Repair Of Duodenal Atresia Research Articles

Multidisciplinary approach to a complex duodenal obstruction: From duodenal atresia to superior mesenteric artery syndrome

We present a 21yo female with a nausea, vomiting, and weight loss. Her history was remarkable for duodenal atresia repair as an infant. Following extensive evaluation, she was found to have progressive dilation of the proximal duodenum and loss of motility without obstruction (megaduodenum) which eventually lead to substantial weight loss resulting in superior mesenteric artery (SMA) syndrome. Given her symptomatic presentation, she was offered surgery and underwent a lateral duodenal tapering procedure and division of the ligament of Treitz and duodenal derotation (Strong procedure). Through the collaborative efforts of gastroenterology, pediatric surgery, radiology, and acute care surgery, she now has excellent functional status, has gained weight, and is asymptomatic. This case serves as an important example that congenital anomalies are a lifelong consideration when caring for patients

Staged repair of esophageal atresia, tracheoesophageal fistula, and duodenal atresia in a newborn

Staged repair of esophageal atresia, tracheoesophageal fistula, and duodenal atresia in a newborn

Association of Age at Duodenal Atresia Repair With Outcomes: A Pediatric NSQIP Analysis

PurposeNeonates with duodenal atresia (DA) are often born prematurely and undergo repair soon after birth, while others are delayed to allow for growth until closer to term corrected gestational age (cGA). Premature infants have been demonstrated to experience worse outcomes, but it is unclear whether delaying surgery mitigates the increased morbidity. This study evaluates the association of timing of DA repair with postoperative morbidity. MethodsWe retrospectively evaluated neonates undergoing DA repair from the National Surgical Quality Improvement Program-Pediatric database (2015–2020). A multivariable regression analyzed factors associated with composite morbidity, including cGA and age in days of life (DOL) at surgery. A propensity score matched analysis was completed in premature neonates born at ≤35 weeks gestation to compare outcomes at similar birth gestational ages (bGA) and birth weight who underwent early (<7 DOL) versus delayed (≥7 DOL) repair. Results809 neonates were included with a median bGA of 36 weeks (IQR 34–38), birth weight of 2.46 kg (IQR 1.96–2.95), and DOL at surgery of 2 (IQR 1–5). Infants born ≤35 weeks represented 35.23% of the cohort. On multivariable analysis, increasing cGA at surgery was associated with decreased morbidity (OR: 0.91, CI [0.84, 0.99]), and increasing DOL at surgery was associated with increased morbidity (OR: 1.02, CI [1.00, 1.04]). On propensity score matched analysis, delayed repairs were associated with increased postoperative ventilation (6 days vs. 2 days, p < 0.05); however, there were no differences in composite or surgical morbidity between early and delayed repairs. ConclusionsMorbidity after DA repair in neonates ≤35 weeks cGA is primarily driven by non-surgical causes, but delaying surgery does not appear to mitigate the risks associated with prematurity. It seems reasonable to consider repair in neonates around 33–34 weeks gestation without prohibitive risk factors. Optimal timing of DA repair requires a delicate balance between these factors. Level of EvidenceLevel III. Type of StudyRetrospective Cohort Study.

Modified circumumbilical approach for duodenal atresia repair : A scarless surgery

Background: Duodenal atresia is a common congenital anomaly causing neonatal intestinal obstruction. The definitive treatment is to restore the intestinal continuity. Laparotomy via upper transverse abdominal incision has been described by many authors as a standard approach for duodenal atresia repair. Here we report a case of newborn underwent duodenal atresia repair via modified circumumbilical approach with satisfactory postoperative outcome. Case presentation: This is a case of premature baby boy, born at 32-week gestation with a birth weight of 1.5kg. Antenatally he was detected to have double bubble sign which was confirmed upon postnatal abdominal radiograph, suggestive of duodenal atresia. He was noted to have a fleshy lump at the umbilicus presumed to be a patent vitello-intestinal duct from the referring hospital. Subsequently he developed umbilical swelling suspicion of umbilical hernia with incarceration and scheduled for emergency umbilical exploration. A circumumbilical incision was made and found to have an umbilical defect with omental herniation, instead of a patent vitello-intestinal duct. A proximal midline incision was made as an extension to the circumumbilical wound enabling a duodenal kocherization and subsequently had duodeno-jejujonostomy anastomosis for the duodenal atresia repair. Postoperative recovery was uneventful with appealing cosmesis. Conclusion: A modified circumumbilical incision is an attractive alternative approach for a duodenal atresia repair. Apart from its cosmetic advantage, the approach provides adequate exposure for similar outcome with transverse abdominal incision.

Duodenal Atresia Repair: A Single-Center Comparative Study.

The use of laparoscopy in the repair of duodenal atresia has been increasing. However, there is no consensus regarding which surgical approach has better outcomes. We aimed to compare the different surgical approaches and types of anastomoses for duodenal atresia repair. Patients who underwent duodenal atresia repair at a single pediatric center were identified between January 2006 and June 2022. Those with concomitant gastrointestinal anomalies or who required other simultaneous operations were excluded. The primary outcome was rate of complications, defined as rate of leak, stricture, and re-operation by surgical approach and technique of anastomosis. A total of 78 patients were included. The majority were female (51.3%, n = 40), with a median age of 4 days (IQR 3.0,8.0) and a median weight of 2.7kg (IQR 2.2,3.3) at repair. The re-operation rate was 7.7% (n = 6), of which two were anastomotic leaks, and four were anastomotic strictures. The leak rate was 5.6% (n = 1/18) for the open handsewn and 4.8% (n = 1/21) for the laparoscopic handsewn technique. The stricture rate was 12.5% (n = 1/8) for the laparoscopic-assisted handsewn, 9.1% (n = 2/22) for the laparoscopic U-clip, 4.8% (n = 1/21) for the laparoscopic handsewn, and none with laparoscopic stapled and laparoscopic converted to open handsewn techniques. No differences were found in complication rate when controlling for surgical approach. The method of surgical approach did not affect the outcomes or complications in the repair of duodenal atresia.

Laparoscopic repair of duodenal atresia using ministapler: Initial experience

• This study shows recent results of duodenal atresia repair by minimal invasive surgery using mini stapler vs laparoscopic hand sewn anastomosis in a tertiary hospital. • Duodenal atresia repair using ministapler for side to side DD anastomosis could make a challenging procedure more simple and reproducible in less expert hands.

Laparoscopic Versus Open Surgical Repair of Duodenal Atresia: A NSQIP-Pediatric Analysis

IntroductionLaparoscopic repair of duodenal atresia in neonates has gained popularity among some pediatric surgeons. Single-center studies suggest comparable short-term outcomes to open surgery. The purpose of this study was to utilize a large, multi-institutional pediatric dataset to examine 30-day post-operative outcomes by operative approach for newborns who underwent duodenal atresia repairs. MethodsWe identified neonates aged ≤1 wk in the 2016-2018 National Surgical Quality Improvement Program-Pediatric -database that underwent a laparoscopic or open repair for duodenal atresia. Preoperative characteristics were compared between operative approaches. Postoperative complications, operative time, postoperative length of stay (LOS), and supplemental nutrition at discharge were assessed using multivariate regressions. ResultsThere were 267 neonates who met inclusion criteria. There were 233 (87%) infants who underwent open repairs and 34 (13%) who underwent laparoscopic repairs. Ten (29%) children who had laparoscopy were converted to open. After adjusting for confounding, laparoscopy was associated with an increase in operative time by 65 min (95% confidence interval 45-87 min, P < 0.001) but a five-day shorter LOS (95% confidence interval −9 to −2, P = 0.006) when compared to laparotomy. There were no significant differences in postoperative complications or supplemental nutrition at discharge. ConclusionsOur findings suggest that laparoscopic repairs of duodenal atresia are associated with shorter postoperative LOS but longer operative times when compared to open repairs. Although the conversion rate to laparotomy remained relatively high, the laparoscopic approach was associated with comparable 30-day postoperative outcomes.

Factors Associated With Adverse Outcomes Following Duodenal Atresia Surgery in Neonates: A Retrospective Study.

ObjectivesThere is limited evidence on the infants' postoperative complications who have undergone surgical repair of duodenal atresia and stenosis. This study aimed to identify the factors associated with poor surgical outcomes after the initial repair.MethodsWe retrospectively reviewed the data of 82 patients who underwent surgery for duodenal atresia and stenosis between January 1994 and December 2013 at our institution. Gestational age, birth weight, fetal growth, and other associated anomalies were recorded. Multivariate regression analyses were used to identify the factors associated with surgical outcomes, including postoperative complications and time to full oral intake.ResultsThe median gestational age was 37.6 weeks, with 30 (37%) preterm (<37 weeks) and 11 (13%) early preterm (<34 weeks) infants. The median birth weight was 2531 g, with 27 (33%) patients < 2000 g and 10 (12%) patients < 1500 g. Postoperative surgical complications were identified in 18 (22%) cases, of which 12 (15%) required additional operations. Multivariate regression analysis revealed that a combination of very low birth weight (<1500 g) and early preterm was significantly associated with both surgical and non-surgical postoperative complications (p = 0.0028 and 0.021, respectively) and a prolonged time to full oral intake postoperatively (p = 0.013).ConclusionVery low birth weight and early preterm were significantly associated with postoperative complications and a prolonged time to full oral intake.

Pitfalls in laparoscopic duodenal atresia repair requiring modifications in approach based on literature review

Pitfalls in laparoscopic duodenal atresia repair requiring modifications in approach based on literature review

Institutional Variation in Gastrostomy Tube Placement After Duodenal Atresia Repair in Children With Trisomy 21.

To compare institutional practice patterns for gastrostomy tube placement in neonates with duodenal atresia (DA) and trisomy 21. A retrospective review of the Pediatric Health Information System (PHIS) from 2015 to 2018 identified infants <10 days old with ICD-10 diagnostic codes for DA and trisomy 21, in addition to procedure codes for an intestinal bypass or duodenoduodenostomy. This cohort was then queried for gastrostomy tube procedure codes and diagnostic codes for associated co-morbidities. Two hundred and nine infants were identified with DA, trisomy 21, and an intestinal bypass. Fifty-seven (27%) underwent gastrostomy placement. Baseline characteristics of those with and without gastrostomy tubes were similar. Patients from 16 hospitals that placed no gastrostomy tubes (No-G-tube-Hospitals) were compared to children from 30 hospitals that placed at least one gastrostomy tube (G-tube-Hospitals). Open atresia repairs occurred more frequently at G-tube-Hospitals, but patients were otherwise similar. There was no difference in readmission at 12 months for gastrostomy placement between children from No-G-tube-Hospitals and those from G-tube-Hospitals that did not undergo gastrostomy during their index admission. One-third of institutions in this study did not place gastrostomy tubes during index admissions for neonates with trisomy 21 and DA, yet this did not negatively impact the length of stay or incidence of subsequent gastrostomy placement as a result. Future research is needed to determine factors that predispose patients to failure without gastrostomy, as well as best practices for post-operative management in these patients to reduce unnecessary tube placement.

Characterization of technical skill progress in a standardized rabbit model for training in laparoscopic duodenal atresia repair

BackgroundLaboratory skills training is an essential step before conducting minimally invasive surgery in clinical practice. Our main aim was to develop an animal model for training in clinically highly challenging laparoscopic duodenal atresia repair that could be useful in establishing a minimum number of repetitions to indicate safe performance of similar interventions on humans.Materials and methodsA rabbit model of laparoscopic duodenum atresia surgery involving a diamond-shaped duodeno-duodenostomy was designed. This approach was tested in two groups of surgeons: in a beginner group without any previous clinical laparoscopic experience (but having undergone previous standardized dry-lab training, n = 8) and in an advanced group comprising pediatric surgery fellows with previous clinical experience of laparoscopy (n = 7). Each participant performed eight interventions. Surgical time, expert assessment using the Global Operative Assessment of Laparoscopic Skills (GOALS) score, anastomosis quality (leakage) and results from participant feedback questionnaires were analyzed.ResultsParticipants in both groups successfully completed all eight surgeries. The surgical time gradually improved in both groups, but it was typically shorter in the advanced group than in the beginner group. The leakage rate was significantly lower in the advanced group in the first two interventions, and it reached its optimal level after five operations in both groups. The GOALS and participant feedback scores showed gradual increases, evident even after the fifth surgery.ConclusionsOur data confirm the feasibility of this advanced pediatric laparoscopic model. Surgical time, anastomosis quality, GOALS score and self-assessment parameters adequately quantify technical improvement among the participants. Anastomosis quality reaches its optimal value after the fifth operation even in novice, but uniformly trained surgeons. A minimum number of wet-lab operations can be determined before surgery can be safely conducted in a clinical setting, where the development of further non-technical skills is also required.

Percutaneous radiologic gastrostomy as bridge to definitive surgery in a very preterm infant with combined esophageal and duodenal atresia

Due to the rarity of the association of esophageal and duodenal atresia, no consensus exists regarding the optimal treatment strategy. However, a staged approach is advised in order to reduce morbidities and improve survival. We report a case of a very preterm infant with combined esophageal and duodenal atresia, treated successfully with a staged approach. Treatment consisted in percutaneous radiologic gastrostomy placement prior to tracheoesophageal fistula ligation and esophageal anastomosis, and in delayed duodenal atresia repair. The use of the radiologic approach for gastrostomy placement proved to be minimally invasive, effective and without complications, even in a very preterm baby.

Development and Preliminary Validation of a Rabbit Model of Duodenal Atresia for Training in Pediatric Surgical Skills

Duodenal atresia is a congenital defect that requires advanced surgical skills. The objective of this study is to present an anatomical defect of duodenal atresia using a rabbit model and evaluate the preliminary experience for the training of surgical skills with pediatric surgeons. Adult white New Zealand male rabbits weighing 3.0 to 4.5 kg were used to create the defect. To simulate the bottom of the dilated blind pouch, the gastric antrum of the rabbit was obliterated using a 2-0 Prolene suture, and the cecal appendix was dissected to simulate the continuation of the duodenum. Participants performed laparoscopic duodenal atresia repair in this animal model using the iPhone trainer. Thirteen pediatric surgeons with experience in laparoscopic duodenal atresia repair assessed this model with a questionnaire on 5-point Likert-type scale. Overall, the simulated model of duodenal atresia obtained a general average score of 4.39. The highest observed average was for its physical realism, whereas the lowest score was in surgical experience. The global opinion of the model obtained a score of 4.40. In addition, all surgeons answered that this rabbit model showed the same complexity as newborns and young children in the repair of this type of defect. The inclusion of new models through rabbits in pediatric surgery programs will allow the development of advanced skills of pediatric residents and surgeons.

IPEG 2018The 27th Annual Congress for Endosurgery in ChildrenApril 11–14, 2018, Seattle, Washington

IPEG 2018The 27^th Annual Congress for Endosurgery in ChildrenApril 11–14, 2018, Seattle, Washington

The Case for Simulation-Based Mastery Learning Education Courses for Practicing Surgeons.

Pediatric surgeons rely on simulation courses to develop skills for safe minimally invasive repair of complex congenital anomalies. The majority of minimally invasive surgery (MIS) training courses occur during short "exposure courses" at annual conferences. Little data are available to support the benefit of these courses relative to the safe implementation of new skills. The purpose of this article is to determine the impact of an exposure course for advanced neonatal MIS on self-perceived comfort levels with independent performance of advanced MISs. Participants of a 4-hour hands-on course for neonatal MIS were surveyed regarding clinical practices and pre- and post-training perceived "comfort levels" of MIS skills for thoracoscopic esophageal atresia with tracheoesophageal fistula (tTEF) repair, thoracoscopic left upper lobe pulmonary lobectomy (tLobe), and laparoscopic duodenal atresia (lapDA) repair. Descriptive analyses were performed. Seventeen participants completed pre- and postcourse surveys. The majority of participants had no prior experience with tLobe (59%) or lapDA (53%), and 35% had no experience with tTEF repair. Similarly, the majority were "not comfortable" with these procedures. After the short course, the majority of surgeons reported that they were "likely to perform" these operations within 6 months, despite low levels of baseline experience and comfort levels. An exposure training course led to immediate perception of increased skills and confidence. However, these courses typically do not provide basic tenets of expert performance that demands deliberate practice. Future course design should transition to a mastery learning framework wherein regular skill assessments, milestones, and unlimited education time are prioritized before implementation of the new skills.

Advanced minimal access surgery in infants weighing less than 3 kg: A single center experience

BackgroundMinimal access surgery (MAS) has gained popularity in infants less than 5kg, however, significant challenges still arise in very low weight infants. Study designA retrospective chart review was performed to identify all infants weighing less than 3kg who underwent an advanced MAS or equivalent open procedure from 2009 to 2016. Advanced case types included Nissen fundoplication, duodenal atresia repair, Ladd procedure, congenital diaphragmatic hernia repair, esophageal atresia/tracheoesophageal fistula repair, diaphragmatic plication, and pyloric atresia repair. A comparative analysis was performed between the MAS and open cohorts. ResultsA total of 45 advanced MAS cases and 17 open cases met the inclusion criteria. Gestational age and age at operation were similar between the cohorts, while infants who underwent open procedures had significantly lower weight at operation (p=0.003). There were no deaths within 30days related to surgery in either group. Only 3 MAS cases required unintended conversion to open. There were 2 (4.4%) postoperative complications related to surgery in the MAS cohort and 2 (11.8%) in the open cohort. ConclusionAdvanced MAS may be performed in infants weighing less than 3kg with low mortality, acceptable rates of conversion, and similar rates of complications as open procedures. Type of studyPrognosis study. Level of evidenceLevel III.

Laparoscopic Repair of Duodenal Atresia: Systematic Review and Meta-Analysis.

To investigate the outcome of laparoscopic repair of duodenal atresia (LRDA) in relation to different approaches with regard to suture material and anastomosis technique. To identify evidence for the safety and efficacy of LRDA compared with the conventional open repair. Systematic search was performed for all studies on LRDA, excluding case reports, and all comparative studies between LRDA and open repair. Chi-square was used to assess associations between complications or conversions rates and different LRDA approaches (suture material, suturing technique). Meta-analysis was employed to compare LRDA and open repair. The complications and conversions rates of LRDA were not affected by the different suture materials (Silk, Vicryl, PDS; p=0.51) or suturing technique (interrupted, continuous; p=0.46). The meta-analysis did not show significant differences between LRDA and open repair in overall complications rate (p=0.88), time to feeds (p=0.12) and hospitalization time (p=0.28), although it revealed longer operative time with LRDA (p<0.0001). LRDA shows comparable safety and efficacy with the open repair, although it is associated with significantly longer operative time. There is no evidence that the type of the suture material or anastomotic technique affects the outcome of LRDA.

Duodenal Atresia: Open versus MIS Repair-Analysis of Our Experience over the Last 12 Years.

Objective. Duodenal atresia (DA) routinely has been corrected by laparotomy and duodenoduodenostomy with excellent long-term results. We revisited the patients with DA treated in the last 12 years (2004–2016) comparing the open and the minimally invasive surgical (MIS) approach. Methods. We divided our cohort of patients into two groups. Group 1 included 10 patients with CDO (2004–09) treated with open procedure: 5, DA; 3, duodenal web; 2, extrinsic obstruction. Three presented with Down's syndrome while 3 presented with concomitant malformations. Group 2 included 8 patients (2009–16): 1, web; 5, DA; 2, extrinsic obstruction. Seven were treated by MIS; 1 was treated by Endoscopy. Three presented with Down's syndrome; 3 presented with concomitant malformations. Results. Average operating time was 120 minutes in Group 1 and 190 minutes in Group 2. In MIS Group the visualization was excellent. We recorded no intraoperative complications, conversions, or anastomotic leakage. Feedings started on 3–7 postoperative days. Follow-up showed no evidence of stricture or obstruction. In Group 1 feedings started within 10–22 days and we have 1 postoperative obstruction. Conclusions. Laparoscopic repair of DA is one of the most challenging procedures among pediatric laparoscopic procedures. These patients had a shorter length of hospitalization and more rapid advancement to full feeding compared to patients undergoing the open approach. Laparoscopic repair of DA could be the preferred technique, safe, and efficacious, in the hands of experienced surgeons.

Low-Cost Simulation Model for Training MIS Repair of Duodenal Atresia Combined with Telementoring Technology: Initial Assessment

Introduction: The use of minimal invasive surgery (MIS) simulation models has been included into our residency program curricula and hands-on courses since 2013. We have previously presented our low-cost tracheoesophageal fistula esophageal atresia simulation model for training in IPEG 2013. The Society of American Gastrointestinal and Endoscopic Surgeons describes telementoring as a relationship, facilitated by telecommunication technology, in which an expert provides guidance to a less experienced learner from a remote location. MIS procedures are an ideal platform for real-time transmission and thus apply telementoring for surgery. We started a project to look at the efficacy of telementoring starting with simulation. Aim: The aim of this 5 minute video is to present a low-cost simulation model for training MIS repair of duodenal atresia (DA) and our first steps with combining telementoring technology. Material and Methods: The base model was introduced into the abdominal cavity of a rubber doll that resembles a 3 kg newborn. We use silicone finger covers and tubular latex balloons (as proximal and distal duodenum and bowel). The cost of materials was less than $50US. Video endoscopic equipment and 3 mm instruments were used. We reproduced all steps of the procedure: dissection of the proximal pouch, finding the distal duodenum below the transverse mesocolon, opening of both blind duodenal ends and performance of a duodenoduodenal anastomosis. We use a validation sheet to evaluate the performance: number of errors and type of injuries, quality of the anastomosis, and time of practice. A video camera was connected with a videoconference equipment through Internet under 1 MB for telementoring. Two pediatric surgery fellows were mentored by three faculties with focus in both the use of the lens and performance of the correct steps to repair a DA. Both of them had previously attended a basic and advanced MIS hands-on programs in our institution and developed skills for advanced suturing and working in small spaces. Mentors and mentees had a human and academic previous relationship. The development checklist sheet was filled after consensus. Results: The procedure was completed without injuries in 75 minutes. Interaction was effective without need to assist them in person. Discussion: Telementoring MIS simulation could assist in the provision of teaching advanced skills worldwide. No competing financial interests exist. Runtime of video: 5 mins This video was presented at 25th IPEG annual meeting, May 24–28 2016, Fukuoka Japan.

Laparoscopic duodenoduodenostomy with parallel anastomosis for duodenal atresia.

Currently, a diamond-shaped anastomosis is preferred for the surgical repair of duodenal atresia (DA) in both open and laparoscopic surgery. We report the results of laparoscopic duodenoduodenostomy with parallel anastomosis (LDPA) in DA. We retrospectively reviewed 22 patients who underwent laparoscopic duodenoduodenostomy from February 2005 to May 2015 in Samsung Medical Center. All patients underwent operation within the first month after birth. Patients who were transversely anastomosed after duodenotomy and patients who underwent simultaneous operation on combined anomalies were excluded. Parallel anastomosis was used in all surgeries. Four trocars were used in laparoscopic repair. After mobilization of both proximal and distal ends, the proximal end was incised transversely and the distal end was incised longitudinally. Duodenoduodenostomy with parallel anastomosis using a 5-0 glyconate monofilament was performed with interrupted sutures. Eleven patients (50%) were male. Median gestational age was 36+6weeks (32+7-40+6). Median age at the time of operation and median body weight were 3days (1-12) and 2.53kg (1.63-3.18), respectively. All patients were diagnosed prenatally and 16 patients (72.7%) had associated anomalies. Median operation time was 142min (96-290) and median postoperative day to start oral feeding was 5days (3-9) and median postoperative day of reaching full feeding was 11days (6-19). Median postoperative day was 13days (10-60). There was no anastomotic leakage or stenosis. Median follow up was 3.5months (1-21). Currently, there is no late complication. LDPA can be performed easily to patients who have DA in neonatal period. It is anatomically natural and the risk of leakage or stenosis does not seem significant. Therefore, parallel anastomosis should be considered as a safe procedural option for laparoscopic duodenoduodenostomy in DA.