Should we be concerned about jejunoileal atresia during repair of duodenal atresia?

Intestinal Atresias

Intestinal atresia is a form of congenital bowel obstruction that requires operative repair in the early neonatal period. Duodenal atresia and jejunoileal (JI) atresia are appropriately seen as distinct entities. Both can be suspected with fetal imaging, which can assist with prenatal counseling of families. Duodenal atresia is more commonly associated with comorbidities, whereas JI atresia is more often an isolated finding. Surgical repair is essential and is typically well tolerated. Although it may take time to achieve intestinal function postoperatively, these infants are usually able to tolerate full feeds after resolution of the ileus. Excellent short- and long-term outcomes for isolated duodenal atresia and JI atresia are expected.

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 Management of Congenital Intestinal Obstruction: Duodenal Atresia and Small Bowel Atresia

Background: Congenital intestinal obstruction occurs in ∼1:2000 live births. Congenital duodenal atresia and duodenal stenosis are frequent causes of intestinal obstruction and occur in 1 per 5000-10,000 live births. Today, duodeno-duodeno anastomosis is still the treatment of choice, and it can be performed safely by minimally invasive surgery, although duodenojejunal anastomosis is surgically simpler and has equal results. Jejunum-ileal atresia or stenosis is a major cause of neonatal intestinal obstruction; its prevalence is 1:330-1:1500 live births. Nowadays, the ability of laparoscopic assisted identification of the atresia and repair by only exteriorization of the small bowel through the umbilicus makes this technique safe and feasible in almost every new born. Methods: This article will describe the operative technique of laparoscopic management of congenital duodenal and small bowel obstruction. Results: For congenital duodenal atresia patients, mortality rate is less than 5% and the majority are secondary to associated comorbidities. There is a low rate of anastomotic leaks, anastomotic stricture, delayed gastric emptying, and bacterial overgrowth. For small bowel atresia patients, complications include anastomotic leak, adhesions, small bowel obstruction, and short bowel syndrome in less than 5% of the patients. The rate of re-operations due to small bowel obstruction in laparoscopic assisted repair patients is less compared with laparotomy patients. Conclusions: Minimally invasive surgery for duodenal and small bowel atresia is safe and feasible and reduces the complications of open surgical procedures.

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.

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.

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.

Case 1: a newborn with bilious emesis

In the introductory article of a new series geared toward pediatric radiology trainees, the radiological management of newborn bilious emesis is discussed through the details of a specific case.

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.