in lieu of the open laparotomy approach (OPN), with varying degrees of success. The merit of this alternative warrants continued investigation. The purpose of this study was to determine whether there were outcome differences after neonatal DA repair based on surgical approach. Methods: IRB approved retrospective review of the National Surgical Quality Improvement Program Pediatric database (2012-2018) was conducted. International Classification of Diseases (ICD)-9 (751.1) and ICD-10 codes (Q41.0) identified DA repair. Patient demographics, perioperative, and postoperative variables were collected. Univariate and multivariate analysis was performed. Unadjusted and adjusted logistic regression models assessed associations between surgical approach and outcomes. Results: A total of 917 cases were identified, 803 (87.6%) OPN, 75 (8.2%) LAP, and 39 (4.2%) LAP to OPN. Median age at surgery was 2 days (interquartile range [IQR] = 1-3). Females represented 56% of the LAP (n = 42), and 51% of the OPN (n = 412, P = .470). The LAP group had higher weight at surgery (2.8 kg, IQR = 2.3-3.1), compared with the OPN (2.6 kg, IQR = 2.1-2.9, P = .009); and longer operative time (161 minutes, IQR = 107-206; OPN 106 minutes, IQR = 85-135, P < .001). In unadjusted models, median postoperative stay was 4 days shorter (95% confidence interval = -7.5 to -0.5) among LAP compared with OPN. Adjusted models for postoperative stay, complication risks, and unplanned reoperation were not statistically different. Conclusion: Most DA repairs are performed through OPN. LAP resulted in shorter length of stay in unadjusted models. Similar incidence of complications and reoperation suggest that LAP may be as safe as OPN, when employed by skilled experienced pediatric surgeons.

The incidence of abdominal surgical site infections after abdominal birth defects surgery in infants: A systematic review with meta-analysis

BACKGROUND

Surgical site infections (SSI) are a frequent and significant problem understudied in infants operated for abdominal birth defects. Different forms of SSIs exist, namely wound infection, wound dehiscence, anastomotic leakage, post-operative peritonitis and fistula development. These complications can extend hospital stay, surge medical costs and increase mortality. If the incidence was known, it would provide context for clinical decision making and aid future research. Therefore, this review aims to aggregate the available literature on the incidence of different SSIs forms in infants who needed surgery for abdominal birth defects.

METHOD

The electronic databases Pubmed, EMBASE, and Cochrane library were searched in February 2020. Studies describing infectious complications in infants (under three years of age) were considered eligible. Primary outcome was the incidence of SSIs in infants. SSIs were categorized in wound infection, wound dehiscence, anastomotic leakage, postoperative peritonitis, and fistula development. Secondary outcome was the incidence of different forms of SSIs depending on the type of birth defect. Meta-analysis was performed pooling reported incidences in total and per birth defect separately.

RESULTS

154 studies, representing 11,786 patients were included. The overall pooled percentage of wound infections after abdominal birth defect surgery was 6% (95%-CI:0.05-0.07) ranging from 1% (95% CI:0.00-0.05) for choledochal cyst surgery to 10% (95%-CI:0.06-0.15) after gastroschisis surgery. Wound dehiscence occurred in 4% (95%-CI:0.03-0.07) of the infants, ranging from 1% (95%-CI:0.00-0.03) after surgery for duodenal obstruction to 6% (95%-CI:0.04-0.08) after surgery for gastroschisis. Anastomotic leakage had an overall pooled percentage of 3% (95%-CI:0.02-0.05), ranging from 1% (95%-CI:0.00-0.04) after surgery for duodenal obstruction to 14% (95% CI:0.06-0.27) after colon atresia surgery. Postoperative peritonitis and fistula development could not be specified per birth defect and had an overall pooled percentage of 3% (95%-CI:0.01-0.09) and 2% (95%-CI:0.01-0.04).

CONCLUSIONS

This review has systematically shown that SSIs are common after correction for abdominal birth defects and that the distribution of SSI differs between birth defects.

[Multiple-center study of laparoscopic and open treatment of duodenal atresia]

OBJECTIVE

To summarize data of a multiple-center study of the treatment of duodenal atresia in 3 children's hospitals of the Siberian Federal District.

MATERIAL AND METHODS

We analyzed postoperative outcomes in 211 patients with duodenal atresia. All patients underwent surgery at various hospitals of the Siberian Federal District: Ivano-Matreninsky Children's Clinical Hospital in Irkutsk (expert hospital) - 120 patients; Center for Maternal and Child Welfare in Krasnoyarsk (learning hospital No. 1) - 51 patients; Kemerovo Regional Children's Clinical Hospital (learning hospital No. 2) - 40 patients. The study has been carried out for 15 years (from January 2005 and to December 2019). Patients were divided into 2 cohorts: group I - 88 patients (laparoscopic formation of duodenal anastomosis); group II - 123 patients (surgery via laparotomy). Demographic data, intra- and postoperative parameters and complications were analyzed.

RESULTS

Preoperative parameters were similar in both groups. Significant between-group differences were found for surgery time (70 vs. 90 min; p<0.001). Initiation of feeding and complete enteral nutrition occurred significantly earlier after laparoscopy (3 vs. 7 days, p<0.001 and 8 vs. 12 days, p<0.001). Incidence of anastomotic leakage significantly differed in both groups (1 patient after laparoscopy and 9 patients after laparotomy, p=0.038). Mortality was absent in the laparoscopy group. In the laparotomy group, this value was 4.9% (p=0.036) and caused by concomitant conditions (prematurity, sepsis, heart defects). Late postoperative complications (adhesive intestinal obstruction, ventral hernias) were absent after laparoscopy and occurred in 5.7% of patients after laparotomy (p=0.023).

CONCLUSION

Laparoscopic correction of duodenal atresia can be safely performed by experienced endoscopic surgeons from different centers united by the same ideology of endoscopic surgery. Laparoscopy ensures less duration of surgery, faster postoperative recovery, less mortality, incidence of early and late postoperative complications.

Laparoscopy-Assisted Versus Open Surgery in Treating Intestinal Atresia: Single Center Experience

INTRODUCTION

Surgical management of jejuno-ileal atresia/stenosis (JIA) is shifting to a minimally invasive approach. Our purpose is to evaluate the safety and feasibility of laparoscopy-assisted surgery (LAS) in JIA by comparing outcomes with a control group of open surgery (OS).

METHODS

A retrospective review of JIA cases was performed. Demographic, surgical, and outcomes data were extracted. LAS cases were compared with OS. Fisher's exact-test for qualitative and Mann-Whitney-test for quantitative values were used. p values <0.05 were considered significant.

RESULTS

Forty-seven patients (24/23, F/M) were included. In 19 (40%), the LAS technique was successfully performed, while 3 (17%) required conversion to OS. No differences were observed between the LAS and OS (n = 28) groups concerning demographic data (sex, mean gestational age, mean weight, associated anomalies) and type of JIA. Operative time was shorter in LAS (112 ± 46 min) compared to OS (138 ± 40 min), p = 0.04. Time to start enteral feeding and time to full enteral was shorter in LAS compared to OS, p = 0.04. No difference was observed between the two groups concerning duration of parenteral nutrition, length of hospitalization and weight at discharge. Overall rate of postoperative complications was 14% (n = 7), with a slightly prevalence in OS (18%) compared to LAS (10%), p = 0.68.

CONCLUSIONS

The LAS technique in the treatment of neonatal JIA is safe and feasible. LAS is associated with shorter operative and restoration of enteral feeding times. The post-operative outcomes in LAS are similar with OS, with a lower rate of postoperative complications.

Duodenal atresia and associated intestinal atresia: a cohort study and review of the literature

PURPOSE

To determine the true incidence of associated intestinal atresia (AIA) in infants with duodenal atresia (DA) and to analyze whether the surgical approach, open versus laparoscopic, would impact on patient outcome when AIA is present.

METHODS

Cohort study We review all DA infants treated at our institution (2001-2016) and analyzed the outcome of those with AIA. Systematic review/meta-analysis Using a defined search strategy and according to PRISMA guidelines, two investigators independently identified all studies on DA and searched cases of AIA to determine its incidence. Data are mean ± SD.

RESULTS

Cohort study Of 140 DA infants, 10 (7%) had AIA (4 type I, 4 type III, 2 type II). All type I AIA (webs) were found in the duodenum. Systematic review/meta-analysis Of 840 studies, 18 were included (2026 infants). The incidence of AIA was 2.8 ± 1.6%. The incidence of missed AIA was 0.8 ± 2.4%. Three comparative studies (759 infants) showed higher risk of missed AIA following laparoscopic (2.9 ± 2.4%) than open repair (0.3 ± 0.1%; p < 0.01).

CONCLUSIONS

The incidence of AIA in DA infants is low and the risk of missing it is higher at laparoscopy than at laparotomy. Regardless the approach, surgeons should carefully investigate bowel continuity to avoid the risk of missing AIA.

A Single Surgeon Laparoscopic Duodenoduodenostomy Case Series for Congenital Duodenal Obstruction in an Academic Setting

Introduction: Laparoscopic duodenoduodenostomy can be performed to repair congenital duodenal obstructions from atresia or duodenal web. There are only a few published case series in the literature. We are reporting on a single surgeon's experience with the operation and discuss the technical aspects of the operation. Material and Methods: A retrospective chart review was performed using the electronic medical record identifying all patients who underwent laparoscopic duodenoduodenostomy or duodenojejunostomy at two institutions by a singular surgeon. Results: Fifteen patients were identified as having undergone laparoscopic duodenoduodenostomy from 2010 until 2017. The weight at the time of the operation ranged from 1.5 to 8.7 kg (median 2.5 kg). The age ranged from 0 days to 15 months (median 3 days). Operative time (including other procedures) ranged from 2 hours 10 minutes to 3 hours 45 minutes with a median of 2 hours 55 minutes. One case was converted to open due to poor visualization. One patient developed a stricture that required open anastomotic revision 4 weeks after the initial surgery. In 1 patient, an enterotomy in the first portion of the duodenum was created from a retraction stitch-this was immediately recognized and repaired by primary laparoscopic closure. One patient had a small anastomotic leak that was treated with antibiotics. There were no mortalities and no intraoperative blood loss requiring transfusion. Conclusion: Laparoscopic duodenoduodenostomy is an operation that can be performed with excellent outcomes following simple steps that are easily taught in a teaching setting.

Laparoscopic versus open surgery for the repair of congenital duodenal obstructions in infants and children

BACKGROUND

Laparoscopic repair of congenital duodenal obstruction (LCDO) was described more than 15 years ago. However, studies comparing outcomes of LCDO with open repair (OCDO) are rare. Standardized assessments of complications using the Clavien-Dindo classification (CDC) and the comprehensive complication index (CCI) are not available.

METHODS

All patients undergoing OCDO or LCDO between 2004 and 2017 were identified from the institutional database by retrospective analysis. Postoperative outcomes were assessed, including all complications using the CDC and the CCI.

RESULTS

Forty-seven consecutive patients were identified; 27 patients underwent LCDO and 20 patients had OCDO. Both groups did not differ regarding demographics, associated congenital anomalies, intraoperative pathologic findings, and operative procedures. LCDO was associated with a longer operative time [mean (SD), 202 (89) vs. 112 (41) min, P < 0.0001], shorter time to initiation of feeds [median (range), 1 (0-4) vs. 3 (1-12) days, P = 0.0027], and shorter time to full feeds [mean (SD), 8.2 (4.1) vs. 12.2 (6.4) days, P = 0.0243] compared to OCDO. Shorter length of postoperative hospital stay in LCDO group was achieved for patients without cardiac anomalies [mean (SD), 9.4 (3.1) days in LCDO group vs. 17.2 (9.4) days in OCDO, P = 0.0396] and patients without other anomalies [median (range), 12 (3-38) days in LCDO group vs. 21 (7-31) days in OCDO, P = 0.0460]. LCDO was associated with a lower CCI [median (range) 0 (0-39.7) vs. 4.3 (0-100), P = 0.0270].

CONCLUSIONS

Despite a longer operative time for LCDO, a number of advantages of LCDO over OCDO were recognized comparing both approaches in the repair of congenital duodenal obstruction. Such advantages include a lower morbidity, reduced time to initiation and completion of full enteral feeds, and shorter length of postoperative hospitalization for patients without concomitant cardiac anomalies and for patients without other anomalies when operated laparoscopic. In view of the present results, LCDO, performed in selected patients, appears to represent a viable alternative to OCDO.

Laparoscopic Repair of Duodenal Atresia: Systematic Review and Meta-Analysis

PURPOSE

To investigate the outcome of laparoscopic repair of duodenal atresia (LRDA) in relation to different approaches with regard to suture material and anastomosis technique. To identify evidence for the safety and efficacy of LRDA compared with the conventional open repair.

METHODS

Systematic search was performed for all studies on LRDA, excluding case reports, and all comparative studies between LRDA and open repair. Chi-square was used to assess associations between complications or conversions rates and different LRDA approaches (suture material, suturing technique). Meta-analysis was employed to compare LRDA and open repair.

RESULTS

The complications and conversions rates of LRDA were not affected by the different suture materials (Silk, Vicryl, PDS; p = 0.51) or suturing technique (interrupted, continuous; p = 0.46). The meta-analysis did not show significant differences between LRDA and open repair in overall complications rate (p = 0.88), time to feeds (p = 0.12) and hospitalization time (p = 0.28), although it revealed longer operative time with LRDA (p < 0.0001).

CONCLUSIONS

LRDA shows comparable safety and efficacy with the open repair, although it is associated with significantly longer operative time. There is no evidence that the type of the suture material or anastomotic technique affects the outcome of LRDA.

Laparoscopic versus open surgery in management of congenital duodenal obstruction in neonates: a single-center experience with 112 cases

AIM

A single center study was conducted to compare the short-term clinical outcome between laparoscopic surgery (LS) and open surgery (OS) repair for neonates with congenital duodenal obstruction (CDO).

METHODS

Medical records of all neonates with bodyweight at surgery over 1500g and without other gastrointestinal anomalies that underwent surgery (duodeno-duodenostomy or duodeno-jejunostomy) for CDO at our center between January 2009 and July 2015 were reviewed. The choice of OS or LS was surgeon-dependent.

RESULTS

One hundred twelve patients were identified, with a median age and weight at surgery 8.5days and 2500g respectively. Forty-four patients underwent OS and 68 patients LS. There were no significant differences between the two groups regarding patient age, gender, weight at surgery, associated anomalies, and mean operative time. Compared to OS, the LS group had lower postoperative complications (5.9% vs 36.4%, p<0.0001), shorter mean time to initial oral feeding and mean postoperative hospital stay (3.9 vs. 7.1days and 8.6 vs. 12.9days respectively, p<0.0001) and better postoperative cosmesis.

CONCLUSIONS

LS treatment for neonatal CDO is associated with lower postoperative morbidity, shorter recovery time and postoperative hospital stay and better postoperative cosmesis than OS.

TYPE OF STUDY

Retrospective Comparative Study.

LEVEL OF EVIDENCE

Level III.

Is laparoscopic surgery better than open surgery for the repair of congenital duodenal obstruction? A review of the current evidences

BACKGROUND/PURPOSE

Whether laparoscopic surgery is superior to open surgery in the repair of congenital duodenal obstruction remains controversial. The objective of this study is to systematically review the literatures, which compare the outcomes of these two operative approaches.

METHODS

A systematic review of the studies comparing these two surgical approaches since 2000 was carried out.

RESULTS

Four retrospective cohort studies comprising 180 patients were eligible for analysis. Duodenal atresia was the most common diagnosis (62.3%). Overall, there were no statistically significant differences in terms of operative duration (SMD: 0.75, 95% CI: 0.46-1.04), ventilator dependence (SMD: 0.04, 95% CI: -0.22 to 0.29), time to initial enteral feeding (SMD: 0.12, 95% CI: -0.14 to 0.38), time to full enteral feeding (SMD: 0.18, 95% CI: -0.15 to 0.50) and hospital stay (SMD: -0.03, 95% CI: -0.29 to 0.22). The overall incidences of anastomotic complications in laparoscopic vs open groups were 4.4% vs 1.8%. Two cases of missed distal pathology were reported in the laparoscopic group.

CONCLUSIONS

Laparoscopic surgery is feasible in the repair of CDO. Study with larger sample size is needed for further analysis to examine whether open or laparoscopic approach is superior. Meanwhile, it is still safe to practice laparoscopic repair of CDO in skilled surgeons, with attention to the possibility of distal pathology.

Duodenal Atresia: Open versus MIS Repair-Analysis of Our Experience over the Last 12 Years

Objective. Duodenal atresia (DA) routinely has been corrected by laparotomy and duodenoduodenostomy with excellent long-term results. We revisited the patients with DA treated in the last 12 years (2004–2016) comparing the open and the minimally invasive surgical (MIS) approach. Methods. We divided our cohort of patients into two groups. Group 1 included 10 patients with CDO (2004–09) treated with open procedure: 5, DA; 3, duodenal web; 2, extrinsic obstruction. Three presented with Down's syndrome while 3 presented with concomitant malformations. Group 2 included 8 patients (2009–16): 1, web; 5, DA; 2, extrinsic obstruction. Seven were treated by MIS; 1 was treated by Endoscopy. Three presented with Down's syndrome; 3 presented with concomitant malformations. Results. Average operating time was 120 minutes in Group 1 and 190 minutes in Group 2. In MIS Group the visualization was excellent. We recorded no intraoperative complications, conversions, or anastomotic leakage. Feedings started on 3–7 postoperative days. Follow-up showed no evidence of stricture or obstruction. In Group 1 feedings started within 10–22 days and we have 1 postoperative obstruction. Conclusions. Laparoscopic repair of DA is one of the most challenging procedures among pediatric laparoscopic procedures. These patients had a shorter length of hospitalization and more rapid advancement to full feeding compared to patients undergoing the open approach. Laparoscopic repair of DA could be the preferred technique, safe, and efficacious, in the hands of experienced surgeons.

Transition from Laparotomy to Laparoscopic Repair of Congenital Duodenal Obstruction in Neonates: Our Early Experience

BACKGROUND

The aim of this report was to review our early experience of the last 7 years with repairs of congenital duodenal obstruction (CDO) to determine the efficacy and outcomes of laparoscopic repairs compared to laparotomy.

METHODS

A retrospective review was conducted on all neonate (<30 days) with CDO between 2009 and 2015. Patients with duodenal atresia, stenosis, web, and annular pancreas were included. Patients with only malrotation or delayed presentation were excluded.

RESULTS

Twenty-six neonates underwent laparoscopy and 30 underwent traditional laparotomy. The operative time was longer in the laparoscopic group (P = 0.001), but time to initiation of feeds and time to full feeds were similar for the laparoscopic and open groups. There was no mortality, anastomosis leakage, or stenosis in the laparoscopic group. Six laparoscopic cases required conversion to an open procedure (23%). In the earlier cases, the open conversion rate was high, but it decreased over time (P = 0.003).

CONCLUSION

Laparoscopic repair is safe and effective for repair of CDO in neonates. Despite operative time was slightly longer in the laparoscopic group, clinical outcomes remained similar to the open group. For pediatric surgeon with experience in laparoscopic techniques, laparoscopic duodenoduodenostomy is a sufficient available procedure.

Complications in neonatal surgery

Neonatal surgery is recognized as an independent discipline in general surgery, requiring the expertise of pediatric surgeons to optimize outcomes in infants with surgical conditions. Survival following neonatal surgery has improved dramatically in the past 60 years. Improvements in pediatric surgical outcomes are in part attributable to improved understanding of neonatal physiology, specialized pediatric anesthesia, neonatal critical care including sophisticated cardiopulmonary support, utilization of parenteral nutrition and adjustments in fluid management, refinement of surgical technique, and advances in surgical technology including minimally invasive options. Nevertheless, short and long-term complications following neonatal surgery continue to have profound and sometimes lasting effects on individual patients, families, and society.

Laparoscopic repair of congenital duodenal obstruction is feasible even in small-volume centres

INTRODUCTION It has been suggested that laparoscopic repair of congenital duodenal obstruction (CDO) should be restricted to a limited number of designated centres of expertise. After gaining extensive experience with intracorporeal suturing in other procedures, we evaluated the feasibility of this approach at the Royal Hospital for Sick Children (RHFSC; Edinburgh, UK). METHODS We conducted a retrospective review of all cases of CDO presenting to the RHFSC from 2012 to 2014. Cases were identified from our electronic database using standardised codes. Data comprised: gestation; birth weight; associated anomalies; patient age and weight at surgery; operative time; complications; postoperative course. RESULTS Five consecutive non-selected cases of isolated CDO were repaired laparoscopically, and all were carried out by the senior surgeon. The male:female ratio was 4:1. Corrected gestational age at surgery was 35-38 weeks, and the weight at surgery was 1.7-3.1 kg. None of our patients had significant associated anomalies. CONCLUSIONS The present study demonstrates the feasibility of laparoscopic repair of CDO in small-volume centres, and is the first report of laparoscopically managed congenital duodenal atresia in twins.

Laparoscopic duodenoduodenostomy with parallel anastomosis for duodenal atresia

BACKGROUND

Currently, a diamond-shaped anastomosis is preferred for the surgical repair of duodenal atresia (DA) in both open and laparoscopic surgery. We report the results of laparoscopic duodenoduodenostomy with parallel anastomosis (LDPA) in DA.

METHODS

We retrospectively reviewed 22 patients who underwent laparoscopic duodenoduodenostomy from February 2005 to May 2015 in Samsung Medical Center. All patients underwent operation within the first month after birth. Patients who were transversely anastomosed after duodenotomy and patients who underwent simultaneous operation on combined anomalies were excluded. Parallel anastomosis was used in all surgeries. Four trocars were used in laparoscopic repair. After mobilization of both proximal and distal ends, the proximal end was incised transversely and the distal end was incised longitudinally. Duodenoduodenostomy with parallel anastomosis using a 5-0 glyconate monofilament was performed with interrupted sutures.

RESULTS

Eleven patients (50 %) were male. Median gestational age was 36 + 6 weeks (32 + 7-40 + 6). Median age at the time of operation and median body weight were 3 days (1-12) and 2.53 kg (1.63-3.18), respectively. All patients were diagnosed prenatally and 16 patients (72.7 %) had associated anomalies. Median operation time was 142 min (96-290) and median postoperative day to start oral feeding was 5 days (3-9) and median postoperative day of reaching full feeding was 11 days (6-19). Median postoperative day was 13 days (10-60). There was no anastomotic leakage or stenosis. Median follow up was 3.5 months (1-21). Currently, there is no late complication.

CONCLUSIONS

LDPA can be performed easily to patients who have DA in neonatal period. It is anatomically natural and the risk of leakage or stenosis does not seem significant. Therefore, parallel anastomosis should be considered as a safe procedural option for laparoscopic duodenoduodenostomy in DA.

Small Bowel Congenital Anomalies: a Review and Update

The small intestine is a complex organ system that is vital to the life of the individual. There are a number of congenital anomalies that occur and present most commonly in infancy; however, some may not present until adulthood. Most congenital anomalies of the small intestine will present with obstructive symptoms while some may present with vomiting, abdominal pain, and/or gastrointestinal bleeding. Various radiologic procedures can aid in the diagnosis of these lesions that vary depending on the particular anomaly. Definitive therapy for these congenial anomalies is surgical, and in some cases, surgery needs to be performed urgently. The overall prognosis of congenital anomalies of the small intestine is very good and has improved with improved medical management and the advent of newer surgical modalities. The congenital anomalies of the small intestine reviewed in this article include malrotation, Meckel's diverticulum, duodenal web, duodenal atresia, jejunoileal atresia, and duplications.

Endoscopic Division of Duodenal Web Causing Near Obstruction in 2-Year-Old with Trisomy 21

INTRODUCTION

Surgical intervention for duodenal atresia most commonly entails duodenoduodenostomy in the neonatal period. Occasionally, type I duodenal atresia with incomplete obstruction may go undiagnosed until later in life. Endoscopic approach to dividing intestinal webs has been reported as successful in patients as young as 7 days of age, and can be a useful modality particularly in patients with comorbidities who may not tolerate open or laparoscopic surgery.

METHODS

A 2-year-old female with a history of trisomy 21 and tetralogy of Fallot underwent laparoscopic and endoscopic exploration of intestinal obstruction as seen on upper gastrointestinal series for symptoms of recurrent emesis and weight loss. After laparoscopy confirmed a duodenal web as the cause of intestinal obstruction, endoscopic division of the membrane was carried out with a triangle tip electrocautery knife and 15 mm radially dilating balloon.

RESULTS

The patient tolerated the procedure well, and also tolerated full age-appropriate diet by time of discharge on postoperative day 2. She remains asymptomatic as of 6 months postoperatively.

CONCLUSIONS

This report describes a successful endoscopic approach for definitive treatment of a duodenal web in a 2-year-old girl with trisomy 21, and laparoscopy confirmed no intraabdominal obstructive process or complication from endoscopy. Endoscopy enables minimal recovery time and suggests an improved method of duodenal web division over pure surgical intervention.

Laparoscopic management of congenital duodenal atresia or stenosis: A single-center early experience

BACKGROUND

The background is to review our experience with laparoscopic repair of congenital duodenal atresia or stenosis (CDAS) and compare postoperative outcome with a group control of laparotomy repair.

METHODS

Retrospective chart review of all cases of CDAS undergoing laparoscopic surgery at our institution between July 2013 and May 2014 and comparison with a group control of open operation performed between 2007 and 2010. Data were compared using Fisher's exact test for qualitative values and Mann-Whitney test for quantitative values. P values less than 0,05 were considered statistically significant.

RESULTS

Ten consecutive cases were identified in laparoscopic group (7 duodenoduodenostomy and 3 duodenojejunostomy) and 19 cases in laparotomy group (16 duodenoduodenostomy and 3 web excision). Median birth weight was lower in laparoscopic group (2125 grams Vs 2777 grams p=0,04). In laparoscopic group, there was no conversion and no intraoperative complication. Median duration of surgery was 90minutes (80-150). In both groups, the surgical morbidity rate was 10%. Median time to initiation of oral feeding was significatively shorter in laparotomy group (8days Vs 4 p=0,009). Median time to full oral feeding and length of stay were shorter in laparotomy but not statistically different. (36days Vs 16,5 p=0,14 and 45,5days Vs 25,5 p=0,09 respectively) After a median follow up of 149,5days (24-355) in laparoscopic group, 8 children had a full oral intake. Five children had a weight below the 10th percentile.

CONCLUSION

The laparoscopic approach for CDAS is safe and reproducible with outcomes similar to open repair even in the beginning of a learning curve for pediatric surgeons with appropriate laparoscopic skills. In this small series, laparoscopy did not appear to decrease time to full oral intake or length of stay. Larger studies are suggested to provide more conclusive results.

Laparoscopic duodenoduodenostomy in neonates: Report of two cases and review of the literature

Congenital duodenal obstruction is traditionally managed by laparotomy. Laparoscopic duodenoduodenostomy (LDD) in neonates is considered a technically demanding operation requiring advanced pediatric laparoscopic skills. To the best of our knowledge, there are no reports of LDD from the Indian subcontinent. Here, we report two cases of successful LDD in neonates and review the relevant literature.

Are paediatric operations evidence based? A prospective analysis of general surgery practice in a teaching paediatric hospital

BACKGROUND/AIM

Paediatric surgical practice should be based upon solid scientific evidence. A study in 1998 (Baraldini et al., Pediatr Surg Int) indicated that only a quarter of paediatric operations were supported by the then gold standard of evidence based medicine (EBM) which was defined by randomized controlled trials (RCTs). The aim of the current study was to re-evaluate paediatric surgical practice 16 years after the previous study in a larger cohort of patients.

METHODS

A prospective observational study was performed in a tertiary level teaching hospital for children. The study was approved by the local research ethics board. All diagnostic and therapeutic procedures requiring a general anaesthetic carried out over a 4-week period (24 Feb 2014-22 Mar 2014) under the general surgery service or involving a general paediatric surgeon were included in the study. Pubmed and EMBASE were used to search in the literature for the highest level of evidence supporting the recorded procedures. Evidence was classified according to the Oxford Centre for Evidence Based Medicine (OCEBM) 2009 system as well as according to the classification used by Baraldini et al. Results was compared using Χ (2) test. P < 0.05 was considered statistically significant.

RESULTS

During the study period, 126 operations (36 different types) were performed on 118 patients. According to the OCEBM classification, 62 procedures (49 %) were supported by systematic reviews of multiple homogeneous RCTs (level 1a), 13 (10 %) by individual RCTs (level 1b), 5 (4 %) by systematic reviews of cohort studies (level 2a), 11 (9 %) by individual cohort studies, 1 (1 %) by systematic review of case-control studies (level 3a), 14 (11 %) by case-control studies (level 3b), 9 (7 %) by case series (type 4) and 11 procedures (9 %) were based on expert opinion or deemed self-evident interventions (type 5). High level of evidence (OCEBM level 1a or 1b or level I according to Baraldini et al. PSI 1998) supported 75 (60 %) operations in the current study compared to 18 (26 %) in the study of 1998 (P < 0.0001).

CONCLUSION

The present study shows that nowadays a remarkable number of paediatric surgical procedures are supported by high level of evidence. Despite this improvement in evidence-based paediatric surgical practice, more than a third of the procedures still lack sufficient evidence-based literature support. More RCTs are warranted to support and direct paediatric surgery practice according to the principals of EBM.

Laparoscopic simple oblique duodenoduodenostomy in management of congenital duodenal obstruction in children

INTRODUCTION

The aim of this report is to present our technique of laparoscopic simple oblique duodenoduodenostomy (LSOD) and its results in management of congenital duodenal obstruction (CDO) in children.

PATIENTS AND METHODS

Medical records of patients with the diagnosis of CDO undergoing LSOD at our center from March 2009 to December 2013 were reviewed. The LSOD used one infra- or transumbilical 5-mm port for the camera and two 3-mm ports for instruments. After mobilization of the distant part of the duodenum, a 5-0 polydioxanone seromuscular suture was placed on the duodenal wall proximal and distal to the obstruction and tacked to the anterior abdominal wall for traction. The lower duodenum was incised longitudinally distal to the traction suture. The upper duodenum incision was placed away from the traction suture and extended downward obliquely. The duodenoduodenostomy was performed as a "simple" anastomosis.

RESULTS

Forty-eight patients were identified with a median age at operation of 11 days. The median weight at operation was 2650 g. Duodenal atresia and annular pancreas were found in 81.2% and 18.8% of patients, respectively. The median operative time was 90 minutes. There was no conversion to open surgery, anastomotic leakage, or stenosis. The median time from the operation to initial oral feeding was 4 days. Of the 48 patients, 97.9% were discharged in good health with a median postoperative hospital stay of 7 days

CONCLUSIONS

The LSOD technique is safe and efficacious and can be a viable option in the management of select cases of CDO in children at experienced centers.

Minimal invasive surgery in the newborn: current status and evidence

The evolution of minimally invasive surgery (MIS) in the newborn has been delayed due to the limited working space and the unique physiology. With the development of smaller instruments and advanced surgical skills, many of the initial obstacles have been overcome. MIS is currently used in specialized centers around the world with excellent feasibility. Obvious advantages include better cosmesis, less trauma, and better postoperative musculoskeletal function, in particular after thoracic procedures. However, the aim of academic studies has shifted from proving feasibility to a critical evaluation of outcome. Prospective randomized trials and high-level evidence for the benefit of endoscopic surgery are still scarce. Questions to be answered in the upcoming years will therefore include both advantages and potential disadvantages of MIS, especially in neonates. This review summarizes recent developments of MIS in neonates and the evidence for its use.

A modern cohort of duodenal obstruction patients: predictors of delayed transition to full enteral nutrition

Background. A common site for neonatal intestinal obstruction is the duodenum. Delayed establishment of enteral nutritional autonomy continues to challenge surgeons and, since early institution of nutritional support is critical in postoperative newborns, identification of patients likely to require alternative nutritional support may improve their outcomes. Therefore, we aimed to investigate risk factors leading to delayed establishment of full enteral nutrition in these patients. Methods. 87 patients who were surgically treated for intrinsic duodenal obstructions from 1998 to 2012 were reviewed. Variables were tested as potential risk factors. Median time to full enteral nutrition was estimated using the Kaplan-Meier method. Independent risk factors of delayed transition were identified using the multivariate Cox proportional hazards regression model. Results. Median time to transition to full enteral nutrition was 12 days (interquartile range: 9–17 days). Multivariate Cox analysis identified three significant risk factors for delayed enteral nutrition: gestational age (GA) ≤ 35 weeks (P < .001), congenital heart disease (CHD) (P = .02), and malrotation (P = .03). Conclusions. CHD and Prematurity are most commonly associated with delayed transition to full enteral nutrition. Thus, in these patients, supportive nutrition should strongly be considered pending enteral nutritional autonomy.

Congenital duodenal obstruction in neonates: a decade's experience from one center

BACKGROUND

Congenital duodenal obstruction (CDO) is one of the most common anomalies in newborns, and accounting for nearly half of all cases of neonatal intestinal obstruction. This study aimed to review our single-center experience in managing congenital duodenal obstruction while evaluate the outcomes.

METHODS

We conducted a retrospective analysis of the records of all neonates dianogsed with congenital duodenal obstruction admitted to our center between January 2003 and December 2012. We analyzed demographic criteria, clinical manifestations, associated anomalies, radiologic findings, surgical methods, postoperative complications, and final outcomes.

RESULTS

The study comprised 287 newborns (193 boys and 94 girls). Birth weight ranged from 950 g to 4850 g. Fifty-three patients were born prematurely between 28 and 36 weeks' gestation. Malrotation was diagnosed in 174 patients, annular pancreas in 66, duodenal web in 55, duodenal atresia or stenosis in 9, preduodenal portal vein in 2, and congenital band compression in 1. Twenty patients had various combinations of these conditions. Presenting symptoms included bilious vomiting, dehydration, and weight loss. X-rays of the upper abdomen demonstrated the presence of a typical double-bubble sign or air-fluid levels in 68.64% of patients, and confirmatory upper and/or lower gastrointestinal contrast studies were obtained in 64.11%. Multiple associated abnormalities were observed in 50.52% of the patients. Various surgical approaches were used, including Ladd's procedure, duodenoplasty, duodenoduodenostomy, duodenojejunostomy, or a combination of these. Seventeen patients died postoperatively and 14 required re-operation.

CONCLUSIONS

Congenital duodenal obstruction is a complex entity with various etiologies and often includes multiple concomitant disorders. Timely diagnosis and aggressive surgery are key to improving prognosis. Care should be taken to address all of the causes of duodenal obstruction and/or associated alimentary tract anomalies during surgery.

Laparoscopic versus open treatment of congenital duodenal obstruction: multicenter short-term outcomes analysis

BACKGROUND

Laparoscopic repair of congenital duodenal obstruction has become popularized over the past decade. Comparative data on outcomes, however, are sparse. We hypothesized that laparoscopic repair of congenital duodenal obstruction could be performed with similar outcomes to traditional open repair.

PATIENTS AND METHODS

Medical records for all cases of congenital duodenal obstruction from 2005 to 2011 at three academic teaching hospitals were retrospectively reviewed. Patients were excluded from the analysis if they had confounding surgical diseases, did not have duodenoduodenostomy during the first hospital admission, had the repair performed before transfer from a referring hospital, or weighed less than 1.7  kg at the time of surgery. Analysis was performed as intention to treat, with laparoscopic converted to open cases included in the laparoscopic group.

RESULTS

Sixty-four cases were included in the analysis (44 open, 20 laparoscopic). Baseline characteristics were similar between the two groups with the exception that the open group, on average, underwent repair later than the laparoscopic group (6 days versus 4 days, respectively). Seven laparoscopic cases were converted to an open procedure (35%), most commonly for difficulty in exposing the decompressed distal duodenum. Laparoscopic repair did take significantly longer than open repair (145 minutes versus 96 minutes, respectively), but clinical outcomes were similar. Complications were rare and were similar between methods of repair. Two patients in the laparoscopic group required subsequent open revision.

CONCLUSIONS

Laparoscopic duodenoduodenostomy for congenital duodenal obstruction is a technically challenging procedure with a steep learning curve. Despite a relatively high conversion rate, clinical outcomes remained similar to the traditional open repair in selected patients.

The neonatal lung--physiology and ventilation

This review article focuses on neonatal respiratory physiology, mechanical ventilation of the neonate and changes induced by anesthesia and surgery. Optimal ventilation techniques for preterm and term neonates are discussed. In summary, neonates are at high risk for respiratory complications during anesthesia, which can be explained by their characteristic respiratory physiology. Especially the delicate balance between closing volume and functional residual capacity can be easily disturbed by anesthetic and surgical interventions resulting in respiratory deterioration. Ventilatory strategies should ideally include application of an 'open lung strategy' as well avoidance of inappropriately high VT and excessive oxygen administration. In critically ill and unstable neonates, for example, extremely low-birthweight infants surgery in the neonatal intensive care unit might be an appropriate alternative to the operating theater. Best respiratory management of neonates during anesthesia is a team effort that should involve a joint multidisciplinary approach of anesthetists, pediatric surgeons, cardiologists, and neonatologists to reduce complications and optimize outcomes in this vulnerable population.

Laparoscopic methods in the treatment of congenital duodenal obstruction for neonates

OBJECTIVE

To evaluate the feasibility of and indication for laparoscopic methods for neonates with congenital duodenal obstruction.

PATIENTS AND METHODS

From September 2009 to October 2012, 40 newborns with duodenal obstruction underwent exploratory laparoscopy. With a lower-pressure pneumoperitoneum of 6-8 mm Hg and a suspending suture for the right liver elevator, the procedure was performed using four trocars 3-5 mm in diameter. Under laparoscopic vision, the causes of duodenal obstruction were diagnosed, and then the operation methods were determined by the type of obstruction.

RESULTS

Of the 40 cases, 4 were duodenal atresia (type II), 8 were duodenal stenosis, 8 were annular pancreas, and 20 were congenital intestinal malrotation. For the cases with duodenal diaphragmatic stenosis a partial excision of the diaphragm was performed after longitudinal incision of the anterior part of the duodenum followed laparoscopically by a transverse suture. For the cases with duodenal atresia (type II) and annular pancreas, a duodenal diamond anastomosis was successfully carried out through a laparoscopic approach. Ladd's operational method was performed in the cases with congenital intestinal malrotation. Feedings were started on postoperative Day 3-7, without abdominal distention and vomiting, and discharge from the the hospital was on postoperative Day 9-14.

CONCLUSIONS

Congenital duodenal obstruction is a common malformation in neonates. The laparoscopic procedure is an important method of diagnosing, and correct operational methods are the key to improve the therapeutic effect in the treatment of congenital duodenal obstruction. The laparoscope has the value of a small incision, microinvasion, and better recovery in diagnosis and treatment for congenital duodenal obstruction. The laparoscopic methods can be performed in neonates safely and are appropriate for a full-term newborn with tolerance to CO2 pneumoperitoneum.

The role of laparoscopy in the treatment of duodenal obstruction in term and preterm infants

PURPOSE

The aim of this study was to evaluate the role of laparoscopy in the surgical treatment of intrinsic and extrinsic duodenal lesions referring to the underlying cause of obstruction.

METHODS

Retrospective chart review of all cases of duodenal obstructions undergoing surgery at our institution between April 2004 and March 2012.

RESULTS

Twenty patients underwent surgery for duodenal obstruction (11 female, 9 male). Seven infants were born prematurely. Eleven infants had extrinsic, seven had intrinsic and two had a combination of intrinsic and extrinsic duodenal lesions. A laparoscopic procedure was initially started in 18 of 20 patients (90 %). Thirteen of the 18 infants (72 %) underwent various laparoscopic procedures: laparoscopic duodenoduodenostomy, resection of a duodenal membrane and the transsection of Ladd's bands. In five patents, a conversion became necessary due to poor visualisation of the duodenum. In three patients (15 %) with extrinsic duodenal lesion a reoperation was necessary. Two of the 20 patients (10 %) were operated with an "open" approach to begin with.

CONCLUSION

Laparoscopy is feasible and safe in most cases. The few conversions were early in the series due to a lack of experience and necessitated by poor visualisation, most often caused by malrotation.

Laparoscopic repair of duodenal atresia: revisited

Background

Since the initial reports of laparoscopic repair of duodenal atresia in neonates, further reports have been scant. Could this be because of unacceptable rates of complications, like anastomotic leakage, as mentioned in later reports? In the present study the laparoscopic repair of duodenal atresia in neonates is revisited.

Patients

Group 1 consisted of 22 patients with duodenal obstruction between 2000–2005 until the laparoscopic approach was abandoned. Of these 22 patients, 10 had Down syndrome and 8 had concomitant malformations. In this group 18 patients were operated laparoscopically. Four patients underwent an open procedure. Group 2 consisted of six patients that underwent operation between 2008 and February 2010.

Results

In group 1 there were four conversions. In 14 patients the procedure could be completed laparoscopically. In five patients postoperative leakage occurred. The complication rate was found to be unacceptably high, and the laparoscopic approach was abandoned. After gaining additional experience in intracorporeal suturing and adjusting the technique, the procedure was started up again in 2008. Since then six consecutive neonates have undergone laparoscopic repair of duodenal atresia without complications.

Conclusions

Laparoscopic repair of duodenal atresia is one of the most demanding pediatric laparoscopic surgical procedures. After initial promising results at the beginning of the twenty-first century a relative “radio silence“ followed, apparently caused by unsatisfactory results. Only considerable adjustments in technique and extensive improvement in experience has led to acceptable outcomes more recently. Laparoscopic repair of duodenal atresia should therefore be restricted to pediatric centers with extensive experience in laparoscopic surgery and intracorporeal suturing.

Laparoscopic surgery for acute neonatal appendicitis

We present the first two cases of acute neonatal appendicitis operated on through the laparoscopic approach. Acute neonatal appendicitis is uncommon and rarely considered by clinicians when assessing the neonatal acute abdomen. Our two cases demonstrate the potential value of diagnostic laparoscopy in the acute neonatal abdomen that poses a diagnostic dilemma. Furthermore, technical modifications of well-established laparoscopic techniques in the older child enable its use in neonates as a therapeutic tool.

Minimally invasive surgery in the neonate

The advent of minimally invasive surgical techniques in the neonate has been delayed due to the limited working space and the unique physiology of the newborn. In the last decade, with the introduction of new instruments and techniques, many of the initial problems have been solved making minimally invasive surgery feasible for a variety of indications in the neonate and a favored approach in specialized centers around the world. Although an increasing number of reports document the feasibility of this exciting technique, data demonstrating its benefit compared to conventional surgery is limited. This review focuses on recent developments in minimally invasive surgery in neonates and the evidence for its use.