1. Congenital Duodenal Obstruction
Nicole Kansier
Pediatric Surgery
June 9, 2011

2. Epidemiology 1/10,000 infants
Majority (75-90%) are distal to ampulla of Vater  bilious emesis, minimal distension
1-3% associated with other obstruction or atresia elsewhere in GI tract
30% associated with Down Syndrome
25-30% associated with cardiac defects
Duodenal atresia twice as common as jejunal or ileal atresia. (those related to interruption of vascular flow during development in utero)
30% with down syndrome
20% with heart disease
Low birth weight

3. Etiologies of Duodenal Obstruction
Duodenal Atresia
Annular Pancreas
Ladd’s Bands (malrotation)
Preduodenal Portal Vein
Duodenal Web

4. Duodenal Atresia 1/2500 births
Twice as common as jejunal or ileal atresia
Duodenal atresia twice as common as jejunal or ileal atresia. (those related to interruption of vascular flow during development in utero)
“Double Bubble” Sign

5. Annular Pancreas 1/15,000 Half without symptoms until adulthood
Nausea, vomiting, early satiety
Abdominal pain with pancreatitis
Also w/ “double bubble sign”

6. Rarer causes of obstruction
Ladd’s Bands
Preduodenal Portal Vein

7. Duodenal Web Vomiting, failure to thrive in early infancy
Perforated webs can have delayed presentation with mild symptoms of emesis, abd pain, food intolerance
10% with other anomalies
Similar mechanism to atresia with failure of recanulization, just more canulization than atresia.

8. Case Presentation: Pt A.D.
1 yo F s/p cloaca repair
Postoperatively with persistent emesis, inability to tolerate PO or G tube feeds
Bilious emesis without distended abdomen within 48 hrs birth

9. Work up: Upper GI, SBFT
Lateral view with “progressive dilatation of the proximal duodenum, distension of the stomach.”

10. Work up: Upper GI
Frontal view with “some contrast that passed into the distal duodenum; second portion of the duodenum had a smooth, rounded inferior margin”

11. Work up: EGD
“Duodenal bulb and second portion of duodenum were quite dilated, unable to pass endoscope past the second portion of duodenum…complete obstruction with a small nipple appearing lesion where bile was coming from.
Could not obtain images. 5/17/11
IMPRESSION:
Duodenal web

12. Surgical Options Open Duodenoduodenostomy Duodenotomy, excision of web
Laparoscopic Duodenoduodenostomy
Endoscopic resection
Duodenojejunostomy
Duodenojejunostomy, fallen out of favor
Ladd’s bands- division of bands, correction of malrotation
Atresia/annular pancreas – duodenoduodenostomy
Web- excised, primary closure

13. 5/19/11: Pt A.D. Duodenal Web Resection
RUQ transverse incision
Kocher maneuver to mobilize duodenum
No evidence of malrotation
Longitudinal incision of dilated duodenum
Partial web visualized, ampulla identified distal to web
Web resected with electrocautery
Bowel examined for other obstruction
Duodenotomy closed transversely, lemberts placed

14. Open Duodenoduodenostomy
RUQ transverse incision
Kocher maneuver to expose duodenum
Transverse incision in dilated proximal duodenum and longitudinal incision in decompressed distal duodenum (Kimura diamond repair)

15. Discussion Points Which duodenal web repair method is best?
Transanastamotic feeding tube?

16. References
Current Surgical Diagnosis & Treatment. Chapter 45: Pediatric Surgery. Albanese, C and Sylvester, K. page 1295.
The Surgical Review. Chapter 10: Pediatric Surgery. Morowitz, M and Nance, M. page
Mustafawi, A and M.E. Hassan. Congenital Duodenal Obstruction in Children: a decade’s experience. Original Article. Dubai, UAE.
Russo MA, Redel CA. Anatomy, histology, embryology, and developmental anomalies of the stomach and duodenum. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger & Fordtran's Gastrointestinal and Liver Disease. 8th ed. Philadelphia, Pa: Saunders Elsevier; 2006:chap 45.
Karnsakul, W. Food Refusal as an Unusual Presentation in a Toddler With Duodenal Web. Clinical Pediatrics :81.
Pediatr Surg Jan;28(1):92-5.
Bailey, PV. Congenital duodenal obstruction: a 32-year review. J Pediatric Surgery Jan; 28 (1):
Kay, S. Laparoscopic duodenoduodenostomy in the neonate. J Pediatric Surgery May; 44(5):
Nicola Lewis. “Pediatric Duodenal Atresia and Stenosis Surgery Treatment & Management” MedScape Reference, Accessed 6/11.