DUODENAL ATRESIA

dr. Lisa

INTRODUCTION

1st described Calder (1733) 1st successful repair Ernst (1914) Prematurity, growth retardation, coexistent malformations 50% cardiac, genitourinary, anorectal, esophageal atresia 30-40% trisomy 21 Down syndrome abn pancreatic tissue, biliary atresia, agenesis of the gallbladder, stenosis of the CBD

PATHOPHYSIOLOGY
Failure of recanalization partial / complete Intrinsic webs (perforate/imperforate), atresia, & stenoses rotation failure of ancreatic ventral anlage annular pancreas

CLASSIFICATION
Stenosis, or incomplete obstruction diaphragm/web + small opening thin web + ballooned distally windsock Atresia / complete obstruction duodenal muscular continuity or pancreatic tissue filled in gap Type I, II, III

TYPE I

TYPE II

TYPE III

RADIOGRAPHIC EXAMINATION

Plain abdominal x-rays classic double-bubble sign dilated stomach & duodenal bulb w/ intraluminal air & fluid, no distal air pattern Intestinal gas beyond duodenum incomplete obstruction Contrast meal malrotation & volvulus Air filled biliary tree rare pancreatic & biliary anomalies Contrast enema inexact for malrotation

DIAGNOSIS

Antenatal dilated stomach, duodenum & polyhydramnios (fetal USG 18 weeks) Perinatal bilious emesis / high gastric aspirates, scaphoid abdomen Plain abdominal x-rays classic double-bubble sign Gas in the distal segment stenosis, perforate web, Ladd bands Delayed diagnosis dehydration, hyponatremia, & hypochloremia

DIFFERENTIAL DIAGNOSIS

Malrotation & Midgut Volvulus

MANAGEMENT

Gastric decompression (NGT) + correction of fluid & electrolyte USG of the head & urinary tract other anomalies Echocardiography cardiac malformation Genetic consultation for chromosomal analysis trisomy / Down syndr? After resuscitation operative correction Urgent surgery if malrotation & volvulus ?

OPERATIVE PROC

Warming overhead warming lights, warming blanket, 24oC operating room Transverse supraumbilical incision Inspected for fixated right colon & rotated ligament of Treitz Malrotation (-) extensive Kocher (lysis to the mesenteric root) duodenal obstruction + pancreas Kimura technique a widely patent diamondshaped anastomosis

KIMURA TECHNIQUE

DUODENOPLASTY

excessively dilated duodenum weak motility + significantly slower peristaltic frequency stasis & bacterial overgrowth LaPlaces Law function & long-term poor emptying improved by reducing diameter longitudinal axis of antimesenteric wall resection w/ appropriate caliber of catheter in the lumen GI stapler

DUODENOPLASTY

PROGNOSIS

Op + ICU + parenteral nutrition

survival 95%

TERIMA KASIH

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