Population-based study of esophageal and small intestinal atresia/stenosis

Delayed Diagnosis of Congenital Duodenal Stenosis in a 16-Year-Old Girl

Background

Duodenal atresia or stenosis are different degrees of the same abnormality. They usually occur at the level of the ampulla of Vater and are thought to be an embryologic defect during the development of the foregut, leading to abnormal recanalization. Complete duodenal atresia is usually symptomatic in the early neonatal period, while partial obstruction (web, stenosis) may have a late presentation and a more challenging diagnosis such as in our case. Case Presentation. The patient, a 16-year-old girl, presented with abdominal pain, recurrent vomiting, and growth failure. An upper GI study with barium showed an image compatible with gastroptosis. Further diagnostic procedures confirmed a rare finding such as congenital duodenal stenosis. She underwent surgical intervention, and the recovery period was uneventful.

Conclusion

Gastroptosis is not diagnostic for a particular disease. This rare radiological finding in children may obscure uncommon diagnosis, such as congenital duodenal stenosis, which can present a diagnostic challenge beyond early childhood.

Clinical application of endoscopic diaphragmotomy and dilation in a congenital duodenal diaphragm

Background

A congenital duodenal diaphragm (CDD) is a rare cause of duodenal obstruction in infants and children. The traditional approach to treatment has been surgical intervention either with excision and duodenoplasty or with bypass through a duodenoduodenostomy, which is invasive and carries the risk of anastomotic leakage.

Aims

To summarize the key points of differential diagnosis and treatment of a CDD under gastroscopy and to evaluate its efficacy and safety.

Methods

The clinical data of patients with a duodenal obstruction diagnosed and treated by gastroscopy in our hospital between January 2019 and December 2022 were retrospectively analyzed. The gastroscopic features of the CDD were summarized. The clinical outcomes of patients with CDD treated by gastroscopy were collected and investigated.

Results

A total of 13 children with a duodenal obstruction underwent a gastroscopic examination and/or treatment, and of these, 10 were diagnosed as having a CDD and 3 were finally diagnosed as having an annular pancreas. A dome-shaped structure during inspiration (9/10) and a guidewire that could be inserted through the opening into the distal lumen (6/10) were the gastroscopic features of the CDD, while the annular pancreas had none of these features. The 10 patients, 4 men and 6 women with the CDD, were treated through endoscopic diaphragmotomy and dilation. The age and weight at operation was 15 days to 7 years (M: 2.25 years) and 2.85-22 kg (M: 13.6 kg), respectively. A total of 11 endoscopic operations were performed in the 10 patients. The time of single operation was 15-55 min (M: 38 min). The patients did not experience complications such as bleeding, pneumoperitoneum, and duodenal papilla injury during the operation. Feeding was started 12-24 h after surgery, and the patients were discharged 2-10 days (M: 7 days) postoperatively. The patients were followed up for 3-36 months (M: 17 months), and none of them had a recurrence of vomiting. However, three showed a recurrence of stenosis in upper gastrointestinal imaging, one of whom underwent a partial diaphragm resection again 2 months after the primary treatment.

Conclusions

A CDD can be confirmed by endoscopy based on its characteristic features. Endoscopic diaphragmotomy and balloon dilation are safe and effective, which can be a new option for minimally invasive treatment of a CDD.

Population-based prevalence study of common congenital malformations of the alimentary tract and abdominal wall in Thailand: a study using data from the National Health Security Office

Background

The study aimed to estimate the prevalence of major congenital anomalies of the alimentary system and the abdominal wall in Thailand using a nationwide hospital discharge database from the National Health Security Office (2017-2020).

Methods

The study extracted data from records with International Classification of Diseases-10 (ICD-10) codes related to esophageal malformation (ESO), congenital duodenal obstruction (CDO), jejunoileal atresia (INTES), Hirschsprung's disease (HSCR), anorectal malformation (ARM), abdominal wall defects (omphalocele (OMP) and gastroschisis (GAS)), and diaphragmatic hernia from the database with patient age selection set to less than 1 year.

Results

A total of 2539 matched ICD-10 records were found in 2376 individuals over the 4-year study period. Concerning foregut anomalies, the prevalence of ESO was 0.88/10 000 births, while that of CDO was 0.54/10 000 births. The prevalence figures of INTES, HSCR, and ARM were 0.44, 4.69, and 2.57 cases per 10 000 births, respectively. For abdominal wall defects, the prevalences of OMP and GAS were 0.25 and 0.61 cases/10 000 births, respectively. The mortality in our cases was 7.1%, and survival analysis found that associated cardiac defects had a statistically significant influence on survival in most anomalies studied. In HSCR, both Down syndrome (DS) (hazard ratio (HR)=7.57, 95% confidence interval (CI)=4.12 to 13.91, p<0.001) and cardiac defects (HR=5.82, 95% CI=2.85 to 11.92, p<0.001) were significantly associated with poorer survival outcomes. However, only DS (adjusted HR=5.55, 95% CI=2.63 to 11.75, p<0.001) independently predicted worse outcomes by multivariable analysis.

Conclusions

Our analysis of the hospital discharge database found that the prevalence of gastrointestinal anomalies in Thailand was lower than that reported in other countries, except for HSCR and anorectal malformations. Associated Down syndrome and cardiac defects influence the survival outcomes of these anomalies.

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.

Epidemiological characteristics of live births with esophageal atresia in Sao Paulo State, Brazil, from 2005 to 2018

Background

The estimated prevalence of esophageal atresia (EA) is 1 in 2500-4500 live births (LBs). Researchers have already identified risk factors, but the mechanisms are still unknown. The aim of this study is to identify EA prevalence trends and its risk factors in the São Paulo State (SPS) population database.

Methods

We conducted a population-based study using all EA cases identified by the Live Births Information System across 14 years (2005-2018) to estimate EA prevalence trends in recent years, stratified by maternal age and SPS geographical clusters. We calculated the prevalence trends, regression coefficient (β), annual percent change (APC), and 95% confidence interval (CI).

Results

We found 820 EA cases among 8,536,101 LBs with a prevalence of 1.0/10,000 LBs in SPS, Brazil. There was no significant difference in distribution by sex. Among all the cases, the majority (65%) were Caucasian; 51.8% were born at term; 43% had weight of ≥2500 g; 95.4% were singleton; and 73.4% of births were by cesarean section. From 2005 to 2018, there was an increasing trend of EA prevalence (APC=6.5%) with the highest APC of 12.2%. The highest EA prevalence rate (1.7/10,000 LB) was found in the group with maternal age of ≥35 years. No significant seasonal variation was found based on the conception month (p=0.061).

Conclusions

EA had an increasing prevalence trend in SPS, Brazil, in recent years, with the highest prevalence rate in the group with maternal age of ≥35 years. No seasonality was observed. This population-based study is the first to summarize the current epidemiology of EA in SPS LB.

The Incidence of Associated Anomalies in Children with Congenital Duodenal Obstruction-A Retrospective Cohort Study of 112 Patients

BACKGROUND

Duodenal obstruction (DO) is a congenital anomaly that is highly associated with other anomalies, such as cardiac anomalies and trisomy 21. However, an overview of additional anomalies and patient-specific risk factors for cardiac anomalies is lacking. Potential association with the vertebral, anorectal, cardiac, trachea-esophageal, renal and limb anomalies (VACTERL) spectrum remains unknown. Therefore, we aim to examine the incidence of associated anomalies, a VACTERL-spectrum association and patient-specific risk factors for cardiac anomalies in patients with DO.

METHODS

A retrospective cohort study was performed between 1996 and 2021. Outcomes were the presence of any additional anomalies. Risk factors for cardiac anomalies were analyzed using multivariate logistic regression.

RESULTS

Of 112 neonates with DO, 47% (N = 53/112) had one associated anomaly and 38% (N = 20/53) had multiple anomalies. Cardiac anomalies (N = 35/112) and trisomy 21 (N = 35/112) were present in 31%. In four patients, VACTERL-spectrum was discovered, all with cardiac anomalies. Trisomy 21 was found to be a risk factor for cardiac anomalies (OR:6.5; CI-95%2.6-16.1).

CONCLUSION

Associated anomalies were present in half of patients with DO, of which cardiac anomalies and trisomy 21 occurred most often, and the VACTERL-spectrum was present in four patients. Trisomy 21 was a significant risk factor for cardiac anomalies. Therefore, we recommend a preoperative echocardiogram in patients with DO. In case a cardiac anomaly is found without trisomy 21, VACTERL-screening should be performed.

Outcome of Tapering Enteroplasty in Managing Jejunoileal Atresia

Background

Jejunoileal atresia (JIA) represents a common cause of neonatal bowel obstruction. There is a discrepancy between the diameters of the proximal and the distal bowel loops and this is managed with excision or tapering of the dilated proximal bowel loop. We aim primarily to evaluate the outcome of tapering enteroplasty (TE) in managing JIA and secondarily to compare the outcome of TE to non-TE.

Materials and Methods

A retrospective analysis of records of all neonatal admissions with JIA from January 2017 to December 2018 at a tertiary university children's hospital. Type and location of atresia, time to full enteral feeds, length of stay (LOS), complications, and outcome were assessed in TE and non-TE groups.

Results

Forty-one patients were included in the study; 29 (70.7%) cases had jejunal atresia and 12 (29.3%) had ileal atresia. Seventeen (41.4%) patients had TE. The median days to full feeds was 19; 28 in the TE group versus 16 in the non-TE group (P = 0.022). Four (9.7%) cases needed a re-exploration because of failure to start feeds; all in the non-TE group. The median LOS was 33 days for TE versus 22 days for non-TE (P = 0.101). Twenty-one cases (51.2%) developed a wound infection and showed a significantly longer median LOS of 29.5 versus 19 days (P = 0.019). Mortality was 7 (17.1%).

Conclusions

TE did not show a superior outcome when compared to resection of the dilated bowel. It was associated with longer time to reach full enteral nutrition and longer LOS.

Delayed development of vacuoles and recanalization in the duodenum: a study in human fetuses to understand susceptibility to duodenal atresia/stenosis

ObjectiveWe compared the cross-sectional areas of the duodenum to the distal small intestine during early gestation to determine if there is a difference in age for recanalization.MethodsSerial sagittal sections of six fetuses of gestational age (GA) 8-10 weeks were examined morphologically to compare the degree of recanalization of the duodenum with to the more distal small intestine.ResultsAt GA 8-9 weeks, the duodenum had more epithelial plugs and vacuoles with no or narrower spaces compared to the distal small bowel. Quantitative assessment at GA 10 weeks showed that the cross-sectional area of the duodenal cavity was significantly less than the distal small bowel.ConclusionThe development and recanalization of vacuoles in the duodenum occurs later than the jejunum and ileum may be involved in the more frequent development of atresia/stenosis of the duodenum compared to more distal gastrointestinal tract.

How can we improve perinatal care in isolated multiple intestinal atresia? A retrospective study with a 30-year literature review

INTRODUCTION

Multiple intestinal atresia (MIA) is a rare cause of neonatal intestinal obstruction. To provide an overview of the current prenatal, surgical, and nutritional management of MIA, we report our experience and a literature review of papers published after 1990.

METHODS

All cases of isolated MIA (non-hereditary, not associated with apple-peel syndrome or gastroschisis) treated at our institution between 2005 and 2016 were reviewed and compared with cases found in the literature.

RESULTS

Seven patients were prenatally suspected of having intestinal obstruction and were postnatally diagnosed with MIA, with a mean 1.7 (1-2) resections-anastomoses (RA) and 6 (1-10) strictureplasties performed, resulting in a mean resected bowel length of 15.1cm (15-25 cm). Median time to full oral feed was 46 days (14-626 days). All patients were alive and none had orality disorder after a mean follow-up of 3.1 years (0.2-8.1 years). Three surgical strategies were found in the literature review: multiple RA (68%, 34/50) including Santulli's technique in four of 34 (12%) and anastomoses over a transanastomotic tube (32%, 16/50), with a 98% survival rate, and short-bowel syndrome for only two patients.

CONCLUSION

Bowel-sparing surgery and appropriate medical management are key to ensuring a favorable nutritional and gastrointestinal outcome and a good prognosis. Prenatal assessment and standardization of the surgical course of treatment remain challenging.

Jejunoileal Atresia: A National Cohort Study

Purpose: Jejunoileal atresia (JIA) is a rare disease. We aimed to determine the overall incidence of this malformation and associated malformations in a national cohort. Furthermore, we compared the treatment results of this cohort with the current literature. Methods: Data from the major health insurance company, which covers ~30% of the German population, were analyzed. All patients with ICD-10-Code Q41.1-9 (atresia of jejunum, ileum, other parts and not designated parts of the small bowel) who underwent any surgical procedure for small bowel were analyzed in a 10-year period between 2007 and 2016. Results: A total of 435 patients were included in the study. The incidence was 2.1 per 10,000 live births. The male:female ratio was 1:2. Sixty-four percent were premature, 21% had associated cardiac anomalies, 16% had abdominal wall defects, 7% had urogenital malformations, and 7% had cystic fibrosis. Sixty percent of all patients with jejunoileal atresia, 57% of patients with accompanying abdominal wall defects and 72% of patients with associated cystic fibrosis required ostomy as the initial procedure. In 25% of all patients, only one intestinal operation was coded. In 39% of patients, two operations were coded. Twelve percent of all patients required feeding gastrostomy or jejunostomy. Sixteen percent of all patients presented with liver-related complications, i.e., cholestasis or liver insufficiency. Six patients underwent an intestinal lengthening procedure (2 Bianchi, 4 STEP). In five patients, initial lengthening was performed within 1 year after the first intestinal operation. Mortality until 1 year after initial surgery was 5%. Of those who died, 88% were premature, 34% had cardiac anomalies and 16% had abdominal wall defects. None had cystic fibrosis. Patients with ostomy significantly more often needed operative central venous line or operative feeding tube. Short bowel was coded significantly more often in these patients. Conclusion: Patients with JIA present with low mortality. The rate of ostomies is higher than in literature. To give clinical recommendations for the initial surgical approach, further clinical research is needed.

Lack of discreet colocalization of epithelial apoptosis to the atretic precursor in the colon of the Fibroblast growth factor receptor 2IIIb mouse and staining consistent with cellular movement suggest a revised model of atresia formation

BACKGROUND

Colonic atresias in the Fibroblast growth factor receptor 2IIIb (Fgfr2IIIb) mouse model have been attributed to increased epithelial apoptosis and decreased epithelial proliferation at embryonic day (E) 10.5. We therefore hypothesized that these processes would colocalize to the distal colon where atresias occur (atretic precursor) and would be excluded or minimized from the proximal colon and small intestine.

RESULTS

We observed a global increase in intestinal epithelial apoptosis in Fgfr2IIIb -/- intestines from E9.5 to E10.5 that did not colocalize to the atretic precursor. Additionally, epithelial proliferations rates in Fgfr2IIIb -/- intestines were statistically indistinguishable to that of controls at E10.5 and E11.5. At E11.5 distal colonic epithelial cells in mutants failed to assume the expected pseudostratified columnar architecture and the continuity of the adjacent basal lamina was disrupted. Individual E-cadherin-positive cells were observed in the colonic mesenchyme.

CONCLUSIONS

Our observations suggest that alterations in proliferation and apoptosis alone are insufficient to account for intestinal atresias and that these defects may arise from both a failure of distal colonic epithelial cells to develop normally and local disruptions in basal lamina architecture.

Congenital duodenal obstruction in the UK: a population-based study

OBJECTIVE

Congenital duodenal obstruction (CDO) comprising duodenal atresia or stenosis is a rare congenital anomaly requiring surgical correction in early life. Identification of variation in surgical and postoperative practice in previous studies has been limited by small sample sizes. This study aimed to prospectively estimate the incidence of CDO in the UK, and report current management strategies and short-term outcomes.

DESIGN

Prospective population-based, observational study for 12 months from March 2016.

SETTING

Specialist neonatal surgical units in the UK.

MAIN OUTCOME MEASURES

Incidence of CDO, associated anomalies and short-term outcomes.

RESULTS

In total, 110 cases were identified and data forms were returned for 103 infants giving an estimated incidence of 1.22 cases per 10 000 (95% CI 1.01 to 1.49) live births. Overall, 59% of cases were suspected antenatally and associated anomalies were seen in 69%. Operative repair was carried out mostly by duodenoduodenostomy (76%) followed by duodenojejunostomy (15%). Postoperative feeding practice varied with 42% having a trans-anastomotic tube placed and 88% receiving parenteral nutrition. Re-operation rate related to the initial procedure was 3% within 28 days. Two infants died within 28 days of operation from unrelated causes.

CONCLUSION

This population-based study of CDO has shown that the majority of infants have associated anomalies. There is variation in postoperative feeding strategies which represent opportunities to explore the effects of these on outcome and potentially standardise approach. Short-term outcomes are generally good.

Predictive Factors for Postoperative Outcome in Children with Jejunoileal Atresia

Background  Jejunoileal atresia is a relatively rare congenital gastrointestinal requiring surgery and long postoperative care. The postoperative outcome is affected by many factors and this study focuses on finding predictors for time to full enteral feeding, length of hospital stay (LOH), and postoperative complications. Methods  This was a retrospective study of all children operated for isolated jejunoileal atresia between 2001 and 2017 at a tertiary center of pediatric surgery. Independent variables regarding demographical-, operative-, and postoperative data were abstracted. Primary outcome was time to full enteral feeding, LOH, and postoperative complications in terms of reoperation or central line complication. Any significant variables from the univariate analysis were further analyzed with logistic regression and presented as odds ratio with 95% confidence interval. Results  After exclusion because of concomitant gastroschisis ( n  = 1), and death before discharge ( n  = 2), 47 patients were further analyzed (49% boys, 53% premature). No significant differences could be seen in the univariate analysis between children with short and long time (median > 17 days) to full enteral nutrition. Patients with longer LOH (median >32 days) had significantly lower birth weight compared with those with shorter LOH; median 2,550 g versus 2,980 g ( p  = 0.04). Patients with a central line complication had significantly longer median time to full enteral feeding (median 27 vs. 12 days, p  = 0.03), and significantly longer median LOH (median 43 vs. 21 days, p  = 0.03), but these parameters were not significant in a multivariate analysis. No significant results were found regarding reoperation. Conclusion  Low birth weight seems associated with an increased LOH in children operated on for jejunoileal atresia, and central line complications seem related to the duration with central line in this group. The small cohort may constitute a power problem in this study and further research regarding the included variables may reveal more potential predictors for the postoperative outcome.

Malformations, choristomas, and hamartomas of the gastrointestinal tract and pancreas

Congenital and hamartomatous lesions of the gastrointestinal tract cause diagnostic challenges for surgical pathologists. Many of these are merely histologic curiosities, whereas others have substantial clinical implications because they herald cancer syndromes or associated anomalies. Although a comprehensive discussion of all developmental abnormalities that can occur in the gastrointestinal tract is beyond the scope of a single manuscript, some entities are more likely to be encountered by surgical pathologists, have important clinical consequences, or pose diagnostic difficulties. The purpose of this review is to discuss the more common malformations and choristomas, as well as hamartomatous lesions that may be clinically important due to their risk for cancer development, frequent associations with heritable cancer syndromes and other anomalies, or potential to simulate other entities.

Population-based birth defects data in the United States, 2010-2014: A focus on gastrointestinal defects

BACKGROUND

Gastrointestinal defects are a phenotypically and etiologically diverse group of malformations. Despite their combined prevalence and clinical impact, little is known about the epidemiology of these birth defects. Therefore, the objective of the 2017 National Birth Defects Prevention Network (NBDPN) data brief was to better describe the occurrence of gastrointestinal defects.

METHODS

As part of the 2017 NBDPN annual report, 28 state programs provided additional data on gastrointestinal defects for the period 2010-2014. Counts and prevalence estimates (per 10,000 live births) were calculated overall and by demographic characteristics for (1) biliary atresia; (2) esophageal atresia/tracheoesophageal fistula; (3) rectal and large intestinal atresia/stenosis; and (4) small intestinal atresia/stenosis. Additionally, we explored the frequency of these malformations co-occurring with other structural birth defects.

RESULTS

Pooling data from all participating registries, the prevalence estimates were: 0.7 per 10,000 live births for biliary atresia (713 cases); 2.3 per 10,000 live births for esophageal atresia/tracheoesophageal fistula (2,472 cases); 4.2 per 10,000 live births for rectal and large intestinal atresia/stenosis (4,334 cases); and 3.4 per 10,000 live births for small intestinal atresia/stenosis (3,388 cases). Findings related to co-occurring birth defects were especially notable for esophageal atresia/tracheoesophageal fistula, rectal and large intestinal atresia/stenosis, and small intestinal atresia/stenosis, where the median percentage of non-isolated cases was 53.9%, 45.5%, and 50.6%, respectively.

CONCLUSIONS

These population-based prevalence estimates confirm some previous studies, and provide a foundation for future epidemiologic studies of gastrointestinal defects. Exploring the genetic and environmental determinants of these malformations may yield new clues into their etiologies.

A Retrospective Study of Cytogenetic Results From Amniotic Fluid in 5328 Fetuses With Abnormal Obstetric Sonographic Findings

OBJECTIVES

The purpose of this study was to evaluate the diagnostic utility of karyotype analysis of amniotic fluid for fetuses with abnormal sonographic findings and to determine the detection rates of abnormal karyotypes.

METHODS

We conducted a retrospective study of 5328 fetuses with abnormal sonographic findings in the first or second trimester enrolled from October 1998 and September 2015. Cytogenetic results from amniotic fluid were obtained in all of these pregnancies. Sonographic abnormalities were stratified according to anatomic system involvement.

RESULTS

A total of 238 abnormal karyotypes were encountered in the 5328 fetuses (4.5%). The highest rate of chromosomal anomalies was in fetuses with structural abnormalities in multiple organ systems (25.7%), followed by an abnormal amniotic fluid volume (7.9%), structural abnormalities in a single system (7.3%), multiple nonstructural anomalies (7.2%), isolated placental abnormalities (7.1%), and isolated soft markers for aneuploidy (2.4%; P < .01). Among abnormalities in a single system, gastrointestinal and neck/body fluids had particularly high detection rates (26.1% and 26.2%, respectively). A detailed analysis suggested that the probability of an abnormal karyotype among every anatomic system was statistically significant (P < .01). This study identified several common indications with extremely high abnormal rates: duodenal atresia (53.1%), holoprosencephaly (48.8%), fetal hydrops (39.5%), cerebellar hypoplasia (32.0%), cystic hygroma (31.5%), absent/short nasal bone (11.0%), and bilateral choroid plexus cysts (8.5%).

CONCLUSIONS

Cytogenetic analysis has important clinical utility in a wide range of settings, such as prenatal diagnosis. For fetuses with indications of a highly abnormal detection rate, karyotype analysis should be suggested.

Intestinal atresia following chemotherapy, presenting as superior mesenteric artery syndrome: A case report

Multi-agent chemotherapy is recognized as the most common and effective treatment for Burkitt lymphoma, and intestinal mucosal injury is a common gastrointestinal complication following intensive chemotherapy. The aim of the present study was to describe a case of non-Hodgkin lymphoma with intestinal obstruction after chemotherapy in a young adult. The patient presented with aggravated vomiting during the second session of chemotherapy, which was initially attributed to superior mesenteric artery syndrome. However, following surgical intervention, the symptom was proven to be due to extreme intestinal stenosis in the ascending part of the duodenum. The patient underwent duodenojejunectomy and end-to-side anastomosis, and he recovered well from the operation. Although intestinal perforation and hemorrhage induced by chemotherapy have been previously reported sporadically, to the best of our knowledge, this is the first case report of distal duodenal obstruction due to intestinal atresia induced by polychemotherapy for lymphoma. We herein analyze the possible underlying reasons for the intestinal atresia and review the clinical and pathological characteristics of previously published relevant studies. The present findings may be helpful for increasing clinical awareness of this type of complication, as well as improving the management of patients treated with cytotoxic chemotherapeutic agents.

Early Reoperations after Primary Repair of Jejunoileal Atresia in Newborns

Aim: To review nine-year experience in managing jejuno-ileal atresia (JIA) by primary resection and anastomosis and identify factors associated with reoperations.

Methods: From April 2006 to May 2015, all consecutive neonates who underwent bowel resection and primary anastomosis for JIA were analyzed retrospectively. Patients with temporary enterostomy were excluded. Patient demographics, types of atresia, surgical techniques, need for reoperations, and long-term outcomes were investigated.

Results: A total of forty-three neonates were included, in which nineteen (44.2%) of them were preterm and fourteen (32.6%) were of low birth weight. Thirteen patients (30.2%) had jejunal atresia whereas thirty patients (69.8%) had ileal atresia. Volvulus, intussusception and meconium peritonitis were noted in 12, 8, and13 patients, respectively. Eight patients (18.6%) had short bowel syndrome after operation. Ten patients (23.3%) required reoperations from 18 days to 4 months after the initial surgery due to anastomotic stricture (n=1), adhesive intestinal obstruction (n=1), small bowel perforation (n=2) and functional obstruction (n=6). Prematurity and low birth weight were associated with functional obstruction leading to reoperation (p=0.04 and 0.01 respectively). The overall long-term survival was 97.7%. All surviving patients achieved enteral autonomy and catch-up growth at a median follow-up of 4.7 years.

Conclusion: Long-term survival of JIA after primary resection and anastomosis are excellent. However, patients have substantial risk of early reoperations to tackle intraabdominal complications.

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.