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Operative management of duodenal atresia

Article  in  Pediatric Surgery International · July 1995

DOI: 10.1007/BF00182213

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Pediatr Surg Int (1995) 10:322-324
ORIGINAL ARTICLE
E. Waever • O. H. Nielsen • E. Arnbj6rnsson
C. M. Kullendorff
Operative management of duodenal atresia
Accepted: 28 November 1994
A b s t r a c t The management of duodenal atresia (DA) in
two Scandinavian pediatric centers is reported. A total of 67
infants with D A were retrospectively analyzed. A high
incidence of associated anomalies was present, including
D o w n ' s syndrome in 40% and cardiac anomalies in 20% of
the infants. No immediate postoperative mortality was
noted. The operative procedures were duodenoduodeno-
stomy and duodenojejunostomy. Follow-up did not dis-
close any frequent gastrointestinal disturbances or differ-
ences in postoperative complications when the two proce-
dures were compared. The prognosis for these patients is
thus determined exclusively by the presence of associated
anomalies, especially D o w n ' s syndrome and cardiac mal-
formations.
Key w o r d s Duodenal atresia • Operative procedure •
Duodenoduodenostomy • Duodenojejunostomy
Introduction
Duodenal atresia (DA) is a well-known form of congenital
bowel occlusion [4] estimated to occur once in every
10,000 live births [3, 10]. Congenital duodenal obstruction
was first described by Calder in 1733 [5]. The first
successful operative correction was reported from Copen-
hagen in 1916 [6]. The survival rate has increasingly
improved and is now virtually never related to the intest-
inal anomaly; fatal results are due to associated anomalies.
In a retrospective study 67 consecutive patients treated
for DA in two Scandinavian centers were analyzed. The
E. Waever • O. H. Nielsen
Department of Pediatric Surgery, Rigshospitalet, Copenhagen,
Denmark
E. Arnbj6rnsson ( ~ ) • C. M. Kullendorff
Department of Pediatric Surgery, University Hospital, S-221 87 Lund,
Sweden
© Springer-Verlag 1995
operative procedures in one center were mainly duodeno-
jejunostomy (DJ), and in the other both duodenoduodeno-
stomy (DD) and DJ. The aim of this investigation was to
compare the results of these two operative procedures. We
have restricted our analysis to patients with true intrinsic
DA; stenosis of the duodenum is a separate entity and is
consequently not included here.
Materials and methods
During the period 1969-1991 31 patients with DA were operated upon
at the Department of Pediatric Surgery of the University Hospital in
Lund, Sweden. During the period 1977-1992 36 patients with DA
were operated upon at the Department of Pediatric Surgery, Rigshos-
pitalet, Copenhagen, Denmark. The records of these patients were
reviewed and the following data were noted: sex, birth weight,
gestational age, the existence of hydramnion, pre-partum examina-
tions with ultrasound (US), birth details, and associated anomalies.
Furthermore, the signs and symptoms on admission, methods of
diagnosis, age at operation, type of atresia, method of operation,
length of hospital stay, and mortality and morbidity were noted. The
demographic data are listed in Table 1.
Prepartum US was performed in 40 patients; in 36 cases it revealed
an intestinal anomaly that later proved to be a duodenal obstruction; in
4 cases the study was regarded as normal. These 4 examinations were
performed during the 17th to 19th week of gestation. In 21 of the 36
patients where prenatal US showed an intestinal anomaly the investi-
gation was performed after the 32nd week of gestation.
The mean birth weight was 2,463 g (980-3,743); 25 patients were
below 2,000 g at birth. The associated anomalies are listed in Table 1.
Twenty-five patients had Down's syndrome; in 9 of these cases the
maternal age was above 35 years. Severe associated anomalies were
never considered a contraindication for surgery. The preoperative
symptoms were vomiting and aspiration in 54 cases (Table 2). The
diagnosis was confirmed by X-ray films of the abdomen, which
showed the "double bubble" sign in 60 cases. In 1 case a barium
swallow showed DA. In 6 cases the diagnosis was made at laparotomy,
indicated due to clinical symptoms of intestinal obstruction. The delay
between birth and operation varied from 1 to 8 days. The delay was due
to late diagnosis and investigations of congenital cardiac anomalies.
The two methods of operation were DD and DJ. A transverse
abdominal incision 1 cm above the umbilicus and slightly to the right
of the midline was used. A gastrostomy was never performed. When
performing DD, the hepatic flexure of the colon was mobilized. The
colon was displaced downwards and medially. The second part of the
duodenum was mobilized by a Kocher maneuver. The end-to-end DD
 323

Table 1 Demographic data from 67 patients with duodenal atresia Table 2 Hospital data from 67 patients with duodenal atresia

Oper~ive procedure Surgical procedure

Duodeno- Duodeno- Total Duodeno- Duodeno- Total

duodeno- j~uno- duodeno- jejuno-
stomy stomy storey storey
Number of patients 22 45 67 Number of patients 22 45 67
Birth weight, mean 2,410 2,550 2,463 Symptoms vomiting 13 25 48
range 980-3,743 1,209-3,400 980-3,743 aspiration 2 4 6
<2,000 g 8 17 25 none 4 9 13
Full-term 9 21 30 (diagnosis known)
Premature ( < 38 weeks) 14 23 37 Diagnosis X-ray: double bubble 20 40 60
Hydramnion yes 14 22 36 X-ray: contrast 1 0 1
no 4 11 15 laparotomy 2 4 6
unknown 5 11 l6 Time of operation
Ultrasound abnormal 11 25 36 <3 days of age 19 38 57
normal 1 3 4 older 3 7 10
Partus normal 15 33 48 Atresia type I 13 22 35
cesarean section 6 13 19 II 3 5 8
Associated anomalies III 6 11 17
Down's syndrome 8 17 25 no information 3 4 7
cardiac anomalies 6 9 15 Hospital stay, mean (days) 23 26 25
malrotation 2 5 7 range 3 - 99 6 - 93 3 - 99
gastrointestinal atresia 1 4 5 Deaths 1 3 4
others 1 1

was performed in one layer, mainly using 5/0 resorbable sutures.
DJ was performed using a retrocolic side-to-side technique. The
anastomosis was made in two layers using a continuous 5/0 resorbable
suture in the mucosal layer and interrupted sutures in the seromuscular
layer. In 19 cases a feeding tube was placed through both types of
anastomosis; all other patients had a feeding tube to the stomach only.
A follow-up barium meal was carried out within 3 months after the
operation in all the patients from Lurid, but not in Copenhagen.
Results
All the patients were operated upon within 2 weeks of birth,
57 within 3 days after delivery. Type I atresia with an intact
diaphragm was noted in 35 cases and type II with two blind
ends of the duodenum connected by a short fibrous cord in
8. Type III atresia with two blind ends of the duodenum
without any connecting fibrous cord was noted in 17 cases.
Information on the type of atresia was missing for the
remaining 7 cases (Table 2). Twenty-two patients under-
went DD and 45 DJ.
No serious early postoperative complications occurred.
No leakage or anastomotic stenosis requiring emergency
reoperation was noted. A considerable number of patients
had problems with vomiting and gastric retention during the
postoperative weeks. They were all dismissed from the
hospital free of gastrointestinal (GI) symptoms. Later 4
patients died because of associated cardiac anomalies.
The mean hospital stay was 25 days ( 3 - 9 9 days). The
long hospital stays were due to the need for total parental
nutrition, problems with enteral feeding, and/or associated
anomalies. The short hospital stays, less than 1 week in 2
cases, were due to cardiac anomalies in 1 case and
pulmonary problems in the other. Both these patients
were transferred to other units of the hospital.
All the infants undergoing operative repair of D A
survived the initial surgical procedure. There were no
significant differences among those operated upon with
DD compared with DJ regarding mortality, prematurity,
and serious associated anomalies. Only 1 of the patients
who underwent DJ was later reoperated due to an anasto-
motic stricture. An enteroanastomosis was performed 16
months after the initial operation.
Follow-up of all the patients in Lund disclosed unspe-
cified GI symptoms, vo~niting, diarrhea and fever in 8
cases; 3 were examined radiologically, excluding a blind
loop and 3 were later operated upon for intestinal obstruc-
tion caused by adhesions. None of the patients in Copenha-
gen were readmitted due to intestinal symptoms.
A comparison of the DD and DJ patients did not disclose
any differences regarding hospital stay, postoperative
course or complications. Accordingly, there seemed to be
no differences in the results related to the operative method
used.
Discussion
Almost all infants undergoing surgery for congenital in-
trinsic duodenal obstruction presently survive; mortality is
associated solely with other congenital anomalies [11, 13,
14]. Nevertheless, the optimal technique for repair remains
controversial. Our results revealed no difference in the
outcomes of the two operative procedures DD and DJ.
The patients reported here differ from many other series [1,
2, 7, 11, 13, 14], as we only included those with true D A
and excluded those with stenosis of the duodenum.
The standard bypass procedure for DA has long been a
retrocolic DJ [8]. DD is reported to be the most physiologic
324
operative procedure, with a lower complication rate and
higher survival [11, 13, 14]. Another technique described is
a diamond-shaped DE) [9]. This method was compared with
conventional DD [12] and was found superior to side-to-
side DJ or end-to-end DD. The advantage of this method
lay in earlier feeding and discharge of the patients from the
hospital. These factors are, however, not sufficient for a
valid comparison. The diamond-shaped DD procedure was
not used in our cases.
DJ is considered an easy method to perform DD, on the
other hand, is considered a more physiologic bypass
procedure for intrinsic duodenal obstruction. However, it
is reported to require considerably more extensive and
difficult dissection, with reflection of the right colon to
mobilize a greater length of duodenum by Kocher's
maneuver. The experienced surgeon performing a DD
does not consider that type of anastomosis technically
more difficult, as it needs only minimal dissection. How-
ever, in cases where the duodenal ends are too far apart or
there is a risk of occlusion of the common bile duct, DJ is
necessary.
In the series presented here a gastrostomy was never
used, although this procedure was included in many other
series [2, 8]. Furthermore, a transanastomotic feeding tube
was used in 19 of the 67 cases. We noted no earlier onset of
full oral feeding in the cases with the feeding tube, and thus,
in our opinion this does not offer any advantage over gastric
drainage through a nasogastric tube as used in our cases. In
6 of our patients the diagnosis of DA was made at
emergency laparotomy, indicated due to clinical symptoms
of intestinal obstruction. We now adopt a diagnostic
protocol similar to that described by other authors [7],
including a preoperative X-ray investigation. Our data on
the duration of hospital stay and time of onset of oral
feeding did not differ between the two procedures or from
other reported series [12].
Postoperative complications such as anastomotic leak-
age or stenosis may not be suitable factors to use for
comparison of the two different types of anastomosis as
these are factors depending more on technical details than
on the actual type of anastomosis used. Some of the patients
operated upon with a two-layer anastomosis developed
unspecified GI disturbances leading to readmission. Those
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operated upon with a one-layer anastomosis had no such
problems.
In summary, our series did not disclose any differences
between the two main surgical methods used, i.e., end-to-
end DD or side-to-side DJ, regarding postoperative com-
plications, mortality or morbidity. Thus, the decision
regarding the choice of technique should be made by the
operating surgeon at the time of repair, depending on the
anatomic conditions found in each individual case.
References
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J Surg 79:133-135
2. Bailey PV, Tracy TF Jr, Connors RH, Mooney DR Lewis JE,
Weber TR (1993) Congenital duodenal obstruction: a 32 year
review. J Pediatr Surg 28:92-95
3. Boyden EA, Cope JG, Bill AH Jr (1967) Anatomy and embryol-
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4. Colborn GL, Gray SW, Pemberton LB, Skandalakis LJ, Skanda-
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for congenital duodenal obstruction. Z Kinderchir 20:253-261
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