Complications Associated With Surgical Treatment of Congenital

Intrinsic Duodenal Obstruction

By Nitsana Spigland and Salam Yazbeck
Montreal, Quebec

6 Although survival rates for infants undergoing surgical Hydramnios was detected on prenatal ultrasound in I9 of 25 cases
treatment for congenital intrinsic duodenal obstruction are (75%) in which this information was available. In nine patients, the
high, long-term follow-up suggests a high complication rate diagnosis of duodenal obstruction was made prenatally, based on a
related to surgical therapy. We reviewed 33 neonates who double-bubble image noted on maternal ultrasound.
underwent surgery for congenital intrinsic duodenal ob- Vomiting and intestinal obstruction were the most frequent
struction during the past 10 years. There were 20 girls and presenting symptoms. Vomiting was bilious in 29 patients (88%) and
13 boys: the mean gestational age was 36 weeks, and mean nonbilious in four patients (12%). Other associated pathological
birthweight was 2,485 g. Bilious vomiting and intestinal conditions are listed in Table 2. All infants had onset of symptoms at
obstruction were the most frequent presenting symptoms. birth, except three patients who became symptomatic on the second
Hydramnios was present in 75% of cases and 21% had day of life. Abdominal x-rays were performed in 31 patients.
associated Down’s syndrome. Findings at laparotomy in- Twenty-seven of 31 (87%) had a double-bubble pattern with no
cluded duodenal atresia (14). annular pancreas (11). and distal air, suggesting the diagnosis of complete duodenal obstruction.
duodenal diaphragm (6). The most frequent surgical proce- Nonspecific gas patterns were found in the remaining four. Upper
dure was side-to-side duodenoduodenostomy (DD), fol- gastrointestinal studies were performed preoperatively in seven
lowed by duodenojejunostomy and resection of web with cases, and suggested the diagnosis of complete or incomplete
Heineke-Mikulicr type duodenoplasty. Bowel transit was duodenal obstruction. All patients underwent surgical intervention
reestablished at a mean of 13.1 days (range, 6 to 45 days). at a mean age of 4.6 days (range, 1 day to 16 months).
Seventy-percent of patients developed postoperative com-
plications, the most frequent being megaduodenum with
RESULTS
blind loop syndrome or bile reflux gastritis (22%). chole-
static jaundice (17%). gastroesophageal reflux (17%). de- Findings at laparotomy included duodenal atresia
layed transit (8%). and bowel obstruction (6%). Six patients (14), annular pancreas (1 l), and duodenal diaphragms
(16%) required secondary surgical procedures for postoper-
(8). In 32 cases the obstruction was at the level of the
ative complications Be, megaduodenum, nonfunctioning
anastomosis, missed intrinsic stenosis). Two patients died second portion of the duodenum, and in one case it was
(6%). Stagnation and functional obstruction in the proximal at the level of the third portion of the duodenum. The
duodenum is the main factor influencing the morbidity rate exact location of the obstruction in relation to the
among these patients. Consideration should be given to the ampulla of Vater was clearly indicated in 28 charts. It
tapering duodenoplasty and diamond-shaped anastomosis
was distal to the ampulla of Vater in 20 cases, at the
in order to help reduce problems associated with megaduo-
denum and help restore earlier bowel transit. level of the ampulla in four cases, and proximal to the
0 1990 by W.B. Saunders Company. ampulla in four cases.
A variety of surgical procedures were performed
INDEX WORDS: Duodenal obstruction; duodenal atresia; (Table 3). The most frequent surgical procedure was
duodenal stenosis: annular pancreas.
side-to-side duodenoduodenostomy, followed by duode-
nojejunostomy, and partial web resection with Heineke-
A LTHOUGH SURVIVAL rates for infants under-
going surgical treatment for congenital intrinsic
duodenal obstruction are high, long-term follow-up
Mickulicz-type duodenoplasty. Tapering duodeno-
plasty with duodenodudonostomy was performed in
two cases, and a diamond-shaped duodenoduodenos-
suggests a high complication rate related to surgical
tomy was performed in one case. Reestablishment of
therapy. In this retrospective analysis, we reviewed the
bowel transit occured at a mean of 13.1 days (range, 6
charts of all patients who underwent surgery for
to 45 days); 15 days for duodenojejunostomy, 12.4
congenital intrinsic duodenal obstruction during the
days for duodenoduodenostomy, and 7.5 days for
past 10 years, with an emphasis on the early and late
complications.
From S&-Justine Hospital, and the Department of Surgery,
MATERIALS AND METHODS University of Montreal, Montreal, Quebec.
Thirty-three neonates were treated for congenital intrinsic duode- Presented at the 21st Annual Meeting of the Canadian Associa-
nal obstruction at Hdpital Sainte-Justine, Montreal, between 1979 tion of Paediatric Surgeons, Edmonton, Alberta, September 20-23,
and 1989. There were 20 girls and 13 boys. The mean gestational age 1989.
was 36 weeks. The mean birthweight was 2,485 g (range, 1,392 to Address reprint requests to Salam Yazbeck. MD, Ste-Justine
4,260 g). Twenty patients had associated congenital anomalies Hospital. 317.5 Ste-Catherine Rd. Montreal, Quebec H3T lC5,
(Table 1). The most frequent associated anomalies included malrota- Canada.
tion (21%). Down’s syndrome (21%). and biliary tract anomalies o 1990 by W.B. Saunders Company.
(12%). 0022-3468/90/2511-0006$03.00/O

Journal of Pediatric Surgery, Vol 25, No 11 (November), 1990: pp 1127-l 130 1127
1128 SPIGLAND AND YAZBECK

Table 1. Distribution of Associated Congenital Anomalies Table 3. Surgical Procedures (33 Patients)
(33 Patients)
Procedure No. of Patients
Anomalv No. of Patients
Standard side-to-side duodenoduodenostomy 19
Malrotation Retrocolic duodenojejunostomy 6
Down’s syndrome Duodenojejunostomy and choledochojejunostomy 1
Biliary tract anomalies Partial web excision with Heineke-Mickulicz type
Cardiac anomalies duodenoplasty 4
Jejunal atresia Duodenoduodenostomy with tapering 2
H-type tracheoesophageal fistula Diamond-shaped duodenoduodenostomy 1
Skull malformation

atresia, and died of sepsis after anastomotic revision

partial web excision with Heineke-Mickulicz duodeno- for ischemic stricture and necrosis. One patient with
plasty. congenital absence of the gallbladder and common bile
Seventy percent of these patients developed postop- duct dilatation had jaundice that resolved spontane-
erative complications (Table 4). The most frequent ously. The last patient had a liver biopsy suggesting
complications included megaduodenum with blind loop extrahepatic biliary obstruction and periportal fibrosis,
syndrome or biliary reflux (22%), cholestatic jaundice but no follow-up is available.
(17%) gastroesophageal reflux (17%), delayed transit One patient developed a postoperative abdominal
for more than 21 days (18%), and bowel obstruction wall abscess, after having an intraoperative duodenal
(8%). injury as a consequence of a bovie burn that required
Six patients required secondary surgical procedures partial resection of the duodenum. Four patients were
for complications that arose in the postoperative period found to have gastroesophageal reflux diagnosed from
(Table 5). Among these patients, three patients re- 3 months to 1 year after the initial surgical procedure.
quired anastomotic revisions. Two patients were reex- One patient is being treated with medical therapy for a
plored for symptoms related to megaduodenum 17 duodenal ulcer that developed after 17 years of persis-
years and 15 months, respectively, after the initial tent biliary reflux.
surgical procedure. Both patients were found to have The overall mortality rate was 6% (2 deaths). Both
markedly dilated, atonic duodenal pouches, functional of these patients had multiple associated congenital
anastomotic obstruction, as well as missed intrinsic anomalies including biliary anomalies. Follow-up
stenoses. One patient with duodenal, jejunal, and distal ranged from 1 month to 8 years with a mean of 2 years.
common bile duct atresias developed an ischemic
stricture and necrosis at the choledochojejunal and DISCUSSION
duodenojejunal anastomoses. Two patients underwent Although there has been a marked improvement in
repeat surgical exploration for postoperative intestinal survival for infants undergoing surgical therapy for
obstruction, secondary to adhesions and volvulus, re- congenital intrinsic duodenal obstruction, much contro-
spectively. One patient, who had massive postoperative versy exists in the literature regarding the best tech-
aspiration, was found to have an H-type tracheoesoph- nique of surgical repair. Modifications in surgical
ageal fistula. Five of the six patients who required techniques over the past two decades were initially
reinterventions had duodenojejunostomy as initial pro- prompted by the high mortality rates associated with
cedures.
Four patients presented with persistent postopera- Table 4. Postoperative Complications (33 Patients)
tive cholestatic jaundice. All four were found to have Comclication No. of Patients 1%)
associated biliary tract anomalies. In one patient with
Megaduodenum (with biliary reflux or blind-
Down’s syndrome and biliary atresia, a Kasai proce- loop syndrome) 5 (22)
dure was not performed and the infant died. A second Cholestatic jaundice 4tlJ)
patient had duodenal, jejunal, and extrahepatic biliary Gastroesophageal reflux 4 (17)
Intestinal obstruction 2 (8)
Table 2. Associated Pathological Conditions (33 Patients) Delayed transit 2 (8)
lschemic anastomotic stricture, bowel necro-
Diagnosis No. of Patients
sis/sepsis 1 (4.6)
Meconium aspiration 2 Abdominal wall abscess 1 (4.61
Respiratory distress syndrome 1 Choking/swallowing difficulty 1 (4.6)
Chylothorax 1 Cardiac failure 1 (4.6)
Renal insufficiency 1 Massive aspiration 1 (4.6)
Macroscopic rectorrhagia 1 Septic arthritis 1 (4.6)
Jaundice 4 TOTAL 23 (JO)
DUODENAL OBSTRUCTION: SURGICAL COMPLICATIONS 1129

Table 6. Secondary Surgical Procedures (6 Patients)

Time Interval
Between First
Postoperative Secondary Surgical and 9scendary
Complication lnltial Procedure Procedure Surgical Procedures

Megaduodenum with biliary reflux Duodenojejunostomy Partial excision missed membrane: take 17yr
down of duodenojejunostomy; duode-
noduodenostomy
Megaduodenum with blind loop syn- Duodenoduodenostomy Partial web excision; revision duodeno- 15mo
drome duodenal anastomosis with tapering
duodenoplasty
lschemic stricture of anastomosis, Duodenojejunostomy and choledo- Take down of choledochojejunal and duo- 1 mo
bowel necrosis chojejunostomy denojejunal anastomoses: jejunal re-
section; redo choledochojejunostomy
and duodanojejunostomy
Intestinal obstruction (adhesive) Duodenojejunostomy Laparotomy; lysis of adhesions 4mo
Intestinal obstruction volvuIus Duodenojejunostomy Laparotomy; reduction of volvulus jejunal 3mo
resection
Massive aspiration Duodenojajunostomv Repair H-type tracheoesophageal fistula 3 wk

anastomotic complications in earlier series. However
more recently, varied techniques have been proposed to
diminish the early and late complication rates.‘-’
When evaluating the early postoperative results of
the various repairs performed in this series, we found
that the mean duration for reestablishment of bowel
transit of 13.1 days, was significantly longer than the
3- to 7-day time interval reported in other series in
which the diamond-shaped anastomosis or tapering
duodenoplasty with duodenoduodenostomy were per-
formed.sg7Y8 Additionally, partial web excision with
Heineke-Mickulicz-type duodenoplasty, was associ-
ated with a more rapid reestablishment of bowel
transit when compared with the bypass procedures.
That’s why we favor this technique for the treatment of
intrinsic duodenal webs, when the proximal duodenal
pouch is not too dilated.
Although the initial postoperative course following
repair of congenital intrinsic duodenal anomalies may
be uncomplicated, certain abnormalies are noted when
long-term results are evaluated.‘*” Megaduodenum
with functional obstruction and stagnation is prevalent
among these abnormalities. In this series, megaduode-
num was the most frequent postoperative complica-
tion, and it was associated with two basic patterns of
clinical presentation: recurrent abdominal pain with
postprandial vomiting, and diarrhea suggestive of a
blind loop syndrome, or alkaline biliary reflux with
resultant gastritis, duodenitis, and peptic ulceration.
Ein et al9 reported three cases of functional obstruc-
tion following duodenoduodenostomy in patients who
presented 6 to 18 months after the initial surgical
procedure. In this series, two patients underwent anas-
tomotic revisions for functional duodenal obstruction,
at 15 months and 17 years of age. Both of these
patients were found to have missed intrinsic stenoses
and in one case, a blind duodenal cul-de-sac was
created, which became obstructed intermittently and
emptied retrograde through the stomach.
The high incidence of gastroesophageal reflux and
biliary reflux associated with megaduodenum in this
series has already been reported.” Additionally, the
fact that persistent biliary reflux can lead to peptic
ulceration, was demonstrated by one of these patients
who developed an anterior bulb duodenal ulcer after 17
years of documented persistent biliary reflux. Others
have suggested the possibility of esophageal stricture
formation and malignancy following long-standing
biliary reflux.”
The high morbidity associated with duodenojejunos-
tomy parallels findings in other series.4 Five of the six
patients who required reintervention, including those
undergoing surgery for intestinal obstruction, had
duodenojejunostomy as the initial procedure.
Postoperative cholestatic jaundice that persists should
alert the clinician to the possibility of associated biliary
tract anomalies and not necessarily to a surgical
complication.”
Although a variety of tapering techniques have been
advocated in the recent pediatric surgical literature,
with emphasis on restoring earlier bowel transit and
minimizing postoperative complications, the impetus
for resection and tapering dates back to a review of
small bowel atresias by Nixon and Tawes12 in 197 1,
They showed that resection of the enlarged proximal
bowel in jejunal atresias was associated with a marked
improvement in survival when compared with direct
anastomosis without resection.
Despite the low mortality rate of 6% in this series,
the high complication rate of 70% has led us to
reevaluate the different surgical techniques for repair
of these anomalies. This complication rate may in part
be a reflection of the fact that duodenojejunostomy was
performed among some of the earlier patients re-
1130
viewed. However, the delayed transit observed with
standard lateral duodenoduodenostomy, as well as the
development of megaduodenum and its associated
complications, leads us to consider the more recently
reported techniques including duodenoduodenostomy
with tapering and the diamond-shaped anastomosis for
duodenal atresia or annular pancreas. We favor partial
web excision with Heineke-Mickulicz duodenoplasty
for intrinsic webs when the proximal duodenum is not
too dilated.
Regardless of the surgical procedure, we can not
REFERENCES
1. Fonkalsrud EW, de Lorimier AA, Hays DM: Congenital
atresia and stenosis of the duodenum. Pediatrics 43:79-83, 1969
2. Girvan DP, Stephens CA: Congenital intrinsic duodenal ob-
struction: A twenty-year review of its surgical management and
consequences. J Pediatr Surg 9:833-839,1974
3. Weitzman JL, Brennan LP: An improved technique for the
correction of congenital duodenal obstruction in the neonate. J
Pediatr Surg 9:385-388,1974
4. Stauffer VG, Irving I: Duodenal atresia: Long term results.
Prog Pediatr Surg 10:49-60, 1977
5. Kimura K, Tsugawa C, Ogawa K, et al: Diamond shaped
anastomosis for congenital duodenal obstruction. Arch Surg 112:
1262-1263,1977
6. Weber TR, Lewis JE, Mooney D, et al: Duodenal atresia: A
comparison of techniques of repair. J Pediatr Surg 21:1133-l 136,
1986
SPIGLAND AND YAZBECK
overemphasize the importance of checking the patency
of the entire distal bowel, prior to construction of the
anastomosis, to avoid missing additional intrinsic
stenoses. It became obvious to us, that long-term
follow-up of these patients is mandatory, because
many of them will eventually develop abnormalities
even if the initial postoperative period is uncompli-
cated. Although the results of early experiences with
the newer techniques seem promising, it is only with
long-term follow-up that we will be able to compare
efficacy with respect to earlier techniques.
7. Weisberger G, Boureau M: Resultats imm6diats et secondaires
des duod6no-duodCnostomies avec modelage dans le traitement des
obstructions duodCnales congCnitales completes du nouveaun6. Chir
Pediatr 23:369-372, 1982
8. Adzick NS, Harrison MR. de Lorimier AA: Tapering duodeno-
plasty for megaduodenum associated with duodenal atresia. J
Pediatr Surg 21:311-312, 1986
9. Ein SH, Shandling B: The late non-functioning duodenal
atresia repair. J Pediatr Surg 21:798-801, 1986
10. Kokkonen ML, Kalima T, Jaaskelainen J: Duodenal atresia:
Late follow-up. J Pediatr Surg 23:216-220.1988
11. Reid IS: Biliary tract abnormalities associated with duodenal
atresia. Arch Dis Child 48:952-957, 1973
12. Nixon HH, Tawes R: Etiology and treatment of small
intestinal atresia: Analysis of a series of 127 jejuno-ileal atresias and
comparison with 62 duodenal atresias. Surgery 69:41-51, 1971