Preampullary congenital duodenal obstruction in a father and son

Congenital duodenal obstruction - Advances in diagnosis, surgical management, and associated controversies

Congenital duodenal obstruction (CDO) occurs due to intrinsic and extrinsic mechanisms but is most often caused by intrinsic duodenal atresia and stenosis. This review will summarize the history, epidemiology, and etiologies associated with the most common causes of CDO. The clinical presentation, complex diagnostic considerations, and current surgical repair options for duodenal atresia and stenosis will also be discussed. Finally, both historical and recent controversies which continue to affect the surgical decision-making in the management of these patients will be highlighted.

Distinct clinical characteristics of patients with congenital duodenal obstruction in a medical center in Taiwan

BACKGROUND

Patients with congenital duodenal obstruction (CDO) predominantly have a postampullary lesion site and a high association with Down syndrome, according to previous reports from Western countries. This study aimed to determine whether there are racial differences in the clinical characteristics of congenital duodenal obstruction, based on the experience from a Taiwanese medical center.

METHODS

The charts were retrospectively reviewed among neonates with CDO who received surgery at National Taiwan University Hospital during the period 1985- 2008. Patients were grouped into a preampullary or postampullary group according to the obstruction in relation to the ampulla of Vater. Other characteristics, including sex, time of diagnosis, operative findings, as well as associated anomalies, were recorded for further analysis.

RESULTS

A total of 30 patients with CDO including 16 with atresia, 10 with mucosal webs, and 4 with stenosis, were recruited; among them, 16 were boys and 14 were girls. In 15 patients (50%), the diagnosis of duodenal obstruction was made prenatally. A total of 11 of the 30 patients (37%) were in the preampullary group and 19 (63%) were in the postampullary group. Seventeen patients (56.7%) had at least one additional anomaly, including four (13%) who had trisomy 21. The preampullary group had significantly fewer associated congenital anomalies than in the postampullary group (27%vs. 74%, p = 0.012).

CONCLUSION

Our cohort showed a relatively lower incidence of postampullary lesions and associated Down syndrome in patients with CDO compared with Western countries. Additionally, patients with preampullary lesions had significantly less association with other anomalies.

Annular pancreas in identical twin newborns

Annular pancreas is a rare congenital anomaly occurring in 1 of every 12,000 to 15,000 live births [Nerwich N, Shi E. Neonatal duodenal obstruction: a review of 30 consecutive cases. Pediatr Surg Int 1994;9:47-50]. It may remain asymptomatic throughout life, present in adulthood, or present in infancy as a high intestinal obstruction. Review of the literature demonstrates only 8 cases of familial annular pancreas and no case of twins exhibiting the disease. We will describe a case of identical (monochorionic diamniotic) female twins with neonatal presentation of duodenal obstruction and annular pancreas, and discuss data supportive of a genetic etiology.

Annular pancreas in children: a recent decade's experience

PURPOSE

Annular pancreas is a recognized cause of duodenal obstruction in children. The authors sought to characterize the clinical, radiologic, and prognostic findings in this disorder through a 10-year review of all patients with annular pancreas.

METHODS

A retrospective review of all annular pancreas cases identified between 1993 and 2002 at 2 tertiary pediatric surgical centers was completed. Factors analyzed included patient demographics, presenting symptoms, associated anomalies, radiologic findings, operation performed, postoperative outcomes, and complications.

RESULTS

Sixteen patients were identified. Four patients (25%) were premature. Twelve patients (75%) presented during the first week of life and the remainder within the first year. All patients presented with vomiting, which was nonbilious in 15 (94%). Five patients (31 %) had chromosomal anomalies, and 6 (38%) had other major congenital malformations. Eleven patients (69%) presented with partial duodenal obstruction. Operations performed were duodenoduodenostomy in 14 (88%), duodenojejunostomy in 1 (6%), and Ladd's procedure in 1 (6%). Enteral feedings were started, and full enteral feeding was achieved at an average of 8.4 days and 15.9 days after operation, respectively. All patients survived and were discharged after an average hospitalization of 24.0 days.

CONCLUSIONS

Patients with annular pancreas have preampullary duodenal obstruction, which is more commonly partial. Duodenoduodenostomy is the appropriate treatment. Prognosis is excellent, despite the frequent association with chromosomal anomalies and major congenital malformations.

Immune deficiency in familial duodenal atresia

The familial occurrence of duodenal atresia is uncommon. This study evaluated the inheritance patterns, the nature and associations, and the presence of immunologic deficits in duodenal atresia recurring in at least three siblings each in two nonrelated families. In the first family, an association with Fanconi's anemia was observed in three of seven pregnancies (2 boys, 1 girl) suggesting an autosomal recessive mode of transmission. Patients died as a result of overwhelming (fungal) septicemia in association with pancytopenia. In a second family, identical multiple atresias occurred in two female siblings born 18 months apart and a third child with a duodenal stenosis. Overwhelming sepsis and a T-cell dysfunction was seen in the postoperative period, which had partially corrected by follow-up at 5 months. A history of family occurrence of duodenal atresia should alert the physician to the possibility of associated pathology including immune deficiency states.

A case of intraperitoneal pancreas

A case of anomalous location of the pancreas is presented. In this case, head and a part of the body of the pancreas were found intraperitoneal. The pancreas was covered by the peritoneum within the omental bursa except its tail. Additionally, the anterior layer of the hepatogastric ligament turned over the hepatoduodenal ligament and continued behind the head of the pancreas together with the peritoneum which formed the posterior wall of the epiploic foramen (Winslow). The peritoneum also covered a part of the posterior surface of the body and directed to the right, forming a recessus just behind the pancreas.